**National Steering Committee for the **

**Reauthorization of the**

**Indian Health Care Improvement Act, P.L. 94-437**

**TITLE III \-- HEALTH FACILITIES**

**DRAFT 1 --- July 16, 1999**

**For Review and Comment Only**

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| +-----------------------------------------------------------+ | |   |
| |                                                               |   |
| | **Indian Health Care Improvement Act (with DRAFT proposed | | |   |
| |                                                               |   |
| | amendments, if any)**                                     | | |   |
| |                                                               |   |
| +-----------------------------------------------------------+ | |   |
| |                                                               |   |
|                                                               | |   |
| |                                                               |   |
| ***Comments and **Options***                                  | |   |
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| |                                                               |   |
|                                                               | |   |
| +-                                                              |   |
| --------------------------------------------------------------+ |   |
|                                                                 |   |
| **TITLE III -- HEALTH FACILITIES**                              |   |
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|                                                                 |   |
+-----------------------------------------------------------------+---+

**CONSULTATION; [CONSTRUCTION AND RENOVATION]{.underline} ~~CLOSURE~~ OF
FACILITIES; REPORTS**

**Sec. 301.** (a) Prior to the expenditure of, or the making of any firm
commitment to expend, any funds appropriated for the planning, design,
construction, or renovation of facilities pursuant to the Act of
November 2, 1921 (25 U.S.C. 13), popularly known as the Snyder Act, the
Secretary, acting through the Service, shall\--

\(1\) consult with any Indian tribe that would be significantly affected
by such expenditure for the purpose of determining and, whenever
practicable, honoring tribal preferences concerning size, location,
type, and other characteristics of any facility on which such
expenditure is to be made, and

+----------------------------------------------------------------------+
|   --------------------------------                                   |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|   \(2\) ensure, whenever practic                                     |
| able, that such facility meets the [construction]{.underline} standa |
| rds of [any recognized accrediting body approved by the Indian Healt |
| h Service ]{.underline}~~the Joint Commission on Accreditation of He |
| alth Care Organizations ~~by not later than 1 year after the date on |
|  which the construction or renovation of such facility is completed. |
|   --------------------------------                                   |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|                                                                      |
| *Accreditation by any recognized accrediting body approved by IHS is |
| acceptable. Specific reference to JCAHO is not necessary. *          |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

(b)(1) Notwithstanding any provision of law other than this subsection,
no Service hospital or outpatient health care facility ~~of the Service
~~or any [inpatient service operated by the Service]{.underline} may be
closed if the Secretary has not submitted to the Congress at least 1
year prior to the date of such ~~hospital or facility (or portion
thereof) is~~ proposed ~~to be closed ~~ [closure]{.underline} an
evaluation of the impact of such proposed closure which specifies, in
addition to other considerations\--

\(A\) the accessibility of alternative health care resources for the
population served by such hospital or facility;

\(B\) the cost effectiveness of such closure;

\(C\) the quality of health care to be provided to the population served
by such hospital or facility after such closure;

\(D\) the availability of contract health care funds to maintain
existing levels of service;

\(E\) the views of the Indian tribes served by such hospital or facility
concerning such closure;

\(F\) the level of utilization of such hospital or facility by all
eligible Indians; and

\(G\) the distance between such hospital or facility and the nearest
operating Service hospital.

+----------------------------------------------------------------------+
|   ----                                                               |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|   \(                                                                 |
| 2\) Paragraph (1) shall not apply to any temporary closure of a faci |
| lity or any portion of a facility if such closure is necessary for m |
| edical, environmental, or [construction]{.underline} safety reasons. |
|   ----                                                               |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|                                                                      |
| *Limitations on closure of health facilities are expanded to cover   |
| any IHS inpatient service.*                                          |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

(c)(1) The Secretary shall submit to the President, for inclusion in
each report required to be transmitted to the Congress under section
801, a report which sets forth\--;

\(A\) the ~~current~~ health [care]{.underline} facility priority system
of the Service, [which shall be developed and maintained in consultation
with Indian tribes, tribal organizations and urban Indian organizations,
provided that Indian tribes' needs shall be given the highest
priority]{.underline}.

\(B\) the [total health care facilities]{.underline} planning, design,
construction, and renovation needs[, including all]{.underline} ~~for
the 10 top-priority~~ inpatient[ and outpatient]{.underline} care
facilities [(including but not limited to all specialized care
facilities such as long-term care facilities and alcohol and drug abuse
treatment),]{.underline} ~~and the 10 top-priority ambulatory care
facilities (~~together with required staff quarters~~)~~,[ shall be
developed in consultation with Indian tribes and tribal
organizations,]{.underline}

\(C\) the justification for such order of priority,

\(D\) the projected cost of such projects, and

\(E\) the methodology adopted by the Service[, in consultation with
Indian tribes and tribal organizations,]{.underline} in establishing
priorities under its health facility priority system.

\(2\) In preparing each report required under paragraph (1) (other than
the initial report), the Secretary shall\--

\(A\) consult with Indian tribes and tribal organizations including
those tribes or tribal organizations operating health programs or
facilities under any [funding agreement]{.underline} ~~contract~~
entered into with the Service under the Indian Self- Determination [and
Education Assistance]{.underline} Act, and

\(B\) review the [total unmet]{.underline} needs of [all]{.underline}
~~such~~ tribes and tribal organizations for [health care]{.underline}
~~inpatient and outpatient~~ facilities [(including staff
quarters)]{.underline}, including ~~their~~ needs for renovation and
expansion of existing facilities.

\(3\) For purposes of this subsection, the Secretary shall, in
evaluating the needs of facilities operated under any
[agreement]{.underline} ~~contract~~ entered into with the Service under
the Indian Self-Determination Act [and Education Assistance
Act]{.underline}, use the same criteria that the Secretary uses in
evaluating the needs of facilities operated directly by the Service.

+----------------------------------------------------------------------+
|   -------------                                                      |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|   \(4\) The S                                                        |
| ecretary shall ensure that the planning, design, construction, and r |
| enovation needs of Service and non-Service facilities[, operated und |
| er agreements ]{.underline}~~which are the subject of a contract for |
|  health services entered into with the Service, under~~ [in accordan |
| ce with]{.underline} the Indian Self-Determination [and Education As |
| sistance]{.underline} Act[,]{.underline} are fully and equitably int |
| egrated into the development of the health facility priority system. |
|   -------------                                                      |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|                                                                      |
| *The IHS should annually report [all]{.underline} health facility    |
| needs (including tribal and urban, with preference given to tribal   |
| needs) and consult on the priority system with tribes and with both  |
| tribal and urban organizations. All programs under the Indian        |
| Self-Determination and Education Assistance Act are covered, not     |
| just Title I contracts.*                                             |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

[(d) ]{.underline}**[REVIEW OF NEED FOR FACILITIES.]{.underline}**[
]{.underline}

[(1) Beginning in the year 2000, the Secretary shall submit to the
President, for inclusion in the report required to be transmitted to the
Congress under section 1671 of this title, a report which sets forth the
needs of IHS and all Indian tribes and tribal organizations, including
urban Indian organizations, for inpatient and outpatient facilities,
including the needs for renovation and expansion of existing facilities
.]{.underline}

[(2) In preparing each report required under paragraph (1) (other than
the initial report), the Secretary shall consult with Indian tribes and
tribal organizations including those tribes or tribal organizations
operating health programs or facilities under any agreement entered into
with the Service under the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450f et seq.).]{.underline}

[(3) For purposes of this subsection, the Secretary shall, in evaluating
the needs of facilities operated under any agreement entered into with
the Service under the Indian Self-Determination and Education Assistance
Act, use the same criteria that the Secretary uses in evaluating the
needs of facilities operated directly by the Service.]{.underline}

[(4) The Secretary shall ensure that the planning, design, construction,
and renovation needs of facilities operated under agreements, in
accordance with the Indian Self-Determination and Education Assistance
Act, are fully and equitably integrated into the development of the
health facility priority system.]{.underline}

+----------------------------------------------------------------------+
| +----------------------------------------------------------------+   |
| | +----------------------------------------------------------+   |   |
| | |   ------------------------                               |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | |   [(5) Every year the Se                                 |   |   |
| | | cretary shall provide an opportunity for nomination of p |   |   |
| | | lanning, design, and construction projects by IHS and al |   |   |
| | | l tribes and tribal organizations for consideration unde |   |   |
| | | r the health care facility priority system.]{.underline} |   |   |
| | |   ------------------------                               |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | | -------------------------------------------------------- |   |   |
| | |                                                          |   |   |
| | | *Fairness in reporting health facility needs is          |   |   |
| | | required. *                                              |   |   |
| | +----------------------------------------------------------+   |   |
| | |                                                          |   |   |
| | +----------------------------------------------------------+   |   |
| |                                                                |   |
| | [(e)]{.underline} All funds appropriated under the Act of      |   |
| | November 2, 1921 (25 U.S.C. 13), for the planning, design,     |   |
| | construction, or renovation of health facilities for the       |   |
| | benefit of an Indian tribe or tribes shall be subject to the   |   |
| | provisions of section 102** **of the Indian Self-              |   |
| | Determination [and Education Assistance]{.underline} Act.      |   |
| +----------------------------------------------------------------+   |
|                                                                      |
| *All Indian Self-Determination and Education Assistance Act programs |
| are included. *                                                      |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

[(f)]{.underline} [The Secretary shall consult and cooperate with Indian
tribes, tribal organizations and urban Indian organizations in
developing innovative approaches to addressing all or part of the total
unmet need for construction of health facilities, including those
provided for in other sections of this Title and other
approaches.]{.underline}

+----------------------------------------------------------------------+
|   --                                                                 |
|   --                                                                 |
|                                                                      |
| *Provide incentives for fostering partnerships among I/T/U without   |
| taking priority away from tribes and seek out creative ways to meet  |
| unmet needs. *                                                       |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**SAFE WATER AND SANITARY WASTE DISPOSAL FACILITIES**

**Sec. 302.** (a) The Congress hereby finds and declares that\--

\(1\) the provision of safe water supply systems and sanitary sewage and
solid waste disposal systems is primarily a health consideration and
function;

\(2\) Indian people suffer an inordinately high incidence of disease,
injury, and illness directly attributable to the absence or inadequacy
of such systems;

\(3\) the long-term cost to the United States of treating and curing
such disease, injury, and illness is substantially greater than the
short-term cost of providing such systems and other preventive health
measures;

\(4\) many Indian homes and communities still lack safe water supply
systems and sanitary sewage and solid waste disposal systems; and

+----------------------------------------------------------------------+
|   ----------                                                         |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|   \(5\) it                                                           |
|  is in the interest of the United States, and it is the policy of th |
| e United States, that all Indian communities and Indian homes, new a |
| nd existing, be provided with safe and adequate water supply systems |
|  and sanitary sewage waste disposal systems ~~as soon as possible~~. |
|   ----------                                                         |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|                                                                      |
| *Funding for safe water and sanitation systems is strengthened.*     |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

(b)(1) In furtherance of the findings and declarations made in
subsection (a), Congress reaffirms the primary responsibility and
authority of the Service to provide the necessary sanitation facilities
and services as provided in section 7 of the Act of August 5, 1954 (42
U.S.C. 2004a).\--

\(2\) The Secretary, acting through the Service, is authorized to
provide under section 7 of the Act of August 5, 1954 (42 U.S.C.
2004a)\--

\(A\) financial and technical assistance to Indian tribes[, tribal
organizations]{.underline} and communities in the establishment,
training, and equipping of utility organizations to operate and maintain
Indian sanitation facilities[, including the provision of existing
plans, standard details, and specifications available in the department,
to be used at the option of the tribe or tribal
organization]{.underline};

\(B\) ongoing technical assistance and training in the management of
utility organizations which operate and maintain sanitation facilities;
and

\(C\) operation and maintenance assistance for, and emergency repairs
to, tribal sanitation facilities when necessary to avoid a[n
imminent]{.underline} health [threat]{.underline} ~~hazard~~ or to
protect the ~~Federal~~ investment in sanitation facilities [and the
investment in the health benefits gained through the provision of
sanitation facilities]{.underline}.

\(3\) Notwithstanding any other provision of law\--

\(A\) the Secretary of Housing and Urban [Development]{.underline}
~~Affairs~~ is authorized to transfer funds appropriated under the
[Native American Housing Assistance and Self-Determination Act of
1996]{.underline} ~~Housing and Community Development Act of 1974 (42
U.S.C. 5301, et seq.)~~ to the Secretary of Health and Human Services,
~~and~~

\(B\) the Secretary of Health and Human Services is authorized to accept
and use such funds for the purpose of providing sanitation facilities
and services for Indians under section 7 of the Act of August 5, 1954
(42 U.S.C. 2004a).

\(C\) [unless specifically authorized when funds are appropriated, the
Secretary of Health and Human Services shall not use funds appropriated
under section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a) to
provide sanitation facilities to new homes constructed using funds
provided by the Department of Housing and Urban Development.
]{.underline}

[(D) the Secretary of Health and Human Services is authorized to accept
all Federal funds that are for the purpose of providing sanitation
facilities and related services for Indians and place those funds into
agreements, authorized under the Indian Self Determination and Education
Assistance Act, (25 U.S.C. 450f, et. seq.), between the Secretary and
Tribes.]{.underline}

[(E) the Secretary may allow funds appropriated under the authority of
section 2004 of title 42 to be used to fund up to 100 percent of the
amount of a tribe's loan obtained under any Federal program for new
projects to construct eligible sanitation facilities to serve Indian
homes.]{.underline}

[(F) the Secretary may allow funds appropriated under the authority of
section 2004 of title 42 to be used to meet matching or cost
participation requirements under other Federal and non-Federal programs
for new projects to construct eligible sanitation
facilities.]{.underline}

[(G) all Federal agencies are authorized to transfer funds identified,
granted or loaned and appropriated, to the Secretary of Health and Human
Services whereby the Secretary of Health and Human Services, or
designee, would be identified as the lead agency whose policies, rules,
regulations and NEPA shall apply in the implementation of facilities
projects.]{.underline}

  --
  --

*For subsections (b) and (c), the IHS's role is expanded to authorize
assistance to tribal organizations in addition to tribes and
communities. Expands the type of assistance that IHS may provide to
address sanitation facility needs. Provides guidelines for HUD-IHS
cooperation and cooperation with other federal agencies, and provides
for a 10-year funding plan.*

  ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  *All investments, not just those of the Federal government, should be protected. **** ****Imminent health threats involve not only the sanitation facility, but also the health benefits gained from the facility.*
  ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

** (c) ~~Beginning in fiscal year 1990, t~~ [T]{.underline}he Secretary,
acting through the Service[ and ]{.underline}[in consultation with
Indian tribes and tribal organizations]{.underline}, shall develop and
begin implementation of a 10-year [funding]{.underline} plan to provide
safe water supply and [sanitary]{.underline} ~~ion~~ sewage and solid
waste disposal facilities [serving]{.underline} ~~to~~ existing Indian
homes and communities[,]{.underline} and to new and ~~to~~ renovated
Indian homes. **

+-----------------------------------+
|   --                              |
|   --                              |
|                                   |
| ***See comments above for (b).*** |
+-----------------------------------+
|                                   |
+-----------------------------------+

** (d) The financial and technical capability of an Indian tribe or
community to safely operate and maintain a sanitation facility shall not
be a prerequisite to the provision or construction of sanitation
facilities by the Secretary.**

  -- --
     
     
  -- --

** (e) ~~(1) ~~The Secretary is authorized to provide financial
assistance to Indian tribes[, ]{.underline}[tribal
organizations]{.underline} and communities [for operation, management
and maintenance of ]{.underline}[their sanitation]{.underline} ~~in an
amount equal to the cost of operating, managing, and maintaining
~~~~the~~ facilities ~~provided under the plan described in subsection
(c) of this section~~. **

(~~2) For the purposes of paragraph (1), the term \"Federal share\"
means 80 percent of the costs described in paragraph (1). ~~

~~(3) With respect to Indian tribes with fewer than 1,000 enrolled
members, the non-Federal portion of the costs of operating, managing,
and maintaining such facilities may be provided, in part, through cash
donations or in kind property, fairly evaluated.~~

+----------------------------------------------------------------------+
|   --                                                                 |
|   --                                                                 |
|                                                                      |
| *Provides financial assistance for operation, management and         |
| maintenance of sanitation facilities. *                              |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

~~ [(f) The Indian family, community or tribe has the primary
responsibility to ]{.underline}[establish, collect, and use reasonable
user fees, or otherwise set aside funding, for the ]{.underline}[purpose
of operating and maintaining sanitation facilities. If a community
facility is ]{.underline}[threatened with imminent failure and there is
a lack of tribal capacity to maintain the ]{.underline}[integrity and/or
the health benefit of the system, then the Secretary is authorized to
]{.underline}[assist the tribe in the resolution of the problem on a
short term basis through ]{.underline}[cooperation with the emergency
coordinator or by providing operation and ]{.underline}[maintenance
service.]{.underline}~~

+----------------------------------------------------------------------+
|   --                                                                 |
|   --                                                                 |
|                                                                      |
| *~~While the tribe or family has ~~~~primary responsibility for      |
| funding ~~~~maintenance, IHS is authorized to ~~~~assist in          |
| emergencies.~~*                                                      |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

~~ [(g)]{.underline}(f)~~ Programs administered by Indian tribes or
tribal organizations under the authority of the Indian
Self-Determination [and Education Assistance]{.underline} Act shall be
eligible for\--

\(1\) any funds appropriated pursuant to this section, and

\(2\) any funds appropriated for the purpose of providing water
supply[,]{.underline} ~~or~~ sewage disposal [or solid waste
facilities]{.underline} ~~services~~,

on an equal basis with programs that are administered directly by the
Service.

+----------------------------------------------------------------------+
|   --                                                                 |
|   --                                                                 |
|                                                                      |
| *All Indian Self-Determination and Education Assistance Act programs |
| are eligible. *                                                      |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

[(h)]{.underline}~~(g)~~(1) The Secretary shall submit to the President,
for inclusion in each report required to be transmitted to the Congress
under section 801, a report** **which sets forth\--

\(A\) the current Indian sanitation facility priority system of the
Service;

\(B\) the methodology for determining sanitation deficiencies;

\(C\) the level of [initial and final]{.underline} sanitation deficiency
for each [type of]{.underline} sanitation facilit[y]{.underline}~~ies~~
[for each]{.underline} project of each Indian tribe or community;

\(D\) the amount of funds necessary to [reduce the identified sanitation
deficiency levels of]{.underline} ~~raise~~ all Indian tribes and
communities to level I sanitation deficiency [as defined in subsection
(h)(4)(A) of this section.]{.underline} ~~; and~~

~~(E) the amount of funds necessary to raise all Indian tribes and
communities to zero sanitation deficiency~~.

\(2\) In preparing each report required under paragraph (1) ~~(other
than the initial report)~~, the Secretary shall consult with Indian
tribes and tribal organizations (including those tribes or tribal
organizations operating health care programs or facilities under any
[agreement]{.underline} ~~contract~~ entered into with the Service under
the Indian Self-Determination [and Education Assistance]{.underline}
Act) to determine the sanitation needs of each tribe [and in developing
the criteria on which the needs will be evaluated through a process of
negotiated rule making]{.underline}.

\(3\) The methodology used by the Secretary in determining[, preparing
cost estimates for and reporting]{.underline} sanitation deficiencies
for purposes of paragraph (1) shall be applied uniformly to all Indian
tribes and communities.

\(4\) For purposes of this subsection, the sanitation deficiency levels
for an [individual or community sanitation system serving
]{.underline}Indian [homes ]{.underline}~~tribe or community~~ are as
follows:

\(A\) [a]{.underline} level I [deficiency]{.underline} is an
[individual]{.underline} ~~Indian tribe~~ or community ~~with a~~
sanitation system\--

\(i\) which complies with all applicable water supply[,]{.underline}
~~and~~ pollution control [and solid waste disposal]{.underline} laws,
and

\(ii\) in which the deficiencies relate to routine replacement, repair,
or maintenance needs;

\(B\) [a]{.underline} level II [deficiency]{.underline} is an
[individual]{.underline} ~~Indian tribe~~ or community ~~with a~~
sanitation system\--

\(i\) which [substantially or recently]{.underline}
complie[d]{.underline} ~~s~~ with all applicable water
supply[,]{.underline} ~~and~~ pollution control [and solid
waste]{.underline} laws, [in which the deficiencies relate to small or
minor capital improvements needed to bring the system back into
compliance;]{.underline} ~~and~~

\(ii\) ~~in which the~~ deficiencies relate to capital improvements that
are necessary to [enlarge or]{.underline} improve the facilities in
order to meet the [current]{.underline} needs ~~of such tribe or
community~~ for domestic sanitation facilities; [or]{.underline}

[(iii) in which the deficiencies relate to the lack of equipment or
training by an Indian tribe or community to properly operate and
maintain the sanitation facilities;]{.underline}

\(C\) [a]{.underline} level III [deficiency]{.underline} is an
[individual]{.underline} ~~Indian tribe~~ or community~~ with a
sanitation~~ system [with water and/or sewer service in the home, piped
services or a haul system with holding tanks and interior plumbing, or
where major significant interruptions to water supply or sewage disposal
occur frequently, requiring major capital improvements to correct the
deficiencies. There is no access to or no approved or permitted solid
waste facility available,]{.underline} ~~which-- ~~

~~(i) has an inadequate or partial water supply and a sewage disposal
facility that does not comply with applicable water supply and pollution
control laws, or~~

~~(ii) has no solid waste disposal facility;~~

\(D\) [a ]{.underline}level IV [deficiency]{.underline} is an
[individual]{.underline} ~~Indian tribe~~ or community ~~with a
sanitation~~ system [where there is no piped]{.underline} ~~which lacks
either a safe~~ water [and/or sewer facilities in the home or the system
has become inoperable due to major component failure or where only a
washeteria or central facility exists;]{.underline} ~~supply system or a
sewage disposal system; and~~

\(E\) [a]{.underline} level V [deficiency]{.underline} is [the absence
of a sanitation system; where individual homes do not have access
to]{.underline} ~~an Indian tribe or community that lacks a~~ safe
[drinking]{.underline} water [or adequate wastewater
]{.underline}~~supply and a sewage~~ disposal ~~system~~.

~~ (5) For purposes of this subsection, any Indian tribe or community
that lacks the operation and maintenance capability to enable its
sanitation system to meet pollution control laws may not be treated as
having a level I or II sanitation deficiency.~~

+----------------------------------------------------------------------+
|   --                                                                 |
|   --                                                                 |
|                                                                      |
| *Reporting requirements are specified and the sanitation deficiency  |
| levels are revised.*                                                 |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**PREFERENCE TO INDIANS AND INDIAN FIRMS**

**Sec. 303.** (a) The Secretary, acting through the Service, may utilize
the negotiating authority of the Act of June 25, 1910 (25 U.S.C. 47), to
give preference to any Indian or any enterprise, partnership,
corporation, or other type of business organization owned and controlled
by an Indian or Indians including former or current federally recognized
Indian tribes in the State of New York (hereinafter referred to as an
\"Indian firm\") in the construction and renovation of Service
facilities pursuant to section 301 and in the construction of safe water
and sanitary waste disposal facilities pursuant to section 302.Such
preference may be accorded by the Secretary unless he finds, pursuant to
rules and regulations promulgated by him, that the project or function
to be contracted for will not be satisfactory or such project or
function cannot be properly completed or maintained under the proposed
contract. The Secretary, in arriving at his finding, shall consider
whether the Indian or Indian firm will be deficient with respect to (1)
ownership and control by Indians,(2) equipment,(3) bookkeeping and
accounting procedures,(4) substantive knowledge of the project or
function to be contracted for, (5) adequately trained personnel, or (6)
other necessary components of contract performance.

+----------------------------------------------------+
|   --                                               |
|   --                                               |
|                                                    |
| *Indian preference in construction is preserved. * |
+----------------------------------------------------+
|                                                    |
+----------------------------------------------------+

\(b\) For the purpose of implementing the provisions of this title,
~~the Secretary shall assure that the rates of pay for personnel engaged
in the~~ construction or renovation of facilities constructed or
renovated in whole or in part by funds made available pursuant to this
title are [exempt from]{.underline} ~~not less than the prevailing local
wage rates for similar work as determined in accordance with~~ the Act
of March 3, 1931 (40 U.S.C. 276a-276a-5, known as the Davis-Bacon Act.)
[For all health facilities, staff quarters and sanitation facilities,
construction and renovation subcontractors shall be paid wage rates not
less than the prevailing wages on similar construction in the locality,
as determined by the Indian tribe, tribes, or tribal organizations
served by such facilities.]{.underline}

+----------------------------------------------------------------------+
|   --                                                                 |
|   --                                                                 |
|                                                                      |
| *Davis-Bacon requirements are waived. Sub-contractors for staff      |
| quarters, sanitation facilities and all health facilities are paid   |
| no less than the prevailing wage determined by the tribe. *          |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[SOBOBA SANITATION FACILITIES]{.underline}**

**[Sec. 304.]{.underline}**[ The Act of December 17, 1970 (84 Stat.
1465), is hereby amended by adding the following new section 9 at the
end thereof:]{.underline}

** **[Sec. 9.]{.underline}**[ ]{.underline}**[ Nothing in this Act shall
preclude the Soboba Band of Mission Indians and the Soboba Indian
Reservation from being provided with sanitation facilities and services
under the authority of section 7 of the Act of August 5,1954 (68 Stat.
674), as amended by the Act of July 31, 1959 (73 Stat.
267).]{.underline}

+----------------------------------------------------------------------+
|   --                                                                 |
|   --                                                                 |
|                                                                      |
| *[This section should be preserved ]{.underline}[(deletion should    |
| only be done ]{.underline}[with Soboba]{.underline}[']{.underline}[s |
| input and would ]{.underline}[need to make clear that Soboba         |
| ]{.underline}[remains eligible for sanitation                        |
| ]{.underline}[facilities and services available ]{.underline}[under  |
| applicable).]{.underline}*                                           |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[EXPENDITURE OF NON-SERVICE FUNDS FOR RENOVATION]{.underline}**

**[Sec. 305.]{.underline}**[ (a)(1)Notwithstanding any other provision
of law, the Secretary is authorized to accept any major
expansion,]{.underline} renovation or modernization by any Indian tribe
of any Service facility, or of any other Indian health facility operated
pursuant to a[n agreement]{.underline} ~~contract~~ entered into under
the Indian Self-Determination [and Education Assistance]{.underline}
Act, including\--

\(A\) any plans or designs for such [expansion,]{.underline} renovation
or modernization, and

\(B\) any [expansion,]{.underline} renovation or modernization for which
funds appropriated under any Federal law were lawfully expended,** **but
only if the requirements of subsection (b) are met.

\(2\) The Secretary shall maintain a separate priority list to address
the needs [for increased operating funds for]{.underline} ~~of~~
~~such~~ [expenses,]{.underline} ~~facilities for~~ personnel or
equipment. [The methodology for establishing priorities will be
developed in consultation with Indian tribes and tribal organizations.
The list of priority facilities will be revised annually in consultation
with Indian tribes and tribal organizations. ]{.underline}

\(3\) The Secretary shall submit to the President, for inclusion in each
report required to be transmitted to the Congress under section 801, the
priority list maintained pursuant to paragraph (2).

\(b\) The requirements of this subsection are met with respect to any
[expansion,]{.underline} renovation or modernization if

\(1\) the tribe or tribal organization\--

\(A\) provides notice to the Secretary of its intent to
[expand,]{.underline} renovate or modernize; and

\(B\) applies to the Secretary to be placed on a separate priority list
to address the needs of such new facilities for [increased operating
funds for expenses,]{.underline} personnel or equipment; and

\(2\) the [expansion,]{.underline} renovation or modernization\--

\(A\) is approved by the appropriate area director of the Service [for
Federal facilities]{.underline}; and

\(B\) is administered by the tribe in accordance with the rules and
regulations prescribed by the Secretary with respect to construction or
renovation of Service facilities.

\(c\) If any Service facility which has been [expanded,]{.underline}
renovated or modernized by an Indian tribe under this section ceases to
be used as a Service facility during the 20-year period beginning on the
date such [expansion,]{.underline} renovation or modernization is
completed, such Indian tribe shall be entitled to recover from the
United States an amount which bears the same ratio to the value of such
facility at the time of such cessation as the value of such
[expansion,]{.underline} renovation or modernization (less the total
amount of any funds provided specifically for such facility under any
Federal program that were expended for such renovation or modernization)
bore to the value of such facility at the time of the completion of such
[expansion,]{.underline} renovation or modernization.

+----------------------------------------------------------------------+
|   --                                                                 |
|   --                                                                 |
|                                                                      |
| *Section 305 includes renovation and all Indian Self-Determination   |
| and Education Assistance Act programs. Includes authorization for    |
| expansion projects in addition to renovation and modernization       |
| projects. Requires a priority list to be developed in consultation   |
| with tribes and tribal organizations to address needs for increased  |
| operating funds.*                                                    |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[FUNDING]{.underline} ~~GRANT PROGRAM~~ FOR THE CONSTRUCTION,
EXPANSION, AND MODERNIZATION OF SMALL AMBULATORY CARE FACILITIES **

**Sec. 306. **(a)(1) The Secretary, acting through the Service[ and in
consultation with Indian tribes and tribal organizations]{.underline},
shall make [funding available]{.underline} ~~grants~~ to tribes and
tribal organizations for the construction, expansion, or modernization
of facilities for the provision of ambulatory care services to eligible
Indians (and noneligible persons as provided in
subsection[s]{.underline} (c)(1)(C) [and (b)(2) of this
section]{.underline}). A grant made under this section may cover up to
100 percent of the costs of such construction, expansion, or
modernization. For the purposes of this section, the term
\"construction\" includes the replacement of an existing facility.

\(2\) [Funding]{.underline} ~~A grant~~ under paragraph (1) may only be
made [available]{.underline} to a[n Indian]{.underline} tribe or tribal
organization operating an Indian health facility (other than a facility
owned or constructed by the Service, including a facility originally
owned or constructed by the Service and transferred to a[n
Indian]{.underline} tribe or tribal organization) pursuant to a[n
agreement]{.underline} ~~contract~~ entered into under the Indian
Self-Determination [and Education Assistance]{.underline} Act.

(b)(1) [Funding]{.underline} ~~A grant~~ provided under this section may
be used only for the construction, expansion, or modernization
(including the planning and design of such construction, expansion, or
modernization) of an ambulatory care facility\--

\(A\) located apart from a hospital;

\(B\) not funded under section 301 or section 307; and

\(C\) which, upon completion of such construction, or modernization
will\--

\(i\) have a total capacity appropriate to its projected service
population;

\(ii\) serve [annually]{.underline} no [fewer]{.underline} ~~less~~ than
500 eligible Indians~~ annually~~[ and other users who are eligible for
services in such facility in accordance with section
813(b)(1)(B)]{.underline}; and

\(iii\) provide ambulatory care in a service area (specified in the
[agreement]{.underline} ~~contract~~ entered into under the Indian
Self-Determination [and Education Assistance]{.underline} Act) with a
population of [no fewer]{.underline} ~~not less~~ than 2,000 eligible
Indians[ and other users who are eligible for services in such facility
in accordance with section 813(b)(1)(B)]{.underline}.

\(2\) [Funding provided under this section may be used only for the cost
of that portion of a construction, expansion or modernization project
that benefits the service population identified above in subsection
(b)(1)(C)(ii) and (iii).]{.underline} The requirements of clauses (ii)
and (iii) of paragraph (1)(C) shall not apply to a tribe or tribal
organization applying for [funding]{.underline} ~~a grant~~ under this
section whose tribal government offices are located on an island.

+----------------------------------------------------------------------+
|   --                                                                 |
|   --                                                                 |
|                                                                      |
| *Consultation is required and the program includes all Indian        |
| Self-Determination and Education Assistance Act tribes. In           |
| calculating service population, non-eligible beneficiaries eligible  |
| under Section 813(b)(1)(B) are included. Funding is not included in  |
| tribal shares or in Indian Self-Determination and Education          |
| Assistance Act awards and cannot be reallocated to other purposes.   |
| Limits reversion of title to the United States for change of use to  |
| five years and allows the Service and tribes to negotiate an         |
| agreement for an alternative result. *                               |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

(c)(1) No [funding]{.underline} ~~grant~~ may be made
[available]{.underline} under this section unless an application [or
proposal]{.underline} for such [funding]{.underline} ~~a grant~~ has
been submitted to and approved by the Secretary. An application [or
proposal]{.underline} for [funding]{.underline} ~~a grant~~ under this
section shall be submitted in such form and manner as the Secretary
shall by regulation prescribe and shall set forth reasonable assurance
by the applicant that, at all times after the construction, expansion,
or modernization of a facility carried out pursuant to
[funding]{.underline} ~~a grant~~ received under this section\--

\(A\) adequate financial support will be available for provision of
services at such facility;

\(B\) such facility will be available to eligible Indians without regard
to ability to pay or source of payment; and

\(C\) such facility will, as feasible without the quality or quantity of
services provided to eligible Indians, serve noneligible persons on a
cost basis.

\(2\) In awarding [funding]{.underline} ~~grants~~ under this section,
the Secretary shall give priority to tribes and tribal organizations
that demonstrate\--

\(A\) a need for increased ambulatory care services; and

\(B\) insufficient capacity to deliver such services.

[(3) The Secretary may provide for the establishment of peer review
panels, as necessary, to review and evaluate applications and proposals
and to advise the Secretary regarding such applications using the
criteria developed pursuant to paragraph (1).]{.underline}

  -- --
     
     
  -- --

[(d) If any facility (or portion thereof) with respect to which funds
have been paid under this section, ceases, within five
years]{.underline} ~~at any time~~ after completion of the construction,
expansion, or modernization carried out with such funds, to be utilized
for the purposes of providing ambulatory care services to eligible
Indians, all of the right, title, and interest in and to such facility
(or portion thereof) shall transfer to the United States[ unless
otherwise negotiated by the Service and the Indian tribe or tribal
organization]{.underline}.

+----------------------------------------------------------------------+
|   --                                                                 |
|   --                                                                 |
|                                                                      |
| *As noted above, the reversionary clause could make it difficult to  |
| obtain loans, so the period has been limited to 5 years. *           |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

[(e) Funding provided to Indian tribes and tribal organizations under
this section shall be non-recurring and shall not be available for
inclusion in any individual tribe's tribal share for an award under the
Indian Self-Determination and Education Assistance Act or for
reallocation or redesign thereunder. ]{.underline}

  -- --
     
     
  -- --

**[INDIAN HEALTH CARE DELIVERY DEMONSTRATION PROJECT]{.underline}**

**[Sec. 307]{.underline}**[(a) ]{.underline}**[HEALTH CARE DEMONSTRATION
PROJECTS.\--]{.underline}**[The Secretary, acting through the Service,
in consultation with Indian tribes and tribal organizations,
]{.underline}is authorized to enter into [funding agreements
]{.underline}~~contracts ~~with, or make grants[ or loan
guarantees]{.underline} to, Indian tribes or tribal organizations for
the purpose of carrying out a heath care delivery demonstration project
to test alternative means of delivering health care and services through
facilities[, including but not limited to hospice facilities,
traditional healing centers, and child care facilities,]{.underline} to
Indians.

\(b\) **USE OF FUNDS.---**[ ]{.underline}The Secretary, in approving
projects pursuant to this section, may authorize funding for the
construction and renovation of hospitals, health centers, health
stations, and other facilities to deliver health care services and is
authorized to\--

\(1\) waive any leasing prohibition;

\(2\) permit carryover of funds appropriated for the provision of health
care services;

\(3\) permit the use of non-Service Federal funds and non-Federal funds;

\(4\) permit the use of funds or property donated from any source for
project purposes; ~~and~~

\(5\) provide for the reversion of donated real or personal property to
the donor~~.~~[; and]{.underline}

[(6) permit the use of Service funds to match other Federal
funds.]{.underline}

\(c\) **CRITERIA.\--**(1)~~ Within 180 days after the date of enactment
of this section, [t]{.underline}~~[The]{.underline} Secretary~~, after
consultation with Indian tribes and tribal organizations,~~ shall
develop and publish [regulations as contained ]{.underline}in the
Federal Register criteria for the review and approval of applications
submitted under this section. The Secretary may enter into a contract
[or funding agreement ]{.underline}or award a grant under this section
for projects which meet the following criteria:

\(A\) There is a need for a new facility or program or the reorientation
of an existing facility or program.

\(B\) A significant number of Indians, including those with low health
status, will be served by the project.

\(C\) The project has the potential to deliver services in an efficient
and effective manner.

\(D\) The project is economically viable.

\(E\) The Indian tribe or tribal organization has the administrative and
financial capability to administer the project.

\(F\) The project is integrated with providers of related health and
social services and is coordinated with, and avoids duplication of,
existing services.

\(2\) The Secretary may provide for the establishment of peer review
panels, as necessary to review and evaluate applications using the
criteria developed pursuant to paragraph (1).

~~(3)(A) On or before September 30, 1995, the Secretary shall enter into
contracts or award grants under this section for a demonstration project
in each of the following service units which meets the criteria
specified in paragraph (1) and for which a completed application has
been received by the Secretary:~~

~~(i) Cass Lake, Minnesota.~~

~~(ii) Clinton, Oklahoma.~~

~~(iii) Harlem, Montana.~~

~~(iv) Mescalero, New Mexico.~~

~~(v) Owyhee, Nevada.~~

~~(vi) Parker, Arizona.~~

~~(vii) Schurz, Nevada.~~

~~(viii)Winnebago, Nebraska.~~

~~(ix) Ft. Yuma, California~~

(~~B~~[3]{.underline}) The Secretary may ~~also~~ enter into [funding
agreements ]{.underline}~~contracts ~~or grants under this section
taking into consideration applications received under this section from
all service areas. The Secretary may not award a greater number of such
[funding agreements ]{.underline}~~contracts~~ or grants in one service
area than in any other service area until there is an equal number of
such [funding agreements ]{.underline}~~contracts~~ or grants awarded
with respect to all service areas from which the Secretary receives
applications during the application period (as determined by the
Secretary) which meet the criteria specified in paragraph (1).

\(d\) **TECHNICAL ASSISTANCE.\-- ** The Secretary shall provide such
technical and other assistance as may be necessary to enable applicants
to comply with the provisions of this section.

\(e\) **SERVICE TO INELIGIBLE PERSONS.\--** The authority to provide
services to persons otherwise ineligible for the health care benefits of
the Service and the authority to extend hospital privileges in service
facilities to non-Service health practitioners as provided in section
~~7~~[8]{.underline}13 may be included, subject to the terms of such
section, in any demonstration project approved pursuant to this section.

\(f\) **EQUITABLE TREATMENT.\--** For purposes of subsection (c)(1)(a),
the Secretary shall, in evaluating facilities operated under any
[funding agreement]{.underline} ~~contract ~~entered into with the
Service under the Indian Self-Determination [and Education Assistance
]{.underline}Act, use the same criteria that the Secretary uses in
evaluating facilities operated directly by the Service.

\(g\) **EQUITABLE INTEGRATION OF FACILITIES.\--**The Secretary shall
ensure that the planning, design, construction, ~~and~~ renovation[ and
expansion]{.underline} needs of Service and non-Service facilities which
are the subject of a [funding agreement]{.underline} ~~contract~~ for
health services entered into with the Service under the Indian
Self-Determination[ and Education Assistance]{.underline} Act, are fully
and equitably integrated into the implementation of the health care
delivery demonstration projects under this section.

~~(h)(1) The Secretary shall submit to the President, for inclusion in
the report which is required to be submitted to the Congress under
section 801 for fiscal year 1997, an interim report on the findings and
conclusions derived from the demonstration projects established under
this section. ~~

  ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  ~~(2) The Secretary shall submit to the President, for inclusion in the report which is required to be submitted to the Congress under section 801 for fiscal year 1999, a final report on the findings and conclusions derived from the demonstration projects established under this section, together with legislative recommendations.~~
  ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

*Demonstration projects using funding agreements, grants or loan
guarantees are authorized with specific criteria and special rules on
use of funds. Hospice facilities, traditional healing centers and child
care facilities are specifically referenced, but are only intended as
examples---not limitations. Continues to provide that facilities can be
shifted from one type to another (reorientation). Allows funds under
this section to be used in matching other Federal funds. *

*The time for the reports under (h)(1) and (h)(2) has passed. *

  --
  --

**~~LAND TRANSFER ~~**

~~ ~~**~~Sec. 308. ~~**~~The Bureau of Indian Affairs[ and all other
agencies and departments of ]{.underline}[the United States
are]{.underline} is~~ authorized to transfer, at no cost, ~~up to 5
acres of~~ land [and improvements ]{.underline}~~at the Chemawa Indian
School, Salem, Oregon, ~~to the Service for the provision of health care
services. ~~The land authorized to be transferred by this section is
that land adjacent to land under the jurisdiction of the Service and
occupied by the Chemawa Indian Health Center.~~ [The Secretary is
authorized to accept such land and improvements for such
purposes.]{.underline}

+----------------------------------------------------------------------+
|   --                                                                 |
|   --                                                                 |
|                                                                      |
| *This section is expanded to cover all land transfers for provision  |
| of health care services. *                                           |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[LEASES ]{.underline}~~[WITH INDIAN TRIBES]{.underline}~~**

**[Sec. ]{.underline}[309]{.underline} ~~804~~**. [(a)]{.underline}**[
]{.underline}**Notwithstanding any other provision of law, the Secretary
is authorized, in carrying out the purposes of this Act, to enter into
leases with Indian tribes [and tribal organizations]{.underline} for
periods not [to be in]{.underline} ~~to~~ excess of twenty
[(20)]{.underline} years. Property leased by the Secretary from an
Indian tribe [or tribal organization]{.underline} may be reconstructed
or renovated by the Secretary pursuant to an agreement with such Indian
tribe [or tribal organization]{.underline}.

\(b\) The Secretary may enter into leases, contracts, and other legal
agreements with Indian tribes or tribal organizations which hold\--

\(1\) title to;

\(2\) a leasehold interest in; or

\(3\) a beneficial interest in (where title is held by the United States
in trust for the benefit of a tribe);

+----------------------------------------------------------------------+
|   ---------                                                          |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|   facilit                                                            |
| ies used for the administration and delivery of health services by t |
| he Service or by programs operated by Indian tribes or tribal organi |
| zations to compensate such Indian tribes or tribal organizations for |
|  costs associated with the use of such facilities for such purposes[ |
| , and such leases shall be considered as operating leases for the pu |
| rposes of scoring under the Budget Enforcement Act, notwithstanding  |
| any other provision of law]{.underline}. Such costs include rent, de |
| preciation based on the useful life of the building, principal and i |
| nterest paid or accrued, operation and maintenance expenses, and oth |
| er expenses determined by regulation to be allowable [pursuant to re |
| gulations under section 105(]{.underline}*[l]{.underline}*[) of the  |
| Indian Self-Determination and Education Assistance Act]{.underline}. |
|   ---------                                                          |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|                                                                      |
| *This section was formally section 804. Leases from tribes to the    |
| IHS for health services are to be considered operating leases and    |
| not be "scored" against the first year's appropriation. The purpose  |
| is to encourage the use of such leases as a financing vehicle for    |
| health facility construction. The cross-reference to the Budget      |
| Enforcement Act may need to be updated.*                             |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[LOANS AND LOAN GUARANTEES]{.underline}**

**[Sec. 310 ]{.underline}**[(a) The Secretary is authorized to establish
a program to provide direct loans, or guarantees for loans, for
construction of health care facilities (including inpatient facilities,
outpatient facilities and associated staff quarters) by Indian tribes,
tribal organizations and urban Indian organizations, provided that
Indian tribes' needs shall be given the highest priority.]{.underline}

[(b) The Secretary is authorized to issue regulations providing for
standards and procedures governing such loans and loan guarantees,
subject to the following conditions:]{.underline}

[(1) The principal amount of a loan or loan guarantee may cover 100% of
eligible costs, including but not limited to planning, design,
financing, site land development, construction, rehabilitation,
renovation, conversion, improvements, medical equipment and furnishings,
other facility related costs and capital purchase (but excluding
staffing);]{.underline}

[(2) The cumulative total of the principal of direct loans and loan
guarantees, respectively, outstanding at any one time shall not exceed
such limitations as may be specified in appropriation acts;]{.underline}

[(3) In the discretion of the Secretary, the program may be administered
by the Service or the Health Resources and Services Administration
(which shall be specified by regulation);]{.underline}

[(4) The Secretary may make or guarantee a loan with a term of the
useful estimated life of the facility, or twenty-five (25) years,
whichever is shorter.]{.underline}

[(5) The Secretary may allocate up to 100% of the funds available for
loans or loan guarantees in any year for the purpose of planning and
applying for a loan or loan guarantee.]{.underline}

[(6) The Secretary may accept an assignment of the revenue of an Indian
tribe, tribal organization or urban Indian organization as security for
any direct loan or loan guarantee under this section. ]{.underline}

[(7) In the planning and design of health facilities under this section,
users eligible under Section 813(b) may be included in any projection of
patient population.]{.underline}

[(8) The Secretary shall not collect fees from Indian tribes, tribal
organizations or urban Indian organizations applying for direct loans or
loan guarantees under this section. ]{.underline}

[(9) Service funds authorized under loans or loan guarantees in this
section shall be eligible for use in matching other Federal funds.
]{.underline}

+----------------------------------------------------------------------+
|   --                                                                 |
|   --                                                                 |
|                                                                      |
| *This new section establishes a program of direct loans and loan     |
| guarantees to address the health facility construction backlog.      |
| Allows funds under this section to be used for matching other        |
| Federal funds. *                                                     |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[TRIBAL LEASING ]{.underline}**

**[Sec. ]{.underline}[311]{.underline} ~~820~~. **Indian tribes
providing health care services pursuant to a [funding agreement
]{.underline}~~contract~~ entered into under the Indian Self-
Determination [and Education Assistance]{.underline} Act may lease
permanent structures for the purpose of providing such health care
services without obtaining advance approval in appropriation Acts.

+----------------------------------------------------------------------+
|   --                                                                 |
|   --                                                                 |
|                                                                      |
| *This section was formally section 820. Includes all Indian          |
| Self-Determination and Education Assistance Act tribes. *            |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**~~DEMONSTRATION PROJECTS FOR TRIBAL ~~**

**~~MANAGEMENT OF HEALTH CARE SERVICES~~**

~~ ~~**~~Sec. 818. ~~**~~(a)(1) The Secretary, acting through the
Service, shall make grants to Indian tribes to establish demonstration
projects under which the Indian tribe will develop and test a phased
approach to assumption by the Indian tribe of the health care delivery
system of the Service for members of the Indian tribe living on or near
the reservations of the Indian tribe through the use of Service, tribal,
and private sector resources.~~

~~ (2) A grant may be awarded to an Indian tribe under paragraph (1)
only if the Secretary determines that the Indian tribe has the
administrative and financial capabilities necessary to conduct a
demonstration project described in paragraph (1).~~

~~ (b) During the period in which a demonstration project established
under subsection (a) is being conducted by an Indian tribe, the
Secretary shall award all health care contracts, including community,
behavioral, preventive health care contracts, to the Indian tribe, in
the form of a single grant to which the regulations prescribed under
part A of title XIX of the Public Health Service Act (as modified as
necessary by any agreement entered into between the Secretary and the
Indian tribe to achieve the purposes of the demonstration project
established under subsection (a)) shall apply.~~

~~ (c) The Secretary may waive such provisions of Federal procurement
law as are necessary to enable any Indian tribe to develop and test
administrative systems under the demonstration project established under
subsection (a), but only if such waiver does not diminish or endanger
the delivery of health care services to Indians.~~

~~ (d)(1) The demonstration project established under subsection (a)
shall terminate on September 30, 1993~~**~~ ~~**~~or, in the case of a
demonstration project for which a grant is made after September 30,
1990, three years after date on which such grant is made.~~

+----------------------------------------------------------------------+
|   --------------                                                     |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|   ~~ (2) By n                                                        |
| o later than September 30, 1996, the Secretary shall evaluate the pe |
| rformance of each Indian tribe that has participated in a demonstrat |
| ion project established under subsection (a) and shall submit to the |
|  Congress a report on such evaluations and demonstration projects.~~ |
|   --------------                                                     |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|                                                                      |
| *This section was formally section 818. Subsections (a) through (d)  |
| are deleted because the period for the demonstration has long since  |
| passed. Subsection (e) was retained with changes, and it appears     |
| below in the newly titled section 312.*                              |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[INDIAN HEALTH SERVICE/TRIBAL FACILITIES JOINT VENTURE
]{.underline}[PROGRAM]{.underline}**

**[Sec. 312]{.underline}**[ (a)]{.underline} ~~(e)(1)~~ The Secretary,
acting through the Service, shall make arrangements with Indian tribes
[and tribal organizations]{.underline} to establish joint venture
demonstration projects under which an Indian tribe [or tribal
organization]{.underline} shall expend tribal, private, or other
available [non-Service]{.underline} ~~nontribal~~ funds, for the
acquisition or construction of a health facility for a minimum of ~~20~~
[10 ]{.underline}years, under a no-cost lease, in exchange for agreement
by the Service to provide the equipment, supplies, and staffing for the
operation and maintenance of such a health facility. A tribe [or tribal
organization]{.underline} may utilize tribal funds, private sector, or
other available resources, including loan guarantees, to fulfill its
commitment under this subsection. [A tribe that has begun and
substantially completed the process of acquisition or construction of a
health facility on/or after October 1, 1993 shall be eligible to
establish a joint venture project with IHS using such heath
facility.]{.underline}

[(b)(1)]{.underline} ~~(2)~~ The Secretary shall make such an
arrangement with an Indian tribe [or tribal organization]{.underline}
only if the Secretary first determines that the Indian tribe [or tribal
organization]{.underline} has the administrative and financial
capabilities necessary to complete the timely acquisition or
construction of the health facility described in paragraph (1).

[(2) The Service shall negotiate an agreement with the Indian tribe or
tribal organization regarding the continued operation of the facility at
the end of the initial 10 year no-cost lease period. ]{.underline}

[(c)]{.underline} ~~(3)~~ An Indian tribe or tribal organization that
has entered into a written agreement with the Secretary under this
subsection, and that breaches or terminates without cause such
agreement, shall be liable to the United States for the amount that has
been paid to the tribe [or tribal organization]{.underline}, or paid to
a third party on the tribe\'s [or tribal organization's]{.underline}
behalf, under the agreement. The Secretary has the right to recover
tangible property (including supplies), and equipment, less
depreciation, and any funds expended for operations and maintenance
under this section. The preceding sentence does not apply to any funds
expended for the delivery of health care services, or for personnel or
staffing~~, shall be recoverable~~.

** **[(d) Recovery for non-use.]{.underline}**[ ]{.underline}**[An
Indian tribe or tribal organization that has entered into a written
agreement with the Secretary under this subsection shall be entitled to
recover from the United States an amount which is proportional to the
value of such facility should at any time within 10 years the Service
cease to use the facility.]{.underline}

[(e) Wherever "health facility" or "health facilities" are used in this
section, they may include quarters needed to provide housing for staff
of the tribal health program.]{.underline}

  --
  --

*This section was formally subsection (e) of Section 818 (Demonstration
Projects for Tribal Management of Health Care Services). The IHS and
tribes may enter into joint ventures under which the tribe is
responsible for the facility and IHS is responsible for equipment,
supplies, and staffing. Provides that the IHS and the tribe, at the time
of entering into a joint venture, shall negotiate to determine the
appropriate course of action at the end of the lease period. Includes
facilities built since October, 1993. Provides for staff quarters
construction. *

  --
  --

**[LOCATION OF FACILITIES]{.underline} ~~PRIORITY FOR INDIAN
RESERVATIONS~~ **

**Sec. [313]{.underline} ~~824~~. **(a) ~~Beginning on the date of the
enactment of this section, t~~ [T]{.underline}he Bureau of Indian
Affairs and the Service shall, in all matters involving the
reorganization or development of Service facilities, or in the
establishment of related employment projects to address unemployment
conditions in economically depressed areas, give priority to locating
such facilities and projects on Indian lands if requested by the [Indian
owner and the]{.underline} Indian tribe with jurisdiction over such
lands[ or other lands owned or leased by the Indian tribe or tribal
organization, provided that priority shall be given to Indian land owned
by an Indian tribe or tribes.]{.underline}

\(b\) For purposes of this section, the term \"Indian lands\" means\--

\(1\) all lands within the~~ limits ~~[exterior boundaries
]{.underline}of any Indian reservation; ~~and ~~

\(2\) any lands title ~~\[~~to~~\]~~ which is held in trust by the
United States for the benefit of any Indian tribe or individual Indian,
or held by any Indian tribe or individual Indian subject to restriction
by the United States against alienation and over which an Indian tribe
exercises governmental power~~.~~[; and]{.underline}

[ ]{.underline} [(3) all lands in Alaska owned by any Alaska Native
village, or village or regional corporation under the Alaska Native
Claims Settlement Act, or any land allotted to any Alaska
Native]{.underline}.

+----------------------------------------------------------------------+
|   --                                                                 |
|   --                                                                 |
|                                                                      |
| *This section was formally section 824. In locating facilities, the  |
| Bureau of Indian Affairs continues to give preference to Indian      |
| lands. The definition of Indian lands is adjusted to make this       |
| provision meaningful in Alaska. *                                    |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[MAINTENANCE AND IMPROVEMENT OF HEALTH CARE FACILITIES]{.underline}**

**[Sec. 314.]{.underline}**[ (a) The Secretary shall submit to the
President, for inclusion in the report required to be transmitted to the
Congress under section 801, a report which identifies the backlog of
maintenance and repair work required at both Service and tribal
facilities, including new facilities expected to be in operation in the
next fiscal year. The report shall also identify the need for renovation
and expansion of existing facilities to support the growth of health
care programs.]{.underline}

[(b) The Secretary is authorized to expend maintenance and improvement
funds to support maintenance of newly constructed space only if such
space falls within the approved supportable space allocation for the
tribe or tribal organization.]{.underline}

[(c) Supportable space allocation set forth in subsection (b) above
shall be defined through the negotiated rulemaking process provided for
under Title VIII.]{.underline}

  --
  --

*This is a new section. Requires a report to Congress on the maintenance
and improvement backlog (including new facilities). *

  -----------------------------------------------------------------------------------------------------------------------------
  *Requires "supportable space allocation" to be defined under the negotiated rulemaking provided in Title VIII of this Act.*
  -----------------------------------------------------------------------------------------------------------------------------

**[TRIBAL MANAGEMENT OF FEDERALLY-OWNED QUARTERS]{.underline}**

** [Sec. 315 . ]{.underline}**[ (a) Notwithstanding any other provision
of law, and consistent with the Section 312 joint venture program, an
Indian tribe or tribal organization may elect to establish the rental
rates for federally-owned quarters operated under an Indian
Self-Determination and Education Assistance Act contract or
Self-Governance compact pursuant to the following
conditions:]{.underline}

[(1) the rental rates for the quarters may be based on the reasonable
value of the quarters (as such terms are defined under section 5911 of
Title 5);]{.underline}

[(2) the rental rates may be established so as to generate sufficient
funds to prudently provide for the operation and maintenance of the
quarters, and, subject to the discretion of the Indian tribe or tribal
organization, to supply reserve funds for capital repairs of the
quarters;]{.underline}

[(3) the quarters shall remain eligible for quarters improvement and
repair (QI&R) funds to the same extent as all quarters used to house
personnel in the IHS programs;]{.underline}

[(4) occupants will be provided no less than 60 days notice of any
change in rental rates;]{.underline}

[(5) the Indian tribe or tribal organization may exercise rights under
this section only if the Indian tribe or tribal organization operates
the hospital or other health facility with which the quarters are
associated under the Indian Self-Determination and Education Assistance
Act. ]{.underline}

[(b) Notwithstanding any other provision of law, an Indian tribe or a
tribal organization may elect to undertake direct collection of rents
from federal employees who occupy federally-owned quarters operated
under an Indian Self-Determination and Education Assistance Act contract
or Self-Governance compact. Rents collected from federal employees shall
be retained by the Indian tribe or tribal organization and need not be
made payable or to otherwise be deposited with the Service, provided
that funds are designated for the maintenance and operation of the
quarters and facilities and are deposited in a separate account for that
purpose. Quarters maintenance and operation funds shall be allocated
according to the discretion of the Indian tribe or tribal organization.
]{.underline}

[(c) Subject to the provisions of paragraphs (a) and (b), the rental
rates for housing provided to an employee by the federal government in
Alaska pursuant to a Self-Determination contract shall be determined on
the basis of -- ]{.underline}

[(1) the reasonable value of the quarters and facilities (as such terms
are defined under section 5911 of Title 5, United States Code) to such
employee, and ]{.underline}

+----------------------------------------------------------------------+
|   ------------------------------------------------------------       |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|   [(2) the circumstances under which such quarters and facil         |
| ities are provided to such employee, as based on the costs of compar |
| able private rental housing in the nearest established community wit |
| h a year-round population of 1,500 or more individuals.]{.underline} |
|   ------------------------------------------------------------       |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|                                                                      |
| *This is a new section. Tribes operating health care under Indian    |
| Self-Determination and Education Assistance Act facilities may       |
| manage associated federally-owned quarters, including setting rental |
| rates and collecting directly from federal employees.*               |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**[APPLICABILITY OF BUY AMERICAN REQUIREMENT ]{.underline}**

**[Sec. ]{.underline}[316]{.underline} ~~310~~.** (a) The Secretary
shall ensure that the requirements of the Buy American Act apply to all
procurements made with funds provided pursuant to the authorization
contained in section 317[, provided that Indian tribes and tribal
organizations shall be exempt from these requirements]{.underline}.

~~ (b) The Secretary shall submit to the Congress a report on the amount
of procurements from foreign entities made in fiscal years 1993 and 1994
with funds provided pursuant to the authorization contained in section
309. Such report shall separately indicate the dollar value of items
procured with such funds for which the Buy American Act was waived
pursuant to the Trade Agreement Act of 1979 or any international
agreement to which the United States is a party. ~~

~~(c~~[)(b)]{.underline} If it has been finally determined by a court or
Federal agency that any person intentionally affixed a label bearing a
'Made in America' inscription, or any inscription with the same meaning,
to any product sold in or shipped to the United States that is not made
in the United States, such person shall be ineligible to receive any
contract or subcontract made with funds provided pursuant to the
authorization contained in section 309, pursuant to the debarment,
suspension, and ineligibility procedures described in sections 9.400
through 9.409 of title 48, Code of Federal Regulations.

~~(d)~~[(c) ]{.underline}For purposes of this section, the term \"Buy
American Act\" means title III of the Act entitled \"An Act making
appropriations for the Treasury and Post Office Departments for the
fiscal year ending June 30, 1934, and for other
purposes[,]{.underline}\"~~,~~ approved March 3, 1933 (41 U.S.C. 10a et
seq.).

+----------------------------------------------------------------------+
|   --                                                                 |
|   --                                                                 |
|                                                                      |
| *Indian tribes and tribal organizations engaged in construction with |
| their own employees are exempted from the Buy American Act, which    |
| remains applicable to other construction contractors. Because the    |
| reporting requirement has passed, part (b) was deleted. Penalty      |
| provisions were preserved. *                                         |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**AUTHORIZATION OF APPROPRIATIONS **

+----------------------------------------------------------------------+
|   -----------------------------------------------------------------  |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|   **Sec. [317]{.underline} ~~309~~.** There are authorized to be     |
| appropriated such sums as may be necessary for each fiscal year thro |
| ugh fiscal year [2012]{.underline} ~~2000~~ to carry out this title. |
|   -----------------------------------------------------------------  |
| -------------------------------------------------------------------- |
| -------------------------------------------------------------------- |
|                                                                      |
| *Appropriations are authorized through 2012.*                        |
+----------------------------------------------------------------------+