Congressional Record -- October 26, 1990

HR 3703 RUMSEY RANCHERIA -- SENATE DEBATE

INDIAN HEALTH MEASURES ATTACHED TO H.R. 3703

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Mr. McCAIN. Mr. President, last evening the Senate considered and
adopted H.R. 3703, legislation to authorize the Rumsey Indian Rancheria.
In the process of moving this legislation, we amended it to include S.
1270 as it had been adopted in the House earlier this week.

S. 1270 is not new to the Senate, as it was adopted by the Senate last
year. As it passed last year, however, S. 1270 was designed solely to
provide Indian tribes with grants to design and implement mental health
delivery systems tailored principally to the native healing of their
peoples. The version we attached to H.R. 3703, however, is much
expanded.

Since the Senate\'s passage of S. 1270, the Senate Select Committee on
Indian Affairs and the House Interior Committee have been working
together to address a number of additional critical Indian health
concerns. They include building an adequate mental health
infrastructure, addressing urban health needs, and the make-up of health
care facilities and programs. Proposals in all of these areas, which
were developed as separate legislation and considered by the two
Committees of Jurisdiction, were incorporated into S. 1270, as the House
passed it this past Monday.

I would like to briefly touch on the first two areas, mental health
infrastructure and urban health, and go into the facilities issue in
some detail.

MENTAL HEALTH

Following Senate consideration of S. 1270, which I authored, I was
pleased to join Senate Inouye in his effort to focus on how to build a
sufficient infrastructure through the existing mental health program.
There is a great need for this, as current service availability pales in
comparison to the level of need. While I focused my effort on assisting
in the process of more appropriately tailoring the services to the needs
of the individual cultural and healing practices of the various tribes
and Indian communities, the concept embodied in S. 1270 as passed by the
Senate, I shared the view of the distinguished chairman of the Senate
Select Committee on Indian Affairs that we just plain need to be doing
more.

There has been much concern on the part of the Select Committee on
Indian Affairs and the House Interior Committee about the high level of
need for greater access to mental health services in Indian country. I
am confident that the increased number of mental health workers that
this legislation will

provide will go a long way toward more effectively meeting the basic
level of need. However, it is my hope that as we learn from the
demonstrations what things work better than our current approach\--and
where flexibility might be warranted in the current system, we will
incorporate these needed changes in even the basic infrastructure of the
system.

URBAN HEALTH

There are also great needs in the area of urban health. I was pleased to
join with my good friend, the chairman of the Senate Select Committee on
Indian Affairs, in his effort to bolster urban Indians\' access to
health care.

Mr. President, it is a well-known fact that a significant number of
native Americans do not live on the reservations\--they dwell in our
urban communities. The reasons for this are numerous. But, the fact is
that many of those dwelling in these urban communities have insufficient
access to health care.

The proposal contained in the legislation we are considering here on the
floor today would provide urban Indians with increased access to care.
Specifically, it would provide support to the urban Indian health
clinics located in some of our larger urban communities. In Arizona, we
are fortunate to have two of these excellent centers. In addition, this
proposal will ensure coordination between Indian health care providers
and other providers in the local community, to ensure that Indian people
have the same access to care as others living in that community.

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INNOVATIVE FACILITIES AND PROGRESS DEMONSTRATION

I would now like to focus for a few minutes on the last addition to S.
1270\--a proposal to allow tribes to demonstrate their ideas about how
health care needs might be met more effectively and appropriately. This
proposal, embodied in S. 2850, was sponsored by every member of the
Select Committee on Indian Affairs and was reported by a unanimous vote
from the committee on October 3.

I have spoken often this year of my deep concern for the fact that our
Nation\'s first citizens have the lowest health status of any population
group in America, and of my commitment to see that their health status
continues to be improved. This legislation, which has been more than a
year in the making, represents one of the critical steps in that
direction.

Certainly, the Indian Health Service, under the able guidance of
individuals such as Dr. Rhoades and his predecessor, Dr. Johnson, has
had much success in dealing with the threat that

many common diseases and maladies pose to the lives of native Americans.
I am sure that with the limited resources available, it is a constant
battle to make further inroads into improving the health status of
native Americans. But there is always more that can be done. And, with
regard to resources, I hope we can do something about their declining
level.

As we all know, health care generally is in a process of rapid change.
Many services, which used to be delivered only in an inpatient hospital,
are now being delivered in an outpatient setting, within the doctors\'
office, and even at home.

Correspondingly, there is great change in the types of facilities that
are being built and the health programs that are being implemented to
address the changes in health delivery, and well as the ever-increasing
financial constraints due to the rapidly escalating cost of our
Nation\'s health care delivery system. In most areas of the health care
delivery system, it is a question of how those resources might best be
utilized.

Reality dictates that the days of a full-blown large inpatient hospital
in every community\--yes, even Indian communities\--are probably behind
us. But, this does not in turn mean that a community should be forced to
forgo access to health care services\--including inpatient beds. This is
true for rural America, and it is true for Indian country.

Over the past couple of years, I have been watching with interest and
concern as recommendations have come forward to close or dramatically
alter existing Indian health care facilities in favor of consolidating
services or replacing an existing facility with one offering a
scaled-down level of services.

Many in the native American community feel that such action may lead to
a further deterioration in access to care, the end result being a
decline in health status rather than an improvement. I have to say that
in many of these cases I agree. On further exploration of this issue, I
found a wealth of ideas among those in the native American community
with regard to how resources might be used differently so that rather
than decreasing access to care, it would be enhanced.

Concepts ranging from outpatient clinics with overnight-stay beds\--to
treat conditions such as foot complications from diabetes or
hydration\--to wellness centers have been supported by the tribes. Some
tribes wish to have the opportunity to join forces with non-Indian
communities and develop facilities that serve both Indians and
non-Indians, or to be able to utilize non-IHS funds for the construction
of IHS facilities. While none of this activity should be coerced, at the
same time, this type of innovative cooperation should not be stifled.
But, that is exactly what current policies are doing. S. 2850 was
developed with the intent of reversing this trend.

When I took this issue to Dr. Rhoads, director of the Indian Health
Service, about 1 year ago for the purpose of exploring how we might be
able to work together to make the system more flexible, I was heartened
to find that he had been thinking this was needed as well. It has been a
pleasure working with Dr. Rhoades and his staff over the past year in
exploring this issue, and I look forward to continuing our work.

On March 22, 1990, the committee held a hearing focusing on these
issues. Specifically, the hearing focused on two questions related to
Indian health care facilities and programs\--primarily those in rural
areas. First, whether there ought to be more flexibility in the type of
health facilities that are constructed and programs that are implemented
in Indian country. And, second, whether the infusion of non-IHS dollars
into the construction of health care facilities would improve the
existing health care delivery system.

Perhaps no clearer evidence of Indian country\'s interest in this issue
exists than the fact that nearly three times as many tribes wanted to
testify as the committee could accommodate. Witness after witness came
forward, telling of innovative ideas for what they could do if the
current system were to be made more flexible.

I, for one, do not believe the fact that tribes have innovative ideas is
anything new. We found the same innovation present with regard to mental
health\--which led the Senate Select Committee on Indian Affairs, and
the Senate, to adopt legislation to fund a demonstration project that
will give tribes the keys for change in that area.

This type of empowerment, giving the keys of change to the very
population to be served, is very consistent with the whole concept of
self-determination. While it may seem to some like a very radical
approach, I am convinced that it is the only way to go. Indian and
native communities know best how to meet the challenges confronting
them. And, I believe that it is just as appropriate in the area of
health facilities and health programs as it is with respect to mental
health.

With that in mind, I worked with many in Indian country to develop
legislation to set up, on a small scale, a pilot program that would
provide some flexibility to allow tribes to demonstrate some of their
ideas about how their health care needs might be met more effectively
and/or appropriately. That proposal is contained in the legislation
before us today.

This proposal was originally embodied in S. 2850 as introduced by
Senators Inouye, Burns, Conrad, Daschle, and myself. Prior to its
adoption in the committee, every member of the committee had added his
name as a cosponsor.

Sepcifically, section III of the legilation before us will establish a
program that would empower native Americans with the

opportunity to demonstrate, by providing some flexibility in the current
system, whether Indian health programs can be structured more
effectively.

This involves the creation of an alternative priority system that would
permit the construction of facilities with the combination of IHS and
non-IHS funds. This alternative system will permit the merging of
programs that have traditionally been kept separate, or involve the
construction of facilities that fall between a full-blown inpatient
hospital and an outpatient clinic.

This demonstration priority system will not in any way threaten the
status of those tribes who are in the existing priority system. In
addition, tribes should rest assured that no movement in the direction
of permitting the construction of facilities with money that are wholly
or partially non-IHS means that we are going to eliminate or decrease
the level of Federal commitment to facilities construction. In point of
fact, I believe if there is to be any change in Federal appropriations
for health facilities construction it surely ought to be an increase.
After all, there is a phenomenal amount of documented need.

Not only will this demonstration project make services available in
areas where they are not currently available, it will permit us to learn
what changes ought to be made in the way in which the Indian Health
Service currently approaches health programs and facilities
construction.

I believe that this demonstration project holds much promise because we
are putting the keys for change into the hands of those who ought to
have them\--the very people who are affected either positively or
negatively by whatever health care service delivery system exists.

Before I conclude, I would just like to offer a special note of
appreciation to my good friend, the chairman of the Senate Select
Committee on Indian Affairs, Senator Inouye, for his continued
leadership in the area of improving the health status of Indian people
and thank him for his support of and assistance with this proposal. In
addition, I would like to thank both Congressman Udall and his staff for
all of the hard work they have put in on this bill. Mr. President, S.
1270\--as amended by the House\--has the strong support of many
throughout Indian country, and I am pleased the Senate supported the
move to attach this to H.R. 3703. These programs will go a long way in
improving the health status of native Americans by supporting the
passage of this important legislation.

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