Draft Report

**On the**

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

**February 1, 2, 1999**

**In**

**Reno, Nevada**

**"SPEAKING WITH ONE VOICE**

**IHS, TRIBES, URBAN"**

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

**For the**

**Alaska, California and Portland Areas**

**I/T/U**

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

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

**INDIAN HEALTH SERVICE**

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

**Assistant Surgeon General**

**Director**

**Indian Health Service**

**Rockville, MD**

**Michael Mahsetky**

**Director of Legislative Affairs**

**Office of the Director**

**Indian Health Service**

**Rockville, MD**

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

**Nurse Consultant**

**Phoenix Area Indian Health Service**

**Phoenix, AZ**

**Submitted by**

**Kauffman and Associates, Inc.**

**P.O. Box 1401**

**Kamiah, ID 83536**

**(208) 935-0665**

**email: kauffman@camasnet.com**

**Jo Ann Kauffman, President**

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

# Introduction

# Background

**Summary of Recommendations**

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

**Crosscutting and Emerging Issues**

**Consensus Recommendations**

**Individual Recommendations**

**Attachments**

###### INTRODUCTION

Of the various statutes, which form the foundation of the U.S. Indian
Health Service (IHS), the Indian Health Care Improvement Act is one of
the most comprehensive and significant in terms of contemporary federal
policies. First enacted in 1976, the IHCIA was authorized the IHS
*"...to implement the Federal responsibility 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 second Regional Consultation meeting to be held was for the IHS,
tribes and urban (I/T/U) health providers in the Alaska, California and
Portland 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
219 participants registered for the Reno meeting. A list of all
participants is attached to this report. The meeting was facilitated by
IHS contractor, Kauffman and Associates, Incorporated (KAI) and
coordinated by the IHS 437 Team and IHS 437 Coordinators from each of
the three Areas. The results of the Reno Regional Consultation 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 Reno
Regional Consultation Meetings. The Regional Consultation meetings were
very much shaped by the recommendations from the participants in the IHS
Roundtable on Reauthorization. In particular, the agenda for the
consultation meeting provided ample time and resources for participants
to ask questions of speakers and panel presenters. The facilitators
encouraged questions or statements from the audience.

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

-   Agenda

-   IHS Roundtable Report on Reauthorization of IHCIA

-   IHS Status Report on IHCIA section-by-section

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

-   Current Issues in Indian Health Policy (Roubideaux)

-   Medicaid Managed Care Issues and Recommendations (NIHB)

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

-   Timeline for FY 2001 Budget Formulation (IHS)

-   Meeting evaluation form

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

Day One Workgroups:

-   Health Professions (Title I)

-   Health Services (Title II and Title VII)

-   Health Facilities (Title III)

-   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

-   Behavioral Health Issues (mental health and substance abuse)

-   I/T/U Partnerships for the Future

-   Medicaid and Managed Care

-   Other Emerging Issues

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

The theme of "Speaking with one voice", was integrated into the
facilitation of each workgroup. Participants were advised that the goal
of the workgroups was to identify those key policy issues and
recommendations around which consensus could be built. The workshop also
identified those issues or recommendations where no consensus was
reached and attempts to articulate the perspectives of the group. During
the general session on the first day, Tony Largo, Santa Rosa Band,
provided a welcome from the California tribes to all attendees. The Area
Directors for each of the three IHS Areas provided opening remarks on
the subject of "unity". IHS officials, Michael Mahsetky and Kitty
Rogers, provided an overview of the reauthorization process and their
goals for the consultation process.

Each of the three Areas were invited to share their specific policy
issues and recommendations for reauthorization during the first morning
of the meeting. In a panel presentation for each Area (California,
Alaska, Portland), numerous issues were raised. H. Sally Smith,
President of the Alaska Native Health Board, stated that due to limited
notice their recommendations did not have tribal approval and Area-wide
consensus had not occurred. However, there were numerous concerns
expressed in the areas of long term care, inhalant abuse, third party
billing, health professions, staff quarters and the elevation of the IHS
agency within DHHS.

The California panel also identified numerous issues and
recommendations. Unlike the other areas, California, had held Area
consultation meetings and had begun to identify consensus
recommendations, although these were not ready for form presentation at
the time of the Regional Meeting. Tribal spokesperson, Rachel Joseph,
explained the uniqueness of California in comparison to the rest of
Indian country. There are 104 federally recognized tribes in California
and many more state recognized. Most tribes are small. The termination
era severely affected California Indian health, closing two hospitals
and eliminating services. The tribes in California have been trying to
rebuild their base ever since. Ms. Joseph cited the 1974 Rincon decision
and the 1979 judgement against the IHS establishing the "equity fund" to
better support California and other underfunded tribes. However,
inequity in funding continues to exist. California will be presented a
comprehensive list of recommendations, which will likely include their
support for continuation of the Equity Fund, and promotion of a more
actuarally sound resource distribution methodology.

The Portland Area panel included representatives from the Lummi Nation,
Puyallup Tribe, the NARA Urban Health program and Northwest Portland
Area Indian Health Board. The IHS has not conducted an Area-wide
consultation process prior to the Regional meeting. Instead, the NPAIHB
has incorporated different aspects of the IHCIA in its regular quarterly
meetings during each meeting for over a year. A variety of
recommendations were emerging through this process, although a formal
written presentation was not available for the Regional Meeting. Their
panel voiced general support for health professions programs and the
regional epidemiology centers, one of which is funded in the Portland
Area. Concerns were also expressed regarding the Medicaid and Medicare
provisions in the IHCIA and the need to waive co-payments, personal
estate liability and improve flexibility. Facilities issues were
identified with specific improvements in the areas of Joint Ventures,
Ambulatory Care construction and long term care facilities. Finally, the
Portland panel expressed strong support for Urban Indian Health and the
Substance Abuse program.

There were important discussions, which occurred during the plenary
sessions as well. Several recommendations were made from the floor of
the general session encouraging the IHS to move forward in developing
specific draft legislation for review by the tribes. Comments were also
made regarding the importance of continued consultation beyond the
regional consultation meetings and seeking clarification on the
reauthorization process. The second day presentation by Dr. Trujillo,
triggered additional discussion regarding the political process for
reauthorization and the importance to keep the lives of our community
members in minds all the time. An elder from the Umatilla Tribe, Mrs.
Bearchum, provided a community person's perspective on the importance of
our work to improve health care and health status. She added that the
group should keep in mind our spirituality as we do this work. A panel
on "Strategizing Politically" provided a forum for tribal and urban
leaders to share information and concerns about the whole process for
reauthorization.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

*41 U.S.C. 5)*

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

# 1. Health Professions (Title I)

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

-   **Health Professions Recruitment program for Indians**: In this
    section grants are made to public or nonprofit private health or
    educational entities or Indian tribes or tribal organizations to
    assist such entities in meeting the costs of identifying Indians
    with a potential for education or training in the health professions
    and encouraging and assisting them in the process of preparation to
    enroll and study for a health career. The work group had concerns
    regarding the length of time for the grants. They stated that the
    grants should be for three (3) or more years.

-   **Health Professions preparatory scholarships for Indians**: The
    purpose of this section is to provide scholarships for undergraduate
    degrees leading towards a field of study in a health profession.
    Yearly re-applications are required. The work group stated that the
    scholarships should be guaranteed (after initial competition and
    award).

-   **Indian Health Profession Scholarships**: This scholarship is
    awarded with an active duty service obligation. The work group
    wanted the health profession type to be extended to licensed
    practical nursing, chiropractic, and acupuncture.

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-   **Continuing Education Allowance**: This section grants continuing
    education funds to health professions in order to encourage them to
    provide health services in the rural and remote areas where Indian
    people reside. The work group stated that there is a lower
    percentage of Indian professionals who have been allowed to
    participate. They recommended that more Indian health professionals
    be included and that resources should be provided so that tribal
    members can access these funds. Communication should be improved
    regarding health professional's continuing education needs.

-   **Nursing Program and Nursing Schools**: This section provides
    grants to higher education institutions to recruit and train nurses,
    nurse midwifes, and nurse practitioners to provide or continue to
    provide health care services to Indians. The work group stated that
    it was not generally known what institutions had been awarded grants
    and they wanted a list of the schools with grants to be communicated
    to Indian country. They also stated that the grant length should be
    extended to five (5) years.

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

The workgroup on Health Services discussed issues related to Title II
and Title VII of the Indian Health Care Improvement Act. These titles
contain a wide variety of direct service related programs. The workgroup
did not limit itself to only making recommendations under these titles.
The workgroup made comments on a variety of issues.

-   **Equity Funding:** The workgroup identified a lack in equity
    funding across various Areas of the Indian Health Service system.
    The group noted that the last time the U. S. Congress attempted to
    adequately address and rectify inequitable funding allocations was
    in Fiscal Year 1991 appropriations. A recommendation was made to
    increase funding again to provide for better equity across the I/T/U
    system, regardless of location. This recommendation relates to the
    Appropriations process and would not affect the reauthorization bill
    language.

-   Agency Linkages: The workgroup discussed federal program
    consolidation for tribal governments, as is provided under P.L.
    102-477, the Indian Employment Training and Related Services
    Demonstration Act of 1992. Under this legislation, tribes are
    allowed to consolidate a variety of federal programs from multiple
    federal agencies into one block grant, combining the application,
    administration and reporting procedures. This federal law has
    eliminated numerous administrative barriers for tribes to better
    administer employment, child care and welfare related programs. The
    workgroup considered a similar approach for health related programs
    to streamline tribal contracting and reporting requirements.
    Specific recommendations were developed to establish within the
    IHCIA a federal statute to allow for IHS, and agencies such as
    Centers for Disease Control (CDC), National Institutes of Health
    (NIH) and Department of Justice (DOJ), to consolidate programs and
    resources to tribes.

-   Epidemiology Centers: The workgroup noted that not all IHS Areas
    have access to the Epidemiology Center resources. The IHS funds only
    four regional Epidemiology Centers currently, in Alaska Area,
    Phoenix Area, Bimidji Area and Portland Area. More centers needed to
    teach and provide technical assistance and support for tribes of all
    sizes and locations. This recommendation may not require a change to
    the IHCIA, but an increase for full funding under existing authority
    through the appropriations process.

-   **Reporting Requirements:** Changes in federal law are recommended
    which would authorize other federal agencies such as the Department
    of Housing and Urban Development (HUD) and the Environmental
    Protection Agency (EPA) to accept the reports required of tribes by
    the Indian Health Service for similar purposes.

-   **Diabetes Prevention, Control and Treatment:** There was extensive
    discussion and consideration of changes to the IHCIA related to the
    prevention, control and treatment of diabetes. Participants were
    concerned that the current Diabetes Initiative of the Indian Health
    Service is limited only to five (5) years. The workgroup recommended
    that this program be integrated into the base budgets of the I/T/U
    for perpetual funding until diabetes is no longer a problem in the
    Indian population. The workgroup also recommends that the IHCIA
    provide authorization for I/T/U's to use diabetes funds under
    Section 204 (d) to support the collection of data. More specific
    programming of diabetes funds are suggested which would target
    prevention funding for all communities, and control and treatment
    funds for those already diagnosed with diabetes. The workgroup
    pointed out that the existing distribution formula for the IHS
    Diabetes Initiative treated the California Area consortia as tribes
    and provided funding for 40 tribes, when there are actually 104
    tribes. This should be corrected.

-   **Catastrophic Health Emergency Fund:** The threshold for when
    Contract Health Service bills can be eligible for payment through
    the CHEF program should be lowered, particularly for smaller tribes
    with a smaller overall CHS budget. The workgroup recommends reducing
    the CHEF threshold by 50% for small tribes and tribes dependent on
    CHS for health care. The workgroup also supports increased funding
    for CHEF, although appropriations requests are not directly related
    to amendments to the IHCIA.

-   **Delivery Areas:** The Contract Health Service Delivery Area
    (CHSDA) which outlines the geographic boundaries for persons
    eligible for Contract Health Services is recommended to be expanded
    through the IHCIA. The workgroup supported the expansion of CHSDA's
    and cited a request in California Area for seven (7) additional
    CHSDA's. There may be other Areas which should receive increased
    CHSDA designation.

-   **Third Party Reimbursements:** The workgroup discussed the problems
    with I/T/U access to third party revenues for patient services. The
    group recommends changes to the IHCIA, which would provide authority
    through the Health Care Financing Administration whereby I/T/U's
    could conduct their own eligibility determination for federal
    medical assistance under Medicaid and CHIP. In particular, this
    determination function will be important for tribes administering
    Temporary Assistance to Needy Families (TANF) programs. Federal law
    should be amended which would allow tribes to directly bill HCFA
    just as a state does. Currently only "states, the District of
    Columbia, and any commonwealth, territory or possession of the
    United States" has this authority to bill directly.

-   **Data and Reporting:** The Indian Health Service data reporting
    system (RPMS) is not working in all I/T/U locations. This is
    resulting in a loss in data and reporting capabilities on Indian
    health issues both nationally and locally. Increased attention is
    needed to ensure adequate staff training and technical assistance is
    provided in all locations. Additional staffing and other resources
    should be provided at the local levels to ensure the viability of
    this important data system.

-   **Your Regional Treatment Centers:** There were a number of
    recommendations regarding the Youth Regional Treatment Centers (RTC)
    first authorized under the Omnibus Anti-Drug Act and funded in most
    Areas of the IHS. Many of the workgroup recommendations request
    increased appropriations, and therefor are not specific to changes
    in the IHCIA. For example, the group recommends increased funding
    for the California Area RTC's. In addition, the group makes
    recommendations to expand the total number of RTC's available to
    Indian youth across the country. The group also recommends providing
    authority for the funds supporting RTC's to be available for
    distribution under tribal shares. Changes in the IHCIA are requested
    to assist RTC's treat youth with "dual diagnosis". The RTC section
    should be amended to authorize, in addition to counseling, medically
    supervised detoxification, education and family counseling in
    advance of admission into treatment. Finally, the workgroup made a
    recommendation that the IHCIA include a "formalized transitional
    aftercare" component is needed for post treatment support.

-   **Long Term Care and Skilled Nursing Facilities**: The workgroup
    discussed the lack of accessible long term and skilled nursing
    facilities across Indian country. Often, these facilities are
    located many miles away from tribal communities, creating hardships
    for families with elders or others in need of long term care. The
    lack of culturally sensitive nursing homes, and long term care is a
    problem as the Indian population grows older. The workgroup
    recommended that the IHCIA authorize comprehensive long term and
    skilled nursing facilities and programs, and that these resources be
    placed in close proximity to tribal communities and villages.
    Specific language should be included to exempt American Indians from
    means testing under Medicare and Medicaid to protect family assets,
    when their elders utilize these resources for long term care.

-   **Hearing Aids**: Expansion of Title II is recommended to include a
    hearing program which would provide comprehensive services for
    Indian children and elders and improve linkages to other resources.

-   **Health Promotion Disease Prevention**: The workgroup made
    recommendations to increase funding of the HPDP program to at least
    parity levels with acute care and treatment programs. A
    recommendation for increased appropriation would not require an
    amendment to the IHCIA, however, language requiring parity funding
    would be an amendment to the IHCIA.

-   **Uniform Pharmacy Benefits**: There was discussion regarding the
    lack of equity across I/T/U's to access pharmacy supplies and
    prices. It was recommended that the IHCIA be amended to authorize
    I/T/U's to access Veteran's Administration and Department of Defense
    or other federal prime vendor contracts for purposes of purchasing
    pharmacy and other supplies.

-   **Substance Abuse**: A variety of issues were discussed related to
    substance abuse prevention, treatment and aftercare. The workgroup
    recommends that the full realm or continuum of care by provided for
    all types of alcohol and substance abuse, including inhalant abuse.
    The would include prevention, education, intervention,
    pre-treatment, treatment, aftercare, family care in all areas,
    including inhalant abuse. The workgroup recommended using the
    Healthy People 2010 Objectives as a means to set specific
    improvement goals and any other appropriate improvement goals. The
    group also recommended that a more comprehensive and effective
    prevention program be integrated into the IHCIA. One "that works".
    The group also recommends that the IHCIA provide authority for
    interagency linkages between the IHS and agencies such as Substance
    Abuse Mental Health Services Administration (SAMHSA) and Centers for
    Disease Control (CDC) for purposes of substance abuse prevention and
    treatment. Finally, it was recommended that the IHCIA be amended to
    mandate the IHS to provide substance abuse services, and clarify
    that tribes may request these services from the IHS.

-   **Community Health Representatives**: Home health care through the
    CHR program was discussed in the workgroup. It was recommended that
    the CHR's receive more training and more equipment to do their jobs
    in tribal communities. An increase in the total number of CHRs is
    recommended, in particular among those qualified to do home health
    care. The workgroup recommends that the Alaska CHAPS program be used
    as a model for delivering home health care in Indian homes. The
    IHCIA should be amended to provide for a specific home health
    program which would qualify for reimbursement through the Health
    Care Financing Administration (HCFA).

-   **Mental Health**: The workgroup discussed the problem of increased
    "youth gang" activities in Indian communities. More emphasis on gang
    prevention and intervention is needed for I/T/U's to respond to the
    problem. It was recommended that the IHCIA authorize linkages to the
    Department of Justice to provide financial support and assistance to
    I/T/U's regarding Indian gang activity. The entire mental health
    function of the IHS needs to be strengthened. The language
    describing "demonstration programs" should be eliminated in place of
    permanent, comprehensive mental health systems for I/T/U's.

-   **Studies/Reports/Demonstrations**: The IHCIA should include
    provisions which ensure the participation and access of smaller
    tribes to studies, reports and demonstration projects. When studies
    or reports are completed, the information and application of
    findings should be made available to the I/T/U system.

-   **Violence**: The IHCIA should include emphasis on the problem of
    domestic violence, including training for clinical staff on early
    identification and intervention. Funding for "safe houses" and
    "shelters" should be made available to tribes and urban programs to
    ensure the safety of victims of violence in Indian communities.

-   **American Indians into Psychology**: There were numerous comments
    regarding this section of Title II. The participants reached
    consensus that there is a need for increased numbers of behavioral
    health professionals, including mental health counselors, social
    workers, and chemical dependency counselors. More funding should be
    targeted to train and employ these professionals. There is also a
    recommendation to provide more emphasis in the IHCIA to the problem
    of depression in Indian communities. It was identified as a major
    problem by this workgroup and mental health services should be
    better targeted to screen and intervene in depression. Finally,
    there was discussion regarding amendment to the IHCIA to authorize
    "prescriptive authority" for Ph.D. level mental health providers,
    however there was NO CONSENSUS on this discussion.

-   **Speech Therapy**: The group recommended increasing the number of
    speech therapist available to the I/T/U system.

-   **Dental**: The workgroup recommended that a "comprehensive dental
    program" be authorized under the IHCIA which would include all
    levels of care, including pedio, endo, ortho, and perio dental care.
    Access to crowns, dentures and pediatrics was also recommended.

-   **Traditional Medicine and Alternative Medicine**: The workgroup
    recommended providing access to traditional and alternative medicine
    through the IHCIA, including the authorization of special funding.
    This program should be integrated into the overall I/T/U system.

-   **Eye Care**: The IHCIA should provide an amendment which would
    authorize a comprehensive eye care program for IHS patients,
    including eye care, special needs of diabetics, retinal screening
    and tonometry for glaucoma and other high risk populations.

# 3. Health Facilities (Title III)

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

-   Accreditation: The current document identifies Joint Commission
    Accreditation of Hospital Organizations (JCAHO). The work group
    stated that the wording needed to be changed "not identifying" JCAHO
    as the specific accreditation authority as there are several other
    IHS approved accrediting authorities. In addition they stated that
    there were other accreditation issues needing to be considered
    throughout the law. In the current law it states that a new facility
    must be accredited by JCAHO within one year after construction is
    completed. Again, the work group stated that the new facility
    construction should meet the IHS standards of construction. The law
    should not specifically refer to JCAHO. It should refer to an IHS
    approved accrediting authority.

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-   Health Facility Priority System: The work group stated that congress
    does not have an accurate picture of all unmet health facility
    needs. The current method favors hospitals and large facilities. An
    accurate and fair reporting system needs to be developed that
    reports annually clearly identifying the needs of smaller ambulatory
    facilities. Hospital rate higher on the construction priority list
    as compared to ambulatory health care facilities. The work group
    stated that the "agency" should not build hospitals where there is
    excessive bed space in urban areas so that construction resources
    can be re-allocted to ambulatory clinics. Existing resources must be
    best utilized in existing health facilities in urban areas. There
    has always been universal allocation of funding. Most IHS Areas go
    without construction funding while other IHS Areas get funding for
    new construction consistently. The work group wanted the current IHS
    priority system changed to allow equity in the distribution of new
    construction funds. They recommended that decisions should be made
    at the local (IHS Area) level as to the allocation of construction
    of new facilities.

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-   Grant Program for the Construction Expansion and Modernization of
    small Ambulatory Care Facilities: The work group stated that this
    section had never been fully funded because congress does not
    realize the scope of the unmet needs. Appropriations will never be
    identified without proper documentation. It was recommended that IHS
    be required to provide an annual report to congress which will
    ensure equity and proper consideration for ambulatory facilities. In
    some cases tribes are funding their own construction through
    commercial or guaranteed loans: It was recommended that funds be
    made available to reimburse 100% of tribe's obligation for loans for
    health care facilities.

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-   Safe Water and Sanitary Waste Disposal Facilities: The work group
    stated that Housing and Urban Development (HUD) would not accept "
    our environmental reviews." It was recommended that there needs to
    be a better coordinated effort between IHS and HUD to meet health,
    safety, and environmental reviews. At the tribes request the IHS
    should be deemed the regulating agency. IHS funds can not be used
    for sanitation facilities for HUD constructed homes. The
    relationship needs to be strengthened between IHS and HUD. HUD must
    clearly know that it has the responsibility for providing funds for
    sanitation facilities for homes they construct. IHS needs to
    continue providing technical assistances.

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-   Sanitation Deficiency System (SDS): the tribes do not have input
    into the total system. Even though the tribes have input into their
    own community needs, they have no input into the system when it
    reaches the Area/HQ levels. It was recommended that the tribes have
    more involvement in the total process including input on the reports
    that are generated at the IHS Area and Headquarters levels.

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-   Maintenance and Improvement (M&I ) funding: M&I funding has not
    increased over the past several years yet the amount of health
    facility space does increase. As more health facility space is
    approved for M&I eligibility, the existing health facilities get
    less funds when they are already under funded. There needs to be
    assurance that new health facilities will be funded with M&I funds
    through additional appropriations from congress.

-   Medicaid and Medicare Construction fund approval: The appropriations
    committee currently must approve use of M&M funds for renovation and
    construction projects over \$1 million dollars. The work group
    stated that congress should be notified as a "need to report"
    however approval for expenditures over this threshold should be
    changed.

-   Leasing: The IHCIA authorizes IHS to lease health care space from
    tribes under a twenty (20) year lease. However the Balance Budget
    Act requires that the full amount of these leases be "scored" in the
    first year of the lease. New language in the IHCIA should waive the
    requirement that the full lease amount be "scored" in the first
    year.

-   Matching Fund Requirement: Agencies that require matching funds do
    not permit funds from other federal agencies to be used as meeting
    the "matching dollar requirement(s)". IHS should be allowed to use
    appropriated federal funds to comply with the matching requirements
    of state, federal and other funding agencies.

-   Other Avenues for funding health facilities: There are not enough
    ways to get health facilities built. The agency needs to have
    multiple ways to get health facilities constructed such as on-time
    revolving loan programs and authority for guaranteed loan programs.

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

**4. Access to Services (Title IV) and Miscellaneous (Title VIII)**

The workgroup on Title IV and Title VIII, only had time to address
issues related to Title IV "Access to Services. There were a variety of
issues discussed. Consensus was reached on all recommendations presented
here.

-   **Licensing and Certification:** The problem of tribal facilities
    seeking state licensure for the provision of federally funded health
    services to IHS beneficiaries was discussed. It was recommended that
    the IHCIA include a provision which would establish a IHS
    certification program for I/T/U's, which states would be required to
    accept as equivalent to state licensure for purposes of
    reimbursement. This certification would include all services
    provided by the I/T/U, whether to Indian or non-Indian patients.

-   **Medicare:** The existing provisions under Section 401 should be
    expanded to clarify that all services which are Medicare billable
    services, may be billed by the I/T/U for IHS beneficiaries,
    regardless if the patients are Indian or non-Indian. Further, the
    Health Care Financing Administration should be instructed by law, to
    allow a "window" of time during which I/T/U's can be eligible to
    build their infrastructure to provide certain Medicare billable
    services, and still be able to bill for those services during that
    window.

-   **Medicaid:** The existing language in the IHCIA restricts
    reimbursement in Medicaid services to facilities. The workgroup
    recommends that all billable services may be billed and paid to
    I/T/U's whether services are proviced directly or by referral
    through an I/T/U., and the state will still receive the full 100%
    FMAP reimbursement.

-   **Non-Indian Beneficiaries:** The workgroup recommends language be
    developed to clarify that Medicare and Medicaid reimbursement to
    I/T/U's be provided and that 100% FMAP provided to states for
    services to IHS eligible Indians and other individuals made eligible
    by section 813(a) or any other provision like it.

-   **Direct Billing Demonstration:** The workgroup recommends that
    Section 405 which provides for a demonstration status for four (4)
    sites, be made permanent for all I/T/U's to participate.

-   **Premiums and Cost Sharing:** The workgroup is recommending that
    all Indian beneficiaries of the IHS shall no longer be required to
    make co-payments or pay premiums for Medicaid, Medicare, CHIP or any
    other federally funded health program. This should be a provision in
    amended Title IV of IHCIA.

-   **Children's Health Insurance Program (CHIP):** The IHCIA should be
    amended to include a provision which clarifies that states will also
    receive 100% FMAP for services provided through I/T/U's for IHS
    eligible patients under the CHIP program, and that there shall be no
    co-payments or premiums required of IHS beneficiaries.

-   **Managed Care:** The workgroup is recommending that provisions be
    included in Title IV which will address the difficulties of I/T/U in
    managed care systems for third party payments for care. The
    workgroup is recommending that I/T/U's be reimbursed for services
    provided to IHS beneficiaries even when an IHS beneficiary is
    enrolled in a managed care entity (through Medicaid, Medicare, or
    private coverage), and that all managed care entities can be billed
    directly by an I/T/U. Another option, which is recommended to
    address managed care problems, is a provision in the IHCIA which
    will authorize I/T/U's to bill states directly for Medicaid/CHIPS or
    other federal health programs, without being required to go through
    a managed care organization or entity.

# 5. Health Services for Urban Indians (Title V)

The purpose of this title is to establish programs in urban centers to
make health care services more accessible to urban Indians. The
discussion was primarily on national issues and methods of inclusion.

-   **Memorandum of Agreement:** Urban Indians are not included in the
    Health Care Finance Administration (HCFA) Memorandum of Agreement
    (MOA) regarding universal rates for Indian Health Service facilities
    and tribes. The work group stated that the urban Indians should be
    included.

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-   **Title V Continuing:** The work group discussed whether the urban
    programs should be dispersed throughout the IHCIA in other titles or
    remain in Title V. The work group stated that the Urban Programs
    should remain in Title V however Title V should specify that Urban
    programs are eligible to participate in other sections with new
    funds to provide for professionals, facilities, services, etc.

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-   **National data on Urban Indians:** There is a lack of national data
    on Urban Indians. An Epidemiological Center for Urban Indians should
    be established to develop data, provide technical assistance to
    urban programs, and conduct needs assessments. This Urban EPI Center
    could be included in one of three or four "Centers of Excellence".

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-   **Identification of new Urban sites:** Many urban areas with large
    Indian populations do not have urban Indian Health programs. The
    agency needs to conduct an assessment for potential new program
    sites using current data. (socio-demographic variables: age, gender,
    and tribe, etc.).

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-   **Consultation process:** I/T/U and affiliated Indian engaged in the
    consultation process at the area level producing recommendations for
    IHCIA. The work group wanted the recommendations from the area to be
    carried forward in the consultation process.

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-   **NIAAA programs:** These programs have authority to be converted to
    Title V. IHS has not completed the process. The work group stated
    that the conversions of all NIAAA programs should be completed by
    the year 2001.

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-   **Relationships:** There is a need for dialogue/relationship
    building process between the Tribes and Urban Programs in order to
    "speak with one voice." The major issues that need to be worked out
    are eligibility-enrollment status, federally recognized vs.
    affiliate Indians, and members from other tribes. In addition there
    are access problems. There are many inconsistencies in access
    regulations which leave many Indians not served.

A.  **Crosscutting and Emerging Issues**

In addition to discussing the individual titles of the existing law, the
participants at the Reno Regional Consultation Meeting, examined
crosscutting and emerging issues which have an impact on I/T/U's now and
into the future, but are not adequately considered in the existing law.
These issues were developed in advance of the consultation meeting,
based upon the analysis conducted by the IHS Roundtable on
Reauthorization. During the general session of the Consultation Meeting,
participants were offered the opportunity to change or amend any of the
"emerging issue" topics. Upon consensus of the full group, these topics
were included and the following recommendations or description of issues
provided.

1\. **Medicaid and Managed Care**

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

-   **100% FMAP:** The work group discussed the inconsistencies from
    state to state on how they managed the 100% federal match of dollars
    for Indian clients. Regulations should be developed to specify the
    IHS encounter rate by law. A joint Tribal and Federal group should
    develop the regulation. These regulations would develop Medicaid
    reimbursement rate for I/T/U's and define what services would be
    covered under the rate.

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-   **Anti-Deficiency Act-**The work group discussed how this act kept
    the IHS from entering into contracts with MCO's because they could
    not assume risks. They stated that IHS (applies to IHS facilities)
    should be exempted from the Anti-deficiency Act for purposes of
    contracting with CO's.

-   **MCO Demonstration Project:** Tribal Governments are interested in
    becoming "MCO's". The work group proposed a demonstration project
    for I/T/U's to become the actual MCO to identify some of the risks
    and issues. It would enable the I/T/U to function as a Network
    Provider to fund a risk pool or any other stop loss mechanism.

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-   **Accreditation and Licensure:** The work group recommended that a
    consolidation accreditation and licensure system be considered as an
    alternative to the existing certification and licensure process.

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-   **Eligibility Determinations:** The work group recommended that
    Tribal Governments be given the authority to make eligibility
    determinations for Medicaid and Child Health Initiative Program
    (CHIP).

2.  **Behavioral Health, Mental Health and Substance Abuse Issues**

This topic was identified as a crosscutting and emerging issue because
of its significant impact on all aspects of the health spectrum. The
costs associated with treating the effects of mental health and
substance abuse problems in Indian communities is significant, and
impacts on I/T/U programs directly and indirectly. The workgroup
addressed these issues and made the following general points.

-   **Fragmentation vs. Holistic Approach:** The participants noted the
    fragmentation in services is in conflict with a holistic approach to
    health care. The group recommends redefining the behavioral health
    field and concepts to focus more on the strengths of our communities
    than on the weaknesses or pathology of disease. The competition and
    conflict between the mental health and substance abuse fields should
    be resolved and a holistic approach supported in the IHCIA.

-   **Local Models:** The authority to create local models in behavioral
    health should be reinforced through the IHCIA. Redefining terms,
    concepts, and approaches that are more appropriate to the culture
    and values of each community should be supported. Comprehensive
    evaluations should be conducted to determine what community models
    exist in Indian country and to share that information with I/T/U's.

-   **Cultural Considerations:** An orientation program should be
    provided for new health providers, in order to bridge between
    traditional and medical practitioners. An ongoing process should be
    developed for staff and communities to integrate or coordinate
    traditional and western healers in the area of behavioral health.

-   **Behavioral Health Scholarships and Education:** The fierce
    competition for higher education in the mental health fields is
    leaving many interested American Indians overlooked. The IHCIA
    should be amended so that more collaboration with tribal colleges is
    provided around behavioral health professional development. The IHS
    scholarship program should be decentralized to ensure equity and
    fairness in the award of support. Information about existing
    demonstration projects attempting to increase the number of Indian
    behavioral health professionals should be shared with all I/T/U's.
    Indian applicants should show a strong commitment to serve Indian
    communities through I/T/U's.

-   **Behavioral Health Models:** The IHCIA should instruct the IHS to
    locate behavioral health models that demonstrate cost effectiveness
    in the provision of mental health and substance abuse services to
    Indian communities. These models should be shared with all I/T/U's
    for consideration. Models which focus on family treatment should be
    highlighted and disseminated.

-   **Alcohol/Substance Abuse Aftercare:** The Aftercare/Continuing Care
    component of the continuum of care is not available in Indian
    communities today. This is an important omission because aftercare
    is critical to sustaining recovery and sobriety. The IHS should
    continue to the next phase in its current evaluation of aftercare in
    IHS sponsored programs and broaden its application. Aftercare should
    be fully funded and developed by the IHS through the IHCIA. Existing
    studies, such as the Aftercare Study conducted by the Native
    American Research and Training Center at the Northern Arizona
    University should be considered in restructuring aftercare by IHS.

-   **Access to Pilot Program Resources:** Existing pilot programs
    funded by the IHS for mental health services should be made
    available to all I/T/U's for replication and sharing of information.

-   **Substance Abuse Staff Training:** The IHS should develop a
    certification and training program for American Indian and Alaska
    Native substance abuse treatment providers. Funding for counselor
    salaries should be increased to attract and retain qualified staff.

-   **Advocacy:** The mental health and substance abuse programs of the
    IHS need a strong advocate at headquarters to push behavioral health
    initiatives. The IHS should include I/T/U's in the development of
    behavioral health objectives and related reports to Congress. Strong
    advocacy is needed to ensure behavioral health issues are funded
    appropriately.

3.  **I/T/U Partnerships for the Future**

The relationship between IHS, tribal and urban programs has been a
important issue which has not received full attention in a national
forum. There have been significant changes in the relationship since the
last reauthorization of the IHCIA. More and more tribes have contracted
or compacted IHS health services. The role of the IHS has changed to one
more of advocacy and support. Urban health providers fill a vital role
in the network of services to American Indian people. This workgroup
attempted to identify major issues for consideration and when possible,
consensus recommendations. In beginning the discussion, the workgroup
agreed it was important to minimize conflicts and continue dialogue
between tribes and urban providers. To accomplish this, open
communication, and mutual respect are important.

-   **Urban Indian Health Programs Needed:** There was consensus that
    urban Indian health programs are needed and fill a vital role in the
    delivery of health services to Indian people.

-   **Government-to-Government Relationships:** There was consensus that
    the government-to-government relationship is between federally
    recognized tribes and the U.S. government.

-   **Tribal Responsibility for Members:** There was consensus that
    tribes have a responsibility for their tribal members wherever their
    members are located, based upon each individual tribal governments'
    determination. It was also recognized there may be individual tribal
    members residing on "public domain allotments" outside tribal
    reservations and not served by existing I/T/U systems, who should be
    considered.

-   **Federal Government Responsibility:** It was agreed that the
    Federal Government has an obligation to provide health services,
    through the IHS, to all American Indian and Alaska Native people
    regardless of where they reside in the United States, including
    urban Indian populations.

-   **Limited Resources for I/T/U System:** The workgroup identified
    that the existing limited resources and inadequate appropriations
    for the I/T/U system should not be allowed to become a divisive
    issue for partnership and mutually supportive relationships among
    tribes and urban providers.

4.  **Entitlement, Benefits Package and Health Disparity**

This workgroup address the issues of entitlement, benefits package and
health disparity. While the group was [not able to arrive at
consensus]{.underline} with regard to recommended changes in the Indian
Health Care Improvement Act, it was able to identify key issues and
recommend a strategy to continue the discussion and analysis. The group
did agree that there are problems with disparity in health resources and
health status across the different regions of the United States. Some of
the major issues which were identified included the following key
points:

-   There is a need for meaningful data to better document health
    disparities across the regions, in order to assess need and arrive
    at a fair and equitable resolution. Each area has its own argument
    for not being funded as well as other areas, such as total per
    capita expenditures; lack of an IHS hospital; rural isolation; lack
    of public health infrastructure; health status indicators or other
    factors. To develop a fair definition of a benefits package, all
    these geographic and historic variables must be taken under
    consideration.

-   "Entitlement" is a concept of the federal government which means an
    individual or group is guaranteed a service regardless of budget
    constraint or increased volume. Entitlements such as welfare have
    been eliminated through welfare reform. Congress is more likely to
    restrict entitlements, such as Medicaid, than to increase
    entitlements to include Indian health. However, interest has been
    expressed by federal policy makers to consider an entitlement option
    in the IHCIA, and finally get a handle on Indian health
    appropriations struggles each year.

-   There is a recognition that American Indian people are, in fact,
    "entitled" to receive certain services, such as health care, due to
    promises made in Treaties and the application of that policy through
    federal laws and court decisions. Indian people generally agree that
    they are entitled to heath services, which were prepaid through the
    cession of millions of acres of Indian land to the United States.
    Federal health care to Indian people should be an entitlement.

-   Discussion of "benefits package" assumes that each geographical
    section of the IHS system is comparable, when it is not. Trying to
    find a way to ensure equity in health benefits, may result in
    reducing funds for some tribal health centers in order to better
    fund other tribal health centers, unless there is a great infusion
    of new dollars. Given that all systems are underfunded, this would
    create additional hardships and division.

-   There are at least three ways to look at the notion of
    "entitlement". (1) An [individual]{.underline} Indian person could
    have an entitlement for certain defined health services, regardless
    of where they reside or where they chose to receive services (like
    Medicaid beneficiaries). (2) [Providers]{.underline} of health
    services, such as the I/T/U system, could be entitled to a certain
    guaranteed level of funding to meet the federal governments
    responsibility to provide health services. (3) Governments, such as
    [tribal governments]{.underline}, could be entitled to receive full
    funding to meet health care needs of American Indians and Alaska
    Natives, or their enrolled membership, and administer that
    responsibility according to their own priorities and considerations.

-   Entitlement could be tracked to a status in health and not to a
    defined list of benefits. Too often a benefits package is viewed as
    the maximum amount of benefits and not the minimum, guaranteed
    benefits.

-   An entitlement approach would potentially allow for all other
    entitlements, such as Medicaid and Medicare, to be consolidated into
    one big national Indian health entitlement package.

```{=html}
<!-- -->
```
-   **Consensus to Continue Examination of Options:** The workgroup did
    not reach consensus on any specific policy recommendation or
    amendment to the IHCIA, but it did agree that the discussion of
    establishing an entitlement to health services for American Indians
    should continue. Specifically, it was agreed that the consideration
    of entitlements and benefits package should continue on two parallel
    tracks: (1) Examine all options for a broader entitlement approach
    for Indian health; and (2) Continue to examine maximizing existing
    discretionary funding to get closer to full funding, and this must
    proceed within the next 2-3 months.

-   **Entitlement for American Indians and Alaska Natives:** There was
    agreement that Indian people are entitled to health care services by
    virtue of massive contributions t this country's benefit. There was
    not consensus as to whether this should be a position for the IHCIA.

5.  **Other Emerging Issues**

The Reno Regional Consultation Meeting provided an additional workgroup
for participants to discuss other crosscutting and emerging issues which
had not been covered in other workgroups. A wide variety of issues were
discussed in this session. The following is a list of the major areas
where consensus was identified. There were many more issued identified,
but time did not permit the group to address all issues.

-   **Indian Child Protection:** The IHCIA should be used to amend the
    American Indian Child Protection Act to provide some flexibility.

-   **Interagency Linkages:** The IHCIA should be amended to provide
    linkages bewteen the IHS and numerous other federal agencies and
    departments to better coordinate resources and functions for Indian
    health.

-   **Public Health Infrastructure:** The IHCIA should address public
    health issues and functions specifically as it relates to the public
    health role of tribal governments. Tribes should be provided the
    funding, under the authority of the IHCIA to develop the necessary
    infrastructure to perform their public health responsibilities,
    including linkages with state systems, the Public Health Service and
    Centers for Disease Control.

-   **Matching Grants:** The IHCIA should include a provision exempting
    tribal governments from matching requirements for all other federal
    grants.

-   **Issues not resolved:** Other areas which were identified, but for
    which the group was not able to reach consensus due to time
    constraints included, expanding the scope of the IHS to include
    emerging issues; incorporating traditional healing services within
    the IHS system; environmental related diseases; examination of the
    positive health aspects of casinos; exemption for tribes under
    Davis/Bacon wage requirements for federal contracts and
    subcontracts.

#### Conclusion

The Reno Regional Consultation Meeting involved a high degree of
participation by the attendees. Quinault Tribal President, Pearl Baller,
led a large discussion session on the final day regarding tribal leader
involvement in the reauthorization of the Indian Health Care Improvement
Act. Although several of the elected leaders had left prior to the last
afternoon, there were still many tribal leaders voicing strong support
and encouragement for the work ahead. This general session discussion
produced several important recommendations from the audience:

-   Tribal leaders must keep their enthusiasm and vision for the
    reauthorization process to be successful;

-   Tribal drafts or key policy drafts should be used by IHS to work
    from;

-   Tribal leaders have a responsibility to ensure UNITY;

-   What are the next steps? Tribal leaders will work with NCAI, NIHB
    and regional or Area health boards to continue the process.

-   Can Area boards, such as NPAIHB provide regular fax updats on the
    reauthorization process?;

-   It is important that tribal leaders address the "Preamble" for the
    Act and include equity as a part of it;

-   We will look to other non-Indian national organizations for
    assistance and support.

**Summary of Consensus Recommendations**

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| ### TITLE I           | **ISSUES**        | **RECOMMENDATIONS**     |
| : Health Professions  |                   |                         |
+-----------------------+-------------------+-------------------------+
| Section 102 Health    | Problems with the | Grant should be         |
| Professions           | grant length      | extended for more than  |
| Recruitment program   | period.           | 3 years.                |
| for Indians           |                   |                         |
+-----------------------+-------------------+-------------------------+
| Section 103 Health    | Yearly            | Scholarships should be  |
| Professions           | re-applications   | guaranteed (after       |
| preparatory           | are required      | initial competition and |
| scholarships for      |                   | award).                 |
| Indians               |                   |                         |
+-----------------------+-------------------+-------------------------+
| Section 104 Indian    | There is a need   | Practical Nurses should |
| Health Profession     | for more Licensed | be added to program     |
| Scholarships          | Practical Nurses  | (funded under section   |
|                       |                   | 103)                    |
+-----------------------+-------------------+-------------------------+
| # Section 104         | Other health      | Chiropractic,           |
|                       | specialties need  | acupuncture and other   |
|                       | to be considered  | practitioners should be |
|                       | for funding.      | considered eligible for |
|                       |                   | scholarship award.      |
+-----------------------+-------------------+-------------------------+
| # Section 104         | Problems          | 1)  Provide technical   |
|                       | identified in the |     assistance with     |
|                       | receipt of        |     application (video, |
|                       | applications that |     web site)           |
|                       | are incomplete or |                         |
|                       | not correctly     | 2)  Simplify the        |
|                       | completed.        |     application form    |
|                       |                   |     and clearly state   |
|                       |                   |     the scoring system  |
|                       |                   |     (why a letter from  |
|                       |                   |     the Tribal Chairman |
|                       |                   |     weighs heavier than |
|                       |                   |     a co-worker).       |
+-----------------------+-------------------+-------------------------+
| Section 105           | No Comments.      |                         |
+-----------------------+-------------------+-------------------------+
| Section 106           | Scholarship       | 1)  Provide continuing  |
| Continuing Education  | programs have     |     education to keep   |
| Allowance             | lower % of Indian |     health              |
|                       | health            |     professionals up to |
|                       | professionals who |     date with           |
|                       | have been allowed |     knowledge.          |
|                       | to participate.   |                         |
|                       |                   | 2)  Provide resources   |
|                       |                   |     that tribal member  |
|                       |                   |     can access funds    |
|                       |                   |                         |
|                       |                   | 3)  Improve             |
|                       |                   |     communications      |
|                       |                   |     regarding health    |
|                       |                   |     professionals'      |
|                       |                   |     continuing          |
|                       |                   |     education needs.    |
+-----------------------+-------------------+-------------------------+
| Section 108 & 109     | No Comment        |                         |
+-----------------------+-------------------+-------------------------+
| Section 112 Nursing   | Not generally     | Provide list of schools |
| Program & Nursing     | known which       | with grant.             |
| Schools               | schools are       |                         |
|                       | awarded the       |                         |
|                       | grants.           |                         |
+-----------------------+-------------------+-------------------------+
| Section 112 Nursing   | Shorter term of   | Extend grant length to  |
| Program & Nursing     | grant awards.     | 5 years.                |
| Schools               |                   |                         |
+-----------------------+-------------------+-------------------------+
| Section 123           | Needs adequate    | Fund it all.            |
|                       | funding           |                         |
+-----------------------+-------------------+-------------------------+

GENERAL COMMENTS ON TITLE I:

If pilot programs in Title worked well, open them up to all. Should all
of or many of these programs be kept centralized (no tribal shares) or
distributed to local programs.

Consider that the federal government and IHS have an obligation to
educate health professional with out an obligation of payback.

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **TITLE 2 & 7: Health | **ISSUES**        | **RECOMMENDATIONS**     |
| Services**            |                   |                         |
+-----------------------+-------------------+-------------------------+
| # Equity              | Equitable funding | 1)  Increase funding to |
|                       | all around, the   |     bring everyone up   |
|                       | last funding for  |     to the same         |
|                       | this occurred in  |     standard of health  |
|                       | 1991.             |     care regardless of  |
|                       |                   |     location.           |
|                       |                   |                         |
|                       |                   | 2)  Funding allocation  |
|                       |                   |     formula.            |
+-----------------------+-------------------+-------------------------+
| # Agency Linkages     | Multiple agencies | 1)  Use 477 as a model  |
|                       | dealing with      |     to include a        |
|                       | health care could |     similar clause in   |
|                       | benefit the       |     437, potential      |
|                       | tribes. P.L.      |     access to more      |
|                       | 102-477 has       |     resources through   |
|                       | useful language   |     more agencies.      |
|                       | for linking       |                         |
|                       | federal programs  | 2)  Apply specific      |
|                       | and streamlining  |     agency linkages     |
|                       | tribal access,    |     into law to         |
|                       | contracting and   |     increase            |
|                       | reporting         |     accountability,     |
|                       | requirements.     |     even if it starts   |
|                       |                   |     with helping IHS in |
|                       |                   |     its role regarding  |
|                       |                   |     the specific        |
|                       |                   |     agency's function.  |
|                       |                   |                         |
|                       |                   | 3)  Linking CDC, NIH,   |
|                       |                   |     DOJ, and Indian     |
|                       |                   |     Health programs.    |
|                       |                   |     (E.g.: 60% of youth |
|                       |                   |     in detention        |
|                       |                   |     facilities are      |
|                       |                   |     Indian, a           |
|                       |                   |     department of       |
|                       |                   |     Justice link would  |
|                       |                   |     help access these   |
|                       |                   |     youth to health     |
|                       |                   |     services, or NIH or |
|                       |                   |     CDC to the Epi      |
|                       |                   |     Centers.)           |
|                       |                   |                         |
|                       |                   | 4)  Linked agencies     |
|                       |                   |     will accept IHS's   |
|                       |                   |     reports as a basis  |
|                       |                   |     of compliance       |
|                       |                   |     requirements, i.e.  |
|                       |                   |     facility studies by |
|                       |                   |     IHS should be       |
|                       |                   |     recognized by all   |
|                       |                   |     Federal             |
|                       |                   |     organizations.      |
+-----------------------+-------------------+-------------------------+
| # Epi Centers         | Epi centers are   | 1)  More Epi centers    |
|                       | not accessible by |     needed to teach and |
|                       | all areas,        |     provide specific    |
|                       | purpose,          |     systems that will   |
|                       | validity, and     |     meet the needs of   |
|                       | applications of   |     small tribes and    |
|                       | successful        |     all sizes of        |
|                       | centers are not   |     clinics.            |
|                       | widely known.     |                         |
|                       |                   | 2)  Link data with      |
|                       |                   |     States and other    |
|                       |                   |     agencies.           |
|                       |                   |                         |
|                       |                   | 3)  Need for Native     |
|                       |                   |     American cohort     |
|                       |                   |     studies to identify |
|                       |                   |     risks more          |
|                       |                   |     completely.         |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **TITLE 2 & 7: Health | **ISSUES**        | **RECOMMENDATIONS**     |
| Services**            |                   |                         |
+-----------------------+-------------------+-------------------------+
| Multiple Reporting    | Recognition and   | IHS reports should be   |
| Requirements          | acceptance of IHS | accepted by other       |
|                       | and tribal        | agencies as a basis of  |
|                       | environmental     | compliance              |
|                       | reports, studies, | requirements, (i.e.     |
|                       | and assessments,  | facility studies by IHS |
|                       | etc., by all      | should be recognized as |
|                       | other Federal     | being valid.)           |
|                       | organizations.    |                         |
|                       |                   | Other reporting         |
|                       |                   | agencies, HUD, EPA.     |
+-----------------------+-------------------+-------------------------+
| Specific Clinical     | Diabetes is under | 1)  "Special diabetes   |
| Services: Diabetes    | funded and needs  |     funds" should be    |
|                       | to be included in |     included in [base   |
|                       | base funding as   |                         |
|                       | any other 638     |   funding]{.underline}, |
|                       | program (not a    |     no longer treating  |
|                       | grant program),   |     it as a "grant"     |
|                       | treated as a      |     program.            |
|                       | short term health |                         |
|                       | issue.            | 2)  Diabetes Programs   |
|                       |                   |     only last 5 years,  |
|                       |                   |     lift 5-year limit,  |
|                       |                   |     funds need to be on |
|                       |                   |     going as part of    |
|                       |                   |     the base program    |
|                       |                   |     funding.            |
+-----------------------+-------------------+-------------------------+
| Diabetes 204 (d) 3    | Amend language to | 1)  Support data        |
|                       | allow funds to    |     collection          |
|                       | support data      |     requirements with a |
|                       | collection        |     mechanism (funding) |
|                       | requirement.      |     to collect data.    |
|                       |                   |                         |
|                       |                   | 2)  Shouldn't require   |
|                       |                   |     data without        |
|                       |                   |     provided funs to do |
|                       |                   |     data collection.    |
+-----------------------+-------------------+-------------------------+
| Diabetes              | Prevalence of     |                         |
|                       | diabetes varies   |                         |
|                       | from tribe to     |                         |
|                       | tribe, will       |                         |
|                       | funding be        |                         |
|                       | variable?         |                         |
+-----------------------+-------------------+-------------------------+
| Diabetes              | Prevention,       | 1)  Separate the        |
|                       | education &       |     activities:         |
|                       | screening are     |     Diabetes control    |
|                       | viewed as         |     and treatment are   |
|                       | separate          |     health concerns of  |
|                       | activities from   |     Indians who are     |
|                       | treatment &       |     already diagnosed.  |
|                       | control; need to  |                         |
|                       | be separated in   | 2)  Screening,          |
|                       | the ICHIA.        |     prevention and      |
|                       |                   |     education are       |
|                       |                   |     community health    |
|                       |                   |     promotion           |
|                       |                   |     activities.         |
+-----------------------+-------------------+-------------------------+
| Diabetes              | Issues specific   | California funding not  |
|                       | to California     | equitable requires      |
|                       | tribes and        | correction. Consortiums |
|                       | treatment         | were treated a single   |
|                       | (funding) of      | tribes, funded for 40   |
|                       | "consortiums".    | tribes when there are   |
|                       |                   | 104 tribes.             |
+-----------------------+-------------------+-------------------------+
| Lower CHEF Threshold  | CHEF threshold    | 1)  Lower CHEF          |
|                       | too high for      |     threshold by at     |
|                       | small tribal      |     least 50% for CHS   |
|                       | program areas.    |     dependent and small |
|                       |                   |     tribal program      |
|                       |                   |     areas.              |
|                       |                   |                         |
|                       |                   | 2)  Increase the number |
|                       |                   |     of dollars in CHEF  |
|                       |                   |     pool.               |
+-----------------------+-------------------+-------------------------+
| CHSDA Changes         | Additional        | 1)  California has      |
|                       | counties to be    |     identified 7        |
|                       | included in       |     additional counties |
|                       | CHSDA.            |     to add to the       |
|                       |                   |     CHSDA.              |
|                       |                   |                         |
|                       |                   | 2)  Additional counties |
|                       |                   |     in other I/T/U's    |
|                       |                   |     may need to be      |
|                       |                   |     added to their      |
|                       |                   |     CHSDA as necessary. |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **TITLE 2 & 7: Health | **ISSUES**        | **RECOMMENDATIONS**     |
| Services**            |                   |                         |
+-----------------------+-------------------+-------------------------+
| Eligibility           | Tribal sites      | Create tribal sites and |
| Determinations        | needed and        | provide authority to    |
|                       | authority to      | determine client        |
|                       | determine         | eligibility for TANF,   |
|                       | eligibility for   | CHIPs, etc.             |
|                       | services.         |                         |
+-----------------------+-------------------+-------------------------+
| Third Party           | 1\) No other      | Clarify billing         |
| Reimbursements        | governmental      | exemption is for States |
|                       | bodies and sub    | only.                   |
|                       | units may apply;  |                         |
|                       | the billing       |                         |
|                       | exemption is for  |                         |
|                       | State only.       |                         |
|                       |                   |                         |
|                       | 2)Language:       |                         |
|                       | 206(g) for        |                         |
|                       | purposes of this  |                         |
|                       | section, "State"  |                         |
|                       | means a State of  |                         |
|                       | the United        |                         |
|                       | States, the       |                         |
|                       | District of       |                         |
|                       | Columbia and any  |                         |
|                       | commonwealth,     |                         |
|                       | territory or      |                         |
|                       | possession of the |                         |
|                       | United States and |                         |
|                       | does not include  |                         |
|                       | a political       |                         |
|                       | subdivision of a  |                         |
|                       | State, a State    |                         |
|                       | instrumentality   |                         |
|                       | or other local    |                         |
|                       | authorities or    |                         |
|                       | local             |                         |
|                       | governmental      |                         |
|                       | units.            |                         |
+-----------------------+-------------------+-------------------------+
| Tribal                | RPMS doesn't work | Addition funding needed |
| Statistics/Data       | at all locations, | to make RPMS work,      |
|                       | staffing and      | additional staff        |
|                       | training          | resources needed in     |
|                       | identified as key | local programs, and     |
|                       | problems.         | training of staff.      |
+-----------------------+-------------------+-------------------------+
| Youth Regional        | Allocation of     | Increase funding        |
| Treatment Centers     | funds to          | allocation for the 3    |
|                       | California.       | treatment centers       |
|                       |                   | located in California   |
|                       |                   | (\$1.3 million not      |
|                       |                   | enough).                |
+-----------------------+-------------------+-------------------------+
| Youth Rehabilitation  | Allocation and    | Support and protect     |
| Treatment Centers     | support of YRTC   | programs that have      |
|                       | to prevent        | risked early start up   |
|                       | shutdown.         | and now need additional |
|                       |                   | support to prevent      |
|                       |                   | shutdown.               |
+-----------------------+-------------------+-------------------------+
| YRTC                  | Funding and       | Fully fund and expand   |
|                       | expansion of      | the number of YRTC's or |
|                       | YRTC's.           | distribute money as     |
|                       |                   | shares.                 |
+-----------------------+-------------------+-------------------------+
| YRTC                  | Expansion of      | Provide YRTC services   |
|                       | programs services | that assist youth with  |
|                       | to meet needs of  | dual diagnosis; these   |
|                       | youth with dual   | clients require extra   |
|                       | diagnosis.        | services.               |
+-----------------------+-------------------+-------------------------+
| YRTC                  | Transitional      | A formalized            |
|                       | aftercare.        | "transitional           |
|                       |                   | aftercare" program is   |
|                       |                   | needed for youth post   |
|                       |                   | treatment.              |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **TITLE 2 & 7: Health | **ISSUES**        | **RECOMMENDATIONS**     |
| Services**            |                   |                         |
+-----------------------+-------------------+-------------------------+
| YRTC                  | Youth in need of  | 1)  Provide             |
|                       | program when      |     (counseling,        |
|                       | there are no      |     medically           |
|                       | available beds at |     supervised detox,   |
|                       | the YRTC.         |     education, family   |
|                       |                   |     counseling, et al)  |
|                       |                   |     to support youth    |
|                       |                   |     and their families  |
|                       |                   |     while waiting for   |
|                       |                   |     bed space at YRTC.  |
|                       |                   |                         |
|                       |                   | 2)  For lack of better  |
|                       |                   |     terms, this might   |
|                       |                   |     be considered a     |
|                       |                   |     "pre-treatment      |
|                       |                   |     support and         |
|                       |                   |     preparation         |
|                       |                   |     program".           |
+-----------------------+-------------------+-------------------------+
| Long Term Care & SNF  | Lack of           | Authorize a             |
|                       | comprehensive     | comprehensive range of  |
|                       | range of long     | long term care and      |
|                       | term or Skilled   | Skilled Nursing         |
|                       | Nursing           | Facilities programs and |
|                       | Facilities (SNF)  | appropriate funds to    |
|                       | programs and      | support them.           |
|                       | funding.          |                         |
+-----------------------+-------------------+-------------------------+
| Long Term Care & SNF  | Nursing Homes are | 1)  Long term care      |
|                       | located far from  |     close to home is a  |
|                       | home & are        |     priority.           |
|                       | foreign to Indian |                         |
|                       | elders & others   | 2)  Assisted living     |
|                       | needing long term |     housing in Alaska   |
|                       | care, creating    |     villages need to be |
|                       | hardships for     |     specifically        |
|                       | families to visit |     included as an      |
|                       | and learn to      |     activity under this |
|                       | provide the       |     authority.          |
|                       | needed care at    |                         |
|                       | home.             |                         |
+-----------------------+-------------------+-------------------------+
| Long Term Care & SNF  | Protect cultural  | Culturally appropriate  |
|                       | rights.           | and sensitive care      |
|                       |                   | should be the           |
|                       |                   | cornerstone for Long    |
|                       |                   | Term Care services.     |
+-----------------------+-------------------+-------------------------+
| Long Term Care & SNF  | Expanded          | Authorize linkages with |
|                       | resources and     | county, state and       |
|                       | partnerships      | others to expand and    |
|                       |                   | improve Long Term Care  |
|                       |                   | services.               |
+-----------------------+-------------------+-------------------------+
| Long Term Care & SNF  | Protection of     | Exemption from Medicare |
| Funding               | personal assets,  | and Medicaid means      |
|                       | means testing and | testing, no spend down  |
|                       | spend down, to    | to protect family       |
|                       | state recovery.   | homes, land, and        |
|                       |                   | personal assets.        |
+-----------------------+-------------------+-------------------------+
| Hearing Aids          | Comprehensive     | Comprehensive hearing   |
|                       | services needed,  | service to include      |
|                       | especially for    | audiometric evaluation  |
|                       | children and      | and treatment,          |
|                       | elders.           | especially for children |
|                       |                   | and elders.             |
+-----------------------+-------------------+-------------------------+
| Hearing Aids          | Linkages to       | Authorize ADA           |
|                       | improve access to | (Americans with         |
|                       | care.             | Disabilities Act)       |
|                       |                   | linkage to provide      |
|                       |                   | assisted hearing        |
|                       |                   | devices for children in |
|                       |                   | schools.                |
+-----------------------+-------------------+-------------------------+
| Health Promotion      | Important program | Reauthorize HPDP and    |
| Disease Prevention    | that has not been | provide parity of       |
| (HPDP)                | adequately funded | funding at levels       |
|                       | or funded at      | comparable to acute     |
|                       | equal levels to   | care and treatment      |
|                       | acute care and    | programs.               |
|                       | treatment         |                         |
|                       | programs.         |                         |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **TITLE 2 & 7: Health | **ISSUES**        | **RECOMMENDATIONS**     |
| Services**            |                   |                         |
+-----------------------+-------------------+-------------------------+
| Uniform Pharmacy      | Individual access | Authorize the right to  |
| Benefits              | to medicines and  | individual access to    |
|                       | other supplies    | medicines and other     |
|                       | varies based on   | pharmaceutical supplies |
|                       | service           | irrespective of on site |
|                       | availability, CHS | service availability,   |
|                       | status or clinic  | CHS status or clinic    |
|                       | size.             | size.                   |
+-----------------------+-------------------+-------------------------+
| Uniform Pharmacy      | Access to 602     | 1)  Authorize tribal    |
| Benefits              | pricing.          |     and urban access to |
|                       |                   |     Veterans Affairs    |
|                       |                   |     (VA) or Department  |
|                       |                   |     of Defense (DOD) or |
|                       |                   |     other Federal prime |
|                       |                   |     vendor              |
|                       |                   |     arrangements, or    |
|                       |                   |                         |
|                       |                   | 2)  Continue to provide |
|                       |                   |     access to 602       |
|                       |                   |     pricing, if they    |
|                       |                   |     have been Federally |
|                       |                   |     Qualified Health    |
|                       |                   |     Center (FQHC)       |
|                       |                   |     qualified.          |
+-----------------------+-------------------+-------------------------+
| Substance Abuse       | Full realm of     | Authorize uniform       |
|                       | comprehensive     | access to a             |
|                       | services is       | comprehensive substance |
|                       | needed, including | abuse (including        |
|                       | treatment for     | inhalants) program      |
|                       | inhalants.        | including: treatment,   |
|                       |                   | pre-treatment,          |
|                       |                   | post-treatment, family  |
|                       |                   | care, and inhalant      |
|                       |                   | abuse, etc.             |
+-----------------------+-------------------+-------------------------+
| Section 209           | Inadequately      | This section is need of |
|                       | funded            | full funding, to        |
|                       |                   | provide for             |
|                       |                   | consultation with       |
|                       |                   | I/T/U.                  |
+-----------------------+-------------------+-------------------------+
| Substance Abuse       | Set specific      | 1)  Utilizing Year 2000 |
|                       | goals.            |     Healthy people      |
|                       |                   |     objectives as a     |
|                       |                   |     model set specific  |
|                       |                   |     improvement goals.  |
|                       |                   |                         |
|                       |                   | 2)  Provide any         |
|                       |                   |     improvement         |
|                       |                   |     objectives proposed |
|                       |                   |     for I/T/U           |
|                       |                   |     consultation.       |
+-----------------------+-------------------+-------------------------+
| Substance Abuse       | Prevention        | Implement a prevention  |
|                       | services need     | program that works.     |
|                       | improvement.      |                         |
+-----------------------+-------------------+-------------------------+
| Substance Abuse       | Federal agencies  | Authorize I/T/U's to    |
|                       | only required to  | link with SAMHSA        |
|                       | link with Tribes  | (Substance Abuse Mental |
|                       | at their own      | Health Services         |
|                       | election.         | Administration), CDC    |
|                       |                   | (Center for Disease     |
|                       |                   | Control) to provide     |
|                       |                   | uniform access to       |
|                       |                   | substance abuse         |
|                       |                   | treatment.              |
+-----------------------+-------------------+-------------------------+
| Substance Abuse       | Not a mandate for | Wording: "Tribe may     |
|                       | tribes, but a     | request" these services |
|                       | mandate for IHS   | and that "IHS is        |
|                       | to provide S/A    | required to provide     |
|                       | services.         | these services".        |
+-----------------------+-------------------+-------------------------+
| Community Health Reps | CHRs need more    | 1)  Authorize CHRs to   |
|                       | frequent training |     receive more        |
|                       | and equipment to  |     frequent training.  |
|                       | provide this      |                         |
|                       | service.          | 2)  Authorize the       |
|                       |                   |     purchase of         |
|                       |                   |     equipment needed    |
|                       |                   |     for CHRs to         |
|                       |                   |     complete health     |
|                       |                   |     assessments.        |
+-----------------------+-------------------+-------------------------+
| Home Visits           | More health       | Increase the number of  |
|                       | qualified health  | qualified personnel     |
|                       | personnel needed. | needed to do home       |
|                       |                   | visits.                 |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **TITLE 2 & 7: Health | **ISSUES**        | **RECOMMENDATIONS**     |
| Services**            |                   |                         |
+-----------------------+-------------------+-------------------------+
| Home Visits           | Seeking examples  | 1)  Authorize IHS to do |
|                       | from CHAPS in     |     home health care,   |
|                       | Alaska, certify   |     therefor eligible   |
|                       | individual home   |     to bill for         |
|                       | health programs   |     services. Have      |
|                       | that "services"   |     HCFA, etc., to      |
|                       | can be billed     |     accept IHS          |
|                       | for.              |     certification --    |
|                       |                   |     Give IHS'           |
|                       |                   |     certification       |
|                       |                   |     "deemed status"     |
|                       |                   |                         |
|                       |                   | 2)  Certification of    |
|                       |                   |     home health program |
|                       |                   |     will allow billing  |
|                       |                   |     for service.        |
+-----------------------+-------------------+-------------------------+
| Mental Health --      | With gang         | 1)  Authorize           |
|                       | infiltration on   |     Department of       |
| Gang Prevention       | reservations and  |     Justice linkage to  |
|                       | Indian            |     provide financial   |
|                       | communities,      |     support and provide |
|                       | behavioral        |     assistance and      |
|                       | prevention        |     consultation with   |
|                       | programs need to  |     I/T/U's.            |
|                       | be beefed up.     |                         |
|                       | Vanderwagon: "60% | 2)  Include Juvenile    |
|                       | of youth in       |     Justice Programs    |
|                       | detention         |                         |
|                       | facilities are    |                         |
|                       | Indian", need to  |                         |
|                       | look for          |                         |
|                       | department of     |                         |
|                       | justice link.     |                         |
+-----------------------+-------------------+-------------------------+
| Mental Health         | Demonstration     | 1)  Strengthen language |
|                       | projects language |     and funding,        |
|                       | needs to be       |     eliminate           |
|                       | eliminated for    |     "demonstration"     |
|                       | comprehensive     |     language in favor   |
|                       | mental health     |     of permanent        |
|                       | services.         |     comprehensive       |
|                       |                   |     mental health       |
|                       |                   |     services/programs.  |
|                       |                   |                         |
|                       |                   | 2)  Demonstration       |
|                       |                   |     projects have the   |
|                       |                   |     connotation of a    |
|                       |                   |     "temporary" fix, or |
|                       |                   |     experimental        |
|                       |                   |     programs; the       |
|                       |                   |     services need to    |
|                       |                   |     become permanent,   |
|                       |                   |     comprehensive and   |
|                       |                   |     fully funded.       |
+-----------------------+-------------------+-------------------------+
| Studies/R             | Small tribes are  | 1)  Communicate with    |
| eports/Demonstrations | underrepresented  |     small tribes and    |
|                       | in planning,      |     include them in     |
|                       | participating and |     studies and policy  |
|                       | overseeing study  |     development. (See   |
|                       | efforts.          |     section 204)        |
|                       |                   |                         |
|                       |                   | 2)  Improve equity in   |
|                       |                   |     information access  |
|                       |                   |     and study           |
|                       |                   |     participation.      |
+-----------------------+-------------------+-------------------------+
| Studies/R             | No access to      | Improve availability of |
| eports/Demonstrations | study results.    | study results, make     |
|                       |                   | study outcomes          |
|                       |                   | available to all.       |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **TITLE 2 & 7: Health | **ISSUES**        | **RECOMMENDATIONS**     |
| Services**            |                   |                         |
+-----------------------+-------------------+-------------------------+
| Mental Health         | Early             | 1)  Authorize training  |
|                       | identification,   |     for mental health   |
|                       | capacity building |     and primary care    |
|                       | needed as part of |     professionals, to   |
|                       | mental health and |     increase their      |
|                       | primary medical   |     capacity to early   |
|                       | care efforts.     |     identify domestic   |
|                       |                   |     violence and        |
|                       |                   |     provide appropriate |
|                       |                   |     intervention.       |
|                       |                   |                         |
|                       |                   | 2)  Include domestic    |
|                       |                   |     violence prevention |
|                       |                   |     and treatment, as   |
|                       |                   |     part of mental      |
|                       |                   |     health program.     |
+-----------------------+-------------------+-------------------------+
| Mental Health         | Home or community | Additional Mental       |
|                       | based             | Health resources are    |
|                       | intervention is   | needed to support home  |
|                       | needed.           | visits for preventive   |
|                       |                   | and intervention        |
|                       |                   | services for domestic   |
|                       |                   | violence.               |
+-----------------------+-------------------+-------------------------+
| Mental                | "Safe Haven"      | Safe houses needed in   |
| Health/Violence       | capacity needed   | communities for         |
|                       | for DV            | battered families.      |
+-----------------------+-------------------+-------------------------+
| Training for Health   | Local programs    | 1)  Increase number of  |
| Professionals         | need more         |     behavioral health   |
|                       | behavioral health |     professionals       |
|                       | professionals.    |     staffing local      |
|                       |                   |     programs, includes  |
|                       |                   |     Mental Health,      |
|                       |                   |     Social Workers, and |
|                       |                   |     Chemical Dependency |
|                       |                   |     Counselors.         |
|                       |                   |                         |
|                       |                   | 2)  Levels of need:     |
|                       |                   |                         |
|                       |                   | ```{=html}              |
|                       |                   | <!-- -->                |
|                       |                   | ```                     |
|                       |                   | (a) Money to programs   |
|                       |                   |     to hire trained     |
|                       |                   |     professionals,      |
|                       |                   |                         |
|                       |                   | (b) Money to go to      |
|                       |                   |     Indian students to  |
|                       |                   |                         |
|                       |                   |    [become]{.underline} |
|                       |                   |     professionals).     |
+-----------------------+-------------------+-------------------------+
| Trained Health        | Under served      | 1)  Need for more       |
| Professionals Section | areas need        |     providers with      |
| 217                   | alternative       |     prescriptive        |
|                       | methods for       |     authority for       |
|                       | meeting mental    |     psychiatric         |
|                       | health medication |     patients'           |
|                       | needs of mental   |     medications.        |
|                       | health clients.   |                         |
|                       |                   | 2)  Consider            |
|                       |                   |     prescriptive        |
|                       |                   |     authority for Ph.D. |
|                       |                   |     level mental health |
|                       |                   |     providers as        |
|                       |                   |     authorized in       |
|                       |                   |     various areas and   |
|                       |                   |     states.             |
|                       |                   |                         |
|                       |                   | **No consensus achieved |
|                       |                   | on this.**              |
+-----------------------+-------------------+-------------------------+
| Trained Health        | Service for       | Improve screening and   |
| Professionals         | depression,       | access to clinical      |
|                       | depression is a   | services for            |
|                       | major problem.    | depression.             |
+-----------------------+-------------------+-------------------------+
| Speech and other      | Need for more     | Increase number of      |
| Therapists            | speech and other  | speech and other        |
|                       | therapists.       | therapists staffing     |
|                       |                   | local programs.         |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **TITLE 2 & 7: Health | **ISSUES**        | **RECOMMENDATIONS**     |
| Services**            |                   |                         |
+-----------------------+-------------------+-------------------------+
| Dental                | Comprehensive     | 1)  Comprehensive       |
|                       | dental services   |     program should be   |
|                       | are needed.       |     authorized (pedio,  |
|                       |                   |     endo, ortho, perio) |
|                       |                   |     are all needed      |
|                       |                   |     {crowns, dentures,  |
|                       |                   |     pediatrics}         |
|                       |                   |                         |
|                       |                   | 2)  Dental equipment is |
|                       |                   |     required to support |
|                       |                   |     service providers   |
+-----------------------+-------------------+-------------------------+
| Traditional and       | Traditional and   | Provision of these      |
| Alternative Medicines | Alternative       | services will require   |
|                       | medicines are     | specific funding,       |
|                       | needed, are       | should compliment       |
|                       | critically        | behavioral and medical  |
|                       | important in      | care, and woven into    |
|                       | behavioral health | every aspect of care.   |
|                       | care services.    |                         |
+-----------------------+-------------------+-------------------------+
| Eye Care              | Comprehensive     | A comprehensive program |
|                       | program is        | will include glasses,   |
|                       | needed.           | special needs of        |
|                       |                   | diabetes patients,      |
|                       |                   | retinal screening and   |
|                       |                   | tonometry for glaucoma  |
|                       |                   | and high-risk           |
|                       |                   | populations.            |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **TITLE III: Health   | **ISSUE**         | **RECOMMENDATION**      |
| Facilities**          |                   |                         |
+-----------------------+-------------------+-------------------------+
| Section 804           | The IHCIA         | The IHCIA should waive  |
|                       | authorizes IHS to | the requirement that    |
|                       | lease health care | the full lease amount   |
|                       | space from tribes | be scored in the first  |
|                       | under a 20 year   | year of the lease.      |
|                       | lease; however,   |                         |
|                       | the Balanced      |                         |
|                       | Budget Act        |                         |
|                       | requires that the |                         |
|                       | full amount of    |                         |
|                       | these leases be   |                         |
|                       | scored in the     |                         |
|                       | first year of the |                         |
|                       | lease.            |                         |
+-----------------------+-------------------+-------------------------+
| Section 820           | The IHS/HQ/DFEE   | Retain Section 820; do  |
|                       | suggested         | not delete as           |
|                       | deleting Section  | recommended by          |
|                       | 820.              | HIS/HQ/DFEE document.   |
|                       |                   | (Possible deletion if   |
|                       |                   | not authorized in the   |
|                       |                   | Self Determination)     |
+-----------------------+-------------------+-------------------------+
| M & I funding         | The Maintenance & | 1)  Division of         |
|                       | Improvement (M&I) |     Facilities &        |
|                       | funding has not   |     Environmental       |
|                       | increased over    |     Engineering (DFEE)  |
|                       | the past several  |     recommends to not   |
|                       | years yet the     |     allow M & I funding |
|                       | amount of health  |     for new health      |
|                       | facility space    |     facilities coming   |
|                       | does increase. As |     on line unless      |
|                       | more health       |     specific funding    |
|                       | facility space is |     has been            |
|                       | approved for M &  |     appropriated by     |
|                       | I eligibility,    |     Congress for that   |
|                       | the existing      |     facility (increased |
|                       | health facilities |     space).             |
|                       | get less funds    |                         |
|                       | when they are     | 2)  There is also a     |
|                       | already under     |     need to identify    |
|                       | funded. Needs to  |     additional funds to |
|                       | be assurance that |     fully fund this     |
|                       | new health        |     initiative.         |
|                       | facilities will   |                         |
|                       | be funded with    |                         |
|                       | M&I Funds,        |                         |
|                       | through           |                         |
|                       | additional        |                         |
|                       | appropriations    |                         |
|                       | from Congress.    |                         |
+-----------------------+-------------------+-------------------------+
| Section 301 (a)       | The current       | 1)  Change of wording   |
|                       | document          |     that does not       |
|                       | identifies JCAHO  |     identify JCAHO as   |
|                       | specifically with |     the specific        |
|                       | regard to         |     accrediting         |
|                       | accrediting       |     authority as there  |
|                       | authority.        |     are several other   |
|                       |                   |     IHS approved        |
|                       |                   |     accrediting         |
|                       |                   |     authorities.        |
|                       |                   |                         |
|                       |                   | 2)  Accreditation       |
|                       |                   |     issues need to be   |
|                       |                   |     consistent          |
|                       |                   |     throughout the      |
|                       |                   |     bill.               |
+-----------------------+-------------------+-------------------------+
| Section 301           | Current law reads | 1)  New health facility |
|                       | that a new health |     construction should |
|                       | facility must be  |     meet the IHS        |
|                       | accredited by     |     standards of        |
|                       | JCAHO within one  |     construction.       |
|                       | year after        |                         |
|                       | completion.       | 2)  Should not          |
|                       |                   |     specifically refer  |
|                       |                   |     to JCAHO but refer  |
|                       |                   |     to an IHS approved  |
|                       |                   |     accrediting         |
|                       |                   |     authority.          |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| Section 306           | Not enough        | Include wording that    |
|                       | federal funding   | says: Secretary may     |
|                       | to support        | allow funds to          |
|                       | construction of   | reimburse 100% of       |
|                       | Indian Health     | tribes' obligations for |
|                       | care facilities.  | funds loaned by Federal |
|                       | Tribes are        | programs for health     |
|                       | funding their own | facilities              |
|                       | construction      | construction.           |
|                       | through personal  |                         |
|                       | funds or          |                         |
|                       | "personal loans"  |                         |
|                       | and must use      |                         |
|                       | health care       |                         |
|                       | dollars to pay    |                         |
|                       | off construction  |                         |
|                       | loans. Funds      |                         |
|                       | would be better   |                         |
|                       | used for          |                         |
|                       | providing health  |                         |
|                       | care.             |                         |
+-----------------------+-------------------+-------------------------+
|                       | HUD won't accept  | Better coordination     |
|                       | our environmental | effort between IHS and  |
|                       | reviews.          | HUD, to meet health,    |
|                       |                   | safety, and             |
|                       |                   | environmental reviews,  |
|                       |                   | the IHS, at the tribes' |
|                       |                   | request shall be deemed |
|                       |                   | as the regulating       |
|                       |                   | agency.                 |
+-----------------------+-------------------+-------------------------+
|                       | Tribes do not     | Tribes should have more |
|                       | have input into   | involvement in the      |
|                       | the Sanitation    | process from start to   |
|                       | Deficiency System | finish and be allowed   |
|                       | (SDS) for         | to have input on the    |
|                       | prioritization of | reports that are        |
|                       | sanitation        | generated at the Area   |
|                       | facilities        | and Headquarters        |
|                       | projects. This is | levels.                 |
|                       | an IHS driven     |                         |
|                       | system. Even      |                         |
|                       | though the tribes |                         |
|                       | have input into   |                         |
|                       | their own         |                         |
|                       | community needs,  |                         |
|                       | they have no      |                         |
|                       | input into the    |                         |
|                       | system once it    |                         |
|                       | reaches the       |                         |
|                       | area/HQ levels.   |                         |
+-----------------------+-------------------+-------------------------+
|                       | Many agencies     | IHS should be allowed   |
|                       | that require      | to use its appropriated |
|                       | matching funds,   | federal funds to comply |
|                       | do not permit     | with the matching       |
|                       | funds for other   | requirements of other   |
|                       | federal agencies  | state, federal and      |
|                       | to be used as     | other funding agencies. |
|                       | meeting the       |                         |
|                       | matching dollar   |                         |
|                       | requirement(s).   |                         |
+-----------------------+-------------------+-------------------------+
|                       | IHS funds cannot  | 1)  The relationship    |
|                       | be used for       |     needs to be         |
|                       | sanitation        |     strengthened        |
|                       | facilities for    |     between IHS and     |
|                       | HUD constructed   |     HUD. HUD must       |
|                       | homes. HUD        |     clearly know that   |
|                       | currently         |     it has the          |
|                       | receives funding  |     responsibility for  |
|                       | for construction  |     providing funds for |
|                       | of homes, which   |     sanitation          |
|                       | includes funds    |     facilities for      |
|                       | for sanitation    |     homes they          |
|                       | facilities.       |     construct.          |
|                       |                   |                         |
|                       |                   | 2)  IHS will continue   |
|                       |                   |     technical           |
|                       |                   |     assistance.         |
+-----------------------+-------------------+-------------------------+
| Section 401           | Appropriation     | There should be no      |
|                       | committees        | restrictions on the     |
|                       | currently must    | dollar limit on use of  |
|                       | approve use of    | M&M dollars for         |
|                       | M&M funds for     | renovation and new      |
|                       | renovation and    | construction.           |
|                       | construction      |                         |
|                       | projects over \$1 |                         |
|                       | million dollars.  |                         |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| Section 402           | A clear           | Definition of health    |
|                       | definition of     | care facility should    |
|                       | heath care        | include mental health,  |
|                       | facilities is     | elder care,             |
|                       | needed. Current   | rehabilitation          |
|                       | IHS definition    | services, alcohol/drug  |
|                       | does not include  | abuse, etc.             |
|                       | the variety of    |                         |
|                       | health care       |                         |
|                       | services          |                         |
|                       | provided.         |                         |
+-----------------------+-------------------+-------------------------+
|                       | Not enough ways   | The agency needs to     |
|                       | to get health     | have multiple ways to   |
|                       | facilities built. | get Indian health       |
|                       |                   | facilities constructed, |
|                       |                   | such as on-time         |
|                       |                   | revolving loan programs |
|                       |                   | and authority for       |
|                       |                   | guaranteed loan         |
|                       |                   | programs funded.        |
+-----------------------+-------------------+-------------------------+
| Section 301 (c)       | Congress does not | 1)  Get and accurate    |
|                       | have an accurate  |     and fair reporting  |
|                       | picture of all    |     system in place     |
|                       | unmet health      |     that is conducted   |
|                       | facility needs.   |     annually, one that  |
|                       | The IHS Priority  |     clearly identifies  |
|                       | System favors     |     needs of smaller    |
|                       | hospitals and     |     ambulatory health   |
|                       | large facilities. |     facilities.         |
|                       |                   |                         |
|                       |                   | 2)  Comprehensive unmet |
|                       |                   |     facilities needs    |
|                       |                   |     report will be      |
|                       |                   |     developed on an     |
|                       |                   |     annual basis and    |
|                       |                   |     submitted to        |
|                       |                   |     Congress.           |
+-----------------------+-------------------+-------------------------+
| Section 306           | Section 306 has   | Require IHS to provide  |
|                       | never been funded | an annual report to     |
|                       | because Congress  | Congress, which will    |
|                       | does not realize  | ensure equity and       |
|                       | the scope of the  | proper consideration    |
|                       | need;             | for ambulatory          |
|                       | appropriations    | facilities.             |
|                       | will not be       |                         |
|                       | identified        |                         |
|                       | without proper    |                         |
|                       | documentation of  |                         |
|                       | the need.         |                         |
+-----------------------+-------------------+-------------------------+
|                       | Hospitals rate    | Agency should not build |
|                       | higher on the     | hospitals where there   |
|                       | construction      | is excessive bed space  |
|                       | priority list as  | in urban areas so that  |
|                       | compared to       | construction resources  |
|                       | ambulatory health | can be re-allocated to  |
|                       | care facilities.  | ambulatory clinics.     |
|                       |                   | Existing resources must |
|                       |                   | be best utilized in     |
|                       |                   | existing health         |
|                       |                   | facilities in urban     |
|                       |                   | areas.                  |
+-----------------------+-------------------+-------------------------+
|                       | Central           | 1)  Re-evaluate the     |
|                       | allocation of     |     current IHS         |
|                       | funding; most IHS |     priority system,    |
|                       | Areas go without  |     change to allow     |
|                       | construction      |     equity in the       |
|                       | funding while     |     distribution of new |
|                       | other IHS Areas   |     construction funds. |
|                       | get funding for   |                         |
|                       | new construction. | 2)  Decisions should be |
|                       |                   |     made locally as to  |
|                       |                   |     how funds should be |
|                       |                   |     allocated for       |
|                       |                   |     facilities          |
|                       |                   |     construction.       |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **TITLE IV ACCESS**   | **ISSUES**        | **RECOMMENDATIONS**     |
+-----------------------+-------------------+-------------------------+
| Section 401 and 402   | Licensing &       | 1)  Indian Health       |
|                       | Certification     |     Service shall       |
|                       |                   |     establish a         |
|                       |                   |     certification       |
|                       |                   |     program for         |
|                       |                   |     I/T/U's, which      |
|                       |                   |     States will be      |
|                       |                   |     required to accept  |
|                       |                   |     to be equivalent to |
|                       |                   |     state licensure for |
|                       |                   |     all programs.       |
|                       |                   |                         |
|                       |                   | 2)  Once certified by   |
|                       |                   |     or through the IHS, |
|                       |                   |     the I/T/U's will be |
|                       |                   |     certified to serve  |
|                       |                   |     both Indians and    |
|                       |                   |     non-Indians. The    |
|                       |                   |     IHS will establish  |
|                       |                   |     its own             |
|                       |                   |     certification       |
|                       |                   |     process or may      |
|                       |                   |     utilize other       |
|                       |                   |     recognized body,    |
|                       |                   |     such as JCAHO.      |
+-----------------------+-------------------+-------------------------+
| Section 401           | I/T/U billing of  | 1)  All Medicare        |
|                       | Medicare          |     billable services   |
|                       |                   |     may be billed by    |
|                       |                   |     the I/T/U for IHS   |
|                       |                   |     beneficiaries,      |
|                       |                   |     including both      |
|                       |                   |     Indians and         |
|                       |                   |     non-Indians         |
|                       |                   |     serviced at         |
|                       |                   |     I/T/U's.            |
|                       |                   |                         |
|                       |                   | 2)  HCFA shall provide  |
|                       |                   |     a "window" of time  |
|                       |                   |     during which        |
|                       |                   |     I/T/U's can build   |
|                       |                   |     up their            |
|                       |                   |     infrastructure and  |
|                       |                   |     come into           |
|                       |                   |     compliance to       |
|                       |                   |     provide additional  |
|                       |                   |     Medicare services,  |
|                       |                   |     and shall be        |
|                       |                   |     certified to bill   |
|                       |                   |     for these services  |
|                       |                   |     during that window. |
+-----------------------+-------------------+-------------------------+
| Section 401           | Medicaid problems | 1)  All Medicaid        |
|                       | due to "facility" |     billable services   |
|                       | based             |     may be billed and   |
|                       | reimbursement.    |     paid to I/T/U's     |
|                       |                   |     whether services    |
|                       |                   |     are provided        |
|                       |                   |     directly or by      |
|                       |                   |     referral through an |
|                       |                   |     I/T/U.              |
|                       |                   |                         |
|                       |                   | 2)  State will receive  |
|                       |                   |     100% FMAP.          |
+-----------------------+-------------------+-------------------------+
| Section 401 and 402   | Medicaid and      | 1)  100% FMAP to states |
|                       | Medicare          |     for services        |
|                       | reimbursement to  |     provided to all IHS |
|                       | I/T/U's for both  |     eligible Indians    |
|                       | Indian and        |     and other           |
|                       | non-Indian        |     individuals made    |
|                       | beneficiaries     |     eligible by section |
|                       |                   |     813 (a) or any      |
|                       |                   |     other provision     |
|                       |                   |     like it.            |
|                       |                   |                         |
|                       |                   | 2)  And Medicare        |
|                       |                   |     reimbursement will  |
|                       |                   |     be provided to      |
|                       |                   |     I/T/U's for these   |
|                       |                   |     patients as well.   |
+-----------------------+-------------------+-------------------------+
| New                   | State recovery of | There should be an      |
|                       | Medicaid funded   | exemption for Indian    |
|                       | services.         | beneficiaries from      |
|                       |                   | state recovery of       |
|                       |                   | medical costs of        |
|                       |                   | services provided to    |
|                       |                   | the elderly and for the |
|                       |                   | birth of an Indian      |
|                       |                   | child.                  |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **TITLE IV ACCESS**   | **ISSUES**        | **RECOMMENDATIONS**     |
+-----------------------+-------------------+-------------------------+
| Section 405           | Direct billing on | Section 405 should be   |
|                       | M/M               | made permanent for all  |
|                       |                   | tribes                  |
+-----------------------+-------------------+-------------------------+
| New                   | M/M cost sharing  | Indian beneficiaries    |
|                       | requirements      | shall no longer be      |
|                       |                   | required to make        |
|                       |                   | co-payments or pay      |
|                       |                   | premiums for Medicaid,  |
|                       |                   | Medicare, CHIP or any   |
|                       |                   | other federally funded  |
|                       |                   | health programs.        |
+-----------------------+-------------------+-------------------------+
| New                   | States and CHIP   | States would receive    |
|                       |                   | 100% FMAP for CHIP      |
|                       |                   | services provided by    |
|                       |                   | I/T/U's. There will be  |
|                       |                   | no premiums for IHS     |
|                       |                   | beneficiaries           |
|                       |                   | regardless of where the |
|                       |                   | services are provided.  |
+-----------------------+-------------------+-------------------------+
| New                   | Managed care      | 1)  I/T/U's shall be    |
|                       | reimbursement     |     reimbursed for      |
|                       |                   |     services provided   |
|                       |                   |     to IHS              |
|                       |                   |     beneficiaries even  |
|                       |                   |     when an IHS         |
|                       |                   |     beneficiary is      |
|                       |                   |     enrolled in a       |
|                       |                   |     managed care entity |
|                       |                   |     (Medicaid, Medicare |
|                       |                   |     and Private         |
|                       |                   |     Insurance           |
|                       |                   |     entities).          |
|                       |                   |                         |
|                       |                   | 2)  All managed care    |
|                       |                   |     entities can be     |
|                       |                   |     billed by an I/T/U. |
+-----------------------+-------------------+-------------------------+
| New                   | Billing States    | Allow I/T/U's to bill   |
|                       | directly.         | the States directly     |
|                       |                   | without being required  |
|                       |                   | to go through a managed |
|                       |                   | care entity for         |
|                       |                   | services provided to    |
|                       |                   | IHS beneficiaries       |
|                       |                   | eligible for Medicaid   |
|                       |                   | and CHIP.               |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **TITLE V URBAN**     | **ISSUES**        | **RECOMMENDATIONS**     |
+-----------------------+-------------------+-------------------------+
|                       | Urban programs    | Include Urban programs  |
|                       | are not included  | in HCFA MOA.            |
|                       | in the HCFA       |                         |
|                       | (Health Care      |                         |
|                       | Finance           |                         |
|                       | Administration )  |                         |
|                       | MOA (memorandum   |                         |
|                       | of agreement)     |                         |
+-----------------------+-------------------+-------------------------+
|                       | Should urban      | Urban programs should   |
|                       | programs remain   | remain in Title V, but  |
|                       | in Title V or be  | Title V should specify  |
|                       | dispersed         | that Urban Programs     |
|                       | throughout the    | [are eligible to        |
|                       | IHCIA in other    | p                       |
|                       | titles?           | articipate]{.underline} |
|                       |                   | in other sections with  |
|                       |                   | new funds to provide    |
|                       |                   | for professions,        |
|                       |                   | facilities, services,   |
|                       |                   | etc.                    |
+-----------------------+-------------------+-------------------------+
|                       | Lack of national  | 1)  EPI (Epidemiology)  |
|                       | data on Urban     |     Center established  |
|                       | Indians           |     for Urban Indian    |
|                       |                   |     Health Institute    |
|                       |                   |     to: develop data,   |
|                       |                   |     provide technical   |
|                       |                   |     assistance to urban |
|                       |                   |     programs, conduct   |
|                       |                   |     needs assessment,   |
|                       |                   |                         |
|                       |                   | 2)  And collect urban   |
|                       |                   |     data on national    |
|                       |                   |     level, and be       |
|                       |                   |     included in one of  |
|                       |                   |     three or four       |
|                       |                   |     "Centers of         |
|                       |                   |     Excellence"         |
|                       |                   |     throughout the      |
|                       |                   |     country.            |
+-----------------------+-------------------+-------------------------+
|                       | Many urban areas  | 1)  Establish new urban |
|                       | with large Indian |     programs.           |
|                       | populations do    |                         |
|                       | not have urban    | 2)  Conduct an          |
|                       | Indian Health     |     assessment of       |
|                       | Programs.         |     potential new       |
|                       |                   |     program sites using |
|                       |                   |     current data        |
|                       |                   |     (numbers, health    |
|                       |                   |     status/needs,       |
|                       |                   |     socio-demographic   |
|                       |                   |     variables: age,     |
|                       |                   |     gender, tribe, etc. |
+-----------------------+-------------------+-------------------------+
|                       | I/T/U and         | Recommendations from    |
|                       | Affiliated        | Area meetings are       |
|                       | Indians           | carried forward in the  |
|                       | (non-federally    | consultation process.   |
|                       | recognized        |                         |
|                       | Indians) engaged  |                         |
|                       | in consultation   |                         |
|                       | process at the    |                         |
|                       | Area level and    |                         |
|                       | produced          |                         |
|                       | recommendations   |                         |
|                       | for IHCIA.        |                         |
+-----------------------+-------------------+-------------------------+
|                       | NIAAA programs    | Complete the conversion |
|                       | have authority to | of all NIAAA programs   |
|                       | be converted to   | and funding from the    |
|                       | Title V, Indian   | Alcohol and Substance   |
|                       | Health Services   | Abuse Programs to Title |
|                       | has not completed | V by the year 2001.     |
|                       | the conversion.   |                         |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **TITLE V URBAN**     | **ISSUES**        | **RECOMMENDATIONS**     |
+-----------------------+-------------------+-------------------------+
|                       | Relationship      | 1)  Need for            |
|                       | between tribes    |                         |
|                       | and urban         |   dialogue/relationship |
|                       | programs.         |     building process    |
|                       |                   |     between the Tribes  |
|                       |                   |     and Urban Programs  |
|                       |                   |     in order to speak   |
|                       |                   |     with one voice.     |
|                       |                   |     Major issues that   |
|                       |                   |     need to be worked   |
|                       |                   |     out include:        |
|                       |                   |                         |
|                       |                   | ```{=html}              |
|                       |                   | <!-- -->                |
|                       |                   | ```                     |
|                       |                   | (a) **Eligibility** --  |
|                       |                   |     issues around       |
|                       |                   |     enrollment status,  |
|                       |                   |     federally           |
|                       |                   |     recognized vs.      |
|                       |                   |     Affiliated Indians, |
|                       |                   |     members from other  |
|                       |                   |     tribes, etc.        |
|                       |                   |                         |
|                       |                   | (b) **Access** --       |
|                       |                   |     because of          |
|                       |                   |     inconsistency in    |
|                       |                   |     access regulations, |
|                       |                   |     many Indians are    |
|                       |                   |     not served.         |
|                       |                   |                         |
|                       |                   | (c) **Equity** -- with  |
|                       |                   |     the majority of     |
|                       |                   |     Indians located in  |
|                       |                   |     urban areas, only   |
|                       |                   |     1% of budget goes   |
|                       |                   |     to serve Urban      |
|                       |                   |     Indians.            |
+-----------------------+-------------------+-------------------------+
|                       | Urban programs    | Urban programs need to  |
|                       | are not always    | be involved in the      |
|                       | involved in       | consultation process in |
|                       | consultation      | order to network and    |
|                       | process           | advocate for their      |
|                       |                   | needs at the national   |
|                       |                   | and tribal levels.      |
+-----------------------+-------------------+-------------------------+
| **CROSS CUTTING**     | **ISSUE**         | **RECOMMENDATION**      |
+-----------------------+-------------------+-------------------------+
| Medicaid and Managed  | To extend 100%    | 1)  Regulations should  |
| Care                  | FMAP to States    |     be developed to     |
|                       | for services      |     specify the IHS     |
|                       | provided to all   |     encounter rate by   |
|                       | individuals made  |     law. A joint Tribal |
|                       | eligible by       |     and Federal group   |
|                       | section 813.      |     will develop the    |
|                       |                   |     regulations.        |
|                       |                   |                         |
|                       |                   | 2)  These regulations   |
|                       |                   |     will develop        |
|                       |                   |     Medicaid            |
|                       |                   |     reimbursement rate  |
|                       |                   |     for I/T/U's' and    |
|                       |                   |     define what         |
|                       |                   |     services would be   |
|                       |                   |     covered under that  |
|                       |                   |     rate.               |
+-----------------------+-------------------+-------------------------+
| Medicaid and Managed  | IHS unable to     | IHS exempted by Anti-   |
| Care                  | participate in    | deficiency Act for      |
|                       | managed           | purposes of contracting |
|                       | care/Medicaid     | with MCO's              |
|                       | systems as full   |                         |
|                       | partner.          |                         |
+-----------------------+-------------------+-------------------------+
| Medicaid and Managed  | Demo project for  | 1)  I/T/U's to be the   |
| Care                  | I/T/U's           |     actual MCO to       |
|                       |                   |     identify some of    |
|                       |                   |     the risks and       |
|                       |                   |     issues.             |
|                       |                   |                         |
|                       |                   | 2)  I/T/U's as Network  |
|                       |                   |     Provider to fund a  |
|                       |                   |     risk pool or other  |
|                       |                   |     stop loss           |
|                       |                   |     mechanism.          |
+-----------------------+-------------------+-------------------------+
| Medicaid and Managed  | Accreditation and | Consolidated            |
| Care                  | Licensure system. | accreditation and       |
|                       |                   | licensure system is     |
|                       |                   | considered as an        |
|                       |                   | alternative to the      |
|                       |                   | existing certification  |
|                       |                   | and licensure process.  |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **CROSS CUTTING**     | **ISSUE**         | **RECOMMENDATION**      |
+-----------------------+-------------------+-------------------------+
| Medicaid and Managed  | Tribes are        | Tribal governments be   |
| Care                  | interested in     | given the authority to  |
|                       | becoming "MCO".   | make eligibility        |
|                       |                   | determinations for      |
|                       |                   | Medicaid and CHIP       |
+-----------------------+-------------------+-------------------------+
| Mental Health &       | "Mental Health"   |                         |
| Substance Abuse       | is stereotyped in |                         |
|                       | Native American   |                         |
|                       | communities.      |                         |
+-----------------------+-------------------+-------------------------+
| Mental Health &       | Fragmentation of  | 1)  Need to redefine    |
| Substance Abuse       | issues vs.        |     our definitions or  |
|                       | holistic          |     concepts (i.e.:     |
|                       | approach:         |     Prevention).        |
|                       | depressions,      |     Tendency to focus   |
|                       | substance abuse,  |     of weakness and not |
|                       | post traumatic    |     strengths.          |
|                       | disorder, abuse,  |                         |
|                       | and domestic      | 2                       |
|                       | abuse.            | )  Competition/Conflict |
|                       |                   |     between Mental      |
|                       |                   |     Health and          |
|                       |                   |     Substance Abuse     |
|                       |                   |     around these issues |
|                       |                   |     requires holistic   |
|                       |                   |     approach.           |
+-----------------------+-------------------+-------------------------+
| Mental Health &       | "Walking the      | 1)  Flexibility to      |
| Substance Abuse       | Talk" regarding   |     create "local       |
|                       | tradition.        |     models" redefining  |
|                       |                   |     terms, concepts,    |
|                       |                   |     approaches that are |
|                       |                   |     more community      |
|                       |                   |     friendly. Tailored  |
|                       |                   |     to the local        |
|                       |                   |     community.          |
|                       |                   |                         |
|                       |                   | 2)  Evaluation: What is |
|                       |                   |     working?            |
+-----------------------+-------------------+-------------------------+
| Mental Health &       | With traditional  | 1)  Orientation         |
| Substance Abuse       | approaches there  |     programs for new    |
|                       | is issue of       |     providers. Bridge   |
|                       | stigma and        |     building between    |
|                       |                   |     traditional and     |
|                       | Cultural          |     medical             |
|                       | competency in     |     practitioners.      |
|                       | treatment         |                         |
|                       | providers from    | 2)  Ongoing process for |
|                       | outside the       |     new staff and       |
|                       | community.        |     community people.   |
|                       | Cultural clash    |     Healing plans need  |
|                       | between           |     to be developed by  |
|                       | traditional and   |     tradition healers   |
|                       | western medical   |     and western         |
|                       | model paradigms.  |     healers.            |
+-----------------------+-------------------+-------------------------+
| Mental Health &       | Education or      | 1)  Funding in existing |
| Substance Abuse       | scholarship       |     language need to    |
|                       | programs are      |     address             |
|                       | fiercely          |     collaboration with  |
|                       | competitive, even |     tribal colleges.    |
|                       | the students'     |                         |
|                       | without straight  | 2)  Decentralize the    |
|                       | "A's" but are     |     scholarship         |
|                       | committed to      |     program.            |
|                       | their community   |                         |
|                       | are sometimes     | 3)  Needs to be         |
|                       | overlooked.       |     equity/fairness in  |
|                       |                   |     award.              |
|                       |                   |                         |
|                       |                   | 4)  Share information   |
|                       |                   |     regarding pilot     |
|                       |                   |     programs.           |
|                       |                   |                         |
|                       |                   | 5)  Applicants' need to |
|                       |                   |     have a commitment   |
|                       |                   |     to their community. |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **CROSS CUTTING**     | **ISSUE**         | **RECOMMENDATION**      |
+-----------------------+-------------------+-------------------------+
| Mental Health &       | Model Programs:   | 1)  Locate project that |
| Substance Abuse       | New approaches    |     demonstrates "cost  |
|                       | that seem to be   |     effectiveness" of   |
|                       | working in Indian |     developing          |
|                       | Country.          |     effective mental    |
|                       |                   |     health/substance    |
|                       |                   |     abuse programs in   |
|                       |                   |     Indian communities. |
|                       |                   |                         |
|                       |                   | 2)  Family treatment,   |
|                       |                   |     working with the    |
|                       |                   |     whole family.       |
|                       |                   |                         |
|                       |                   | 3)  Findings from this  |
|                       |                   |     project disseminate |
|                       |                   |     throughout Indian   |
|                       |                   |     country.            |
+-----------------------+-------------------+-------------------------+
| Mental Health &       | Aftercare and     | 1)  Continue current    |
| Substance Abuse       | continuing care   |     aftercare study in  |
|                       | is not available  |     next phases and     |
|                       | in many           |     broader expansion.  |
|                       | communities.      |     Fund aftercare now. |
|                       |                   |                         |
|                       |                   | 2)  Incorporate         |
|                       |                   |     existing studies    |
|                       |                   |     such as the         |
|                       |                   |     aftercare study     |
|                       |                   |     recently done at    |
|                       |                   |     the Native American |
|                       |                   |     Research and        |
|                       |                   |     Training Center at  |
|                       |                   |     the Northern        |
|                       |                   |     Arizona University. |
+-----------------------+-------------------+-------------------------+
| Mental Health &       | Pilot Programs    | 1)  If successful, open |
| Substance Abuse       |                   |     up to everyone      |
|                       |                   |     else.               |
|                       |                   |                         |
|                       |                   | 2)  Disseminate         |
|                       |                   |     information from    |
|                       |                   |     pilot projects,     |
|                       |                   |     studies, etc.       |
+-----------------------+-------------------+-------------------------+
| Mental Health &       | Training staffs   | 1)                      |
| Substance Abuse       | and pay issues.   |  Certification/training |
|                       |                   |     programs for        |
|                       |                   |     American            |
|                       |                   |     Indian/Alaska       |
|                       |                   |     Native staff for    |
|                       |                   |     substance abuse     |
|                       |                   |     treatment           |
|                       |                   |     providers.          |
|                       |                   |                         |
|                       |                   | 2)  Competitive pay to  |
|                       |                   |     retain trained      |
|                       |                   |     staff.              |
+-----------------------+-------------------+-------------------------+
| Mental Health &       | Objectives in     | 1)  Dr. Trujillo and    |
| Substance Abuse       | status report for |     the Secretary of    |
|                       | mental            |     DHS should include  |
|                       | health/substance  |     Tribes in reporting |
|                       | abuse need a      |     of status of        |
|                       | strong advocate   |     objectives to       |
|                       | within Indian     |     Congress.           |
|                       | Health Service to |                         |
|                       | get it pushed     | 2)  Mental health and   |
|                       | through.          |     substance abuse     |
|                       |                   |     issues become       |
|                       |                   |     funding priority.   |
|                       |                   |                         |
|                       |                   | 3)  Level of "need"     |
|                       |                   |     funded, does this   |
|                       |                   |     adequately reflect  |
|                       |                   |     the true mental     |
|                       |                   |     health/substance    |
|                       |                   |     abuse needs.        |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **CROSS CUTTING**     | **ISSUE**         | **RECOMMENDATION**      |
+-----------------------+-------------------+-------------------------+
| **I/T/U Partnership   | Minimizing        | 1)  Need to work toward |
| For The Future**      | conflicts,        |     minimizing          |
|                       | continuing        |     conflicts,          |
|                       | dialogue between  |     continuing          |
|                       | I/T/U's           |     dialogue,           |
|                       |                   |     communication       |
|                       |                   |     between tribes and  |
|                       |                   |     urban programs      |
|                       |                   |     needs improvement,  |
|                       |                   |     respect is          |
|                       |                   |     necessary.          |
|                       |                   |                         |
|                       |                   | 2)  Protocols and       |
|                       |                   |     forums based on     |
|                       |                   |     "Seattle" model     |
|                       |                   |     could be considered |
|                       |                   |     in improving        |
|                       |                   |     communications.     |
+-----------------------+-------------------+-------------------------+
| I/T/U Partnership For | Urban Indians     | Urban Indian Health     |
| The Future            | need services     | programs are needed.    |
+-----------------------+-------------------+-------------------------+
| I/T/U Partnership For | Government to     |                         |
| The Future            | government        |                         |
|                       | relationships is  |                         |
|                       | between federal   |                         |
|                       | government and    |                         |
|                       | tribes.           |                         |
+-----------------------+-------------------+-------------------------+
| I/T/U Partnership For | Tribes'           | 1)  Tribes              |
| The Future            | responsibility    |     responsibility      |
|                       | for their people. |     [for]{.underline}   |
|                       |                   |     their people and    |
|                       |                   |     [to]{.underline}    |
|                       |                   |     their people,       |
|                       |                   |     wherever they are,  |
|                       |                   |     based on individual |
|                       |                   |     tribal government's |
|                       |                   |     determination.      |
|                       |                   |                         |
|                       |                   | 2)  These               |
|                       |                   |     determinations by   |
|                       |                   |     Tribes to serve     |
|                       |                   |     their members may   |
|                       |                   |     be based on their   |
|                       |                   |     governmental        |
|                       |                   |     authorities,        |
|                       |                   |     priorities,         |
|                       |                   |     resources, and      |
|                       |                   |     other               |
|                       |                   |     determinations.     |
+-----------------------+-------------------+-------------------------+
| I/T/U Partnership For | Individuals       | There are other         |
| The Future            | residing on       | individuals residing on |
|                       | "public domain    | public domain           |
|                       | allotments" and   | allotments and other    |
|                       | other allotments. | allotments that need to |
|                       |                   | be considered in the    |
|                       |                   | I/T/U partnership.      |
+-----------------------+-------------------+-------------------------+
| I/T/U Partnership For | An insufficient   | 1)  We will not let     |
| The Future            | resource for      |     limited resources   |
|                       | Tribes, urban or  |     be a divisive issue |
|                       | other programs to |     for the I/T/U       |
|                       | provide health    |     partnership.        |
|                       | services to their |                         |
|                       | members.          | 2)  Federal government  |
|                       |                   |     has obligation to   |
|                       |                   |     provide health      |
|                       |                   |     care, Indian Health |
|                       |                   |     Service has         |
|                       |                   |     responsibility for  |
|                       |                   |     all American        |
|                       |                   |     Indians/Alaska      |
|                       |                   |     Natives no matter   |
|                       |                   |     where they are.     |
+-----------------------+-------------------+-------------------------+
| Entitlement Benefit   | There are regions | Work along two tracks:  |
| Package & Health      | (including all of |                         |
| Disparity             | California) that  | 1)  Examine options     |
|                       | do not have       |     (outside the box)   |
|                       | hospitals.        |     in a broader        |
|                       |                   |     entitlement         |
|                       |                   |     approach            |
|                       |                   |                         |
|                       |                   | 2)  Continue to examine |
|                       |                   |     maximization of     |
|                       |                   |     existing            |
|                       |                   |     entitlements (M/M)  |
|                       |                   |     to get closer to    |
|                       |                   |     full funding.       |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

  ------------------------ -------------------- --------------------------
  **CROSS CUTTING**        **ISSUE**            **RECOMMENDATION**

  Entitlement Benefit      Need meaningful data 
  Package & Health         on health            
  Disparity                disparities in order 
                           to assess need.      

  Entitlement Benefit      "Entitlement" is     
  Package & Health         virtually always     
  Disparity                seen as an           
                           individual benefit,  
                           and outsiders would  
                           not understand that  
                           "entitlement" would  
                           apply to a group in  
                           this case.           

  Entitlement Benefit      Entitlement benefits 
  Package & Health         could be applied in  
  Disparity                at least three       
                           different ways: (1)  
                           individual patient   
                           entitlement; (2)     
                           program I/T/U system 
                           entitlement; or (3)  
                           tribal government    
                           entitlement.         

  Entitlement Benefit      Reduce funding to    
  Package & Health         some tribal health   
  Disparity                centers in order to  
                           bring other clinics  
                           up.                  

  Entitlement Benefit      Disparity in health  
  Package & Health         status and funding   
  Disparity                levels.              

  Entitlement Benefit      In defining need,    
  Package & Health         there has to be      
  Disparity                agreement. Then an   
                           unwieldy number of   
                           variable get         
                           introduced so each   
                           group feels          
                           represented.         

  Entitlement Benefit      There is perception  
  Package & Health         that gaming tribes   
  Disparity                have less "need".    

  Entitlement Benefit      Need a mechanism to  
  Package & Health         separate our         
  Disparity                financial needs from 
                           a voluntary annual   
                           budget (annual       
                           appropriation).      

  Entitlement Benefit      It is a Federal      
  Package & Health         responsibility to    
  Disparity                provide health care  
                           to Indian people;    
                           health care for      
                           Indian people should 
                           be an entitlement.   
  ------------------------ -------------------- --------------------------

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

  ------------------------ -------------------- --------------------------
  **CROSS CUTTING**        **ISSUE**            **RECOMMENDATION**

  Entitlement Benefit      Access must include  
  Package & Health         access to health     
  Disparity                care AND access to   
                           Indian heath care.   

  Entitlement Benefit      Funding packages     
  Package & Health         need to be joined    
  Disparity                together to become a 
                           lump sum. Combine    
                           money for all        
                           eligible Medicare or 
                           Medicaid tribal      
                           members with IHS.    
                           Many poor Indians do 
                           not apply for money  
                           they are entitled    
                           to. If it came       
                           through a bundled    
                           Indian Health        
                           package, the tribes  
                           and tribal members   
                           could access that    
                           funding.             
  ------------------------ -------------------- --------------------------

Entitlement Benefit Package & Health Disparity's

POINTS OF CONCENSUS: Indian people ARE entitled to health care services
by virtue of massive contributions to this country's benefit.

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **CROSS CUTTING**     | **ISSUES**        | **RECOMMENDATIONS**     |
+-----------------------+-------------------+-------------------------+
| ##                    | Implementation of | Use IHCIA to amend      |
| Other Emerging Issues | the Indian Child  | American Indian Child   |
|                       | Protection Act    | Protection Act to all   |
|                       |                   | some flexibility, while |
|                       |                   | implementing the intent |
|                       |                   | of the Law.             |
+-----------------------+-------------------+-------------------------+
| ##                    | Linkages with     | Expand authorized       |
| Other Emerging Issues | other agencies to | linkages to other       |
|                       | construct         | federal agencies and    |
|                       | facilities;       | departments to include  |
|                       | involve other     | all function and        |
|                       | Agencies and      | services                |
|                       | departments in    |                         |
|                       | facilities        |                         |
|                       | construction.     |                         |
+-----------------------+-------------------+-------------------------+
| ##                    | Public Health     | 1)  The act should      |
| Other Emerging Issues | issues/functions  |     address Public      |
|                       | as it relates to  |     Health Issues and   |
|                       | tribal            |     functions as it     |
|                       | governments.      |     relates to tribal   |
|                       |                   |     governments and     |
|                       |                   |     should include all  |
|                       |                   |     public health       |
|                       |                   |     issues/functions.   |
|                       |                   |                         |
|                       |                   | 2)  Consider inserting  |
|                       |                   |     a section in the    |
|                       |                   |     act that address    |
|                       |                   |     public health       |
|                       |                   |     issues function     |
|                       |                   |     (Epi center) and    |
|                       |                   |     combining issues    |
|                       |                   |     from through out    |
|                       |                   |     the act.            |
|                       |                   |                         |
|                       |                   | 3)  Authorize funding   |
|                       |                   |     to allow tribes t   |
|                       |                   |     develop the public  |
|                       |                   |     health capacity at  |
|                       |                   |     tribal level.       |
|                       |                   |                         |
|                       |                   | 4)  Linkage with        |
|                       |                   |     State(s) to allow   |
|                       |                   |     tribes to access    |
|                       |                   |     funding for Public  |
|                       |                   |     Health services.    |
+-----------------------+-------------------+-------------------------+
| Other Emerging Issues | Exempt tribal     | Limited/flexible waiver |
|                       | match for all     | of Grant matching       |
|                       | Grants.           | requirement(s).         |
+-----------------------+-------------------+-------------------------+
| Other Emerging Issues | Certify that      | Not an issue, Authority |
|                       | tribes may take   | already present (638)   |
|                       | title to federal  |                         |
|                       | "Real Property".  |                         |
+-----------------------+-------------------+-------------------------+
| Other Emerging Issues | Linkages to other | Deal with on a case by  |
|                       | Federal           | case basis.             |
|                       | Age               |                         |
|                       | ncies/Departments |                         |
+-----------------------+-------------------+-------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

REGIONAL MEETING: ALASKA, PORTLAND, CALIFORNIA AREA

+-----------------------+-------------------+-------------------------+
| **CROSS CUTTING**     | **ISSUE**         | **RECOMMENDATION**      |
+-----------------------+-------------------+-------------------------+
| Other Emerging Issues | #                 | Expand scope of IHS     |
|                       | Emerging services | authorized services to  |
|                       |                   | include emerging        |
|                       |                   | services. (no           |
|                       |                   | consensus)              |
+-----------------------+-------------------+-------------------------+
| Other Emerging Issues | Traditional       | Authorize the ability   |
|                       | programs in the   | to operate Traditional  |
|                       | IHS facilities.   | programs in the IHS     |
|                       |                   | facility.(no consensus) |
+-----------------------+-------------------+-------------------------+
| Other Emerging Issues | Environmental     | Authorize the IHS to    |
|                       | related diseases  | deal with environmental |
|                       |                   | related diseases.       |
|                       |                   |                         |
|                       |                   | (no consensus)          |
+-----------------------+-------------------+-------------------------+
| Other Emerging Issues | Health aspects of | Create venue to         |
|                       | casinos           | articulate positive     |
|                       |                   | health aspects of       |
|                       |                   | Casinos.                |
|                       |                   |                         |
|                       |                   | (no consensus)          |
+-----------------------+-------------------+-------------------------+
| ##                    | Exempt Tribes on  | Exempt Tribes and       |
| Other Emerging Issues | Davis Bacon       | tribal organizations    |
|                       | wages.            | from having to pay      |
|                       |                   | Davis Bacon wages on    |
|                       |                   | contracts and           |
|                       |                   | subcontracts.           |
|                       |                   |                         |
|                       |                   | (no consensus)          |
+-----------------------+-------------------+-------------------------+

**Other Emerging Issues'**

**General Comments: A statement of linkages should be emphasized perhaps
as part of preamble.**

### Summary of Individual Recommendations

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

RECOMMENDATIONS AS SUBMITTED BY INDIVIDUALS

+-------------+-----------------+--------------------------------------+
| # TITLE     | # ISSUES        | # RECOMMENDATIONS                    |
|  II -- Heal |                 |                                      |
| th Services |                 |                                      |
+-------------+-----------------+--------------------------------------+
| 202(a)(1)   | Catastrophic    | "In recognition of the need for      |
|             | Health          | additional resources to meet the     |
|             | Emergency Fund  | extraordinary costs of catastrophic  |
|             |                 | illness, natural disasters, or newly |
|             |                 | emerging infectious disease          |
|             |                 | epidemics such as HIV/AIDS, the      |
|             |                 | Indian catastrophic health emergency |
|             |                 | fund (hereinafter referred to this   |
|             |                 | section as the "fund") is            |
|             |                 | established."                        |
+-------------+-----------------+--------------------------------------+
| 202(a)(5)   | Catastrophic    | "A portion of these funds may be     |
|             | Health          | used to purchase HIV/AIDS            |
|             | Emergency Fund  | medications in bulk and made         |
|             |                 | available for national distribution  |
|             |                 | to all qualified IHS-funded health   |
|             |                 | systems."                            |
+-------------+-----------------+--------------------------------------+
| 2XX         | National I/T/U  | Section 2XX -- In recognition of the |
|             | New Drugs       | fact that newly emerging diseases    |
|             | Purchasing,     | like HIV/AIDS do occur, and the      |
|             | Storage and     | drugs used to treat such diseases    |
|             | Distribution    | are often extraordinarily costly,    |
|             | Programs        | this Act makes a provision for the   |
|             |                 | purchase, storage and distribution   |
|             |                 | of such drugs through a national,    |
|             |                 | centralized and contracted service.  |
|             |                 |                                      |
|             |                 | (a) The Secretary, acting through    |
|             |                 |     the Service, and in consultation |
|             |                 |     with the Health Resources and    |
|             |                 |     Services Administration, shall   |
|             |                 |     establish a national drug        |
|             |                 |     purchasing, storage and          |
|             |                 |     distribution program for         |
|             |                 |     newly-developed and expensive    |
|             |                 |     drugs to treat emerging diseases |
|             |                 |     such as HIV/AIDS for I/T/U,      |
|             |                 |     through a grant to a private     |
|             |                 |     non-profit corporation with      |
|             |                 |     national scope. This grant       |
|             |                 |     shall:                           |
|             |                 |                                      |
|             |                 | ```{=html}                           |
|             |                 | <!-- -->                             |
|             |                 | ```                                  |
|             |                 | (1) Include the selection of a       |
|             |                 |     single I/T/U pharmacy for        |
|             |                 |     storage at an advantageous       |
|             |                 |     location.                        |
|             |                 |                                      |
|             |                 | (2) Require the collection of        |
|             |                 |     demographic and epidemiological  |
|             |                 |     data on each patient being       |
|             |                 |     treated with such drugs for      |
|             |                 |     reportable diseases, and the     |
|             |                 |     sharing of such data with each   |
|             |                 |     state epidemiology department in |
|             |                 |     which the patient resides, and   |
|             |                 |     with the Centers for Disease     |
|             |                 |     Control and Prevention.          |
|             |                 |                                      |
|             |                 | (3) Require such drugs to be         |
|             |                 |     purchased at the lowest possible |
|             |                 |     cost to the federal government.  |
|             |                 |                                      |
|             |                 | (4) Require the drug formulary to be |
|             |                 |     based on that of the state with  |
|             |                 |     the broadest selection of        |
|             |                 |     approved drugs.                  |
|             |                 |                                      |
|             |                 | (5) Require such drugs to be made    |
|             |                 |     available to any individual      |
|             |                 |     qualified to receive services in |
|             |                 |     the I/T/U.                       |
+-------------+-----------------+--------------------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

RECOMMENDATIONS AS SUBMITTED BY INDIVIDUALS

+-------------+-----------------+--------------------------------------+
| #           | # ISSUES        | # RECOMMENDATIONS                    |
| TITLE -- II |                 |                                      |
|             |                 |                                      |
| **Health    |                 |                                      |
| Services**  |                 |                                      |
+-------------+-----------------+--------------------------------------+
| Section 214 | Epidemiology    | Add 214(a)(7) as follows:            |
|             | Centers         |                                      |
|             |                 | "Epidemiology centers shall be       |
|             |                 | responsible in each area for         |
|             |                 | collecting and submitting case       |
|             |                 | reports on behalf of the tribes for  |
|             |                 | all reportable infectious diseases   |
|             |                 | to the state epidemiologist's office |
|             |                 | in which the case is located. This   |
|             |                 | is required in order to insure the   |
|             |                 | effective coordination of disease    |
|             |                 | surveillance within each state's     |
|             |                 | boundaries, and nationally. Such an  |
|             |                 | arrangement will respect tribal      |
|             |                 | governments' relationship to the     |
|             |                 | Federal Government."                 |
+-------------+-----------------+--------------------------------------+
| Title II    | Tribes unable   | Lower CHEF threshold by 50% for      |
|             | to meet the     | tribes.                              |
|             | 100% CHEF       |                                      |
|             | threshold.      |                                      |
+-------------+-----------------+--------------------------------------+
| Health      | Community       | Request \$1.5 million increase in    |
| Services/Pr | Health          | training dollars, possibly more,     |
| ofessionals | Representatives | [per]{.underline}                    |
|             |                 | [year]{.underline}. Currently        |
|             |                 | training dollars is inadequate. As   |
|             |                 | Community Health Representatives     |
|             |                 | expand services as a valuable        |
|             |                 | component of Indian Health, we need  |
|             |                 | an increase in funding for more      |
|             |                 | positions in all 12 areas.           |
|             |                 | Population growth in Indian country  |
|             |                 | demands for more Community Health    |
|             |                 | Representatives.                     |
+-------------+-----------------+--------------------------------------+
| 216 --      | Can the grant   | All organizations focusing on        |
| Indian      | be allocated to | improving health of Native American  |
| Youth Grant | IHS Contracted  | and Alaska Indians be eligible to    |
| Program     | Clinics         | receive funding from these grants.   |
+-------------+-----------------+--------------------------------------+
| Universal   | Many T/U        | Provide equitable access to          |
| P           | facilities are  | prescription medication regardless   |
| rescription | unable to       | of CHS status, availability of       |
| Benefit     | provide         | on-site pharmacy services, clinic    |
| (Add item K | prescription    | size, clinic location, or governance |
| of section  | medication      | status (I/T/U).                      |
| 201)        | benefits. "Gap" |                                      |
|             | Indian patients |                                      |
|             | are unable to   |                                      |
|             | get the         |                                      |
|             | medicines       |                                      |
|             | prescribed at   |                                      |
|             | their clinic    |                                      |
|             | visit,          |                                      |
|             | effectively     |                                      |
|             | negating the    |                                      |
|             | benefit of the  |                                      |
|             | clinic visit.   |                                      |
+-------------+-----------------+--------------------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

RECOMMENDATIONS AS SUBMITTED BY INDIVIDUALS

+-------------+-----------------+--------------------------------------+
| #           | # ISSUES        | # RECOMMENDATIONS                    |
| TITLE -- II |                 |                                      |
|             |                 |                                      |
| **Health    |                 |                                      |
| Services**  |                 |                                      |
+-------------+-----------------+--------------------------------------+
| # Heal      | # Public Heal   | # In the act, ADD, the               |
| th Services | th function --  | public health function for Indian la |
|             | IHCIA does not  | nd and for Indian people; also inclu |
|             | address the tri | de environmental health and other pu |
|             | bal governments | blic health services as appropriate. |
|             |  and federal go |                                      |
|             | vernment's role | 1)  The act addresses the many       |
|             |  for public hea |     public health issues, the act    |
|             | lth for Indian  |     does not address the public      |
|             | lands and reser |     health responsibility of Tribal  |
|             | vations and for |     governments; and establish       |
|             |  Indian people. |     funding mechanism for other      |
|             |                 |     federal public health dollars,   |
|             |                 |     not funded by IHS.               |
+-------------+-----------------+--------------------------------------+
| #           | # Hea           | # Put under IHS authorit             |
| Comprehensi | dStart Programs | y for improved service delivery/adap |
| ve school h |                 | tability to rural and cultural -- wh |
| ealth educa |                 | ile still meeting intent. Need flexi |
| tion progra |                 | bility here -- extremely difficult t |
| ms. New aut |                 | o deliver under current regulations. |
| hority over |                 |                                      |
+-------------+-----------------+--------------------------------------+
| # TITLE III | # ISSUES        | # RECOMMENDATIONS                    |
+-------------+-----------------+--------------------------------------+
| Section 3 - | Definition of   | Include language and advocate for    |
| Declaration | "Indian", we    | change in language to include        |
| of Health   | are fooling     | "non-Federally recognized            |
| Objectives  | ourselves if we | groups/terminated groups" -- Then    |
|             | say we are      | and only then can we truly say we    |
|             | speaking with   | speak with one voice even this P.L.  |
|             | one voice.      | 94-437 reads its obligation to all   |
|             |                 | Native Americans in providing health |
|             |                 | care. . . no need to say more.       |
+-------------+-----------------+--------------------------------------+
| Section 3   | Leasing         | Reauthorization should raise issue   |
| -- Health   | authority under | of eliminating "Scoring Penalty"     |
| Facilities  | §804 (§804,     | which limits use of §804 to use IHS  |
|             | not§104)        | lease funds to pay off construction  |
|             | Funding         | loan -- may need to amend balanced   |
|             |                 | budget act but may be able to work   |
|             |                 | it out with OMB. National workgroup  |
|             |                 | should meet with OMB.                |
+-------------+-----------------+--------------------------------------+
| # TITLE IV  | # ISSUES        | # RECOMMENDATIONS                    |
+-------------+-----------------+--------------------------------------+
| Title IV -- | Medical and     | Indian tribes that administer a      |
| Access to   | CHIP            | tribal TANF program are authorized   |
| Health      | eligibility     | to determine eligibility for         |
| Services    |                 | Medi-Cal and Children's Health       |
|             |                 | Insurance Program.                   |
+-------------+-----------------+--------------------------------------+
| Access      | Is there any    | If so, need language to allow this.  |
|             | prohibition     | Also need to allow Indians who never |
|             | against I/T/Us  | signed up for Medicare Part B, to do |
|             | using service   | so without having to pay large       |
|             | dollars or      | dollar amounts now required.         |
|             | collections to  |                                      |
|             | purchase        | Also need to look at estate recovery |
|             | Medicare Part   | for Medicaid -- Impact of requiring  |
|             | B, co-pays for  | elders to sign up for Medicaid for   |
|             | Medicare, or to | QUMBY, SLIMBY, home health care --   |
|             | buy private     | need to get waiver from estate       |
|             | health          | recovery requirements (for those who |
|             | insurance?      | are CHS eligible at a minimum) for   |
|             |                 | Indians.                             |
+-------------+-----------------+--------------------------------------+
| Access --   | California      | Equitable funding be distributed     |
| Contract    | tribes are      | equally and increase from \$114 per  |
| Health Care | reimbursed at   | patient to the national level per    |
| Shortfalls  | \$114.00 per    | user of \$259.                       |
|             | patient user    |                                      |
|             | verses \$259.00 |                                      |
|             | reimbursement   |                                      |
|             | at the National |                                      |
|             | level.          |                                      |
+-------------+-----------------+--------------------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

RECOMMENDATIONS AS SUBMITTED BY INDIVIDUALS

+-------------+-----------------+--------------------------------------+
| # TITLE V   | # ISSUES        | # RECOMMENDATIONS                    |
+-------------+-----------------+--------------------------------------+
| Section 5XX | Prevention and  | "(a) The Secretary, through the      |
|             | treatment of    | Service, shall make grants to urban  |
|             | HIV/AIDS and    | clinics, substance abuse treatment   |
|             | other           | programs, and other American         |
|             | sexua           | Indian/Alaska Native urban           |
|             | lly-transmitted | community-based organizations for    |
|             | diseases        | programs to improve the prevention   |
|             |                 | and treatment of HIV/AIDS and other  |
|             |                 | sexually-transmitted diseases.       |
|             |                 |                                      |
|             |                 | (b) Any grant made by the Secretary  |
|             |                 |     under this section shall include |
|             |                 |     requirements that:               |
|             |                 |                                      |
|             |                 | ```{=html}                           |
|             |                 | <!-- -->                             |
|             |                 | ```                                  |
|             |                 | (1) A thorough needs assessment be   |
|             |                 |     completed in the first year of   |
|             |                 |     the program to identify the most |
|             |                 |     promising areas of intervention  |
|             |                 |     and appropriate target           |
|             |                 |     populations.                     |
|             |                 |                                      |
|             |                 | (2) Grantees be encouraged to seek   |
|             |                 |     technical assistance for program |
|             |                 |     development from providers       |
|             |                 |     funded by the Centers for        |
|             |                 |     Disease Control and Prevention's |
|             |                 |     National and Regional Minority   |
|             |                 |     Organizations program and the    |
|             |                 |     Health Resources and Services    |
|             |                 |     Administration Special Projects  |
|             |                 |     of National Significance         |
|             |                 |     program.                         |
|             |                 |                                      |
|             |                 | (3) All prevention programs be       |
|             |                 |     targeted to specific             |
|             |                 |     sub-populations who are at risk  |
|             |                 |     based on evidence provided by    |
|             |                 |     disease surveillance, other      |
|             |                 |     epidemiological studies,         |
|             |                 |     behavioral studies, criminal     |
|             |                 |     justice records, and similar     |
|             |                 |     community profile data.          |
|             |                 |                                      |
|             |                 | (4) Proposed intervention be         |
|             |                 |     grounded in what has been        |
|             |                 |     learned through behavioral       |
|             |                 |     science and through traditional  |
|             |                 |     cultural teachings.              |
|             |                 |                                      |
|             |                 | (5) All proposed treatment of case   |
|             |                 |     services programs participate in |
|             |                 |     the National Native American     |
|             |                 |     AIDS Prevention Center's         |
|             |                 |     national research database.      |
|             |                 |                                      |
|             |                 | (6) Evaluation studies be built into |
|             |                 |     each project's overall design    |
|             |                 |     after the first year of          |
|             |                 |     assessment.                      |
|             |                 |                                      |
|             |                 | ```{=html}                           |
|             |                 | <!-- -->                             |
|             |                 | ```                                  |
|             |                 | (c) The Secretary shall also,        |
|             |                 |     through the Service, insure that |
|             |                 |     necessary sums are available to  |
|             |                 |     grantees for the purchase of     |
|             |                 |     technical assistance.            |
+-------------+-----------------+--------------------------------------+
| #           | # ISSUES        | # RECOMMENDATIONS                    |
|  TITLE VIII |                 |                                      |
+-------------+-----------------+--------------------------------------+
| # Prov      | # At presen     | Provide T/U's with direct VA Prime   |
| ide for Dir | t, T/U's sites  | Vendor access.                       |
| ect Access  | that wish to ac |                                      |
| to the VA P | cess the VA's P |                                      |
| rime Vendor | rime Vendor pro |                                      |
|             | gram must go th |                                      |
|             | rough an Indian |                                      |
|             |  Health Service |                                      |
|             |  intermediary.  |                                      |
|             | Tribes should b |                                      |
|             | e able to have  |                                      |
|             | direct access t |                                      |
|             | o the VA Prime  |                                      |
|             | Vendor program. |                                      |
+-------------+-----------------+--------------------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

RECOMMENDATIONS AS SUBMITTED BY INDIVIDUALS

+-------------+-----------------+--------------------------------------+
| #           | # ISSUES        | # RECOMMENDATIONS                    |
|  TITLE VIII |                 |                                      |
+-------------+-----------------+--------------------------------------+
| #           | # Many T/       | Provide for continued '602' access   |
|  Insure con | U programs acce | to T/U's after their FQHC status     |
| tinued '602 | ss '602' pharma | "sunsets".                           |
| ' drug pric | ceutical pricin |                                      |
| ing access  | g as outlines i |                                      |
| even after  | n the Veterans  |                                      |
| FQHC status | Health Care Act |                                      |
|  "sunsets". |  of 1992. At pr |                                      |
|             | esent, T/U's ar |                                      |
|             | e able to acces |                                      |
|             | s this pricing  |                                      |
|             | by virtue of th |                                      |
|             | eir FQHC status |                                      |
|             | . T/U's may pre |                                      |
|             | fer '602' prici |                                      |
|             | ng to Federal C |                                      |
|             | eiling Pricing  |                                      |
|             | (FCP) because a |                                      |
|             | ll clinic patie |                                      |
|             | nts (Indian and |                                      |
|             |  non-Indian) ar |                                      |
|             | e legal benefic |                                      |
|             | iaries of this  |                                      |
|             | pricing schedul |                                      |
|             | e as spelled ou |                                      |
|             | t by HCFA's Off |                                      |
|             | ice of Drug Pri |                                      |
|             | cing (ODP). Onl |                                      |
|             | y Indian patien |                                      |
|             | ts are legal be |                                      |
|             | neficiaries of  |                                      |
|             | FCP (VA Prime V |                                      |
|             | endor) priced p |                                      |
|             | harmaceuticals. |                                      |
+-------------+-----------------+--------------------------------------+
| # Se        | # Lack of t     | More regional/area meetings to       |
| ction I --  | ime to address  | clearly identify and discuss issues  |
| P.L. 94-437 | quality each se | impacting Tribes. During this        |
|             | ction. I was in | consultation process --we not only   |
|             | volved with the | want to "speak with one voice" -- in |
|             |  workshop -- "A | order to be in with each other -- we |
|             | ccess" -- we we | need appropriate time to discuss     |
|             | re to address a | each section or else we will not     |
|             | nd review for r | "speak with one voice" and find      |
|             | ecommendation S | ourselves out of unison. Although we |
|             | ection VI & VII | have the same issues, California     |
|             | I -- Due to the | tribes are impacted by the need to   |
|             |  lengthy debate | discuss at length these issues.      |
|             |  of Section IV  |                                      |
|             | -- we never got |                                      |
|             |  to the point o |                                      |
|             | f section VIII. |                                      |
+-------------+-----------------+--------------------------------------+
| # C         | # ISSUES        | # RECOMMENDATIONS                    |
| ROSSCUTTING |                 |                                      |
+-------------+-----------------+--------------------------------------+
| # M         | # "Estate       | To delete this criteria from the     |
| edicaid & M |  Recovery" unde | Medicaid language. As it creates an  |
| anaged Care | r Medicaid laws | unnecessary hardship when we enforce |
|             |                 | the Payor of Last Resort Rule. No    |
|             |                 | one wants to have their spouse or    |
|             |                 | children sacrifice their homes for   |
|             |                 | recovery of a debt which is a        |
|             |                 | guaranteed right as an "Indian" as   |
|             |                 | an IHS beneficiary.                  |
+-------------+-----------------+--------------------------------------+

REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

RECOMMENDATIONS AS SUBMITTED BY INDIVIDUALS

+-------------+-----------------+--------------------------------------+
| # C         | # ISSUES        | # RECOMMENDATIONS                    |
| ROSSCUTTING |                 |                                      |
+-------------+-----------------+--------------------------------------+
| #           | # Limi          | That other funding sources (other    |
|             | ts on indirect  | than IHS and BIA), must accept the   |
|             | rate by outside | tribe's or tribal organizations'     |
|             |  organizations. | approved indirect rate when that     |
|             |                 | tribal organization is fulfilling    |
|             |                 | the mission of the IHS.              |
|             |                 |                                      |
|             |                 | At this time other agencies          |
|             |                 | sometimes place a limit on the       |
|             |                 | amount of indirect charges. This     |
|             |                 | drives up the overall indirect rate  |
|             |                 | for the tribal health care delivery  |
|             |                 | program.                             |
+-------------+-----------------+--------------------------------------+
| #           | #               | There must be a national meeting for |
|             |  National consu | policy officials to review, respond  |
|             | ltation meeting | and revise recommendations of the    |
|             |                 | drafting team(s).                    |
|             |                 |                                      |
|             |                 | Accurate data must be available to   |
|             |                 | substantial recommendations in       |
|             |                 | reauthorization (i.e., diabetes      |
|             |                 | funding).                            |
+-------------+-----------------+--------------------------------------+

**Attachments**