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INDIAN HEALTH

FIELD HEARING

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS 

UNITED STATES SENATE

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

AUGUST 15, 2007

Printed for the use of the Committee on Indian Affairs

(

(II)

COMMITTEE ON INDIAN AFFAIRS 

BYRON L. DORGAN, North Dakota, Chairman 

LISA MURKOWSKI, Alaska, Vice Chairman 

DANIEL K. INOUYE, Hawaii 

KENT CONRAD, North Dakota 

DANIEL K. AKAKA, Hawaii 

TIM JOHNSON, South Dakota 

MARIA CANTWELL, Washington 

CLAIRE MCCASKILL, Missouri 

JON TESTER, Montana 

JOHN MCCAIN, Arizona 

TOM COBURN, M.D., Oklahoma 

JOHN BARRASSO, Wyoming 

PETE V. DOMENICI, New Mexico 

GORDON H. SMITH, Oregon 

RICHARD BURR, North Carolina 

SARA G. GARLAND, Majority Staff Director 

DAVID A. MULLON JR. Minority Staff Director 

(III)

C O N T E N T S 

Page 

Hearing held on August 15, 2007 ........................................................................... 1 

Statement of Senator Dorgan ................................................................................. 1 

Statement of Senator Tester ................................................................................... 3 

WITNESSES

Clark, H. Westley, M.D., J.D., M.P.H., Director, Center for Substance Abuse 

Treatment, Substance Abuse and Mental Health Service Administration, 

U.S. Department of Health and Human Services ............................................. 14

Prepared statement .......................................................................................... 17

Eaglefeathers, Melbert ‘‘Moke’’, President, National Council of Urban Indian 

Health; Director, North American Indian Alliance; accompanied by Marjorie 

Bear Don’t Walk, Executive Director, Indian Health Board, Billings, MT ..... 65

Prepared statement .......................................................................................... 67

Joseph, Jr., Andy, Chair, Health and Human Service Committee, Colville 

Confederated Tribes ............................................................................................. 109

Killsback, Jace, Billings Area Representative, National Indian Health Board, 

Council Member, Northern Cheyenne Tribe; accompanied by Stacy Bohlen, 

Executive Director, National Indian Health Board and Dr. Joseph 

Erpelding, Orthopedic Surgeon, Billings, Montana ........................................... 31

Prepared statement .......................................................................................... 34

King, Tracy ‘‘Ching’’, Council Member, Fort Belknap Indian Community, Assiniboine Tribe ...................................................................................................... 95

Lankford, Carole, Vice-Chair, Salish Kootenai Tribes; accompanied by Kevin 

Howlett, Health Director, Salish Kootenai Tribes ............................................. 94

Little Coyote, Eugene, President Northern Cheyenne Tribe ............................... 96

Prepared statement .......................................................................................... 97

Little Plume, Edwin, Chairman, Health Committee, Blackfeet Tribal Business 

Council .................................................................................................................. 101

Prepared statement .......................................................................................... 102

McDonald, Dr. Joseph F., President, Salish Kootenai College ............................ 49

Prepared statement .......................................................................................... 51

North, Charles Q., M.D., M.S., Acting Chief Medical Officer, Indian Health 

Service; accompanied by Pete Conway, Director, Billings Area Office, Indian 

Health Service ...................................................................................................... 5

Prepared statement .......................................................................................... 8

Real Bird, Ken, Representative, Crow Tribe ......................................................... 110

Red Eagle, Darryl, Tribal Executive Board Member, Fort Peck Assiniboine 

Sioux Tribe ........................................................................................................... 82

Prepared statement with attachments ........................................................... 83

Stewart, Leo, Vice-Chairman, Confederated Tribes of Umatilla Indian Reservation ................................................................................................................. 100

Venne, Carl, Chairman, Crow Tribe ...................................................................... 111

Walk Above, Ms., Member, Crow Tribe ................................................................. 109

White, Ada M., Health Service Director, Crow Tribe ........................................... 53

Prepared statement .......................................................................................... 57

Wheeler, Julia Davis, Tribal Council Member, Nez Perce Tribe ......................... 95

Windy Boy, Hon. Jonathan, Council Member, Chippewa Cree Tribe Business 

Committee; Montana Representative, House District 32 ................................. 60

Prepared statement .......................................................................................... 62

APPENDIX

Adams, Barry, Browning MT, prepared statement .............................................. 163

Page

IV

Belcourt, Gordon, Executive Director, Montana–Wyoming Tribal Leaders 

Council, prepared statement with attachment .................................................. 129

Brown, Dick, President, MHA—an Association of Montana Health Care Providers, prepared statement .................................................................................. 116

Confederated Salish and Kootenai Tribes of the Flathead Nation, prepared 

statement .............................................................................................................. 113

Clairmont, Gwen, Member of the Confederated Salish and Kootenai Tribes, 

prepared statement .............................................................................................. 124

Fort Belknap Indian Community Council, prepared statement .......................... 155

Gavin, Shawna M., Chair, CTUIR Health Commission, letter, dated August 

14, 2007, to Hon. Byron L. Dorgan ..................................................................... 172

Johnson, Laurene, Member of the Confederated Salish and Kootenai Tribes, 

prepared statement .............................................................................................. 118

Juneau, Carol, State Senator, Senate District 8, Montana, prepared statement ...................................................................................................................... 160

Myers, David B., M.D., Billings MT, prepared statement .................................... 159

Nez Perce Tribe, prepared statement .................................................................... 168

Norgaard, Margaret, CEO, Northeast Montana Health Services (NEMHS), 

prepared statement .............................................................................................. 122

Sinclair, John, President, Little Shell Tribe of Chippewa Indians of Montana, 

prepared statement with attachments ............................................................... 126

Stone, Lou, Member of the Sngaytskstx Tribe, prepared statement ................... 119

Ward, Alex, Associate State Director, AARP Montana, prepared statement ..... 166

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INDIAN HEALTH 

WEDNESDAY, AUGUST 15, 2007

U.S. SENATE, COMMITTEE ON INDIAN AFFAIRS, Crow Agency, MT 

Pursuant to notice, the Senate Committee on Indian Affairs Field 

Hearing was held on August 15, 2007, at the Crow Tribal MultiPurpose Building, 4 Cap Hill Road, Crow Agency, Montana. 

[Opening prayer offered by Mr. Earl Old Person.] 

[Crow Tribe Color Guard and Drum Presentation.] 

OPENING STATEMENT OF HON. BYRON L. DORGAN,

U.S. SENATOR FROM NORTH DAKOTA 

Senator DORGAN. Ladies and gentlemen, we will call to order this 

U.S. Senate Committee Hearing. It’s the Committee on Indian Affairs in the U.S. Senate. 

I’m Senator Byron Dorgan, the Chairman of the Committee. I am 

joined by Senator Jon Tester, a member of our Committee from the 

State of Montana. 

We are joined by Sara Garland, who is the Chief of Staff on the 

majority side of the Committee, and David Mullon, who is the 

Chief of Staff on the minority side of the Indian Affairs Committee. 

I want to thank, first of all, all of you for being in attendance. 

I know from just having visited with a number of you, we have Indian leaders and members of tribal governments and folks from all 

around this region, and I very much appreciate your taking the 

time to be with us today. 

I want to especially say to Chairman Venne, with whom I’ve had 

a chance to have a lengthy conversation today about these issues, 

thanks to your leadership, thank you for hosting us. I’m deeply 

honored to be here with the Crow Nation. 

To Earl Old Person, thank you very much for the blessing today. 

Earl and I were able to ride on a subway car underneath the 

United States Capitol about three, 4 weeks ago, and I asked him 

how long he has been in tribal leadership, and I think Earl told me 

that he’s been the Tribal Chair since 1964. And if you want a definition of commitment and leadership, look at a commitment from 

1964 to today. God bless you. 

Thank you very much for being here, Earl. 

I want to especially say, because I am in the State of Montana, 

how appreciative I am of being able to serve with Senator Max 

Baucus, with whom I’ve served for some long while. Max does a 

great job for Montana and for our country, and pays a lot of attention to and works hard on Indian issues. 

2

I want to also say that we have been joined in the U.S. Senate 

by someone new, someone who I think brings a real breath of fresh 

air to the U.S. Senate and to the Senate Indian Affairs Committee, 

and that is Senator Jon Tester. 

We are, as you know, pushing very, very hard to get the Indian 

Health Care Improvement Act done and to the President for signature. No one has been more important to that push and to our success in getting it out of the Indian Affairs Committee, our success 

in getting a commitment—Senator Baucus is going to mark it up 

on September 12th in the Finance Committee—our success in getting the majority leader, Senator Harry Reid, to say that he will 

give us opportunities on the floor of the Senate to get this passed. 

No one has been more instrumental in that than Senator Jon 

Tester. He is a tireless worker on behalf of American Indians; a 

tireless worker in search of good, thoughtful, sensible policies that 

address health care, housing, education and all the things that we 

know need addressing on Indian reservations in this country. 

So, I can’t thank you enough for sending a real partner to Washington, D.C. to work on these issues. 

Now, I’m here because I was invited. I’ve taken over the reins 

of the chairmanship of the Committee of the Senate, the Committee on Indian Affairs. I’ve held some listening sessions around 

the country. We’ve held some hearings. 

I’ve decided this; I’m just a little tired of waiting for good things 

to happen. We have to make good things happen. We shouldn’t 

have patience. When we have people dying because we don’t have 

adequate health care on the reservations of the first Americans, the 

people who were here first, we ought not have patience to let that 

happen. 

When we have people living in inadequate housing, I’m out of patience. We shouldn’t say that’s okay. When we have children going 

to school through classroom doors that we know are not real class 

settings, we shouldn’t accept that. And so, I’m just out of patience. 

I’m a little out of sorts. 

I believe that we ought to impose on everyone in the decisionmaking capacity in our government to say, keep your promise. You 

made the promises, you’ve broken too many. It’s time that you 

ought to keep them. And that deals with health care, education, 

housing and more. And this Committee is going to work to see that 

happen. 

I was given the honor of an Indian name in a ceremony with the 

Standing Rock Sioux Tribe some long while ago, and the Indian 

name given me was Cante un Wiyukcan, which they said means 

‘‘thinks with his heart.’’

Well, my heart tells me that we don’t have a lot of time. My 

heart tells me that there are people living among us who need us, 

and need answers. They need good schools; they need better health 

care, and they need decent shelter. And that’s the mission of this 

Committee. 

So, I want to thank Senator Tester for inviting me here to Montana. 

Let me just say one additional point. I wish very much I could 

stay for about three or 4 days. Chairman Venne gave us a little 

ride around the area where there’s a lot of camping going on, a lot 

3

of preparation for a very big event in the Crow Nation. I’ve not 

been to this event at the Crow Nation, but I’ve heard a lot about 

it. 

I sat next to a person on the airplane coming into Billings today, 

who was coming here from Iowa. He said well, I come to this celebration every year on the Crow Nation. 

So I’ve heard about it and I wish I could stay, but I can’t. But 

I know that you all are going to have a great, great few days ahead 

of you. 

So, Senator Tester, we will hear testimony from a wide-range of 

witnesses today, but before we do, again, I want to thank you, 

thank you for your leadership, thank you for focusing a laser on 

these issues. 

You and I and other members of the panel of the Indian Affairs 

Committee are going to get things done, and we’re going to push 

until that happens. 

So, Senator Tester, let me call on you for some comments, and 

again, thank you, very much. 

STATEMENT OF HON. JON TESTER,

U.S. SENATOR FROM MONTANA 

Senator TESTER. Thank you, Mr. Chairman, for taking the time 

out of your busy schedule to come to Montana and visit with us. 

To the people of the State of Montana here in Indian Country, it’s 

critically important. It’s no small measure, I know how busy you 

are, and I appreciate you making the time to be here. 

I also want to welcome all my friends that are here that have 

come to listen and testify. 

You know, I think Montanans really appreciate, Mr. Chairman, 

you holding this hearing in Montana to address what we all know 

is a very critical issue. 

Health care in Montana’s Indian Country is in serious trouble. 

American Indian citizens are suffering, and we really need to address the problem now. 

I am truly outraged by the statements, and I heard it again 

today by Chairman Venne, and that is you don’t get sick in June, 

after June in Indian Country. That is absolutely unacceptable, and 

I’m sorry you have to wait until your illness gets to a point where 

you may lose a limb or your life. 

Those are examples of health care in Third World countries. We 

don’t live in a Third World country. American Indians are Americans, American citizens who are entitled to deserve respect in this 

country. Our Federal Government signed binding legal treaties 

many years ago and those treaties are still in effect today. Those 

treaties promised that in exchange for millions of acres of land and 

vast amounts of natural resources, our government would use some 

of those dollars that emerged from those lands to provide American 

Indians with adequate health care, education and housing, economic development to distinct quality of lives. 

Everybody in this room knows over the past several hundred 

years the government has failed to tell the truth to the American 

Indian, cheated the Indians, and failed to fulfill promises made 

many, many years ago. 

4

The government got what it wanted out of the deal, but so far, 

Mr. Chairman, the government has failed to hold up its end of the 

deal. The result is that several generations later, our government 

still has legal obligations to live up to its end of the bargain. 

Since then, the price of health care has literally gone through the 

roof and will continue to go up. We need to address the situation 

now. We need to fund the system. This cannot wait to be funded 

any longer. We need to change the national priorities and introduce 

legislation to fix this broken system. 

All of us in the room know that merely to explain about the problem is not enough, we need to act and we need to act now. 

For my part, I’m seeking for some of the following actions; cosponsoring the Indian Health Care Improvement Act that Senator 

Dorgan talked about, that hopefully will be out of Finance by September 12. The last time it was passed was 1999. That’s totally, totally ridiculous, and unacceptable. 

Also, I have introduced THE PATH Act that is a result of some 

hearings that I had in Browning 3 months ago. This important legislation will award grants and draft cooperative agreements with 

the Department of Health and Human Services and the tribal colleges and universities, to help Indian Country meet their staffing 

needs in health care. 

It will establish a coordinating officer to assure seamless transition and administration; establish community-based health and 

wellness affairs, and begin to address illness and injury before it 

gets to a life or limb situation. 

It will develop and expand public health professional educational 

opportunities, establish an endowment for rural tribal colleges to 

expand health education, and create health prevention and disease 

prevention research, particularly in the areas of diabetes. 

Tribal colleges and universities Faculty Loan Forgiveness Act, it 

does what it says, it will help forgive loans to individuals that want 

to teach in tribal colleges, to recruit and train more qualified professors at those tribal colleges or universities, particularly in the 

field of nursing or health-related fields. 

Our goal, Mr. Chairman, should be to give equal access to health 

care for all Montanans. Make no mistake, Mr. Chairman, I’m not 

here today working to provide Indians with superior quality health 

and quality of life, I’m simply working to fulfill the promises our 

grandfathers made over a hundred years ago. 

Today, we focus on three vital issues in American Indian health 

care, immediate health care needs, recruiting and retaining of 

health care professionals, and improving the reimbursement process. 

In the end, Mr. Chairman, it is truly my goal on this committee, 

to re-prioritize issues affecting Indian Country. If the President can 

justify spending $3 billion a week to first destroy and then rebuild 

Iraq, the government certainly has the money to fund an Indian 

health care system. 

This issue is not about money, Mr. Chairman, it is about priorities, and American Indians deserve to be a higher priority in this 

country. For that reason, I want to thank you very, very much for 

coming to Montana and making Indian health care a national priority. 

5

I look forward to working with you, Mr. Chairman, in this session of Congress, to continue to shift our priorities to improving Indian health care. 

With that, I just want to thank you very, very much for the opportunity that you’ve given all the good people here to talk about 

an issue that’s so critically important. 

Mr. Chairman. 

Senator DORGAN. Senator Tester, thank you very much. 

This is a formal hearing of the U.S. Senate, but I want to do 

something just a little bit unusual. As I saw the flags brought in, 

I saw some very beautiful people behind the flag-bearers and one 

of them caught my eye. And if I could ask to have that young lady 

brought forward, I want to tell you something. 

[Kailyn Old Crow brought forward.] 

What I wanted to tell you is as I watched her come in following 

the flags, it occurred to me that we’re talking about all these issues 

today, but what we’re talking about is not about us, it’s not about 

me, it’s not about you, it’s about Kailyn. That’s what this is about. 

It’s about our children. It’s about our future, and I can’t think of 

a more beautiful symbol of our future than this young lady. God 

bless you. 

Thank you very much. 

Dr. Charles North is the Acting Chief Medical Officer of the Indian Health Service, and Dr. Westley Clark, the Director of the 

Center for Substance Abuse Treatment. I’d like both of them to 

come forward and take their chairs at the witness table, please. 

Dr. Charles North, the Acting Chief Medical Officer of the Indian 

Health Service is accompanied by Mr. Pete Conway, the Director 

of the Billings Area Office of the Indian Health Service, and Dr. 

Westley Clark, Director of the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. 

We appreciate both of you taking time to be with us today at our 

invitation, and we will obviously include your entire statement as 

a part of the permanent Committee records. 

We would ask that both of you summarize, following which we 

would like to ask a series of questions. As you testify, I’d like to 

ask that you pull the microphone as close as possible so that everyone in the audience can hear clearly the testimony you are giving. 

Dr. Charles North, you may proceed. 

STATEMENT OF CHARLES Q. NORTH, M.D., M.S., ACTING CHIEF 

MEDICAL OFFICER, INDIAN HEALTH SERVICE;

ACCOMPANIED BY PETE CONWAY, DIRECTOR, BILLINGS 

AREA OFFICE, INDIAN HEALTH SERVICE 

Dr. NORTH. Good morning, I am Dr. Charles Q. North, Acting 

Chief Medical Officer of the Indian Health Service. 

I am glad to be here this afternoon, and I would like to thank 

Chairman Venne also for having us at Crow Agency. 

Today I am accompanied by Mr. Pete Conway, the Area Director 

for the Billings Area of the Indian Health Service, and we’re both 

pleased to have the opportunity to testify on behalf of the Indian 

Health Service Director, Dr. Charles Grim, on the status of the Indian Health Service and the health of Indian people. 

6

The Indian Health Service has the responsibility for the delivery 

of health services to more than 1.9 million federally-recognized 

American Indians and Alaska Natives through a system of Indian 

Health Service, tribal and urban operated facilities and programs 

governed by statutes and judicial decision. 

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 populations that we serve. 

The agency’s goal is to insure that comprehensive, culturally acceptable personal and public health services are available and accessible to the service population. 

We are here today to discuss Indian health and the IHS focus on 

improving the health of Indian people, and eliminating health disparities through health promotion and disease prevention, behavioral health and chronic disease management. 

We will also address issues related to Indian health manpower, 

access to health care, consultation and contract health care. 

I would like to also note that the Health and Human Services 

Department summer of 2007 Indian Country bus tour to promote 

prevention and healthier living is here today and will follow the 

hearing. 

As part of the ‘‘Healthier US Starts Here’’ initiative, the U.S. Department of Health and Human Services is joining local officials 

and health care partners to raise awareness of the importance of 

preventing chronic disease and illness, promoting Medicare preventive benefits, and providing information about how individuals can 

take action to maintain and improve their health. 

This effort supports the Indian Health Service goal to create 

healthier American Indian and Alaska Native communities by developing and implementing effective health promotion and chronic 

disease prevention programs. 

We want to recognize the Crow Tribe for the outstanding work 

it does to promote healthy living in its community. Chairman 

Venne has been a great friend to the Department by hosting our 

former Deputy Secretary and our Assistant Secretary for Health, 

and we are here to thank his staff for all their efforts to make Indian Country healthier. 

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 that are significantly higher than the rest of the U.S. general population. 

Alcoholism rates are 550 percent higher; diabetes rates are almost 200 percent higher; unintentional injury rates, 154 percent 

higher; suicide is 57 percent higher, and homicide is 108 percent 

higher than the general population. 

Making significant reductions in health disparity rates can be 

achieved by implementing the best practices in medicine, using traditional community values, and building the local capacity to address these health issues and promote healthy choices. Since 1997, 

the Special Diabetes Program for Indians funding of $150 million 

has expanded our diabetes prevention and treatment efforts. These 

funds support over 300 IHS tribal and urban community-based diabetes prevention and treatment projects, along with a demonstraVerDate 0ct 09 2002 10:35 Dec 12, 2007 Jkt 038721 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 S:\DOCS\38721.TXT JACK PsN: JACKF
7

tion project focused on primary prevention of type 2 diabetes in 35 

separate American Indian and Alaska Native communities. 

The competitive grant initiatives focus on American Indian and 

Alaska Native adults with pre-diabetes to determine if an intensive 

life-style intervention can be successfully implemented in our communities. 

One of the models we are using was developed by the National 

Institutes of Health that proved that diabetes could be prevented. 

This program will cover a four-year period. The outcomes of the 

demonstration project will enable us to learn what may be applicable to other communities throughout Indian Country. 

Indian health manpower is a critical issue, it’s a critical issue 

here in Crow. IHS tribal and urban Indian health programs cannot 

function without adequate health care providers. 

Indian Health Manpower programs, which is also authorized in 

the Indian Health Care Improvement Act that you mentioned earlier, consists of the Indian Health Service 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 health care and professionals of American Indian and Alaska Native descent. Since its inception in 1977, more than 7,000 

American Indian and Alaska Native students have participated in 

the program. 

The IHS Scholarship Program has been the starting point for the 

careers of a number of health professionals now working in the 

Federal, tribal and urban Indian health programs. 

Many are also involved in academia continuing to help identify 

promising young American Indian and Alaska Native students and 

recruiting them to the health professions. 

The IHS Loan Repayment Program is very effective in both the 

recruitment and retention areas. There are currently 723 health 

professionals in the Loan Repayment Program. 

Access to health care can be promoted by the Environmental 

Health and Engineering Program of the Indian Health Service, 

which is a comprehensive public health program administered by 

Indian Health and tribes. 

Indian self-determination and self-governance and consultation 

are extremely important to this administration. 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. 

Indian Tribes now administer 54 percent of our budget with IHS 

funds transferred through self-determination contracts and compacts. IHS adheres strongly to its long-standing tribal consultation 

policy. 

The Indian Health Service purchases medical and dental services 

from providers in the private sector though its Contract Health 

Services program, which is a component of the Indian health care 

system. 

In Fiscal Year 2007, the CHS program is funded at $543 million. 

Patients are referred to the private sector health facilities, programs and practitioners for treatment when needed services are 

unavailable as direct care through the Indian health care system. 

8

The CHS program makes payment for speciality services and inpatient care to private sector facilities and providers in accordance 

with established eligibility and medical priority guidelines. 

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

the opportunity to report on Indian Health Service programs serving American Indians and Alaska Natives and their impact on the 

health status of our populations. 

We will be happy to answer any questions that you may have. 

[The prepared statement of Dr. North follows:]

PREPARED STATEMENT OF CHARLES Q. NORTH, M.D., M.S., ACTING CHIEF MEDICAL

OFFICER, INDIAN HEALTH SERVICE

Mr. Chairman and Members of the Committee: 

Good morning, I am Dr. Charles Q. North, Acting Chief Medical Officer for Indian 

Health Service (IHS). Today I am accompanied by Mr. Pete Conway, Area Director, 

Billings Area IHS. We are pleased to have this opportunity to testify on behalf of 

Dr. Charles W. Grim, Director, IHS on the status of Indian Health. 

The IHS has the responsibility for the delivery of health services to more than 

1.9 million Federally-recognized American Indians and Alaska Natives (AI/ANs) 

through a system of IHS, tribal, and urban (I/T/U) operated facilities and programs 

governed by statutes and judicial decisions. The mission of the agency is to raise 

the physical, mental, social, and spiritual health of AI/ANs 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 duty is to uphold the Federal Government’s responsibility 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 statutes are at the core of the Federal Government’s responsibility for 

meeting the health needs of American Indians/Alaska Natives (AI/ANs): The Snyder 

Act of 1921, P.L. 67-85, and the Indian Health Care Improvement Act (IHCIA), P.L. 

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 provides the authority for the provision of 

Federal programs, services and activities to address the health needs of AI/ANs. The 

IHCIA also includes authorities for the recruitment and retention of health professionals serving Indian communities, health services for urban Indian people and the 

construction, replacement, and repair of health care facilities. 

We are here today to discuss Indian health and the IHS focus on improving the 

health of Indian people and eliminating health disparities through health promotion 

and disease prevention, behavioral health and chronic disease management. We will 

also address issues related to Indian health manpower, access to health care, consultation, contract health services and claims processing, eligibility, medical priorities and the Catastrophic Health Emergency Fund (CHEF). 

HHS Summer 2007 Indian Country Bus Tour to Promote Prevention and 

Healthier Living 

This summer, as part of the ‘‘A Healthier US Starts Here’’ initiative, the U.S. Department of Health and Human Services (HHS) is joining local officials and health 

care partners to raise awareness of the importance of preventing chronic disease 

and illness, promote Medicare preventive benefits, and provide information about 

how individuals can take action to maintain and improve their health. 

By the end of August, the bus tour will have visited each of the 48 continental 

states to promote preventive services. While the bus tour is promoting healthier living with the country as a whole, the Indian Health Service has participated to promote and recognize the health promotion/disease prevention activities that Indian 

Country practices on a daily basis to promote healthier living. 

This effort supports the Indian Health Service’s goal to create healthier American 

Indian and Alaska Native communities by developing and implementing effective 

health promotion and chronic disease prevention programs. This is accomplished in 

collaboration with our key stakeholders, the American Indian and Alaska Native 

people, and by building on individual, family, and community strengths and assets. 

9

On April 18, 2007, HHS hosted a kickoff event with Tribal Leaders and National 

Tribal Organizations in Washington, D.C. at the Smithsonian’s National Museum 

of the American Indian. Since this event, HHS has visited over 20 Tribal Communities and we have over 6 tribal stops remaining and with one occurring right after 

this hearing here at the Crow Tribe. 

We are here this afternoon with our prevention tour to recognize the Crow Tribe 

for the outstanding work it does to promote healthy living in its community. Chairman Venne has been a great friend to the Department by hosting our former Deputy Secretary and our Assistant Secretary for Health and we are to thank his staff 

for all their efforts to making Indian Country healthier. We will recognize his tribal 

prevention programs; recognition of 50+ fitness challenge participants; and his Meth 

activities coordinator. 

Health Disparities 

While the mortality rates of Indian people have improved dramatically over the 

past ten years, Indian people continue to experience health disparities and death 

rates (2001–2003) that are significantly higher than the rest of the U.S. general population (2002: National Vital Statistics Reports: Vol. 53 No. 5. National Center for 

Health Statistics):

• Alcoholism—551 percent higher • Diabetes—196 percent higher • Unintentional Injuries—154 percent higher 

• Suicide—57 percent higher 

• Homicide—108 percent higher

These statistics are startling, yet they are so often repeated that some view them 

as insurmountable facts. But every one of them is 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. 

Many issues that face the families nationally also affect families in Indian Country, and these problems are often magnified in the confines of Indian Country. If 

it is a problem nationally, it is magnified when it comes to Indian Country. Indian 

families are besieged by the numbing effects of poverty, lack of resources, and limited economic opportunity. Frustration, anger, and violence are among the prominent effects of this situation, and, while very understandable, they are equally unacceptable. 

Accordingly, the IHS is focusing on screening and primary prevention in mental 

health especially for depression, which manifests itself in suicide, domestic violence, 

and addictions. The agency is also working to more effectively utilize available treatment modalities; and, to improve documentation of mental health problems. We now 

have more effective tools for documentation through the behavioral health software 

package. We are also working with Tribal communities to focus on these mental 

health needs. 

Cardiovascular disease (CVD) is the leading cause of mortality among Indian people. This is a health disparity rate that the President, the Secretary of Health and 

Human Services, and the IHS are committed to eliminating. The Strong Heart 

Study, a longitudinal study of cardiovascular disease in 13 AI/AN communities, has 

clearly demonstrated that the vast majority of heart disease in AI/AN occurs in people with diabetes. In 2002, IHS was directed to address ‘‘the most compelling complications of diabetes,’’ including the most critical complication of heart disease. The 

IHS is working with other HHS 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 AI/AN communities. The IHS has begun several programs to encourage employees and our tribal and urban Indian 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. 

Good oral health is essential to improving individuals’ overall health and well 

being. The oral health of AI/AN people has improved in some age groups, but has 

gotten worse in others. While poor dental health is a significant problem for AI/ANs 

of all ages, the magnitude and long-term effects of the problem are greatest among 

very young children. The most recent oral health survey administered by the Indian 

10

Health Service showed that the AI/AN people experience some of the highest oral 

disease rates reported in the world. The 1999 IHS survey of Oral Health Status and 

Treatment Needs indicate the following:

• The majority of very young children experience tooth decay, with 79 percent of 

children aged 2–4 years reporting with a history of dental decay;

• Since 1991, there has been a significant increase in tooth decay among young 

AI/AN children between 2–5 years of age;

• The majority of AI/AN children as a group have tooth decay and the prevalence 

of decay increases with age: 87 percent of the 6–14 year olds and 91 percent 

of the 15–19 year olds had a history of decay;

• Most adults and elders have lost teeth because of dental disease or oral trauma. 

78 percent of adults 35–44 years and 98 percent of elders 55 years or older had 

lost at least one tooth because of dental decay, periodontal (gum) disease or oral 

trauma; and,

• Periodontal disease is a significant health problem for both adults and elders. 

59 percent of adults 35–44 years and 61 percent of elders have periodontal 

(gum) disease.

In addition, the vacancy rate for dentists is at the highest level in our 52 year 

history, with 27.6 percent of authorized positions are vacant. In addition to the high 

vacancy rate, there is great concern over the oral health disparities experienced by 

the American Indian and Alaska Native people. 

We need to focus our efforts on these age groups that have shown declines in oral 

health status. Tribes have increasingly identified access to preventive and curative 

dental care as a major health priority; and the IHS and tribes will continue to advocate for additional resources for oral health. 

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 United States (source: 2003–2004 National Health Interview Survey 

and 2004 IHS Outpatient database). 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 (source: IHS Division of Program Statistics). As diabetes develops at younger ages, so do related complications such as blindness, amputations, and end stage 

renal disease. Fortunately, the diabetes mortality rate for the entire AI/AN population did not increase between 1996–1998 and 1999–2001, so we are hopeful that 

we may be seeing a change in the pattern of diabetes mortality. In fact, the overall 

mortality rate for American Indians and Alaska Natives decreased approximately 3 

percent between these same time periods (source: IHS Division of Diabetes Statistics and CDC Center for Health Statistics). And there is good news in that we have 

recently measured a slight, but statistically significant, decline in kidney failure in 

the AI/AN 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 for diabetes patients is staggering. The 

cost of managing care for treating diabetes ranges from $5,000–$9,000 per year with 

the annual cost per patient exceeding $13,000 (source: American Diabetes Association). 

In 1997, the Special Diabetes Program for Indians (SDPI) grant program was enacted and provided $30 million per year for a five year period to IHS for prevention 

and treatment services to address the growing problem of diabetes in AI/ANs. In 

2001, Congress appropriated an additional $70 million for Fiscal Years 2001 and 

2002. The program was funded at $100 million in Fiscal Year 2003. Then in 2002 

Congress extended the SDPI through 2008, and increased the annual funding to 

$150 million for FY 2004–2008 with the directive to address ‘‘primary prevention 

of type 2 diabetes and the most compelling complication of diabetes—cardiovascular 

disease.’’ We are proud to announce that in FY 2004 our Division of Diabetes Treatment and Prevention launched a competitive grant to implement two demonstration 

projects. One is focused on primary prevention of type 2 diabetes in people diagnosed with pre-diabetes to determine if an intensive life-style intervention can be 

successfully implemented in AI/AN communities. This effort is based on the NIH 

sponsored study called the Diabetes Prevention Program which provided evidence 

that type 2 diabetes could be prevention with lifestyle intervention. The other demVerDate 0ct 09 2002 10:35 Dec 12, 2007 Jkt 038721 PO 00000 Frm 00014 Fmt 6633 Sfmt 6621 S:\DOCS\38721.TXT JACK PsN: JACKF
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onstration project is focused on cardiovascular risk reduction in people diagnosed 

with type 2 diabetes. Thirty-six AI/AN communities were awarded diabetes prevention demonstration projects and 30 AI/AN communities were awarded cardiovascular risk reduction demonstration projects in November 2004. These demonstration projects will cover a four year period. The outcomes of the demonstration 

projects will enable us to learn what may be applicable to other communities 

throughout Indian country. The last year of the demonstration projects will be 

aimed at dissemination of lessons learned to other tribal communities across the nation. 

With 65 percent of the IHS Mental Health budget and 85 percent of the alcohol 

and substance abuse budget going directly to tribally operated programs, tribes and 

communities are now taking responsibility for their own healing. They provide effective treatment and prevention services within their own communities. 

A primary area of focus is Dr. Grim’s renewed emphasis on health promotion and 

disease prevention. This is our strongest front in the ongoing battle to eliminate 

health disparities which have plagued our people for far too long. 

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 a more a western diet and sedentary lifestyle, 

chronic diseases emerge as the dominant factors in the health and longevity of the 

Indian population as evidenced by the increasing rates of cardiovascular disease, diabetes, and oral health problems. Most chronic diseases are affected by lifestyle 

choices and behaviors. 

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 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 AI/

AN people. 

Indian Health Manpower 

IHS, Tribal and Urban Indian health programs could not function without adequate health care providers. The Indian Health Manpower program which is also 

authorized in the Indian Health Care Improvement Act (P.L. 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 AI/AN 

health care professionals. Since its inception in 1977, more than 7,000 AI/AN students have participated in the program, with the result that the number of AI/AN 

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. 

The IHS Scholarship Program has been the starting point for the careers of a 

number of AI/AN health professionals now working in IHS, tribal, and urban Indian 

health programs. Many are also involved in academia, continuing to help identify 

promising AI/AN students and recruit them to the health professions, thereby helping to produce a self-sustaining program. We have had several instances of parents 

going through the program, followed later by their children and not a few of the 

reverse, with 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 (LRP) is very effective in both the recruitment 

and retention areas. There are currently 723 health professionals in the LRP. 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; while loan repayments are a way for participants to provide service in return 

for assistance in repaying loans that could otherwise be overwhelming. 

12

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. 

Access to Health Care: The Environmental Health and Engineering Program 

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 drinking 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 AI/AN homes now have safe water and mortality from unintentional injuries has been reduced by 58 percent between 1972–1974 and 2001–2003. Unfortunately, 12 percent of Indian homes still lack adequate sanitation facilities compared 

to one percent of the rest of the United States population; and the leading cause 

of death for AI/ANs between the ages of 1 and 44 years of age is unintentional injuries. Improvement in these areas is integral to our mission. 

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. There are 48 hospitals, 272 health centers, 11 school health centers, over 2,200 

units of staff housing, 320 health stations, satellite clinics, and Alaska village clinics, and 11 youth regional treatment centers supporting the delivery of health care 

to AI/AN people. The IHS is responsible for managing and maintaining the largest 

inventory of real property in the DHHS, with over 9.6 million square feet (899,000 

gross square meters) of space, and the Tribes own over 6 million square feet 

(571,000 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. Most of these 

facilities were replacements of inadequate health care facilities. We have substantially improved our health care delivery capability in the newer health care facilities 

and continue to improve access to services through health care facilities construction—health care facilities construction remains a priority. 

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 AI/AN 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, and to plan carefully on how to best utilize any available 

resources. The IHS Health Care Facilities Construction program is fully prepared 

to address the needs identified through this process. 

Indian Self Determination/Self-Governance 

The IHS has been contracting with Tribes and Tribal Organizations under the Indian Self Determination and Education Assistance Act, P.L. 93-638, as amended, 

since its enactment in 1975. We believe the IHS has implemented the Act in a manner consistent with Congressional intent when it passed this cornerstone authority 

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 

operated programs has grown steadily over the years to the point where today over 

54 percent of our budget is transferred through self determination contracts/compacts. 

Consultation 

A primary goal of the Agency has always been to involve Indian tribes and people 

in the activities of the IHS. Last year Dr. Grim adopted a revised IHS Tribal Consultation Policy that will enhance the partnership between the IHS and this country’s 562 Federally recognized Tribes for the foreseeable future. The policy is the 3rd 

consultation policy adopted by the IHS since 1997. Its adoption fulfills a commitment Dr. Grim made to Tribal Leaders that the Agency’s consultation policy and 

practices will continually be subject to review and improvement. 

The policy, which was developed by IHS and Tribal Leaders, contains an improved 

definition of consultation and the circumstances under which it needs to occur. The 

13

policy also commits the IHS to assisting Tribal governments in establishing meaningful dialogue and consultation with other HHS agencies and State governments. 

It revises the budget formulation process within IHS to allow for more meaningful 

Tribal participation and it contains requirements that IHS report to Tribes on IHS 

consultation, its outcomes and effectiveness. 

Overview of CHS program 

The IHS purchases medical and dental services from providers in the private sector through its Contract Health Service program, which is a component of the Indian health care system. In Fiscal Year 2007 the CHS program is funded at $543 

million. Patients are referred to the private sector health facilities, programs and 

practitioners for treatment when needed services are unavailable as direct care 

through the Indian health care system. 

The CHS program is administered through 12 IHS Area Offices and consists of 

163 IHS and Tribal Service Units (SU). The CHS funds are provided to the Area 

Offices which in turn provide resource distribution, program monitoring and evaluation activities, and technical support to Federal and Tribal operating units (local 

level) and health care facilities providing care. 

The CHS funds are used in situations where:

• No IHS or Tribal direct care facility exists; 

• The direct care element cannot provide the required emergency or specialty 

services; and/or, 

• The direct care facility has an overflow of medical care workload.

The CHS program makes payment for specialty services and inpatient care to private sector facilities and providers in accordance with established eligibility and 

medical priority guidelines. 

The CHS program contracts with Blue Cross/Blue Shield of New Mexico as its fiscal intermediary (FI) to ensure payments are made in accordance with the IHS payment policy and quality control requirements. An important and integral function 

of the FI is to provide highly effective management reports relative to the provision 

of services to our patient population and provision of services by health care providers from the private sector. 

Eligibility 

To be eligible for CHS, an individual must be of Indian descent and belong to the 

Indian community served by the Tribal Contract Health Service Delivery Area 

(CHSDA). Generally, the Tribal CHSDA encompasses the Reservation, trust land, 

and the counties that border the Reservation. The individual must also either: (1) 

reside on a Reservation located within the CHSDA; or (2) if he/she resides within 

the CHSDA but not on a Reservation, he/she must also be a member of the Tribe(s) 

located on the Reservation or of the Tribe(s) for whom the Reservation was established, or maintain close economic and social contact with the Tribe(s). The following 

individuals remain eligible for CHS during periods of temporary absence from their 

CHSDA residence:

• Students who are temporarily absent from their CHSDA during full-time attendance of vocational, technical, and other academic education. The coverage 

ceases 180 days after completing the course of study.

• A person who is temporarily absent from his/her CHSDA due to travel or employment.

• Other persons who leave the CHSDA temporarily. Their eligibility continues for 

a period not to exceed 180 days from their departure.

• Children placed in foster care outside of the CHSDA by court order and who 

were eligible for CHS at the time of the court order.

Payor of Last Resort Rule 

The IHS is the payor of last resort and therefore the CHS program must ensure 

that all alternate resources that are available and accessible, such as Medicare 

Parts A and B, state Medicaid, state health program, private insurance, etc. are 

used before the CHS funds can be expended. An IHS or Tribal facility is also considered a resource, and therefore, the CHS funds may not be expended for services reasonably accessible and available at IHS or Tribal facilities. In FY06, IHS received 

$681 million in Medicaid, Medicare and Private Insurance collections And, the agency continues to strive toward maximizing these other sources of payment. 

14

Medical Priorities 

To ensure funds are available throughout the year, medical priorities are used to 

authorize CHS funds. There are five levels of care within the medical priority system; they range from emergent/acutely urgent care services to preventive and chronic tertiary care. Generally, IHS and Tribal funding programs currently reimburse 

only for Medical Priority I cases, which are for emergent/acutely urgent care. 

Catastrophic Health Emergency Fund (CHEF) 

The CHS program also includes a Catastrophic Health Emergency Fund (CHEF) 

in the amount of $18 million. This fund pays for high cost cases and catastrophic 

costs. The CHEF is used to help offset high cost contract care cases meeting a 

threshold of $25,000. In FY 2006, the CHEF program provided funds for over 671 

high cost cases in amounts ranging from $1,000 to $875,000 over the $25,000 

threshold. 

Mr. Chairman, this concludes my statement. Thank you for this opportunity to 

report on IHS programs serving American Indians and Alaska Natives and their impact on the health status of AI/ANs. We will be happy to answer any questions that 

you may have.

Senator DORGAN. Dr. North, thank you very much. 

Next we will hear from Dr. Westley Clark. Dr. Clark is the Director for Substance Abuse Treatment. 

Dr. Clark, you may proceed. 

STATEMENT OF H. WESTLEY CLARK, M.D., J.D., M.P.H.,

DIRECTOR, CENTER FOR SUBSTANCE ABUSE TREATMENT, 

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICE

ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Dr. CLARK. Thank you, Mr. Chairman, and I want to acknowledge Senator Tester and committee staff. 

I’m speaking on behalf of Dr. Terry Cline, who is the Administrator of the Substance Abuse and Mental Health Service Administration, commonly called SAMHSA. 

I am pleased to have this opportunity to join you and share with 

you how SAMHSA is working to create healthier tribal communities. 

I am Dr. H. Westley Clark, the Director of the Center for Substance Abuse Treatment. It is important for us to acknowledge the 

issues of substance abuse and mental health problems experienced 

among American Indians and Alaska Natives. 

We know that American Indians and Alaska Natives suffer disproportionately from substance use disorders, and they interfere 

with health, interfere with major obligations at work, school, or 

home. 

According to combined data from the National Survey on Drug 

Use and Health, American Indian and Alaska Natives over the age 

of 12 were more likely than members of other racial and ethnic 

groups to have a past year alcohol use disorders, to have past year 

illicit drug use disorders, and specifically, rates of past year marijuana, cocaine, and hallucinogen use, were higher among American 

Indians and Alaska Natives than other groups. 

With respect to mental health concerns among American Indian 

and Alaska Natives, between 1999 and 2004, suicide was the second leading cause of death among youths between the ages of 10 

and 24. We also know that trauma and PTSD are significant critical issues for the American Indian community. 

15

Our work at SAMHSA requires partnership and the passion of 

others in order to make the largest impact possible. We work with 

the Indian Health Service, the Department of Justice, and the Bureau of Indian Affairs in ways that are instrumental in our success 

in assisting tribal communities in training and technical assistance. 

Our state partners are partnering with tribes and tribal communities to meet service needs. Tribal leaders across the country are 

expanding dialogue with SAMHSA every day. We acknowledge the 

importance of self-governance and self-determination. 

One important tool to enhance collaboration are the tribal training and technical assistance sessions that SAMHSA, the Department of Justice, the Office of Justice Programs and the Department 

of the Interior, Bureau of Indian Affairs have conducted this year 

focusing on tribal priorities related to public safety and public 

health for families and communities. 

Four of these cross-agency sessions have been held this year, and 

they were designed so that Federal agency partners could share information on funding opportunities and agency initiatives with 

tribes and tribal organizations. 

Also included on the agenda for these sessions were opportunities 

for tribal leaders to consult with Federal officials on public safety, 

justice, and public health issues. 

We also rely on these tribal consultation sessions to gain insight 

on tribal priorities and gauge needs on pressing health and human 

services issues in tribal communities. Some of the most pronounced 

areas of concerns expressed at these sessions surround methamphetamine use, suicide and access to Federal grants. 

SAMHSA’s proposed FY 2008 budget reflects these concerns. Our 

mission in Indian Country, and around the country, has been more 

focused and more clear with the release of our FY 2008 proposed 

budget. 

SAMHSA Administrator, Dr. Terry Cline, has completed testimony on the FY 2008 SAMHSA budget and there are a few highlights I would like to share about the $3.2 billion proposal. 

We continue to invest available resources in priority areas like 

screening, brief intervention, referral and treatment, criminal and 

juvenile justice and drug courts, access to recovery, substance 

abuse prevention, children’s mental health services, suicide and 

school violence prevention, HIV/AIDS, and mental health system 

transformation. This information is available on our website. 

I want you to recognize two priorities, and that is our screening, 

brief intervention program and our treatment drug courts. They 

have received increases for this budget year and tribes are eligible 

to apply for both. 

Currently, the Cook Inlet Tribal Council in Anchorage operates 

an SBIRT program. In FY 2008, approximately $25 million is proposed for new SBIRT grants to increase screening. This objective 

is to wed primary care and substance abuse and mental health together so that we can identify problems early. 

Approximately $32 million is proposed to fund 75 treatment drug 

court grants. Again, tribes and tribal organizations are encouraged 

to apply for both of these important initiatives. 

16

With respect to suicide prevention, SAMHSA’s FY 2008 budget 

includes $3 million for youth suicide prevention which will expand 

on a long-term commitment to tribal youth through the Native Aspirations project. 

The Native Aspirations initiative is a five-year project that is operated though a contract with Kauffman and Associates, a Native 

American business located in Spokane, Washington. 

SAMHSA consulted with tribes through the contractor, and to 

date, 24 tribal communities are participating in the Native Aspirations project, including the Crow Nation. With continued input 

from tribal leaders, we expect to expand this initiative in future 

years to include additional tribal sites. 

Our Access to Recovery program, or ATR program, permits states 

and tribal organizations to provide clinical substance abuse treatment as well as recovery support services through a voucher-based 

system. 

The ability to provide recovery support services is key to this 

grant, and it allows culturally appropriate and traditional healing 

practices to be reimbursed through the grant. Currently, the California Rural Indian Health Board was one of our first ATR grantees and it continues to serve as an example. For our second round 

of ATR grants, up to $98 million is available to fund approximately 

18 new ATR grants in FY 2007, and we expect that more than one 

tribe will be awarded a grant in this new addition. 

Since the recognition of a growing methamphetamine problem 

nationwide, SAMHSA has continued to put a strong emphasis on 

prevention. 

In FY 2006, SAMHSA awarded ten methamphetamine prevention grants of approximately $350,000 each for up to 3 years. The 

grant program is to support expansion of methamphetamine prevention, intervention and/or infrastructure development. 

Of the ten grants awarded, two were to tribes, the Cherokee Nation of Oklahoma and the Native American Rehabilitation Association of the Northwest. The grant program is designed to address 

the growing problem of methamphetamine abuse and addiction by 

assisting localities to expand prevention interventions that are effective and evidence-based, and to increase capacity through infrastructure development. 

In addition, SAMHSA is a part of the HHS Indian Country 

Methamphetamine Initiative along with the Office of Minority 

Health and the National Institutes of Health. 

Through this project, approximately $1.2 million was awarded to 

the American Association of Indian Physicians and its partners, to 

address the outreach and education of Native American communities on methamphetamine abuse. 

Five tribes are included in this project, the Winnebago Tribe, 

which has been funded as a preventionsite, the Navajo Nation and 

the Northern Arapaho Tribe, which are intervention and treatment 

sites, and the Crow Tribe and Choctaw Nation which are treatment 

and recovery sites. 

The Montana–Wyoming Tribal Leaders Council has a SAMHSA 

suicide prevention grant, and as a grantee, they are implementing 

the Planting of Seeds of Hope Project. 

17

In many ways, this Council has led the way in developing new 

collaborations between all of the tribes in Montana and Wyoming, 

along with the states, in order to share resources, ideas, and truly 

work together on suicide prevention activities. 

These new collaborations are building hope across the tribes and 

the states to overcome what once seemed an overwhelming and impossible problem to solve alone. These partnerships are leading the 

country in developing new strategies for saving the lives of our 

youth, and together they are spreading the word that suicide is a 

preventable tragedy. 

To continue to address the suicide clusters on Standing Rock, the 

tribe applied and was competitively awarded a youth suicide prevention and early intervention program grant in October, 2006. 

This grant is bringing together community leaders to implement 

a comprehensive tribal youth suicide prevention and early intervention plan at Standing Rock that is identifying and increasing 

youth referrals to mental health services and programs, increasing 

protective factors, reducing risk factors for youth suicide, and improving access to intervention services. Additionally, SAMHSA is 

establishing a new tribal advisory committee and is accepting 

nominations for community members. Similar to other SAMHSA 

advisory committees, the purpose of the Tribal Advisory Committee 

is to assist SAMHSA in carrying out its mission in Indian Country. 

Key to carrying out our agency mission in Indian Country is increasing awareness of and access to our grants. In response to comments at the 2006 HHS Tribal Consultation meetings and the 

HHS/ASPE published Barriers to American Indian/Alaska Native/

Native American Access to DHHS Programs report, SAMHSA convened an internal workgroup to develop strategies to remove barriers in discretionary grant announcements. 

Senator DORGAN. Mr. Clark, I’m going to have to ask you that 

you summarize, please. 

Dr. CLARK. One of the most important things is we want to make 

sure that tribes have access to our funding. I think one of the 

things that we view in these requests for proposals is making sure 

that tribes are not precluded from participating as states or other 

organizations have. So I’m pleased to note that we have done this. 

We’re also having other strategies like the tribal policy academy 

on co-occurring disorders and that tribes are along in that effort so 

that we can deal with substance abuse and mental health problems 

of the tribes. 

So changes are underway, and we are working collectively with 

tribal communities and tribal governments so that we can address 

mental health and substance abuse problems. 

Thank you. 

[The prepared statement of Dr. Clark follows:]

PREPARED STATEMENT OF H. WESTLEY CLARK, M.D., J.D., M.P.H., DIRECTOR,

CENTER FOR SUBSTANCE ABUSE TREATMENT, SUBSTANCE ABUSE AND MENTAL

HEALTH SERVICE ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN

SERVICES

Chairman Dorgan and Members of the Committee, I am Dr. H. Westley Clark, 

Director of the Center for Substance Abuse Treatment, Substance Abuse and Mental 

Health Services Administration or commonly called SAMHSA. I bring greetings 

from Dr. Terry Cline, SAMHSA Administrator. I am pleased to have this opporVerDate 0ct 09 2002 10:35 Dec 12, 2007 Jkt 038721 PO 00000 Frm 00021 Fmt 6633 Sfmt 6621 S:\DOCS\38721.TXT JACK PsN: JACKF
18

tunity to join you and share with you how SAMHSA is working to create healthier 

tribal communities. However, before I detail a few of SAMHSA’s initiatives, I think 

it is important to underscore the extent of substance use and mental health problems experienced among American Indians and Alaska Natives. 

American Indians and Alaska Natives suffer disproportionately from substance 

use disorders (defined by symptoms such as withdrawal, tolerance, use in dangerous 

situations, trouble with the law, and interference in major obligations at work, 

school, or home during the past year) compared with other racial/ethnic groups in 

the United States. According to combined data from the 2002–2005 National Survey 

on Drug Use and Health (NSDUH) conducted by SAMHSA, American Indian and 

Alaska Natives over the age of 12 were more likely than members of other racial/

ethnic groups to have a past year alcohol use disorder (10.7 vs 7.6 percent). They 

were also more likely to have a past year illicit drug use disorder (5.0 vs 2.9 percent). Specifically, rates of past year marijuana, cocaine, and hallucinogen use disorders were higher among American Indians and Alaska Natives than among other 

racial/ethnic groups. 

One factor that may be driving the disparity in substance use between American 

Indian/Alaska Native youth and other youth is a higher rate of substance use risk 

factors among American Indian and Alaska Native youth. For example, data from 

the 2002 and 2003 National Survey on Drug Use and Health show that American 

Indian/Alaska Native youth are more likely than youth of other racial/ethnic groups 

to perceive moderate to no risk of substance use and less likely to perceive strong 

parental disapproval of substance use. 

With respect to mental health concerns among American Indian and Alaska Natives, between 1999 and 2004, suicide was the second leading cause of death among 

youth between the ages of 10 and 24, compared to the third leading cause of death 

among the youth population as a whole. Spirituality may play a protective role in 

reducing suicide attempts. Specifically, a study of American Indian tribal members 

living on or near their Northern Plains reservations between 1997 and 1999 showed 

that those with a high level of cultural spiritual orientation had a reduced prevalence of suicide compared with those with a low level of cultural spiritual orientation. 

Our work at SAMHSA does not stand alone—it requires partnership and the passion of others in order to make the largest positive impact. For example, our partners at the Indian Health Service, the Department of Justice (DOJ) and the Bureau 

of Indian Affairs are instrumental in our success in assisting tribal communities in 

training and technical assistance. Our State partners are partnering with Tribes 

and Tribal communities to meet service needs. In addition, our grantees are hard 

at work in the field providing services. And, Tribal leaders across the country are 

expanding the dialogue with SAMHSA everyday. All are examples of the type of collaborative efforts that create a wider reach than any single agency can provide 

alone. 

One important tool to enhance collaboration are the Tribal Training and Technical 

Assistance Sessions that SAMHSA, the Department of Justice, Office of Justice Programs (DOJ/OJP) and the Department of the Interior (DOI), Bureau of Indian Affairs (BIA) have conducted this past year focusing on tribal priorities related to public safety and public health for families and communities. Four sessions were held 

in FY 2007. It should be noted that the fourth session included a 1-day Tribal Methamphetamine Summit hosted by the Office of National Drug Control Policy 

(ONDCP). These cross-agency sessions are designed so that Federal agency partners 

can share information on funding opportunities and agency initiatives with Tribes 

in one setting. Community challenges, best practices and lessons learned have been 

embedded into the session agendas to provide Tribes the opportunity to share their 

experiences and adapt strategies to their unique circumstances in their tribal communities. Also included on the agenda for these sessions are opportunities for Tribal 

leaders to consult with Federal officials on public safety, justice and public health 

issues. And, of course, we also rely on these Tribal Consultation Sessions to gain 

insight on Tribal priorities and gauge needs on pressing health and human services 

issues in tribal communities. Some of the most pronounced areas of concerns expressed at these sessions surround methamphetamine use, suicide and access to 

Federal grants. 

SAMHSA’s proposed FY 2008 Budget reflects those concerns. Our mission in Indian Country and around the country has become much more focused and more 

clear with the release of the FY 2008 proposed budget. SAMHSA Administrator Dr. 

Terry Cline has completed testimony on the FY 2008 SAMHSA budget and there 

are a few highlights I would like to share about the $3.2 billion proposed for 

SAMHSA. 

19

We are continuing to invest available resources in program priority areas such as: 

Screening, Brief Intervention, Referral and Treatment (SBIRT); Criminal/Juvenile 

Justice and Drug Courts; Access to Recovery; Substance Abuse Prevention; Children’s Mental Health Services; Suicide and School Violence Prevention; HIV/AIDS; 

and Mental Health System Transformation.. A comprehensive list of our grants can 

be found on our website: www.samhsa.gov/grants/.

I want to draw your attention to a few of these priorities briefly. Two of these 

priorities—the SBIRT program and the Treatment Drug Courts—have received increases this budget year and tribes are eligible to apply for both. Currently, the 

Cook Inlet Tribal Council in Anchorage, Alaska operates an SBIRT grant. For FY 

2008, approximately $25 million is proposed for new SBIRT grants to increase 

screening, brief interventions, and referral to treatment in general medical and community health care settings. Approximately $32 million is proposed to fund about 

75 Treatment Drug Court grants. Tribes and Tribal Organizations are encouraged 

to apply for both of these important initiatives. With respect to suicide prevention, SAMHSA’s FY 2008 Budget includes $3 million for youth suicide prevention which will expand on a long-term commitment to 

tribal youth through the Native Aspirations project. The Native Aspirations initiative is a 5-year project that is operated through a contract with Kauffman and Associates, Inc. (KAI)—a Native American business located in Spokane, Washington. 

SAMHSA consulted with Tribes through the contractor and to date 24 tribal communities are participating in the Native Aspirations project. With continued input 

from Tribal leaders, we expect to expand this project in future years to include additional tribal sites. 

I don’t want to just talk about proposed grant opportunities, but also current ones 

as well. One grant program I want to highlight is SAMHSA’s Targeted Capacity Expansion Grants (TCE) program. In May 2007, SAMHSA announced $10.2 million in 

TCE Grants to expand or enhance a community’s ability to provide a comprehensive, integrated, and community-based response to a targeted, well-documented substance abuse treatment capacity problem and/or improve the quality and intensity 

of services. Applications were accepted under four Categories: (1) Native American/

Alaska Native/Asian American/Pacific Islander Populations; (2) E–Therapy; (3) 

Grassroots Partnerships; and (4) Other Populations or Emerging Substance Abuse 

Issues. Tribes were eligible to apply under all four categories and SAMHSA expects 

to award up to 16 grants in 2007, with an average grant amount of $500,000 per 

year for up to 3 years. 

Another program priority area is SAMHSA’s Access to Recovery (ATR) program. 

The ATR program permits grantees (i.e., States and Tribal Organizations) to provide 

clinical substance abuse treatment as well as recovery support services through a 

voucher-based system. The ability to provide recovery support services is a key issue 

of this grant program because it allows clients to pursue and maintain their recovery through many different and personal pathways, including traditional healing 

practices. The California Rural Indian Health Board was one of the first ATR grantees and it continues to serve as an example of what can be accomplished through 

tribal collaborations. For our second round of ATR grants, up to $98 million is available to fund approximately 18 new ATR grants in FY 2007 of which $25 million is 

expected to support treatment for clients using methamphetamine. 

Since the recognition of a growing methamphetamine problem nationwide, 

SAMHSA has continued to put a strong emphasis on prevention. In FY 2006 

SAMHSA awarded 10 Methamphetamine Prevention grants of approximately 

$350,000 each for up to 3 years The grant program is to support expansion of methamphetamine prevention, interventions and/or infrastructure development. Of the 

10 grant awards 2 were to Tribes, the Cherokee Nation of Oklahoma and the Native 

American Rehabilitation Association of NW, Inc., of Portland, Oregon. The grant 

program is designed to address the growing problem of methamphetamine abuse 

and addiction by assisting localities to expand prevention interventions that are effective and evidence-based and/or to increase capacity through infrastructure development. 

SAMHSA is a member of the Office of National Drug Control Policy, Executive 

Native American Law Enforcement Workgroup along with members from DOJ, Indian Health Services, DOI, Tribal Police, and the Federal Bureau of Investigation. 

This workgroup is designed to coordinate and address the multidimensional aspect 

of methamphetamine use in Indian Country. In addition, SAMHSA is part of the 

HHS Indian Country Methamphetamine Initiative (ICMI) along with the Office of 

Minority Health and the National Institutes of Health. Through this project, nearly 

$1.2 million was awarded to the American Association of Indian Physicians (AAIP) 

and its partners to address the outreach and education needs of Native American 

communities on methamphetamine abuse. The partners are developing a culturally 

20

appropriate national information and outreach campaign on methamphetamine use 

in Indian Country. They are also developing a methamphetamine abuse education 

kit, documenting and evaluating promising practices in education on methamphetamine use, and creating methamphetamine awareness multi-disciplinary education 

teams. Five Tribes are included in this project—the Winnebago Tribe, which has 

been funded as a preventionsite, the Navajo Nation and the Northern Arapaho 

Tribe, which are intervention and treatment sites, and the Crow Tribe and Choctaw 

Nation which are treatment and recovery sites. 

The Montana–Wyoming Tribal Leaders Council has received a SAMHSA suicide 

prevention grant and as a grantee they are implementing the ‘‘Planting of Seeds of 

Hope Project.’’ In many ways, this Council has led the way in developing new collaborations between all of the Tribes in Montana and Wyoming, along with the 

States, in order to share resources, ideas, and truly work together on Suicide Prevention activities. These new collaborations are building hope across the Tribes and 

the States to overcome what once seemed an overwhelming and impossible problem 

to solve alone. These partnerships are leading the country in developing new strategies for saving the lives of our youth and together they are spreading the word that 

suicide is a preventable tragedy. 

In the Aberdeen Area, SAMHSA continues to work closely with the Standing Rock 

Sioux Tribe to respond to an outbreak of suicide clusters on their reservation. In 

2005, through a SAMHSA Emergency Response Grant (SERG), SAMHSA staff and 

the One Sky Center staff began working with the Tribe to design and implement 

a suicide prevention program at Standing Rock. Based on SAMHSA’s recommendation, tribal leadership mandated that the program must be Addiction and Dependency certified by the State of North Dakota. A Bismarck-based consultant from 

SAMHSA’s Disaster Technical Assistance Center (DTAC) has assisted the Tribe 

with this process. The Tribe has funded two additional behavioral health staff positions to provide case management services and arrange for treatment and ancillary 

services for at-risk clients, which is making a difference. The strategic suicide prevention plan that was developed and implemented at Standing Rock is being considered as a model by other Indian reservations and the Indian Health Service. Although the SERG grant funding ended in December 2006, the Tribe was competitively awarded a Youth Suicide Prevention and Early Intervention Program grant 

in October 2006. This new grant is bringing together community leaders to implement a comprehensive tribal youth suicide prevention and early intervention plan 

at Standing Rock that is identifying and increasing youth referrals to mental health 

services and programs, increasing protective factors, reducing risk factors for youth 

suicide, and improving access to intervention services. 

SAMHSA is also working with the Office of National Drug Control Policy, the Office of Justice Programs/Bureau of Justice Assistance within the Department of Justice and with the National Alliance for Model State Drug Laws on regional planning 

events to identify common issues and concerns among States that may require interstate resolutions or a Federal focus to address methamphetamine use. Through this 

partnership, three regional planning events were conducted in FY 2007. Attendance 

included representatives of substance abuse programs, law enforcement agencies, 

the criminal justice system, community coalitions and counties, cities and local municipalities. The goal was the identification of best practices that will be replicated 

in other States. 

In response to the inescapable link between addiction, mental illness, and crime, 

SAMHSA is coordinating across Federal agencies through our participation on the 

Native American Law Enforcement Task Force. When prevention and treatment 

services are targeted to adult and juvenile offenders the benefits are three-fold. 

First, if we prevent addiction, drug related crime will decrease. Second, if we intervene early and get the appropriate treatment services in place, recidivism rates 

drop. And third, as SAMHSA increases recovery support services, reentry success 

rates climb and public safety is increased. It just makes sense for SAMHSA to 

strengthen partnerships with the law enforcement communities both in Indian 

Country and around the country. We have reached out to police organizations, correctional organizations, as well as the National District Attorneys Association to 

open the paths to collaboration. And, we will continue working closely with DOJ as 

well. 

As you may know, the Department of Health and Human Services (HHS) revised 

its Tribal Consultation Policy in March 2005. Members of the Tribal–Federal Team 

contributed to developing the necessary recommendations. In early 2006, SAMHSA 

used the HHS document as a basis to create a starting point for revising the 

SAMHSA policy. We shared that document with tribes at each of the Regional sessions to solicit comments. During that process, we asked for volunteers interested 

in serving on a workgroup to assist with further review and revision of the Tribal 

21

Consultation Policy. In June of 2006, a Technical Team workgroup was formed. The 

first meeting of the workgroup produced a second draft of the SAMHSA Tribal Consultation Policy which was reviewed and comments as well as resulting edits were 

incorporated in the final Tribal Consultation Policy. SAMHSA’s goal was to have a 

signed Tribal Consultation Policy by early 2007 and I’m very proud to say we have 

accomplished that. Additionally, SAMHSA is establishing a new Tribal Advisory 

Committee and is accepting nominations for committee members. Similar to other 

SAMHSA advisory committees, the purpose of the Tribal Advisory Committee is to 

assist SAMHSA in carrying out its mission in Indian Country. 

Key to carrying out our Agency mission in Indian Country is increasing awareness of and access to our grants. In response to comments at the 2006 HHS Tribal 

Consultation Meetings and the HHS/ASPE published ‘‘Barriers to American Indian/

Alaska Native/Native American Access to DHHS Programs’’ report (April 2006) 

SAMHSA convened an internal workgroup to develop strategies to remove barriers 

in discretionary grant announcements. As a result, in August 2006 a Tribal Grants 

Review Team—with members from four Tribes/tribal organizations—reviewed nine 

previously published SAMHSA Requests for Proposals (RFAs). Their findings and 

recommendations were provided to SAMHSA grants and policy officials, some of 

which have already been incorporated into FY 2007 SAMHSA RFAs. 

In addition to increasing the voice of Tribes and Tribal Organizations through the 

various avenues mentioned, SAMHSA is also committed to increasing technical assistance to our tribal partners on improving services. For instance, through 

SAMHSA’s Addiction Technology Transfer Centers (ATTCs), SAMHSA is planning 

one or more special projects to provide technical assistance on treatment-related 

issues through partnerships with Regional Indian Health Boards. We are very excited about this new partnership and expect to have it underway in early FY 2008. 

Also, SAMHSA’s Center for Substance Abuse Prevention will be awarding a contract 

for a Native American Technical Assistance Resource Center that will provide targeted technical assistance to current Tribal Strategic Prevention Framework State 

Incentive Grants grantees and prospective grant applicants. 

I also want to mention that recently we participated in the IHS–SAMHSA 5th Annual National Behavioral Health Conference held June 11–14 in Albuquerque, New 

Mexico. This annual conference is an important training and networking opportunity for American Indians and Alaska Natives working in the behavioral health 

fields with the Indian Health Service. 

Similarly, I’m pleased to announce that plans are underway at SAMHSA for a 

Tribal Policy Academy on Co-Occurring Substance Abuse and Mental Health Disorders in September 2007. The purpose of this Academy is to improve and expand 

access to effective, culturally relevant, and appropriate prevention and treatment 

services and supports for individuals with and at-risk for co-occurring substance use 

and mental disorders. The Academy will bring together Tribal Teams of officials 

with policymaking influence in conjunction with nationally recognized faculty and 

facilitators who will assist the Teams to develop an Action Plan for expanding access and improving co-occurring treatment and prevention services in their communities. The Academy will also help to identify promising practices in Tribal communities that may assist other Tribes to address co-occurring disorders in new and innovative ways. 

Changes are underway—changes that will result in improved coordination of 

SAMHSA services to tribal communities. Ultimately the result will be healthier tribal communities—communities where lives are full and where native language, culture and traditions including native healing approaches can flourish. SAMHSA continues to look forward in assisting each of you in any way we can. Thank you.

Senator DORGAN. Dr. Clark, thank you very much. 

Senator TESTER.

Senator TESTER. Thank you, Mr. Chairman. I have a few questions here, first for Dr. North, who is the Chief Medical Officer of 

the Indian Health Service. 

Early this year, we asked your representative about the adequacy of the budget for this year for Indian Health. The response 

we got was, it’s pretty good, we can meet most of the needs. Yet, 

when we talk with folks in Indian Country, we get a very different 

answer. 

Do you think the budget request was sufficient to meet the 

needs? 

22

Dr. NORTH. The budget in direct care, in all the facilities, maintenance, is about $3.2 billion. In addition to that, we have increased our third-party revenue this year substantially. It’s now 

about three-quarters of a billion dollars. 

We think with the tribal contract, the 638 health centers and 

hospitals, that we may be bringing in a billion dollars in thirdparty revenue this year in addition to the appropriated funds. 

Senator TESTER. So do you think that it was sufficient to meet 

the needs? 

Dr. NORTH. There are always needs that can be served in Indian 

Country. 

Senator TESTER. Okay. Well, interestingly enough, I think this 

story could be repeated with any of the six other reservations in 

this state. As we were driving down from the airport with Chairman Venne today, I said, Carl, when did Indian Health services 

run out? He said I think it was about the first of June here in 

Crow. That indicates to me that the program is underfunded. 

What does that indicate to you? 

Dr. NORTH. I would like to ask the Area Director to comment 

specifically on the contract health services funding in the local 

service unit and the area. 

Senator TESTER. Do you want to defer to Mr. Conway at this 

time? Do you understand the question Mr. Conway? 

Mr. CONWAY. I believe so. Senator Tester, my thoughts on that 

is that we’ve heard stories, Carl Venne has told us stories about 

contract care. I think that whole issue centered around contract 

care is it probably not funded at the adequate level to provide all 

health care needs. What does that cost? Sometimes the cost share 

dollars may be another source to help cover those types of costs. 

Senator TESTER. Are you allowed to make recommendations up 

the ladder for additional dollars, whether it’s contract health care 

or some other item? 

Mr. CONWAY. I’m allowed to make recommendations to Dr. Grim, 

who is our boss. 

Senator TESTER. Okay. How do you feel those recommendations 

have been accepted, received, I should say? 

Mr. CONWAY. I think generally the recommendations have been 

well received. I think that at meetings of the Area Directors there 

are problems in other areas also that are talked about need, where 

it goes from there. 

Senator TESTER. How do you characterize the working relationship that you maintain with the tribal governments, how do you 

characterize that? Is it cooperative, productive, adversarial, how do 

you classify that? 

Mr. CONWAY. I think generally for the most part the working relationship that we maintain with the tribes is cooperative. I think 

there’s some issues that are always going to come up which may 

be adversarial. I think working through the Montana–Wyoming 

tribal leaders, and them being in Billings, being able to just walk 

up the street and discuss issues, I think it’s been a real bonus. 

Senator TESTER. So what issues are adversarial? What avenues 

do you use for reconciliation? Do you just say this is the way it is, 

too bad, or is there a process you go through? 

23

Mr. CONWAY. The process that I go through actually is to sit 

down across the table with tribal leaders and talk it over, just sit 

down and discuss the issue. 

Senator TESTER. Okay. Other than dollars, is there anything we 

can do in Congress to make your job easier? 

Mr. CONWAY. I think some of the things you can do is look at 

some of the administrative requirements that we have, and perhaps, some HR things possibly, being able to offer somebody a job, 

those types of things. 

Senator TESTER. The last question, do you take any administrative things off the top regarding what goes out? 

Mr. CONWAY. No, my understanding is funding for the Area Office, this has been funding before I got there, the cost of living and 

things like that. 

Senator TESTER. Thank you, Mr. Conway. 

Mr. North, when I talk to folks in Indian County, they talk about 

the fact they can’t get health care at certain times of the year unless they are life or limb, a loss of limb is involved. 

How do you suggest that we move away from a system that waits 

until the injury or the health problem disaster, and encourages 

more preventive maintenance or adaptive maintenance? 

Dr. NORTH. We have a program in health promotion, disease prevention that’s nationwide. We think it’s better to prevent these conditions and ask for treatment later whether it’s direct or through 

contract care. 

This area has a very high rate of contract health emergency 

funding, which is a reinsurance program in contract care, indicating to me that there are probably many opportunities to prevent 

illness in an early stage or altogether. 

Senator TESTER. Do you work through Mr. Conway or through 

the tribe directly to encourage prevention programs in this case? 

Dr. NORTH. Yes, we have a nationwide program. One of our Director’s three initiatives is health promotion and disease prevention. 

We’re working closely with CMS on that also, and we have some 

favorable rates now, Medicare like rates with hospitals all over the 

country which helps save our contract health care dollars. 

Senator TESTER. Thank you. 

Before I go to Dr. Clark, I just want to make a comment, when 

we asked about the adequacy of the budget, Senator Dorgan was 

there and the Indian Affairs Committee, and they talked about 

that budget being adequate, when, in fact, we know when we go 

out in the field, it’s not adequate. 

I think we’re wasting a lot of time, I think the budget is just flat 

not adequate because it hasn’t been a priority. 

Things would change a lot, from my perspective, if you guys 

would walk up to your bosses, or to the Secretary, and say, we need 

more dollars because we’ve got people dying out there unless we 

get more dollars for health care. 

There’s a lot of things out there that are really important, and 

we can go down the list from housing to water to roads, but if 

you’re sick, you’re not going to care, and if you have the opportunity to get people to help you if you’re that sick, it’s just going 

to cost more and more money for health preventatives. 

24

With that, I do have a couple of questions for Dr. Clark. 

A couple things, Dr. Clark. In your testimony, when you talked 

about early intervention and drug use and suicide, in particular in 

Indian Country, are you seeing any impacts of that early intervention, are you seeing suicide rates becoming static or going down, 

and the same thing with drug use? 

Dr. CLARK. One of the most important things from our point of 

view is working with tribes and tribal organizations to deliver the 

services. So, as a service delivery organization, we had opened our 

portfolio up to tribes and tribal organizations, and as result of economics, monitored the performance of the tribe and tribal organizations as we do for every other provider, and we’re seeing that more 

people are being provided services to. 

So from the economic point of view, it’s simply a matter of saying 

that I can cure the problem. We believe that working with tribes 

and tribal organizations with our resources, we are having a positive impact. Senator Tester: Okay. That’s good. That’s positive. We 

need to continue along that line. 

What can we in Congress do to really attack some of the root 

causes of moving toward drug addiction or suicide? 

Dr. CLARK. Well, of course, making sure that we have an adequate work force, making sure that there’s adequate collaboration 

between agencies so that this partnership between IHS, the Bureau of Indian Health Affairs, and the tribes, can work together so 

that we can target our interventions in such a way to produce satisfactory results. 

Senator TESTER. Okay. One last question, Dr. North, I do have 

one more question for you, and thank you, Dr. Clark. 

You talked about a manpower program that 7,000 students have 

utilized, is that total or is that in the last year? The number really 

doesn’t matter as much as the next question I’m going to ask, and 

that is, do you monitor the number of the folks that utilize this 

manpower program that actually come back into Indian Country 

and provide service? 

Dr. NORTH. Yes, we do. That’s 7,000 students since 1977, which 

is the year I joined the Indian Health Service 30 years ago. 

Senator TESTER. And how many of them come back to Indian 

Country? 

Dr. NORTH. We have more information on that, that’s a complex 

answer. If you’d like, I could provide that for the record. 

Senator TESTER. I would like more information on that, and also 

try to find out what’s going to encourage them to come back to 

their homes. 

With that, thank you very much, Mr. Chairman. 

Senator DORGAN. Senator Tester, thank you very much. 

Let me ask a couple of questions of Dr. North and Mr. Conway. 

I want to ask about contract health care because Chairman 

Venne indicated this morning, that I believe at this point, on this 

reservation in the Crow Nation, they are out of contract health care 

dollars. 

Chairman Venne, you are out of contract health care dollars at 

this point in the fiscal year and probably ran out somewhere in 

June or July; is that correct? 

Chairman VENNE. That’s correct. 

25

Senator DORGAN. If that’s the case, what that means is that if 

you are here in the Crow Nation and have a problem, a medical 

problem for which there is not treatment here, perhaps you need 

a specialist of some type, they’re not going to pay for that specialist 

unless there is a life or limb at stake, you’ve got to lose a limb or 

lose your life; is that correct, Dr. North? 

Dr. NORTH. And also special senses, hearing and eyesight would 

be included in priority one and child birth. 

Senator DORGAN. If that is the case, if we’re out of contract 

health care here now, the Fiscal Year ends at the end of September, of course, I’ve had a tribal chairman say they were out of 

contract health care funds in January. Former Chairman Tex Hall 

used to say on that reservation everybody understood don’t get sick 

after June because there’s no contract health care money. 

If that’s the case, isn’t it a fact, then, that we are rationing 

health care to Native Americans? 

Dr. NORTH. The Indian Health Service is the payer of last resort 

when it comes to referrals and notification of emergency care. All 

other alternate resources must be used first, like Medicare, Medicaid, private insurance, workmen’s compensation, Veterans Administration benefits and county indigent programs and state indigent programs where they exist. 

So, we’re not the only payor of health care for Native Americans. 

There are several other options. 

Senator DORGAN. Dr. North, you are absolutely correct about 

that, there are other payors in certain circumstances, but you, the 

Indian Health Service, represented by this government, is responsible. I mean, you do have a commitment. Others may or may not 

have a commitment, but we do know that the Indian Health Service does have a commitment. 

Senator Tester was asking the question the right way, I think. 

We have these hearings in Washington, D.C. or in Montana or elsewhere, and we ask questions, and what we always get is, you know 

what, things are pretty good, we’re doing the best we can. We’ve 

made a couple percent improvement here or there, but it seems to 

me the following: 

Dr. Grim has admitted under my pretty intense questioning a 

couple of times, that the amount of health service that is required 

for American Indians is being covered to the tune of about 60 percent. That means 40 percent of the health service that is needed 

is not available. That means there’s rationing of health care available. 

And I think it ought to be on the front page headlines of every 

newspaper, because I think it’s scandalous, and what I don’t understand is how we finally get people to speak up on this. 

I’m not trying to badger you, but Senator Tester made a point 

and I made a point to Dr. Grim when he was just re-nominated. 

We said why don’t you risk your job, if necessary, to speak out. 

Risk your job, if necessary, to speak out. 

The fact is, you’ve got some awfully good people working in Indian Health Service, in Public Health Service. I admire them, some 

terrific, committed, dedicated people. God bless them for doing it. 

But the fact is, they’re doing it without the resources they need, 

and we have to find a way to deal with that. And the only way that 

26

we’re going to do it is to get the Indian Health Service to stop saying things are pretty good and to start telling us exactly what’s 

happening. Now, Dr. North, you or Mr. Conway can respond, but 

Mr. Conway, isn’t it a fact that here on the Crow Nation if they’re 

out of contract health care money at this point, that somebody can 

be pretty sick but it may not be life or limb and they’re going to 

be told we’re sorry, just wait, you’re going to have to wait?, not 

we’re sorry about the pain, but the pain is yours, not ours, we don’t 

have the money, you wait. 

Isn’t that what happens? Am I wrong about that, or isn’t that 

what’s happening? 

Dr. NORTH. We have to live with the reality of medical care daily. 

I’ve done that for 30 years as a physician in the Indian Health 

Service with my patients, and I think——

Senator DORGAN. I can’t hear you, I’m sorry. 

Dr. NORTH. I’ve been a family doctor for 30 years in the Indian 

Health Service, and I understand what you’re saying, sir. We 

struggle to find the best resources for our patients, the best referral 

sources and the best methods to diagnose, treat and cure, and it 

takes creativity at times, sir. 

Senator DORGAN. Well, are you frustrated? 

Dr. NORTH. I find this struggle to be a good struggle and one 

worth fighting. 

Senator DORGAN. All right. Well, let me ask this additional question. 

I assume that somewhere at the bottom of this structure, there 

are dedicated Indian Health Service employees who are saying we 

don’t have enough resources, we need more. We’re the ones that 

are seeing the patients that we can’t take care of, so we need the 

additional resources. We need the additional equipment. We need 

the additional facilities, and that goes up the line someplace. 

My understanding is that the tribes are even asked to comment 

and to work and to make recommendations. 

Is there a circumstance where the tribes are involved in discussions up the line when, for example, the Indian Health Service goes 

to the Secretary and the Secretary goes to the Office of Management and Budget, or is it a circumstance where when it leaves at 

this level, the Indian Health Service, at that point there’s no more 

consultation, it’s just the Office of Management and Budget and 

perhaps the Secretary and somebody else makes the decision with 

no consultation with tribes at that level? 

Dr. NORTH. We take pride in tribal consultation at every level of 

the Indian Health Service. About 70 percent of our employees are 

Native American and are community members in many cases, and 

are family members of the tribal leaders and often tribal leaders 

themselves, so we feel like we work very closely with the communities and we have good two-way communications with tribal leaders. 

Senator DORGAN. I should have mentioned, it’s the Secretary of 

Health and Human Services, on other issues it’s the Secretary of 

the Interior on Indian funding issues. 

But Mr. Conway, let me ask you that question about someone 

who is ill here on the Crow Nation Reservation, and is probably not 

going to die, but is in substantial pain, needs to go to a specialist 

27

somewhere else because the service isn’t available here, tell me 

what happens in that case. 

Mr. CONWAY. Maybe what would happen in that case, they will 

be deferred until the next year when we have some money. I think 

our job is probably the issue of asking for us to appropriate more 

money. 

I think in my area, I think Chairman Venne receives 50 percent 

of the Health Service funding. I think we know that, at least in 

this area, we have service units that are funded at 58, 56 percent 

are being funded, all the way up to probably 76 or 78 percent. 

And I think what we have to conclude from that, if they’re funded at that level, there must be some needs out there that we need 

to continue to work on. 

Senator DORGAN. And isn’t that another way of saying that 

health care is being rationed to American Indians, really? 

Mr. CONWAY. Yes, it’s a way of saying that we do not have 100 

percent of the funding. If we’re keeping track of every service unit 

in the country, what the level they’re being funded at is, we have 

other areas probably in the Dakotas that are probably funded at 

40 percent level of needed funds. 

Senator DORGAN. All I can tell you is I think most Americans, 

most Americans, if they’ve got a provider, health insurance, some 

other type of system, VA, they get sick, they want to go to a doctor, 

and if they’re in pain they want to get it fixed, they want to get 

that pain resolved. 

It appears to me, and I say this from having visited many Indian 

reservations and talked to a lot of patients, it appears to me we’re 

in a situation where we don’t allocate enough funding so that, for 

example, here you’re out of contract health care money, and the 

person that needs that help is going to be told you just live with 

the pain because your need is going to be deferred. 

I’m not saying you don’t do all you can do, that’s my point. My 

point isn’t that the three of you don’t do all that you can do. My 

point is we don’t have anybody in the system that comes to us and 

pounds on the table and says publicly, in front of everybody, here’s 

what’s happening and we need to fix it. 

What happens is they come to these hearings and they say, we’re 

doing the best we can. Well, you know what, if it’s 40 percent 

health care that’s not available to people that need it, that’s not 

good enough. The best we can is not good enough. 

And so, I really want to work with Chairman Venne and Senator 

Tester, with you, with some dedicated people in the Indian Health 

Service and regional officials, but we need, we really need to see 

some evidence of frustration and anger, saying this isn’t working 

and it needs to be fixed. That’s what we need from you. 

Dr. Clark, I’ve not asked you a question, but you know that I 

have held multiple hearings on the issue of teen suicide and, you 

know, where there are young people who feel that it is hopeless 

and they are helpless. 

I’ve been to the reservations where it’s happened. And the fact 

is, mental health services were not available. They just were not 

available. And it’s true that we’re making some strides, but we’re 

not anywhere near where we need to be. And I hope that you and 

others in the administration will begin speaking out as well. 

28

Methamphetamine addiction is a devastating addiction, and we 

can’t treat that by putting somebody in a treatment program for 2 

weeks, because that doesn’t work. This is long-term and difficult 

and expensive, but it’s the only way we can solve these problems. 

I’m not going to ask you any questions, except I thank you for 

your testimony. I want to get to the other witnesses, the tribal witnesses. 

Senator Tester has another question. 

Senator TESTER. One point real quick. I would hope that this 

panel would stay around for the next panel group. 

One of the things I would like to inserted in the record, Chairman Venne passed along to me. 

In this region, it is not only underfunded, it’s 48 million in the 

red on contract care here right now. That means when we’re talking about Crow, Fort Belknap, Fort Peck, Rocky Boy, Salish and 

Northern Cheyenne, they’re all in the same boat. 

Right now on this reservation 28 positions are not filled in this 

hospital, 28. That’s just not good, so I just wanted that put in the 

record. 

Senator DORGAN. And before I let you go, one final point, I believe, and I believe, Dr. North, in your testimony you reiterate, I 

believe there is a trust responsibility that the Federal Government 

has for Indian health care. This isn’t an option. This isn’t a case 

where we say, well, on an optional basis we’ll provide health care. 

I believe there is a trust responsibility. If that trust responsibility exists, and I think most all of us believe it exists by custom 

and by law, then we are far short of meeting the needs and keeping 

our promise, and that’s the point of it all. 

Let me release you by saying, you are representatives of a lot of 

dedicated health professionals, I understand that. I don’t ever want 

to diminish some Indian Health Service doctor, Public Health Service physician or others working in these kinds of circumstances. I 

don’t ever want to diminish what they do. God bless them for doing 

it. 

But we as a country, and we as health care professionals, we in 

the Congress, starting with the President’s budget, have to own up 

to our responsibility now, not later. 

So, thank you very much for testifying. 

Next I’d like to call to the witness table Dr. Joe McDonald, who 

is the President of the Salish Kootenai College, Ms. Ada White, the 

Health Service Director of the Crow Tribe, Mr. Jonathan Windy 

Boy, the Chairman of the Subcommittee on Health Care, Montana–

Wyoming Tribal Leaders Council, if you will come forward when I 

call your name. Also, Mr. Moke Eaglefeathers, who is the President 

of the National Council of Urban Indian Health Board, and Director of North American Indian Alliance. 

Just let me mention briefly that Dr. Joe McDonald is accompanied by Ms. Marjorie Bear Don’t Walk, the Director of the Indian 

Health Board of Billings. 

Others on the panel are accompanying Ms. Stacy Bohlen, Executive Director of the National Indian Health Board. We have Jace 

Killsback, Billings Area Representative of the National Indian 

Health Board, Council member of the Northern Cheyenne Tribe, 

29

and Dr. Joseph Erpelding, an orthopedic surgeon from Billings, 

Montana. 

We have many of you testifying on the second panel. I want to 

tell you that your entire testimony will be made a part of the 

record. And I wish that you would summarize for us, and at some 

point, if you’re unable to summarize, you may hear me bang the 

gavel, gently for you, of course. 

I also want to tell you before we call on this panel, that we will 

ask any other testimony from any member of this audience or anyone listening, any testimony can be submitted by you or you can 

do it by fax or you can do it through the Internet or you can call 

the Indian Affairs Committee in the U.S. Senate, Washington, D.C. 

We will make your formal testimony a part of the record even 

though you have not been called as witnesses, but you will have 

the opportunity to make statements and provide statements to this 

Committee. And that opportunity will exist for 2 weeks following 

today, and it will be open to you to submit such testimony. 

Dr. Erpelding has surgery at 3 o’clock today, I understand, so because of your surgery schedule, we want to call on you first. 

So, Dr. Erpelding, why don’t you proceed? And again, I would ask 

all the witnesses to speak directly into the microphone so that all 

in this gymnasium will be able to share in your comments. 

Dr. ERPELDING. Chairman, Senator and distinguished guests, 

thank you for allowing me this opportunity. 

About a year ago, I was getting frustrated with the trend that 

I’ve seen practicing here for 11 years, that it’s just gotten to the 

point where I searched out to try and look for some solutions outside of the current system, and I think Stacy is going to talk about 

that. 

But, in essence, the trend has been a gradual decline in access 

and an increase in severity and diversity of disease, and I can 

share some specific numbers that illustrate that. 

What I’ve been told is that IHS funding is currently at 54 percent of need, and the reason I don’t know, but the result is that 

I cannot take care of patients that come in and need care, and it’s 

very frustrating. 

Access is limited by deferral of service. Patients wait anywhere 

from 2 weeks to a year to be seen in a clinic. I’ve had a patient 

wait 6 years to get a total joint replacement, 6 years. 

Senator DORGAN. Six years for what? 

Dr. ERPELDING. For a total joint replacement. 

Orthopedic care is the most common deferred service. There frequently is no wait list. The surgery list that we had here at Crow 

3 years ago was lost. We had about 60 patients on that list. The 

list got lost; those patients have to come back in, be seen, be evaluated and get back on the list. So, we’ve got some areas that we 

need to work on. 

The deferral of service has consequences. I looked at the total 

joint and back patients that were waiting for surgery, 60 percent 

of them were on opiates, 60 percent. That’s their way of coping 

with pain. If they can’t get the surgery, they need something. 

Last year we shut down the OR here for 2 months because we 

ran out of money, and I couldn’t come down and do surgery here. 

I come down here and do surgery. There’s also a decrease in emVerDate 0ct 09 2002 10:35 Dec 12, 2007 Jkt 038721 PO 00000 Frm 00033 Fmt 6633 Sfmt 6601 S:\DOCS\38721.TXT JACK PsN: JACKF
30

ployment and an increase in secondary disease due to lack of access. 

I can give you some numbers; total joint patients the last 5 

years, my non–Indian health service patients, the average age is 

631⁄2. The Indian Health Service patients, the average age was 

54.2. 

Why? I would submit some of this reflects a lack of access. It reflects a lack of health opportunities earlier in the onset of arthritis, 

and it’s seen many years later. But a nine-year difference in average age for total joint replacement, that is sad. 

When I looked at 20 patients that had ACL reconstructions, 20 

that were non-IHS and 20 that were Indian Country patients, 95 

percent of those that were Indian Country patients had a torn cartilage. That leads to an increase in arthritis. Only 10 percent of 

those who were non-IHS, had torn cartilage. 

Why? The average wait for a non-IHS patient was 2 months. The 

average wait for an Indian County patient, 13 months. We can’t 

keep doing this. 

I’ve brought some solutions to the state. I was the President of 

the Orthopedic Society in the state. I’ve asked us to focus on health 

disparity education, medical and nonmedical. People need to know 

about this. They need to know that there’s a disparity and how can 

we help. 

We need to improve the cultural competency of those of us involved. I’ve got a surgery scheduled this Friday, it’s during Crow 

Fair for heaven’s sake. People wait a year to go to the Fair, and 

unfortunately, I tried to change it, could not, but that’s cultural 

recognition, that I shouldn’t be offering surgery on a week that is 

very important to this Nation. 

Additionally, there’s prevention principles that we need to focus 

on. But most important, I listened to Michael Porter, who is a Harvard professor and strategist a couple days ago at a leadership conference, and he said American people respond and make things 

happen. He also said we need to provide value. When we look for 

increase in funding, we need to provide value when we do that. 

One of the areas that came up when I chatted with the Billings 

Area Office, is they need an infusion in business minds. It’s difficult to do third-party collections if they don’t understand how to 

do it. The private sector knows how to do it. This is an area where 

we can garner additional funds without a lot of increase in cost. 

The others areas that I’m concerned about is we measure things, 

but the measurements aren’t accurate, so it’s garbage in, garbage 

out. We need to measure access for diagnosis, not just well, they’re 

going to see a specialist, but do they get a diagnosis. And then we 

need to measure access for treatment better. 

I plead with those of you that have the ability to improve the 

funding for health opportunity initiatives in Indian Country, and I 

thank you for the opportunity to talk. 

Senator DORGAN. Dr. Erpelding, thank you very much. Dr. 

Erpelding, as I indicated, has surgery scheduled today and so we 

took his testimony first. 

Thank you very much, and thank you for submitting testimony 

and giving us a different perspective, your perspective as an orthopedic surgeon on some very important issues. If you need to leave 

31

at this point, we will understand. Let me next call on Stacy Bohlen, 

and Stacy Bohlen is the Executive Director of the National Indian 

Health Board. 

Stacy, you may proceed. 

Ms. BOHLEN. Thank you. 

On behalf of the National Indian Health Board, Mr. Chairman 

and Senator Tester, thank you for allowing the National Indian 

Health Board to be here today. Dr. Erpelding was here as a witness for the National Indian Health Board, and as you said, I am 

the Executive Director. 

I’m a member of the Sioux St. Marie Tribe of Chippewa Indians 

in Michigan, and I am actually accompanying Mr. Jace Killsback, 

who is a councilman for Northern Cheyenne, and he is also a Board 

member of the National Indian Health Board, so I’m going to turn 

this over to him, if you don’t mind, sir. 

Senator DORGAN. All right. 

STATEMENT OF JACE KILLSBACK, BILLINGS AREA

REPRESENTATIVE, NATIONAL INDIAN HEALTH BOARD, 

COUNCIL MEMBER OF THE NORTHERN CHEYENNE TRIBE; 

ACCOMPANIED BY STACY BOHLEN, EXECUTIVE DIRECTOR, 

NATIONAL INDIAN HEALTH BOARD AND DR. JOSEPH 

ERPELDING, ORTHOPEDIC SURGEON, BILLINGS, MONTANA 

Mr. KILLSBACK. First of all, greetings Chairman Dorgan, Senator 

Tester and esteemed members of the Senate Indian Affairs Committee. 

As Stacy mentioned, my name is Jace Killsback, a member of the 

Northern Cheyenne Tribal Council, and also a Board member representing the Billings Area for the National Indian Health Board. 

Stacy will providing me with some technical assistance. 

On behalf of the National Indian Health Board, it is an honor 

and a pleasure to offer this testimony on health care issues in Montana and nationally. 

Our testimony today will focus on contract health service policy 

and practices and the consequences of poor funding and poor surveillance impacts on American Indians in Montana. 

During our discussion, we will focus on the lack of orthopedic 

care in Montana, and how contract health services or CHS funding 

implementation have created this crisis in Montana. 

We especially acknowledge the leadership of Senator Tester in 

organizing and holding this hearing on these critical issues. 

So please allow me to express again my gratitude of the tribes 

for the work the committee has done in advancement of the reauthorization of the Health Care Improvement Act. 

And we’re especially thankful for the leadership that Senator 

Dorgan has provided and his tendency to bring this legislation to 

a successful conclusion to be enacted this year. 

This bill will not only advance without the vigilance of the tribes, 

but also Congressional leaders like Senator Dorgan, and we hope 

that you will continue to be a champion of this effort. 

We also would like to acknowledge the work of Senator Baucus 

and his assurance from the Senate Finance Committee that they 

will mark up the bill September 12. We look forward to seeing this 

bill progress of community consideration for the Senate floor. 

32

A snapshot of the health care status of American Indians and 

Alaska Natives, they have a lower life expectancy and higher disease burden than all other Americans. Roughly 13 percent of American Indians and Alaska Native deaths occur for those under the 

age of 25. This is three times the rate of the U.S. population. 

Our youths are more likely to commit suicide at 70 percent in Indian Country. These are involved with alcohol. We haven’t found 

the effects of methamphetamine abuse. 

American Indians have a life expectancy rate 6 years less than 

any other group in the United States, and rates for heart disease 

are twice the rate for Americans, and this continues to increase 

while the rate among the general public is decreasing. 

The Center for Disease Control reported earlier this year that for 

the first time in 75 years of cancer disease surveillance, the rates 

of cancer in the U.S. are decreasing. This is true for all groups except for American Indians, for whom cancer rates are continuing to 

increase. 

Disproportionate quality, poor education, cultural differences, 

and the absence of adequate health care and delivery are why 

these disparities continue to exist. The true tragedy is that most 

of these illnesses which American Indians suffer from are completely preventable. 

It’s also because the funding for Indian health care on a per capita basis is half of what Federal prisoners receive. 

For the proud nations of people who fought for their freedom to 

protect their way of life and negotiated honestly for a few considerations like health care and education for their people in exchange 

for the land they had given up with their lives, surely Congress can 

do better. 

You guys are pretty familiar with the statutory provisions for 

health care for American Indians, which again, is under the Snyder 

Act of 1921 and Health Care Improvement Act. 

There are two types of services, direct services that are provided 

to IHS at our tribal hospitals and clinics, and our contract health 

services which are provided by the private sector facilities, and providers are based on referrals from IHS from the tribal CHS program. 

CHS services are utilized when a direct care facility is not available, the direct care facility is not capable of providing the required 

emergent or specialty care, or is not capable of providing the care 

due to medical care workload. 

CHS authorizes, subject to the availability of alternate resources, 

such as Medicaid, Medicare and private health insurance. Due to 

the limit of CHS funding, CHS regulations require that services 

must be preapproved at the local CHS program and determined to 

be medically indicated within medical priorities. 

If the services are provided in an emergency situation, notification must be made to the local CHS program within 72 hours. The 

majority of CHS services are authorized for priority medical, emergent or acutely urgent care services. 

These services are defined in the CHS manual as services that 

are necessary to prevent the immediate death or serious impairment of the health of an individual. 

33

Other medical priorities include priority two for Indian health 

care, and priority three, secondary health care issues. Priority four, 

prompt tertiary and extended health care services such as rehabilitation. 

For those services that are within the medical priorities but are 

considered elective or not emergent or not authorized for pain due 

to lack of CHS funding, are considered deferred services. 

In Fiscal Year 2006, the IHS received over 150,000 requests for 

services that were deferred. If they had been approved and paid, 

they would represent $176 million from the CHS. The data on 

these numbers for deferred services is not consistent among the 

IHS areas and is probably under reported. 

Because the general deferred services are never authorized and 

never paid for, there is little incentive for an Indian patient to request IHS programs to pay for their services. 

As an example, the Northwest Portland Indian Area Health 

Board has estimated that due to lack of data on deferred services, 

that they have estimated there are probably 300 million of unmet 

needs for CHS in their area alone. 

Senator DORGAN. I’m afraid I’m going to have to ask you to summarize the remainder of your statement in order that we might get 

all of the statements in from others. 

Mr. KILLSBACK. Here in Montana, we represent the large landbased tribes, and we are the most desperate, the most needy of the 

neediest. Our communities are rural, and a lot of times we see economic development being pushed on our tribes, and the notion is 

here, we can’t have economic development without healthy communities. 

The payor of last resort is something that, again, reflects a perception in Indian Country of the culture of IHS. We have patients 

that go in and are not being treated until there is appropriate 

funding, and so what you have is a creation of an addiction, painkillers. 

This has also allowed for some issues in the communities for 

black market drug trade of prescription drugs that isn’t being addressed also. 

The culture of IHS in the continuing fighting for funding has the 

Indians playing the numbers game. Some numbers that are interesting, consider we have 30-year-olds walking around like 50-yearolds on our reservation. 

Because of the deferments also, we are not keeping accurate 

records so we don’t have the appropriate data even for diagnosis, 

and how can we get the proper amount of funding for treatment 

if we don’t have the proper number for diagnosis or referrals. 

I just want to wrap it up by saying that the reimbursement issue 

that was brought up earlier, it’s not IHS that’s improving the thirdparty reimbursements, it’s tribes improving third-party reimbursements, and yet, those reimbursements are still being utilized 

against us in the budget process when it comes to the IHS budget 

formulation. 

Thank you for allowing us to testify. 

[The prepared statement of Mr. Killsback and Dr. Erpelding follows:]

34

PREPARED STATEMENT OF JACE KILLSBACK, BILLINGS AREA REPRESENTATIVE,

NATIONAL INDIAN HEALTH BOARD, COUNCIL MEMBER, NORTHERN CHEYENNE TRIBE

AND DR. JOSEPH ERPELDING, ORTHOPEDIC SURGEON, BILLINGS, MONTANA


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Senator DORGAN. Mr. Killsback, thank you very much. I have 

read ahead of you in your testimony and you have provided, I 

think, some very important data and statistics on these issues. We 

appreciate that very much. 

I’m sorry to ask you to summarize at the end, but we have so 

many witnesses and I want to make sure all of them have an opportunity, but I want to thank you for putting together about 12 

pages of some very useful information about Wyoming, Montana, 

about some of the data that we are seeking, so thank you very 

much. 

And Ms. Bohlen, thank you very much for bringing Mr. Killsback 

and Dr. Erpelding with you as well. 

Dr. Joe McDonald is with us and we will hear next from Dr. Joe 

McDonald, President of the Salish Kootenai College. 


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Dr. McDonald, thank you very much, and as I indicated to others, you may summarize and your entire statement will be made 

a part of the permanent record. 

DR. JOSEPH F. MCDONALD, PRESIDENT, SALISH KOOTENAI 

COLLEGE 

Dr. MCDONALD. Honorable Jon Tester and Mr. Chairman, my 

name is Joe McDonald, I’m the President of the Salish Kootenai 

College. It’s really an honor to appear before you today and provide 

this testimony. I thank you very much. 

And I extend a special thanks to Chairman Venne and the Crow 

Tribe for hosting this field hearing and nice lunch and the nice facility you have here and the excitement of the celebration that’s 

about to begin. 

I can’t say enough about the need for recruitment of American 

Indian people into the medical provider professions, ranging all the 

way from CNAs to medical doctors. 

It’s difficult to recruit these people into our rural areas and get 

them to stay. And I think if we could recruit members of tribes and 

have the tribal colleges provide the training, that they would come 

and they would stay, and we would not have the shortage that we 

have on our reservations. I think they would provide consistent 

service. 

At Salish Kootenai College, we have been offering nursing for 

about 18 years now, and we’ve had 400 and some nurses graduate, 

200 and some have been American Indian nurses. Our passing 

grade on the Implex has been over 90 percent. 

They told us when we started that, you know, Indians couldn’t 

pass that test. They said, Joe, after all, they have to take this test. 

Well, we do take it and we do it well. 

The doctors say that our nurses are very good. You go to the hospitals in our western Montana, they say, Joe, you’ve really got 

some great nurses there. And so the Indian people can do this, and 

they can do it well. 

We have nurses working here at the Crow Hospital, as we have 

at all the IHS facilities, Indian Health Care facilities in Montana 

and much throughout Indian Country. 

When we started our program in 1989, our research showed that 

there was one American Indian in nurses training in Montana that 

year. This year, just this year, we’ll have 46 American Indian students in our classes in Salish Kootenai this fall. 

So given a chance, the American Indian students, they will enter 

the field, they will take on the challenge of becoming a nurse. 

We also have a dental assisting technology program. We hoped 

it could grow into a dental hygiene program, but it hasn’t to this 

stage, but they do take the licensure to be certified dental assistants and they’re working throughout the southwest. We have some 

even in Alaska and in dental clinics around our reservations. 

There’s a need to have more of these programs, licensure programs in many medical fields, such as dental hygiene, occupational 

therapy, all the different x-ray programs, the medical records technology, all of them. There’s a tremendous need for that. 

50

We in the tribal colleges could do that well if we just had the resources. We can do the training, and we can do the recruiting if 

we have the resources. 

Health care in Montana is one of the fastest growing areas of 

employment. It’s one of the biggest employers in Ronan, and provides one other opportunity for Indians to get employment. 

In order to do the recruitment, our K–12 students need to be encouraged to think about these health care programs, and appropriate classroom instruction is needed and counseling is needed to 

build confidence and competence so that the Indian students at the 

sixth grade level, seventh grade level decide that I’m going to be 

a nurse or I’m going to be a doctor or I’m going to be a x-ray technician, or whatever it might be, because they can do that. 

We need to build a pipeline, a pipeline in Indian Country that 

will go from kindergarten all the way through the chosen profession. 

Once students are recruited in the program, they need help to 

overcome a lot of barriers and problems that they encounter. 

Finance is certainly a problem, individual finance is a problem. 

Many of the students come that need help in basic skills, college 

skills. They need to complete prerequisites before entering the 

nursing program. A lot of times they burn up a lot of their Pell 

grant eligibility getting ready to enter into the nursing program. 

Once they enter the nursing program, the study demands are 

enormous and they need confidence building, they need a pat on 

the back, they need a push and support. 

The graduating nurse must be very skilled and very confident, 

and we can’t cut any slack with them because they have to be good 

and they have to be very good. 

The costs of the college for the health care provider training are 

much greater than the average other programs that we offer. At 

Salish Kootenai College we really struggle to find the fiscal resources and the instruction staff to maintain the nursing program. 

Every year as we get into the budgeting, part of the program is 

on the chopping block. We have not done it; we have been struggling with being able to meet those needs. 

Our salaries are not adequate. It’s tough to recruit them with the 

salaries we pay. We have an opportunity right now to recruit an 

American Indian nurse that’s been completing her doctorate degree. We’d like to have her come back, but I’m not sure that we 

could negotiate or get through that. 

So, I believe that Indian students can be recruited and retained 

if given the opportunity, that retention of the student depends on 

adequate funding for the college to provide the program. 

I think the solution is to continue to adequately fund the Tribal 

College Act, and I know that you’ve been a leader in that, and if 

we could just get our funding equal to the state allocation averages 

for 2 and 4-year mainstream colleges, we would be doing well. 

I’m pleased to hear that the legislation, THE PATH, has been introduced, because I think that’s going to be a big help. I’m also 

pleased to hear that the Indian Health Care Improvement Act, Improvement Reauthorization Act is going to be marked up. 

51

We have suggested some amendments to it. I understand many 

of them have been included. I’ve included that in my testimony 

that we have suggested it, so I really do thank you for that. 

So, Mr. Chairman and Senator Tester, we thank you for inviting 

us and for considering any of our suggestions in the amendments. 

In closing, I want to extend my sincere thank you for your commitment and hard work in support of our nation’s tribal colleges 

and Indian tribes. 

I think that both of you are true role models for lawmakers, and 

I really appreciate it. 

Thank you very much for taking this time. 

[The prepared statement of Dr. McDonald follows:]

PREPARED STATEMENT OF JOSEPH F. MCDONALD, PRESIDENT, SALISH KOOTENAI

COLLEGE

Honorable Senators John Tester and Byron Dorgan, 

It is an honor to appear before you and offer this testimony. Thank you very 

much. I also extend my thanks to the Crow Tribe for hosting this field hearing. 

There is a need to recruit American Indian students into the various medical provider professions ranging from LPN’s to medical doctors. It is difficult to recruit 

skilled medical professionals to work in our rurally isolated Indian communities. 

The most efficient way is to recruit, and train American Indian medical staff. They 

are more willing to serve on their reservations and will provide consistent service 

to their communities. 

At Salish Kootenai College we started a nursing program in 1989. Thus far we 

have graduated 432 nurses, 202 are American Indian nurses. Our passage rate of 

NCLEX certification examination has averaged over 90 percent. Our American Indian nurses that have graduated from Salish Kootenai College serve the hospital 

here at Crow Agency as well as the hospitals on the Blackfeet Indian Reservation, 

the Fort Belknap Indian Reservation, the health service agencies on each reservation, private hospitals, nursing homes, and home health agencies throughout Montana. 

When we started our nursing program in 1989 there was only one identified 

American Indian student in nursing programs in Montana. This fall we will have 

46 American Indian students in our nursing education program. We will also have 

41 non-Indian students. 

We also have a training program for dental assisting technology. Graduates of the 

program are eligible to take the Licensure Examination and become certified dental 

assistants. Our graduates work in Indian dental clinics throughout ‘‘Indian Country’’ and Alaska. Some go on to become dental hygienists. 

There is a need to have educational programs that lead to licensure in other medical fields such as dental hygiene, occupational therapy, x-ray technicians, laboratory technicians, medical records technology, and many others. 

Health care is one of the fastest growing areas for employment in Montana. It 

provides a great opportunity for employment for American Indian people. 

Our K–12 students on our Reservations need to be encouraged to think of working 

in the health care field. Appropriate classroom instruction and counseling is needed 

to build confidence, competence, and desire to pursue a career in the health care 

field. 

Once students are recruited into the program, they require help to overcome the 

many barriers and problems they encounter. Individual finance is a problem. In addition to family maintenance, students have the cost of going from Pablo to Missoula 

or Kalispell for their hospital practicum. Tutoring is needed, and counseling services 

are a necessity. 

Many of the Indian students that come need help in basic college skills and need 

to complete prerequisites before entering the nursing programs. Once they enter the 

nursing program, the study demands are enormous. The graduating nurse must be 

very skilled and competent. 

Costs to the college for health care provider training are much greater than for 

most training in fields of study. 

At Salish Kootenai College we really struggle to find the fiscal resources and the 

instructional staff to maintain our nursing education programs. We are competing 

poorly for faculty salaries and our turn over rate of nursing instructors is much 

higher than for the rest of our college. 

52

In summary, American Indian students can be recruited and retained in health 

care professions such as nursing. Retention depends on adequate funding for the 

student and adequate funding for the college providing the program. Continuing to 

increase the funding of the Tribal College Act would be a great help and would get 

tribal colleges funding equal to the state allocation averages for 2 and 4 year mainstream institutions. 

The passage of the legislation, S. 1779 entitled THE PATH will help greatly also. 

It is an Act that will help prepare an American Indian health workforce, improve 

health and wellness of students and their families, and combat substance abuse. It 

has been introduced by you two Senators and I thank you for it. And I speak for 

all of our colleges in extending thanks to you. 

Passage of the Indian Health Care Improvement Reauthorization Act of 2007 will 

provide valuable assistance to our tribal colleges. We have asked for some amendments in the legislation. The amendments address: (1) delivery of health training 

programs; (2) recruitment and retention of Native American nurses in our associate 

and bachelor degree programs; (3) scholarship payback options that would allow 

payback to include teaching in a tribal college nursing program; and (4) addition of 

a provision that would authorize TCU-based social work and psychology degree programs. 

The specific amendments are as follows:

‘‘SEC. 104(b)(1) INDIAN HEALTH PROFESSIONS SCHOLARSHIPS, ACTIVE 

DUTY SERVICE OBLIGATION—OBLIGATION MET’’

Add a subsection (D) to read ‘‘In a teaching capacity in a tribal college nursing 

(or related health profession) program.’’

‘‘SEC. 113. INDIAN RECRUITMENT AND RETENTION PROGRAM.’’

Add a subsection (c) to read: ‘‘Tribal college health education programs shall be 

accorded priority for funding pursuant to this section.’’

‘‘SEC. 115(d) QUENTIN N. BURDICK AMERICAN INDIANS INTO NURSING 

PROGRAM, PREFERENCES FOR GRANT RECIPIENTS’’—

Add a subsection (5) to read: ‘‘Programs conducted by tribal colleges.’’

‘‘SEC. 115(f) QUENTIN N. BURDICK AMERICAN INDIANS INTO NURSING 

PROGRAM, ACTIVE DUTY SERVICE OBLIGATION’’—

Add a subsection (5) to read: ‘‘teaching in a tribal college nursing program.’’

‘‘SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY COLLEGES. (a) 

GRANTS TO ESTABLISH PROGRAMS—(1) IN GENERAL—

It is essential to recognize that several tribal colleges, including Salish Kootenai 

College, are accredited as 4-year institutions of higher education by regional accrediting associations, rather than classified or accredited as ‘‘community colleges.’’ Construed to its logical extreme, Salish Kootenai College could arguably be considered 

ineligible for a training grant under this section, notwithstanding that it is a community college in the more global sense. We do not think this is Congress’ intent. 

We therefore recommend modifying the first sentence of this subsection to read:

‘‘The Secretary, acting through the Service, shall award grants to accredited 

and accessible community colleges or tribal colleges for the purpose of assisting 

such colleges in the establishment of programs which provide education in a 

health profession leading to a degree or diploma in a health profession for individuals who desire to practice such profession on or near a reservation or in an 

Indian Health Program.’’

We further recommend that this language change be reflected in subsection 

‘‘118(a)(2) AMOUNT OF GRANTS,’’—which should also increase the minimum annual grant award, as follows:

‘‘The amount of any grant awarded to a community or tribal college under paragraph (1) for the first year in which such a grant is provided to the community 

or tribal college shall not exceed $250,000.’’

The rationale for the increase of the first-year ceiling level from $100,000 to 

$250,000 rests with the fact that it is virtually impossible to adequately or credibly 

initiate a health career-training program with $100,000. This low amount is a setup for failure from the beginning and accordingly needs to be increased. 

Also, the term ‘‘or tribal college’’ should be inserted after the phrase ‘‘accredited 

and accessible community colleges’’ or ‘‘community college’’ in Sections 118(b)(1), (2), 

and Section 118(c). 

Under Section 118(b)(2)(C)(i), strike the word ‘‘advanced’’ before the phrase ‘‘baccalaureate or graduate’’, as it is redundant, confusing, and unnecessary. 

53

As to Section 118(a) and (b), we urge that language be added to the effect ‘‘Priority for the award of funds under this subsection shall be accorded to accredited 

tribal colleges with nursing programs.’’

Finally, for purposes of consistency, we recommend that the title of Section 118 

be changed to read: ‘‘HEALTH TRAINING PROGRAMS OF COMMUNITY OR 

TRIBAL COLLEGES.’’

‘‘SEC. 126. SUBSTANCE ABUSE COUNSELOR EDUCATIONAL CURRICULA 

DEMONSTRATION PROGRAMS’’

We recommend that tribal college social work and psychology programs be added 

to this section. In the case of Salish Kootenai College, our former substance abuse 

program has been incorporated in our new social work program. This appears to be 

the trend. The same holds true for psychology programs, which have essentially incorporated former stand-alone substance abuse curricula under the psychology rubric.

‘‘SEC. 126 (c) TIME PERIOD OF ASSISTANCE; RENEWAL’’

A 1-year period is simply too short of a timeframe to administer or renew an academic program. Accrediting agencies require a minimum of a 3-year timeframe for 

approval of any new program. These types of programs are two or 4-year programs, 

i.e., multi-year. Program and student learning outcomes (and academic planning 

and assessment, and budgeting) are accordingly based on multi-year timeframes, 

usually 3–5 years. In short, a 1-year life period is wholly unrealistic from all relevant perspectives.

Mr. Chairman, we thank you for considering our concerns regarding these much 

needed amendments to the Indian Health Care Improvement Act. We respectfully 

ask you to include this letter in the record of the Committee’s mark-up of S. 1057. 

In closing, please accept my sincere thank you for your longstanding commitment, 

hard work, and support of our Nation’s tribal colleges and Indian tribes. You are 

a true role model for lawmakers, and we will forever appreciate your service. My 

kindest regards. 

Thank you for taking the time to hear about health care for American Indians.

Senator DORGAN. Dr. McDonald, thank you very much. 

Let me mention, as I prepare to recognize Ada White, that THE 

PATH legislation that you referred to is legislation that Senator 

Tester and I have jointly introduced in July. 

Senator Tester has added a great deal with this idea to the opportunities in education, and I am proud to be a partner with him 

and we intend to push it. And I think it’s a testament to Senator 

Tester’s concern and aggressiveness on these issues. So thank you 

very much for mentioning that. 

Next we will hear from Ms. Ada White, the Health Service Director of the Crow Tribe. 

Ms. White, if you will pull the microphone very, very close, and 

you may summarize and your statement will be part of the record. 

STATEMENT OF ADA M. WHITE, HEALTH SERVICE DIRECTOR, 

CROW TRIBE 

Ms. WHITE. Good afternoon, distinguished members of the U.S. 

Senate. I am welcoming you to Crow Country, and I thank you for 

this great opportunity to provide testimony on behalf of the Crow 

Tribal health concerns. 

As stated earlier, my name is Ada White. Like many people in 

this room, I have devoted most of my life to working for the Crow 

Tribe. I can find a lot of value in the fact that we’ve had a lot of 

development, and I’ve been with the tribe for over 36, 37 years. 

I share this information because I want to illustrate my passion 

and commitment to the health and welfare of the Crow people. 

Throughout my years of being involved, I have always worked to 

strengthen tribal sovereignty, to further tribal self-determination, 

54

and to remain vigilant in helping enforce other Federal trust responsibilities. 

Senator Dorgan and Senator Tester, and other members of the 

Indian Affairs Committee, I commend your commitment to Indian 

Country. I commend your vigilance in watching what’s happening 

on Capitol Hill, protecting our interests. 

In particular, I am certainly indebted to your work in working 

for the reauthorization of the Indian Health Care Improvement 

Act, working on a special diabetes initiative, and also keeping in 

the forefront that it is the responsibility of the Federal Government 

to honor trust agreements, trust responsibilities as it relates to 

health care. 

Unfortunately, this is a challenge that we must continually work 

on, and that is to dispel the myth that scheduled ordinance provision of Indian health care is optional. And as we have heard from 

a speaker alluded to earlier, health care is a must; money is a must 

to develop health care. 

And as stated by my colleague from the Fort Peck Reservation, 

James Melbourne, he and I spoke, he says the issue of entitlement 

versus discretionary funding must be addressed by Congress. 

Health care provider for the Federal Government, as stated earlier, is based on the various acts and treaties, and for the Crow 

Tribe, it’s the 1868 Treaty at Fort Laramie, the 1904 Crow Tribe 

Federal agreement and the 1920 Crow Allotment Act. 

Despite all this, today we are facing that fact that Indian Health 

Service is appropriating less than half of the necessary funding to 

provide basic medical services for the Crow people. 

I bring to your attention, and I’ve attached it to my testimony, 

a recent article entitled ‘‘Cardiovascular Risk Factors in Montana—

American Indians With or Without Diabetes.’’

The rationing of health care for American Indians described in 

the recent Institute of Medicine report on racial and ethnic disparities, emphasizes the lack of resources for preventive care in this 

population. And certainly we know that we get a lot of lip service 

on prevention, but when it comes to providing money for the actual 

provision of those activities, we have no funds. 

I am now going to direct my comments to the health care as it 

is, as we experience it here on the Crow Reservation. And I know 

that in the audience, Crow people are listening to how I cover this 

topic. 

You have been inundated with statistics. I can see them coming 

out of your ears. I know that’s all you hear in Washington, D.C. 

Today, I am going to present some real information as to what it 

means for Crow people to receive health care. 

And before I do, I know that my comments and my observations 

may be perceived by some as bashing of Indian Health Service people, however, I want to take this time to commend the highly committed, the deeply compassionate and under appreciated health 

care professionals who serve our community. 

However, I must be honest about dire conditions that exist here 

on Crow Reservation so that we may work together to address the 

problems. And as alluded to earlier, these problems are apparent 

in all of the reservations within the Billings Area. 

55

I direct your attention to a meeting held in Billings, Montana 

August 2, 2006, wherein Dr. Charles Grim, the Director of the Indian Health Service, was asked for improved health services. Dr. 

Grim responded, quote, ‘‘Indian Health Service, people are the 

services.’’ So what does that do when you look at Indian health 

care, that means we look at people providing those services within 

the IHS system. 

As has been shared, in June of 2006, the Crow service unit fiscal 

deficit was approximately 4.3 million. At a meeting yesterday, I 

was told that the deficit is 12.3 for this year. I asked at that time, 

have you resolved that 4.3 deficit, and no, it has not. 

That just illustrates the accumulation of the deficits that have 

gone on here at the Crow service unit historically. 

I remember several years ago, I asked a question to the acting 

Service Unit Director about personnel and project costs. Again, I 

quote, ‘‘67 percent of the local budget was applied to personnel salaries.’’

I remember a comment that our esteemed chairman asked Dr. 

Charles Grim in Billings. He said, ‘‘If there are no funds for pay 

raises, why give it?’’ Dr. Charles Grim at the time responded that 

he got that money from third-party reimbursements. And we know 

that third-party reimbursements is a collection activity that sometimes is realized, most often not. 

Again, at the same meeting in Billings, Montana on August 7, 

2006, Billings Area IHS Director Pete Conway stated, quote, ‘‘As 

the dollar get’s tighter, there is a need to find ways to cut in other 

areas.’’ The implications of this statement are evidenced in many 

areas. 

For example, one, according to Indian Health Service, there has 

been a 46 percent increase in denials from Indian Health Service 

for services through the contract health service program from 2001 

to 2006. In an article in the Great Falls Tribune, IHS stated that 

it’s an effort to budget the funds available efficiently. 

Two, the deferred contract health service list increases daily. For 

those waiting in excess of several years and living in constant pain, 

there is often prolonged use of pain medication that cause a host 

of other medical problems, which may too go unaddressed due to 

the lack of funding. 

As people like to say, ‘‘if it ain’t broke, don’t fix it.’’ In this case, 

CHS is beyond repair. We pose a challenge for the decisionmakers 

in IHS to explore other options. If the CHS system is not working, 

come forth with something else that will. 

Third point, prescriptions originating from contract health care 

referrals are not filled locally. Over the counter medications are not 

provided locally. Certain drugs have been eliminated. The result is 

that financially strapped individuals are unable to purchase needed 

medications that have been prescribed for them. 

Many of us in here are working, but there are many Crow people 

living out there that have very little money to purchase over the 

counter medications. A member of the Crow legislative body 

brought to my attention the fact that his wife cannot get the arthritis medication that she had been receiving for treatment prior 

years. 

56

I go on to point four, access to proper health care is inadequate, 

and in many cases, is denied. I know every Crow person in this 

room listening to this testimony can provide examples of the deficiency and lack of health care, and I encourage those persons to 

share their stories with members of the Senate Committee. 

I will personally at this point share with you two cases involving 

members of my family. Additionally, I will be providing several 

more copies of letters that have been provided for me. 

Senator DORGAN. Ms. White, I want you to share both of those 

cases, and then following that, I need to have you summarize because we have to have the other testimony. 

Ms. WHITE. Thank you. Thank you. 

Senator DORGAN. But why don’t you share both of those cases. 

Ms. WHITE. First, you have here a very cute little girl in her native outfit, that was very hard work, good to see, but difficult. People say there is a thousand words in pictures. I show this picture 

of my 5-year-old granddaughter. This was taken at the Lodge 

Grass Pow-Wow last July. My granddaughter left us, she died 

short of a year ago. 

From May, 2006 to August of 2006, numerous visits were made 

to the clinic at Crow. During this time, Ta’shon (phonetic) was 

treated for depression. During one of her clinic visits, Ta’shon’s 

grandfather pointed out the bulbous condition on her fingertips and 

toes, which is indicative of a lack of oxygen. 

In June, 2006, I spoke with Ta’shon’s doctor and asked the doctor 

to eliminate cancer and leukemia. On August 7, 2006, my granddaughter was rushed from the Crow clinic to St. Vincent Hospital 

in Billings due to a collapsed lung. 

She was airlifted to Denver. After being there 5 days, we were 

told that she had a tumor that was untreatable and incurable. She 

died on September 1st. 

The point is, if she had been diagnosed earlier, could some of 

that have been prevented? I believe she spent the last 2 years of 

her life in unmedicated pain. One premature death of a child who 

suffered excruciating pain is too much for the conscience. 

Case two, Ta’shon’s great-grandmother, Ada Rides the Horse was 

brought to the Crow Emergency Room, waited 3 hours, taken by 

her daughter to the Hardin Clinic, transferred from the Hardin 

Clinic to St. V’s, she died in the Emergency Room from a ruptured 

aneurism. 

The RN who was working at the Crow Emergency Room says 

later to Ada’s daughter, I’m sorry, if I would have known, I would 

have taken your mother right in. 

Those are the two stories I’d like to share. There are other points 

here. We have received a lot of information. We compliment you, 

the support that you have given us. 

Pryor people, Lodge Grass people are concerned about the continual discussions about the possibility of closing those clinics, and 

again, the same financial considerations exist. People do not have 

the money to come to Crow. 

Again, you will get all the information, and I present this to the 

Committee. 

Thank you very much. 

[The prepared statement of Ms. White follows:]

57

PREPARED STATEMENT OF ADA M. WHITE, HEALTH SERVICE DIRECTOR, CROW TRIBE

To the august Members of the U.S. Senate, serving on the Senate Select Committee of Indian Affairs, welcome to Crow Country. On behalf of the Crow Tribal 

Members, I thank you for this opportunity to provide Crow Tribal Health concerns 

to this esteemed Body. 

My name is Ada White, I am a member of the Crow Tribe, and currently employed by the Crow Tribe as the Director of the Crow tribal Health Department. 

Previously, some 17 years ago, I worked in Tribal Health, as the Director of the 

Community Health representatives Program for nineteen years. I briefly worked for 

Indian Health Service for 18 months, and returned to Crow Tribal Employment in 

the Administrative Department (Finance, Social Services and Administrative Officer) for 10 years. I then became employed by the Little Big Horn College as the 

Grants and Contracts Officer for 3 years, and have been back with the Crow Tribe, 

at the Health Department for an additional 4 years. I share my employment history 

for the sole purpose in validating the commitment and involvement I’ve had in the 

various aspects of Tribal Health development. Throughout these years, the maintenance and protection of the Federal Trust Responsibility; the strengthening of Tribal Sovereignty, and the enhancement of Tribal self-determination have been dominant in my endeavors. 

Senator Dorgan, Senator Tester and other members of the Senate Committee on 

Indian Affairs, I commend your vigilance, in assuring the Indian Tribes of this 

Country that Indian Health Care is a Federal Trust Responsibility. 

However, as Tribal Groups continue to work with the Federal Government, this 

Trust Responsibility must be promulgated and enforced. According to my Colleague 

(James Melborne) from the Ft. Peck Reservation, ‘‘the issue of entitlement versus 

discretionary funding must be addressed by Congress.’’

On July 3, 2007, an article in the Great Falls Tribune stated, ‘‘access to and the 

availability of health care for the First Americans of this Nation was a trust contract in the Constitution in 1787.’’ Certainly, Members of the Crow Tribe firmly believe health care is assured in the Ft. Laramie Treaty of 1855. 

We are also cognizant of this Great Nation’s growing pains in affording basic 

human rights to its citizenry: the need for the Civil Rights Act; the need for the 

Voting Rights Act (there is a pending case here in Big Horn County, filed by the 

Citizens Equal Rights Alliance a right winged group alleging ‘‘denying non-tribal 

members an opportunity to participate effectively in the political process on an 

equal basis with other members of the electorate. .’’); the list can go on and on. To 

those associated with the current Administration in Washington, D.C. alleging ‘‘race 

based’’ considerations, I strongly urge their perusal of printed materials and studies 

which document racism in the delivery of health care; race based discrepancies in 

health care and funding restrictions prohibiting resource parity. 

I quote from an article, CARDIOVASCULAR RISK FACTORS IN MONTANA 

AMERICAN INDIANS WITH AND WITHOUT DIABETES, ‘‘Yet the rationing of 

health care for American Indians described in the recent Institute Of Medicine Report on Racial and Ethnic Disparities emphasizes the lack of resources for preventive care in this population.’’ A dichotomy is self-evident wherein a major study indicates a lack of funding for preventive care, and Indian Health is emphasizing 

Health Promotion and Disease Prevention. Or, most likely it’s the ‘‘catch up’’ syndrome. 

Honorable Senators Dorgan and Tester, we know you are monitoring this race 

based phenomena very closely, and you have voiced your displeasure, and for this 

we are most grateful. 

I will now proceed in localizing my observations to the Crow Tribal Health Care 

concerns. Let me emphasize, that my observations and comments are not to be interrupted as ‘‘Indian Health Service Bashings.’’ I know we have many Health Professionals highly committed, deeply compassionate and under recognized for their 

services. 

HEALTH CARE MEANS ACCESSING HEALTH RESOURCES. HEALTH CARE 

MEANS THE PROVISION OF HEALTH SERVICES. BEING HEALTHY MEANS 

A CONDITION OF WELLNESS, OR FEELING WELL. 

At a meeting in Billings, Montana, August 2, 2006, Dr. Charles Grimm, the Director of Indian Health Service was asked about the prospect for improved health services, and his response was, ‘‘Indian Health Service people are the services.’’ So this 

leads one to focus attention on ‘‘the people.’’

THE CURRENT STATE, RELATIVE TO HEALTH CARE, OF THE CROW INDIAN HEALTH SERVICE HOSPITAL AND CLINICS HAS EXCEEDED THE CRISIS MODE. What is being provided by Indian Health Service is woefully inadequate 

and can be classified as scandalous, unconscionable. 

58

Approximately 3 years ago, the Acting CEO of the Crow Service Unit stated that 

‘‘67 percent’’ of the local budget was applied to personnel salaries. 

June 2006, Indian Health Service indicated the Crow Service Unit fiscal deficit 

was approximately 4.3 million. 

August 2, 2006 at a meeting in Billings, Montana, Mr. Pete Conway, the Director 

of the Billings Area Indian Health Service stated: ‘‘As the dollar gets tighter, there 

is a need to finds ways to cut in other areas.’’ What implications does this comment 

bear locally, Consider:

1. According to Indian Health Service, there has been a 46 percent increase in 

denials from Indian Health Service for services through the Contract Health 

Service Program from 2001 to 2006. It’s an effort to budget the funds available, 

$520.5 million in Fiscal Year 2006 efficiently’’ (Great Falls Tribune Article, July 

3, 2007).

2. The deferred Contract Health Service surgical list increases daily. For those 

waiting in excess of several years, and experiencing continual pain, prolonged 

usage of pain medication leaves other undesirable results.

3.Prescriptions originating from Contract Health Care referrals are not filled locally. Over the Counter Medications are not provided locally.

Financially strapped individuals are unable to purchase needed medications. Is 

this a National policy for all Indian Health Service Facilities?

4. Access to proper health care is inadequate or in some cases denied. Each 

Crow Person in this room, listening to this testimony, can provide examples of 

unanticipated results of this concern. I personally share with you the following 

two cases.

Case One: My 5 year old granddaughter, Ta’Shon Rain Little light, died September 1, 2206. From May of 2006 to August 7, 2006, numerous visits were 

made to the Crow Clinic for services. During this time, Ta’Shon was being 

treated for depression. During one of the Clinic Visits, Ta’Shons Grandfather 

pointed out the bulbous condition of her finger tips and toes. This condition 

is indicative of a lack of oxygen. June 2006, I spoke with Ta’shons Doctor and 

I asked the Doctor to eliminate cancer and leukemia. August 7, 2006, My 

Granddaughter was rushed from the Crow Clinic to St. Vincent Hospital in 

Billings, Montana for a collapsed lung. The next day Ta’Shon was air lifted 

to the Denver Children’s Hospital, where she was diagnosed with an untreatable, incurable form of cancer. The question remains, what if this tumor was 

detected earlier, would it have made a difference? Our baby lived with 

unmedicated pain, the last 3 months of her life. Even one premature death 

is too much.

Case Two: June 2003, Ta’Shons Great Grandmother, Ada Rides Horse visited 

the Crow Emergency Room for stomach pain. After a wait of 3 hours, her 

daughter transported her to the Hardin Hospital (12 miles NW of Crow) for 

care. Ada Rides Horse was admitted, and then transferred to the St. Vincent 

Hospital in Billings, where she died in the Emergency Room from a ruptured 

aneurysm. The ordeal did not end here. The RN who was working in the 

Crow Emergency Room later approached Ada Rides Horse’ daughter and said: 

‘‘I’m sorry, if I were clairvoyant, I would have taken your mother right in.’’

5. The excessive waiting time for services (Out Patient Clinic, ER, Pharmacy) 

needs to be addressed. Throughout the years, the local facility has tried to modify some of the national trends and adapt them for local operations, but rather 

that producing a positive result, the bureaucratic stratum increases. Case at 

hand is having a walk in clinic; add walk in clinic plus a speciality clinic; add 

walk in clinic, speciality clinic, plus prescheduled appointments with specified 

providers. Tuesday, August 8, 2007, I waited 3 hours at the Out Patient Clinic, 

then I was called to the ER for care. The waiting continues, patients become 

angry, and providers become defensive.

The problem in waiting, and not having enough providers on a given day could 

be addressed by having some of the professional health administrators, including 

the Commissioned Officers Corp provide some ‘‘hands on’’ care. Again, I am reminded of Dr. Grimm’s Statement that Our health care is the ‘‘Indian Health Service People.’’

I inquired about the list of Medical Professionals posted on the wall in the Crow 

Waiting Room, and the ER Nurse stated that ‘‘1⁄2 of them have left.’’ This may be 

so, however, three of the current Physician’s are employed part-time (Wilson, L. 

59

Byron, Upchurch). This certainly affects the level of care, and may also affect the 

recruitment process, because it ties up 1.5 positions. 

Our distinquished Crow Tribal Chairman, Mr. Carl Venne asked Dr. Charles 

Grimm, the Director of Indian Health Service, ‘‘if no additional funding is provided 

for pay raises, why give it? ’’ Dr. Grimm responded, ‘‘We make up for this with third 

party reimbursements.’’ What impact does the fluctuations in third party collections 

have on this reasoning? Futhermore, a pay and time audit may be necessary to fully 

understand the issues surrounding employee pay. What we do know is that the salary and benefits for Commissioned Officer Corp Members runs much higher than 

it does for a Civil Service Employee. 

There are several other concerns that impact the level of resources, which impacts 

the level of care.

1. It has been reported to the Crow tribal Health Board that non-beneficiaries 

receive treatment at the Crow facility. The concern becomes one in determining 

whether reimbursements are received for these services?

2. Vacant positions need to be advertised and filled according to established procedures and Federal requirements; in lieu of filling these positions, contracts 

are awarded for services. Is there a sizable cost savings in this procedure? Recently there was controversy in the way the Director of Nursing position was 

filled, and then ‘‘unfilled.’’ Actions of this sort impact the morale of the service 

Unit, which in turn impacts the kind of service Crow People receive.

Certainly, we applaud the efforts of this Senate Committee on Indian Affairs and 

their passionate support in pursing the: reauthorization of the Indian Health Care 

Improvement Act; recognizing the effects of Diabetes and addressing the Special Diabetes initiative. Yet the need for quality health care, which resonated in the past, 

and continues today, is an ever present challenge. How does the equalization in 

health care occur? As long as we have a dual health care system (the haves and 

the have not’s); as long as socioeconomic disparities are apparent, there is going to 

be a continual need for this Committee Senators. 

The provision of Dialysis is a health concern, and Indian Health Service can no 

longer bury its head in the sand, hoping this issue will dissipate. We need one funding source for this, available for all Tribes. Diabetes is the fifth (out of ten) ranked 

health problem for the Crow Reservation. 

We need to continually fund the Epidemiology Center serving the Billings Area 

Tribes. The data collected will be made available to and will be utilized by the specific Tribes. 

Funds need to be identified and made available for HPV immunizations. A recent 

article in the Billings Gazette identified the Crow reservation as having the highest 

reported cases of HPV infections. Approximately 50 percent of the Crow Tribal enrollment is under the age of 30. This is the age group with pronounced sexual activity. 

Long term planning and resource identification needs to be addressed for the 

problems associated with aging, especially for the ‘‘baby boomers.’’ It is anticipated 

that Cancer and Diabetes will have an increased prevalence in this group. Expanded 

care for this age group includes: nursing home care; assisted living; independent living services (including home monitoring and health tracking measures); ophthalmology; prosthetics; mental health. 

Senators, the Crow People have a rich heritage. There is a bit of ethnocentrism, 

for Crow Speakers still abound, traditional and cultural practices are adhered to. 

It is this identity has been the cohesiveness quality that has kept the Crow Tribe 

distinct among other groups. 

Again, thank you for this opportunity to share the Health Concerns of the Crow 

People.

Senator DORGAN. Ms. White, thank you very much, and thank 

you for your powerful statement, and we grieve for your loss of that 

beautiful young girl. 

Let me also thank you for 17 years of work in Indian health care. 

That’s great dedication. We appreciate your being here and we will 

read very carefully the testimony you have presented as well. 

State Representative Jonathan Windy Boy. Representative 

Windy Boy, thank you very much for coming. Let me ask if you 

would summarize. 

60

I think following your testimony, we will hear from Mr. Moke 

Eaglefeathers as well. So if you would summarize, we would appreciate it very much. 

We thank you for your service and thank you for being here, 

Representative. 

STATEMENT OF HON. JONATHAN WINDY BOY, COUNCIL

MEMBER, CHIPPEWA CREE TRIBE BUSINESS COMMITTEE; 

MONTANA REPRESENTATIVE, HOUSE DISTRICT 32

Mr. WINDY BOY. Thank you Chairman Dorgan and Senator Tester for having this hearing. 

For the record, my name is Jonathan Windy Boy. I’m a member 

of the Chippewa Cree Tribal Council, and also State Legislator representing House District 32, Chairman of the Rocky Boy Health 

Board, and also been appointed Chairman of the National Caucus 

of Native American State Legislators Committee on Health. 

I’m going to kind of zip through my testimony here because you 

can probably get a copy of it and highlight it. 

The situation today is the under-funding of Indian health care 

and American Indian health disparities. Under-funding of Indian 

health care for some time now in the United States is not under 

the true meaning of health services for American Indian people. 

The medical inflationary rate over the past 10 years sat at 11 

percent. The average increase for IHS accounts over the same period has been only 4 percent so that those numbers are kind of off 

a little bit from each other on the true need. 

In FY 1984, IHS services account received 777 million; in FY 

1993, the budget totaled 1.5 million. Still 13 years later in 2006, 

the budget for health services was 2.7 billion, when to keep pace 

with inflation and population growth, this figure should be more 

like 7.2 billion. 

American Indians die at higher rates than other Americans from 

tuberculosis at 600 percent higher; alcoholism, 510 percent higher; 

motor vehicle crashes, 229 percent higher; diabetes, 18 percent 

higher; unintentional injuries, 152 percent higher; homicides, 61 

percent higher. 

There are many challenges in the existing health care budget, 

and one of the things that you have heard earlier from some of the 

Federal Government is that Medicaid third-party reimbursements 

has been accounted for. 

And I think the misnomer with that, I feel is that should not be 

included in IHS funding, because that is pretty much a given for 

the tribes and the states at 100 percent last year. So I think that 

should be excluded from the IHS budget. 

You know, Mr. Chairman, Senator, aside from all of these facts 

and figures and all of that, I want to go back to a real life happening at home. I have an aunt that’s 77 years old. For several 

years now she’s been diagnosed as a diabetic. She travels to Great 

Falls Monday, Wednesday and Friday for dialysis. That’s 120 miles 

from Rocky Boy to Great Falls. 

I have some of my constituents at home that go to dialysis three 

times a week to Billings, and that’s 250 miles one way. 

So if you take those figures, you’re looking at 1500 miles a week 

to Billings, approximately 720 miles to Great Falls and back. 

61

If you can imagine the same situation with Fort Peck having to 

come to Billings, which is approximately 300 miles one way, and 

if a diabetic has to go through the dialysis that’s needed just to 

stay alive, the remoteness that we have is one of the factors that 

tribes in Montana are up against. 

Fort Belknap is in a similar situation. They’re about 200 miles 

from Billings, round-trip 400, multiply that times three, 1200 

miles. Great Falls is about 160 miles one way. So the remoteness 

is really a factor that hasn’t really been placed into call here. 

One of the things when you’re talking about contract health services, right now in the middle of July, we have over 360-some thousand dollars short in my contract health services budget, and I still 

have 3 months to go. And if I’m going to be only having to provide 

life or limb for those members, I’m going to be in a real stickler 

here very shortly. 

One of the things too, you know, about recently with the contract 

health dollars, there’s something that isn’t talked about. You know, 

when a person who has an emergency to them which does not fall 

under the regulations of IHS regulations, then that individual will 

go to the Emergency Room. In my case, we go to Havre or Great 

Falls. 

If they don’t fit under those standards, qualifications to receive 

contract health service dollars, then those bills are going to accrue 

and accrue and accrue, and finally those hospitals are going to send 

them to the credit bureau and that’s a reality. And I’m even on 

that credit bureau for health services. 

One of the things too, you know, it was kind of ironic to hear 

that a dentist from Helena that testified in Senator Baucus’ hearing on CHIP a couple months ago, provided testimony, and why it 

was ironic to me is because he said that there was a child who 

needed surgery, orthodontic surgery, a child from Box Elder, and 

that’s, come to find out that’s one of my grandkids. And if they had 

waited a couple more days, that child would have died from that. 

So, you know, the levels of what the Feds and everybody else 

tells you, that everything’s fine and dandy, you know, that’s a 

bunch of hogwash. 

Every time as a tribal leader, we go to D.C., we go to HHS, we 

go to different departments. The one thing that they tell us, is 

okay, you go back to the states, we’ve funneled more money into 

the states that you’re eligible for. We have grants that the tribes 

are eligible for. 

If you know the granting process, there’s 560-some tribes across 

the country, and if we have to complete, the ones with the best 

grant writers are going to get the money. So that’s another thing 

that we’re up against as tribal leaders as well. 

And also, too, on Medicaid, we talk about Medicaid and the barriers that we see. One of the things that we see on my local level 

is, I’ll give you an example of an elderly couple. Right away that 

elderly couple, on any reservation, when they see a brand-new, 

spanking new car come driving up the driveway, a non-native guy 

looking like Jon Tester—in jest, Jon—but anyway, right away 

they’re going to be cautious. 

They’re going to take a couple of steps back because they’re not 

going to trust. Trust is a real thing that we’re up against as far 

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as one of the barriers. And I think in order to make the Medicaid 

eligibility process, we need to train our home to be in that process. 

So again, I want to thank you for having this hearing, and thank 

you for letting me be a part of your panel, and I’ll be open for questions. 

Thank you. 

[The prepared statement of Representative Windy Boy follows:]

PREPARED STATEMENT OF HON. JONATHAN WINDY BOY, COUNCIL MEMBER,

CHIPPEWA CREE TRIBE BUSINESS COMMITTEE; MONTANA REPRESENTATIVE, HOUSE

DISTRICT 32

Good afternoon, Chairman Dorgan and Senator Tester. My name is Jonathan 

Windy Boy. I am an enrolled member of the Chippewa Cree Tribe of Rocky Boy’s 

Reservation and a citizen of the beautiful State of Montana. I have the honor to 

serve as a council member for the Chippewa Cree Tribe Business Committee. I also 

serve as a Representative in the Montana State Legislature, House District 32. I 

serve as the Chairman of the Rocky Boy Health Board, the governing body for the 

Chippewa Cree Health Center. I also serve as the chair of the Montana Wyoming 

Tribal Leaders Council—Subcommittee on Health and I was recently appointed the 

interim Chairman of the National Caucus of Native American State Legislators’—

Subcommittee on Health. I appreciate this opportunity to address the healthcare 

issues of the Montana Tribes. I would like to thank the Committee for the opportunity to testify at this ‘‘Field Hearing on Indian Healthcare.’’

Before I begin this testimony, I would like to reaffirm the foundation of the provision of health services in relationship to the sovereign status of Tribes.

‘‘No right is more sacred to a nation, to a people, than the right to freely determine 

its social, economic, political and cultural future without external interference. The 

fullest expression of this right occurs when a nation freely governs itself.’’

The Late Joseph B. DeLaCruz, Former President, Quinault Nation, 1972–1993.

The Foundation: Tribal Sovereignty and the Provision of Health Services 

The overarching principle of Tribal sovereignty is that Tribes are and have always 

been sovereign nations, Tribes pre-existed the Federal Union and draw our right 

from our original status as sovereigns before European arrival. 

The provision of health services to Tribes is a direct result of treaties and executive orders entered into between the United States and Tribes. This Federal trust 

responsibility forms the basis of providing health care to Tribal people. This relationship has been reaffirmed by numerous court decisions, Presidential proclamations, and Congressional laws. 

The Situation Today: Underfunding of Indian Healthcare and American Indian/Alaska Native Health Disparities 

Underfunding of Indian Healthcare 

For some time now, the United States has not funded the true need of health 

services for AI/AN people. The medical inflationary rate over the past 10 years has 

averaged 11 percent. The average increase for the Indian Health Service (IHS) 

health services accounts over this same period has been only 4 percent. This means 

that IHS/Tribal/Urban Indian (I/T/U) health programs are forced to absorb the mandatory costs of inflation, population growth, and pay cost increases by cutting health 

care services. There simply is no other way for the I/T/U to absorb these costs. The 

basis for calculating inflation used by government agencies is not consistent with 

that used by the private sector. OMB uses an increase ranging from 2–4 percent 

each year to compensate for inflation, when the medical inflationary rates range between 7–13 percent. This discrepancy has seriously diminished the purchasing 

power of Tribal health programs because medical salaries, pharmaceuticals, medical 

equipment, and facilities maintenance cost Tribes the same as they do the private 

sector. 

In FY 1984, the IHS health services account received $777 million. In FY 1993, 

the budget totaled $1.5 billion. Still, thirteen years later, in FY 2006 the budget for 

health services was $2.7 billion, when, to keep pace with inflation and population 

growth, this figure should be more than $7.2 billion. This short fall has compounded 

year after year resulting in a chronically under-funded health system that cannot 

meet the needs of its people. 

63

As the Federal Government develops models that aim to reduce or eliminate racial and ethnic disparities (i.e., ‘‘Closing the Gap’’) a balance needs to be made between the Federal deficit model (comparison to All U.S. Races) and a positive development model. Otherwise health policy (and the subsequent allocation of funding toward Indian healthcare) will be determined on the basis of Tribes being a 

marginalized minority and not as sovereign nations with distinct treaty rights, 

which have been negotiated with the ‘‘full faith and honor of the United States of 

America.’’

American Indian/Alaska Native Health Disparities 

American Indians have long experienced lower health status when compared with 

other Americans. Disproportionate poverty, discrimination in the delivery of health 

services and cultural differences has contributed to the lower life expectancy and 

disproportionate disease burden suffered by American Indians. American Indians 

born today have a life expectancy that s 2.4 years less than the US All Races. 

American Indians die at higher rates than other Americans from:

• Tuberculosis—600 percent higher • Alcoholism—510 percent higher • Motor Vehicle Crashes—229 percent higher • Diabetes—18 percent higher • Unintentional injuries—152 percent higher • Homicide—61 percent higher

Some of these health disparities are historic. Alcoholism continues to be a serious 

challenge to American Indian health. Since its introduction to Tribal people early 

in this Nation’s history, alcohol has done more to destroy Indian individuals, families and Tribal communities than any disease. Today in 2007, Tribal people are 

dying at a rate 510 percent HIGHER than other Americans from alcoholism. The 

overall impact of these health disparities has made us ‘‘at-risk’’ communities, weakened and vulnerable. In fact, as reported in a Denver, Colorado newspaper, the 

Wind River Reservation in Wyoming was targeted by Mexican drug cartels because 

of their history with alcoholism. The drug dealers figured that the Tribal community 

(already inundated in alcohol addiction) would be easy to infiltrate for drug distribution. Their business plan included marrying into the Tribe, giving free samples to 

get people addicted and then get them to distribute to support their addiction. This 

is an approach that is being implemented throughout Indian Country. 

Given the significant health disparities that Tribal people suffer, funding for Indian healthcare should be given the highest priority within the Federal Government. Many of the diseases that Tribal people suffer from are completely preventable and/or treatable with adequate resources and funding. 

The Challenges: Access to Medicaid Services, Medicaid and Medicare Reimbursements, Recruitment and Retention of Health Providers 

Access to Medicaid Services 

The IHS budget cannot provide the health services needed thus Tribes must depend upon alternate health resources, such as, Medicaid for critically needed 

healthcare for our people. The Indian health system is funded at less than 60 percent of need and is heavily dependent upon Medicaid. Understanding this, accessing 

Medicaid is an important health issue. 

The barriers to accessing Medicaid have been identified by Tribes through out the 

years. Though there has been some positive movement, many of those identified barriers still remain. The most critical of those identified is the application and eligibility determination process. This is the first gate and if a Tribal member cannot 

get through the first gate—access to needed healthcare is denied. The application 

and eligibility determination barriers are often protocols developed to ‘‘cost contain’’ 

or manage the National Medicaid budget. Unfortunately, Tribal people often cannot 

afford to jump through the ‘‘hoops’’ of a budget management protocol and the denial 

of access to care can be disastrous for the individual Tribal member and their family. 

In FY 2004, the Chippewa Cree Tribe and the Confederated Salish & Kootenai 

Tribes partnered with the State of Montana and CMS/Region VIII to begin discussion on how to alleviate the barriers to accessing Medicaid for the Montana Tribes. 

In May 2007, the Chippewa Cree Tribe signed an agreement with the Governor of 

Montana and the State of Montana to contract Medicaid Eligibility Determination. 

Having the ability and authorization to determine Medicaid eligibility onsite at our 

Tribal healthcare center will facilitate access to care for eligible Indian users that 

are eligible Medicaid users. Getting access to healthcare through Medicaid to those 

eligible Montana citizens (whether Indian or non-Indian) as soon as possible beneVerDate 0ct 09 2002 10:35 Dec 12, 2007 Jkt 038721 PO 00000 Frm 00067 Fmt 6633 Sfmt 6621 S:\DOCS\38721.TXT JACK PsN: JACKF
64

fits the recipient and the State of Montana. A healthy state community is one where 

its citizens can fully participate in education, employment and economic development. 

Medicaid and Medicare Reimbursement 

Thirty-one years ago, in 1976, in response to the health conditions in Indian 

Country, Congress provided the IHS and Tribes with the authority to bill for and 

receive Medicaid and Medicare reimbursements for services provided to American 

Indian beneficiaries. Today, Medicaid and Medicare reimbursements provide a critical source of supplemental funding for the underfunded IHS and Tribal healthcare 

delivery service programs. 

Originally Congress did not intend for Medicaid revenue to ‘‘offset’’ the strained 

Indian Healthcare budget but to supplement it. Today, the IHS and Tribes are expected to bill and collect for Medicaid to replace IHS appropriations. In the FY 2008 

budget Request Congressional Justification includes specific amounts of Medicaid 

and Medicare collections (total of $625,193,000) as part of its total FY 2008 President’s request of $4.1 billion. Members of the Committee, we need this situation 

remedied in order to realize an appropriate level of funding for Indian healthcare. 

The Indian health system is funded at less than 60 percent of need and is heavily 

dependent upon Medicaid payments. States receive 100 percent FMAP for Medicaid 

services provided in an IHS or Tribal facility. These facilities have a limited capability to provide all needed direct care. Any health care not provided by the facility 

is referred to a private or public provider. The state must then provide the regular 

state Medicaid match for that eligible Indian user/eligible Medicaid user. Thus 

states are given an incentive to limit the benefits that American Indians referred 

to outside providers would receive under the state Medicaid plan. 

A current issue relating to both Medicaid and Medicare is the imposition of increased cost sharing or premiums. States may charge a co-payment for medical services or drugs. The rationale for charging co-payments is to achieve a more appropriate utilization of Medicaid covered services. First of all American Indian participation is very low and the imposition of a co-pay has a negative effect as many 

American Indians cannot afford even a modest co-pay (and why would they if they 

can receive services from IHS without a co-pay). This could prevent them from enrolling in Medicaid or Medicare, which could deprive the chronically underfunded 

IHS or Tribal facility critical Medicaid revenue. 

Imposing a co-payment has not changed the utilization of American Indian Medicaid or Medicare beneficiaries because IHS and Tribes do not charge co-pays to 

their beneficiaries. Instead co-pay amounts are cost shifted to the Indian health programs, causing a further reduction to services they can provide. 

Recruitment and Retention of Health Providers 

The recruitment and retention of health providers has been a barrier to effective 

healthcare delivery for Montana Tribes. As in most rural areas of this Nation, Montana Tribes are challenged with providing a continuity of care, because of a high 

turnover of healthcare providers. Montana Tribes are located in geographically isolated areas (only Alaska has a remoteness designation more severe than Montana). 

Montana is considered a ‘‘frontier’’ area with a population of less than 6 people per 

square mile. 

It is a challenge to recruit health providers that will commit to a long term, interact and invest in the Tribal Community and work to understand and respect the 

Tribal culture and traditions. These attributes for health providers are imperative 

to the effective provision of healthcare for our Tribal communities. Ideally, most 

Tribes want a Tribal member as their healthcare provider, knowing that a Tribal 

member would have the maximum investment for their community. 

Chairman Dorgan and Senator Tester, it will take the commitment of the Administration, the U.S. Congress, the State of Montana, and the Montana Tribes to insure that the issues I have presented are addressed and accomplished by reauthorizing the Indian Healthcare Improvement Act. The provisions of the IHCIA will insure that Montana Tribes will have access to building the healthy Montana Tribal 

communities where healthcare is more than a promise but a reality for every man, 

women and child. I thank you for this opportunity to provide testimony.

Senator DORGAN. Representative Windy Boy, thank you very 

much. Thanks for your service in the state legislature, and thank 

you for coming today to testify. 

65

Our final witness is Mr. Moke Eaglefeathers, President of the 

National Council of Urban Indian Health and Director of North 

American Indian Alliance. 

He is accompanied by Ms. Marjorie Bear Don’t Walk, Director of 

the Indian Health Board of Billings. 

I might mention that we had a meeting in Washington D.C. a 

while back and Mr. Eaglefeathers was there as well. 

So, let me ask you to proceed for the final bit of testimony, and 

let me see if we can get a microphone over to you. 

Mr. Eaglefeathers, why don’t you proceed. Once again, if you 

would please summarize, your entire statement will be made a part 

of the permanent record. 

MELBERT ‘‘MOKE’’ EAGLEFEATHERS, PRESIDENT, NATIONAL 

COUNCIL OF URBAN INDIAN HEALTH; DIRECTOR, NORTH 

AMERICAN INDIAN ALLIANCE; ACCOMPANIED BY MARJORIE 

BEAR DON’T WALK, DIRECTOR, INDIAN HEALTH BOARD,

BILLINGS, MT 

Mr. EAGLEFEATHERS. It is an honor for me to be here on behalf 

of the National Council of Urban Indian Health, which is a 36-

member organization, and 120,000 urban Indian patients that are 

served annually. 

I would like to take this opportunity to thank you, and the opportunity to provide the testimony and address an assessment of the 

Indian Health Care Improvement Act. 

My name is Melbert Eaglefeathers. You know me as ‘‘Moke’’. I 

am the Executive Director of the North American Indian Alliance 

here in Montana. I also serve as the President of the National 

Council of Urban Indian Health. I am a Northern Cheyenne enrolled member here in Montana. 

I am honored to serve as a representative of the urban Indian 

population. Thank you for providing me the opportunity to testify 

in support of the reauthorized Indian Health Improvement Act. 

Urban Indian Health program has spent the last year regrouping 

and solidifying relationships with local and national tribal leaders. 

One thing Salish Kootenai was to work on tribal relationships, I’ve 

spent many hours in tribal leaders’ offices and meetings discussing 

health concerns. To understand this issue is to look at our next 

generation for our health care issue. 

At this time, I would like to turn to my colleague, Marjorie Bear 

Don’t Walk, to talk about the Montana program. 

Thank you. 

Senator DORGAN. Thank you very much. 

Ms. Bear Don’t Walk, why don’t you proceed? 

Ms. BEAR DON’T WALK. Good afternoon, Chairman Dorgan, Senator Tester. 

I would like to say that the Urban Indian Health program, we 

need more money. At the present time 67 percent of Indian people 

live off the reservation and they receive 1 percent of the Indian 

Health Service budget. By saying that, I would also like to say, 

that we do not receive any funds for contract care. 

So, for all of the people who are having problems getting contract 

care money, we have none. So our problem with contract care is 

that if you are ill and you need contract care, you can forget it. 

66

The other problem that we have is we need more dollars, period. 

One percent of the budget provides the minimal health care, which 

is very insulting to any Indian person, let alone a hurting Indian 

person who is not eligible for contract care anywhere. 

In Billings, there are about 10,000 Indians, about half of them 

are Crows and they are eligible for contract care. About a fourth 

of them are Northern Cheyenne, and they are ineligible for contract care, even though it is the Crow/Northern Cheyenne hospital. 

All of the others, and the largest number are Sioux and Chippewas, 

are not eligible for contract care. 

I am a member of the Confederated Salish and Kootenai Tribe. 

Forty-one years ago, when I was young and foolish, I married a 

Crow Indian. 

[General laughter.] 

Senator DORGAN. All right, you’re done testifying. 

[General laughter.] 

Proceed, I’m sorry. 

Ms. BEAR DON’T WALK. His name is Urban Bear Don’t Walk, and 

I have worked in urban health in excess of 20 years. So, it is kind 

of interesting for the definitions of Indian people, of reservation 

and urban Indians, when urban Indian, the name Urban came 

from a fifth century pope who urbanized Europe. 

So we have been branded with the term ‘‘Urban Indians’’. And 

I hear very often that urban Indians have more opportunity for 

health care. That truly is bull. The Indians who have opportunities 

in urban areas are the Indian Health Service workers who have insurance. 

Almost all of the other Indians that I know of, unless they work 

for the Federal Government, do not have insurance. So if you’re 

working two jobs or three jobs and you have children and you need 

health care, you’ve got to make a choice, you can use Indian Health 

or someplace else. 

I have felt that we need to advocate for all Indian people, that 

we are all considered as the people who were here when Columbus 

landed. 

The Federal Government has done a lot to divide us all, and I 

would like to see that stop. And we have continued, as Indian people, to divide ourselves also, and I think that we need to stop that 

also. 

We, as Indian people, are here in the area of a large number and 

my children, while they are Salish and Crow, are enrolled as Crow 

Natives. 

So I would like to ask the Senate to give more money to urban 

Indians for health care, and I would like to see the health care of 

urban Indians to be as valuable as anybody else’s health care. 

I would like to see Indians, the money appropriated per capita 

for people in the United States, I would like to see where Indian 

people are no longer at the bottom of that list. 

I thank you very much. 

[The prepared statements of Mr. Eaglefeathers and Ms. Bear 

Don’t Walk follow:]

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PREPARED STATEMENT OF MELBERT ‘‘MOKE’’ EAGLEFEATHERS, PRESIDENT, NATIONAL

COUNCIL OF URBAN INDIAN HEALTH; DIRECTOR, NORTH AMERICAN INDIAN ALLIANCE


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PREPARED STATEMENT OF MARJORIE BEAR DON’T WALK, EXECUTIVE DIRECTOR, 

INDIAN HEALTH BOARD, BILLINGS, MT


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Senator DORGAN. Thank you very much for your testimony. 

Thanks to all of you for your testimony. 

I know that you have told on occasion a North Dakota joke. 

We’ve told a Montana joke from time to time over on the North Dakota side of things, but I must tell you that coming to Montana 

today has been really impressive for me. 


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The number of people who have attended this hearing, your passion, the statements by the witnesses, that is impressive and a 

very powerful, strong statement. 

You come here at a time when there is a Crow Fair, which I’m 

told, I’ve not attended it, but I’m told is widely attended and much 

anticipated. I hope all of you have a wonderful opportunity to participate in that. 

Chairman Venne has been wonderful today to me and to Senator 

Tester, as well. 

I’m going to have to leave in a little while, and I hope you will 

excuse me. I think you will when I tell you why. 

I have to be on an airplane at the Billings airport, and the reason I have to be off an airplane about midnight tonight, is tomorrow morning I am taking my daughter to college as a freshman, 

and we’re driving her to college for her first year of college. And 

so you understand, I hope, how important that is to me to be there 

and catch that airplane. 

So I will take my leave in a few minutes and ask Senator Tester 

to continue chairing the remainder of this hearing. 

I also want to say this, David Mullon, who I introduced earlier, 

is a member of our staff, has been a member of the staff as a Chief 

of Staff and now Chief of Staff to the minority, David is from the 

Cherokee Tribe in Oklahoma. David is right here. 

Heidi Frechette, sitting over there, Heidi, would you stand up? 

Heidi is a counsel, an attorney on our staff in the Indian Affairs 

Committee, and she is from the Menominee Tribe in Wisconsin. 

At the end of this hearing, both David and Heidi will also be 

here and available to spend time with those who have some issues 

you want to discuss personally with our staff. And I’d like you to 

feel free to seek them out if you would. 

My understanding also is that Senator Tester will, following 

questioning of this panel, be taking some brief statements by other 

tribal officials who have come today and who have not been able 

to testify. 

But if you will allow me to take my leave for the purpose I have 

described, I want to tomorrow morning be driving my young daughter to her first year in college, and so I want to catch that airplane 

out of Billings. 

But again, let me say a heartfelt thanks, and to tell you this, 

with Senator Tester, myself, Senator Baucus, and so many others, 

we will work very, very hard. 

This is not just some other time. This is the time for us to demand that these things get fixed, and I pledge to you that’s what’s 

going to happen. We’re going to work and work and work, and 

we’re going to get things fixed and make some progress. 

So, let me with that turn it over to Senator Tester to chair the 

remainder of the hearing, and I thank you for your hospitality and 

your passion, and I say God bless to all of you. 

Senator TESTER. Senator Dorgan, I just want to express my 

thanks to you, Senator Dorgan, as Chairman of the Indian Affairs 

Committee and a true leader in the U.S. Senate for the work that 

you have done, really working for, not only the folks in Indian 

Country, but everybody in the United States that needs help. 

79

Thank you very much for your commitment and your public service to this country. 

I do have a few questions, and we’ll kind of jump around a little 

bit. 

I’ll start with Joe, if you’ve got a mike that works, Joe, in front 

of you. 

First of all, Joe, my compliments to you on really a top rate organization. You’ve done a great job educating folks in Indian Country, 

and I hope you continue in that venue for many, many more years. 

You talked a little bit about having tribal colleges do the training 

for everybody, not everybody, but as many people as possible that 

could deal with health care in Indian Country. And you had talked 

about in 1989 you had one nurse in the program and now you’ve 

got as many as 46. 

Over the last few years, I’ll ask you the same question I asked 

Dr. Moore, have you been able to track where any of these students 

have ended up at? Have you been able to determine whether these 

they stayed in Salish Kootenai Country. or have they gone to some 

other reservation somewhere else? 

Dr. MCDONALD. Yes, pretty well. I could go to the nurse director. 

We have their pictures on the wall, and that way I could point at 

the nurse and she would tell me pretty much where they’re at because it’s very close, and we did keep track of them. 

Senator TESTER. Did most of them stay in Indian Country? 

Dr. MCDONALD. The American Indian nurses stayed, they most 

generally stayed. We just lost one to Portland. The Sisters of Providence made an offer to her she couldn’t turn down. 

Senator TESTER. Okay, good. 

You talked about adequate funding for tribal colleges in order for 

you to be successful, in order for students being able to afford to 

go to your institution. 

Just where are you at funding-wise as far funding for trial colleges if we’re going to push this along, are you underfunded, are 

you adequately funded, where are you at? 

Dr. MCDONALD. We’re really underfunded for nursing. Nursing 

costs the college about $10,000 per student. 

Senator TESTER. Okay. 

Dr. MCDONALD. And our money we get on the Student Tribal 

College Act is about $5,000. We try to keep the tuition down for 

them, so we get about $7,500 of that $10,000. 

Senator TESTER. Well, thank you. It’s good to know that nursing 

is something that’s going to require some additional resources. 

Would you pass the mike down to Ada, if you’re available for a 

few questions. I do have a few for you. 

I asked, I think I asked Pete Conway about the working relationship between Indian Health and the tribes, so I’m going to ask you 

the same question. 

I want to start with your perspective, and I hope it’s the same, 

but I’m asking the question to find out. Is your working relationship that you maintain within your health service, would you classify it as productive, cooperative, adversarial overall? 

Ms. WHITE. I think it’s a work relationship that is fairly—there’s 

a lot of mutual respect, a mutual coming together sharing ideas. 

80

There are points that I raise and I make them very aware that 

my presence there is most often in an advocacy position. I may articulate, I may question in a manner that may be a little 

confrontational, or whatever, but it’s a give and take, I believe a 

productive relationship. 

Senator TESTER. Good, outstanding. 

You are put in a very difficult position because you have to make 

health care decisions when they have more sick people than they 

have money. How do you do that? How do you deal with that? 

Ms. WHITE. You’re asking me how I make health care decisions 

in view of restrictive funds? 

Senator TESTER. Correct. 

Ms. WHITE. I try to put myself in the shoes of the medical providers, and I look at the doctors, some of them being extremely capable and competent, not being able to take care of what’s presented to them. 

Now, having explored that, sometimes I marvel, I wonder what 

goes through their heads, because on my side of the point, certainly 

we have very limited funds to operate on. Certainly we’re not the 

direct service provider that IHS is, but I am sensitive to that issue, 

that there is a profound need for more funds. 

Senator TESTER. Okay. 

You talked about, and I just want to make sure that I heard 

what you said, you said that there is no money for prevention; did 

I hear that correctly? 

Ms. WHITE. My comments had to be tailored somewhat from my 

original draft that I sent you. That’s why I resubmitted those copies of the information I received. 

I am a person that believes in the buck stops here. If I’m in a 

position to make a decision, I certainly do, and if I have to defer 

to higher-ups, I certainly do that. 

However, in response to your question, what do we mean by prevention and promotion? It becomes a semantical game. I believe 

that the money is not there for people to do an adequate job in promoting health information, health concepts and in providing the 

opportunities for promotion to exist. 

We’re at a point where that is a novel idea. I do not see how we 

can emphasize promotion and prevention when basic care is not 

being provided. You have to be well to listen. 

You have to have the information at an early age. You have to 

be educated to understand what some of the ideas are, and I think 

sometimes we get bogged down with lofty ideals. 

Senator TESTER. That’s a good point. 

I’ll just tell you that for both promotion and prevention, to my 

perspective, is one and the same because it’s about education. But 

I hear what you’re saying. Thank you very much, Ada. 

Jonathan Windy Boy, I’ve got a question or two for you. Jonathan, good to see you again. I want to tell you that you being in 

the legislature, you understand that oftentimes we’re put in positions where you’ve got X number of dollars and you need to spread 

it around between health care and infrastructure projects and education. 

Sometimes I see this as being in the same boat, where you’re pitting one tribe against another tribe for financial resources. 

81

My question is, and they may already be doing it, so you’ll have 

to enlighten me on this, how can Montana Indian Nations work together to promote and improve health care in Indian Country and 

not be in competition with one another? 

Mr. WINDY BOY. Well, first of all, thank you, Mr. Tester. I think 

there is a number of ways that the tribes and the government can 

work together. 

First of all, one of the things, to use an example of what we did 

most recently, in 2003, if you recall, there was the Medicaid redesign—or 2005, I’m sorry, the Medicaid redesign that came in effect. 

And what that allowed us to do is to demonstrate how to stretch 

the dollar for health care. 

And what that basically did, it allowed the tribes and the state 

to do, is to think outside the box, basically. The result of that was 

to try to access existing resources that are available, and in this 

case, Medicaid, Medicare, was that vehicle. 

Realizing that Federal dollars have been limited to the IHS accounts, there are other resources outside that, and CMS has definitely been a part of that. 

Demonstrating part of that, Senator Tester, is that we have 

partnered with the state of Montana. Governor Schweitzer has 

come to the table and we have signed agreements. And I think that 

while the atmosphere is friendly, I think it’s best that we take advantage of that to try to think outside the box. 

And realizing that, like you mentioned, that the dollars are limited to make it stretch, but I think by doing that, we’re going to 

make things better hopefully for everybody. 

Senator TESTER. Okay, thank you. 

I’ll just say that the point that you made, and you made many 

good points, but one of the points that you made that I thought was 

particularly appropriate, especially for Montana, is the remoteness. 

And, you know, people back in Washington, D.C. talk about rural 

areas. We’re beyond rural, we’re frontier. It’s a huge issue when 

you talk about distance in this state to get quality health care. And 

it’s something that when we talk to our folks back east that are 

administering the programs, the only way you can ever appreciate 

it is if you drive between Rocky Boy and Billings and back in the 

same day. That’s one hell of a drive. So, you know, that’s important. 

I want to pass it down to Stacy and Jace, and I’ll just ask a question, either one of you can answer it. Do you have a working mike? 

Just curious how the needs of Montana tribes compare with 

other tribes in the Nation. 

Mr. KILLSBACK. Well, like I mentioned before, the tribes in Montana are large land-based tribes with large populations, and our 

needs reflect those of the direct service tribes. 

Another example is during the budget formulation process this 

year, the tribes got together and said the number one priority, instead of piecemealing prevention, different types of health care 

needs, we all came together at the table and said contract health 

service is the number one priority. And that’s the message we need 

to take to D.C. when you do describe the needs. 

Senator TESTER. So the major disparity between Montana tribes 

and other tribes in the U.S. is in contract health care? 

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Mr. KILLSBACK. I think it could be seen as a possibility because 

we are direct service tribes and we don’t have the access to—well, 

the money is a big factor and that’s why contract health is the 

number priority here as well. 

So I believe our area and Aberdeen Area, those areas with a 

large population of urban areas, these populations are served, have 

similar issues concerning funding, have similar relations concerning health care, access to health care. 

Ms. BOHLEN. Can I say something about that? 

Senator TESTER. Yes, Stacy. 

Ms. BOHLEN. Thank you, Senator Tester. 

I think that one of the real challenges that Indian Country faces 

is the lack of reliable data on where the disparities specifically are, 

who’s being treated, who’s being turned away, what the outcome of 

a person being turned away is, where do they go from here, do they 

ever get care. 

At the National Indian Health Board, we’re trying to come up 

with programs, like we’re trying to work with the American Academy of Orthopedic Surgeons to get a volunteer orthopedic program 

for the Indians in this state. And it’s very difficult to start because 

we don’t have the data about where everyone is, what the problems 

are. 

I think that’s something that Congress could really help with. 

Senator TESTER. And as the good doctor, Joe Erpelding said, the 

data is probably not necessarily good data, and so we need to work 

on that. 

I’m going to take just a few minutes here to have some other 

comment by elected officials, and I’ve got to get out of here by 

shortly after 3, so I’m in the same kind of boat. 

What I’m going to do is this, if we could get a representative, if 

you want, if you can add to it, to talk about health care. I know 

there’s a lot of other issues, but health care is it. 

Go ahead, state your name for the record and what tribe you represent. You’re going to have 2 minutes, and I’ve got to hold you 

strictly to it, otherwise I can’t give everybody a chance to speak. 

Go ahead. 

STATEMENT OF DARRYL RED EAGLE, TRIBAL EXECUTIVE 

BOARD MEMBER, FORT PECK ASSINIBOINE SIOUX TRIBE 

Mr. DARRYL RED EAGLE. Thank you, Senator Tester. My name 

is Darryl Red Eagle. I’m tribal executive Board member for the 

Fort Peck Assiniboine Sioux Tribe. 

Senator TESTER. Sir, what I’ll ask you to do is talk into that 

mike, summarize your statement, your written testimony. You will 

turn it in and it will be a part of the record. So summarize it very 

quickly. I’m sorry, but this is not something we normally do anyway. 

Speak into that other mike, please. 

Mr. RED EAGLE. The Fort Peck Tribes appreciate the committee 

having this hearing in Montana, and urge swift passage of this Act. 

If you have any questions, we will be glad to respond. 

Thank you. 

[The prepared statement of Mr. Red Eagle follows:]

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PREPARED STATEMENT OF DARRYL RED EAGLE, TRIBAL EXECUTIVE BOARD MEMBER, 

FORT PECK ASSINIBOINE SIOUX TRIBE


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TESTIMONY OF JOHN MORALES, JR., CHAIRMAN, ASSINIBOINE AND SIOUX TRIBES, 

FORT PECK RESERVATION


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Senator TESTER. Thank you very much. Next up? 

STATEMENT OF CAROLE LANKFORD, VICE–CHAIR, SALISH 

KOOTENAI TRIBES; ACCOMPANIED BY KEVIN HOWLETT, 

HEALTH DIRECTOR, SALISH KOOTENAI TRIBES 

Ms. LANKFORD. I am Carole Lankford, Vice-Chair of Salish 

Kootenai Tribes. I want to thank you for coming out and giving us 

this opportunity. 

We are submitting written testimony and I would also like to 

give my tribal health director a chance to say a few words. 

Senator TESTER. Thank you. 

Mr. HOWLETT. Senator Tester, my name is Kevin Howlett, I’m 

the Health Director for the Salish Kootenai Tribes. I would just 

like to thank you for holding this hearing. 

I think the issues that have been addressed have been certainly 

sincere, and I think that as you look across Indian Country, it isn’t 

just Crow, it’s every reservation that has these kinds of issues. 

Things have got to change. People have got to think about this 

differently and we really have to move health care into the twentyfirst century. 

We will be submitting testimony, and thank you and Senator 

Dorgan for having us at this hearing. 

Senator TESTER. Thank you, I appreciate it, and the problems 

are not exclusive to here, but all Indian Country. 

Go ahead. 


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STATEMENT OF TRACY ‘‘CHING’’ KING, COUNCIL MEMBER, 

FORT BELKNAP INDIAN COMMUNITY, ASSINIBOINE TRIBE 

Mr. KING. Good afternoon, Senator Tester, my name is Tracy 

‘‘Ching’’ King, I’m the Assiniboine representative at large of Fort 

Belknap. 

I want to personally thank you for looking into the matter of my 

daughter who is a combat vet of the Iraq war and the mistreatment she had with the Veterans Administration in Helena. I appreciate that. 

But I’d also like to say that the Tribal Council believes they don’t 

have a good relationship with Indian Health Service. If you look at 

the disparities of the funding, it’s somewhere in the 60 percent 

range. 

In the corporate world, Wall Street, there’s like incentives built 

into some of the people in corporate America. Corporate America 

executives received $154.9 billion, billion. for incentives for the past 

10 years. 

And the top 20 executives in Wall Street, their salary is 260 mil- lion and up to $1.5 billion totaling $13 billion that corporate America gets. 

170 years ago, my grandfather fought with Sitting Bull, my three 

grandfathers, and I come from a family of leaders and veterans. My 

daughter is a combat vet. My nephew is a combat vet, my brother, 

and I think we need to listen to our needs. 

Thank you. 

Senator TESTER. Appreciate your comments, appreciate your 

service and your family’s service. 

Next up? 

STATEMENT OF JULIA DAVIS WHEELER, TRIBAL COUNCIL 

MEMBER, NEZ PERCE TRIBE 

Ms. JULIA DAVIS WHEELER. Yes, good afternoon. Good afternoon 

everyone, my brothers and sisters that are here. My name is Julia 

Davis Wheeler, and I’m a Nez Perce Tribal Council woman from 

the Nez Perce Tribe in Idaho. 

The Nez Perce Tribe is one of the 42 tribes in the northwest that 

count on contract support costs to take care of the majority of our 

major health needs. We do not have hospitals, even though in our 

treaties it’s stated that we would have hospitals. 

Nonetheless, having no hospitals, we need to have inpatient facilities. Regional centers of excellence would be a great help in 

helping those of our people that are suffering. 

The Nez Perce Tribe is a self-governance tribe by choice of the 

General Council, not the Tribal Council, the General Council. This 

has been a good move, but this also comes with inadequate funding. I just returned from a self-governance meeting in Bellingham, 

Washington, and we talked about that issue. 

The tribe has been working tirelessly with the issue of trying to 

recoup contract support costs that were formerly withheld for certain Fiscal Years. We’re trying to get that money from the Indian 

Health Service. 

Claims have been dated back to 2005. Two years later we received letter after letter stating that the $600,000 claim that we 

have put in has not been processed. This is a shame. This is a 

96

shame and an atrocity to the people that are counting on contract 

health service. 

I wanted to bring this to your attention, but I also wanted to 

echo what everyone has stated here. 

But I want to end my comments with something that is very 

near and dear to me, as well as the descendants of chiefs here in 

this room. 

Chief Joseph stated 120 years ago; I have heard talk and talk, 

but nothing is done. Good words do not last long until they amount 

to something. Good words do not give my people good health and 

stop them from dying. Good words will not give my people a home 

where they can live in peace and take care of themselves. I’m tired 

of talk that comes to nothing, it makes my heart sick. But I remember all the good words and all the broken promises. Too many 

misrepresentations have been made. Too many misunderstandings 

have come up between the white man about the Indians. There 

need be no trouble, treat all men alike, give them all an even 

chance to live and grow. All men were made by the same Great 

Spirit Chief. They are all brothers and the Earth is the mother of 

all people. 

I end my speech with this from Chief Joseph. Thank you. 

Senator TESTER. Thank you. 

STATEMENT OF EUGENE LITTLE COYOTE, PRESIDENT 

NORTHERN CHEYENNE TRIBE 

Mr. LITTLE COYOTE. Good afternoon. I’m Eugene Little Coyote, 

President, Northern Cheyenne Tribe. 

I’ll be very brief. Of course, the Northern Cheyenne Tribe strongly encourages and supports the reauthorization of the Indian 

Health Care Improvement Act. 

We have three priorities we were going to mention today, diabetes and dialysis, methamphetamine prevention. We have a war on 

meth on the Northern Cheyenne, and I’d like to mention that 

Chairman Venne and the Northern Cheyenne Tribe have a interdepartmental coalition, Safe Trails Task Force. We’re doing very 

well on that. 

Third is contract health care. We need increased funding in all 

areas of Indian health care, and the Northern Cheyenne will submit a detailed written testimony on these. 

Thank you. 

[The prepared statement of Mr. Eugene Little Coyote follows:]

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PREPARED STATEMENT OF EUGENE LITTLE COYOTE, PRESIDENT NORTHERN

CHEYENNE TRIBE


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Senator TESTER. Thank you very much, Eugene, appreciate it. 

STATEMENT OF LEO STEWART, VICE–CHAIRMAN, 

CONFEDERATED TRIBES OF UMATILLA INDIAN RESERVATION 

Mr. STEWART. Good afternoon, my name is Leo Stewart. I’m the 

Vice-Chairman of the Confederated Tribes of Umatilla Indian Reservation, which consists of Walla Walla—I almost said Nez Perce 

because the Cayuse is part of the Nez Perce and the Umatillas. 

One of the things, we would like to thank you a lot for reintroducing the Indian health care plan. 

Another thing, too, is that we have strong care need, like Julia 

Davis said about the Indian health care for hospitals in our areas. 

It’s really a need. 

It shouldn’t specifically be put into designated areas, but into the 

remote areas that would help our people a lot, and the reaching out 

for these kinds of funds to make these things work. 

Another thing, too, is to the support of all our funds that is important to let the unfairness of facility construction fund is when 

it takes over 50 percent of IH budget increases to phase in staff 

and to new facilities, and only three to four of the areas get the 


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participant end of facility construction plan, so that’s what we 

need. 

So I’d just like to thank you and thank you for letting me have 

this time. 

Senator TESTER. Thank you for your comments. 

And this applies to everybody, we take written comments, so 

please, if there’s more that you wanted to say that you couldn’t, 

write them and send them in. 

Go ahead. 

STATEMENT OF EDWIN LITTLE PLUME, CHAIRMAN, HEALTH 

COMMITTEE, BLACKFEET TRIBAL BUSINESS COUNCIL 

Mr. LITTLE PLUME. Good afternoon, Mr. Tester, appreciate you 

coming back to Montana, as well as Mr. Dorgan, Senator Dorgan. 

We appreciate your good words for funding for us back in D.C. 

As a new member of our Tribal Council, I sit on the health committee and chair that committee. As you know, being a new guy 

like yourself in Washington, I experience pretty much the same on 

our home reservation, funding for health care. 

Our hospital, in the 30 years since the original facility expansion, 

many variables have changed. Most noticeably, the hospital visits 

have continued to increase steadily over the time from 60,000 outpatient visits in 1984 to 124,000. 

Our hospital has become a regional hospital, which originally 

was designed for the Blackfeet people which our treaty stated. 

At this time, our hospital visits takes in patients from all the 

urban centers in the state of Montana. We have patients coming 

from Illinois, Idaho, Minnesota, Oregon, Washington State, North 

and South Dakota, are traveling to the Blackfeet Community Hospital in Browning for their health care needs. 

The Browning hospital, which was designed for the health of the 

Blackfeet people has become a regional health facility for many 

other tribes. The impact of this has become very noticeable to our 

own people as their needs for health care are not being met. 

So, with that, I thank you for listening to today’s testimony. 

[The prepared statement of Mr. Little Plume and Ms. Tatsey follow:]

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PREPARED STATEMENT OF EDWIN LITTLE PLUME, CHAIRMAN, HEALTH COMMITTEE, 

BLACKFEET TRIBAL BUSINESS COUNCIL AND JANE TATSEY, HEALTH

ADMINISTRATOR, BLACKFEET TRIBE HEALTH DEPARTMENT


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Senator TESTER. Thank you. 


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STATEMENT OF ANDY JOSEPH, JR., CHAIR, HEALTH AND 

HUMAN SERVICE COMMITTEE, COLVILLE CONFEDERATED 

TRIBES 

Mr. JOSEPH. Good afternoon to my friends here in the Crow Nation and Senator Tester. My name is Andy Joseph, Jr. I’m the chair 

of the Health and Human Service Committee for the Colville Confederated Tribes. 

I’m also the Vice-Chair for the Northwest Portland Indian Health 

Board of 43 tribes in Washington, Idaho and Oregon. 

The testimony that I’d like to give is on the IHS budget. The Office of Management and Budget requires the staff to work on rulesbased budget.For the last 4 years we’ve had to work on a rulesbased budget of 2 percent or 4 percent. 

This last meeting we requested a 23 percent increase in current 

spending. That pays for the pay act, Federal employees get a raise 

every year. It covers the inflation and it also covers the population 

growth for all of the nations. 

By being stuck with a rules-based budget every year, we have to 

go back there. Dr. Grim negotiates for us the funding that has been 

given and he’s not a tribal leader. I want to see tribal leaders at 

the table. 

I pushed a resolution to have a leader from NCAI, a leader from 

the National Health Board, a direct service type representative to 

be at that table. Government staff according to Executive Order 

should not be talking for us. 

As you know, he’s a commissioned officer and he doesn’t have the 

high rank to tell his superiors what we really need, and he’s paid 

to save money for the government, but it’s costing a lot of our people’s lives. 

I imagine if you took the numbers down of all the people we’ve 

lost over the years, we’d be right up there with our soldiers that 

we’re losing in Iraq. 

Senator TESTER. Please, please put it in written testimony. I’m 

literally going to have to walk out of here in 1 minute. So thank 

you very much. 

Mr. JOSEPH. We’ll send in our written testimony from the Northwest Portland Area Indian Health Board on our health care status. 

Senator TESTER. I appreciate that very much. 

The next two very quick comment, I mean very quick comment 

because I’ve got to boogie. 

STATEMENT OF MS. WALK ABOVE, MEMBER, CROW TRIBE 

Ms. WALK ABOVE. Good afternoon, Jon Tester, I’m (inaudible) 

Walk Above. I’m a parent, I’m a member of the Crow Tribe. 

My baby has been having health problems, which he’s okay now, 

but I have these bills and I’ve written to the hospital here for them 

to pay for my bill and have them pay for it, and they didn’t approve 

it. 

So I wrote a letter to the Indian Health Service in Billings and 

they denied my letter. So I wrote a letter to Washington, D.C. I 

haven’t heard from them yet, but I would really appreciate it if 

they would help me. 

And I’m glad that you’re here to hear our testimonies because we 

cannot go to Washington, D.C. and to go and see you. 

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Thank you. 

Senator TESTER. That’s one of the reasons we’re here. Thank you 

very much. 

STATEMENT OF KEN REAL BIRD, REPRESENTATIVE, CROW 

TRIBE 

Mr. REAL BIRD. Thank you, I’m Ken Real Bird. I’m a victim of 

this flawed health——

Senator TESTER. Are you an elected official? 

Mr. REAL BIRD. Yes, I represent the legislative branch of the 

Crow Tribe. I’m a victim of this outfit right here. And I think that 

there needs to be some law so the issue of malpractice is addressed 

by IHS doctors. 

See, when they do something wrong, it’s acceptable because 

they’re covered by IHS, but the individual who causes the problems, the doctor needs to be liable for some of the things that they 

have done. 

Now, there’s so many problems with the IHS, especially in management. And one of the things that I’d like to bring out is that 

us Indian people have to wait 5 hours or more to get health care. 

Senator TESTER. Could you do me a favor? Could you write it 

down and send it in because——

Mr. REAL BIRD. Yes, I could send it out. I’ve written two letters 

before you were elected. I wrote one to Burns and Baucus on this 

issues of my problems that I’ve dealt with. 

Thank you. 

Senator TESTER. That would be great. If you could do that, that 

would be marvelous. Thank you. 

At this point in time, I have to hurry and I’d like to thank you 

because we’re out of time. I want to first of all thank some staff 

people here, Mark Jette and Amanda Arnold from my staff; Anna 

Sorrell from Governor Schweitzer’s staff; Richard Litsey and Jim 

Corson from Senator Baucus’ staff; and David Mullon who is from 

Senator Murkowski’s staff, the ranking minority. 

I will tell you this, there was one lady that got up and spoke 

from the Nez Pearce that talked about Chief Joseph, talked and 

talked and nothing was done. 

I can tell you this, and I can speak for Senator Dorgan when I 

say that, it takes 60 votes to get things done in the U.S. Senate 

so we can’t do it alone, we need 58 other people to help us out. 

But we will work and we will work and we will continue to work 

to make sure that health care is adequate in Indian County. We 

will be diligent on that, make no mistake about it. 

And finally I want to thank the folks who provided us with the 

facility and the great dinner. 

I want to thank Chairman Carl Venne. Carl, I want to thank you 

very, very much, not only for your friendship but for your hospitality and courtesy in doing all the work necessary to help pull this 

thing off. 

Thank you very much. 

Before we go, I want Carl to get the last word in. 

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STATEMENT OF CARL VENNE, CHAIRMAN, CROW TRIBE 

Chairman VENNE. Senator, I want to thank you for coming and 

the committee. If you look at that map of the United States over 

there, it says Council of large land-based tribes. That’s where most 

of the Indian people live. That’s where most of the land is that Indians own, and we are the poorest of the poorest in the United 

States of all ethnic groups. 

It’s sad to see when you look at the Federal budget, when you 

see wild horses out in the Pryors, when we in this region are in 

the red for $48 million and they give them horses, which we don’t 

ride or don’t eat, $40 million a year. 

Something is wrong in this country. We, as Indian leaders, need 

to speak up. We don’t beg no more. It’s rightfully yours because of 

the treaties that we have done with these United States. 

During the time of war, 70 percent of all young men and women 

from all of the tribes enlist to go to war. Did you know that? You’re 

the largest population or ethnic group in these United States who 

serve this country, but yet to be treated like we are today, is not 

good. 

We, as leaders, have to speak up. You should be mad at what 

this administration has done to Indian tribes throughout the country. 

They wanted to do something way a long time ago when they infested army blankets and gave it to us and everybody got smallpox 

and died. Is that what is still going on today with this administration? 

No, don’t take a backseat to nobody. You’re entitled as Indian 

people. 

The Indian people working for Indian Health Service, don’t be 

afraid to speak up. You know what is wrong. You know what we 

need. How can Dr. Grim sit in his office and say no, we don’t need 

no more money when he has a committee that says we need a lot 

more money. 

What is going on in this country? We’re not begging the U.S. 

Government. They made promises. 

I can only speak for my tribe, if you look at the Powder River 

Basin, the billions and billions of dollars that this government has 

made off of it, and yet we’re treated like this today. It’s time for 

Indian leaders to get up and speak. 

And I want to thank Senator Tester and his Committee for coming to Crow Country, and I appreciate what they’re trying to do for 

us, but we need to speak up and back them up. We need to get out 

the vote also. 

Thank you. 

[Whereupon, at 3:15 p.m. the hearing was adjourned.] 

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APPENDIX

PREPARED STATEMENT OF THE CONFEDERATED SALISH AND KOOTENAI TRIBES OF THE

FLATHEAD NATION


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PREPARED STATEMENT OF DICK BROWN, PRESIDENT, MHA—AN ASSOCIATION OF

MONTANA HEALTH CARE PROVIDERS


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PREPARED STATEMENT OF LAURENE JOHNSON, MEMBER OF THE CONFEDERATED

SALISH AND KOOTENAI TRIBES


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PREPARED STATEMENT OF LOU STONE, MEMBER OF THE SNGAYTSKSTX TRIBE


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PREPARED STATEMENT OF MARGARET NORGAARD, CEO, NORTHEAST MONTANA

HEALTH SERVICES (NEMHS)


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PREPARED STATEMENT OF GWEN CLAIRMONT, MEMBER OF THE CONFEDERATED

SALISH AND KOOTENAI TRIBES


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PREPARED STATEMENT OF JOHN SINCLAIR, PRESIDENT, LITTLE SHELL TRIBE OF

CHIPPEWA INDIANS OF MONTANA


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Attachments


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PREPARED STATEMENT OF GORDON BELCOURT, EXECUTIVE DIRECTOR, MONTANA–

WYOMING TRIBAL LEADERS COUNCIL


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Attachment


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PREPARED STATEMENT OF THE FORT BELKNAP INDIAN COMMUNITY COUNCIL


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PREPARED STATEMENT OF DAVID B. MYERS, M.D., BILLINGS MT


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PREPARED STATEMENT OF CAROL JUNEAU, STATE SENATOR, SENATE DISTRICT 8, 

MONTANA


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PREPARED STATEMENT OF BARRY ADAMS, BROWNING MT


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PREPARED STATEMENT OF ALEX WARD, ASSOCIATE STATE DIRECTOR, AARP MONTANA


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PREPARED STATEMENT OF THE NEZ PERCE TRIBE


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Æ


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