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38–552 PDF 2007

S. HRG. 110–214

NOMINATION OF CHARLES W. GRIM TO BE

DIRECTOR OF THE INDIAN HEALTH SERVICE

HEARING

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS 

UNITED STATES SENATE

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

JULY 26, 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 July 26, 2007 ............................................................................... 1

Statement of Senator Barrasso ............................................................................... 21

Statement of Senator Coburn ................................................................................. 2

Statement of Senator Domenici .............................................................................. 26

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

Statement of Senator Murkowski ........................................................................... 4

Statement of Senator Smith ................................................................................... 32

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

Statement of Senator Tester ................................................................................... 5

WITNESSES

Grim, Charles W., D.D.S., M.H.S.A, Assistant Surgeon General; Director, 

Indian Health Service, U.S. Department of Health and Human Services ...... 8

Prepared statement .......................................................................................... 12

Biographical information ................................................................................. 16

Smith, Chad, Principal Chief, Cherokee Nation ................................................... 5

APPENDIX

Letters of support for Dr. Grim’s nomination ....................................................... 41–87

Nomination withdrawal letter ................................................................................ 103

Written Questions Submitted to Charles W. Grim ...............................................88–102

(1)

NOMINATION OF CHARLES W. GRIM TO BE 

DIRECTOR OF THE INDIAN HEALTH SERVICE 

THURSDAY, JULY 26, 2007

U.S. SENATE, COMMITTEE ON INDIAN AFFAIRS, Washington, D.C. 

The Committee met, pursuant to notice, at 9:30 a.m. in room 

485, Senate Russell Office Building, Hon. Byron L. Dorgan, Chairman of the Committee, presiding. 

OPENING STATEMENT OF HON. BYRON L. DORGAN,

U.S. SENATOR FROM NORTH DAKOTA 

The CHAIRMAN. We will call the hearing to order. 

This is a hearing of the Senate Indian Affairs Committee, a hearing on the nomination of Charles Grim to be Director of the Indian 

Health Service. 

The two witnesses today I will introduce: The Honorable Chad 

Smith, Principal Chief, Cherokee Nation of Oklahoma; and Dr. 

Charles Grim, who is the Director of the Indian Health Service, 

U.S. Department of Health and Human Services. 

This hearing, as I said, is about the renomination or the nomination for Charles W. Grim to continue to serve as Director of the Indian Health Service. 

If I could ask the two witnesses to take their place at the table. 

Today, the Committee meets to consider the nomination of Dr. 

Charles Grim to be Director of the Indian Health Service. On May 

21 of 2007, President Bush sent Dr. Grim’s nomination to the Senate. This is a reappointment for another term of 4 years. Previously, Dr. Grim was confirmed by the Senate as Director and was 

sworn into office in the summer of 2003. 

I will ask today that we hear an introduction from the Chief of 

the Cherokee Nation. I will call on my colleague, Dr. Coburn, for 

remarks in a moment. I note that Dr. Grim is no stranger to this 

Committee. I believe you have already appeared on three occasions 

in this year alone to present the Department’s views on the Fiscal 

Year 2008 budget request, the Special Diabetes Program, and reauthorization of Indian Health Care and other matters. 

All of us know that the Indian Health Care Improvement Act 

was last reauthorized in 1992. Legislation to amend and reauthorize the Health Care Improvement Act has been considered by the 

106th, 107th, 108th, 109th and now the 110th Congress. 

At our hearing on the Indian health bill in early March, Dr. 

Grim, you accompanied Dr. John Agwunobi, the Assistant Secretary for Health, and both of you pledged to work with this ComVerDate 0ct 09 2002 11:30 Dec 20, 2007 Jkt 038552 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 S:\DOCS\38552.TXT JACK PsN: JACKF
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* The information referred to has been printed in the Appendix. 

mittee toward the enactment of reauthorization of the Indian 

Health Care Improvement Act. I reiterate my goal of accomplishing 

reenactment during this Congress. 

The Committee has received statements of support today from a 

wide number of people and interests for Dr. Grim’s nomination: 

The Choctaw Nation of Oklahoma, the Commissioned Officers Association of the U.S. Public Health Service, the Cherokee Nation, 

the American College of Obstetricians and Gynecologists, the Albuquerque Area Indian Health Board, the Chief of Psychology at 

Massachusetts General Hospital of Harvard Medical School, the 

Seminole Nation of Oklahoma, and let me include all the rest of 

them in the record. Those are just a few. 

I ask consent that these and other letters be part of the record 

of today’s hearing. * 

Before I recognize the Vice Chairman, I want to state what the 

process will be for moving this nomination forward. Committee 

members will ask questions this morning, and more will be submitted to you in writing, Dr. Grim. Once the Committee has received the responses and Members feel their questions have been 

answered, we anticipate we will seek to report out this nomination 

at the next scheduled business meeting, again providing that we 

have received the responses. 

We appreciate your being here today, and appreciate your work 

on a wide range of issues. 

The Vice Chair of the Committee is not yet here, but she is on 

her way. Let me call on Dr. Coburn. 

STATEMENT OF HON. TOM COBURN,

U.S. SENATOR FROM OKLAHOMA 

Senator COBURN. Thank you, Mr. Chairman. I am grateful to you 

for this opportunity to introduce somebody we all know and respect 

and a fellow Oklahoman as the President’s choice to head the Indian Health Service for another 4 year term. 

He really needs no introduction to our Committee. He has been 

a friend to this Committee and all of us who seek a new direction 

for Indian health care for many years. His efforts to modernize the 

delivery of health care in Indian Country have often been met by 

resistance within the bureaucracy and here in Congress, but he 

continues his fight nonetheless with class, integrity and a tireless 

commitment to the people he serves. If you can’t tell by his accent, 

Dr. Grim is a proud Oklahoman and he is also a proud member of 

the Cherokee Nation. 

While his distinguished career has taken him all over the Country, and now to Rockville, much of it has taken place in our home 

State of Oklahoma. He was born in Tulsa, lived in Cushing and 

grew up in Cushing, graduated from the University of Oklahoma. 

He has served his State as a practicing dentist, as well as at the 

Indian Health Service as Administrator in Oklahoma City. 

In his later capacity as Oklahoma City Area Director, Dr. Grim 

was responsible for the delivery of IHS programs for all of Oklahoma, Kansas and parts of Texas. If you don’t know what an awesome task that is, let me kind of describe it. In addition to Kansas 

3

and Texas operations, the system served over three dozen Oklahoma tribes, an estimated 12,000 hospital admissions a year, and 

1.3 million outpatient visits a year. His system hospital region delivered almost 2,700 babies a year as well. 

The experience in Oklahoma City gives Dr. Grim a very unique 

and important perspective on the state of Indian health care. I 

would guess the Oklahoma region is probably the most diverse 

within the system. Among our nearly 40 tribes, you see everything 

from cutting edge health care to near Third World conditions. You 

will see tribes operating their own standalone health care facilities 

like the Cherokee Nation and others, and then you will see traditional IHS-directed health care. You will see innovative preventionbased medicine and you will see long Soviet-style lines for treatment of chronic disease. 

Dr. Grim has seen it all, the good, the bad and the ugly. More 

important, he has seen how Federal policies, funding priorities, and 

bureaucracies can rob tribal citizens of even the most basic health 

care options. 

I want to applaud Dr. Grim for his commitment to collaborating 

with other Federal and non-Federal agencies to make the most of 

the scarce resources he has had, and for his particular passion for 

disease prevention, which is the answer for our health care problems. 

In a very real sense, the future of Indian health care is in the 

hands of this Committee and Dr. Grim. We can choose to fight 

business as usual and policies that say the current system is good 

enough, or we can take this historic moment to revolutionize health 

care for tribal citizens. 

Do we empower tribal citizens to make their own health care decisions? Or do we leave them hostage to a system designed for the 

last century? The choice is ours to make. 

In the months ahead, we must turn our attention to reauthorization of the Indian Health Care Improvement Act. The experience 

of Dr. Grim as Director will continue to be an invaluable asset as 

we move forward. We should leave no option off the table, and I 

believe one of those options must be health care portability and 

competition for those in Indian Country. 

Tribal citizens have a right to quality health care, not the right 

to a promise of quality health care. If the current system isn’t serving their needs, the ought to be given the right to access that need 

wherever they can find it. I am looking forward to the hard work 

that lies ahead of us. 

In closing, I want again to express my confidence in you, Dr. 

Grim, in your leadership. The man before us has proven that. He 

is up to the task and capable and committed to the mission at 

hand. Government programs and bureaucracies matter little when 

they fail the very people they are intended to serve. Dr. Grim realizes this and that is why I am extremely pleased that President 

Bush has asked for us to confirm him yet again. 

And one final note I would note. There is a great personal sacrifice for Dr. Grim in fulfilling this mission. His wife and kids remain at home in Hobart. He has a 1-year old. The travel and time 

away is extremely stressful on both him, his wife and his kids. 

4

Your example of sacrifice to serve this Nation does not go unnoticed. 

The CHAIRMAN. Senator Coburn, thank you very much. 

Vice Chairman Murkowski? 

STATEMENT OF HON. LISA MURKOWSKI,

U.S. SENATOR FROM ALASKA 

Senator MURKOWSKI. Thank you, Mr. Chairman. 

You know, it seems like just yesterday that Chuck Grim was 

sworn in to lead the Indian Health Service. It was August 6 of 

2003. I was there. On August 6, Chuck Grim was sworn in as the 

seventh Director of the Indian Health Service on the campus of the 

Alaska Native Medical Center in Anchorage. Secretary Tommy 

Thompson was there. You took the oath in the company of Aleuts, 

of Eskimo, Indians, and the health care providers that serve them. 

I thank you for honoring Alaska’s native people in this way. I don’t 

believe that you have let us down in any way. 

Four years later, you are back before this Committee seeking 

confirmation for a second term. I appreciate the comments of my 

colleague here from Oklahoma. There are probably a few people 

that are wondering why you are back for the re-up and why do you 

want this job again. You will certainly have an opportunity to answer that question this morning. But we recognize that this is not 

an easy job. You can be assured that this Senator understands 

that. It is not easy coordinating health care delivery in some of the 

most remote corners in the Country. It is not easy recruiting health 

care professionals to work in those remote places. It is not easy to 

recruit people to work in facilities that are too old, that are too 

small, that lack decent employee housing, and in some cases lack 

running water and indoor plumbing. 

We know that it is not easy to address the perplexing rates of 

chronic disease in Indian Country. It is not easy to hold the responsibility for lowering the rates of diabetes and suicide in Indian 

Country. 

We also know that it is not easy doing your job knowing that Administrations, past and present, have chronically under-funded Indian health care delivery. It is not easy to see other elements of 

your department, like NIH and CDC, get generously plussed-up on 

the Senate floor, while you are lucky to make by with single digit 

increases, not even enough to cover inflation. 

And we know that it nos easy facing the Chairman’s ever more 

creative questions about how much money you think this Nation 

can spend on Indian health care delivery. And it is not easy answering him knowing full well that these decisions are in no way 

within your control. 

It is not easy to do your job knowing that this Nation spends 

more money providing health care to prisoners than it does to Indians. And it is not easy to confront slogans like ‘‘don’t get sick after 

June’’ because the contract health money has run out. 

So if you were to choose to stand down after six very successful 

years, four as Director and two as Interim Director, I would certainly understand. But I am glad that you have decided to re-up, 

if you will, for another term. I am not alone in this. The Committee 

has received letters of endorsement from the Friends of Indian 

5

* The information referred to has been printed in the Appendix. 

Health and from tribes and tribal organizations who have written 

on your behalf. Mr. Chairman, I would ask that they be made a 

part of the record. I have here 22 different letters of support. * 

I personally appreciate your unwavering support for the Dental 

Health Aide Therapist Program for Alaska. We know that without 

your support, we might not have been able to work out what I believe was truly a win-win situation with the dental profession that 

ended the lawsuits and puts the focus on care where it needs to 

be. 

In the exercise of our responsibilities, the Committee, as you 

know, will probably have some tough questions for you this morning, but as you tackle those questions, don’t forget for a minute 

that we all appreciate what you have done and what you have to 

work with. 

We don’t get to say ‘‘thank you’’ often enough, so I want to close 

on those words. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Senator Murkowski, thank you very much. 

Let me call on the Honorable Chad Smith, Principal Chief of the 

Cherokee Nation of Oklahoma. Chief Smith, why don’t you proceed, 

following which I will call on Dr. Grim. 

Let me ask you to hold for a moment. I see our colleague Senator 

Tester has arrived. I would like, before we take testimony, Senator 

Tester, if you have any opening comments, I would be happy to 

have them at this point. 

STATEMENT OF HON. JON TESTER,

U.S. SENATOR FROM MONTANA 

Senator TESTER. Thank you, Mr. Chairman. Sorry I am late. 

I would just say that there is plenty of work to do in Indian 

Country when it comes to health care and making it function. I will 

be interested to hear your comments. I will ask some questions 

afterwards, but I think that you know as well as we the kind of 

situation that is going on Indian Country and how we need to have 

some real proactive work to get it fixed. 

So thank you. 

The CHAIRMAN. Senator Tester, thank you very much. 

Chief Smith? 

STATEMENT OF CHAD SMITH, PRINCIPAL CHIEF, CHEROKEE 

NATION 

Mr. SMITH. Thank you very much. 

My name is Chad Smith, Principal Chief of the Cherokee Nation. 

It is my honor to appear in front of you this day to express our support and desire that you confirm Charles—we usually call him 

Chuck—as the leader of the Indian Health Service. Charles Grim 

has been a great friend to Indian Country. He has great support. 

The thing that we share with him is a vision about increasing 

the health care for Indian Country. One of the great initiatives that 

we have had in partnership with the Indian Health Service helped 

led by Dr. Grim is the Joint Venture Program. For example, in 

Muskogee we are just finishing the touches on a $24 million facilVerDate 0ct 09 2002 11:30 Dec 20, 2007 Jkt 038552 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 S:\DOCS\38552.TXT JACK PsN: JACKF
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ity, 200,000 square feet, which will provide 200 jobs and create several hundred thousand patient visits in the next few years. It is 

that kind of collaboration and cooperation that is helping us make 

a change in the quality of health care. 

For example, the Cherokee Nation since 2002, in cooperation 

with Dr. Grim and the Indian Health Service, we have been able 

to deliver 1.2 million patient visits. Eight years ago when I took 

office, the highest complaints we received in the Cherokee Nation 

was health care complaints. Of course, those complaints have diminished each year. 

Now, to my great delight, we are receiving compliments, compliments from people about the quality of health care, how it is increasing, how we are getting funding for cancer treatment and the 

equipment for the diabetes epidemic. 

So we are very thankful for Dr. Grim and his leadership. We believe in Indian Country we all share that same kind of sentiment. 

What is unique in the situation is that Dr. Grim is well received 

in not only Indian Country, but in the State of Oklahoma. 

I have the opportunity to present to him at this time a declaration by the Governor of the State of Oklahoma declaring this day 

Dr. Charles Grim Day in Oklahoma. I will just read a very few 

paragraphs: ‘‘Whereas Charles Grim, the Director of the Indian 

Health Service, Assistant Surgeon General, holds the rank of Rear 

Admiral in the Commissioned Corps of the United States Public 

Health Service, and is a native of Oklahoma and a citizen of the 

Cherokee Nation, whereas on July 16th, 2003 the U.S. Senate 

unanimously confirmed Dr. Charles Grim to serve a 4-year term as 

the Indian Health Service Director, now I Brad Henry, Governor of 

the State of Oklahoma, proclaim July 26, 2007 as Charles W. Grim 

Day in the State of Oklahoma.’’

The information referred to follows:]

7


726day.eps
8

That, with the letters that the Committee has received and the 

support of the State of Oklahoma and the Cherokee Nation, and everybody that he comes in contact with, I think is great evidence 

that he has done a good job in dealing with a great and serious demand of health care. 

Thank you very much. 

The CHAIRMAN. Chief Smith, thank you very much. We appreciate your being with us and your testimony. 

Dr. Grim, thank you. You have an opening statement, I believe. 

Is that correct? 

Dr. GRIM. Yes, sir. 

The CHAIRMAN. You may proceed with your opening statement. 

We will then ask a series of questions. 

STATEMENT OF CHARLES W. GRIM, D.D.S., M.H.S.A, ASSISTANT 

SURGEON GENERAL; DIRECTOR, INDIAN HEALTH SERVICE, 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Dr. GRIM. Mr. Chairman, Madam Vice Chair—and I have not 

gotten to congratulate you in person, Senator Murkowski, congratulations on your new role with this Committee—and other distinguished Members of the Senate Committee on Indian Affairs. 

The CHAIRMAN. Will you pull that microphone closer to you, Dr. 

Grim? 

Dr. GRIM. OK. It is a pleasure and an honor for me to have been 

nominated by the President, supported by tribal governments 

across the Nation, endorsed by Secretary Leavitt, and for this Committee to consider renewing my term as Director of the Indian 

Health Service. 

I would also like to personally thank Senator Coburn for introducing me. 

To be nominated for a second term to lead the Indian Health 

Service and to be in a position to continue my service on behalf of 

so many Indian people is a wonderful and a humbling opportunity, 

as well as a great honor and a challenge. As I sat and listened to 

some of you speak about the challenges that there are across Indian Country, we have a lot of work yet ahead of us. 

I want to acknowledge members of my family who could not be 

here today, and thank Senator Coburn for recognizing their sacrifice. My wife, Dr. Gloria Grim, our sons Steven, Jake, Chance and 

the newest one, Nicholas. I would also like to introduce my family 

members who are here with me this morning. They are sitting 

right back here: my mother, Mrs. Ruth Grim, my sister Ms. Denise 

Grim, and my daughter, Ms. Kristen Grim. 

All of my family have been very supportive of me while I have 

held this role and they have also sacrificed to allow me to be in this 

position. 

I also want to acknowledge my late father, Charles Grim, who 

along with my mother has always been a source of strength and 

pride to me. 

For those on the Committee and for those attending this hearing, 

I will quickly introduce myself. Most of you know me, but my name 

is Charles Grim. I am a member of the Cherokee Nation of Oklahoma. I come from the town of Cushing, Oklahoma. I am a doctor 

of dental surgery and I also have a master’s in health services adVerDate 0ct 09 2002 11:30 Dec 20, 2007 Jkt 038552 PO 00000 Frm 00012 Fmt 6633 Sfmt 6601 S:\DOCS\38552.TXT JACK PsN: JACKF
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ministration, which focuses on the management and administration 

of health services, dental care and hospital and ambulatory care. 

I have been a member of the U.S. Public Health Service for 24 

years, which include 5 years as the Director of the Indian Health 

Service. The IHS is one of the largest operating divisions within 

HHS, with a program-level budget of over $4 billion in 2007, and 

more than 15,000 employees. The agency responds to the needs of 

more than 560 federally recognized sovereign tribal nations in 35 

different States. 

Indian tribes are IHS’s partners, as well as our customers in providing approximately 60,000 in-patient admissions, 9.4 million outpatient visits, and almost 1 million dental visits annually to approximately 1.8 million American Indians and Alaska Natives at 

more than 500 sites across the Nation. We also serve 600,000 more 

American Indians and Alaska Natives at 34 urban sites across the 

Nation. 

The IHS has a proud history of dramatically improving the 

health of Indian people. Since the passage of the Indian Self-Determination and Education Assistance Act in 1975, the greater involvement of Indian tribes and Indian people in the decisions affecting their health has produced significant health improvements. 

Indian life expectancy has increased by 8.7 years since 1973. While 

significant disparities still exist, mortality rates have decreased for 

maternal deaths, tuberculosis, gastrointestinal disease, infant 

deaths, unintentional injuries and accidents, pneumonia and influenza, homicide, alcoholism and suicide. 

Rates of some health disparities are decreasing, but the 2001 

through 2003 rates of most leading causes of death for Indian people still remain more than double the rates for the rest of America. 

In the early history of the IHS, the greatest achievements in reducing these disparities were through increased medical care and 

public health efforts, that included massive vaccination programs 

and bringing safe water and sanitation facilities to reservations 

and communities. I believe future reductions in these disparities of 

any significance will be made through health promotion and disease prevention efforts and programs, rather than through treatment. 

In fulfilling the Federal Government’s commitment to American 

Indian and Alaska Natives to provide high quality health service, 

in the past 4 years I have focused the IHS on specific health initiatives to address the goals, needs and the current health status 

trends of our people. I believe the future of tribal communities depends on how effectively the IHS system addresses chronic diseases, and therefore we initiated a chronic care initiative in 2003. 

Preventing and treating chronic diseases requires an entirely different approach for care delivery. I am proud to inform this Committee that in 2007, there are now 14 sites within the Indian 

health system who are applying new evidence-based approaches to 

managing chronic care as a result of this initiative. We are receiving assistance from a full partnership that has been established 

with the renowned Institute for Health Care Improvement. They 

have commented that with the models that we are implementing, 

if we are able to carry it out throughout our entire system over 

10

time, it could be a model for the Nation on how to deal with chronic 

care in the years ahead. 

A second initiative that we have implemented is around behavioral health. It has three programmatic parts, and I don’t think 

these items will be of any surprise to the Committee and why we 

have prioritized them. It is methamphetamine intervention, suicide 

prevention, and family safety and protection. 

This initiative increases the emphasis on both clinical and community-based health promotion and disease prevention efforts. Our 

collective ability is focused on implementing programs designed to 

prevent disease, rather than relying exclusively on treatment. One 

half of IHS’s areas will be integrating behavioral health into local 

tribal area health board plans. They are sharing now best and 

promising practices of how to integrate behavioral health with our 

other two initiatives of chronic care and health promotion disease 

prevention. 

We are also forging numerous collaborations with other organizations like the National Boys and Girls Clubs of America to increase 

clubs on reservations; the Nike Corporation, to promote healthy 

lifestyles; CDC, to fund IHS positions supporting epidemiology and 

disease prevention activity; the Mayo Clinic, to support efforts to 

reduce cancer and other related health burdens; Harvard and 

Johns Hopkins Universities to improve American Indian health 

and wellness; and the VA, to better coordinate the numerous efforts to enhance the health care provided to American Indian and 

Alaska Native veterans. Those are just a sample of the partnerships we have forged over the last 4 to 5 years. 

The third initiative is health promotion and disease prevention. 

Our goal is to create healthier American Indian and Alaska Native 

communities by developing and disseminating proven strategies 

through collaboration with key stakeholders. Again, a few examples. Together with the Mothers Against Drunk Driving, we are addressing underage drinking by training Indian youth. We have a 

partnership with the University of New Mexico Prevention Center, 

who developed the American Indian Across the Lifespan Physical 

Activity Kit, which Indian communities can use to promote more 

active lifestyles. 

Now, all 12 of the IHS area offices have a health promotion disease prevention coordinator to support the IHS tribal and urban 

programs in developing, implementing and evaluating health promotion and chronic disease prevention activities. We focus on use 

of traditional practices and values to communicate effective model 

programs such as breast feeding, language and cultural training in 

early childhood and elementary settings. 

One of my top business priorities has been to implement a market-based business plan that actively promotes innovation. The 

plan enhances the level of patient care through increased revenue, 

reduced cost and improved business processes. In Fiscal Year 2006, 

IHS generated approximately $700 million in third-party revenue 

and saved $352 million through the use of negotiated contracts 

with private providers to get the lowest cost possible when purchasing care. 

In an environment of increased Federal accountability, it was important for me to institute the restructuring of IHS’s approach to 

11

performance management at the national level. In 2005, I activated 

the IHS Performance Achievement Team to guide the agency toward a more consistent, efficient and effective performance management approach to achieve a results-oriented organizational culture. Accountability for performance measures are now part of the 

performance appraisal criteria at all organizational levels. 

I attribute the improved agency performance accomplishments to 

our strong focus on accountability. As an example, the IHS was recognized in 2006 as a national leader in the use of health information technology to electronically provide clinical quality measures 

related to monitoring the Government Performance and Results 

Act performance indicators. The agency implemented that program, 

and with our annual targets in 2002 when 72 percent of those targets were met. In the agency’s latest report for 2006, 82 percent of 

the clinical and nonclinical targets were either met or exceeded, a 

documented increase of 10 percentage points since 2002. 

Our tribal stakeholders have also helped support program assessment. As a result, 65 percent of tribally operated health programs voluntarily provided performance data and other information demonstrating their achievement of program goals and management standards. 

We have made consistent progress in addressing the management areas that are included in the President’s management agenda, the Government-wide management improvement initiative. The 

Indian Health Service has met standards for success in carrying 

out our action plans and we have earned green scores for progress 

for five management areas and one program initiative for 2006. 

We continue to implement improvements in plans for six programs that were assessed by the program assessment and rating 

tool, a program evaluation instrument of the OMB. All six programs were rated adequate or higher, with the IHS having one of 

the highest overall averages in the Federal Government by 2005. 

The IHS is the only Federal program delivering hands-on care to 

Indian people based on the government to government treaties. 

Today we are facing many challenges. Change and challenge is 

nothing new to the history of the Nation or to Indian nations. Our 

history attests to our ability to respond to these challenges, to overcome adversities that we sometimes face, and to maximize our opportunities. 

I have a great passion about this organization and our mission 

to raise the health of our people to the highest level. My actions 

will always reflect the honor of being entrusted to provide health 

services to American Indian and Alaska Native people. I am ready 

to recommit to the job of the Director of the Indian Health Service 

and to working with this Committee and this Administration and 

tribal governments around the Country toward our shared goals 

and objectives. 

I will be pleased to respond to any questions that you may have 

concerning my nomination. 

Thank you. 

[The prepared statement and biographical information of Dr. 

Grim follow:]

12

PREPARED STATEMENT OF CHARLES W. GRIM, D.D.S., M.H.S.A, ASSISTANT SURGEON

GENERAL; DIRECTOR, INDIAN HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Mr. Chairman, Madam Vice-Chair, and other distinguished members of the Senate Committee on Indian Affairs: 

It is a pleasure and an honor for me to have been nominated by the President, 

supported by tribal governments across the Nation, endorsed by Secretary Leavitt, 

and for this Committee to consider renewing my term as director of the Indian 

Health Service. 

I’d like to thank and acknowledge my family who could not be here today. They 

have all sacrificed to allow me to serve in this position, my wife Dr. Gloria Grim, 

our sons Steven, Jake, Chance and Nicholas. I’d also like to introduce here today 

my mother, Ms. Ruth Grim, sister Ms. Denise Grim and my daughter Ms. Kristen 

Grim. 

I am proud to renew the pledge I made at my first confirmation hearing before 

this Committee four years ago, to both the Federal and tribal governments, to do 

my best to uphold the Federal Government’s commitment to raising the health status of American Indians and Alaska Natives to the highest level. I remain committed to working with this Committee, the Administration, and Tribal Governments toward our shared goals and objectives. 

The IHS delivers health services to approximately 1.9 million federally-recognized 

American Indians and Alaska Natives through a system of IHS, tribal, and urban 

operated facilities and programs based on treaties, judicial determinations, and Acts 

of Congress. The mission of the agency is to raise the physical, mental, and social 

health of American Indians and Alaska Natives to the highest level, in partnership 

with the population we serve. The agency goal is to ensure that comprehensive, culturally acceptable personal and public health services are available and accessible 

to the service population. Our foundation is to uphold the Federal Government’s 

commitment to promote healthy American Indian and Alaska Native people, communities, and cultures. 

For those on the Committee and those attending this hearing, I would like to provide some background about myself. I am Charles W. Grim, a member of the Cherokee Nation of Oklahoma. I come from the town of Cushing, Oklahoma. I am descended from those who walked the Trail of Tears. I would like to acknowledge my 

late father, Charles Grim and my mother Ruth Grim, whose confidence in me has 

always been a source of strength and pride. I draw my strong sense of heritage and 

culture from my family. From early in my life I envisioned working for the Indian 

Health Service as an important way to help Indian people. Upon my graduation 

from dental school, my aunt Ms. Dorothy Snake also encouraged me to work for the 

IHS as part of my National Health Service Corps educational scholarship pay back 

requirement. 

My first assignment with the IHS was at the Indian health Center in Okmulgee, 

Oklahoma. Working there was like coming home and fulfilling the dream I had as 

a teenager to help Indian people. I knew then and I know now, just as strongly, 

that working for the Indian Health Service is a part of my life. I cannot imagine 

being as satisfied or having such a sense of reward working anywhere else. To be 

nominated for a second term to lead the Indian Health Service, and to be in a position to do so much for so many Indian people, is wonderful and humbling opportunity, as well as a great honor. 

In addition to my personal connection and desire to lead the agency, I am a Doctor of Dental Surgery and I have a Masters degree in Health Services Administration with focus on the Management and Administration of health services, dental 

care, and hospital and ambulatory care. I have served with the U.S. Public Health 

Service for 24 years—through assignments to various offices and programs of the 

Indian Health Service, including five years as the Director of the Indian Health 

Service. I am ready to recommit to the job of Director of the Indian Health Service. 

Rates of some health disparities are decreasing, but the 2001–2003 rates of most 

leading causes of death for Indian people remain more than double the rates for the 

rest of America—for injuries, the rate for Indian people is 154 percent of the rate 

for the general U.S. population; for alcoholism, 551 percent; for diabetes, 196 percent; for homicide, 108 percent; and for suicide, 57 percent. 

The rate of diabetes-related kidney failure in American Indians and Alaska Natives is 3.5 times higher than the general U.S. population, although the incidence 

of new cases has declined 18.5 percent in our population since 1999 (while it is still 

going up in whites and African Americans). Cardiovascular disease (CVD) is the 

number one killer of American Indian and Alaska Native adults. CVD is increasing 

in American Indian and Alaska Native population while it is decreasing in the genVerDate 0ct 09 2002 11:30 Dec 20, 2007 Jkt 038552 PO 00000 Frm 00016 Fmt 6633 Sfmt 6621 S:\DOCS\38552.TXT JACK PsN: JACKF
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eral U.S. population. Diabetes is the strongest risk factor in up to 70 percent of the 

CVD seen in our population. Amputations due to diabetes still occur at rates 3 to 

4 times the rates for the rest of the nation. 

And the tragedy of Sudden Infant Death Syndrome (SIDS) occurs at two times 

the rate of the U.S. general population. American Indian and Alaska Native (15–

24 years) suicide mortality within Indian families occurs at three times the rate 

than for other families. 

In the early history of the Indian Health Service, the greatest achievements in 

reducing health disparities were through increased medical care and public health 

efforts that included massive vaccination programs and bringing safe water and 

sanitation facilities to reservation homes and communities. I believe future reductions in disparities of any significance will be made through health promotion and 

disease prevention efforts and programs rather than through treatment. 

American Indians and Alaska Natives have the highest rate of type 2 diabetes for 

all age groups of any ethnic or racial group in the U.S. The prevalence of type 2 

diabetes in American Indians and Alaska Natives is 2.2 times higher than for nonHispanic whites and the death rate from diabetes is 3 times higher than the general 

U.S. population—but it has been shown that with moderate changes in diet and exercise, such as reducing body weight by 7 percent and walking for 30-minutes a day 

5–6 days per week—the onset of diabetes can be delayed and, in some cases, can 

be prevented. 

Cardiovascular disease is now the leading cause of mortality among Indian people, 

with a increasing rate that is nearly 11⁄2 times that of the U.S. general population; 

but by modifying or eliminating health risk factors such as obesity, sedentary lifestyles, smoking, high-fat diets, and hypertension, that trend may be reversed. 

We need to invest in our communities so that despair does not fill the lives of 

our children. The IHS suicide morality rate among Indian youth is three times that 

of the general population. There are many programs, not just those of the Indian 

Health Service, which can be implemented to reduce or eliminate the number of our 

children who are killing themselves. 

I believe the more we focus on promoting good health the less will be needed for 

treating the consequences of poor health. The Indian Health Service has a proud 

history of dramatically improving the health of Indian people. Since the passage of 

the Indian Self-Determination and Education Assistance Act in 1975, the greater involvement of Indian Tribes and Indian people in the decisions affecting their health 

has produced significant health improvements for Indian people: Indian life expectancy has increased by 8.7 years since 1973 and while significant disparities still 

exist, mortality rates have decreased for maternal deaths, tuberculosis, gastrointestinal disease, infant deaths, unintentional injuries and accidents, pneumonia 

and influenza, homicide, alcoholism, and suicide. 

Tribes are IHS’s partners as well as customers in providing approximately 60,000 

inpatient admissions, 9.4 million outpatient visits, and 954,000 dental visits annual 

to approximately 1.8 million American Indians and Alaska Natives at more than 

500 sites and 600,000 more American Indians and Alaska Natives at 34 urban sites. 

The Agency responded to the needs of more than 560 federally recognized sovereign 

Tribal nations in 35 states. 

I will continue to support the decision of Tribes to contract, compact, or retain 

the Indian Health Service as their provider of choice. The Indian Self-Determination 

Act allows Tribes to manage their own health programs. In addition, this Administration and the Secretary have put their words into action and increased the involvement of tribal representatives in advising and participating in the decisionmaking processes of the Department. 

We also invest wisely in our communities and in promoting good health. Health 

status is the result of interwoven factors such as socioeconomic status, educational 

status, community and spiritual wellness, cultural and family support systems, and 

employment opportunities, to name a few. The connection between poverty and poor 

health cannot be broken just by access to health services or treatment alone. 

Based on identified trends in Indian healthcare, I believe we must begin to lay 

the groundwork now for the health environment we want to have 5, 10 or 20, years 

in the future. I believe we must focus on emerging infectious and chronic disease 

patterns, and the related increasing cost of pharmaceuticals to treat and prevent 

disease. These issues can best be addressed through health promotion and disease 

prevention activities, so that our people will improve their health, which will decrease the demand for health services and pharmaceuticals. 

Preventing disease and injury is a worthwhile financial and resource investment 

that will result in long-term savings by reducing the need for providing acute and 

chronic care and expensive treatment processes. It also yields the even more important humanitarian benefit of reducing pain and suffering and prolonging life. 

14

In the past four years, I focused the IHS on specific health initiatives to address 

the goals, needs, and health status trends of American Indian and Alaska Native 

people. I believe the future of Tribal communities depends on how effectively the 

Indian health care system addresses chronic diseases, and therefore initiated a 

Chronic Care Initiative in 2003. Preventing and treating chronic disease requires an 

entirely different approach for care delivery. 

I implemented strategies within the Indian health system that improve the health 

status of patients and populations affected by chronic conditions and reduce the 

prevalence and impact of those conditions by adapting and implementing a chronic 

care model. We are now committed to developing patient and family-centered care 

processes that apply across multiple chronic conditions (instead of care based on 

managing individual diseases). I am proud to inform the Committee that, in 2007, 

fourteen sites within the Indian health system are piloting new approaches to managing chronic care as a result of my Chronic Care Initiative with assistance from 

a full partnership established with the renowned Institute for Healthcare Improvement. 

My Behavioral Health Initiative has three programmatic parts—methamphetamine intervention, suicide prevention, and family safety and protection—and increases the emphasis on both clinical and community-based health promotion and 

disease prevention (HP/DP) efforts. We are focusing on using our collective ability 

to develop and implement programs designed to prevent disease rather than relying 

exclusively on treatment of disease. One half of IHS Areas will be integrating behavioral health into local Area Tribal Health Board plans. They share best and 

promising practices of how to integrate behavioral health with the other two initiatives. 

We are forging collaborations with other organizations like the National Boys and 

Girls Clubs of America to increase clubs on reservations, NIKE Corporation to promote healthy lifestyles, CDC to fund IHS FTEs supporting epidemiology and disease 

prevention activities, Mayo Clinic to support efforts to reduce cancer and related 

health burdens, and Harvard University to improve American Indian and Alaska 

Native health and wellness. 

Through these initiatives, we target health outcomes that will have a beneficial 

impact, and attempt to change basic practices and procedures as well as unhealthy 

behaviors. Therefore, my third initiative is health promotion/disease prevention. 

American Indian and Alaska Native patients will see increased focus on screening 

and primary prevention in mental health, actions aimed at HP/DP to promote 

healthy lifestyles, and increased primary prevention of chronic disease. 

My business emphasis focuses on strengthening the infrastructure of the Indian 

health system. The infrastructure supports a very comprehensive public health and 

clinical services delivery program, including such diverse elements as water and 

sewage facilities, diabetes prevention and wellness programs, and emergency medical services. The IHS is the largest holder of real property in the Department with 

over 9 million square feet of space. There are 48 hospitals, 272 health centers, 11 

school health centers, 320 health stations, satellite clinics, and Alaska village clinics, and 11 youth regional treatment centers that support the delivery of health care 

to our people. 

Just as the health challenge has changed since 1955 when the IHS was transferred to the Department of Health, Education, and Welfare; so too has the infrastructure needed to meet those new health demands. In 1955, our 2,500 employees 

and annual appropriation, of approximately $18 million ($124 million in today’s dollars), provided health services for a population of 350,000 with a life expectancy 58 

years for men and 62 years for women. In Fiscal Year 2006, we increased to a staff 

of approximately 15,000 and an appropriation of $3.2 billion, supplemented by over 

half a billion dollars from our third-party collection efforts, which provides health 

services for 1.9 million American Indians and Alaska Natives with an average life 

expectancy of 72.3 years. 

Our collections are critical to the solvency of our programs because these funds 

return to the service unit to pay for additional staff, equipment, or other infrastructure elements to address the health needs of that community. One of my top priorities has been to implement a market-based business plan that actively promotes 

innovation. The plan enhances the level of patient care through increased revenue, 

reduced costs, and improved business processes. In Fiscal Year 2006, IHS generated 

approximately $700 million in third party revenue and saved $352 million through 

the use of negotiated contracts with private providers to get the lowest costs possible when purchasing care. For Fiscal Year 2007, the agency’s overall program authority is over $4 billion dollars. 

In an environment of increased federal accountability, it was important for me to 

institute the restructuring of the IHS’s approach to performance management at the 

15

national level. In 2005, I activated the IHS Performance Achievement Team to guide 

the Agency toward a more consistent, efficient, and effective performance management approach to achieve a results-oriented organizational culture. Accountability 

for performance measures is now part of the performance appraisal criteria at all 

organizational levels. 

I attribute the improved Agency performance accomplishments to our strong focus 

on accountability. For example, the IHS was recognized in 2006 as a national leader 

in the use of health information technology to electronically provide clinical quality 

measures related to monitoring the Government Performance Results Act (GPRA) 

performance indicators. The Agency implemented reporting on GPRA annual targets 

in 2002 when 72 percent of the targets were met. In the agencie’s latest 2006 report, 

82 percent of the clinical and non-clinical targets were either met or exceeded. I am 

proud of the continuous improvement shown by the percentage that reached 82 percent in 2006, a documented increase of 10 percentage points since 2002. 

Tribal stakeholders updated their health priorities in order to help support program assessment and as a result 65 percent of the Tribally-operated health programs voluntarily provided performance data and other information that demonstrated their achievement of program goals and management standards. 

The IHS has made consistent progress in addressing management areas included 

in the President’s Management Agenda, a government-wide management improvement initiative. The IHS met standards for success in carrying out action plans. The 

IHS continued to implement improvement plans for six programs assessed by the 

Program Assessment and Rating Tool, a program evaluation instrument. All six programs were rated Adequate or higher with IHS having one of the highest overall 

averages in the Federal Government by 2005. 

We have continued to effectively implement results-oriented management by 

achieving a 10 percent relative increase in four areas of program performance by 

2007. In 2006, IHS made significant increases in rates for all four program measures over their 2005 levels: screening for alcohol use among female patients of childbearing ages increased 16 percent, domestic violence screening increased 15 percent, 

diabetic patients assessed for LDL cholesterol increased 9 percent, and pneumococcal vaccinations for elders increased 8 percent. The Agency has consistently demonstrated ability to impact targeted performance measures and successfully leverage 

performance management to advocate for improved health status for American Indian and Alaska Native people. 

The IHS is the only federal program delivering hands-on care to Indian people 

based on a government-to-government relationship and today we are facing many 

challenges. Change and challenge is nothing new to the history of the nation or to 

Indian nations. Our history attests to our ability to respond to challenges, to overcome adversities that we sometimes face, and to maximize our opportunities. 

I have great passion about this organization and our mission to raise the health 

of our people to the highest level possible. My actions will always reflect the honor 

of being entrusted to provide health services to American Indian and Alaska Native 

people. I am ready to lead the Indian Health Service, with honor and respect for 

our ancestors, and to work with you and the Administration for the benefit of American Indian and Alaska Native people. 

I am pleased to respond to any questions you may have concerning my nomination. 

Thank you. 

16

BIOGRAPHICAL INFORMATION


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Background Information 

Charles W. Grim, D.D.S., M.H.S.A., Director of the Indian Health Service (IHS), 

is an Assistant Surgeon General, and holds the rank of Rear Admiral in the Commissioned Corps of the United States Public Health Services (USPHS). He was appointed by President George W. Bush as the Interim Director in August 2002, received unanimous Senate confirmation on July 16, 2003, and was sworn in by 

Tommy G. Thompson, Secretary of the Department of Health and Human Services 

(HHS), on August 6, 2003, in Anchorage, Alaska. Dr. Grim is a native of Oklahoma 

and a member of the Cherokee Nation of Oklahoma. 

As the IHS Director, Dr. Grim administers a $4 billion nationwide health care delivery program composed of 12 administrative Area (regional) Offices. As the principal federal health care provider and health advocate for Indian people, the IHS 

is responsible for providing preventive, curative, and community health care to approximately 1.9 million of the Nation’s 3.3 million American Indians and Alaska Natives in hospitals, clinics, and other settings throughout the United States. 

Dr. Grim serves as the Vice-Chair of the Secretary’s Intradepartmental Council 

on Native Americans Affairs (ICNAA). The ICNAA was established by the HHS Secretary to develop and promote HHS-wide policy to provide quality services for American Indians and Alaska Natives; promote departmental consultation with tribal 

governments; develop a comprehensive departmental strategy that promotes tribal 

self-sufficiency and self-determination; and promote the tribal/federal governmentto-government relationship on an HHS-wide basis. Under Dr. Grim’s leadership, the 

IHS has received numerous national awards for innovation and quality, including 

the 2005 Nicholas E. Davies Award for the IHS Clinical Reporting System. 


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In 2004 Dr. Grim established three closely related Agency-wide initiatives: Behavioral Health, Chronic Care, and Health Promotion and Disease Prevention. Through 

changing behaviors and lifestyles and promoting good health and health environment, critical steps are being taken in improving the health of American Indians 

and Alaska Natives. Already these initiatives are transforming the Indian health 

care system and the way Indian communities receive health care. Working with 

Tribes in concert with the principles of self-determination and self-governance, Dr. 

Grim’s leadership has made a positive impact on the health and well-being of American Indian and Alaska Native patients, families, and communities. The initiatives 

also are closely aligned with the HHS Priorities such as prevention and health 

transparency established by HHS Secretary Michael O. Leavitt. 

Dr. Grim graduated from the University of Oklahoma College of Dentistry in 1983 

and began his career in the IHS with a 2-year clinical assignment in Okmulgee, OK, 

at the Claremore Service Unit. Dr. Grim was then selected to serve as Assistant 

Area Dental Officer in the Oklahoma City Area Office. He was appointed as the 

Area Dental Officer in 1989 on an acting basis. 

In 1992, Dr. Grim was assigned as Director of the Division of Oral Health for the 

Albuquerque Area of the IHS. He later served as Acting Service Unit Director for 

the Albuquerque Service Unit, where he was responsible for the administration of 

a 30-bed hospital with extensive ambulatory care programs and seven outpatient 

health care facilities. Later career appointments included serving in the Albuquerque Area Office as the Director for the Division of Clinical Services and Behavioral Health, and Acting Executive Officer. 

In April 1998, Dr. Grim transferred to the Phoenix Area IHS as the Associate Director for the Office of Health Programs. In that role, he focused on strengthening 

the Phoenix Area’s capacity to deal with managed care issues in the areas of Medicaid and the Children’s Health Insurance Program of Arizona. He also led an initiative within the Area to consult with Tribes about their views on the content to be 

included in the reauthorization of the Indian Health Care Improvement Act, Public 

Law 94-437. 

In 1999, Dr. Grim was appointed as the Acting Director of the Oklahoma City 

Area Office, and in March 2000 he was selected as the Area Director. As Area Director, Dr. Grim managed a comprehensive program that provides health services to 

the largest IHS user population, more than 280,000 American Indians comprising 

37 Tribes. 

In addition to his dentistry degree, Dr. Grim also has a master’s degree in health 

services administration from the University of Michigan. Among Dr. Grim’s honors 

and awards are the U.S. Public Health Service Commendation Medal (awarded 

twice), Achievement Medal (awarded twice), Citation, Unit Citation (awarded twice), 

and Outstanding Unit Citation. He has also been awarded Outstanding Management and Superior Service awards by the Directors of three different IHS Areas. 

He also received the Jack D. Robertson Award, which is given to a senior dental 

officer in the United States Public Health Service (USPHS) who demonstrates outstanding leadership and commitment to the organization. The Governor of Oklahoma recognized Dr. Grim’s achievements by proclaiming June 11, 2003 ‘‘Charles 

W. Grim Day.’’ He was further honored by the State of Oklahoma by being selected 

as a Spirit Award Honoree during their American Indian Heritage Celebration on 

November 17, 2003. Dr. Grim was awarded the Surgeon General Medallion on February 26, 2007 at the annual meeting of the National Combined Clinical Directors. 

Dr. Grim is a member of the Commissioned Officers Association, the American 

Board of Dental Public Health, the American Dental Association, the American Association of Public Health Dentistry, and the Society of American Indian Dentists. 

Dr. Grim was appointed to the Commissioned Corps of the USPHS in July 1983.

The CHAIRMAN. Dr. Grim, thank you very much. 

We have been joined by Senator Barrasso. Senator Barrasso, welcome. 

STATEMENT OF HON. JOHN BARRASSO,

U.S. SENATOR FROM WYOMING 

Senator BARRASSO. Thank you, Mr. Chairman. 

The CHAIRMAN. Senator Barrasso, do you have an opening statement that you wish to give? Or would you just like to take your 

turn at questioning? 

22

Senator BARRASSO. Mr. Chairman, I don’t have a statement at 

this time. 

The CHAIRMAN. Thank you very much. Well, let us welcome you 

to this Committee. We are very pleased that you are here and that 

you will once again lend a Wyoming voice to the work that has 

been done previously on this Committee. 

Senator BARRASSO. Thank you, Mr. Chairman. 

The CHAIRMAN. Dr. Grim, let me make a couple of observations. 

First of all, you are a good guy. I have enjoyed working with you. 

I think you have a very strong background in public health. I admire your work and admire your commitment. I intend to support 

your renomination. 

As you know, I have great trouble with what has happened with 

respect to Indian health. In many ways, I think you are required 

to manage a scandal. I regret that because of the scandal, at least 

40 percent of the health care needs of American Indians is unmet. 

That means there is full-scale rationing going on with respect to 

health care. That normally would be front page headline news in 

this country, but it isn’t these days. It just goes on all the time. 

We have to find a way to address it. 

Now, in your past appearances before this Committee, you have 

talked about, let me quote, ‘‘the IHS is the Federal agency responsible for delivering health services to more than 1.9 million American Indians and Alaska Natives. Two major statutes are at the 

core of the Federal Government’s responsibility for meeting the 

health needs of American Indians and Alaska Natives—the Snyder 

Act and the Indian Health Care Improvement Act.’’

That implies to me that you have previously indicated to this 

Committee that you believe there is a trust responsibility rooted in 

law for the health care for Native Americans or American Indians. 

Am I correct about that? 

Dr. GRIM. I think the quotes that you gave and the two laws that 

I indicated are the cornerstone authority that lays out the government’s responsibility to Indian people for health care. 

The CHAIRMAN. Is there a disagreement on that in the Administration? The reason I ask the question is I understand the OMB 

has taken that language out of the testimony you have given today, 

and has a disagreement about that language. 

Dr. GRIM. I don’t believe there is any misunderstanding with the 

Administration that those two laws lay out clearly the government’s responsibility to Indian people. 

The CHAIRMAN. Why would the Office of Management and Budget take that language out of the testimony? 

Dr. GRIM. As you are well aware, my testimonies and our bill reports and things like that get cleared through numerous levels. 

Sometimes changes are made. It was not communicated to me the 

exact rationale for that, but in past testimonies you have heard me 

make those quotes and these have cleared the department and the 

Office of Management and Budget. 

The CHAIRMAN. And you stand by that responsibility that you 

previously described? 

Dr. GRIM. Yes, sir. 

The CHAIRMAN. Dr. Grim, let me ask a couple of questions about 

the quality of the Indian health care service. Before I do that, I inVerDate 0ct 09 2002 11:30 Dec 20, 2007 Jkt 038552 PO 00000 Frm 00026 Fmt 6633 Sfmt 6601 S:\DOCS\38552.TXT JACK PsN: JACKF
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dicated that in previous testimony, you have admitted, and it has 

kind of been like pulling teeth, and I understand why—you have 

certain responsibilities at the witness table to the Administration—

but you have admitted that the unmet needs of Indians with respect to their health care is somewhere around 40 percent. Am I 

accurate about that? 

Dr. GRIM. Yes, sir. That was an actuarial study. 

The CHAIRMAN. So if we have a population for whom we have a 

trust responsibility and my colleague, Senator Murkowski, pointed 

out that we spend about twice as much per person providing health 

care to those that are incarcerated in Federal prisons as we do for 

the health care needs of American Indians, and about 40 percent 

of the need is unmet, that is a very serious problem. My guess is 

that people die as a result of those unmet needs. 

The question is the quality of the Indian Health Service. I want 

to ask you about that. I go to places where Indian Health Service 

professionals deliver health care. I walk away very often deeply admiring the folks who serve in the Indian Health Service and Public 

Health Service generally. 

But we had testimony before this Committee, and let me read 

just a bit of it, and ask for your observations. This is testimony 

from doctors who are in the private sector who have seen American 

Indians. Let me quote one, ‘‘Quality of care at Indian Health Service facilities has been a documented problem. I have seen this problem since I have worked with the Indian Health Service in 1997 

until today. A diabetic patient sees me with fluid in her knee joint. 

She has gone to the Indian Health Service for evaluation and was 

told by the physician to wrap her knee in cabbage leaves for several days. I obtained an MRI of her knee and found a torn anterior 

cruciate ligament.’’

Well, he goes on to describe a fellow on an Indian reservation 

who had a bad arm. He was a rancher, a 60 year old rancher with 

a bad arm. He said a one-armed rancher isn’t worth a whole lot; 

couldn’t earn much to eat, and so on. He finally got surgery, but 

it was one of those life and limb contract health issues. And the 

list goes on about these things. The same doctor described a woman 

that was brought into the hospital having a heart attack on the Indian reservation, put in an ambulance, brought into the hospital 

with an 8 by 10 piece of paper taped to her thigh, and as they unloaded her onto the hospital gurney to admit her to the emergency 

room, they looked at the 8 by 10 piece of paper taped to this woman’s thigh and it said, ‘‘By the way, we are out of contract health 

care money, so if you admit this patient, understand you are admitting this patient at your own risk’’—a woman having a heart attack. 

So we have these stories coming to us. This is not about you or 

your leadership. It is about the dramatic under-funding of the Indian health care system. I ask about the quality with this question. 

Tell me about the quality issues, and when we hear this kind of 

testimony, what should we make of it? 

Dr. GRIM. Well, first, I would like to remind the Committee that 

we have facilities in over 500 different locations in 35 States, in 

some of the most rural and isolated areas of the Country. The second thing I would like to remind the Committee is that we do hear, 

24

you and I, I think all the Senators in here, probably get letters either about contract health services or about issues that have arisen 

over time like this. But we do provide 9 million outpatient visits, 

60,000 in-patient, over 1 million dental visits. I don’t even mention 

the mental health and all the other sorts of services we provide. 

We get a few complaints on issues in that nine million plus visits 

over time. But all of our facilities have a quality assurance process 

in place. All of our hospitals are accredited by the Joint Commission on the Accreditation of Health Care Organizations. That is an 

external organization, as you know, that accredits private sector organizations. They all passed those. Those that aren’t accredited by 

JCAHO undergo AAAHC for ambulatory health care. And all these 

organizations require a quality assurance program. 

So we do have those in place, Senator. I want to assure you of 

that, and assure you that the things that you are raising are very 

rare exceptions as opposed to the rule of what is going on out 

there. 

The CHAIRMAN. But the services are not near what is necessary. 

You and I have discussed the death of a 14 year old girl who didn’t 

have access to mental health treatment after lying in bed in a fetal 

position for 90 days, missing school, no mental health capabilities, 

and not even a car to drive this little girl to mental health had 

somebody thought that maybe she ought to go there. 

So there is a dearth of services available in many of these circumstances and that is a serious problem a well. 

Senator Coburn raised a question about shouldn’t American Indians, for whom we have a trust responsibility for their health care, 

simply be able to go to any hospital and get the health care? We 

pay the bill. I would support that. But wouldn’t that cost a substantial amount of money? And I would support that, by the way. 

But there is not a ghost of a chance of getting that through this 

President’s budget or this Congress. 

But if we had a system where we say we have a trust responsibility, if you have a health care need and it is not available to be 

addressed where you live, go to a hospital and we will pay contract 

health support for it. What would that cost? 

Dr. GRIM. I am not sure that we have a figure for that. We can 

see if there is a figure that could be placed on that. I am not sure 

that is a study that we have ever done. One of the things I can tell 

you is that whenever we are able to refer a patient for contract 

health services, as you know, the law states that that is to be the 

payer of last resort. So we try to make those services go as far as 

possible, and we try to make access for our patients to the services 

that they need through the use of making sure that any of them 

that are eligible for Medicare, Medicaid or private insurance are 

enrolled in that, and then we use the appropriate referral mechanisms for that particular type of insurance, and we make sure they 

get the care in the private sector, either with third-party revenue, 

and to the extent that CHS resources last, with CHS. 

So in one essence, we are doing that to the extent we can within 

the existing programs that are available, both outside the Indian 

Health Service and within the Indian Health Service. 

The CHAIRMAN. Dr. Grim, I am going to ask one more question, 

because we have many colleagues who wish to ask questions. I will 

25

wait until the end to ask additional questions. But contract health 

funds run out early in the year. We have had tribal Chairs tell us 

that they run out of Contract Health Service money in January. 

Many of them tell us in June. And then it is life and limb, which 

is really rationing of health care. 

But one final question, the IHS supports tribal management of 

their health programs through Self-Determination contracts and 

Self-Governance contracts, as you have said. The Supreme Court 

held that in the Cherokee Nation v. Leavitt case, the IHS was obligated to pay full contract support costs due to the tribes who operated health programs and facilities under the Self-Determination 

Act. Is the IHS still insisting that the new Self-Governance compacts contain clauses waiving the tribes’ rights to contract support 

costs? I understand that was the case. Are we still doing that? 

Dr. GRIM. What we are asking them to do is to just indicate in 

the contracts that they are able to operate a program if they want 

to assume it, with the possibility of there not being either 100 percent of the contract support costs available to them, or potentially 

any of those contract support costs. That is what we are asking 

them to agree to in the contracts now. 

The CHAIRMAN. But that doesn’t even make any sense, does it? 

If you want—well, I will leave it at that. That doesn’t make any 

sense at all. If we are saying we would like you to move toward 

Self-Determination, and, oh by the way, if you do, you have to 

waive your right to contract support costs. I don’t understand why 

the Administration is doing that. 

Well, Dr. Grim, you are a good guy——

Dr. GRIM. I can answer that further if you would like. 

The CHAIRMAN. Go right ahead. 

Dr. GRIM. I mean, we have an existing line item or sub-activity 

for contract support costs. When that is insufficient to take care of 

the demand out there, that has necessitated us putting that into 

place. The Supreme Court decision told us, and that was before we 

had a cap on our appropriations, the Appropriations Committee has 

now put a statutory cap on the amount that is able to be spent. 

But prior to that cap, the Supreme Court said that you, the agency, 

and you, the Federal Government, should not be entering into commitment that you cannot meet. 

So we are trying to allow the expansion of self-governance and 

self-determination still with the awareness that we don’t have 

sometimes in a given year the CSC funds available for the number 

of contracts. 

The CHAIRMAN. Dr. Grim, we either have the responsibility, the 

trust responsibility, or we don’t. And if we do, we can’t delegate 

that somewhere. I think it is a disincentive to the Self-Governance 

compacts that a tribe might wish to enter into if you say, oh, by 

the way if you do this, you are going to waive your right to contract 

support costs. As you said, it is a matter of money, but we are so 

far short of dealing with the health needs of these folks. 

You are a good person. I am going to support your renomination. 

I have enjoyed working with you. 

Dr. GRIM. Thank you, Senator. 

The CHAIRMAN. But as I said, in many ways I think you are required to manage a scandal because of the rationing of health care, 

26

which I deeply regret. But I think you are a nominee that has a 

terrific background for this job. If you had the money, coupled with 

your background, then we would have something. We are going to 

continue to push for that. 

Dr. GRIM. I will continue to work with you, Senator. 

The CHAIRMAN. Senator Murkowski? 

We have been joined by several of our colleagues, and we had 

made opening statements. I don’t know whether, and if some of you 

can’t stay and would wish to make a brief opening statement. 

Are you able to stay for questions? If not, you could make a brief 

opening statement and then I would ask Senator Murkowski to 

proceed. 

Senator DOMENICI. I would like to make an opening statement.′′

The CHAIRMAN. Please do, and then I will recognize the Vice 

Chair. 

STATEMENT OF HON. PETE V. DOMENICI,

U.S. SENATOR FROM NEW MEXICO 

Senator DOMENICI. First, Mr. Chairman, I want to thank you for 

joining me as a co-sponsor of a very important bill with reference 

to the Indian people, and that is the diabetic bill. A number of you 

on this Committee have joined us. We are going to pass another 

major diabetic funding bill, Dr. Grim, and you know that we started seven or 8 years ago with a little tiny bill and it has grown with 

the national commitment, and you have as a result a rather significant diabetes program for the Indians. 

If the Indian people will just continue their participation, you 

may indeed prove that entire reservations like the Navajo Nation 

won’t let themselves die because of the DNA factor that exists, and 

they are so heavily laden with diabetes. I commend you for insisting that this be run properly with the universities and that you get 

your share. 

Mr. Chairman, I want to comment that we could look at all different aspects of the shortage that we have, but I think the basic 

one that we better get to and see if we can find a way, I am going 

to suggest it later in a bill form, but I think the infrastructure, that 

is the buildings, are so decrepit and so deficient that they are getting close to what we had 5 years ago, 4 years ago, with Indian 

education, where we could not in all good conscience tell people to 

go see Indian education buildings on the United States side. There 

were better ones in Alaska, a little better. But we couldn’t invite 

friends to go see most of them because they were so bad. 

What we did is we got a commitment out of the President that 

if he won, he would put up a huge amount every year for 5 years 

of his presidency and we just about wiped out the needs on education, on the new school buildings. I think we ought to consider 

a similar things for the candidates for President that are running 

in both parties, and get them to commit to us that they will have 

a certain amount in their budgets. 

You know, this year we have $12 million in the budget for capital 

improvements for a deficiency of $3 billion. Now, that is almost 

asking the accountants, to hire some accountants and say we agree 

to pay you, and we hope in the process you will provide health 

27

care; $12 million is such a small amount compared to $3 billion in 

needs. You can’t pay the administrative costs. 

We just have to get somebody up there in the White House to 

commit that on a regular basis for a number of years, we will get 

$500 million or $600 million and rebuild some old hospitals and do 

the things that are required. 

This gentleman knows all about that, and he knows how to lead 

it. The problem is you can’t lead that with nothing. I think he 

should be confirmed. I think, however, that we should ask him as 

he finally gets confirmed that regardless of his being an employee 

of the Administration, that he speak out on some of the more egregious situations. 

I think some of them deserve your comment, even though you 

work for the Administration. There are facilities that deserve you 

saying, as a doctor, these ought to be fixed; they shouldn’t be serving human beings, much less Indian people. 

Thank you, Mr. Chairman. 

Dr. GRIM. Thank you, Senator. 

The CHAIRMAN. Senator Domenici, thank you very much. 

Senator Tester is presiding on the floor of the Senate at 10:30. 

Let me call on Senator Murkowski, and if we can allow Senator 

Tester just following you, if he has the time, to ask a couple of 

questions. I would like to do that. 

Senator MURKOWSKI. Well, if you really have to be there at 

10:30, I will defer to you, Senator Tester, and then take my turn 

after that. 

Senator TESTER. That is very kind of you, Senator. Thank you 

very, very much. I appreciate that. 

Dr. Grim, I, too, want to reflect the statements of the Chairman 

that you are a good fellow, and I would be remiss if I didn’t once 

again point out that you have a great haircut. 

[Laughter.] 

Dr. GRIM. I like yours, too. 

[Laughter.] 

Senator TESTER. The Native Americans, the system is upside 

down, the health care system. One of the issues that I have looked 

at a little bit is Native American people to provide health care for 

the Native Americans. Is there anything that Indian Health is 

doing to encourage more Native Americans to get into the health 

care profession and to come back to the reservations? 

Dr. GRIM. Yes, sir. We are, actually. We have one program in 

particular, our scholarship program, that has about $12 million in 

it per year. We run between 400 and 500 students at any given 

time. The unique thing about our program compared to some scholarship programs is that we have a pre-professional component to 

it. We can pay for undergraduate work as well as the professional 

work. Over the course of the years Indian Health Service has been 

around, we have gone from, well just in the last 25 years, we have 

increased by 272 percent the number of Indian professionals we 

have. We have with that program provided 1,000 doctors, 2,200 

nurses, and 300 dentists. 

They also have an obligation back to our system, and we tallied 

the other day that obligation to date there have been over 11,000 

28

service years that have been provided back to Indian people because of that program. 

Senator TESTER. And those scholarships are available throughout 

every State in the Union? 

Dr. GRIM. It is a nationally run program, so they are available 

nationally, yes. 

Senator TESTER. Good. The VA has signed a memorandum of understanding with the Indian Health Service in five areas. You are 

probably familiar with them. They are all laudable. The VA has 

taken no action in Montana, at least, and I don’t know if they have 

taken any action anywhere else. 

What can you do to ensure that those areas of concern that are 

listed in that VA MOU, and I can list them to you, but you know 

what they are. 

Dr. GRIM. Yes, sir. I do. 

Senator TESTER. Follow through on them. 

Dr. GRIM. Since you raised an issue that there is nothing there, 

we will look into it and get back to you. But there are a huge 

amount of things occurring and it varies across the Nation, but one 

of the things I will say that my counterpart at the VA and I have 

worked together closely to bring life to that MOU. We have had 

some historic meetings that had never occurred before between our 

regional directors and the VA VISN directors. They were working 

meetings on how we could bring life in all of the regions across the 

Country to that MOU. 

Senator TESTER. That is good. 

Dr. GRIM. So I know there are varying levels of achievement to 

date, but we are continuing to work on it. 

Senator TESTER. A last question, and very quickly, in your written testimony, and you may have said it in your verbal testimony 

too, you talk about injuries 154 percent of norm; alcoholism, 551 

percent; diabetes, 196 percent; homicide 108 percent; suicide 57 

percent, the list goes on and on and on. I mean, it is a travesty 

and it is something that quite honestly anybody that would read 

this would be very, very concerned about. 

As quick as you can, in three or four bullet points, what could 

we do to get this to reasonable figures? I am talking about the occurrences of these terrible things, you know, two times sudden infant death syndrome. The list goes on and on and on. What can we 

do? What can we do? 

Dr. GRIM. I can give you a long answer, but I won’t and we can 

provide more for the record. But quickly, we are partnering with 

groups that we have never partnered with before around all those 

things that you mentioned. 

Second, we have recognized it is not just a health system issue, 

it is a societal issue. There needs to be safe housing, safe roads, 

and things like that. And so we are reaching out and so are the 

Indian leaders in those communities to address some of those 

issues, too. 

I think the third thing that I would say is that as we looked at 

the epidemiology of all of those things that you just mentioned, 

that is how we settled with Indian Country on the three initiatives 

that we are working on. If you looked at all those things you mentioned—prevention—almost all of them are preventable. Many of 

29

them, if not all of them, have behavioral health components. And 

then another load on our system is the chronic care. 

So we chose those three things to focus on and we are starting 

to build and integrate all those three initiatives. 

Senator TESTER. In closing, I just want to say one thing. That is, 

that you are very close to Indian health care as far as the delivery 

system. You are a decisionmaker that can really make a difference. 

I would hope, and I am not making any claims that the Administration is doing this, trust me. But I would just hope that if the 

Administration is doing things that you don’t agree with, that you 

put your job on the line to make sure that they are done right, that 

the right thing is done. 

I think you are a good person. I do think you are in a difficult 

situation, but there is plenty of opportunity here to improve the 

system, and that is a good sign. 

Thank you very much. 

Thank you, Senator Murkowski, once again, I appreciate it. 

The CHAIRMAN. Senator Tester, thank you very much. 

Senator Murkowski? 

Senator MURKOWSKI. Thank you, Mr. Chairman. 

Dr. Grim, I think that you should note that your appearance 

here this morning before the Committee has drawn out more Senators than we have seen up here in a while. It could be because 

everybody thinks you are a good guy, but I think probably the underlying reason is we all appreciate that when it comes to representing our constituents, whether they are Alaska Natives or 

Cherokees or where they are, that when it comes to health care 

and providing for the health and the well being of these constituents of ours, that we have an enormous responsibility. Our statistics are statistics that we simply are not proud of. It is a very challenging place that you are in. Again, I will repeat my thanks to you 

for the efforts that you take on this. 

As a Committee, we have certainly agreed that the Indian 

Health Care Reauthorization Act should be our number one priority. What can you do at this point in this Congress to help us facilitate that? What can we be doing more of? What can you be 

doing at your level to make sure that the President has this on his 

desk this year? 

Dr. GRIM. I think you could ask my Legislative Director or anyone on my staff that works closely with that bill. There has been 

more interest and involvement from the department and the Administration on this bill in the last few years than there ever has 

been. We have been working extensively and tirelessly, I might 

add, to try to get the bill report to the Committee. As you know, 

the bill changes slightly each year and we have to compare it to 

the last Senate and House bills to get comments in. 

But we are still working on the bill report, and while I can’t commit to a timeframe today, it is still going back and forth in clearance. It has not sat on anyone’s desk since the last time I was here. 

And I will continue to work on it, Senator. 

Senator MURKOWSKI. I appreciate your commitment to that, but 

I think, again for those of us that recognize the very, very high priority of this, we don’t want to be doing this next year and checking 

what we did last year on the bill when it has been sitting around 

30

for 10 years plus. Now is well past time that we again get this to 

the President for his signature. So I appreciate all that you can do 

to help us facilitate that. 

I want to ask you, the Amnesty International report that came 

out several months back, I know that you have reviewed it. It was 

yet one more devastating report in terms of the statistics. But 

there were really some very damning messages that came from 

that in terms of what we are seeing at many of the IHS facilities, 

lacking the clear protocols for treating the victims of sexual violence; 44 percent of the facilities lack personnel trained to provide 

the emergency services; a statement that IHS has not prioritized 

the implementation of the nurse examiners, some really very, very 

troubling revelations that came out in this. 

I would like for you, Dr. Grim, to just response to this report as 

it relates to the shortcomings in the IHS response. And also to ask 

you, there have been many that have approached me from the sexual and domestic violence community that have said that IHS is 

not devoting sufficient attention to addressing the needs of the victims, the survivors, to bring the perpetrators to justice. I want to 

know whether you feel that this criticism is valid, in your judgment, so if you can address some of the outcomes from that Amnesty International report. 

Dr. GRIM. I have read the report, Senator Murkowski, as soon as 

it came out. We have had a group looking at it. As you know, the 

report was primarily focused on other issues in Indian Health—jurisdictional issues, law enforcement. But we did take seriously the 

recommendations that came forward that dealt with our system. 

We have had a group looking at it. I don’t personally believe that 

all of the criticisms that were leveled, all the recommendations are 

valid, nor able to be carried out in our system. First, let me say 

that. 

Senator MURKOWSKI. Do you think that IHS has the mandate or 

the authority to address some of the issues that are raised by Amnesty International? 

Dr. GRIM. I feel we have the authority to do it. The problem is 

the ability, if you will. 

Senator MURKOWSKI. Ability financially or in what way? 

Dr Grim. What they were measuring us against essentially was 

the sexual assault nurse examiner, which is the gold standard, if 

you will, for forensic examinations for sexual assault. It is really 

not just an Indian Health Service issue, it is a rural issue, if you 

will, all around the Country. Even some of our hospitals that might 

be capable of carrying out a SANE program or a SART program, 

defer to another hospital in their city that have it. 

Part of it is the training is rather demanding for the sexual assault nurse examiners. Many of our nurses are community members. A high percentage of our nurses are American Indian or Alaska Native. The secondary trauma that they go through dealing 

with the victims make it an extremely difficult job to retain people 

in. Then the length of time that the examinations take, especially 

in our smallest and most rural facilities—you know, whenever you 

have the workload demands, sometimes it makes it impractical to 

do that. 

31

What I will say, and I want to point out to the Committee, is 

that whenever a person who has been sexually assaulted does show 

up at our facilities, they are treated well. They are treated with 

compassion. We have 500 facilities, as I said, across the Nation. 

I cannot assure you today, although I can try to find out, that 

100 percent of them have protocols on domestic violence, but all of 

our major facilities, the facilities that I mentioned that are accredited by JCAHO, AAAHC, protocols for dealing with domestic violence and sexual assault patients are there. Many, many of our 

physicians and nurses have the required training to do the sexual 

assault exams. We get the rape kits. We do those. Those that aren’t 

trained to actually do it can hold evidence until State troops or others, or tribal police show up. 

So I guess what I want to leave the Committee with is that, 

number one, we are looking at all those recommendations and we 

are taking them seriously. Second, the people that are coming into 

our facilities are getting the care that is necessary, although it is 

not always a SANE program. Any of our facilities that are close 

enough for the patients to be easily transported to a SANE program are then transported. Usually, we refer out from our emergency departments when there is one of those close enough because 

we realize that right now it is measured as sort of the gold standard of care. 

And the last thing I would say just in closing is that the report 

criticizes us for not having a national policy on this. But I told you 

that all of our facilities that are accredited are required to have 

such things. For many, many practice-related things, we don’t develop national policies. There are policies and procedures in place 

that the medical staff have there locally that are just standards of 

care in the medical community. 

So I don’t want anyone who has read that report to think that 

people are being neglected. But when you go to the most isolated 

parts of Indian Country, sometimes they have to be taken a long 

ways to get to somebody that can do the forensic exam or to hold 

the evidence. 

Senator MURKOWSKI. Well, we will followup with you on certain 

aspects of this. 

Dr. GRIM. I will work with you on that. It is a big concern. 

Senator MURKOWSKI. I appreciate that. 

One last question, very quickly so that we can get to the rest of 

my colleagues here. You and I have discussed at great length the 

focus on prevention. I absolutely support your focus in this area in 

a way that we can help to reduce the health care costs and deal 

with so much of what faces so many in Indian Country. 

You have been an advocate for healthy nutrition, which we know 

is a key aspect when it comes to prevention, particularly in some 

of the diseases that we are seeing, this escalation in numbers like 

diabetes and the complications. 

What is going on specifically to improve the nutrition programs 

within Indian Country, within the Alaska Native communities? 

You know, in Alaska one of our great challenges is how you get 

fresh vegetables and fruits out to villages. The cost is impossible 

and the condition of the fresh produce is such that you are not willVerDate 0ct 09 2002 11:30 Dec 20, 2007 Jkt 038552 PO 00000 Frm 00035 Fmt 6633 Sfmt 6601 S:\DOCS\38552.TXT JACK PsN: JACKF
32

ing to pay the $3 for the black banana. What are we doing to make 

a difference in this area? 

Dr. GRIM. You have perhaps in your State one of the largest challenges in that arena, perhaps as anyone except for poverty reasons 

in other locations that just flat-out don’t allow people to do that. 

One of the things that we are doing, and I think everyone—tribal 

programs, Federal programs, and urban—have recognized that nutrition is an important part of health care. More and more programs are trying to ensure that they have nutritionists and dieticians on staff. A lot of the work with the tribes and the tribal organizations or with the tribal communities that we work in are starting to focus on going back to more traditional diets. That is starting to have a lot of resonance and a lot of success in communities, 

as opposed to what a nutritionist in an urban area might suggest 

to someone that they do. 

But we are trying to do what we can to improve. We have a list 

of issues that we could show you that we are doing. A lot of them 

are within our diabetes program. They really led the way across 

the Country on both nutrition, physical activity programs, and 

things like that. 

But you do have some big challenges, as you mentioned, for a lot 

of the rural communities in your State. 

Senator MURKOWSKI. Again, that is another one that we will look 

forward to working with you on. My colleague has suggested that 

the answer is frozen vegetables, and he forgets that in the icebox 

of the north, we don’t have refrigerators up there. 

Dr. GRIM. Good answer. I wish I would have thought of that. 

Senator MURKOWSKI. Yes. 

[Laughter.] 

Senator SMITH. For the record, Mr. Chairman, Madam Vice 

Chair, they are fresher than fresh by the time they get to Alaska. 

Senator MURKOWSKI. We just can’t afford the cost to plug in the 

refrigerator for the freezer unit. 

The CHAIRMAN. Senator Smith? 

STATEMENT OF HON. GORDON H. SMITH,

U.S. SENATOR FROM OREGON 

Senator SMITH. Thank you, Mr. Chairman. 

I appreciate very much Dr. Grim being here. I am honored to 

support your renomination and look forward to voting for that. 

I also want to thank our Chair and Vice Chair and their staffs 

for working with me and my staff on an issue that—I am glad Senator Domenici is not here to talk about, he will have a different 

opinion on it—but it relates to the Health Care Improvement Act 

Amendments of the 2007 bill we are working on. What I am talking about is literally the construction formula, the health facilities 

and area distribution fund. 

As it is now, New Mexico and Arizona benefit disproportionately 

to other tribes. I wish those tribes nothing but the best and I am 

anxious to support a larger budget if that is what it takes. I don’t 

want to disadvantage them. But I do want to make clear that the 

current formula just is not fair to other tribes throughout the 

Country. 

33

So what I want to find out from you is if the Indian Health Service has the authority under section 301 of S. 1200 to both pursue 

and implement an area distribution fund methodology. 

Dr. GRIM. As I stated earlier, our views, our Senate bill report 

on that is still pending, and we have never implemented. We have 

a demonstration authority similar to that in our existing authorization in our current legislation. When our legislative and facilities 

people have looked at that, and we feel like it gives us the ability 

to do that, it has just never been done. 

The Congress, we work with them very closely and they are fairly directive in the funds that they provide for our facilities program. So I guess my answer to you, Senator, would be it has never 

been tried, but we think that the authority probably exists in current legislation. 

Senator SMITH. So there is no current time line to shift from the 

current list to the new work list? There is nothing like that at this 

point? 

Dr. GRIM. The existing list has been there for about 15 years. We 

closed it about that many years ago because of the size of it. Those 

that are still in progress on the list, plus those that still exist, 

number about 20. We are right now preparing a final report to go 

through clearances with the department and OMB on the new facilities priority system. I believe that the multitude of options that 

that new system is going to allow is going to allow me to work with 

the Administration and with Congress to work on all the projects 

that have been initiated, plus look at the ways that we will implement the new methodology. 

Senator SMITH. I just want to emphasize the importance of this 

because as important as our tribes are in New Mexico and Arizona, 

I do want to state for the record that the current distribution is inequitable. The system needs more money, but the new formula 

needs to get done and it needs a time line and we need a transition 

period. 

We have nine federally recognized tribes in Oregon. There is 

hardly a time I go home and meet with them that they don’t mention the importance of our coming up with an agreement on this 

issue and pass this bill. It is essential to have a decent health care 

facility if you are going to provide decent health care, and many 

of them simply don’t have that. They are due that. 

So I look forward to working with you, Mr. Chairman, Madam 

Vice Chair, to get this bill passed, get this new formula in place. 

It is long overdue. 

Thank you. 

[The prepared statement of Senator Smith follows:]

34

PREPARED STATEMENT OF HON. GORDON H. SMITH,

U.S. SENATOR FROM OREGON


726gor1.eps
35


726gor2.eps
36

The CHAIRMAN. Senator Smith, thank you very much. 

Senator Barrasso? 

Senator BARRASSO. Thank you very much, Mr. Chairman. 

Dr. Grim, congratulations. It is so good to see your family here. 

Mrs. Grim, your son, you have a lot to be proud of. He does a remarkable job. 

I am proud of the accomplishments you have had in the last 4 

years. I know what you have done in terms of domestic violence; 

your efforts in vaccination, both for the very young and the elderly 

in terms of the flu; some of the screenings you have done for substance abuse. 

In my previous life, I worked quite a bit with patients injured, 

and the concern I had with those that Senator Tester talked about 

earlier—the suicide, the unintended injuries, substance abuse, domestic abuse. 


726gor3.eps
37

I am concerned also about some of the additional preventive 

things like the diabetic work. I know between the late 1990’s and 

2003, we have been the incidence of diabetes almost doubling in 

this population of folks. But I am seeing it also in younger people. 

I am seeing the teenagers. We used to think of as malnutrition 

back when we were in school is people starving, but now malnutrition seems to be on the other side, the obesity issue which is contributing to this. 

So first, if I could ask you if you are really focused also on the 

younger folks, and not just for the diabetes. Then the second question will have to do with substance abuse, because sometimes I am 

taking care of very young folks who are injured, and you talk about 

when their substance use began, and abuse, and it is at a young, 

young age. 

Dr. GRIM. First, let me say that we are concerned about the same 

thing greatly. Our statistics have shown some of the greatest increases in those younger populations. One of the things I would say 

about the moneys that Congress made available for us in the Special Diabetes Program for Indians, a huge amount of those dollars 

are going toward primary prevention, secondary prevention, a focus 

on childhood obesity. We are seeing that, too, as one of the largest 

problems. 

And so, yes, we are strongly working on that. A lot of the work 

that is being done in those programs is primarily with the youth. 

We are taking care of our existing patients that have diabetes. We 

are watching those closely that have pre-diabetes, and working 

with them both with nutrition and physical activity sorts of therapy. 

But a lot of the programs and the dollars are going on education 

to youth, on physical activity programs for those. And we have 

partnered, as I said earlier, with both the Boys and Girls Clubs of 

America to introduce programs into their clubs that are dealing 

with basically educational things for the youth about the decisions 

they make today and how it will affect their heath in the future. 

We are partnering with several other agencies on that, too, with 

Boys and Girls Clubs. Nike has joined us in a drive to increase 

physical activity levels in Indian communities. So there is a lot 

going on in primary prevention and a lot of it is directed at youth. 

Senator BARRASSO. Thank you, Mr. Chairman. Because along 

those lines, Dr. Grim, I see the folks in Wyoming who live in the 

general neighborhood of our Wind River Reservation, and know 

that the average lifespan of a man is in his late 70’s, and a woman 

in the early 80’s. Yet on the reservation itself, it is 491⁄2. I just 

think that we still have a much bigger job to do and a significant 

responsibility to those citizens. 

So anything you can do that will help we certainly would be 

grateful for. I certainly plan to look forward to supporting your 

nomination and voting in favor of you. 

Dr. GRIM. Thank you, Senator. 

The CHAIRMAN. Dr. Grim, the first thing I read this morning 

when I began looking at material after I woke up was from National Public Radio report last evening. The title was ‘‘Rape Cases 

on Indian Lands Go Uninvestigated.’’ Most of this is about law enVerDate 0ct 09 2002 11:30 Dec 20, 2007 Jkt 038552 PO 00000 Frm 00041 Fmt 6633 Sfmt 6601 S:\DOCS\38552.TXT JACK PsN: JACKF
38

forcement. The circumstances are almost unbelievable, almost as 

unbelievable as the inability to get medical care for some. 

I raise it for one reason. This is a young woman who was brutally raped, Leslie Ironroad. Nobody investigated the rape. She 

died about 10 days later. Nobody investigated it, not the BIA, not 

the FBI, nor anybody else. The Justice Department has said that 

one in three Native American women will be raped in her lifetime. 

My colleague from Alaska raised this issue of violence against 

women. 

One of the things that I saw in this report, on this reservation, 

the Standing Rock Reservation, the reservation has one women’s 

shelter. The health center and the shelter try to reach out and help 

these women. The health center doesn’t have rape kits to collect 

the DNA evidence necessary to prosecute attackers. They are inadequately staffed, can’t even spare an exam room for the hour it 

takes to complete the rape examination. 

Staff physician Jackie Quizno in Bismarck said she sees rape 

cases several times a month. They turn over the information on the 

women to the BIA police and Federal prosecutors and nothing happens. That is law enforcement, but it is also health in some respects. 

It just broke my heart again this morning to read this. We have 

been through this with respect to teen suicide issues and violence 

against women. We are going to hold a hearing on these issues, the 

violence against women issues. 

I do hope we can begin to make some progress. Let me just say 

what a couple of my colleagues have said to you. You serve at the 

pleasure of the President, but you serve the needs of American Indians. I hope that you will, if necessary, when necessary, take a 

risk here and there, and speak out and speak aggressively about 

how far short we are of meeting the needs. Because this Administration and previous Administrations have really not done what we 

should do. 

I asked you the question not to embarrass you today about the 

Office of Management and Budget, but you have been pretty direct 

with us when testifying here. You have indicated that you believe 

there is a trust responsibility. You have cited the laws for the responsibility. When I learned that OMB had asked that it be taken 

out of today’s testimony, I asked why. I know you are not able to 

answer that, but it bothers me because we have to do better. 

Senator Murkowski and I and Senator Barrasso, we don’t want 

to sit at these hearings every year and just say, you know, we regret what is happening out there. We have to fix what is happening out there, and you have to help us, and this President has 

to help us, and the Congress, Republicans and Democrats, have to 

come together to say that we have to do better. 

So again, I am pleased to support your renomination. I think you 

are an awfully good person and you are very well qualified. My 

dealings with you have been extensive and you have always been 

up front and direct. I appreciate that, Dr. Grim. 

As our colleague from Oklahoma said, public service is a wonderful opportunity, but in many cases a very significant responsibility 

and burden as well. Your family is elsewhere. You are here. I 

thank you for your commitment to public service. Work with us 

39

and help us, and let’s hope in the future when we have a hearing, 

you and I and this Committee can say, you know something, we 

raised a little hell here and we got a lot done, because we demanded that it get done. 

Dr. Grim, we will move your nomination through this Committee. I think I speak on behalf of virtually every member of this 

Committee: thank you for your public service. 

This hearing is adjourned. 

Dr. GRIM. Thank you, Senator. 

[Whereupon, at 10:50 a.m., the Committee was adjourned.] 

(41)

APPENDIX


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* Responses to written questions were not available at the time this hearing went to press.

WRITTEN QUESTIONS SUBMITTED TO CHARLES W. GRIM * 


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Æ


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