Draft Report

**On the**

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

**January 12, 13, 1999**

**In**

**Rapid City, South Dakota**

**"SPEAKING WITH ONE VOICE**

**IHS, TRIBES, URBAN"**

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

**For the**

**Aberdeen and Billings Areas**

**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**

###### 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 to 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 during this
next year and through-out 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 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 will
convene I/T/U's in their Area for the purpose of reviewing the Indian
Health Care Improvement Act and developing specific recommendations. At
the Regional Consultation Meetings the Areas will have the opportunity
to discuss their issues and recommendations with I/T/U's from other
Areas, in an effort to reach consensus and resolution. The results of
each Regional Meeting will be consolidated into a Draft Regional Report.
After all four Regional Meetings have been conducted a Final National
Report will be issued. The stated goals and objectives of this
consultation process were identified by IHS headquarters 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 first Regional Consultation Meeting was held in Rapid City, South
Dakota, on January 12, 13, 1999. It was convened for the I/T/U's in the
Aberdeen and Billings Areas of the IHS. The Regional Consultation
Meeting was well attended and provided participants with the opportunity
to better understand the Indian Health Care Improvement Act and to begin
to identify significant policy issues and major recommendations. A total
of 134 participants registered for the Rapid City 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 Aberdeen and Billings 437
Coordinators. The results of the Rapid City meeting are contained in
this report

Currently, the following Regional Meetings are planned or 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 23, 24 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 sponsored roundtable, served
as one of several resource documents for the participants at the Rapid
City Regional Consultation Meetings. The Rapid City Consultation Meeting
was 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

-   Aberdeen Area IHS Recommendations

-   Billings Area IHS Recommendations

-   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)

-   Urban Health (Title V)

-   Access and Miscellaneous (Title IV and Title VIII)

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

-   Strategizing Politically for Reauthorization

-   Medicaid and Managed Care

-   Other Emerging Issues

These two sets of recommendations were developed in breakout workgroups,
and then shared with the whole group during plenary reports.

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. Secondly, the
workshop would also identify those issues or recommendations where no
consensus was reached and attempt to articulate the perspectives of the
group. Unfortunately, the amount of time dedicated to each work group
topic was limited. However, each work group did identify several major
policy issues and consensus recommendations.

###### 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

The Indian Health Care Improvement Act (IHCIA) is a compilation of many
legislative initiatives to address Indian health care problems across
the nation. Each title represents a major effort to address the
disparities in health status for American Indians. The first day of the
Rapid City Regional Consultation meeting was dedicated to addressing
each of the major Titles of the IHCIA. A total of three hours were spent
on each Title, and the work groups then reported out their consensus
recommendations. The following represents a summary discussion of those
consensus recommendations.

1.  **Health Professions (Title I)**

The Indian Health Manpower Title I, commonly referred to as "Health
Professions", has twenty three (23) sections which describe methods of
increasing the number of Indians entering the health professions and
programs authorized to assure adequate supply of 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.

The recommendations and themes of the discussions were very diverse
moving from broad statements regarding the roles of tribal colleges in
health manpower training and giving the Indian Health Service Area
office the authority to operate the scholarship and loan repayment
program to very specific changes in the language regarding eligibility
of grants for colleges.

The Health Professions Recruitment Program for Indians was addressed in
the final plenary report back session of the conference. There were
several individuals that asked questions regarding Section 102, wanting
more information on the availability of the funds and what tribes have
been funded previously by this section. They expressed a need for this
program to be expanded. In addition vocational training at the
elementary and high school is needed to develop health professionals in
all tribal communities.

-   **Health Preparatory and Professions Scholarship Programs:**
    Specifically the recommendation on Section 103 is to delegate to the
    Indian Health Service Area offices the authority to operate the
    scholarship and loan repayment programs. In addition language should
    be included so that the scholarship and loan repayments would be
    non-taxable. In Section 104, Registered Records Administrators (RRA)
    and Dental Hygienist should be added as health professions

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-   **Continuing Education Allowance:** Section 106 creates Continuing
    Education allowance for professional staff. There should be an
    expansion in this section that includes "the opportunity for a
    health professional to receive funds to increase skill level or
    expanded study in specialty areas. There needs to more training
    incentives for gaining additional skills for those individuals that
    choose a career serving Indian people.

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-   **Community Health Representatives:** Statements regarding Section
    107 included increasing the specialty funding level and developing a
    funding formula for the Community Health Representative program. The
    recommended formula was one (1) CHR for every 350 people. It was
    also recommended that the tribal colleges be given the opportunity
    to develop capacities for training health professionals and work in
    collaboration with the CHR program to develop a certified or
    credentialled Home Health Care Professional program.

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-   **Loan Repayment Program:** Indian Health Service Loan Repayment
    Program Section 108 recommendations state that the Scholarship and
    loan repayment are non-taxable. In addition to this section all
    other sections that have scholarships, loan repayments or retention
    bonuses should not be subject to taxes.

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-   **Nursing Program:** Section 112 (a) should remain in the law,
    however change the wording to Tribal College Nursing programs as
    opposed to Public and Private Colleges. Wording should read "Tribal
    College Accredited Nursing Programs." The public health nurses
    working in the tribal communities should be increased using a
    population formula that would provide a ratio of 1 to every 500
    people by the year 2010. In addition the funding for tribal nursing
    programs should be increased.

-   **Tribal Culture and History:** Section 113, Tribal Culture and
    History, is to continue with stronger language making it a mandatory
    requirement.

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-   **Health Training Programs for Community Colleges**: In Section 115
    there should be a \$3 million dollars annually for accredited Tribal
    colleges. This funding would support five lead colleges who enter
    into collaborative agreements with three to four other tribal
    colleges to provide an Associate/Baccalaureate Program in nursing.
    Expand the ability of students to fulfil their payback at Tribal
    Colleges.

The major themes evolving were: (1) regional (IHS Area) control of the
scholarship programs; (2) expanded opportunities for tribal colleges to
be involved in health professions training; (3) non-taxable
scholarships, loan repayments and retention bonuses; (4) increased
health careers programs at the tribal level; (5) additional funding for
Community Health Representatives positions and Public Health Nursing;
(6) and a mandatory requirement for the Tribal Culture and History
program to be developed.

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

A wide range of issues were discussed in this work group, including
direct patient care, contract health services, domestic violence, sexual
abuse, mental health issues, substance abuse, emergency medical
services, long-term care, diabetes, physical therapy, dialysis,
rehabilitation, hospice care, transportation, elderly abuse, nursing
homes, nutrition, women's and men's health issues, teen health,
traditional medicine, and community based services. It was not possible
to address each issue in the detail necessary to develop specific
recommendations. However, the participants did develop specific
recommendations for consideration in amending the IHCIA.

-   **Core Benefits Package:** The full scope of health services shall
    be provided to address prevention of disease, acute treatment of
    disease and chronic disease management. The services available shall
    be no less than that which is listed as "medical and other health"
    services provided to federal Medicaid beneficiaries as described in
    federal regulation. Full consideration of traditional native healing
    practices and support for these practices shall be a part of the
    identified services.

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-   **Mental Health Services:** The participants addressed the problems
    of suicide and domestic violence in Indian communities. The IHCIA
    shall provide full mental health services to address the physical,
    emotional, spiritual concerns of the patients and the Indian
    communities.

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-   **Reimbursement:** The I/T/U's shall be reimbursed for services
    provided similar to states. (Needs clarification from the Resource
    Person).

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-   **Entitlement and Means Testing:** The work group discussed the
    concept of changing the federal Indian health system from a
    discretionary program to an "entitlement" program. The consensus of
    the workgroup was to amend the IHCIA in a way, which would establish
    in federal law that the government of the United States shall
    provide full entitlement to health services for American Indians and
    Alaska Native beneficiaries. In relation to American Indian
    entitlement to health care services, the IHCIA must also specify
    that there will be no "means testing" applied to tribal governments
    or to individual American Indians and Alaska Natives to determine
    eligibility for services specified under the IHCIA.

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-   **Substance Abuse Services:** The work group discussed multiple
    substance abuse issues including expanding the education and
    prevention curriculum to keep pace with newer problems such as
    methamphetamines, inhalant abuse, gambling and other addictive
    behaviors. The group also discussed the need for better and more
    action oriented collaboration among the various federal agencies,
    such as the IHS, BIA, HUD and Office of Indian Education. The IHCIA
    should build upon the Regional Treatment Center system to expand to
    provide regional treatment for women with children and expanded
    geographical access. Inpatient treatment should also have authority
    to include "long term care" for patients who require longer
    treatment for substance abuse or related issues. The IHCIA should
    provide for better integration of the substance abuse treatment and
    prevention program with other IHS initiatives, such as mental health
    services, injury prevention, medical care, traditional native
    healing and other programs. The IHCIA should provide authority for
    regional certification of alcohol and substance abuse counselors.
    Finally, the IHCIA should ensure that the full "continuum of care"
    is provided, including education, prevention, detox, treatment, and
    aftercare. The lack of a formal aftercare component in the I/T/U
    system is a major weakness in the existing effort to address
    substance abuse in Indian communities.

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-   **Colleges and University Collaboration:** Grants to colleges and
    university for the purposes of developing and maintaining American
    Indian career recruitment programs for all health professions. (Need
    more explanation from the Resource Person)

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-   **Emergency Medical Services:** The group recommended that the "full
    scope" of emergency medical services should be accessible to
    American Indian and Alaska Native beneficiaries of the I/T/U system,
    including pre hospital care, EMT staffing, emergency vehicles,
    equipment, training and support.

3.  **Health Facilities (Title III)**

Health Facilities has 10 sections which includes construction/renovation
of hospitals and clinics and safe water and sanitary waste disposal
facilities construction. The major discussion of this title centered
around Section 301 (c) which authorizes Indian Health Service to submit
a report to Congress that sets forth the current health facility
priority system and the right for every Indian family to have a home
with safe water. The work group did not have time to consider all the
sections that are under this title.

-   Facilities Construction: Section 301. (a) states as the title
    Consultation; Closure of Facilities; Reports. It was recommended
    that the title be changed due to the fact that it could be
    misinterpreted to mean that there needs to be consultation regarding
    closure of facilities and reports regarding this effort. This
    discussion stated that the Indian Health Service (IHS) never
    presented the actual total facility needs of all the tribes to
    Congress. The recommendation was to identify the total facility
    needs to Congress instead of the top ten (10). The IHS needs to
    obtain tribal consultation of the priority system methodology. IHS
    needs to look at facilities needs for services such as long term
    care and dialysis. When these services are authorized facilities
    should be authorized for construction. There needs to be flexibility
    in adjusting the use of a facility space. For example if there is a
    need for more outpatient services the inpatient services/facilities
    should not be closed. Language should be proposed that allows IHS to
    shift emphasis of a facility from one type of service to another
    without penalty or without the facility changing its' place on the
    priority system.

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-   Safe Water and Sanitary Waste Disposal Facilities: Section 302 was
    discussed in regard to the Sanitation Projects. It was stated that
    every family had the right to water that is disease potential free,
    drinkable and be used without concern. The water supplies must meet
    other agency standards such as Environmental Protection Agency (EPA)
    and the Safe Drinking Water Act, (SDWA). Other recommendations on
    this section were for IHS to provide to tribes technical assistance
    to establish their utility systems through finance rate studies and
    costs for better tribal decisions.

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-   Medicare and Medicaid Construction Funds: A paragraph needs to be
    added to allow reporting of expenditures of M/M funds for facilities
    rather than pre-approval. This eliminates the need to secure
    approval from Congress prior to the use of M/M funds for facilities
    construction.

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-   Tribal Construction of Quarters: A recommendation was made that
    "Demonstration Project" language be written into the new law that
    allows IHS to guarantee rent for staff quarters built by the tribe.
    Other comments suggested to authorize this under the joint venture
    section.

The group did not have time to discuss all the issues and concerns. The
major findings were: (1) A method for reporting all the facility needs
each year to congress instead of the priority system of sending forward
ten (10) sites; (2) that tribes should not be penalized for new
facilities listings if there population's needs are more ambulatory in
nature or that there population has special needs such as long term care
and dialysis; (3) that IHS be able to guarantee rent for staff quarters
built by the tribes; (4) that M/M funds only need to be reported to
Congress prior to expenditure for facilities construction; (5) and that
IHS should provide technical assistance to the tribe as they set up
their water and sewer systems.

4.  **Urban Health (Title V)**

# 

# There are several urban Indian programs in the Aberdeen and Billings Areas. Title V has fourteen (14) sections. Due to the fact that most of the urban programs present were NIAAA transfers under Section 513 (a-e), the majority of the discussion focused on mental health and substance abuse. Participants also discussed the need to collaborate with tribes and tribal organizations and other state and federal agencies.

-   **Infrastructure Development:** It was recommended that language be
    inserted that allows funds for infrastructure development. It was
    stated that there was a need for new programs to receive start up
    costs and mature programs to receive administrative costs annually.
    In addition it was felt that there should be special waivers for
    those individuals who have "committed violent crimes", successfully
    rehabilitated themselves over substantial time and are wanting to
    serve as counselors. With the federal laws they are unable to serve.

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-   **Urban Substance Abuse Treatment:** An additional Youth Treatment
    Centers in each area should be authorized. Additional treatment
    resources are needed to provide access to urban Indian youth. The
    vast distances involved in accessing current RTC's and need for
    family involvement and support during treatment justifies the
    authority for more centers.

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-   **Medicaid and Medicare:** The Urban Indian Programs should have
    access to the Medicaid/Medicare IHS negotiated rate that has been
    established by Health Care Financing Administration (HCFA) through
    the Memorandum of Agreement (MOA). Amendments to the Social Security
    Act through the IHCIA should include a provision to allow all the
    I/T/U's to participate.

5.  **Access (Title IV)**

-   **Definition of Facility:** Title IV of the Indian Health Care
    Improvement Act amended Titles 18 and 19 of the Social Security Act
    to allow the U.S. Indian Health Service system to bill for services
    provided to Medicare and Medicaid eligible patients. One of the
    problems identified at Rapid City was the fact that the language
    amending Title 18 is different from the language amending Title 19.
    As a result, only IHS hospitals and "skilled nursing facilities"
    (SNF) are eligible to bill under Title 18, Medicare. The language
    amending Title 19, Medicaid, is more flexible, allowing "any other
    type of facility", including freestanding (non-hospital based) IHS
    and tribal outpatient facilities to bill for Medicaid eligible
    beneficiaries. As a result, one of the recommendations from Rapid
    City was to amend Section 401 and change the designation of
    "hospital or skilled nursing home" and use instead the same
    designation of facility as exists in Section 402.

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-   **Non-638 Services:** Another issue raised during the Rapid City
    consultation was the problem tribally operated "nursing homes" have
    qualifying for Medicaid and Medicare billing under the state 100%
    FMAP, when that nursing home is not operating under an IHS Indian
    Self-Determination Act contract, or in lieu of the federal
    government. Since the IHS does not operate nursing homes, tribes
    cannot contract to operate nursing homes in lieu of the IHS. Yet,
    several tribes in the Aberdeen Area are moving toward developing
    tribal nursing homes. The State of South Dakota has established a
    cap on the number of nursing homes allowed within the state and
    eligible to bill Medicare or Medicaid. To qualify for the 100% FMAP,
    the state is interpreting the provision of Title IV to apply only to
    IHS or tribes operating under the Indian Self-Determination Act on
    behalf of the IHS. Therefore, the Rapid City participants are
    recommending that the language specifically provide coverage for
    tribal health services, whether operated under P.L.93-638 or through
    other means and other resources.

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-   **100%** **FMAP Rates for CHS Referrals:** Participants expressed
    concern that states were reluctant to cover referrals to outside
    specialists or hospitals, which are provided by Contract Health
    Service providers. Therefore, the participants recommended that
    Title IV be amended to cover Medicare or Medicaid reimbursements to
    states under the 100% FMAP, including CHS services provided through
    the referral of a qualifying IHS or tribal provider.

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-   **Eligibility Determination:** The I/T/U participants in Rapid City
    expressed concern about the difficulty in securing eligibility
    determination for Medicaid eligible patients. Section 404 was
    intended to provide Grants and Contracts through the IHS with tribal
    organizations, however this has not been funded or implemented. The
    IHS expressed concern in its status report on IHCIA, that to fully
    implement Section 404 would require the administrations of HCFA and
    states to comply. Without needed authorizing language requiring HCFA
    and state participation, this section can not be fully implemented.
    Therefore, the participants recommended that Section 404 be amended
    to allow for I/T/U's to be authorized to make "eligibility
    determinations" for Medicaid.

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-   **Medicare Part B:** Participants expressed concern that Indian
    elderly who are eligible for Medicare are not participating in the
    Part B program because of the requirement for premium payments. As a
    result, the I/T/U providers are not able to bill for outpatient
    services, home health and all other Part B services. Only hospital
    based Part A services are authorized under Title IV. The
    participants are recommending that two alternatives be examined in
    the reauthorization of the IHCIA. (1) That the IHCIA amend the
    Social Security Act to provide an across-the-board waiver of any and
    all premiums for IHS beneficiaries who are otherwise eligible for
    Medicare services; or (2) that the IHCIA be amended to give greater
    strength to the provision that Congress appropriate additional funds
    to cover the premium payments for Indian beneficiaries to
    participate in Part B Medicare.

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-   **Direct Relationship with HCFA:** The Rapid City participants
    expressed concerns about dealing with the states, and the
    inconsistencies from state to state in how tribes are treated with
    regard to Medicaid reimbursement. The 100% FMAP to states should
    have eliminated any obstacles for reliable reimbursements to I/T/U's
    for Medicaid beneficiaries. Instead, some states still find ways to
    create obstacles for tribes in terms of requirements for managed
    care, restrictions on services covered, or caps within each state.
    The participants recommended that the IHCIA include an amendment to
    the Social Security Act which clearly establishes the authority for
    the Health Care Financing Administration (HCFA) to deal directly
    with tribes, as it does with states. Further, the participants
    recommended that I/T/U's be consulted by HCFA in establishing how
    this direct relationship for billing and payment of Medicaid
    services would be operated.

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-   **Use of Third Party Revenues to Off-Set Budget:** Although the
    existing IHCIA already includes language prohibiting the use of
    Medicaid and Medicare revenues from being used to off-set
    appropriations to the Indian Health Service, Congress and the Office
    of Management and Budget continue to supplement appropriations with
    anticipated revenues. The participants recommend that stronger
    language be developed which cannot be circumvented by the budget and
    appropriations process.

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-   **Accreditation and Certification:** Participants expressed concerns
    about meeting state-established standards and criteria for
    certification to participate under Medicare and Medicaid. The Indian
    Health Service requires accreditation of accepted certifying bodies,
    such as the Joint Commission for the Accreditation of Health Care
    Organizations. These standards are equal to or exceed the
    certification standards of states. The participants recommended that
    I/T/U's should be authorized under the IHCIA to be eligible for
    Medicare or Medicaid reimbursement, if meeting existing IHS
    standards. I/T/U's should not have to be forced to meet additional
    state standards.

##### Crosscutting and Emerging Issues

Health care, as an industry and as government policy has changed
significantly since the last reauthorization of the Indian Health Care
Improvement Act in 1992. Health care providers have restructured into
managed care organizations as a means to reduce costs and be competitive
as large purchasers of health coverage, such as State Medicaid agencies
and employers seek to control costs. The federal government has
transferred more and more discretion to the states for the
administration of federal health initiatives including Medicaid reforms,
child health and welfare reform. Tribal governments have increased the
proportionate share of IHS, which is now contracted or compacted by
tribes. This has resulted in a downsizing of IHS functions and
operations. All the while, the costs associated with providing health
services continue to escalate at a pace greater than federal
appropriations to I/T/U's. As a result, I/T/U's have become more and
more dependent upon their ability to bill third parties, such as
Medicaid, to supplement health care budgets. The following sections
provide a summary of discussions and consensus recommendations reached
by each of the work groups examining crosscutting and emerging issues.

1.  **Entitlement, Benefits Package and Health Disparities**

This work group discussed a variety of issues related to the
disparities, which exist from one region to the next with regard to
health services. In some cases, the disparities were due to access to
direct service systems, and others are more dependent upon limited CHS
dollars. Still, vast geographical barriers to health services and
limited public health infrastructure affect other regions. The group
discussed the disparities in access to complex or specialty services due
to the inadequacies of the Contract Health Services (CHS) program
funding and allocations. The lack in "portability" of IHS coverage was
also cited as an underlying contributor to disparities in health
services. Uniform benefits are not currently available to IHS
beneficiaries across the board. There is no one, single benefits package
that all IHS beneficiaries enjoy. The scope of services are dependent
upon location, access to direct services, availability to specialty care
and CHS funds to pay for that care, and basic geographical,
transportation issues. While there was consensus that the disparities in
health services must be addressed, there were few specific
recommendations on how to accomplish equity.

-   **Mental Health:** Access to mental health services and mental
    health initiatives should not be limited to health services or
    confined to the medical model. A more expanded and flexible approach
    to mental health may improve access.

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-   **Federal Collaboration:** IHCIA should provide authority for
    greater coordination and collaboration with other federal agencies,
    and eliminate barriers to I/T/U's from fully participating in the
    resources of other federal programs, such as Medicaid and Medicare.

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-   **Prevention is the Key:** A minimum level of prevention must be
    funded at each level of the I/T/U system, focusing on health
    problems of each community, such as diabetes prevention.

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-   **Per Capita Equity for IHS:** Before equity can be achieved within
    the IHS system, the IHS should be treated fairly within the federal
    system. For example, the IHS per capita appropriation is drastically
    lower than the per capita appropriation for Medicaid, VA or Bureau
    of Prisons.

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-   **Flexibility:** Another key to achieving equity and reducing
    disparities is to allow for greater flexibility for I/T/U's to
    utilize their existing resources, including hospital beds, in ways
    that make the most sense locally.

2.  **Strategizing Politically**

-   **Preparing for IHCIA:** The work group which discussed
    "strategizing politically" included a number of elected tribal
    officials and other I/T/U representatives. The group discussed the
    need for I/T/U's across the United States to "speak with one voice"
    in order to achieve full reauthorization of the IHCIA. The strengths
    and weaknesses of our political unity were discussed and various
    strategies for ensuring reauthorization examined. The timing of the
    legislative process was also discussed. In summary, the participants
    in the work group made only a few recommendations. The group
    recommended that tribal leaders undertake several strategies to (1)
    inform U.S. elected officials about the IHCIA and the timing for
    reauthorization; (2) coordinate with other tribal leaders to keep
    the reauthorization of the IHCIA a top policy priority nationally;
    and (3) urge the five authorizing committees in the House and Senate
    to hold hearings on the IHCIA. Other recommendations which I/T/U's
    should consider included: (1) begin to gather statistics and health
    profile data about Indian health; (2) prepare mailing lists and
    draft letters for support; and (3) research the authorizing
    committee assignments state affiliations.

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-   **Entitlement Authorization:** The group also discussed the
    political advantages and disadvantages of pushing Congress to
    authorize the Indian health system as an **"entitlement"** for
    American Indians, as opposed to a discretionary program in the
    budget. The **advantages** include, (1) an expanded package of
    guaranteed services for all beneficiaries; (2) there is no cap on
    entitlement spending; (3) it would finally fulfill Treaty
    obligations to provide health care; (4) there would be no strings
    attached or red tape; (5) it would reduce or eliminate health
    disparities across Indian country. The **disadvantages** to seeking
    "entitlement" authorization include, (1) it would likely be Medicaid
    based and limited to Medicaid benefits; (2) Congressional committees
    will likely insist that a "means test" or income eligibility
    determination be required for participants; (3) would the IHS system
    or I/T/U system still be needed if all patients were entitled to
    services anywhere?; (4) the problem of integrating public health and
    traditional healing into a medical model of health care would need
    to be addressed; and (5) such an entitlement would eliminate the
    need for Titles II and VII in the IHCIA. After reviewing the
    advantages and disadvantages, it was the consensus of this work
    group that American Indian and Alaska Native leaders should push for
    entitlement authorization under the IHCIA.

3.  **Medicaid and Managed Care**

The Medicaid and Managed Care Workshop was attended by Tribal Officials,
Indian Health Service and State and Regional Medicaid personnel. This
was a good mix for a discussion on issues and problems that contractors
faced in dealing with Section 1122 and 1115 Medicaid waivers. The state
and federal participants gave background information and then the group
made a recommendation based on the discussion, which was a consensus of
the group.

-   Medicaid and Medicare OMB Reimbursement Rate: The work group
    recommended that I/T/U be allowed to collect Medicare Part B in Free
    Standing Clinics. I/T/U's are deemed managed care programs within
    the state and therefore should all receive OMB reimbursements. The
    State Children's Health Insurance Program should embrace the same
    recommendations made for Medicaid, i.e. tribal consultations,
    managed care, cost sharing and 100% FMAP.

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-   Standards of Care Requirements: Allow tribal contractors to
    participate in the quality and peer reviews or an alternative
    process that meets HCFA review criteria.

> The work group wanted a process developed for informal appeals with
> HCFA before Medicaid and Medicare status is denied.

-   Consultation by State and HCFA: The participants stated that the
    I/T/U's should participate at the consultation phase with HCFA and
    states on plans for manage care including renewals of state waivers.
    Regulations should be developed in consultation with the I/T/U's and
    states for standardized reimbursements throughout the states
    recognizing the availability of 100% FMAP as an incentive to protect
    and enhance I/T/U facilities.

-   Other: The work group recommended that IHS patients be exempt from
    the "spend down" requirement for patients who are eligible for
    Medicaid coverage. They also felt that a clarification is needed for
    the definition of an encounter, the situations and services of
    situations where the 100% FMAP applies.

4.  **Other Emerging Issues**

The purpose of this work group was to allow participants the opportunity
to identify any new, crosscutting or emerging issue which had not yet
been discussed. As a result a wide variety of new health issues were
identified. Those included the following:

-   **Telemedicine and Teleradiology:** The Alaska Telemedicine
    Demonstration Program should be expanded to the lower 48 states and
    made available, where appropriate, to I/T/U's.

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-   **Nursing Homes:** The IHS should receive authority in the IHCIA to
    begin to develop all aspects of nursing homes, including
    construction, certification, maintenance, licensure and contract for
    operation.

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-   **New Tribes:** The IHCIA should include language which would
    specify that when Congress recognizes new tribes, new dollars must
    be appropriated to cover all associated services.

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-   **Prevention:** The IHCIA should include a comprehensive approach to
    prevention, including creating an impetus through mental health
    services toward wellness; home-based family-centered services;
    primary and secondary prevention; incorporation of Traditional
    Native healing methods; personal fitness; and incorporation of
    health care a wellness centers.

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-   **Policy on Tribal Sovereignty:** There is currently no statement in
    the IHCIA which adequately affirms the federal trust responsibility
    and recognizes tribal sovereignty. This needs to be included as the
    foundation or theme throughout the IHCIA.

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-   **Per Capita Spending:** Including in the findings of the IHCIA
    should be the display of how much lower per capita spending on
    Indian health is when compared to other federal health efforts, such
    as Medicaid, the Veterans Administration and even the Bureau of
    Prisons.

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-   **CHS Expansion:** The IHCIA should provide for an expansion of
    Contract Health Services "priority one" to include the costs
    associated with family members who must travel with the patient to
    receive needed medical care. Family involvement is a cultural
    requirement.

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-   **Medicare Age Adjustment:** The IHCIA should amend the Medicare
    statute to allow for younger age Indian elders to be enrolled, to
    more closely correspond with the lower life expectancy of American
    Indians and younger onset of chronic, life threatening diseases.

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-   **Y2K Compliance:** The IHS should sponsor a Y2K conference for all
    I/T/U's and develop a web page to ensure all I/T/U's are in Y2K
    compliance.

###### LISTING OF CONSENSUS ISSUES 

-   **Listing of Work Group Consensus Recommendations**

-   **Listing of Recommendations Submitted by Individuals**

**REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT**

**ABERDEEN/BILLINGS REGIONAL MEETINGS -- RECOMMENDATIONS SUBMITTED BY
INDIVIDUALS**

+---------------+------------------------+----------------------------+
| **TITLE --    | **ISSUES**             | **RECOMMENDATIONS**        |
| I**           |                        |                            |
|               |                        |                            |
| **Health      |                        |                            |
| Professions** |                        |                            |
+---------------+------------------------+----------------------------+
| Section 115   | Support of Nursing     | Authorizing language in    |
|               | Programs               | section 115 to provide     |
|               |                        | \$3,000,000 in operational |
|               |                        | support to tribal          |
|               |                        | colleges. This funding     |
|               |                        | will support 5 lead        |
|               |                        | colleges who will enter    |
|               |                        | into collaborations with   |
|               |                        | 3-4 other tribal colleges  |
|               |                        | to provide an Associate    |
|               |                        | Degree in nursing.         |
+---------------+------------------------+----------------------------+
| (Section 112) | Need for these grants  | Grants to accredited       |
|               | at Tribal College      | nursing programs ADN and   |
| Nursing       | Schools of Nursing,    | BSN be entitlement grants  |
| Program:      | Programs costs exceed  | and be increased to        |
| Nursing       | the reimbursement from | \$250,000.                 |
| Recruitment   | BIA for tribal college |                            |
| and Retention | support for these      |                            |
| Grants        | programs. Tuition and  |                            |
|               | Tribal College Act     |                            |
|               | money pay for about    |                            |
|               | 50% of the cost.       |                            |
+---------------+------------------------+----------------------------+
| \(107\)       | Number of CHRs         | Develop a formula (ie      |
| Community     |                        | 1/350) to increase the     |
| Health        |                        | number of CHRs positions   |
| Re            |                        | in IHS funds to            |
| presentatives |                        | accommodate and address    |
|               |                        | the higher level of        |
|               |                        | services provided by       |
|               |                        | certified CHR personnel.   |
|               |                        |                            |
|               |                        | Training needs -- Basic    |
|               |                        | CHR training is provided   |
|               |                        | at HQ level -- Need to     |
|               |                        | address specialty training |
|               |                        | needs of tribes            |
|               |                        |                            |
|               |                        | Diabetes                   |
|               |                        |                            |
|               |                        | HIV-AIDS                   |
|               |                        |                            |
|               |                        | Injury prevention          |
|               |                        |                            |
|               |                        | For CHRs to be the health  |
|               |                        | educators.                 |
|               |                        |                            |
|               |                        | CHR-PCL -- Need funds for  |
|               |                        | training and equipment to  |
|               |                        | accomplish IHS needed      |
|               |                        | database of CHR services.  |
+---------------+------------------------+----------------------------+
| **TITLE --    | # **ISSUES**           | # **RECOMMENDATIONS**      |
| I**           |                        |                            |
|               |                        |                            |
| **Health      |                        |                            |
| Professions** |                        |                            |
+---------------+------------------------+----------------------------+
| \(107\)       | # To expand the tr     | # Provide nurse MS or      |
| Community     | ibal directorship posi |  BSN in rural health, or p |
| Health        | tion to that of a nurs | ublic health to direct and |
| R             | e MS or BSN in rural h |  train the CHR position pr |
| epresentative | ealth or public health | oviding high quality healt |
| Program       | . To then be able to p | h care to all individuals. |
|               | rovide training, etc.  |                            |
+---------------+------------------------+----------------------------+

**REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT**

**ABERDEEN/BILLINGS REGIONAL MEETINGS -- RECOMMENDATIONS SUBMITTED BY
INDIVIDUALS**

+---------------+------------------------+----------------------------+
| **TITLE --    | # **ISSUES**           | # **RECOMMENDATIONS**      |
| II**          |                        |                            |
|               |                        |                            |
| **Health      |                        |                            |
| Services**    |                        |                            |
+---------------+------------------------+----------------------------+
| \(206\)       | # Ability for IHS t    | # Give authority to IHS    |
| subsection f  | o hire self-insured tr |  upon a resolution by trib |
|               | ibes at tribes option. | e to bill their insurance. |
+---------------+------------------------+----------------------------+
| Contract      | # Current C            | # Most responsible ind     |
| Health        | HS guidelines inhibits | ividuals would not abuse t |
| Service       |  or prohibits thereby  | he system, on the contrary |
|               | discouraging eligible  | , would be extremely grate |
|               | enrolled members of an | ful for the care they are  |
|               | y federally recognized | given. If an individual ut |
|               |  tribe from living whe | ilized an IHS facility for |
|               | rever they may choose  |  health care (For example) |
|               | because they would hav |  a person living in Billin |
|               | e difficulty paying fo | gs, Mt. And went to the Cr |
|               | r health care, if they | ow S.U. for care and was d |
|               |  can afford it at all. | etermined by the IHS provi |
|               |                        | der at Crow that this pers |
|               |                        | on was in need of further  |
|               |                        | care by a specialist. They |
|               |                        |  should be eligible for th |
|               |                        | at care from their home re |
|               |                        | servation, CHS program. Th |
|               |                        | e process and way the poli |
|               |                        | cy is stated now mandates  |
|               |                        | once an individual moves o |
|               |                        | ff the reservation and est |
|               |                        | ablishes residency off the |
|               |                        |  reservation, he/she is th |
|               |                        | en considered or ceases to |
|               |                        |  exist as an Indian accord |
|               |                        | ing to our CHS guidelines. |
+---------------+------------------------+----------------------------+
|               | # Car                  | # The reauthor             |
|               | ry over of previous CH | ization of Contract Health |
|               | S budgets are lost in  |  Service dollars that are  |
|               | the federal system, du | carried over in previous y |
|               | e to pending claims an | ears to be reallocated for |
|               | d not reallocated to t |  use in local CHS budgets. |
|               | he local service unit. |                            |
+---------------+------------------------+----------------------------+
| 204 Diabetes  | # Staffing and Funding | # IHS responsibility fo    |
| Service/Home  |                        | r nursing home and funding |
| Health Care   |                        |                            |
|               |                        | 1.  Expansion funds for    |
|               |                        |     dialysis unit.         |
|               |                        |                            |
|               |                        | 2.  Mental health funding  |
|               |                        |     to deal with increase  |
|               |                        |     youth behavioral       |
|               |                        |     problems.              |
+---------------+------------------------+----------------------------+
| Health        | # Alcoh                | # All                      |
| Services      | ol and substance abuse | I/T/U alcohol programs str |
|               |                        | ive to get program accredi |
|               |                        | ted (CARF) and strongly re |
|               |                        | commend all counselors be  |
|               |                        | Northwest, State and Natio |
|               |                        | nally certified. Our clien |
|               |                        | tele deserve the best, and |
|               |                        |  we as managers and admini |
|               |                        | strators should strive for |
|               |                        |  the best in our programs. |
+---------------+------------------------+----------------------------+

**REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT**

**ABERDEEN/BILLINGS REGIONAL MEETINGS -- RECOMMENDATIONS SUBMITTED BY
INDIVIDUALS**

+---------------+------------------------+----------------------------+
| **TITLE --    | # **ISSUES**           | # **RECOMMENDATIONS**      |
| II**          |                        |                            |
+---------------+------------------------+----------------------------+
| Health        | # Pr                   | # Take the public hea      |
| Services      | evention of disease an | lth perspective on trends  |
|               | d illness that affect  | and statistical informatio |
|               | our native population. | n on illnesses and disease |
|               |                        | s within the health system |
|               |                        |  delivery areas. The major |
|               |                        | ity of health problems are |
|               |                        |  addressed with medical in |
|               |                        | tervention and the main ca |
|               |                        | use go untouched or sporad |
|               |                        | ically addressed. Many ill |
|               |                        | nesses, health problems an |
|               |                        | d diseases are caused by a |
|               |                        | ddictions which we find, i |
|               |                        | s the main cause to these. |
|               |                        |                            |
|               |                        | ### Overeati               |
|               |                        | ng -- Causes obesity -- or |
|               |                        | thopedics, diabetes, dialy |
|               |                        | sis, heart disease, mental |
|               |                        |  health, cancers, asthma,  |
|               |                        |                            |
|               |                        | [Smoking]{.underline} --   |
|               |                        | Hypertension, heart        |
|               |                        | disease, lung diseases,    |
|               |                        | cancer.                    |
|               |                        |                            |
|               |                        | [Substance                 |
|               |                        | Abuse]{.underline} --      |
|               |                        | Injuries, cirrhosis,       |
|               |                        | dialysis, homicides,       |
|               |                        | sexual, spouse, child,     |
|               |                        | elderly abuse,             |
|               |                        | deteriorates the family    |
|               |                        | structure, violence, and   |
|               |                        | FAS, FAE.                  |
|               |                        |                            |
|               |                        | [Gambling]{.underline} --  |
|               |                        | Malnutrition, abuses,      |
|               |                        | deteriorates family        |
|               |                        | structure.                 |
|               |                        |                            |
|               |                        | Resources such as staff    |
|               |                        | and funding needs to be    |
|               |                        | available to make          |
|               |                        | community based program    |
|               |                        | changes in nutrition,      |
|               |                        | exercise and behavior      |
|               |                        | modification. With         |
|               |                        | emphasis on behavior       |
|               |                        | modification.              |
+---------------+------------------------+----------------------------+
| II -- Health  | #                      | # As                       |
| Services      | Lack of staff to meet  |  we see our population gro |
|               | growing demands of new | wing, patients living long |
|               |  and older facilities. | er, drug and alcohol abuse |
|               |                        | , etc. we are seeing an in |
|               |                        | creased workload. The budg |
|               |                        | et should be funded at a l |
|               |                        | evel to meet this demand,  |
|               |                        | and should grow each year. |
+---------------+------------------------+----------------------------+
| II -- Health  | # Preventive Health    | #                          |
| Services      |                        | National Health Objective  |
|               |                        | Year 2000 is being revised |
|               |                        |  in year 2002 -- this docu |
|               |                        | ment would be very helpful |
|               |                        |  in this planning process. |
+---------------+------------------------+----------------------------+
| Title II --   | # Fu                   | # Expand CHEF or           |
| Health        | nding for transplants. | have a separate funding pr |
| Services      |                        | ogram through CHS that are |
|               |                        |  not covered under M/M to  |
|               |                        | pay for organ transplants. |
+---------------+------------------------+----------------------------+
| New -- Title  | #                      | # Authorize and            |
| II            |                        | direct the Indian Health S |
|               |                        | ervice to enhance and expa |
|               |                        | nd prevention initiatives  |
|               |                        | to reduce chronic disease, |
|               |                        |  mental health, substance  |
|               |                        | abuse and injuries and to  |
|               |                        | ensure that tribes and urb |
|               |                        | ans have the same access t |
|               |                        | o prevention services to w |
|               |                        | hich citizens have access. |
+---------------+------------------------+----------------------------+

**REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT**

**ABERDEEN/BILLINGS REGIONAL MEETINGS -- RECOMMENDATIONS SUBMITTED BY
INDIVIDUALS**

+---------------+------------------------+----------------------------+
| **TITLE --    | # **ISSUES**           | # **RECOMMENDATIONS**      |
| II**          |                        |                            |
+---------------+------------------------+----------------------------+
| 205 -- Title  | # Hospice Care         | # Re                       |
| II            |                        | view HCFA Regulations rela |
|               |                        | ted to end of life issues. |
|               |                        |                            |
|               |                        | Currently Hospice Care     |
|               |                        | begins when the patient is |
|               |                        | thought to be within 6     |
|               |                        | months of death.           |
|               |                        | Regulations also restrict  |
|               |                        | reimbursement for certain  |
|               |                        | medications. (Non          |
|               |                        | intervenes chronic pain    |
|               |                        | medications)               |
|               |                        |                            |
|               |                        | Language should focus on   |
|               |                        | changing the regulations.  |
+---------------+------------------------+----------------------------+
| II -- Health  | #                      | # Format health se         |
| Services      |                        | rvices by physical, spirit |
|               |                        | ual, emotional and social. |
+---------------+------------------------+----------------------------+
| Title II --   | # Dialysis staffing    | # The Omaha Tribe of       |
| Health        |  and operating funds ( | Nebraska has contracted wi |
| Services      | Dialysis Unit Funding) | th a Dialysis company for  |
| (201)         |                        | seven years. This facility |
|               |                        | /company brings their own  |
|               |                        | staff and operating costs  |
|               |                        | to our dialysis facility f |
|               |                        | or services they provide.  |
|               |                        | However, this contract wil |
|               |                        | l be ending this FY1999. T |
|               |                        | herefore, the Omaha Tribe  |
|               |                        | is in dire need to receive |
|               |                        |  funding to keep these ser |
|               |                        | vices on going. This recom |
|               |                        | mendation should not only  |
|               |                        | be included in the amendme |
|               |                        | nts to P.L. 94-437 but [fu |
|               |                        | nded]{.underline} as well. |
+---------------+------------------------+----------------------------+
| Title II --   | #                      | # The Omaha Tr             |
| Health        | Nursing Home and Assis | ibe of Nebraska has a 25-b |
| Services      | ted Living funding (St | ed nursing home. The Omaha |
| (201)         | affing and operations) |  Tribe is in dire need of  |
|               |                        | funding for this foregoing |
|               |                        |  program. More than 30 Ind |
|               |                        | ian tribes/bands/organizat |
|               |                        | ions own and operate nursi |
|               |                        | ng homes on their reservat |
|               |                        | ions -- most of them opera |
|               |                        | te under third party fundi |
|               |                        | ng. This recommendation sh |
|               |                        | ould not only be included  |
|               |                        | in the amendments to P.L.  |
|               |                        | 94-437 but funded as well. |
+---------------+------------------------+----------------------------+
| Title II &    | # Chronical            | # Continuum of care        |
| VII -- Health | ly mentally ill and al |                            |
| Services      | cohol, and other drugs | Day hospital programs      |
|               |  related brain damage. |                            |
|               |                        | Supervised living          |
|               |                        |                            |
|               |                        | Case Management            |
|               |                        |                            |
|               |                        | Halfway houses             |
+---------------+------------------------+----------------------------+
| Title II &    | # Acutely Suicidal     | # Jails not be used as saf |
| VII -- Health |                        | e rooms -- That hospitals  |
| Services      |                        | or other ways to protect t |
|               |                        | hese patients be mandated. |
+---------------+------------------------+----------------------------+

**REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT**

**ABERDEEN/BILLINGS REGIONAL MEETINGS -- RECOMMENDATIONS SUBMITTED BY
INDIVIDUALS**

+---------------+------------------------+----------------------------+
| Title II &    | # Wh                   | # The funds be             |
| VII -- Health | ite Vs Califano Cases  | authorized with the same a |
| Services      |                        | uthorities as .06 (CHS) fu |
|               | # (ND & SD only)       | nds \[OGC has given opinio |
|               |                        | n this is a CHS program.\] |
|               |                        |                            |
|               |                        | 1.  These case are         |
|               |                        |     catastrophic (\$6000   |
|               |                        |     to \$10,000/mo.) That  |
|               |                        |     they access CHEF funds |
|               |                        |     with parity of other   |
|               |                        |     medical illnesses.     |
|               |                        |                            |
|               |                        | 2.  Authorize these        |
|               |                        |     "Mental Health" funds  |
|               |                        |     to be administered in  |
|               |                        |     .06 (CHS) accounts to  |
|               |                        |     streamline bureaucracy |
|               |                        |     involved.              |
+---------------+------------------------+----------------------------+
| Title II &    | #                      | # Access                   |
| VII -- Health |  Mental Health Parity  |  to CHEF funds for mental  |
| Services      | (Consistent with the F | illnesses and/or alcohol o |
|               | ederal Law i.e., "Ment | r other drug problems enco |
|               | al Health Parity Act') | untered in our Indian popu |
|               |                        | lation on the same basis a |
|               |                        | s other medical illnesses. |
+---------------+------------------------+----------------------------+
| Health        | # Ne                   | # Be included in funding.  |
| Services      | ed for wellness center |                            |
|               | s to go along with our |                            |
|               |  health care facilitie |                            |
|               | s for patients -- card |                            |
|               | iac rehabilitation --  |                            |
|               | stroke rehabilitation  |                            |
|               | -- diabetic care, etc. |                            |
+---------------+------------------------+----------------------------+
| Health        | # Fu                   | # This planning process s  |
| Services      | nding based upon GPRA. | hould review the GPRA acti |
|               |                        | vities imposed on the S.U. |
+---------------+------------------------+----------------------------+
|               | # Eyeglasses           | # Provide funding f        |
|               |                        | or eyeglasses based on per |
|               |                        | centage of patients with e |
|               |                        | yeglasses and the unemploy |
|               |                        | ment rate per reservation. |
+---------------+------------------------+----------------------------+
|               | # Orthodontic care     | # Expand dental s          |
|               |                        | ervices for coverage to in |
|               |                        | clude orthodontic level I. |
+---------------+------------------------+----------------------------+
|               | # Procurement of H     | # Exempt from FAR -- Dev   |
|               | ealthcare Services --  | elop healthcare specific p |
|               | through Federal system | rocurement system for IHS. |
|               |                        |                            |
|               | Physicians, nursing,   |                            |
|               | equipment, etc.        |                            |
+---------------+------------------------+----------------------------+
| **TITLE --    | # **ISSUES**           | # **RECOMMENDATIONS**      |
| Emerging      |                        |                            |
| Issues**      |                        |                            |
+---------------+------------------------+----------------------------+
| (New), Not    | Telecommunications     | Authorize and direct the   |
| currently in  |                        | Indian Health Service to   |
| the Act       |                        | ensure that the necessary  |
|               |                        | technology is available to |
|               |                        | tribes and urban Indian    |
|               |                        | programs to support        |
|               |                        | patient care and patient   |
|               |                        | information.               |
|               |                        |                            |
|               |                        | i.e. LAN (local area       |
|               |                        | networks)                  |
|               |                        |                            |
|               |                        | WAN (wide area networks)   |
|               |                        |                            |
|               |                        | Telemedicine               |
|               |                        |                            |
|               |                        | GIS Systems                |
+---------------+------------------------+----------------------------+

**REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT**

**ABERDEEN/BILLINGS REGIONAL MEETINGS -- RECOMMENDATIONS SUBMITTED BY
INDIVIDUALS**

+---------------+------------------------+----------------------------+
| **TITLE --    | # **ISSUES**           | # **RECOMMENDATIONS**      |
| Emerging      |                        |                            |
| Issues**      |                        |                            |
+---------------+------------------------+----------------------------+
| Health Status | Oral Health            | A stronger, more           |
| Disparities   |                        | comprehensive oral health  |
|               | 1.  Access to dental   | program is needed.         |
|               |     care in Indian     | National infrastructure of |
|               |     country is very    | I.H.S. dental program      |
|               |     poor. About 25% of | needs to be strengthened.  |
|               |     Native Americans   |                            |
|               |     access care per    |                            |
|               |     year, as compared  |                            |
|               |     to 60% U.S.        |                            |
|               |     national average.  |                            |
|               |                        |                            |
|               | 2.  There remains a    |                            |
|               |     huge backlog of    |                            |
|               |     untreated disease. |                            |
|               |     For example,       |                            |
|               |     Indian children    |                            |
|               |     have about 200% to |                            |
|               |     300% more tooth    |                            |
|               |     decay than their   |                            |
|               |     non-Native         |                            |
|               |     American           |                            |
|               |     counterparts. You  |                            |
|               |     are not asked to   |                            |
|               |     believe this on    |                            |
|               |     faith alone. The   |                            |
|               |     dental program has |                            |
|               |     data to support    |                            |
|               |     this statement     |                            |
|               |     from the 1990 IHS  |                            |
|               |     national oral      |                            |
|               |     health survey,     |                            |
|               |     regional surveys   |                            |
|               |     since then, and    |                            |
|               |     the 1999 IHS       |                            |
|               |     national oral      |                            |
|               |     health survey in   |                            |
|               |     progress.          |                            |
|               |                        |                            |
|               | 3.  Not only is there  |                            |
|               |     a huge backlog of  |                            |
|               |     untreated disease, |                            |
|               |     but also the       |                            |
|               |     current disease    |                            |
|               |     rates are at least |                            |
|               |     double the U.S.    |                            |
|               |     national average.  |                            |
|               |     Again, empirical   |                            |
|               |     data exists to     |                            |
|               |     document this      |                            |
|               |     statement.         |                            |
|               |                        |                            |
|               | 4.  Federal pay        |                            |
|               |     structures are     |                            |
|               |     inadequate to      |                            |
|               |     compete with the   |                            |
|               |     private sector.    |                            |
|               |     This has led to a  |                            |
|               |     recruitment and    |                            |
|               |     retention crisis;  |                            |
|               |     the vacancy rate   |                            |
|               |     among IHS dentists |                            |
|               |     is about 25% at    |                            |
|               |     present, and has   |                            |
|               |     steadily risen     |                            |
|               |     during recent      |                            |
|               |     years. In contrast |                            |
|               |     to a decade ago,   |                            |
|               |     very few new       |                            |
|               |     dental graduates   |                            |
|               |     now express        |                            |
|               |     interest in IHS.   |                            |
|               |     Most of those who  |                            |
|               |     do demand loan     |                            |
|               |     repayment, which   |                            |
|               |     available to only  |                            |
|               |     a very small       |                            |
|               |     number of dentists |                            |
|               |     each year.         |                            |
|               |                        |                            |
|               | 5.  The national       |                            |
|               |     infrastructure of  |                            |
|               |     the dental program |                            |
|               |     has been eroded in |                            |
|               |     recent years,      |                            |
|               |     virtually          |                            |
|               |     eliminating        |                            |
|               |     national           |                            |
|               |     initiatives and    |                            |
|               |     preventive         |                            |
|               |     dentistry          |                            |
|               |     projects. Without  |                            |
|               |     strengthening the  |                            |
|               |     infrastructure at  |                            |
|               |     Area and National  |                            |
|               |     levels, the        |                            |
|               |     situations         |                            |
|               |     outlined above are |                            |
|               |     unlikely to        |                            |
|               |     improve.           |                            |
+---------------+------------------------+----------------------------+

**REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT**

**ABERDEEN/BILLINGS REGIONAL MEETINGS -- RECOMMENDATIONS SUBMITTED BY
INDIVIDUALS**

+---------------+---+------------------------+----------------------------+
| **TITLE --    |   | **ISSUES**             | **RECOMMENDATIONS**        |
| III**         |   |                        |                            |
|               |   |                        |                            |
| **Health      |   |                        |                            |
| Facilities**  |   |                        |                            |
+---------------+---+------------------------+----------------------------+
| Title III,    |   | Joint Venture          | Include joint venture      |
| Health        |   | Demonstration Project  | demonstration language to  |
| Facilities    |   |                        | include "inpatient         |
|               |   |                        | facilities"                |
+---------------+---+------------------------+----------------------------+
| Title III,    |   | Joint Venture and/or   | Add language authorizing   |
| Health        |   | Demonstration          | "Joint Venture" and/or     |
| Facilities    |   | Project(s)             | "Demonstration" project(s) |
|               |   |                        | for construction,          |
|               |   |                        | staffing, equipment, etc., |
|               |   |                        | to include services to     |
|               |   |                        | non-Indians in medically   |
|               |   |                        | under served areas.        |
|               |   |                        |                            |
|               |   |                        | -HHS -- HRSA               |
|               |   |                        |                            |
|               |   |                        | -HAS -- CSAT -- SAMSHA     |
|               |   |                        |                            |
|               |   |                        | -HUD                       |
+---------------+---+------------------------+----------------------------+
| 306, Grant    |   | Out-Growth of          | The Omaha Nation needs     |
| Programs for  |   | facilities due to      | funding for the following  |
| the           |   | increase number of     | programs in construction   |
| Construction, |   | patients               | of new facilities.         |
| Expansion,    |   |                        |                            |
| Moderation of |   |                        | 1.  Nursing home/Assisted  |
| Small         |   |                        |     Living funding         |
| Ambulatory    |   |                        |     (construction,         |
| Care          |   |                        |     staffing, and          |
| Facilities    |   |                        |     operation)             |
|               |   |                        |                            |
|               |   |                        | 2.  Specialty Clinic Bldg. |
|               |   |                        |                            |
|               |   |                        | > (office & examination    |
|               |   |                        | > rooms)                   |
+---------------+---+------------------------+----------------------------+
| Title III,    |   | Nursing Home and       | The Omaha Tribe of         |
| Health        |   | Assisted Living        | Nebraska has a 25-bed      |
| Facilities    |   | funding                | Nursing home owned and     |
|               |   |                        | operated by the Omaha      |
|               |   | \- Construction        | Tribe of Nebraska since    |
|               |   |                        | 1979. The Omaha Tribe is   |
|               |   |                        | in diar need of            |
|               |   |                        | construction of this       |
|               |   |                        | facility. For our nursing  |
|               |   |                        | home to be self-sufficient |
|               |   |                        | it must be expanded to a   |
|               |   |                        | 50-bed nursing home. More  |
|               |   |                        | than 3o Indian             |
|               |   |                        | tribes/bands/organizations |
|               |   |                        | own and operate nursing    |
|               |   |                        | homes on their             |
|               |   |                        | reservations -- most of    |
|               |   |                        | them operate under third   |
|               |   |                        | party reimbursement. This  |
|               |   |                        | recommendation should not  |
|               |   |                        | only be included in the    |
|               |   |                        | amendments to P.L. 94-437  |
|               |   |                        | but funded as well.        |
+---------------+---+------------------------+----------------------------+
| Title III,    | S |                        | Reassessment of the GSA    |
| Health        | e |                        | Government Quarters Rental |
| Facilities    | r |                        | Rates, these current rates |
|               | v |                        | are a deterrent to         |
|               | i |                        | Recruitment and local      |
|               | c |                        | retention of health care   |
|               | e |                        | providers. These rates are |
|               | U |                        | for above the local rental |
|               | n |                        | rates and higher or equal  |
|               | i |                        | to monthly purchase rates. |
|               | t |                        | Reassessment and authority |
|               | Q |                        | given to the local service |
|               | u |                        | units.                     |
|               | a |                        |                            |
|               | r |                        |                            |
|               | t |                        |                            |
|               | e |                        |                            |
|               | r |                        |                            |
|               | R |                        |                            |
|               | e |                        |                            |
|               | n |                        |                            |
|               | t |                        |                            |
|               | a |                        |                            |
|               | l |                        |                            |
|               | R |                        |                            |
|               | a |                        |                            |
|               | t |                        |                            |
|               | e |                        |                            |
|               | s |                        |                            |
+---------------+---+------------------------+----------------------------+

**REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT**

**ABERDEEN/BILLINGS REGIONAL MEETINGS -- RECOMMENDATIONS SUBMITTED BY
INDIVIDUALS**

+---------------+-------------------------+----------------------------+
| # **          | # **ISSUES**            | # **RECOMMENDATIONS**      |
| TITLE -- IV** |                         |                            |
|               |                         |                            |
| **Medica      |                         |                            |
| id/Medicare** |                         |                            |
+---------------+-------------------------+----------------------------+
| # (402)       | # Extended              | # To authorize 638 t       |
|               | 100% FMAP to urban Indi | ribes, independent tribes  |
|               | an programs -- Jim Cham | and urban programs to acce |
|               | berlain, Urban Programs | ss rates that the IHS has  |
|               |                         | negotiated with providers. |
|               |                         |                            |
|               |                         | # "On                      |
|               |                         | e Federal price" legislati |
|               |                         | ve proposal that would ena |
|               |                         | ble IHS to receive Medicar |
|               |                         | e-like rates from hospital |
|               |                         | s. Hospitals would have to |
|               |                         |  pay Medicare rate as a co |
|               |                         | ndition of participation.  |
|               |                         |                            |
|               |                         | # Amend this               |
|               |                         |  legislative proposal to i |
|               |                         | nclude 638, independent tr |
|               |                         | ibes, and urbans programs. |
+---------------+-------------------------+----------------------------+
| # 4           | # I                     | # The s                    |
| Access (Medic | nability to collect for | tate (Wyoming) requires ce |
| are/Medicaid) |  Medicaid eligibles for | rtification as a community |
|               |  mental health services |  mental health program to  |
|               |                         | be remunerated for MH serv |
|               |                         | ices. This is the same iss |
|               |                         | ue as the home health and  |
|               |                         | nursing home recommendatio |
|               |                         | n as presented in Title 5. |
+---------------+-------------------------+----------------------------+

#########  REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

**ABERDEEN/BILLINGS REGIONAL MEETINGS -- RECOMMENDATIONS SUBMITTED BY
INDIVIDUALS**

+---------------+---+-------------------------+----------------------------+
| # *           |   | # **ISSUES**            | # **RECOMMENDATIONS**      |
| *TITLE -- V** |   |                         |                            |
|               |   |                         |                            |
| **Urban**     |   |                         |                            |
+---------------+---+-------------------------+----------------------------+
| Throughout    |   | Recognition of Urban    | Language added to          |
|               |   | Programs as Indian      | guarantee Urban Programs   |
|               |   | Organization            | Recognition as Indian      |
|               |   |                         | Organizations and Indian   |
|               |   |                         | Health Care Providers.     |
+---------------+---+-------------------------+----------------------------+
| Throughout    |   | Recognition of Native   | Language to be added to    |
|               |   | Americans               | guarantee federal          |
|               |   |                         | recognition of Urban       |
|               |   |                         | Indians as Native          |
|               |   |                         | Americans regardless of    |
|               |   |                         | whether they live on or    |
|               |   |                         | near a reservation.        |
+---------------+---+-------------------------+----------------------------+
|               | # |                         | #                          |
|               |   |                         |                            |
+---------------+---+-------------------------+----------------------------+
| Title VIII/V  | O |                         | 1.  Establish language     |
|               | v |                         |     that prioritizes       |
|               | e |                         |     funding of tribes over |
|               | r |                         |     urbans when            |
|               | l |                         |     populations/SDA        |
|               | a |                         |     overlaps.              |
|               | p |                         |                            |
|               | p |                         | 2.  Implement a            |
|               | i |                         |     competitive process    |
|               | n |                         |     under Title V/XIX to   |
|               | g |                         |     allow tribal nonprofit |
|               | / |                         |     organizations to bid   |
|               | d |                         |     on services, complies  |
|               | u |                         |     with the Buy Indian    |
|               | p |                         |     Act.                   |
|               | l |                         |                            |
|               | i |                         | 3.  Include tribes in a    |
|               | c |                         |     collaborative effort   |
|               | a |                         |     to evaluate area/urban |
|               | t |                         |     funding within         |
|               | i |                         |     relevant SDAS.         |
|               | o |                         |                            |
|               | n |                         |                            |
|               | s |                         |                            |
|               | o |                         |                            |
|               | f |                         |                            |
|               | s |                         |                            |
|               | e |                         |                            |
|               | r |                         |                            |
|               | v |                         |                            |
|               | i |                         |                            |
|               | c |                         |                            |
|               | e |                         |                            |
|               | s |                         |                            |
|               | / |                         |                            |
|               | p |                         |                            |
|               | o |                         |                            |
|               | p |                         |                            |
|               | u |                         |                            |
|               | l |                         |                            |
|               | a |                         |                            |
|               | t |                         |                            |
|               | i |                         |                            |
|               | o |                         |                            |
|               | n |                         |                            |
|               | / |                         |                            |
|               | S |                         |                            |
|               | e |                         |                            |
|               | r |                         |                            |
|               | v |                         |                            |
|               | i |                         |                            |
|               | c |                         |                            |
|               | e |                         |                            |
|               | D |                         |                            |
|               | e |                         |                            |
|               | l |                         |                            |
|               | i |                         |                            |
|               | v |                         |                            |
|               | e |                         |                            |
|               | r |                         |                            |
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+---------------+---+-------------------------+----------------------------+
| #             | # |                         | #                          |
|               |   |                         |                            |
+---------------+---+-------------------------+----------------------------+
| Urban Health  | B |                         | 1.  Open competition for   |
| (Title V)     | u |                         |     these funds every 3    |
|               | y |                         |     years based on ability |
|               | - |                         |     to provide services.   |
|               | I |                         |     If Urban Indian can    |
|               | n |                         |     competitively go after |
|               | d |                         |     other funds under the  |
|               | i |                         |     various titles -- then |
|               | a |                         |     does this open Title V |
|               | n |                         |     to tribal              |
|               | A |                         |     organization.          |
|               | c |                         |                            |
|               | t |                         | 2.  Language in bills has  |
|               | - |                         |     to be appropriate for  |
|               | - |                         |     all entities.          |
|               | i |                         |                            |
|               | f |                         | 3.  Home Health Care is an |
|               | t |                         |     overlooked service --  |
|               | h |                         |     need funds             |
|               | e |                         |     appropriated for these |
|               | r |                         |     services especially    |
|               | e |                         |     since the language is  |
|               | i |                         |     already in the bills.  |
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|               | . |                         |                            |
+---------------+---+-------------------------+----------------------------+
| Title V       | G |                         | This would prevent         |
|               | i |                         | redundancy of services and |
|               | v |                         | promote efficiencies,      |
|               | e |                         | economies of scale.        |
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|               | . |                         |                            |
+---------------+---+-------------------------+----------------------------+

**REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT**

**ABERDEEN/BILLINGS REGIONAL MEETINGS -- RECOMMENDATIONS SUBMITTED BY
INDIVIDUALS**

+---------------+-------------------------+----------------------------+
| # **T         | # **ISSUES**            | # **RECOMMENDATIONS**      |
| ITLE -- VII** |                         |                            |
+---------------+-------------------------+----------------------------+
| Title VII --  | Program Service Data    | Officially "toss" the      |
| Substance     |                         | CDMIS RPMS module.         |
| Abuse         |                         |                            |
| Services      |                         | Endorse [one]{.underline}  |
|               |                         | software package for       |
|               |                         | I/T/Us to use.             |
|               |                         |                            |
|               |                         | IHS has contracted with a  |
|               |                         | private sector vendor to   |
|               |                         | customize software for     |
|               |                         | Indian programs.           |
|               |                         |                            |
|               |                         | \*Accurate Assessments\*   |
|               |                         | ASI Software               |
+---------------+-------------------------+----------------------------+
| Title VII --  | Memorandum or agreement | \* Add HUD, HHS, HRSA to   |
| MOA           | with BIA -- other       | MOA. . .                   |
|               | federal agencies. . .   |                            |
|               |                         | HUD -- Provides facilities |
|               |                         | and funding, i.e., funds   |
|               |                         | for Drug elimination       |
|               |                         | programs.                  |
|               |                         |                            |
|               |                         | HRSA -- Rural health care  |
|               |                         |                            |
|               |                         | HHS -- SAMSHA/CSAT can     |
|               |                         | augment substance abuse    |
|               |                         | resources                  |
|               |                         |                            |
|               |                         | BIA -- BIA and office or   |
|               |                         | Indian education totally   |
|               |                         | unaware or existing MOA .  |
|               |                         | . . (570 services).        |
+---------------+-------------------------+----------------------------+
| #             | # ISSUES                | # RECOMMENDATIONS          |
| TITLE -- VIII |                         |                            |
+---------------+-------------------------+----------------------------+
| Title VIII -- | Contracting for         | Need amendment to          |
| Miscellaneous | services at Medicare    | establish Medicare         |
|               | rates                   | schedule as the rates that |
|               |                         | I/T/U's pay for all        |
|               |                         | contracted medical         |
|               |                         | services. This would       |
|               |                         | streamline the difficult   |
|               |                         | contracting process and    |
|               |                         | would preserve CHS funds.  |
+---------------+-------------------------+----------------------------+
| Title VIII or | To access DRG rates at  | To include in language or  |
| V             | Medicare rates and all  | law "To allow all tribal   |
|               | government pricing.     | health providers, IHS 638  |
|               |                         | contractors or otherwise,  |
|               |                         | to piggyback Medicare      |
|               |                         | pricing for hospitals and  |
|               |                         | other health providers,    |
|               |                         | and to piggyback the VA    |
|               |                         | rate for pharmacy          |
|               |                         | pricing."                  |
+---------------+-------------------------+----------------------------+
| Section 819   | Sexual abuse at Fort    | Additional resources be    |
|               | Peck currently cost     | allocated to combat youth  |
|               | \$2,800 for youth       | sexual abuse. On-going     |
|               | sexual abuse treatment  | need for evaluation        |
|               | per month for 18-24     | including assessment,      |
|               | months. This depletes   | diagnosis, and treatment   |
|               | the CHS budget when     | is limited. Resources of   |
|               | there are 10-15 youth   | staff and treatment is     |
|               | offenders and 20-30     | urgently needed.           |
|               | victims. No dollars     |                            |
|               | were appropriated to    |                            |
|               | the Fort Peck Service   |                            |
|               | Unit.                   |                            |
+---------------+-------------------------+----------------------------+

###### ATTACHMENTS 

-   **IHS Area Specific Recommendations**

-   **I/T/U Area Recommendations**