hearing of the of the health subcommittee is called to order and today we're having a hearing on h r two seven zero weight the indian health care improvement act amendments of two thousand and nine and i'll  yield to myself for opening statement initially and then we'll get to the other members for over the past ten months our country has been engaged in an important debate about how to reform our nation's health care system but what few people realize is that for over the past ten years a similar debate has been going on in indian country and here congress and as well as in congress about how to reform the health care system that serves american indians and alaska natives since one thousand nine hundred ninety legislation has been pending before the congress to reauthorize the indian health care improvement act which is the cornerstone legal authority for the provision of health care to american indians and alaska natives i know for those tests to testifying before us today and for many of those in the audience is well known that the federal government has a legal and i would say moral responsibility to provide free and quality health care to this country's native peoples this responsibility often referred to as the trust responsibility is born from a legal doctrine consisting of various treaties contracts and court decisions putting all the legal aspects aside i think the trust responsibility can be summed up by saying that something is owed to american indians for the lands that they were both voluntarily given that they voluntarily gave to the united states or were forcefully taken as well as the atrocities that were committed against their people and what is owed to them is a pledge from this government ensure that their well being is taken care of after centuries of mistreatment but the federal government has consistently failed to live up to this responsibility in almost every aspect they have mismanaged the lands that they hold in trust for native peoples american indian students struggle to receive a proper education that is on par with their peers who are non indian and most important the quality of healthcare services available to american indians certainly falls well below the rest of the general population which in turn has resulted in worse health outcomes for native communities now i can't tell you how many times i've ever cited the statistics i'm going to now give you and i'm sure everyone in this room has heard them too many times as well but i do want everyone to understand what's at stake for native americans ages fifteen to forty four years mortality rates and more than twice those of the general population american indians and alaska natives have substantially higher rates of disease in the rest of the us population based on recent statistics american indians and alaska natives have seven times the rate of tuberculosis more than six times the rate of alcoholism nearly three times the rate of diabetes and a sixty two percent higher rate of suicide the indian health service also estimates that more than two thirds of health care that is needed for american indians and alaska natives is simply denied over the course of the health reform debate some opponents have used the statistics and pointed to the indian health service as an example of the failures that would occur under government run health care system i even had this is some of my town meetings but these perpetrators of the i h s are unfortunate gratuitous and misleading the not failed rather the federal government has historically failed to properly fund the i gess a two thousand and four report on native american health issued by the u s commission on civil rights found that inadequate federal funding was the major obstacle to eliminating disparities in native american health care the report stated that annual increases in funding for the and health service did not include adjustments for inflation or population growth and were significantly less than those allocated to other arms of the department of health and human services and this is an important point indeed less is spent on providing health care to american indians per capita than any other sub population in fact we spend more money to provide health care to federal inmates than we do for american indians and i think that's probably the most shocking statistic of all we have made some headway in recent months provisions relating to indian health were included in legislation enacted earlier this year including chip pro russian ship as i call it and the a r r a the recovery act or the stimulus bill in both bills were able to include provisions that would improve outreach and enrollment of american indians eligible for medicaid and chip in addition the recovery act included a substantial increase in funding for the indian health service and in may of this year the i h s released to five hundred million of those funds to be used for health facilities construction or maintenance and improvements health information technology sanitation facilities construction and health equipment that will help improve health care in indian country in addition to these funds president obama proposed a thirteen percent increase for the i h s in his fiscal year two thousand and ten budget proposal and i'm happy to say that both the house and the senate are on track to approve the level of funding requested by the president or even exceed it simply by adequately funding the indian health service we can substantially increase the health and wellbeing of native communities but we can't simply say we're going to increase funding for the i chess and call it a day because it's not just a matter of funding it's a matter of making sure these programs work well and can meet the needs that are present in those communities the bill we're looking today we're looking at today would make important changes to the delivery of health care services in indian communities to make sure needs act in various legislation as well as in the health care reform bill that's moving is an ongoing effort and we're still trying to do that as much as possible but i do think that we need a hearing today because whatever isn't included obviously we would like to move a separate legislation if that becomes necessary and so having the hearing today is the is which is a legislative hearing is our effort to to continue down that path as quickly as possible i want to thank our witnesses for testifying we have some new faces including dr e that rebel who is the new director of the chess we also have some returning witnesses including rachel joseph who is the co chair of the national tribal steering committee to reauthorize the indian health care that the hearing got off on time with with members from the minority party here too to welcome you and i look forward to your testimony on a point that we will add to this debate and it was debated in the last reauthorization it was addressed in the senate legislation and we have this debate now with the overall health care reform is the issue of taxpayer funds that will go to abortion abortion services there many of us who will will not will want to maintain the position of high language amendment which has been very important in the past legislation it is under challenge today and so it's important for you all to know that all the many of us in the pro life community it's really a bipartisan group of members republicans and democrats who will make sure want to really ensure that taxpayer dollars not go for those specific type virgin islands ms kristiansen who has actually both to both of my colleagues who are here today have had major roles in pushing this legislation so i appreciate both  being here and all that you've done the gentleman from the virgin islands thank you thank you mr chairman and thank you for holding this hearing you know preparing for this hearing today just we candled my indignation over the way indigenous people of this country have been treated i don't think it even rises to the level of benign neglect it really can when one looks at the tragic impact it has had on individuals families tribes and native populations over the centuries but h r twenty seven zero eight the indian health care improvement amendments of two thousand and nine is a good and welcome start really just scratches the surface disease illness or the converse health and well being don't exist in a vacuum they are the consequences of genetics to some degree and behavior as well but the most influential factor is the environment for the environment affects behavior for sure and can even have some impact on the genetics given to the to ration of the environment in which native people are now confined to their extremely poor health low life expectancy and adverse health behavior resulting in high rates of injury suicide alcoholism and other substance abuse would be expected outcomes of any population group having had no change in the indian health service hundred seventy six despite the dire health indicators and given the many advances in health knowledge and technology is truly a shame the fact that we have not been able to pass a reauthorization since two thousand and one is also unacceptable so i'm glad that we're having this hearing today following on the one in the committee a natural resource resources where the chairman and i are both also members and i'm also pleased that in addition to the provisions in chip and a  r a that h r thirty two hundred includes some care provisions and i'm proud to say that the tri caucus has included i care provisions in our health equity bill and that we fully include the concerns of our american indian alaskan hawaiian native brothers and sisters in our efforts in our initiatives but this can only be considered first step in the effort that we owe to these first members of the american family so i look forward to working with the chairman alone and ranking member deal to make sure that the indian health care improvement act amendments of two thousand and nine are finally passed in two thousand and nine so thank you for holding this hearing thank you to the witnesses who are here with us today not only for being here but for all of the work that you've done over the years to improve upon the bill that we have indian health the indian health improvement act i know that this is a major priority for you mr chairman and for the subcommittee and i'm eager to lend my support and help achieve the goal of reauthorization during this congress one of my primary outcomes and access the american indian and alaska native people have long experience lower health status when compared with other americans and a recent report from the agency for health research and quality outlined a number of areas in which american indians and alaskan natives lag behind others and the specific areas where these disparities are growing worse the report uses a number of measures to assess access to care including prenatal care rate of preventative screening and other basic services that are key to preventing illness and disease one of the most alarming and difficult issues to address is the rampant spread of diabetes indian country lack of public health initiatives leave families without the information they need to get healthy and to stay healthy and diabetes ends up being a persistent chronic disease that costs the indian health service an extraordinary amount of money but much more importantly to many native americans their lives that's why i'm especially proud of a facility i want to boast about it in the district that i represent run by the whole chunk nation the house of wellness is a state of the art facility designed to offer a full range of health services with a focus on prevention and wellness it is a fitness and aquatic facility featuring a range of programs designed to promote exercise a professionally trained staff indoor walking track and studio life style classes house of wellness also offers childcare services for parents who need a little bit of time to take care of their own health and it  also offers a health clinic and pharmacy services to help meet the needs of the community both native and non native through promotion of exercise and helping people of all ages focus on prevention facilities like this one can change the health trajectory of many native american families the indian health service also provides vital water and sanitation assistance to its members of the whole chunk nation as you know ensuring that  and provides access to safe and clean water is one of the most important steps we can take towards improving the health of communities it is unacceptable to me that we have a language so long without reauthorizing this incredibly important legislation i want to thank our witnesses here today who will help us understand how much more pressing the need becomes with each passing day again mr chairman thank you for convening this hearing and i i also must apologize i'm going to be skipping between two simultaneous hearings this afternoon but i hope to be here as long as i can to hear your testimony thank you and we'll now move to our witnesses and on our first panel we have  director of the indian health service thank you for being here today i guess i normally say that we have we have five minutes but since you're the only witness i'm not going to worry about it too much but thank you if you'd established to meet the federal trust responsibility to provide health care for american indians and alaska natives the mission of the indian health service in partnership with american indian alaskan native peoples to raise the physical mental social and spiritual health to the highest level the indian health service provides high quality comprehensive primary care and public health services through a system of tribal and urban operated facilities to nearly one point five american indians alaskan native through hospitals health centers clinics located in thirty five states however meeting the mission of the indian health service has become increasingly challenging over time population growth increased demand for services rising medical costs and the growing burden of chronic disease have placed significant strain on the system in the opening statement of my confirmation hearing before the senate committee on indian affairs i stated that despite these challenges i see evidence of hope and change i've worked in a variety of projects and national initiative over the past sixteen years that show me the great potential that exists to improve access and quality of health care i know that thousands of dedicated and committed career staff in the indian health system work hard every day to provide health care to their patients in the face of all these challenges and i have seen support from tribes in congress for change and improvement in the indian health service i believe we are a unique moment in time where we have the opportunity to take great strides towards fulfilling the mission of the indian health service and improving the health of american indian and alaska native president obama's commitment to improve health care for american alaskan native people is reflected by significant funding increase for the indian health service as you mentioned in f y two thousand and ten while the president the secretary and i all understand that money alone is not the whole answer but significant increase in resources for recommended in the president's budget is essential for the agency to increase services and effectively its mission now is the time to begin the important work of bringing change to the indian health service to improve health care quality to modernize and upgrade to expand health promotion and disease prevention and to ensure that american indians and alaska natives are able to get the health care that they deserve passage of the indian health care improvement act will be an important step towards the the department strongly support reauthorization of the indian health care improvement act and supports the effort to ensure that able to meet the healthcare needs of american indians and alaska natives and takes into account increased tribal administration of health programs it's within this context today that we offer our views on h r twenty seven zero eight we will provide if you comment today and we will provide additional comments once you've had an opportunity to conduct a complete review of this important first we know that the authority for that catastrophic health emergency fund or chef included in title two of the existing authority has actually been excluded from this bill we recommend its inclusion because the chef program is a key component of the contract health program administered by the us and tribal health programs shaft provides funding for high cost cases which cannot be absorbed by local service contract healthcare program our next comments are in title one i just offers health professions scholarships to american indian alaskan native students who agree to sign a legal contract agreeing to a service dog upon completion of their health professional training unfortunately a small number of students default on their service obligation we believe the determination of whether to discharge or suspend the defaulted obligation should remain interested as is under current law to a review board charged with making impartial case by case decisions based on a detailed review of the request we recommend that the new consultation requirement in this section of title one be dropped defaulting on this obligation is a serious breach of a legal contract and the resolution must be decided in impartial manner but also offers a loan repayment program to help professionals who agreed to work in areas of high vacancy or need in a list of or a vacancy required under the section this modification means that award approvals would be based on other priorities undermining the development of our annual priority list so to keep the intent of the loan repayment program consistent with the goal of improving recruitment and retention of health professionals in areas of high vacancy we recommend the term notwithstanding be replaced by the term consistent with the priority list sewer projects in indian country are written testimony provides examples of the problems with these definitions we recommend retaining current law to distinguish the various levels of deficiencies which the term allocating existing resources in addition to the comments made certain provisions of the charge twenty seven zero eight there will be additional comments once we've had an opportunity to conduct a complete review of this important  chairman that concludes my testimony i appreciate the opportunity to appear before you to discuss the reauthorization of the indian health care improvement act of two thousand and nine and we are committed to working with you sure the  authority i'll be happy to answer any questions that you have thank you thank you and i will take questions from the panel i'll start with myself first so let me thank you for actually getting specific because unfortunately and and i would sounds partisan but in the previous administration we we i don't remember any of the open testimony being you know specific about the bill and i also appreciate the fact that you're going to get back to us quickly because as i said i would like to see as much of this included in the health care reform as possible and so you know as we move with that whatever comments we could get from the administration would be very important you know over the next few weeks or the next few months i want to try to get in three questions here quickly if i can you know  legislation has languished for many years in congress so could you tell us why it's so important to reauthorize the act and what are the consequences for the i s and those who rely upon it that we haven't or that if we continue not to re better care for the patients that we serve the consequences of not acting or again our patients are waiting for this important legislation to be reauthorized ok and then the second question  you know i want to thank you and from the president obviously for making you know the additional funding available that's in the budget clearly that's very important but i didn't rely solely on its annual appropriations to finance services to what tribe it collects reimbursements for medicare medicaid and private payers so how important is it to make sure the tribal members are enrolled in other public programs like medicare or medicaid or private the health system make it difficult for us to meet our mission and so we rely on the ability of serving patients to have other resources in terms of insurance or medicare or medicaid coverage  third party reimbursements from the sources stream least for some of our facilities over half of their operating budget comes from third party reimbursement so they serve an extremely important source of care for  i think some of the barriers that we have to having some of our patients enroll in the forms of coverage is that the paperwork can be confusing there may be a mis understanding of why they need to that i know you're able to offer as some of the administration's position on organizational structural changes and you said we're going to get back to more which again i'd appreciate as soon as possible but did you want to talk a little more about any of these organizational structural changes today particularly the elevation of the director to the position of assistant secretary because that's been an important part of this legislation for a long time we understand that the proposal to elevate the director of the indian health service john assistant secretary level is extremely important to our tribe and that's been a recommendation by them because they would like their health care needs to be addressed at the highest levels in the department i'm working with the secretary and her staff on exploring this issue once we receive once we develop a position on it we will let you know but we definitely understand that the health needs of the american indians and alaska natives need to be addressed at the highest levels in the department of health and human services and we are committed to that and that's obviously one that if you could get back to it as quickly as possible thank you thank you thank you and thanks so much for your testimony appreciate it good luck with everything thank you very much and the second panel to come forward our second panel has four witnesses and i'll introduce them starting on my left is the honorable jefferson keel who is a lieutenant governor of the chickasaw nation and president elect of the national congress of american indians and then is rachel joseph who is co chair of the national tribal steering committee for the reauthorization of the indian health care improvement act and then we have another joseph andrew joseph jr who is chairman of the human services committee direct services tribe advisory committee and finally dr patrick rock who is executive director of the indian health board of minneapolis and president elect of the national council of indian health thank you for being here and thank you for all that you've done over the years and on this legislation as i said you know we have five minutes but there's not a lot going on today so we're not going to stick to that too much and we'll start mr keel thank you mr chairman good afternoon and first i want to i want to begin by just saying as the president of the national congress for american indians i'm honored to be asked to present testimony to our friends at the health subcommittee of the energy and commerce committee on behalf of the national congress for american indians  the health care services delivered to american indians and alaskan natives any country extended thanks for your hard work over the last several years on health care improvement act we appreciate all that you and the committee have done now it is time to disparities in our communities and why the reauthorization is so desperately needed all of which the committee is very familiar with what i would like to do today is simple i'd like to ask him to set a schedule and procedure for when the bill will be passed and act over the last ten years in as worked side by side with the national steering committee for the reauthorization of the indian health care improvement act and the national indian health board for  same procedures we work with numerous committee staff on drafting language watch leadership in the house change and i've seen two presidents come and go in office with each passing year there seems to be a new must pass priority the health care is relegated to the sidelines the nation is now focused on reforming the health insurance industry as with the rest of the country this issue is of critical importance to tribes and we support the efforts of the national health reform bills its goal is to provide cost saving feature for health care delivery by shifting to health care delivery paradigm and to preventive health any country has been waiting for and asking for these updates for over ten years we do not believe that national health insurance reform should be used as an excuse for abandon abandoning the effort to reauthorize the health care improvement act we now come before the committee to ask for assurance that as the nation moves forward with health reform indian country will be included in our building health care improvement act will be passed what i ask again to the committee is what is your strategy for passing   the hard work of the staff in drafting the protections needed within that bill and a dedication of the committee in passing those key provisions we now asked at that same enthusiasm and commitment be provided by the indian health care improvement  we appreciate your ongoing support for improving health care for indian i also acknowledge the contribution of tribal leaders who have served on the n s c over the past ten years the foundation of our participation in this  on two principles one that the legislation allowed nobody gresham from current law and that the health care system be modernized and strengthened in the chairman's opening statement he responded the health status and the statistics of our population no other segment of the american population experiences greater health disparities than the american indian and alaska native populations the heartbreaking aspect of the knowledge that a majority of illnesses and there are preventable if additional funding and modern programatic approaches to health care were available despite two centuries of treaties and promises american indians and alaska natives endure health conditions and a level health care that would be unacceptable to most americans today i respectfully request congress to fulfill our nation's responsibilities to indian people by reauthorizing the indian health care improve an act this year the indian health care improvement act also needs to be a permanent law that's we urged the committee to amend h r twenty seven zero eight to remove the sunset date and permanently authorize appropriations for the  programs our request for permanent authorization is not unique congress has personally authorized other several indian laws such as the snyder act in the south determination education systems act and other laws which i listed in my written testimony there are many provisions in the bill which embody the improvements needed for the indian health care system i would like to highlight just three of them section two zero eight recognizes the need for tribal epidemiology centers to be expressway authorized to access the data they need to monitor the incidence of diseases in indian communities and how tribes an urban indian organization design programs to attack those diseases complete fulfillment of this mission requires the centers to operate like public health authorities and to access indian country data compiled by h h s agencies secondly we strongly support the bills revisions to current law author zing a comprehensive system of behavioral health program title seven authorizes the interger ation of programs for mental health social services domestic and child abuse use suicide and substance abuse attacking these chronic problems is vital to improve the quality of life in indian country and strengthening indian families lastly section eight zero seven addresses a serious issue in indian country when tribes are compelled to try to sail the funding gap by expanding direct services augmenting contracts how care paying premiums for medicare part b and b and developing south insurance plans for their members unfortunately the tax consequences of such efforts are unclear section eight zero seven will clarify that these benefits are tax exempt as they should be they were prepaid through this is stationed at over four hundred million acres of tribal lands and other resources american indians alaskan native people are entitled to health care and should not be taxed when their tribe stepped in to assist them in obtaining care while the n c is extremely supportive of this bill there are a few provisions that require revision an additional provisions we would like to see inserted into the bill our proposals are outlined in the section by section revisions document which was included with my written testimony submitted for the record i would like to clean  by sharing my personal observations and experiences with this reauthorization which have been the most positive and uplifting experience in my life and at the same time the most frustrating experience during the consultation with the tribes that began in one nine hundred ninety eight and continued to nine hundred ninety nine tribal leaders across the country made some strong commitments that we would spend long hard hours no cellphones with one of our ground rules which is pretty exciting as a tribe develop a consensus on the proposal that we submitted to congress we believe that consensus was necessary so that you know we would not be in a divide and conquer position but as you balance the diverse and the v needs of our tribes it was it was a tremendous project an undertaking and we did it and we've been able to maine consensus through all these years point and of course our job is not done mr fortunate that we have that kind of communication i also would be remiss if i did not acknowledge support an ongoing efforts of chairman ray hall waxman and rangle and former chairman don young and of course chairman years there's no reason in our view that this legislation should not be enacted this year i'd be happy to respond to any questions that you have and look forward to working with you to get this job done thank you thank exercise of self determination and fulfillment of the federal trust responsibility five hundred sixty four federally recognized tribes provides direct care health care services for over one hundred trades and accounts for over fifty percent of the total population served since nine hundred ninety nine tribes have been seeking reauthorization of the union health care improvement act however ever for reasons it is difficult to understand passage of the indian health care improvement act reauthorization bill has been obstructed each year by concerns of unrelated non indian issues i hope the committee will work with this to ensure that this bill is not sidetracked this year and the bill is passed as soon as possible for the indian people federal recognize federal responsibility to provide health services represents a pre paid tribes hold in a firm that the treaties with the federal government ensure that health care will be delivered effectively in our communities to exchange for the millions of acres of valuable land that our ancestors ceded to day the indian health care improvement act continues to be a vital important policy  that honors these treaties and serves as a foundation for delivery of health care to indian people i'd like to speak on a few provisions of h r two seven zero eight that would have significant impact for a direct service tribes for section two one to provide six express thirty four craves to operate hospice long term care bested it assisted living programs to supply health services and homes and community based settings such delivery methods are common in the rest of the country but are rare in indian country second elevation of stricter as an assistant secretary level within the department of health and human services would be a strong step in creating a direct link to address the needs of trades expression direct service trades with an assistant secretary position tribes have invested into the process for over ten years as a tribal leader and need to justify the resources that my tribe puts into trips to washington d c i know that these vital resources could be put continual thirty for our health care system the bill should be amended to ensure that there is a sion for appropriations as permanent the responsibilities of this office would honor the relationship by providing technical support to direct service trades and serving as a point of contact for tribal consultation i think the committee for the opportunity to provide these comments and will be please answer any questions the committee may have thank you thank you dr rock thank you good afternoon subcommittee for holding this hearing the urban indian health program serves over one hundred fifty thousand american indians and alaska natives anneli through thirty six urban indian programs across the country it is a comprehensive health delivery system th integrates public health preventive health measures behavioral health and primary care services the urban indian programs providing health services various levels of services depend upon the needs of the community in the funding our programs are both innovative and cost effective as a whole program leverage two dollars for every dollar of any health service investment we are we are also a unique system of care designed to fulfill the trust responsibility to union people living in urban areas congress has repeatedly stated that the government's trust responsibility extends to american in an alaskan native living away from their tribal home from the original snyder act hundred twenty one to the health care improvement act congress has affirmed and reaffirmed its commitment to ensure that trust responsibility to any people is met regardless of where they reside despite commitment the trust responsibility to any people has not been fully met in health care delivery system is innovative and well situated to address the health disparities suffered by any people in a comprehensive cultural culturally appropriate manner however th union health delivery system needs full funding and modernization promised by this bill in order to meet its mission h r twenty seven only provides a number of new tools and updates for the new health providers these programs and modernizations will help the union health delivery system tackle a serious health disparities facing our people i would like to take the opportunity to highlight three provisions that i believe will greatly benefit urban and health providers such as myself first section five one five conforming with urban indians in order to in order to trust responsibility to urban areas are fully met urban ngs need the opportunity promised by the section to discuss the health needs of urban indians with the federal government second section five to one authorization for urban and organizations h r twenty seven zero eight creates tools and programs to address behavioral health disparities  people especially with regard to indian youth suicide this provision assures that urban indian programs will have such programs available through them through title five of h c i a third section five two two health information technology health information technology is the future of health delivery a provider that does not develop infrastructures and systems now will be will be behind the advances of medi same permanency second mccooey also ask the committee to restore urban indians to section three the declaration of national union health policy removing urban indians from this provision is regression from current law by not including urban ensconce opens the door to inferences that it no longer believes that the trust responsibility extends to urban indians we believe that dropping urbanists from this provision was done in error and asked the committee to restore urban indians third night asked the committee to restore urban areas to section two hundred one of title to these provisions pertain to third party billing a critical necessity for any health provider including urban indians in the section would greatly help urban organizations strengthen their third party building capacity which could be a difference between fiscal stability a the necessary modernization for in health delivery system and all in health providers from in the health service to urban indian health providers will benefit greatly from this passage while there are there are few provisions important for myself initially and my colleague from the virgin islands let me let me address some of the things that you mentioned first mr hill talked about schedule and procedure for moving the bill and i would just you know like to reiterate what i said before which is that you know i'd like to see as much of this included in the in the larger health care reform as possible and so it may very well be that until we know where we're going with that in the next few weeks that you know we would have to wait until that sort of resolved then i wanted to mention what with regard to ms joseph i'm very much supportive of the of what you suggest about not taxing health benefits provided by tribes i mean my view going back to what i said in the opening statement is that you know since we have a responsibility on the part of the federal government to provide health care completely for native americans if and we're not doing it if the tribe set in to make up for that difference it's even more outrageous to consider taxing them for it when we're supposed to be providing that benefit completely so i've sent letters to i r s and of course you know co sponsored the legislation that would change that would make it clear that they're not taxable now that's a ways and means issue as you know it doesn't actually come before this committee but it's something that we're mindful of as well you know as we move forward with the with the health care reform i wanted to ask you because several of you mentioned about the you know making the the act permanent and i was going to ask ms joseph initially i mean there is some precedent for that especially with respect to indian law but tell me in a little more detail why you think there is a need for permanent authorization and why is that you know the expenditure of resources that chairman joseph spoke to we certainly don't want to have to go through that exercise but more importantly we think if we have a permanent authorization and congress we know can revisit that revise and amend as necessary we think that in the future we would have an opportunity to focus on one or two or three issues that need to be addressed and have some extensive conversations and dialogue spent on those issues and we think that we should do more of that ok i want to d s mr just a different question and that's about long term care services  you raised that in your testimony and this is something that i'm very interested in you know there's probably not going to be much in the health care reform the larger health care reform on that because of the expense but i'm curious to know more about you know the long term care supports and services provided in indian country i mean how how are the american indian elders provide a long term care now and how would they revise the story under this  rest we have every agency on aging and we have some of the people that take care of our elders at home some of our elders because of  sanitation reasons need to be cared for twenty four hours a day you know every day of the year and you know we all would like to take our last breath in our own home but  concern is that if you know elders have to be taken to a nursing home or some institution off the reservation is that very common now amongst tribes i imagine you try to prevent that but  is that very common that they have to actually go to you know i don't know what i call a mainstream nursing home off the reservation because of the lack of sufficient funding for a lot of our elders become men into more of a you course talked about the urban indian health program primarily and you mentioned that the minute health program and how the last administration tried to eliminate it from the bill first i never quite understood that can you talk about the how that urban indian program why it's so important that it stays in place and needs to be expanded the way this bill proposes and you know we hear various things that there are more and more you know native americans that are moving off reservation living in cities but then we also hear that a lot of them are coming back if well maybe that's less so now with the recession or maybe more so i don't know i mean i guess it depends upon whether there's economic opportunities on the reservation but i want to comment on that in terms of you know particularly now with the recession and where we're going in the next few years certainly well that makes two of us that we didn't understand why we were zero out to begin with but we play a really important part of far as health care system in how service provides we see a number of patients that are either in transition there that are moving in and through the twin cities specifically my program the twin cities in minneapolis and st paul people are looking for work i see a number of patients of mine still practice medicine  that have lost their jobs they have no insurance they have absolutely nowhere to go they have no access to care even though we our clinic is right smack right smack in the middle of several hospitals we have the university system there we have a couple of private hospital systems there that offer clinical services to what our patients feel like they don't have the access there because they don't have the funding to to pay for health care and we often see folks that come in that have really advanced disease their diabetes take for example is to point to where now they're starting to see kidney problems or eye problems and we try our best seeing patients one on one every day we do see a number of folks that are just moving to the twin cities looking for opportunities for work again some of the statistics that we see these days that are sixty percent of native populations live in urban settings and i would be interested to see what the what the new census data will show as we head into the census as to what what what that is now currently but  a number of patients who have lost their jobs i've had one gentleman who who worked in the foundry lost his job as surance he is a native man he was enrolled in a wider band of a general a northern minnesota  his wife recently was recently diagnosed with cancer so she the family was struggling and let alone him losing his job and presenting to me with a new onset congestive heart failure which requires of course treatment therapies that he couldn't afford so that's one person that i see it but it's every day every day we're open we see you ok thank you very much thank all of you before i work together and we will have it in a vested interest also from an urban standpoint being part of that system we think that we can provide really a rush high quality of care to our patients  the high prevalence of death injury from auto accidents of suicide has always been something that i've been concerned about and i noticed similar patterns of not only an american indian but alaskan natives and i wonder if i don't think that just treating substance abuse and alcoholism is enough because there are all kinds of conditions i said in my opening statement  there anywhere that you can see that we could do something with that that would address maybe some of the social determinants as well we've talked about the modernization of approaches in medicine and to me one of the more the newer  some of the newer thinking is about the social determinants but anybody have any what would you attribute the high prevalence of that's a major in suicide on the reservation and how can we addresses a number those issues you raised and we think you know with a comprehensive approach whom able to use our money more efficiently which i do believe that some of the safety funding related to ambulance and so forth and so on that comes to another agency in h h s and through the state and some states you know have a better working relationship with their tribes and some don't so some of that you know yes there is language in the bill that addresses traditional healers and it's you know a tribe by tribe situation and patient by patient and you know as the patients and the doctors apologize for coming in at the last minute but i don't want to miss the opportunity to let you all know that i am a big supporter of the indian health care improvement act amendments and i am a partner with you in trying to get health better health care i am from chicago where in my district there is the american indian center and  in my chicago office which isn't far from there i have a star quilt that was given to me by the chicago indian health service and i work very very closely with them and and  and you know i want to make sure that the resources that are needed are always available the organization does operate a health clinic conducts education and outreach and diabetes provides home visits to people with diabetes to ensure they're managing the disease correctly in illinois there's about seventy three thousand american indian and alaskan natives and really there's a big concentration in my district so i just really wanted to congratulate you on your advocacy on the good work that you've been doing and to make sure that i didn't miss the opportunity to tell you that i am grateful for your advocacy for the care that you provide and for the chance to work with you to make it even better thank you i have back thank you and thank you all i know this was a short hearing today but i don't want you know that doesn't anyway take away from you know our efforts to try to move this bill or as i've said funds my own grand baby had to be heart flighted out a little over a year ago in two spokane and that cost over ten thousand dollars that's where the chef money comes into play it's almost like  drafting error and we're conscious of it and we're going to try to correct it you know as we move along because i know how important it is so thank you for bringing the talk of tension again all right thanks very much and we do intend to move forward thank you thank you without objection the hearing of the subcommittee is adjour