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S. HRG. 109–26

INDIAN HEALTH

HEARING

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS

UNITED STATES SENATE

ONE HUNDRED NINTH CONGRESS

FIRST SESSION

ON

OVERSIGHT HEARING ON THE STATUS OF INDIAN HEALTH CARE

APRIL 13, 2005

WASHINGTON, DC

(
COMMITTEE ON INDIAN AFFAIRS

JOHN McCAIN, Arizona, Chairman

BYRON L. DORGAN, North Dakota, Vice Chairman

PETE V. DOMENICI, New Mexico

CRAIG THOMAS, Wyoming

GORDON SMITH, Oregon

LISA MURKOWSKI, Alaska

MICHAEL D. CRAPO, Idaho

RICHARD BURR, North Carolina

TOM COBURN, M.D., Oklahoma

DANIEL K. INOUYE, Hawaii

KENT CONRAD, North Dakota

DANIEL K. AKAKA, Hawaii

TIM JOHNSON, South Dakota

MARIA CANTWELL, Washington

JEANNE BUMPUS, Majority Staff Director

SARA G. GARLAND, Minority Staff Director

(II)
(III)

C O N T E N T S

Page

Statements:

Coburn, M.D., Hon. Tom, U.S. Senator from Oklahoma ............................... 3

Dorgan, Hon. Byron L., U.S. Senator from North Dakota, vice chairman,

Committee on Indian Affairs ....................................................................... 1

Grim, M.D., Charles W., director, IHS, Department of Health and Human

Service ............................................................................................................ 4

Hartz, Gary, director, Office of Environmental Health and Engineering,

Department of Health and Human Service ................................................ 4

Ignace, Georgiana, president, National Council on Urban Indian Health .. 23

Inouye, Hon. Daniel K., U.S. Senator from Hawaii ....................................... 2

Joseph, Rachel, cochairperson, National Steering Committee for the Reauthorization of the Indian Health Care Improvement Act, and chairwoman, Lone Pine Paiute Shoshone Reservation ...................................... 22

McCain, Hon. John, U.S. Senator from Arizona, chairman, Committee

on Indian Affairs ........................................................................................... 1

Petherick, J.T., executive director, National Indian Health Board .............. 19

Power, Kathryn, director, Center for Mental Health, Substance Abuse,

and Mental Health Services Administration, Department of Health and

Humane Services .......................................................................................... 6

Roanhorse, Anslem, executive director, Navajo Nation, Department of

Health ............................................................................................................ 25

Rolin, Buford, vice chairman, Poarch Creek Band of Indians and cochairperson, National Steering Committee for the Reauthorization of the

Indian Health Care Improvement Act ........................................................ 22

Russell, Beverly, executive director, National Council on Urban Indian

Health ............................................................................................................ 23

Smith, H. Sally, chairman, National Indian Health Board .......................... 19

Thomas, Hon. Craig, U.S. Senator from Wyoming ........................................ 4

Vanderwagen, M.D., Craig, acting chief medical officer, IHS, Department

of Health and Human Service ..................................................................... 4

APPENDIX

Prepared statements:

Grim, M.D., Charles W. ................................................................................... 37

Johnson, Anthony D., chairman, Nez Perce Tribal Executive Committee .. 44

Joseph, Rachel (with attachment) ................................................................... 46

Murkowski, Hon. Lisa, U.S. Senator from Alaska (with attachment) ......... 81

Power, Kathryn ................................................................................................. 88

Roanhorse, Anslem ........................................................................................... 98

Russell, Beverly (with attachment) ................................................................. 111

Smith, Chad, principal chief, Cherokee Nation ............................................. 150

Smith, H. Sally (with attachment) .................................................................. 155

Walker, M.D., R. Dale, director, One Sky Center: American Indian/Alaska

Native National Resource Center for Substance Abuse and Mental

Health Services, Oregon Health and Sciences University (with attachment) .............................................................................................................. 180

Additional material submitted for the record:

Hobbs, Straus, Dean and Walker, LLP, resolution and report ..................... 188

(1)

INDIAN HEALTH

WEDNESDAY, APRIL 13, 2005

U.S. SENATE, COMMITTEE ON INDIAN AFFAIRS, Washington, DC.

The committee met, pursuant to notice, at 9:33 a.m. in room 485,

Senate Russell Building, Hon. John McCain (chairman of the committee) presiding.

Present: Senators McCain, Burr, Coburn, Dorgan, Inouye, Murkowski, and Thomas.

STATEMENT OF HON. JOHN MCCAIN, U.S. SENATOR FROM

ARIZONA, CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

The CHAIRMAN. Welcome to the committee oversight hearing on

the status of Indian health care. While the Indian Health Service

has reported progress, the mortality rate among Native Americans

from causes as diverse as diabetes, tuberculosis, certain types of

cancer and suicide remain shockingly high, above the national average and unacceptably high.

For a number of Congresses, this Committee has sought to reauthorize the Indian Health Care Improvement Act, but to date this

has not been done. I hope that the testimony we receive today will

inspire and inform our efforts as we again seek to update the law

to reflect the current health needs in Indian Country.

Senator Dorgan.

STATEMENT OF HON. BYRON L. DORGAN, U.S. SENATOR FROM

NORTH DAKOTA, VICE CHAIRMAN, COMMITTEE ON INDIAN

AFFAIRS

Senator DORGAN. Mr. Chairman, thank you very much. We will

hold many hearings in this committee, none more important than

the issue of focusing on health care, because most other things in

life are not very satisfactory if you do not have access to good

health care.

I want to mention that we held a meeting in the Oval Office 1

day some years ago with certain tribal chairs, and they came in.

One of them stood up and said, ‘‘I come from a Third World country,’’ and he read for the President the data, the statistics about

his reservation. They are likely similar to the statistics nationally.

Native American youths are twice as likely to commit suicide, in

the Northern Great Plains, 10 times more likely to commit suicide

than other Americans statistically. They are five times more likely

to die from alcoholism. They are six times more likely to die from
2

tuberculosis. The rate of death from diabetes is three to four times

that of other Americans, twice the rate of accidental deaths.

So this is a very serious issue. I held a meeting, Mr. Chairman,

several weeks ago in North Dakota because there had been a rash

of five suicides of young people on an Indian reservation in North

Dakota. I did not invite the press or others. We just had a long

quiet meeting with a lot of people who were involved in these

issues. It is heartbreaking.

You hear stories that are just devastating. I will not go into great

length today, but I have spoken about Avis Little Wind, a young

girl who took her life a while back after spending 90 days in bed

in a fetal position, missing 90 days of school. I went up to that reservation and talked to all the people about it. They could not figure

out how to put together somebody to help this young woman. Her

sister committed suicide. Her dad had committed suicide. Her

mother was dysfunctional.

And this goes on and on and on. I asked today to have some special testimony from some experts who are involved in mental

health, and I am really pleased that Kathryn Power is with us

today. We have others who will testify today about these issues. I

just want to say that as we try to work through the health issues,

I want to see if we can spend some time on this issue, particularly

teen suicide on Indian reservations.

I also want to make the point that Medicare spends about $6,000 per person on health care. The VA spends about $5,200 per person;

Medicaid about $3,900 per person. We spend about $3,800 per prisoner because we have Federal responsibilities for the health care

of Federal prisoners. The Indian Health Service spends about

$1,600 per person for health care of American Indians, and there

we have a trust responsibility as well.

We have a very big challenge. I look forward to working with

you, Mr. Chairman, and other members of this committee to address these health care issues, which we talk about every year and

on which very slight progress is made and so much is yet to be

done.

Mr. Chairman, thank you very much.

The CHAIRMAN. Thank you.

Senator Inouye.

STATEMENT OF HON. DANIEL K. INOUYE, U.S. SENATOR FROM

HAWAII

Senator INOUYE. I thank you very much, Mr. Chairman. I wish

to commend you for holding this hearing on such an important

issue.

As you have indicated, Mr. Chairman and Mr. Vice Chairman,

Indian health has improved over the years, but when you compare

it to the general population of the United States, or for that matter

to the Third World, we still rank the lowest on practically every

health indicator. Preventive health programs and services are

needed more than ever. A few weeks ago, we were once again tragically reminded that one’s health involves much more than physical

health. It is also mental health. I refer to the Red Lake, Minnesota

Reservation. I hope that we can do much more than we are doing

now.
3

Thank you very much.

The CHAIRMAN. Senator Coburn.

STATEMENT OF HON. TOM COBURN, M.D., U.S. SENATOR FROM

OKLAHOMA

Senator COBURN. Mr. Chairman, thank you for holding this hearing. We have the largest number of Native Americans of any State

in Oklahoma. We have a diversity of care given in our State.

Hastings Hospital in Tahlequah does a wonderful job. They are

overburdened because of the load they have, but we have other hospitals that do a terrible job. One of the markers for that is what

we paid out in malpractice claims, the Federal Government did, for

poor delivery of care in many places in Oklahoma.

Although I will not be able to stay for the hearing because I have

two other committees going on at the same time, I think it is really

important that what Senator Inouye said, prevention is our key,

whether it is mental health, whether it is diabetes, and we need

to be about putting more dollars into prevention than we do in

treatment because we are going to save billions of dollars over the

years.

The other point that I would make, and I think everybody ought

to be aware of, in the long run we will not be able to continue to

increase the funding for any of the programs for Native Americans

if we do not get a handle on our other spending. As you look to see

what the demands on Native American health care is going to be,

and then the demands on the discretionary budget that we are

going to be facing, it is very important that wherever we spend

money, we spend it wisely. We spend the money not on facilities,

but on programs that make a big difference in health.

So I appreciate your having this hearing. There is a lot of work

to do in the Native American community to bring their health care

up to par and to meet our obligations and our treaty obligations.

Part of that is quality enhancement through the physicians that

are working there. I hope to bring to you in the very near future

an analysis of the malpractice claims paid through the Federal

courts in this country by area so that you can see where we are

lacking. There are significant areas where we do not have the quality individuals treating Native Americans that we should. Part of

that is pay and part of it is other problems, but we can correct that

and we should correct that, and we should bring up the standard.

The final thing that I would say is best practices are the way we

do that. We need to incentivize that through Native American

health and Indian health services so that they follow that. We have

great programs that are out there now that will improve care, cut

costs and increase availability of those services, and we ought to

be about enforcing that that becomes a part of the Indian Health

Service.

Thank you, Mr. Chairman.

The CHAIRMAN. Thank you very much.

Senator Thomas.
4

STATEMENT OF HON. CRAIG THOMAS, U.S. SENATOR FROM

WYOMING

Senator THOMAS. Thank you, Mr. Chairman. I too have to go to

another hearing this morning, but I did want to thank you for having this. The tribes in our State, this is probably one of the outstanding issues that we need to talk about. So I certainly want to

work with this as we go, and I do not have an opening statement.

I just wanted to tell you how important it is.

The CHAIRMAN. Thank you very much, Senator Thomas.

Our first panel is Dr. Charles W. Grim, who is the director of the

Indian Health Service, Department of Health and Services; and A.

Kathryn Power, the director of the Center for Mental Health, Substance Abuse and Mental Health Service Administration of the Department of Health and Human Services.

Dr. Grim, we will begin with you, and perhaps for the record, we

can identify who is with you, and you as well, Ms. Power.

Mr. GRIM. Certainly, Mr. Chairman.

STATEMENT OF CHARLES W. GRIM, M.D., DIRECTOR, INDIAN

HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN

SERVICES, ACCOMPANIED BY CRAIG VANDERWAGEN,

ACTING CHIEF MEDICAL OFFICER; AND GARY HARTZ,

DIRECTOR, OFFICE OF ENVIRONMENTAL HEALTH AND

ENGINEERING

Mr. GRIM. Mr. Chairman and members of the committee, my

name is Charles Grim, director of the Indian Health Service. I will

be the only one giving an opening statement today, but I have with

me Gary Hartz, our director for the Office of Environmental Health

and Engineering, and Craig Vanderwagen, our acting chief medical

officer.

The CHAIRMAN. Welcome.

Mr. GRIM. We are very pleased today to be able to have this opportunity to testify on behalf of Secretary Leavitt on the status of

Indian health. I will summarize my prepared statement and submit a complete written statement for the record.

The CHAIRMAN. Without objection.

Mr. GRIM. It is also a pleasure to testify along with Kathryn

Power, the director of the Center for Mental Health Services with

the Substance Abuse and Mental Health Services Administration.

The Indian Health Service [IHS] and SAMHSA have strengthened

our partnerships over the last several years and are doing more

than we ever have together for Indian country around mental

health and substance abuse issues.

You have asked us here today to discuss the status of Indian

health by focusing on health disparities and other related issues

such as urban Indian health, Indian health care facilities, Indian

self-determination, and part D of the Medicare Modernization Act.

I would also like to share with you our concerns and efforts related

to the recent tragic events at Red Lake.

I spent part of last week at the Red Lake Chippewa Reservation

in Minnesota and witnessed first-hand the results of the devastation brought by the shootings at the Red Lake High School. I met

with the tribal chairman and the council. I met with our hospital

staff who treated the victims, and I met with many of the mental
5

health teams that we had brought in to provide some additional

surge assistance to the community.

I also saw a community that was beginning to unite and draw

strength from the support of these mental health professionals and

also from their tribal spiritual leaders and the various community

traditional healing ceremonies they were having.

In the midst of the trauma and the upheaval caused by the

shootings, I also saw a sense of hope and a spirit of collaboration

among the community and the tribal leaders, among the State, and

among the many Federal programs that were there. The IHS is

working closely with SAMHSA, with the Administration for Children and Families, and its Administration for Native Americans,

the Office of Minority Health and other departments within the Department of Health and Human Services to aid the tribe.

We have also been joined by the Department of the Interior, Bureau of Indian Affairs, the Department of Justice and the Department of Education. I want to thank all those Federal departments

that are working together to help us improve the overall health of

Indian people in the Red Lake community during this crisis.

The thing we need to ask ourselves is how do we prevent such

incidents from occurring in the future. First, the IHS continues to

focus on screening and primary prevention in mental health, especially for depression which manifests itself in our population in suicide, domestic violence and addictions. Second, we must continue to

focus on the effective utilization of treatment modalities that are

available and we are currently seeking to improve the documentation of our mental health problems.

The IHS is currently utilizing effective tools for documentation to

the behavioral health software package and we are working with

the communities who are focusing more on these mental health

needs. Today, approximately 80 percent of the mental health budget and 97 percent of the alcohol and substance abuse budget in the

IHS is going directly to tribally operated programs, and the tribes

and communities themselves are now taking responsibility for their

own healing. They are providing effective treatment and prevention

services within their own communities, and in addition our fiscal

year 2006 budget request included a $59-million increase for that

mental services line item, which is a 7.7-percent increase over the

2005 level.

Fortunately, the incidence and prevalence of many of the infectious diseases that we once faced as the leading cause of death and

disability among American Indians and Alaska Natives have dramatically decreased due to the increased medical care and public

health efforts, including massive vaccination programs and sanitation facility construction programs. As the population lives longer

and adopts more of a Western diet and often a more sedentary lifestyle, chronic diseases have emerged as the dominant factor in the

health and longevity of Indian people. We are seeing increasing

rates of cardiovascular disease, hepatitis C virus, obesity and diabetes. Many of the chronic disease are affected by lifestyles and behavioral health choices.

Our primary focus today is on the development of more effective

prevention programs in American Indian and Alaska Native communities. We have begun many programs along with those commu-
6

nities to encourage the employees of the agency, as well as our tribal and health program partners, to lose weight and exercise. There

are programs such as Walk The Talk, Just Move It, and the Take

Charge Challenge. We have found that they are all cost-effective in

that they help prevent both diabetes and many other chronic diseases and the sequela of them such as heart disease.

We are trying to address many of the things that we face in Indian country with three primary focus areas now. Those are health

promotion, disease prevention, continued and increased focus on

behavioral health, and the third focus area of chronic disease management. As you indicated in some of your opening comments, Indian health has progressively improved since the passage of the Indian Health Care Improvement Act in 1976. The IHS has honored

its commitment to improve the health status of eligible American

Indian and Alaska Natives as provided by the Indian Health Care

Improvement Act, and has worked with tribes since the Indian

Self-Determination and Education Assistance Act was enacted in

1975 to assist in the successful transition of IHS-administered

health programs to tribal control and administration.

Prevention and health promotion programs continue to be a personal priority of mine and the Secretary, and they have received

a $33 million funding increase in the President’s fiscal year 2006

proposed budget for the IHS.

We recognize, however, that many health disparities continue to

exist between American Indians and Alaska Natives and all other

groups in the United States. We seek to address this through continued support of these health promotion and disease prevention

programs targeted at some of the diseases that have the highest

mortality rates in our population.

In addition, our scholarship and loan repayment programs provide opportunities to recruit and retain young Indian professionals

to serve their communities, wile the Sanitation Facilities Construction Programs continue to provide safe water, wastewater disposal,

and solid waste systems for the well-being of many communities.

Through effective ongoing consultation with tribes, and urban Indian programs, the Federal Government is benefiting from the communication that enables all parties to understand the needs and

the most effective ways to address them.

Mr. Chairman, this concludes my statement. Thank you for the

opportunity to discuss the Indian health programs that are serving

our communities today and their impact of the health status on

American Indians and Alaska Natives. We will be happy to answer

any questions the Committee might have.

[Prepared statement of Dr. Grim appears in appendix.]

The CHAIRMAN. Thank you very much.

Ms. Power.

STATEMENT OF A. KATHRYN POWER, DIRECTOR, CENTER FOR

MENTAL HEALTH, SUBSTANCE ABUSE AND MENTAL HEALTH

SERVICES ADMINISTRATION, DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Ms. POWER. Good morning, Mr. Chairman and members of the

committee. I am Kathryn Power, director of the Center for Mental
7

Health Services within the Substance Abuse and Mental Health

Services Administration, SAMHSA.

I am very pleased to offer testimony this morning on behalf of

Charles Curie, the administrator of SAMHSA. I will submit written

testimony for the record.

The CHAIRMAN. Without objection.

Ms. POWER. I want to thank you for the opportunity to describe

how SAMHSA is working to provide effective mental illness and

substance abuse treatment services, as well as substance abuse

prevention and mental health promotion services in Indian country.

It is also a privilege to testify along with Dr. Charles Grim, director of the Indian Health Service, particularly this morning about

this very important issue. SAMHSA and IHS have developed a

very strong working partnership reflected in our current interagency agreements to work efficiently and effectively together to

help meet the public needs of American Indians and Alaska Natives.

My testimony will focus on two specific issues of great concern

to the public health of American Indian and Alaska Native youth.

These issues are suicide and violence. Sorrowfully, there are reallife examples to illustrate the impact of suicide and violence in Indian country. Recently, a suicide cluster occurred on the Standing

Rock Reservation in North and South Dakota. Eight young people

took their lives and dozens more attempted to do so.

Tragically, many other reservations have similar stories to tell.

Suicide is now the second-leading cause of death behind accidents

for Alaska Native and American Indian Native youth aged 15

through 24. The suicide rate for this population is 2.5 times or 250

percent times higher than the national average. More than one-half

of all persons who commit suicide in Indian communities have

never been seen by mental health providers.

For particular groups of American Indians, depression and substance abuse are the most common risk factors for completed suicide. Mental health and substance use disorders are also risk factors for violence. The recent example of violence in Indian country

is the tragedy at Red Lake. On March 21, 2005, a 17-year-old high

school junior shot and killed his grandparents, five students, a

teacher and a security officer and himself. Red Lake Nation is an

impoverished community. Thirty-nine percent of the population

lives below the poverty line. Four out of five students at Red Lake

High School qualify for free or reduced lunch. One-third of the

teenagers on this reservation are not in school, are not working

and are not looking for work, compared with about 20 percent on

all reservations.

This event has led to community grief, to community turmoil and

trauma. In response, SAMHSA has sent several staff on-site to coordinate services and technical assistance in collaboration with the

IHS and the tribe. This involves support of the health care team,

the educational programs, social services, support of the tribal

council, and the community at large. SAMHSA staff has also provided technical assistance to the tribe in an effort to help them access emergency funds, especially those funds available through the

SERGE grant mechanism.
8

With regard to programs that address violence and suicide, we

know that in 1999 in response to school shootings in Kentucky, Arkansas, Oregon, and other States, Congress took action and

launched the Safe Schools/Healthy Students Initiative under the

collaborative leadership of the Departments of Education, Health

and Human Services and Justice. The Safe Schools/Healthy Students Program awards 3-year grants of $1 million to $3 million per

year to school districts to do the following: Collaborate with local

law enforcement and mental health agencies; promote the healthy

development of school-age children; and promote mental health and

prevent violence in youth by using evidence-based programs with

demonstrated long-term positive effects.

Two tribal sites were funded in the initial cohort of 54 grantees

out of a pool of close to 500 applications. In particular, these two

tribal grantees emphasized the poverty of their communities. Repeatedly, researchers from different fields have firmly established

that poverty and its contextual life circumstances are major determinants of violence. Violence is most prevalent among the poor regardless of race. It is common knowledge that conditions on Indian

reservations are deplorable, but the information presented by these

applications was shocking nonetheless.

Our Safe Schools/Healthy Students grantee in Pinon, Arizona

wrote in its application, and I quote,

Within the boundaries of the richest country in the world exist a Third World nation. The Navajo Nation in Northern Arizona is among the poorest and most desolate regions of the United States. The area has only one paved road for travel, 92

percent of the children receive free or reduced-price lunches, and 60 to 90 percent

of residents live without basic services such as plumbing, running water, kitchen,

sewers, and telephones, compared to less than 1 percent of the U.S. population at

large.

Close quote.

These are the problems that this Safe Schools/Healthy Students

grantee worked to address and by and large they were successful

in turning a school community away from violence and toward resilience and toward productive and meaningful lives. In January,

SAMHSA launched the National Suicide Prevention Lifeline, 1-800-

273-TALK. The national hotline is part of the National Suicide Prevention Initiative.

Additionally, SAMHSA under the authority of the Garrett Lee

Smith Memorial Act announced the availability of fiscal year 2005

funds for State-sponsored youth suicide prevention and early intervention programs.

Mr. Chairman and members of the committee, SAMHSA takes

very seriously the challenges present in Indian country, which include very few trained service providers, major transportation barriers, and multi-generational poverty. SAMHSA is engaged in addressing the issues and challenges in Indian country that rob communities of their most valuable resources, their children and their

future. The vital treatment and prevention efforts that SAMHSA

has undertaken are designed to address these problems and are

improving services for all of the children, youth and families in

Alaska and across Indian Country. These programs are working

and our cooperation and collaboration with IHS is effective.
9

Mr. Chairman and members of the committee, thank you for the

opportunity to appear before you today. I will be pleased to answer

any questions you may have.

[Prepared statement of Ms. Power appears in appendix.]

The CHAIRMAN. Thank you very much.

Ms. Power, more than one-half of all persons who commit suicide

in Indian communities have never been seen by a mental health

provider. Is that right?

Ms. POWER. That is correct.

The CHAIRMAN. How does that compare with the non-Indian population?

Ms. POWER. I think that there are statistics, Mr. Chairman, that

show that of those individuals who have committed suicide, that

many of them have in fact seen a primary care physician prior to

the completion of suicide, but statistically I probably will have to

get you that information. But we do have indications that for those

individuals, both children and adults, who have completed suicide,

they do have usually an interaction with someone, whether it is a

mental health provider or a primary care provider in the 90 days

before the completed act of suicide.

The CHAIRMAN. Do you see a connection between substance

abuse or alcohol abuse and suicide?

Ms. POWER. Absolutely, Mr. Chairman.

The CHAIRMAN. Is it usually associated with suicide?

Ms. POWER. There is often the presence of either a substance

abuse disorder or the presence of the use of substances, either alcohol or drugs, prior to the completion of a suicide.

The CHAIRMAN. Is there a large percentage that are from singleparent homes?

Ms. POWER. Of those individuals, Mr. Chairman, who are suicidal?

The CHAIRMAN. Yes.

Ms. POWER. I think that the family conditions and the economic

conditions contribute enormously to the presence of depression. We

know that depression is the single most dominant indicator of presuicidal activity. If depression exists, then depression comes from

a variety of not only internal factors, but also external factors. The

fact that there may be disrupted family life, there may be a low

socioeconomic condition. All of those contribute to the factors that

would lead individuals who have experience of depression to then

move further and consider taking their own lives.

The CHAIRMAN. Senator Murkowski probably knows more about

this than I do, but is there an isolation factor here of tribes either

in the Lower 48 or in Alaska that contributes to this?

Ms. POWER. I think both. This is certainly not just a Lower 48

issue. I think that the isolation leads to the social disconnectedness, which leads to the discontinuity, which leads to the lack of

hope, which leads to the lack of belief in the future. I know that

in particular the school violence that occurred in Bethel, AK and

in Springfield and in Paducah was actually the reason why Congress developed the Safe Schools/Healthy Students Program.

So yes, in fact isolation is a major contributor to the identity of

the culture, to the disconnectedness of their lives and to the belief

and the hope of their own future.
10

The CHAIRMAN. Obesity or diabetes?

Ms. POWER. I am going to ask Dr. Grim.

Mr. GRIM. I think Ms. Power did an outstanding job of talking

about the multi-factorial nature of suicide and depression. Certainly, people in our population that have obesity and have gone

on to get other chronic diseases, diabetes and others, we have seen

that, often they will have co-occurring depression along with the

chronic disease. In many people, we are still educating them about

the preventive aspects of diabetes, but for many, many years we

would see youth that would automatically come into some of our

facilities and say ‘‘when will I get diabetes and how long will it be

before I die?’’

With the moneys that Congress has given us over the last several years to work on the special diabetes program for Indian funding that is now at $150 million a year, those grants have made

huge, huge impact on getting a lot more educational, physical activity and nutrition sorts of primary prevention programs out in the

communities that are starting to impact that sort of a feeling of

hopelessness about chronic diseases.

The CHAIRMAN. Switching gears just for a second, on January 31,

the committee sent a letter to Secretary Leavitt seeking his commitment to reauthorizing the Indian Health Care Improvement

Act. We still have not gotten a response. Do you know anything

about that?

Mr. GRIM. I know that a response is being prepared, Senator. I

was told that it should be on the way. The committee should have

it shortly. I have not had an opportunity, as you know, Secretary

Leavitt has been here less than 60 days, to speak with him directly

about that, but I know they are preparing the response.

The CHAIRMAN. I know he has a very heavy schedule. I hope that

you could schedule a phone call to him to ask him to get us a response.

I thank the witnesses.

Senator Dorgan.

Senator DORGAN. Mr. Chairman, thank you.

Dr. Grim, thank you.

Ms. Powers, thank you for being here.

Dr. Grim, let me ask you about Contract Health Services. I was

on a reservation some months ago and they were telling me about

the Contract Health Service problem. This is a reservation that has

inadequate health care, inadequate facilities to address a chronic

health problem that comes up in a short period. So you transport

somebody or someone is moved to a hospital 60 miles away, gets

service under Contract Health Services and then the bill is not

paid. This goes on. They try to collect the bill from the patient. The

patient gets a bad credit rating because the Contract Health Service’s bill has never been paid.

There was a recent court decision about this with respect to two

tribes, and the Supreme Court handed down a decision in the Cherokee Nation of Oklahoma v. Leavitt that the Indian Self-Determination Act required the Indian Health Service to pay tribes certain

contract support costs, which the Federal Government had not

been paying.
11

So how much does the IHS owe the tribes that were at the center

of that case, number one, if you can tell me? And how much are

owed to other tribes with respect to Contract Health Services that

have no been paid?

Mr. GRIM. The case was just adjudicated. We estimate that the

amount the agency owes the two tribes that were in that is approximately $15.6 million for contract support costs that were due

the tribe between 1994 and 1997. From 1998 on, the Congress put

a statutory cap on our contract support costs, which is a different

line item within our budget than the other one you were asking

about, contract health services. The contract health services line

item does not have that statutory cap and we do distribute those

funds on a formula basis throughout the Nation. As you indicated,

each region of the country is asked to live within that budget on

an annual basis because it is limited. Each area is at different levels throughout the year. I would ask our Chief Medical Officer if

he would like to add anything to that, but the Supreme Court hearing affected contract support costs, and not our contract health

service budget.

Senator DORGAN. Thank you.

Mr. GRIM. Is there anything you would like to add, Dr.

Vanderwagen?

Mr. VANDERWAGEN. Senator, I think you highlighted a chronic

issue that afflicts many communities, and that is, the inability to

fully cover those costs that are accrued when we have to purchase

care from a private sector environment. We have electronic payment systems now that we can turn most bills around in 45 days,

but there continue to be problems with certain locations where we

do need to fix that problem.

Senator DORGAN. I am going to send you some additional questions on that because, as I said, I have heard from people who say

their credit rating is ruined despite the fact that they had approved

contract health services that they accessed.

Let me tell you about the meeting I held recently, Ms. Power and

Dr. Grim. What they were telling me, the people who came to that

meeting, particularly from the Standing Rock Tribe, if a young kid

is addicted to drugs or alcohol, there is virtually no opportunity to

quickly get that person into long-term treatment that is able to

shed that addiction. The treatment is just not available.

So you have these people that are hopelessly addicted, young

kids that are hopelessly addicted to alcohol or to drugs who really

need to be put in a program, an in-residence program, and it is not

available. Is that true around the country on reservations generally?

Ms. POWER. I believe it is a difficulty, Senator, in terms of first

of all identifying individuals who have those problems and who are

willing to step forward and want to get into treatment. Then the

second difficulty is access to the treatment. Is the treatment available to them in a location where they can actually get to it? And

third, the difficulty that comes over the long term. You really do

have to have a personal commitment to wanting to stay engaged

in both drug and alcohol prevention and treatment programs.

I think one of the things that we have tried to do, particularly

with Indian tribes, is to make sure that all of the American Indian
12

and Native Alaskan and tribal organizations, first of all, are eligible for all of our substance abuse prevention and treatment grants.

That has really been an effort that my boss has really extended to

us at the staff level, saying you will in fact do everything you can

to make sure, unless there are overriding compelling reasons, to

make sure that every opportunity for substance abuse prevention

and substance abuse treatment grants are available to the tribal

organizations.

We also, of course, are looking to use our resources at SAMHSA

to make sure that the need is addressed, particularly through our

Access to Recovery Program. We had several tribal organizations

that competed for the Access to Recovery.

Senator DORGAN. Ms. Power, I am sorry for interrupting you, but

isn’t it the case, wouldn’t you and Dr. Grim both agree that there

simply are not enough treatment opportunities available around

the country on reservations for those who are addicted to alcohol

and drugs? I mean, we are woefully short of treatment. You are

talking about what we are doing, and I appreciate all that, but isn’t

it the case that we are just way short of what is necessary to get

a young person into a treatment facility when they are addicted to

drugs and alcohol?

Ms. POWER. I think that certainly in talking about the access

issue, Senator, I believe it is correct that it is very difficult for

many people across America, and particularly on the tribes, to have

access to those services, very difficult.

Senator DORGAN. Yes; some of those young people say it is impossible almost. At this meeting I held, we were talking about suicides and attempted suicides. They said that in 1 year on the

Standing Rock Reservation there were 288 suicides or attempted

suicides in 1 year; 288. They talked about the lack of mental health

treatment available to them. They said, well you know, you have

to go to your family, you have to reach out. And one young girl

stood up and she said, ‘‘Well, you know, I was being raped repeatedly by my father when I was thinking about suicide. I could not

go to him and I could not go to my mother. She was in a dysfunctional situation and would have been angry about it and no believe

me in any event.’’ So she said, ‘‘I had to work through this myself

somehow.’’ But she said, ‘‘There really was no avenue for me to express myself on these issues.’’ She fortunately got through this.

But as you indicated, there are a lot of young kids that are not

getting through it, and the young boy on the Red Lake Reservation,

I do not know much about that case except what I have read in

the press. But once again, a serious lack of mental health services,

just a serious lack. I have had people at witness tables who were

in charge of these issues for tribes, and who broke down in sobs

saying, ‘‘I had to even beg to try to borrow a car to take a young

kid to a clinic who was having a desperate time.’’ This was a reservation where this little Avis Little Wind hung herself recently.

She did not have access to psychological care that she should have

had. There are lots of people who knew she needed it, but there

was no access to get it to her in a remote location.

So the only point I am making is that this is a real serious crisis

and we have to say that instead. I know we are making some

progress in all these areas, and Dr. Grim, your testimony described
13

that. But I am much more interested not in the 16 percent improvement here or 18 percent improvement there. I am interested

in how far are we from the goal, because I think Senator McCain

indicated and my colleague Senator Inouye indicated, we are still,

even with our improvements, which are reasonably small, we are

still so far from where the rest of America’s population is on these

circumstances with respect to tuberculosis, mental health, all these

issues.

So we just have to do much more. I appreciate very much the

contribution, Ms. Power, you have made this morning on a very important issue. Dr. Grim, I hope that you will work closely with us

to identify where are the urgent priorities here so that we can

begin thinking through, Senator McCain and I and the committee,

how we deal with them.

Thank you very much for your testimony.

The CHAIRMAN. Senator Inouye.

Senator INOUYE. Thank you.

It is true that statistically the health of Indian country has improved, but the demographic picture of Indian country is like any

other community. You have your very wealthy and your very poor.

My question is, are the improved statistics in some sense due to

the self-help programs that Indians have had because they are

making money?

Mr. GRIM. I think that certainly is a part of it, Senator Inouye.

I do not know that we can statistically quantify what that is, but

it is clear that tribes that have done well and are doing well economically have put some of those tribal revenues into health programs, both preventive as well as treatment. So we would have to

say that certainly that is part of it. Plus, as you heard, the multifactorial nature not only of mental health and suicide issues, but

of health in general. It is more than having just a clinic or a hospital in your community, but it is also having educational opportunities, good jobs and socio-economic development.

So I think there are many tribes that have seen that it is wise

to put the moneys that they have made into the health of their people and they have done that in a variety of ways. I am not sure

we can quantify that.

Senator INOUYE. I am certain you know that there are many

tribes who run their own schools, run their own hospitals and clinics. Have they done well?

Mr. GRIM. Yes, sir; they most certainly have. They are able to

make the decisions at a local level on the programs that they want

to run. One of the things that we are looking forward to seeing the

results of soon is that the Office of Management and Budget is

going to be looking through their PART analysis at the tribal side

of our health program. They have looked at the Federal side, at our

facilities programs and sanitation facilities; at our Urban Indian

Health Program and in this next cycle, they will be looking at that

particular program. The preliminary data are showing outstanding

results.

Senator INOUYE. In other words, if they were not helping themselves, the statistics would be much worse.

Mr. GRIM. That is perhaps a fair assessment.
14

Senator INOUYE. Can you tell us whether the budget that has

been presented is a good and fair one? Or in your professional opinion, do you think we should get more?

Mr. GRIM. I think the President’s budget proposal for 2006 for

the IHS is a very good budget when you take a look at the priorities that are on the nation right now, The department has listened

to tribal consultation throughout the country, and one of the things

that you will see in this budget that you have not seen requested

in a while is inflation and population growth. Tribal leaders have

told the department and the Administration over the course of the

last year’s consultations that the Indian community was growing at

a rate that needed to be addressed in the budget. So you do see

a sizable increase for both population growth and in inflation in almost every line item of the budget. So we were very pleased with

the budget.

Senator INOUYE. Are you suggesting that the budget that was

presented would be adequate to cope with the problems that the

Chairman and the Vice Chairman all indicated this morning?

Mr. GRIM. The issues that we all raised around the Red Lake incident, we are not sure if the resources that the department, speaking just for HHS here, the funds that we are making available

have been what have been asked for to date. We are still waiting

to see from the council what their overall list of needs are. We do

not know whether those immediate crisis needs are going to be able

to be met within the budget, but the priorities that were raised by

the Chairman and the Vice Chairman this morning are addressed

in the fiscal year 2006 budget.

Senator INOUYE. My last question, in determining the budget, is

Indian country given an opportunity to provide an input? Do you

consult with them?

Mr. GRIM. Yes, sir; we have regional consultations within each

of the 12 regions of Indian Health Service. We also then have a national budget consultation around the formulation of this year’s

budget. It just so happens that today and tomorrow are the national budget formulation sessions for the fiscal year 2007 budget

that we are holding with representatives from Indian country. So

there is extensive input at the regional and national levels to our

budget.

Senator INOUYE. So you are suggesting that Indian country is

satisfied with the budget?

Mr. GRIM. You would have to ask them that, sir.

Senator INOUYE. In your consultation, did they say they were

happy?

Mr. GRIM. They have asked for higher priorities in some areas

in total dollar amounts, but the agency has always tried to follow

the priorities that they have set out in categorical order when the

budget is presented and in the intervening months with the department and OMB we have tried to follow those priorities consistently

for the last 7 or 8 years that we have been holding these tribal

budget consultations.

Senator INOUYE. Thank you.

The CHAIRMAN. Senator Murkowski.

Senator MURKOWSKI. Thank you, Mr. Chairman. I do have an

opening statement that I would like included in the record.
15

The CHAIRMAN. Without objection.

[Prepared statement of Senator Murkowski appears in appendix.]

Senator MURKOWSKI. Thank you.

Welcome to you, Dr. Grim and welcome to you, Ms. Power.

As we look at those factors and those issues in our lives that

cause things like depression that lead to suicide, there are certain

things that are going to be tough in my State. We are always going

to be a big State. We are probably never going to be connected like

the rest of the Lower 48 is connected, but I would like to think that

through the assistance of the communities, through the assistance

of the State and others, we really can provide for that level of service.

The point was raised by the Vice Chairman in terms of access.

We know that when it comes to treatment facilities, I would agree

we are woefully lacking. It is an issue where we might know that

we have a problem coming up. We might have a child who has sent

the message, and yet we are not picking up on it. We do not know

what to do quite with it. Both in the incident in Red Lake and the

incident in Bethel, the young man had told others that they were

going to do harm. I do not know whether it is we do not believe

the kids, we do not know what to do next, but we are not picking

up and we are not offering the help that needs to be given in a

timely enough manner.

I want to ask you, the fact that in Bethel and the Red Lake High

School, both of these were public high schools. They were not BIA

schools, and yet IHS is the significant provider of behavioral health

services in both of these communities. What kind of collaboration

goes on between the public schools and the BIA and IHS in an effort to deal with instances like this? This is a question directed to

either one of you.

Mr. GRIM. I will ask Dr. Vanderwagen if he would respond for

the agency.

Mr. VANDERWAGEN. Senator, I have not seen you. Congratulations on the reelection.

I think in these small communities, we are the provider of the

community. Because they are small communities, I think all the

staff, whether they are on the public education side or whether

they are on the health side, recognize a common purpose and a

common need to act in a common way. I think in both Bethel and

in Red Lake, well certainly in Red Lake, I can say that the psychology staff from our facility at Red Lake was working with the school

system to try and assure that there were counseling services available.

I think that the Chairman and Mr. Inouye helped us back in the

mid-1980’s to try and get treatment center capacity, but we are at

the state where we essentially have one treatment facility per

State. I think in Alaska we split that into two, but that does not

offer many opportunities for the school and us to refer children and

youth when they have the kind of needs that you have just identified.

Senator MURKOWSKI. So then tell me what it is that we do. None

of us want to repeat any of these incidents in any community

across the country. When the signal is sent by the young person,

are we intervening?
16

Mr. VANDERWAGEN. It is a fairly complex situation, but to simplify it as much as I can, it is family; it is educational systems and

it is the health system and often the law and order system that

have to work comprehensively in those small communities to provide the support structure. We know that foster care is a real challenge and a real issue, so that children for instance who have troubled families do not have many options within a community for referral, and that is a real challenge for tribal communities to work

out.

It is very difficult because there are not always the full range of

alternatives that we might have elsewhere in the country vis-a-vis

dealing with isolation as it impacts on the availability of those resources and the use of those resources.

There is not a simple solution to these issues. It has to be a community-wide effort. Certainly, what we are trying to demonstrate

with Red Lake is that there is a Federal-wide effort that has to be

there to support the community. Those are the lessons we have

learned about this thus far.

Senator MURKOWSKI. I think one of the lessons that we learned

out of the Bethel incident was that after that horrific incident, the

community came together and there was a healing process, for lack

of a better term, but the community really galvanized. Unfortunately, it took multiple deaths in order to galvanize that community, in order to get that support. So we are not there if the action

is coming after the deaths.

Mr. VANDERWAGEN. That is true.

Senator MURKOWSKI. Dr. Grim, I would like to ask you very

quickly about village safe water and sanitation facilities. I am

pleased to see that IHS sanitation facilities construction program

has received a small bump-up in the President’s budget. You have

been working in conjunction with the EPA and rural development

in USDA to move forward with some of the progress that we have

made in my State to provide for sanitation facilities. I am disappointed because in the USDA budget and the EPA budget, in

both of those, we have seen very significant reductions, which

means that IHS sanitation facilities construction budget is the only

one that is actually holding steady.

My question to you is, are you going to be able to do it alone?

What does this do to the progress that we have made and that we

continue to need to make in order to be able to meet the health

and sanitation needs our in rural Alaska?

Mr. GRIM. I am going to ask Mr. Hartz to address that. He is

our expert on sanitation facilities. We are doing everything we can

to work with both those other agencies.

Mr. HARTZ. Senator Murkowski, thank you for the question. The

cooperation that has come from the other agencies has been real

critical, and especially what we have gotten through the State of

Alaska. The 121 Program, as we have referred to sanitation facilities, brings in typically anywhere from 30 cents to 50 cents on

every $1 appropriated to enhance further what we can get with the

amount appropriated.

Secretary Thompson was extremely helpful in continuing to advocate for sanitation facilities funding, so we have been able to sustain our funding level. We are aware that what is happening else-
17

where could have some impact on funding, but we are really

pleased at how the tribes and our own staff are using our dollars

as seed money to try to continue to get additional resources to supplement our $93-plus million appropriation. Within the last year,

we have actually had contributions in the range of nearly $50 million added to those appropriations.

Senator MURKOWSKI. We need to keep working on this one together, because you know that this is too significant in my State.

I was just home this weekend and you make some progress with

health statistics and then this weekend I read that the tuberculosis

rate is now up again among Alaska Native people. You make

progress on one end and then you lose it on another. So we need

to keep working on this.

Thank you, Mr. Chairman.

The CHAIRMAN. Senator Burr.

Senator BURR. Thank you, Mr. Chairman.

I thank our panel.

I am going to try to keep focused on whether we have sufficiently

addressed the funding need that is out there. By my calculation,

the Administration’s budget recommends about a 2-percent increase. Is there anywhere else in health care today where a 2-percent increase would meet the rising cost of health care?

Mr. GRIM. I am not sure about the answer to the question you

pose about anywhere else that could be met with 2.1 percent. I

think one of the things, if you look at our budget detail a little bit,

we are taking a pause in construction for this year. That was an

ability to shift those funds over into the health care side. What appears to be a $63-million increase really on the health care side

ends up being around $146 million increase. So in essence that

more than doubles that 2 percent increase.

Senator BURR. So now we are up to 4 percent. Is there anywhere

in health care today that a 4-percent increase would meet the current inflation rate in health care?

Mr. GRIM. In general medical inflation, perhaps it would. In specifics, for example pharmaceuticals that are increasing at a greater

rate, it does not keep pace with that level of inflation.

Senator BURR. There have been tremendous successes within the

population, with the decrease of disease, the decrease of mortality

specifically. Those decreases in mortality also bring a higher cost

of maintenance. Is that figured into the model?

Mr. GRIM. It is very true what you say, that with the increased

longevity of our population, and it has gone up significantly over

the years that the IHS has been in operation. With that lengthening of their life span have come more chronic diseases that are

more expensive to treat and often have higher levels of pharmaceutical care costs and things like that. Those things are being factors into the health system, but again the chronic diseases that we

face have forced the agency to look at our initiatives and our priorities.

As I mentioned in my testimony, we are focusing very heavily on

three areas now: Health promotion/disease prevention because we

are trying to get ahead of that curve of the chronic diseases, and

so we are putting more money and more time and energy into that,

and focus very heavily on behavioral health in collaboration with
18

other agencies like SAMHSA and with tribal communities because

not only the mental health needs of the communities, but many of

the chronic diseases have behavioral health and lifestyle choice

issues that we are working on. And then we are working more diligently on chronic disease management.

There are a lot of chronic disease management models out there

that we do not have fully implemented in all of our programs that

can allow us to be more cost-effective in the way we manage chronic diseases. I think we are doing an outstanding job and have been

for a number of years in the way we manage diabetes as a chronic

disease. We are starting to get a handle on that, I believe. But

many of the emerging chronic diseases that we are facing now, cardiovascular disease, obesity, certain types of cancer and asthma

and things like that, we could I think manage better. So we are

looking at many chronic disease management models and trying to

implement those.

So with the focus of those three areas, we are trying to get the

most out of every dollar that we receive.

Senator BURR. I certainly commend you for the progress. Clearly,

the individuals covered are benefited from that progress. I also look

at the unique ability that we have to identify those genetic traits

that come in the form of disease, and really other medical-related

areas that we really can put our finger on and understand how

much of an impact it has on select communities.

My only warning is, and I understand the constraints that we

have in budgets, but the one thing that we have learned from

health care is that if you try to shortcut the process, the back end

is much more expensive; that our ability to educate, to insert prevention and wellness into the system saves us money from a standpoint of per-incident emergency treatment, in-patient care. We continue to vacillate in the entire health care atmosphere of where do

we put our emphasis. Every time we go to prevention and education, the back-end savings are significant. I just do not want us

to lose perspective.

I think it is difficult to do everything that you just talked about

when we look at a 2- or a 4-percent increase. I know I am not telling you anything you do not already know, but I think it is important that we really keep in the center of this debate, that if we

want to accomplish this, it is going to cost something.

I thank you, Mr. Chairman.

The CHAIRMAN. I want to thank the witnesses, and we look forward to seeing you again. Dr. Grim, I hope we can move forward

on the reauthorization of the Indian Health Care Act. We need to

have the Administration’s position on it.

Mr. GRIM. Yes, sir.

The CHAIRMAN. Thank you very much.

Mr. GRIM. Thank you.

Ms. POWER. Thank you, Mr. Chairman and members of the committee.

The CHAIRMAN. Thank you.

Our next panel is H. Sally Smith, chairman, National Indian

Health Board of Washington, DC. She is accompanied by J. T.

Petherick, executive director, National Indian Health Board. Rachel Joseph, Cochairperson, National Steering Committee for the
19

Reauthorization of the Indian Health Care Improvement Act, and

chairwoman of the Lone Pine Paiute Shoshone Reservation in Lone

Pine, CA. She is accompanied by Buford Rolin, vice chairman,

Poarch Creek Band of Indians; Georgiana Ignace, president, National Counsel on Urban Indian Health. She is accompanied by

Beverly Russell, executive director, National Council on Urban Indian Health; Anslem Roanhorse, executive director, Navajo Nation,

Department of Health, Window Rock, AZ.

Ms. Smith, we will begin with you.

STATEMENT OF H. SALLY SMITH, CHAIRMAN, NATIONAL INDIAN HEALTH BOARD, ACCOMPANIED BY J.T. PETHERICK,

EXECUTIVE DIRECTOR

Ms. SMITH. Thank you very much.

Chairman McCain, Vice Chairman Dorgan, distinguished members of the Senate Indian Affairs Committee, I come from

Dillingham, AK in the southwest part of Alaska. I am Yupik Eskimo. On behalf of the National Indian Health Board, it is an

honor and a pleasure to provide a broad overview today of our public health needs in terms of access to care, health disparities and

public health issues throughout Indian country.

In the coming weeks, we look forward to working with the committee on crafting and achieving the implementation of the reauthorization of the Indian Health Care Improvement Act. We hope

that today this snapshot of health care in Indian country will assist

the committee as we work toward this goal.

With limited time, Mr. Chairman, I am going to touch on a few

topics. My written statement provides a far more extensive survey

of health care in Indian country and I ask that it be included in

the record.

The CHAIRMAN. All of the written statements of the witnesses

will be included in the record without objection, including yours.

Please proceed.

Ms. SMITH. Thank you.

The National Indian Health Board serves federally recognized

American Indians’ and Alaska Natives’ tribal governments, and

certainly we do this by advocating for health care, as well as upholding, as described earlier, the Federal Government’s trust responsibility to the American Indians and the Alaska Natives.

I want to now go into a framework for discussion by saying that

on September 11, 2001 the United States changed forever. While

we knew the threats of terrorist attacks were possible, as a Nation

we did not collectively confront the issue and make as necessary

sweeping changes until the events of September 11 occurred. We

are now facing a similar dilemma in Indian country. Across Indian

country, the crisis in health care is well documented and well

known to both lawmakers and Indian communities for which they

are tasked with addressing basic human needs and health care

needs as well.

For example, at several congressional hearings before this one,

we have testified, and I go to my notes to make sure that I have

this correct, the United States invests nearly twice the funds for

the health care of a Federal prisoner as it does on an American Indian or Alaska Native, as earlier described by Mr. Dorgan.
20

Our life expectancy is nearly 6 years less than any other race or

ethnic group in America; 13 percent of our deaths occur in those

younger than 25, a rate three times higher than the average U.S.

population.

Two years ago, the U.S. Commission on Civil Rights reported

that American Indian youths are twice as likely to commit suicide,

again underscoring earlier comments. Our people are 630 percent

more likely to die from alcoholism; 650 percent more likely to die

from tuberculosis; 318 percent more likely to die from diabetes; and

204 percent more likely to suffer accidental death as compared

with other groups. All of this information is shocking, but none of

it is new.

The health care crisis in Indian country continues. Nowhere is

the need more urgent, as earlier again described, than the incidents that happened at the Red Lake Reservation. That tragedy

has left Indian country with a heavy heart, but it has also brought

to light the collective resolve and ability of our Native peoples to

respond to tragedy in a supportive and awe-inspiring manner.

Tribes across this Nation quietly delivered support and aid to the

Red Lake community.

As in any community, unanswered need can foster unimaginable

tragedy. As we review the status of health care delivery systems

in Indian communities, we cannot afford to allow the behavioral

and the mental health infrastructure in Indian country to continue

unaddressed. Today, let us begin again and do as a great Lakota

leader, Sitting Bull, said, ‘‘Let us put our minds together and see

what life we can make for our children.’’

I want to touch a little bit on public health, to follow-up with my

comments with regard to the incident at the Red Lake Reservation.

In Indian country, we realize that we have a public health epidemic. There is a growing body of empirical evidence in the Americas, as well as across Europe, Asia and other continents, that very

clearly demonstrates the effectiveness of prevention. Prevention

works. It is much easier and less costly to prevent disease, disability, injury and premature death than to treat poor health conditions once present.

Today, little is known about the capacity for preventing disease

and reducing mortality throughout Indian country. By leveraging

the Indian Health Service shares, other public resources, and private revenues, many tribal governments make substantial contributions to prevention investments, but these investments are not

the scale in order to address adequately the needs of an improved

prevention infrastructure.

Tribes are increasingly developing ideas on new programs, services, capacities and approaches needed to help improve the health

in Indian country. Additionally, Indian country is learning about

changes in communities that impact both positively or negatively

the health of Native populations. But these programs are grossly

underfunded, and relative to State and county governments, tribes

do not benefit equally from Federal and State resources intended

for the public good.

I want to talk about the WIN! Initiative.

The CHAIRMAN. I would like to remind you, Ms. Smith, that we

have about a 5-minute limit on opening statements, so please.
21

Ms. SMITH. Thank you.

The CHAIRMAN. Thank you.

Ms. SMITH. Thank you, very quickly.

The WIN! Initiative, earlier you were talking about prevention,

the National Indian Health Board has launched this initiative and

I would be happy to provide information for you. Again, it covers

a new vision for preventing disease and promoting health in Indian

country.

There is one area that my written testimony covers. It is a dental

health aid program and the therapists in Alaska. I call your attention to that. I will not cover that at this time, but I do want to very

quickly talk about the Medicare Modernization Act of 2003, as well

as the drug card, and then close my comments. Thank you.

There are several provisions contained in the Medicare Modernization Act of 2003 that have the potential to seriously negatively impact the Indian health care system. Chief among these is

a new prescription drug benefit. As implemented by the CMS, it

will severely impact American Indians and Alaska Natives because

of lost Medicaid revenue to the Indian health care system. The loss

is estimated to be between $25 million to $50 million. The new provisions will severely impact Native people who are dual-eligible,

those eligible for both Medicaid and Medicare, by eliminating the

Medicaid prescription drug benefits, and with them a much-needed

funding source.

With regard to the drug card, very quickly, there is no requirement in the drug card plan. CMS will chose, will be the ones that

will work with Indian and tribal pharmacies. Further complicating

the situation, the plan into which the Alaska Native and American

Indian dual-eligible will be enrolled may not be the plan into which

the local ITU pharmacy contracted. Our people receive prescription

drugs from ITU pharmacies at no cost to them. I am asking very

quickly that we need help in rectifying this particular issue.

In closing, on behalf of the National Indian Health Board, we

certainly want to thank the Senate Committee on Indian Affairs for

its investment of time, expertise and action into investigating and

improving the health care delivery systems for American Indians

and Alaska Natives.

Thank you for considering our testimonies, and we certainly,

from the National Indian Health Board, pledge to work with the

committee in any area that we can. Again, I will provide written

testimony, but let me close by saying again what the great leader

said, and that is, ‘‘Let us put our minds together and see what life

we can make for our children.’’ They are critically important.

Thank you.

[Prepared statement of Ms. Smith appears in appendix.]

The CHAIRMAN. Thank you very much.

Rachel Joseph.
22

STATEMENT OF RACHEL JOSEPH, COCHAIRPERSON, NATIONAL STEERING COMMITTEE FOR THE REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT,

AND CHAIRWOMAN, LONE PINE PAIUTE SHOSHONE

RESERVATION, ACCOMPANIED BY BUFORD ROLIN, VICE

CHAIRMAN, POARCH CREEK BAND OF INDIANS, AND

COCHAIRPERSON, NATIONAL STEERING COMMITTEE FOR

THE REAUTHORIZATION OF THE INDIAN HEALTH CARE

IMPROVEMENT ACT

Ms. JOSEPH. Mr. Chairman, Vice Chairman Dorgan, Senators of

the committee, I am Rachel Joseph, chairwoman of the Lone Pine

Paiute Shoshone Reservation and cochairperson for the National

Steering Committee for the Reauthorization of the Indian Health

Care Improvement Act.

Our project last year served 3,514 Indians, active users at three

clinics. It takes 6 hours to drive north to south; 10 percent of our

population is 65 years and older, 26 percent of our population is

below the poverty level, and 15 percent of our households do not

have telephones. Our pneumoccal vaccination rate is 48 percent

below the Healthy People 2010 goal and our mammography rate is

49 percent below the Healthy People 2010 goal.

Our rate for diabetics having blood sugar levels within the recommended range of 15 percent above the Healthy People 2010 goal.

And diabetics having blood pressure within the recommended

range is only 4 percent below the Healthy People 2010 goal. We believe these two indicators are a reflection of our special diabetes

funding and funding for cardiovascular risk reduction, which we receive through the competitive process.

Among the disparities articulated today was the significant rates

of mental health disorders. There is approximately one psychologist

per 8,333 American Indians, compared to one per 2,213 for the general population.

Medical inflation has grown over 200 percent since 1984. Unfortunately, the Government calculation is not the same rate used by

the private sector. OMB uses a rate of 1.9 percent to 4 percent per

year for inflation, when medical inflation is between 6.2 percent

and 18 percent. This discrepancy has seriously diminished the purchasing power of our programs because pharmaceuticals, medical

equipment and other costs are the same for the private sector and

tribes. From yesterday’s USA Today front page, ‘‘Drug Prices Outstrip Inflation, Costs Up 7.1 Percent.’’ A number of months ago, I

was looking at the inflationary cost for pharmaceuticals. I noted

that among those inflationary costs, the drugs for diabetes and cardiovascular disease are the highest, only behind antidepressant

meds. So we are affected even greater.

The Northwest Portland Area Indian Health Board estimates

that the IHS budget has lost over $2.46 billion in purchasing power

over the last 14 years. In California, like so many other programs

in the country, we are seeing employee benefit take-backs, reduced

hours of operation, and reductions in staffing levels, and more staff

burnout.

As Dr. Grim testified, there is a request in the President’s 2006 budget for $33 million for population growth, and we heartily support that because this is the first time in over a decade that we
23

have seen a request for population growth. The National Center for

Health Statistics reports that our population is increasing at 1.7

percent a year, which translates to 70,000 additional Indians coming into the health care system annually.

In 1999, tribes consulted extensively and presented consensus

recommendations on these issues, and these issues we want addressed in the reauthorization in the Indian Health Care Improvement Act. We wanted reauthorization to be responsive to the current needs and to enhance opportunities for more revenue and to

facilitate more self-determination.

To accomplish these following recommendations, we included the

authorization that scholarship assistance be tax exempt. We would

authorize funding for critically needed dialysis programs, and to

authorize screening for all scans for cancers, and not just

mammographies. We want to authorize more options for tribes to

address facility needs and to authorize a comprehensive continuum

of behavioral health care which emphasizes a collaboration between

alcohol and substance abuse programs, social services, and mental

health care.

The conclusion of the 1928 Marion Commission, and I will summarize, reflects the status almost the same as it was then today.

The inadequacy of appropriations has prevented the development

of an adequate system of public health administration and medical

relief work. I felt great frustration and even anger as I prepared

my oral thoughts and testimony for today because our plight remains almost the same decade after decade.

I questioned myself, are we not telling the story? And I know we

are, because I see it reflected in testimony after testimony. I see

it in newspaper editorials and more recently in the reports from

the U.S. Civil Rights Commission. I respectfully ask your support

and assistance in doing whatever is necessary to reauthorize the

Indian Health Care Improvement Act and help us deal with the

many budget challenges that we face every single day. The statistics we talked about today are our grandparents, our nieces and

our nephews, and our aunties.

Thank you for this opportunity to present testimony. My written

testimony has been submitted. Thank you.

[Prepared statement of Ms. Joseph appears in appendix.]

Senator DORGAN. Ms. Joseph, thank you very much for your testimony.

Senator McCain had to attend another committee gathering, and

so we will proceed. The next witness is Georgiana Ignace, the president of the National Council of the Urban Indian Health organization in Washington, DC. Ms. Ignace, you may proceed.

STATEMENT OF GEORGIANA IGNACE, PRESIDENT, NATIONAL

COUNCIL ON URBAN INDIAN HEALTH, ACCOMPANIED BY

BEVERLY RUSSELL, EXECUTIVE DIRECTOR

Ms. IGNACE. Chairman McCain and committee members, my

name is Georgiana Ignace. I am Menominee from Wisconsin and

president of the National Council on Urban Indian Health.

In 1998, NCUIH was formed and they have a membership representing urban Indian health programs in 34 cities. But first, let’s

briefly account how the Indians became urban Indians: The BIA
24

Relocation Act, the promise that the American Indian will have a

better life, a job and education; the General Allotment Act, where

many lost their land and were forced to move to nearby cities and

towns; adoption of Indian children to non-Indian families; boarding

schools where children were removed from their families to boarding schools far away from home.

Today, the urban Indians consider the Indian community in the

cities their home.

Another statistic: In 1976, Congress passed the Indian Health

Care Improvement Act. This act was to raise the status of health

care for American Indians and Alaska Natives; 29 years, and those

22 years were a deadline for achieving it has passed. And yet

today, Indians whether reservation or urban still continue to have

the highest health care statistics that are negative.

What we know about the urban Indian, urban Indian unemployment is double that of all races. Urban Indian poverty levels are

three times that of any other race. Urban Indian high school dropout rate is over 75 percent. Urban Indians have a high mortality

rate from alcoholism and related causes than any other races. The

urban Indian suicide rate is four times that of all other races, and

urban Indians have three times the national rate for diabetes and

heart disease.

How can the health status of urban Indians be improved? Certainly by the passage of the Indian Health Care Improvement Act

and also adequate funding for IHS so that they may accomplish

that goal set in 1976 by Congress.

NCUIH supports the recommendations of the national steering

committee and with the reauthorization of the Indian Health Improvement Act, title V Access to Health Services, section 511

Grants for Alcohol and Substance Abuse-related Services, section

515, Federal Tort Claims Act coverage, section 521, authorization

of appropriations. Also increased funding for urban Indian programs.

The urban Indian represents 60 percent of all Indian populations

and receives only 1 percent of Indian health dollars. Although

NCUIH requested a $6.4-million increase to the 2006 budget,

urban Indian health programs only received an estimated increase

of $1 million. NCUIH urges this committee and Congress to recognize this need and help increase the funding for these programs.

Also, Federal medical assistance percentage, to place FMET back

into the words of the Indian Health Care Improvement Act policy.

NCUIH urges this committee and Congress to help urban Indians expand State Medicaid funding. As you heard, America is nowhere near the lofty goal that they set in 1976.

In conclusion, I would like to take this opportunity to thank you

for your support last year for making permanent section 512, Demonstration Projects in Oklahoma. As a result, these excellent clinics

will be able to continue to provide very valuable health care services to urban Indians in Oklahoma City and Tulsa.

Also, in conclusion, NCUIH looks forward to working with this

committee toward achieving the goal they set in 1996. Thank you

for this opportunity on behalf of NCUIH to provide testimony on

urban Indian health care issues.
25

Senator DORGAN. Ms. Ignace, thank you very much for being

present and providing testimony to the committee today.

Finally, we will hear from Anslem Roanhorse, executive director,

Navajo Nation, Department of Health, Window Rock, AZ.

Mr. Roanhorse, welcome, you may proceed.

STATEMENT OF ANSLEM ROANHORSE, EXECUTIVE DIRECTOR,

NAVAJO NATION DEPARTMENT OF HEALTH

Mr. ROANHORSE. Vice Chairman Dorgan, distinguished members

of the Senate Committee on Indian Affairs, my name is Anslem

Roanhorse. I am the executive director for the Navajo Division of

Health in Window Rock, AZ.

On behalf of the Navajo Nation, I am honored to present this testimony to you. I would like to highlight some of the information

that we have given you in our written statement, and also we

would like to request that our written statement be made part of

the record.

Senator DORGAN. Without objection.

Mr. ROANHORSE. The Navajo Nation expands into three States

and three Federal regional offices, region VI Texas, region VIII Colorado and region IX in California. The Navajo Division of Health

operates with a budget of around $79 million. That includes Federal funds, State funds, tribal resources and we employ over 1,000

staff members that work with Indian people throughout the Navajo

Nation.

We also administer 18 programs, that includes health education,

nutrition services, alcohol and substance abuse counseling and

treatment. We do diabetes prevention, public health nursing, and

also work with breast and cervical cancer prevention.

The IHS is still the primary health care provider for the Navajo

Nation. The health care network includes 5 hospitals, 6 health centers, 15 health stations, and 22 dental clinics. The Navajo Nation

appreciates the slight increases to the IHS budget for the past fiscal year. Senators, those increases were absorbed by increasing

medical costs, pharmaceutical and mandatory inflationary costs.

Although the fiscal year 2006 IHS budget request includes increases to the contract health services and preventive health,

which we appreciate, it however reveals a cut to the health care

facilities construction by nearly $86 million. Health care facilities

construction has been the Navajo Nation’s top priority for the past

3 fiscal years. Although the Navajo area has been very fortunate

to receive Federal funds for new hospitals and new health care centers in recent years, there remains a great unmet need for new facilities on the Navajo Nation, with their current population of

about 237,000 people and growing.

Some existing facilities are inadequate, too small, and require replacement. There are many areas within Navajo Nation that will

require new hospitals and health centers in the coming years to

support our increasing population. That being said, the Navajo Nation is grateful for the new staffing funds proposed for the Pinon

Health Care Center and Four Corners Regional Health care Center

in Red Mesa, AZ. A new health care center in Kayenta was recently added which we also ask for your support.
26

By the way, the Navajo Nation does not support the IHS plan

to pause in construction. The Navajo Nation is challenged by numerous complex and unique barriers to reach its public health

goals, including funding, facilities, transportation, information,

technology and workforces. Despite these barriers, we are doing our

best to provide services that include prevention services and also

education.

Recruitment and retention of additional health care professionals

is a great concern for the Navajo Nation. Currently, the Navajo

Area Indian Health Services is experiencing a high vacancy rate for

doctors, nurses, dentists, and pharmacists ranging from 17 percent

to 20 percent. Recently, the Navajo Nation embarked on developing

a trauma system development to reduce death and disability

caused by traumatic injuries among the Navajo people. Presently

after the initial care is provided by local hospitals, the majority of

our critical care patients are transferred to off-reservation trauma

centers. The Navajo Nation is now wanting to do something about

this to try to work with facilities to establish and upgrade our own

facilities.

Over the past 2 years, the Navajo Division of Health has been

battling with increased numbers of transmission of syphilis and

HIV cases. Again, we are trying to do our best to address some of

these emerging needs.

Currently, the Navajo Department of Health Services operates

two adolescent treatment centers, which is for approximately

35,000 Navajo adolescents who are in need of treatment. But again,

we are doing our best to meet the unmet needs, and then the Division of Health also operates two adult treatment centers for population of about 179,000 Navajos. Again, we are trying to do our best

to meet the needs. There is an emerging issue with methamphetamine and also of course we also have to deal with the alcohol

abuse and substance abuse.

With respect to the Navajo Nation, we also have always included

the use of traditional healers and our conventional medicine.

Again, we would like to continue to work on expanding traditional

services to incorporate it as part of our treatment modalities.

Then we also do our best to meet the needs of those people that

are afflicted by cancers. Right now, we do not have any cancer center on the reservation, but again we have to work with the surrounding towns to have our patients treated. Especially diabetes is

also another area that we have been doing a lot of work on, and

we think that we beginning to make some impact. We are doing

education. We are teaching patients on nutrition , and then also beginning to really promote exercise.

Poor roads in Indian country have been a great challenge for us.

Right now because of the rising cost of gasoline, it is now also beginning to impact our services. Certainly, it is impacting the Navajo families because of the cost of gasoline which is, as you all

know, over $2 per gallon. This is what the Navajo people have always been experiencing for the past several years. So again, a lot

of these services have to be taken to remote and isolated communities.

In conclusion, on behalf of the Navajo Nation, thank you for your

time and assistance in considering our issues and recommendations
27

to improve our health care in Indian country. I will be pleased to

respond to any questions that you may have.

Thank you.

[Prepared statement of Mr. Roanhorse appears in appendix.]

Senator DORGAN. Mr. Roanhorse, thank you very much.

Let me ask a couple of questions and call on my colleagues, and

then I will finish with a couple of additional questions.

Senator Burr asked a question of Dr. Grim and Ms. Power that

I think is on point. I would ask any of you, with a roughly 2-percent increase in funding for Indian Health Services, is there any

other conclusion but that we will lose ground on our health care

issues on Indian reservations because we all know that the health

care medical inflation is running at a very high rate, much above

the amount that is requested for additional services in the budget.

In addition to that, the one area where we see a rather substantial

increase in population in my State, and I expect most States, is on

Indian reservations. So the budget fails to not only keep pace with

the increased population, but also medical inflation.

So isn’t it a case, as I think Senator Burr was attempting to ask,

isn’t a case that we are almost certain to lose ground in our efforts

here in trying to make progress in Indian health care? Ms. Smith,

do you want to answer that?

Ms. SMITH. Thank you very much.

Absolutely. I come from Alaska. I have been in Alaska since

1970. The Native population in Alaska has doubled. With the type

of funding, the slight increases that we have been receiving, and

I appreciate the fact that we have, the Indian Health Service has

received a slight increase, still and all across Indian country during

the budget formulation process, it reverberates that we are funded

at about 59 percent level of need.

Translated, there is not enough money out there to meet the

needs of Indian communities. Many, many of our tribes and tribal

organizations have compacted and contracted. In doing so, it brings

the ability for us to be more flexible in delivering health care. We

have tried to be as innovative, partnering, to stretch the dollar to

make more services available, more culturally available. But your

primary question is, no there is never enough money.

Senator DORGAN. But that is not my question, is there ever

enough money. My question is more specific than that. Let me just

say, I am going to ask the other three as well. I have always liked

Dr. Grim. I think the Indian Health Service struggles with limited

resources to do a very significant job.

But I also know that he would not be in that job very long if he

came to this table to say, you know something, the President’s

budget here dramatically underfunds what we really need. He

would not keep his job, so he cannot do that. He must come to this

table to represent the Administration’s budget. I understand that.

But I think the lack of the siren here that is necessary to say,

we have a bona fide, full-scale crisis on many reservations, particularly with young children, but also the elderly and other not getting the care they need because we do not have a system that

works and it is not funded properly. When I say we do not have

a system that fully works, I mentioned earlier when kids have addictions or adults have addictions, there is just very few opportuni-
28

ties for them to get in-residence help for that addiction, which all

of us understand is necessary to shed the addiction of substance

abuse to alcohol or drugs and so on.

Ms. Joseph, do you want to respond?

Ms. JOSEPH. Thank you, Senator Dorgan.

As I stated, we are losing purchasing power. We are moving our

resources around, reducing staff in some instances, shortening our

hours of service. So we certainly are not going to gain ground when

we have to approach health care delivery in that way.

Senator DORGAN. Ms. Ignace?

Ms. IGNACE. For the urban Indian health programs, the Federal

Government only pays the States the regular Federal Medicaid

matching rate. The urban Indians cannot really take advantage of

this. As a result, we would certainly agree to increases in FMET.

Senator DORGAN. Okay.

Mr. Roanhorse.

Mr. ROANHORSE. Thank you for the question, Senator.

The 2 percent and 4 percent recommendation by IHS, this is not

supported by the Navajo Nation. The instruction that was given to

me as a representative from the Navajo Area to go to the national

budget formulation process is to accept a minimum of 20 percent.

So the tribal leaders on my reservation, the health care providers

are seeing a huge gap and the need.

If I can maybe personalize this, and tell you about some of the

things that we have to do. Just imagine that we have a person that

is afflicted by cancer. Currently because of no cancer center close

to the Navajo Nation, we are expected to send our clients to Albuquerque, NM, which is a 3-hour drive away, and in most cases 4

hours. Or they have to go to Phoenix, AZ. So just imagine that.

These are the people that have limited income.

Sometimes they have to take off work in order to travel. And

then once they get to Albuquerque, they have to figure out a way

to maybe perhaps if they need to stay there for radiation therapy,

then they need to dish out some money, whatever that they may

have for overnight lodging, meals. And then in some cases, they

may not even have any adequate transportation, no vehicles.

So what happens? What happens is that they just sit at home

and then also just until it is too late, and they finally go to the hospital and the doctor will say, we are doing our best to treat you,

but it may be a very advanced state. That is the situation that we

encounter, Senator.

Senator DORGAN. I am going to ask about addiction treatment

and some other issues, but let me call on my colleagues.

Senator Murkowski.

Senator MURKOWSKI. Thank you.

When we get to budget time, and I think it is universal, at least

from the witness stand, that we do not have enough to do the job,

and that is something that we have to reckon with. We have to

deal with.

I have been very troubled by the statistics that face Alaska Natives in my State. We are at the top of all the bad categories for

many, many reasons. But I have had multiple conversations with

Dr. Grim and conversations with you, Ms. Smith, about the emphasis on prevention. We know that when we are talking about diabe-
29

tes, particularly the onset of adult diabetes, much of that is related

to diet. When we look to, you mentioned the dental care issue in

the State. Our children up north are wandering around with no

teeth, and it is not because the baby teeth have come out. It is because the adult teeth are rotted by the time they are in high

school.

So much of that is due to the diet, due to the fact that we do

not have drinking water for the children to drink; that we do not

have fresh milk for them to drink. And so much of this comes back

to prevention. We can discuss at every budget hearing whether or

not we have enough money, but until we take control of those

things that we can control, and we can control our diet, and we can

control aspects of our life about living healthier lifestyles.

I am not convinced that we are doing enough when it comes to

the education component; when it comes to teaching our young people about healthy lifestyles. Ms. Smith, you mentioned an initiative

I believe it was called the WIN! Initiative.

Ms. SMITH. Yes.

Senator MURKOWSKI. Are we giving the focus that you think we

need to give when it comes to education and prevention so that we

will in successive generations hopefully have healthier children,

healthier people?

Ms. SMITH. Thank you very much.

Every time we have the opportunity to advance education in any

area and particularly in the area of prevention, it is critical that

we do so. Are we doing enough? We are beginning and moving forward today, but we are also just beginning this entire discussion

about prevention. If we do not continue to build on health promotion and disease prevention today, we will not ever be able to

afford down the road the causes of neglecting to put money into

health promotion and disease prevention initiatives and programs.

I believe that the tribes and the tribal organizations across the

Nation stand ready and are working very closely in collaboration

with the IHS on the health promotion and disease prevention initiative, and recognize that we need to take the forward steps as

tribes and as parents to see about prevention within our own families, within our own tribes, within our own nations.

And so every time that the question is asked, are we doing

enough, for the moment maybe we are, but no, it is really never

enough. So I am very excited about the WIN! Initiative that I mentioned from the National Indian Health Board. Again, I say it is

a new vision; it is an ongoing vision of living healthy lives, making

behavioral changes, and moving toward all American Indians at

last being healthy at the onset, and not having to spend huge

amounts of money later on in life when a good prevention program

could have prevented such maybe tragic outcomes.

Senator MURKOWSKI. Let me ask you just one more question

here. I appreciate your being here, Sally.

When we talk about how we might have prevented either the incident in Bethel or the incident in Red Lake, and we try to look

for those warning signs, we try to pick up on them. The point was

made earlier that we do not have access to appropriate or certainly

enough treatment facilities.
30

So oftentimes, it is not the structured treatment facilities that we

need. What we need are culturally appropriate or culturally significant programs within the communities that are going to make a

difference, that are going to make a difference for that Evan

Ramsay who would then feel part of his community and not feel

that he has to react in the manner in which he did.

Do you feel that we are doing enough to provide for the flexibility

through the funding to allow for communities to create programs

that might work within their own unique situation? Do they have

that flexibility currently?

Ms. SMITH. I will give you a two-part answer. With regard to

flexibility, compacting and contracting tribes have the ability to be

flexible in delivering a program. That is the flexibility part. With

regard to the funding, it is critically important as funding comes

into the country, that tribes and tribal organizations be mentioned

specifically in the language so that the money can come from the

funding agencies directly to tribes and tribal organizations.

That is a critical piece in making sure that at least within the

American Indian and Alaska Native communities, the needs of

those people, our people are being addressed, and addressed in that

culturally compatible way that you just described.

Senator MURKOWSKI. Thank you, Mr. Chairman.

Senator DORGAN. Senator Murkowski, thank you very much.

Dr. Grim, could you scoot your chair back up? I want to ask you

another question if I might, and ask others to respond to it. Thank

you very much.

I mentioned at the start of this that the IHS spends $1,600 per

person per year for health care. That is less than one-half of what

we spend for Federal prisoners, and we have trust responsibility

for American Indians, for health care. We also have sole responsibility for the health care of those we have incarcerated in Federal

prisons.

If we spend $3,800 per person in Federal prisons for health care,

and less than one-half of that for American Indians, compare that

with $6,000 that Medicare spends per person, VA $5,200, Medicaid

at $3,900. Can you describe for me the disparity here? Why would

we spend one-half as much per person on Indian reservations for

health care as we do for Federal prisoners?

Mr. GRIM. I do not know if I can explain the disparity to you in

exactly the way you asked, Senator, but what I will say is that one

of the things that the agency has done along with tribes as partners is that, and that the department itself has looked at a change

in philosophy, is that it is not just Indian Health Service dollars

that should be trying to serve our Indian population, but it should

be moneys within SAMHSA, as Ms. Power pointed out, and within

other parts of the department, too. And we are making many more

grants available throughout the rest of the department.

We are also very actively, both tribes and the IHS, tapping into

Medicare and Medicaid funding. We have the ability through the

Indian Health Care Improvement Act to bill Medicare and Medicaid and private insurances and we are trying to bring additional

resources through those programs into the agency, too. So we are

looking at it as an entire Government responsibility, not just IHS,
31

and we are trying to reach out to other partners across the Government with tribes that perhaps in the past did not.

One of the things that Ms. Smith said that anytime new funding

comes up, it should mention tribal governments. The department

took a very strong effort and initiative to make sure that any

grants within the Department of Health and Human Services that

were appropriate for tribes, spelled out in fact in their grant announcement that tribes were available. So we have tried to make

changes like that. While they may seem like they are changes on

the margin, I think they are very important changes.

Senator DORGAN. You see, Dr. Grim, that is why I said I like

you. You always see things, the glass is always half full for you.

I say that with some admiration because I think it is important to

be hopeful and to see things in a positive light.

On the other hand, with respect to health, if the glass if half

empty, the half that is gone relates to people’s ability to live a

healthy lifestyle. In some cases, it relates to the difference between

life and death. It relates to the difference between having a good

day and a day filled with pain.

So I am not insistent on seeing the glass half full, but I am insisting on seeing if we have met our trust responsibilities. If not,

why not? And if not, how do we start doing that?

When I asked the question about the amount of money we spend

per Federal prisoner, and we have a responsibility when we incarcerate someone to meet their medical needs, and we do. From a

small jail cell, even someone on death row, when they are ill, they

are taken someplace to treat that illness. When they need surgery,

they get surgery. The fact is, we have a responsibility and we meet

it for people that we put in Federal prison.

We also have a trust responsibility for health care for American

Indians. My sense is if it is not one-half of that which we spend

on Federal prisoners, it is something still substantially below that

which we spend on Federal prisoners. I am not certain how we get

to the point where we meet our obligation if we always say, well,

we are just making improvements.

We really have to set a baseline to say, here is the responsibility

the Government has and here is how the Government meets that

responsibility. I will give you a specific example. I toured a reservation. I do not remember. I think they have 7,000 people or somewhere in that neighborhood. They had one dentist working out of

an old trailer house. Now, if you think taking care of your teeth

is part of good health, and I do, and I think most people would, is

that sufficient? If not, then how do we correct that?

Do you all see that kind of anecdotal evidence virtually everywhere you go? One dentist working out an old trailer house, trying

to do the best he or she can, but dramatically understaffed on all

these issues and underfunded and working long hours, but really

not making much progress against a population base that is far too

large.

Ms. Joseph.

Ms. JOSEPH. Thank you, Senator.

Among the family, we always hope to compliment each other. As

Dr. Grim talked about the half-full glass, I will talk about the halfempty glass.
32

You know, the disparities in funding can take different approaches, but we did have a work group to address the Federal disparities index. It was early, you recall, to addressing the level of

need funded.

Senator DORGAN. Yes.

Ms. JOSEPH. That work group primarily was constituted to make

some recommendations on how the distribution from the Indian

Health Care Improvement Fund would be made to death inequities. What they did, and it was I believe a very objective, scientific

approach to addressing this disparities index. What they established as the yardstick was the Federal employees’ benefit package.

And then they moved that package around to 100 different geographic areas in the country and made a determination of what it

would cost to provide that package of benefits to a Federal employee.

Of course, you know, the highest costs tended to be in Alaska

and San Diego County. That was kind of the denominator. And

then for the numerator, what they did was total the amount of dollars that was actually provided for personal health care. So that excluded wrap-around services such as community health representatives, public health nurses, health educators and emergency medical services need.

That denominator reflected a level of need or disparity in funding

of the Indian programs compared to the benefits provided to the

Federal employee. Based on that effort, it was determined it would

take at least an additional $9 billion to $10 billion to address that

disparity in personal health care services.

Senator DORGAN. Let me ask Dr. Grim about that. Again, you

represent the Administration’s budget. I understand that. I do not

want you to lose your job. But I also want you to respond to the

proposition Ms. Joseph has just advanced that if we really were

going to provide parity with the meeting of our responsibility here,

and in cases of the type I just described you would have not one

dentist working out of a trailer house, you would have sufficient

dentists to meet the population, just to take that small piece.

Isn’t it the case if you were really trying to meet the parity that

I think our trust responsibilities require, that there would need to

be substantial additional funding?

Mr. GRIM. I could cite for you a number of statistics and we can

provide those for the record about our access to care in dental that

we have right now. It is between 20 and 25 percent of our population are able to access that. That is not the same in the Nation

as a whole. It has been pointed our numerous times today the disparities in the various health indicators. And some of that is money

issues, Senator Dorgan; some of it is access issues, recruitment and

retention of providers. In many of our locations, it is the ability to

have adequate housing for providers available when they come onsite.

So it is a very complex issue and I cannot answer the question

as simply as you place it.

Senator DORGAN. But I think that if you say, for example, American Indians have access at the rate of 25 percent to dental services, that means 75 percent do not have access to dental services.
33

It means that we are substantially short of the resources necessary

to provide at least that kind of care.

Is that not accurate?

Mr. GRIM. That would be an accurate statement.

Senator DORGAN. Yes; and let me go back just for 1 moment to

the issue of substance abuse. One of the things that I was told at

a meeting I had recently was that the young person who was for

example hooked on methamphetamine, a deadly drug with dramatic addiction capabilities, or a young person who had become an

alcoholic or addicted to some other drug, that person then goes into

a cycle of dependency, depression, perhaps threatened suicide.

And to the extent that they reach out and find somebody in mental health in that tribe or in IHS, what happens they say is they

are sent then to, perhaps they are sent to a psychiatric unit for

evaluation, released in probably 1 or 2 days, and with no followup. And that goes on and on and on.

Again, in most cases, reservations, not all, but in most cases reservations are very remote, and so access, if you are referred to

mental health treatment, is somewhere else, and if they turn you

out in 2 days with no follow-up, you really have not addressed the

fundamental issue.

Again, that gets back to the question of how many people are

available to work in mental health on these reservations, psychologists, psychiatrists, and so on? The young woman named Avis Little Wind who took her life recently, there was one psychologist. I

went and met with the school counselors, met with the young girl’s

classmates and others. It was quite clear that there was not the

kind of health care capability for mental health that should have

been available that might have saved this young girl’s life.

I expect that is true on most reservations. That is why I raise

the question today. Your testimony, Dr. Grim, is always helpful to

us because it does describe where we are in fact making some

progress. But I think we might be better off starting from the proposition of where we expect to be, where we should be, and then

measuring the distance from there to where we are, and then describing how we get there and what kind of resources are necessary, what kind of reorganization is necessary. We seldom ever

talk about it in those terms and I think we should because all of

us who visit reservations and sit down and have long serious talks

about the health care issue, and I should mention that we have a

crisis not only in health care, but in housing and also in other

areas as well.

I think that health care is just primary because if you do not

have your health, you do not have the capability to live the life you

want to live, and nothing else is able. You cannot hold a job. You

cannot go to school.

So health care is primary and I think we really need to identify

this as a crisis, an emergency, and try to look at this differently,

rather than just each year saying, all right, we are short of money,

this is a problem, let’s incrementally move toward solving it. We

need to re-think that. I know Senator McCain is very aggressive

and very interested in addressing these health care issues in a

positive way and so am I.
34

I would ask the panel as we close, any final last comment, and

then I will ask Dr. Grim for a last comment.

Ms. JOSEPH. Senator Dorgan, I got a note here that said, Rachel, when you spoke about the disparity in funding, I stated $9 million

to $10 million, and did I mean that. Absolutely, I did mis-speak.

It is $9 billion to $10 billion.

Senator DORGAN. I think you said billion.

Ms. JOSEPH. Oh, that is right. I did mean to say $10 billion.

Senator DORGAN. In your testimony, I did not expect you were talking in $9 million or $10 million in quantity. [Laughter.]

Ms. JOSEPH. I appreciate your comments on the alcohol and substance abuse problems. In the reauthorization consultation process,

we heard from tribal leader after tribal leader that urged us to authorize a comprehensive approach. Very often, we provide treatment in recovery programs, but do not provide the necessary aftercare, which will certainly facilitate the reduction of the recidivism

rates that we are all challenged with.

Senator DORGAN. But isn’t it true that most of the treatment is

outpatient treatment and not the kind of treatment in most instances you need? In-residence treatment for addiction is critical

and it exists in very few locations.

Ms. JOSEPH. Yes.

Senator DORGAN. I find that all over.

Ms. JOSEPH. Outpatient is mostly provided.

Senator DORGAN. Is there anybody else that feels like they want

to make a final comment here? Then I am going to turn to Dr.

Grim and then we are going to adjourn the hearing. All right, yes,

Mr. Roanhorse.

Mr. ROANHORSE. Thank you, Senator Dorgan.

I just wanted to add a few more information to my testimony this

morning. I appreciate your interest in behavioral health services.

Again, the Navajo Division of Health through the Department of

Health, behavioral health services is trying to meet a lot of demands for our work which has to do with addressing alcohol abuse,

substance abuse, and then now with meth. And then also we do

this by operating two adolescent treatment centers which only have

a few beds.

Senator DORGAN. How many beds?

Mr. ROANHORSE. One has 20 beds, the second one has 24 beds.

And then we also have 13 outpatient centers that serve over 11,000

clients. And then we also, this summer the Navajo Nation Council

also passed the Controlled Substance Act of 2004, which I think

would be one way of banning meth, but again it is a huge endeavor. We have to deal with some people that have to go into the remote areas of the Navajo Nation and then with $12 they can be

able to purchase ingredients, and then they can in turn then sell

for a huge amount of funds. And then that in turn causes a lot of

behavioral problems. So these are some of the situations that we

encounter on a daily basis.

And then another plan that we are trying to address is there is

a 72-bed hospital that we are trying to, or a 72-bed residential

treatment center that we are planning on setting up in Shiprock,

NM. That is taking the former IHS facility, but in order to get to

that point, it is going to cost of $10 million, so we have been going
35

to the State legislature. We have been going to the Navajo Nation

Council just to raise funds to make sure that facility is renovated.

So we hope that we can start at least the renovation started this

summer.

So at least, these are some of the things that we are beginning

to work on. Anything that you can do to help us out, I know money

is tight everywhere, but I also think that, and I am reminded by

my tribal leaders.

Senator DORGAN. Mr. Roanhorse, we must be brief. I asked for

a brief comment.

Mr. ROANHORSE. I am sorry. Okay. So than you very much for

allowing me to share these thoughts with you.

Senator DORGAN. Thank you for your testimony. Your testimony

is very significant and we appreciate it.

Anyone else?

Ms. SMITH. Yes, thank you; thank you, Senator. I wanted to

place on the record, earlier you mentioned about dental health

care. In Alaska, our children are 21⁄2 times the national rate for

and the need for dental health care. I mean, it is just incredible

up there. As part of meeting that challenge, the Alaska Native

Health Board has gone on and took a step in something called the

Dental Health Aid Therapist Program.

Senator DORGAN. I am familiar with that.

Ms. SMITH. Thank you very much, but I wanted you to know that

again as part of recognizing that we have a need and being

proactive about it, we are moving forward in that regard. So thank

you very much.

Senator DORGAN. Thank you, Ms. Smith.

Ms. Ignace.

Ms. IGNACE. Yes; in the past several years, versions of the Indian

Health Care Improvement Act did not include a reference to urban

Indians. We would like that to remain in that policy, simply because we serve, we consider ourselves a multi-tribal clinic, where

we serve not just one tribe, but many tribes that live in the city.

Senator DORGAN. All right. Thank you very much.

Dr. Grim, in the construction of the Administration’s budget, I do

not know whether you are able to provide this for me, but I would

be interested in what the IHS request was to OMB for funding in

this coming fiscal year. Do you have that at hand?

Mr. GRIM. I do not have that at hand. We could respond to you

for the record.

Senator DORGAN. Was it substantially higher than that which

now is in the President’s budget?

Mr. GRIM. I just do not have that at hand, Senator, right now.

Senator DORGAN. Was it higher or lower?

Mr. GRIM. I do not recall. We can get that to you for the record.

I appreciate your support of Indian health issues.

Senator DORGAN. Dr. Grim, I said I liked you. [Laughter.]

Mr. GRIM. I have always liked you, Senator Dorgan.

Senator DORGAN. I find it hard to believe you do not know that.

My expectation would have been that you would have asked for a

rather substantial amount of money that is necessary to fund the

Indian Health Service programs and that the Office of Management and Budget, as they kick these things up to the White House
36

where the President’s budget has cut them substantially. But you

do not know that at this moment, is that correct?

Mr. GRIM. I would prefer if I could respond for the record to you

on that.

Senator DORGAN. All right. You respond for the record and I will

make it a part of the record at the next hearing.

Mr. GRIM. Okay, thank you.

Senator DORGAN. Let me, Dr. Grim, thank you for being here,

and let me thank the four witnesses on this panel. On behalf of

Senator McCain and I, we pledge to continue to work hard on Indian health care issues because we think it is an urgent priority.

This hearing is adjourned.

[Whereupon, at 1:33 a.m., the committee was adjourned, to reconvene at the call of the Chair.]
(37)

APPENDIX

ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD

PREPARED STATEMENT OF CHARLES GRIM, M.D., DIRECTOR OF THE INDIAN HEALTH

SERVICE [IHS]

Mr. Chairman and members of the committee.

Good morning, I am Dr. Charles Grim, Director of the Indian Health-Service

[IHS]. Today, I am accompanied by Robert G. McSwain, Deputy Director; Gary J.

Hartz, Director, Office of Environmental Health and Engineering; and Dr. W. Craig

Vanderwagen, Acting Chief Medical Officer. We are pleased to have this opportunity

to testify on behalf of Secretary Leavitt on the status of Indian Health.

The IHS has the responsibility for the delivery of health services to an estimated

1.8 million federally recognized American Indians and Alaska Natives through a

system of IHS, tribal, and urban [I/T/U] operated facilities and programs based on

treaties, judicial decisions, and statutes. The mission of the agency is to raise the

physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level, in partnership with the population we serve. The agency

goal is to assure that comprehensive, culturally acceptable personal and public

health services are available and accessible to the service population. Our foundation is to uphold the Federal Government’s obligation to promote healthy American

Indian and Alaska Native people, communities, and cultures and to honor and protect the inherent sovereign rights of tribes.

Two major pieces of legislation are at the core of the Federal Government’s responsibility for meeting the health needs of American Indians/Alaska Natives: The

Snyder Act of 1921, Public Law 67–85, and the Indian Health Care Improvement

Act [IFICIA], Public Law 94–437, as amended. The Snyder Act authorized regular

appropriations for ‘‘the relief of distress and conservation of health’’ of American Indians/Alaska Natives. The IHCIA was enacted ‘‘to implement the Federal responsibility for the care and education of the Indian people by improving the services

and facilities of Federal Indian health programs and encouraging maximum participation of Indians in such programs.’’ Like the Snyder Act, the IHCIA provided the

authority for the provision of programs, services and activities to address the health

needs of American Indians and Alaska Natives. The IHCIA also included authorities

for the recruitment and retention of health professionals serving Indian communities, health services for people and the construction, replacement, and repair of

health care facilities.

We are here today to discuss the status of the Indian health by focusing on health

disparities and other related issues such as Urban Indian health, Indian health care

facilities, Indian self determination, and portions of the Medicare Modernization

Act.

While the mortality rates of Indian people have improved dramatically over the

past 10 years, Indian people continue to experience health disparities and death

rates [1999–2001] that are significantly higher than the rest of the U.S. general population (2000):

• Tuberculosis—533 percent higher
38

• Alcoholism—517 percent higher • Diabetes—208 percent higher • Accidents—150 percent higher • Suicide—60 percent higher • Homicide—87 percent higher.

While some view these statistics as insurmountable facts, they are influenced by

behavior choices and lifestyle. Making significant reductions in health disparity

rates can be achieved by implementing best practices, using traditional community

values, and building the local capacity to address these health issues and promote

healthy choices. For fiscal year 2006, IHS is requesting a total budget of $3.8 billion,

including an increase of $80 million for inflation and population growth which will

allow for a renewed focus on health disparities.

It is the mission of the Indian Health Service to provide services and programs

that promote healthy choices and assist in enabling tribes to educate their members

about prevention and treatment programs that address the unique needs of their

individual communities.

I just returned from the Red Lake Band of Chippewa Indians in Minnesota and

saw firsthand the results of the devastation brought about by the shootings at the

Red Lake High School. I also saw the community coming together and drawing

strength from the support of mental health professionals and tribal spiritual leaders. There is much to do, yet there is a sense of hope and a spirit of collaboration

among the community and tribal leaders, the State and Federal programs. Within

the Department of Health and Human Services alone, the Office of the Secretary’s

Office of Intergovernmental Affairs as well as the Department’s operating divisions,

including the Substance Abuse and Mental Health Services Administration

[SAMHSA], the Administration for Children and Families [ACF] and its Administration for Native Americans, and the Office of Minority Health are joining the Bureau

of Indian Affairs [BIA] within the Department of the Interior, the Department of

Justice [DOJ], and the Department of Education to assist the tribe and community.

My thanks to all those involved that are working together to improve the overall

health of Indian people in Red Lake and throughout Indian country.

How do we prevent such incidences from occurring? First, IHS focuses on screening and primary prevention in mental health especially for depression which manifests itself in suicide, domestic violence, and addictions. Second, we focus on the effective utilization of treatment modalities that are available; and, we are seeking

to improve the documentation of mental health problems. IHS is currently utilizing

effective tools for documentation through the behavioral health software package.

And, we are working with communities who are focusing more on these mental

health needs. In addition, our budget request includes $59 million for IHS mental

health services, an increase of 7.7 percent over fiscal year 2005.

With 80 percent of the mental health budget and 97 percent of the alcohol and

substance abuse budget in IHS going directly to tribally operated programs, the

tribes and communities themselves are now taking responsibility for their own healing. They provide effective treatment and prevention services within their own

communities.

A primary area of focus that I have identified based on these statistics is a renewed emphasis on health promotion and disease prevention. I believe this will be

our strongest front in the ongoing battle to eliminate health disparities plaguing our

people for far too long. Although IHS has long been an organization that emphasizes

prevention, I am calling on the agency to undertake a major revitalization of its

public health efforts in health promotion and disease prevention. Field, tribal, and

urban participation in the initial stages of planning and implementation of this revitalization is critical to its success.

Fortunately, the incidence and prevalence of many infectious diseases, once the

leading cause of death and disability among American Indians and Alaska Natives,

have dramatically decreased due to increased medical care and public health efforts

including massive vaccination and sanitation facilities construction programs. As

the population lives longer and adopts more of a Western diet and sedentary lifestyle, chronic diseases emerge as the dominant factors in the health and longevity

of the Indian population with the increasing rates of cardiovascular disease, Hepatitis C virus, and diabetes. Most chronic diseases are affected by lifestyle choices

and behaviors.

The incidence and prevalence of diabetes has been increasing dramatically since

1972. American Indians and Alaska Natives have the highest prevalence of type 2

diabetes in the world. The prevalence of type 2 diabetes is rising faster among

American Indian and Alaska Native children and young adults than in any other

ethnic population, increasing 106 percent in just one decade from 1990 to 2001. As

diabetes develops at younger ages, so do related complications such as blindness,
39

amputations, and end stage renal disease. We are hopeful, though, that we may be

seeing a change in the pattern of diabetes mortality because the diabetes mortality

rate for the entire American Indians and Alaska Natives population did not increase

between 1996–98 and 1999–2001. In fact, the overall mortality rate for American

Indians and Alaska Natives decreased approximately 1 percent between these same

time periods. And there is good news that we have recently measured a slight, but

statistically significant, decline in kidney failure in the American Indians and Alaska Natives diabetic population as well.

What is most distressing however about these statistics is that type 2 diabetes

is largely preventable. Lifestyle changes, such as changes in diet, exercise patterns,

and weight can significantly reduce the chances of developing type 2 diabetes. Focusing on prevention not only reduces the disease burden for a suffering population,

but also lessens and sometimes eliminates the need for costly treatment options.

The cost-effectiveness of a preventive approach to diabetes management is an important consideration, since the cost of caring of diabetes patients is staggering. According to a recent American Diabetes Association study, the managed care cost for

treating diabetes annually per patient exceeds $13,000.

In 1997, the Special Diabetes Program for Indians [SDPI] was enacted and provided $150 million over a 5-year period to IHS for prevention and treatment services

to address the growing problem of diabetes in American Indians and Alaska Natives. In 2001, Congress appropriated an additional $70 million for fiscal years 2001

through 2002, and an additional $100 million for fiscal year 2003. Then in 2002

Congress extended the SDPI through 2008, and increased the annual funding to

$150 million with the directive to address ‘‘primary prevention of type 2 diabetes.’’

These funds have substantially increased the availability of services—physical activity specialists, registered dietitians and nurses, wellness and physical activity centers, newer and better medications—which have led to a steady increase in the percentage of diabetics with ideal blood sugar control. We are proud to announce that

our Division of Diabetes Treatment and Prevention launched a competitive grant

demonstration project focused on primary prevention of type 2 diabetes in 35 American Indians and Alaska Natives communities in November 2004. This program is

focusing on American Indians and Alaska Natives adults with pre-diabetes to determine if an intensive lifestyle intervention can be successfully implemented in American Indians and Alaska Natives communities. Our efforts are based on a model developed by the National Institutes of Health [NIH] that proved diabetes could be

prevented. These programs will cover a 4-year period. The outcomes of the demonstration projects will enable us learn what may be applicable to other communities throughout Indian country.

Cardiovascular disease [CVD] is the leading cause of mortality among Indian people. The Strong Heart Study, a longitudinal study of cardiovascular disease in 13

American Indians and Alaska Natives communities, has clearly demonstrated that

the vast majority of heart disease in American Indians and Alaska Natives occurs

in people with diabetes. In 2002, we were also directed to address ‘‘the most compelling complications of diabetes,’’which of course is heart disease with the increased

SDPI funding. The IHS is working with other DHHS programs, including the Centers for Disease Control and Prevention and the National Institutes of Health’s National Heart, Lung, and Blood Institute, to develop a Native American Cardiovascular Disease Prevention Program.

Also contributing to the effort are the IHS Disease Prevention Task Force and the

American Heart Association.

Our primary focus is on the development of more effective prevention programs

for American Indians and Alaska Natives communities. The IHS has begun several

programs to encourage employees and our tribal and health program partners to

lose weight and exercise, such as ‘‘Walk the Talk’’ and ‘‘Take Charge Challenge’’ programs. Programs like these are cost effective in that prevention of both diabetes and

heart disease, as well as a myriad of other chronic diseases, are all addressed

through healthy eating and physical activity.

In summary, preventing disease and injury, promoting healthy behaviors and

managing chronic diseases are a worthwhile financial and resource investment that

will result in long-term savings by reducing the need for providing acute care and

expensive treatment processes. It also yields the even more important humanitarian

benefit of reducing pain and suffering, and prolonging life. This is the path we must

follow if we are to reduce and eliminate the disparities in health that so clearly affect American Indians and Alaska Natives people. We will spend $330 million on

specific health promotion and disease prevention activities in fiscal year 2005.

IHS, Tribe and Urban Indian health programs could not function without adequate health care providers. The Indian Health Manpower program which is also
40

authorized in the Indian Health Care Improvement Act [Public Law 94–437, as

amended] consists of several components:

• The IHS Scholarship Program;

• The IHS Loan Repayment Program; and

• The IHS Health Professional Recruitment Program.

The IHS Scholarship Program plays a major role in the production of American

Indians and Alaska Natives health care professionals. Since its inception in 1977,

more than 7,000 American Indians and Alaska Natives students have participated

in the program, with the result that the number of American Indians and Alaska

Natives health professionals has been significantly increased. The program is

unique in that it assists students who are interested in or preparing for entry into

professional training. Most scholarships only provide assistance to those who have

been accepted into a health professional training program. By providing this preparatory assistance, the program ensures that even those participants who do not

complete their health professions training are better prepared to return to their

communities and become productive members.

The IHS Scholarship Program [LRP] has been the starting point for the careers

of a number of American Indians and Alaska Natives health professionals now

working in IHS, tribal, and health programs. Many are also involved in academia,

continuing to help identify promising American Indians and Alaska Natives students and recruit them to the health professions, thereby helping to produce a selfsustaining program. We have had several instances of parents going through the

program, followed later by their children, and in some cases, we have even seen children being followed by their parents. The average age of our students is 28 years,

well above the norm for college students. It is not uncommon for students to have

attended 5 or more colleges or universities during the course of their academic careers, not because they failed in the first four, but because they had to move in

order to have the employment they needed to support their families.

The IHS Loan Repayment Program is very effective in both the recruitment and

retention areas. The program provides an incentive both to bring health professionals into the IHS and to continue their employment with the agency. Keeping

health professionals for longer periods of time provides a benefit to the overall Indian health program by increasing continuity of care.

The scholarship and loan repayment programs complement one another. Scholarships help individuals rise above their economic background to become contributing

members of the community and participate in improving the well-being of the community. Loan repayment participants often graduate with large debt burdens which

cause them to accept jobs with the highest salaries. The program is a way for them

to provide service in return for assistance in repaying loans that could otherwise

be overwhelming.

The recruitment program seeks to maximize the effectiveness of both programs,

as well as to make the IHS more widely known within the health professional community and to assist interested professionals with job placement that best fits their

professional and personal interests and needs. Our fiscal year 2006 request includes

$32 million for Indian Health Professions, an increase of 3.6 percent over fiscal year

2005.

Another important aspect of our health care delivery system is the Urban Indian

Health Program [UIHP] authorized by Congress in 1976 with the passage of the Indian Health Care Improvement Act. Title V of the IHCIA was intended to make

health services available to communities that were not otherwise met by an IHS administered health program. Urban American Indians and Alaska Natives are often

times not included in the urban community health planning process because they

represent a smaller percentage of the population in the urban areas in which they

reside.

For many urban Indians, the UIHP may serve as a primary care provider or may

provide critical assistance in helping urban Indians to access health care in the

urban community. In this regard, UlHPs are remarkably successful. All UIHPs conduct extensive eligibility determinations, education about services, training in how

to access services, assistance in applying for and qualifying for and state health benefits’ programs, assessment of patient needs and referral, and in some cases transportation to other health care sites. Many Urban Indians now get health care services from a variety of sources for which they are eligible as a result of the UIHP

efforts. However, some may experience economic, cultural, and language barriers

which can make it difficult for Urban Indians to access such programs. In addition,

eligibility may vary over time in response to job conditions, personal circumstances

and eligibility guidelines making continuity of care difficult to achieve.
41

In order to address the growing needs of Urban Indian populations, UIRP organizations partner with and received assistance and funding from many Federal health

care agencies, including DHHS sister agencies, the Department of Veterans Affairs,

and State and local governments. In fact, during 2003, title V funding represented

48 percent of all funding received by the UIHPs, with the remaining 52 percent received as a result of collaborations. Through these collaborative efforts, the U1HPs

work to obtain maximum health care services for Urban Indians.

In summary, the UIHP was established to provide basic services to eligible Indians who are not living on or near a reservation where the IHS or a tribal program

would otherwise provide for their healthcare. The UIHP is very successful in assisting eligible Urban Indians to utilize health care services when such services are

available. When Urban Indians are not eligible for other programs, or lack access

to basic health care, the UIHP provides basic services to Indian clients to the extent

resources are available. Equal access and utilization of health care services by

Urban Indians is achievable in combination with UIHP and other public and private

sources. Our fiscal year 2006 request includes $33 million for Urban Health, an increase of 4.4 percent over fiscal year 2005.

The Environmental Health and Engineering program is a comprehensive public

health program administered by IHS and tribes. Two examples are the sanitation

facilities construction program which provides safe water, wastewater disposal, and

solid waste disposal system; and the injury prevention program which focuses on

unintentional injuries. As a result of these two successful programs, 88 percent of

American Indians and Alaska Natives homes now have safe water and unintentional injuries have been reduced by 53 percent between 1972 and 1996. Unfortunately, 12 percent of the homes still lack adequate sanitation facilities compared to

1 percent of the rest of the United States population; and the leading cause of death

for American Indians and Alaska Natives between the ages of 1 and 44 years of age

is unintentional injuries. Improving in these areas is integral to our mission. Our

fiscal year 2006 request will provide water and waste disposal services to 20,000 existing Indian homes.

The Environmental Health and Engineering program provides access to health

care services through the health care facilities program which funds Federal and

tribal construction, renovation, maintenance, and improvement of health care facilities where health care services are provided. There are 49 hospitals, 231 health centers, 5 school health centers, over 2000 units of staff housing, and 309 health stations, satellite clinics, and Alaska village clinics supporting the delivery of health

care to American Indians and Alaska Natives people. The IHS is responsible for

managing and maintaining the largest inventory of real property in the DHHS, with

over 9.5 million square feet [880,000 gross square meters] of space and the Tribes

own over 3.7 million square feet [353,000 gross square meters]. This is in part the

result of tribally funded construction of millions of dollars worth of space to provide

health care services by the Indian Health Service funded programs.

Over the past decade, $600 million in funding has been invested in the construction of health care facilities which include, 1 Medical Center, 5 Hospitals, 9 Health

Centers, 3 Youth Regional Treatment Centers, 500 units of Staff Quarters, 27 Dental Units, and 21 Small Ambulatory Program construction projects. IHS has substantially improved its health care delivery capability in the newer health care facilities but we are still providing health care in a number of older and overcrowded

facilities. At the same time, the resources to maintain and improve this space have

remained steady over this past decade at $38 million 10 years ago to $49 million

in fiscal year 2005.

In response to a Congressional request to revise the Health Care Facilities Construction Priority System, we have been working to better identify the health care

delivery needs. This will enable us to prioritize the need for health care facilities

infrastructure. We are using a master planning process to address the complex nature of health care delivery for American Indians and Alaska Natives communities.

Both the Federal Government and Tribes will be able to use these plans to identify

our greatest needs for services and health care facilities. In the time of fewer resources, we want to plan carefully on how to best utilize any possible resources. The

IHS Health Care Facilities Construction program is fully prepared to address the

needs identified through this process. The program recently received one of the

highest Program Assessment Rating Tool scores in the Department of Health and

Human Services.

The IHS has been contracting with Tribes and Tribal organizations under the Indian Self-Determination and Education Assistance Act, Public Law 93–638, as

amended, since its enactment in 1975. IHS has implemented the act in a manner

that re-affirms and upholds the government-to-government relationship between Indian tribes and the United States. The share of the IHS budget allocated to tribally
42

operated programs has grown steadily over the years to the point where today over

50 percent of our budget is transferred through self-determination contracts/compacts. This percentage includes 30 percent of our budget transferred to 303 tribes

and tribal organizations through self-governance compacts and funding agreements.

Our budget request for Contract Support Costs includes an increase of $5 million,

sufficient to cover the contract support costs of the estimated number of new contract requests in fiscal year 2006.

As the principal author of major statutes affecting Indian health, this committee

is aware that a primary goal has always been to involve Indian and people in the

activities of the IHS. I would like to acquaint the committee with an initiative that

I undertook last year to revise the policy that governs tribal consultation and participation in the activities of the IHS. Over the last 7 months, the IHS has worked

closely with a representative group of tribal leaders and officials to revise our

present Consultation policy with the intention of improving the process to ensure,

to the maximum extent permitted by law, that leaders and officials are true partners with the IHS in policy development, budget allocation, and other activities. I

anticipate that our ‘‘new’’ Consultation Policy and the improvements to the consultation process that it sets forth will be formally adopted by me next month, in May

2005. Our new policy will be our third revised Consultation Policy since 1997. The

IHS is committed to improving consultation based on our experiences in this important area and our continuing discussions with Leaders concerning consultation activities in the IHS.

American Indians and Alaska Natives will also benefit from several provisions in

the Medicare Prescription Drug, Improvement, and Modernization Act of 2003

[MMA]. In 2004 and 2005, the transitional assistance credit of $600 per year for

low-income Medicare beneficiaries, including American Indians and Alaska Natives,

might provide additional Medicare revenue for prescription drugs dispensed at IHS

facilities in fiscal year 2005. The Medicare part D prescription drug benefit program,

when implemented in January 2006, will make the new part D prescription drug

benefit available to American Indians and Alaska Natives Medicare beneficiaries.

Other sections of the act authorize a 5-year expansion of benefits covered under

Medicare part B for American Indians and Alaska Natives beneficiaries.

In addition, the MMA introduced a number of provisions that expanded preventive benefits coverage in January 1, 2005. Beneficiaries whose Medicare part B coverage begins on or after January 1, 2005, will be covered for an initial preventive

physical examination within 6 months of enrollment. This exam includes counseling

or referral with respect to screening and preventive services such as pneumococcal,

influenza, and hepatitis B vaccinations; screening mammography; screening pap

smear and pelvic exam; prostate cancer screening; colorectal cancer screening; diabetes outpatient self-management services; bone mass measurement; glaucoma

screening; medical nutrition therapy services; cardiovascular screening blood test;

and diabetes screening test which will be given to beneficiaries at risk for diabetes.

The cardiovascular screening blood test and diabetes screening test do not have

a deductible or co-pays, so beneficiaries do not incur any cost. This is an additional

incentive for those with limited resources who might not otherwise access these benefits.

The Centers for Medicare and Medicaid Services [CMS] is collaborating on education and outreach with the American Cancer Society, the American Diabetes Association, and the American Heart Association to help maximize attention to Medicare’s new preventive benefits and help seniors to use them. CMS also plans to assist IHS in training IHS, tribal, and urban Indian health pharmacy staff on Medicare part D, so staff and Indian Medicare beneficiaries will better understand the

new Medicare prescription drug benefit.

In summary, Indian health has improved progressively since enactment of the Indian Health Care Improvement Act in 1976. The IHS has honored its commitment

to improve the health status of all eligible American Indians and Alaska Natives

as provided by IHCIA and has worked with tribes since the passage of the ISDEAA

in 1975 to assist in the successful transition of the IHS administered health programs to tribal control and administration. Prevention and health promotion programs continue to be a personal priority of mine and have received a $33 million

funding increase in the President’s fiscal year 2006 proposed budget.

We recognize, however, that health disparities continue to exist between American Indians and Alaska Natives and all other groups in the U.S., and we seek to

address this need through continued support of health education and disease prevention programs targeted at diseases with some of the highest mortality rates. In

addition, our scholarship and loan program provides opportunities to recruit and retain young Indian professionals to serve their communities, while the sanitation facilities construction program continues to provide safe water, wastewater disposal,
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and solid waste disposal systems for the well being of many communities. And,

through ongoing consultation, both Tribes and the Federal Government benefit from

communication that better identify priorities and how they might best be addressed.

Finally, enactment of the MMA will provide much needed prescription drug coverage in a manner intended to enhance the well being of tribal members.

Mr. Chairman, this concludes my statement. Thank you for this opportunity to

discuss the Indian health programs serving American Indians and Alaska Natives

and their impact on the health status of American Indians and Alaska Natives. We

will be happy to answer any questions that you may have.
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Æ