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74–575 PDF 2002

S. HRG. 107–103

INDIAN HEALTH CARE IMPROVEMENT ACT

HEARING

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS

UNITED STATES SENATE

ONE HUNDRED SEVENTH CONGRESS

FIRST SESSION

ON

THE INDIAN HEALTH CARE IMPROVEMENT ACT FOCUSING ON

PERSONNEL ISSUES AND URBAN INDIAN HEALTH CARE PROGRAMS

JULY 31, 2001

WASHINGTON, DC

(
COMMITTEE ON INDIAN AFFAIRS

DANIEL K. INOUYE, Hawaii, Chairman

BEN NIGHTHORSE CAMPBELL, Colorado, Vice Chairman

FRANK MURKOWSKI, Alaska

JOHN McCAIN, Arizona,

PETE V. DOMENICI, New Mexico

CRAIG THOMAS, Wyoming

ORRIN G. HATCH, Utah

JAMES M. INHOFE, Oklahoma

KENT CONRAD, North Dakota

HARRY REID, Nevada

DANIEL K. AKAKA, Hawaii

PAUL WELLSTONE, Minnesota

BYRON L. DORGAN, North Dakota

TIM JOHNSON, South Dakota

MARIA CANTWELL, Washington

PATRICIA M. ZELL, Majority Staff Director/Chief Counsel

PAUL MOOREHEAD, Minority Staff Director/Chief Counsel

(II)
(III)

C O N T E N T S

Page

Statements:

Bird, Michael, president, American Public Health Association, Albuquerque, NM ......................................................................................................... 6

Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado, vice chairman, Committee on Indian Affairs .............................................................. 1

Culbertson, Kay, executive director, Denver Indian Health and Family

Services, Inc., Denver, CO ............................................................................ 30

Hall, Robert, president, National Council of Urban Indian Health, Washington, DC ..................................................................................................... 19

Hill, Barry T., director, Natural Resources and Environment, General

Accounting Office, Washington, DC ............................................................ 5

Hunter, Anthony, health director, American Indian Community House,

New York, NY ............................................................................................... 21

Inouye, Hon. Daniel K., U.S. Senator from Hawaii, chairman, Committee

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

Malcolm, Jeffrey, senior evaluator, Natural Resources and Environment,

General Accounting Office, Washington, DC .............................................. 5

Meyers, Carol, executive director, Missoula Indian Center, Missoula, MT . 24

Vanderwagen, William C., acting chief medical officer, Office of the Director, Indian Health Service, United States Department of Health and

Human Services, Rockville, MD .................................................................. 2

Waukazoo, Martin, executive director, Native American Health Center,

Oakland, CA .................................................................................................. 26

APPENDIX

Prepared statements:

Bird, Michael (with attachment) ..................................................................... 50

Conrad, Hon. Kent, U.S. Senator from North Dakota .................................. 45

Culbertson, Kay ................................................................................................ 58

Daschle, Hon. Tom, U.S. Senator from South Dakota .................................. 45

Forquera, Ralph, executive director, Seattle Indian Health Board (with

attachments) .................................................................................................. 97

Hall, Robert ....................................................................................................... 75

Hill, Barry T. (with attachments) ................................................................... 65

Hunter, Anthony (with attachments) ............................................................. 87

Meyers, Carol .................................................................................................... 53

Taylor, Jr., Wayne, chairman, Hopi Tribe ...................................................... 61

Valadez, Ramona, executive director, Native Direction, Inc. (with attachments) ............................................................................................................ 139

Vanderwagen, William C. ................................................................................ 48

Waukazoo, Martin ............................................................................................ 56

Additional material submitted for the record:

Magedanz, Tom, staff, South Dakota-Tribal Relations Committee, memorandum (with attachments) ......................................................................... 152

Perdue, Karen, commissioner, Department of Health and Social Services,

Alaska ............................................................................................................ 158

(1)

INDIAN HEALTH CARE IMPROVEMENT ACT

TUESDAY, JULY 31, 2001

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

The committee met, pursuant to notice, at 10:05 a.m. in room

485, Russell Senate Building, Hon. Daniel K. Inouye (chairman of

the committee) presiding.

Present: Senators Inouye, Conrad, and Campbell.

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

HAWAII, CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS

The CHAIRMAN. The committee meets this morning to receive testimony on the challenges confronting the Indian Health Service,

privately-administered health care programs, and urban Indian

health care programs with regard to recruiting and retaining

health care professionals today and in the years ahead.

Today’s hearing will also address the challenges confronting the

urban Indian health care programs as they address the health care

needs of Indian people residing in urban areas—a population which

now represents 60 percent of the total population in Indian country.

The committee is pleased to welcome the witnesses. We look forward to your testimony.

Before we do, I am pleased to call upon our vice chairman.

STATEMENT OF HON. BEN NIGHTHORSE CAMPBELL, U.S. SENATOR FROM COLORADO, VICE CHAIRMAN, COMMITTEE ON

INDIAN AFFAIRS

Senator CAMPBELL. Thank you, Mr. Chairman.

In the 106th Congress the committee held four hearings on various parts of S. 212, and today we will continue with that series

of hearings. This bill would reauthorize the Indian Health Care Improvement Act, the core act that authorizes the majority of Indian

health programs.

We have both said many times in the past Mr. Chairman, the

American Indians and Native Alaskans continue to suffer the worst

health status of any group in America. Since 1976 this act has been

a powerful tool in helping tribes and the IHS change the health

status of Native populations for the better. Since the initial passage of the act, the death rate among the Native population has decreased in all categories, and the provision of health services has
2

improved overall. I believe S. 212 will put us on the right path of

achieving the goals that we first set out to accomplish in 1976.

Today we’ll discuss an issue of growing concern to me, and that’s

the provision of health care for our urban Indian population. Over

one-half of our Indian population lives off-reservation, most of them

in urban areas, and yet funding for the urban programs in the IHS

system is still only 1.14 percent of the entire IHS budget and has

remained stable for the last 3 years, even though the urban Indian

population is growing.

Today we’ll also look at the personnel programs of IHS. One of

the purposes of the Health Care Improvement Act was to increase

the number of Native people who enter this profession. I think the

act has already helped many individuals enter the profession, but

I also think we need to look more closely to see if we are doing all

we can do to attract more Indian people, as well as other dedicated

health professionals, in the Indian Health Services.

I look forward to the hearing, Mr. Chairman. Thank you for calling it.

The CHAIRMAN. I thank you very much.

Our first panel consists of the following: The acting chief medical

officer, Office of the Director, Indian Health Service, Department of

Health and Human Services, Dr. William C. Vanderwagen; the director of the Natural Resources and Environment, General Accounting Office, Barry T. Hill, and he will be accompanied by Jeffrey Malcolm, senior evaluator, Natural Resources and Environment; and the president of the American Public Health Association,

Michael Bird.

I am pleased to call upon Dr. Vanderwagen. Welcome.

STATEMENT OF WILLIAM C. VANDERWAGEN, ACTING CHIEF

MEDICAL OFFICER, OFFICE OF THE DIRECTOR, INDIAN

HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN

SERVICES, ROCKVILLE, MD

Mr. VANDERWAGEN. Thank you, Mr. Chairman, and good morning to you. It is so good to see you here.

We appreciate greatly the committee taking the time to review

with us the issues of concern to the committee and to Indian people

with regards to Indian health manpower and the needs of urban

Indian people.

I have a prepared statement which I would ask to be entered

into the record.

The CHAIRMAN. Without objection, so ordered.

Dr. VANDERWAGEN. Thank you, sir.

As both you and the vice chairman have noted, sir, the health

status of Indian people still lags well behind that of the general

U.S. population. Diabetes is at least four-fold what it is in the general population, alcoholism is seven-fold what it is in the general

population, et cetera.

The Congress has given us what I view to be a very sacred mission, and that is to elevate the health status of American Indians

and Alaska Natives to the highest possible level and develop the

capacity of Indian communities to manage and direct their own

health care systems.
3

Today, as we talk about manpower, I think the issue of have we

discharged that responsibility with some success around building

local capacity is what we would like to talk with you about. We believe there are clear indicators of success.

For example, in the ITU setting—that is, in the Indian Health

Service, tribal, and urban programs—and we are a health system

now that encompasses those three facets—Federal, tribal, urban— 75 percent of the staff in those organizations are Indian people,

and it is because of the scholarship program, it’s because of the

CHR program.

I like to believe that the woman who 30 years ago became a CHR

supported her daughter through the scholarship program to become

an RN, and now her daughter is attending medical school, and

we’ve seen that kind of change in the development of professional

skills and capacities in the Indian communities. We think that is

good public health. It strengthens those communities and their

ability to take care of issues.

We’ve also had a variety of other opportunities provided to us in

terms of how we approach recruitment and retention. Today we

have with us here in this audience a number of folks who are working with Indian Health Service this summer. They are future leaders in Indian health. Some of them are wearing uniforms. They

came to the co-step program. We have two medical students from

the Uniformed Services University here. We have students in the

undergraduate area who are here courtesy of the Washington Internship for Native Students at AU. We have people who are here

because of the externship program that we have available to us

under the Indian health manpower authorities. These are the future leaders of Indian health. So we believe there has been success

in developing Indian people’s capacity to manage and deliver their

own health system.

There are still recruitment issues to be addressed. Using the loan

repayment authority provided, we have been able to expand the

number of individuals, professional individuals that we are able to

bring to Indian country to assist us in meeting these health challenges of diabetes, of alcohol, and other issues. This would include

podiatrists, pharmacists, nurses, dentists, physicians. We continue

to have vacancy rates that exceed the general population. Our physician-to-population ratio still exceeds 1-to-1,000, compared to, say,

the District, where it is 1-to-250. So we still have recruitment challenges to address.

We have significant retention challenges, as well. The difficulty

in being isolated, cultural transition, and dealing with a system

that is severely rationed does lead to turnover, and, in fact, those

vacancy rates that I mentioned earlier in some measure are reflective of those issues.

The average tenure of our staff is less than we would like it to

be. Physicians stay on average 8 years. Nurses stay on average 12

years. We’d like to see them for a whole career. That is a challenge

that we have in front of us yet in manpower recruitment and retention.

The urban programs are a significant concern to us in the agency. In the last 5-to-7 years, under the leadership of our director, Dr.

Trujillo, we have taken the approach that I mentioned earlier—
4

that we are the Federal, the tribal, and the urban programs that

are a health system for delivery of health services to Indian people.

As Mr. Campbell noted, significant increases in urban population

are confronting us, in part because cities have now grown to reservation boundaries. Albuquerque can no longer grow north, west,

or south, because they have reached reservation boundaries. And,

in fact, those Indian people who live on those reservations are now

urban Indians in that they live within an SMSA. On the other

hand, the population that was moved in the 1950’s and their children and grandchildren has expanded significantly, as well. So

there are real issues to address in meeting the health needs of

urban people.

While we talk about health statistics in Indian populations, we

don’t have the data we need to fully understand the specific issues

that affect urban Indian people. We have only now, in the last 11⁄2

years, established an epidemiology center with a focus on health

needs of urban Indian people. The data needs are large for trying

to understand where the issues are and how we can best address

them, and that’s a task that we’re taking on in consultation with

urban people.

Urban Indians have been included fully in the consultation process around budget allocation. They have been included in the budget formulation process. We will continue to include them as active

partners in this health system for Indian people, and we believe

that they are active and viable partners.

I would be remiss if I didn’t note that most of those programs,

on average only about one-third of their funding comes through the

Federal sector funded by Indian Health Service. A significant

amount of their funding comes from other Federal programs and

State and county programs, as well. They have been very successful at surviving and expanding their programs. I will give you but

one example.

In Los Angeles County, a 400-square-mile area, the Indian population is diffusely scattered throughout that area. The approach

that has been developed is a managed care approach with case

managers, since there’s really no focused population of urban people, and these case managers work with individual urban people to

identify the best care locations for those people, whether they’re in

the northeast corner of the county or they’re in the southwest corner of the county, and it has been a very successful program.

Because of unique needs in behavioral health, the State and

county, and particularly the county of Los Angeles, have now

helped that clinic start an active outpatient behavioral health program. They just opened it 5 months ago. One-half of the county

commissioners appeared at the opening of this program, and it is

a testimony to the resourcefulness of those Indian people in L.A.

as to the quality of the job that they have been able to do.

There are real challenges, and we appreciate the opportunity to

be here today, and I’ll be happy to answer any questions you may

have as the hearing progresses.

Thank you.

The CHAIRMAN. I thank you very much, Doctor.

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

The CHAIRMAN. May I now call on Mr. Hill.
5

STATEMENT OF BARRY T. HILL, DIRECTOR, NATURAL RESOURCES AND ENVIRONMENT, GENERAL ACCOUNTING OFFICE, WASHINGTON, DC, ACCOMPANIED BY JEFFERY MALCOLM, SENIOR ANALYST

Mr. HILL. Thank you, Mr. Chairman. It is certainly a pleasure

for Mr. Malcolm and me to appear before this committee. We’re

here today to discuss the issue of Federal tort claims coverage for

tribal contractors, and my comments this morning will focus specifically on the FTCA coverage and claims history for tribal self-determination contracts at the Indian Health Service.

If I may, I’d like to briefly summarize my prepared statement

and submit the full text of my statement for the record.

The CHAIRMAN. Without objection, so ordered.

Mr. HILL. Last year we issued a report to this committee on the

combined FTCA claims history for tribal self-determination contracts at the Indian Health Service [IHS] and the Bureau of Indian

Affairs [BIA]. That report provides more details about the provisions that extended FTCA coverage to tribal contractors and four

emerging legal issues affecting FTCA coverage for those contractors.

For my testimony today, we’ve updated the status of the IHS

claims since our report last year, and the figures I will be presenting were current as of July 15, 2001.

Let me start my testimony today by briefly describing the process

for implementing FTCA coverage for tribal self-determination contracts.

We are here today because accidents happen, and when those accidents are caused by the negligent actions of a tribal employee,

the injured parties may be able to seek compensation from the Federal Government for their personal injuries. For example, if a patient receives negligent care at a tribal health facility or there is

an accident involving a tribal ambulance, the injured party may be

able to seek compensation from the Federal Government. Federal

regulations implementing FTCA prescribe the process that Federal

agencies must follow in resolving claims arising from the negligent

or wrongful acts of Federal employees. With the extension of FTCA

coverage to tribal contractors, tribal employees or volunteers under

a self-determination contract are considered Federal employees for

the purpose of FTCA coverage.

According to the FTCA regulation, claims are subject first to the

administrative review and determination by the Federal agency

whose actions gave rise to the claim. These claims must be presented in writing to the agency within two years, and they must

contain a request for a specific amount of compensation.

At the administrative level, claims arising from IHS programs

are filed with the Department of Health and Human Services

Claims Branch in Rockville, MD. The Claims Branch has been delegated authority to resolve claims of $10,000 or less, and the Department’s Office of General Counsel issues administrative determinations for claims in excess of $10,000.

Due to medical malpractice considerations, medical-related

claims go through a much more rigorous review process than nonmedical claims.
6

If the claim is not resolved administratively, a lawsuit may be

filed in Federal court where the Department of Justice will defend

it. Administrative and legal settlements may be paid from agency

funds, the U.S. Treasury, or a tribe’s private liability insurance if

duplicate coverage exists.

The Department of Health and Human Services identified 114

claims involving tribal contractors of IHS programs that were filed

during fiscal years 1997–99. The total damages claimed were $487

million, with patient care activities accounting for nearly 45 percent of these claims and vehicle accidents accounting for another

35 percent.

These claims involve tribally-contracted programs for 40 contractors. The Navajo Nation, the largest tribe, had the most claims,

with 14, and 6 other contractors had 5 or more claims during this

3-year period. The damages claimed ranged from a low of $75 to a high of $100 million, with a median claim amount of $1 million. And, as of July

15, 40 claims had resulted in settlement payments, 18 were ultimately denied, and the final outcome of 56 claims is still pending

either administratively or in litigation. A total of 58 claims or 51

percent have been brought to closure at a cost of $680,000 out of

the $230 million claimed in those cases. The small, simple claims

for minor incidents, such as a fender bender, are generally resolved

quickly, while the large, complex claims may take longer to resolve. The total settlement figure paid to date amounts to $680,000;

however, this figure will likely increase as the remaining claims

are resolved.

Finally, we found that claims involving tribal contractors are

being processed the same way as claims involving Federal employees, and that the percentage of tribal claims approved and the

amount awarded are comparable with the resolution of other FTCA

claims at the Department of Health and Human Services.

Mr. Chairman, that concludes my statement. I’d be pleased to respond to any questions that you or members may have.

The CHAIRMAN. Thank you very much.

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

The CHAIRMAN. Now may I call on Mr. Bird.

STATEMENT OF MICHAEL BIRD, PRESIDENT, AMERICAN

PUBLIC HEALTH ASSOCIATION, ALBUQUERQUE, NM

Mr. BIRD. Good morning, Mr. Chairman and members of the

committee. You have my written document which has been submitted to you. I’d like now just to go into a narrative description on

my comments.

I am Michael Bird, Santa Domingo and San Juan Pueblo Indian

from New Mexico. I am president of the American Public Health

Association. I’m the first American Indian president of the American Public Health Association in 128 years, so if patience is a virtue Indian people must be very virtuous.

Today I am representing the Friends of Indian Health, the coalition of over 40 organizations and individuals. We thank you for the

opportunity to testify today and to comment on health care personnel issues that we think should be addressed in the reauthorization

of the Indian Health Care Improvement Act.
7

I’d like to share a quote with you:

The first Americans, the Indians, are the most deprived and most isolated minority group in our Nation. On virtually every scale of measurement—employment, income, education, and health—the conditions of the Indian people ranks at the bottom.

Mr. Chairman, this quote was made over 30 years ago by then

President Richard M. Nixon. Unfortunately, little has changed

since then, especially in regards to health care for American Indians and Alaska Natives.

Recently, a member of the Friends of Indian Health sought care

from the Phoenix Indian Medical Center for a 1 o’clock doctor’s appointment. He left his home at 11 a.m., arriving at noon. He knew

that he needed to arrive 1 hour before his appointment because patients are seen on a first-come, first-served basis, even those with

scheduled appointments. At this facility, the patient-to-doctor ratio

is overwhelming. Not only does it serve Indian patients within the

Phoenix city limits, but also patients are brought to the Phoenix

Indian Medical Center by vans from adjacent reservations that lack

inpatient services.

Our friend was eventually seen, but also told that his back condition had worsened and that he would probably need surgery. Because of a lack of orthopedists at Phoenix Indian Medical Center,

he was unable to schedule consultation until September 27.

The patient’s checkup took all afternoon. This experience is not

unique. There is disparity in access to care throughout the Indian

health care system. Or another way to view this situation is to

compare the IHS to the Phoenix Veterans Medical Center, which

is within 1 mile from the Phoenix Indian Medical Center. The total

number of outpatient visits at the VA facility was over 8,000, compared to more than 14,000 at the Phoenix Indian Medical Center,

a difference of over 6,000. The VA employs nine psychologists,

while the Phoenix Indian Medical Center employs four. The total

number of behavioral staff at the VA was 75, as compared to 17

at the Phoenix Indian Medical Center.

The Friends of Indian Health believes that by improving access

to treatment and prevention the IHS will make significant strides

in reducing health disparities and mortality rates. This was demonstrated by the placement of a podiatrist with the Winnebago and

Omaha Tribes. During his 4-year tenure, the average annual leg

amputations fell from 16 to 0. Not only did this improve the daily

living and quality of life for the patients and their families, but resulted in a cost savings of over $2 million in surgical expenses.

But the IHS needs to move quickly to better recruit and retain

providers. If the Administration waits too long, the competition will

become more intense. Therefore, the Friends of Indian Health suggest that Congress take the following steps:

No. 1, make loan repayments tax free. Currently, the IHS pays

providers $20,000 annually, an additional 20 percent of that sum

to the Internal Revenue Service [IRS]. Totally, $3.4 million goes to

the IRS from the IHS loan repayment account. If the loans were

tax free, 170 more providers could be available.

No. 2, give IHS health care personnel 3-year student loan

deferments. Volunteers in programs like the armed forces, Peace

Corps, or Domestic Volunteer Service do not have to repay the
8

principal of or the interest on any student loan for 3 years. This

provision does not apply to those working in IHS or for tribes. This

oversight can cost recent graduates more than $1,000 a month.

Faced with this burden, many health care professionals cannot afford to join the IHS or work for tribes or urban programs.

No. 3, conduct exit interviews. As the IHS approaches the next

decade and must compete for health personnel, the Friends of Indian Health believes that it should require exit interviews determining whether staff are leaving because of non-competitive salaries, high debt burden, inadequate housing, or lack of esprit de

corps would be essential to quickly making corrections to prevent

others from leaving.

No. 4, recruit active and retiring health care professionals interested in providing care on a part-time or temporary basis. The

American Academy of Pediatrics has received more than 300 requests from active physicians for information about short-term pediatric opportunities at IHS sites. Additionally, we believe that

many other providers are not ready to completely retire and would

be willing to volunteer 1 week, 1 day, 1 month, or even 6 months

to their service. Their experience and expertise particularly are in

high demand. The IHS needs to create a program where such volunteers can be recruited, and assure them that liability would not

be a problem.

Mr. Chairman, the definition of insanity is doing the same thing

over and expecting a different outcome. Therefore, if, in fact, we desire to make changes to produce different outcomes, we have to

begin today. The Friends of Indian Health believes our recommendations can move us in that direction.

Mr. Chairman and members of the committee, this concludes my

testimony. I will be happy to answer any questions you might have.

Thank you.

The CHAIRMAN. I thank you very much, Mr. Bird. I find your testimony most enlightening.

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

The CHAIRMAN. May I begin my questioning with Dr.

Vanderwagen.

I gather that the pay scale of the IHS is tied to DOD; is that correct?

Mr. VANDERWAGEN. Yes, sir; that’s true.

The CHAIRMAN. But does that include bonuses and cost of living

allowances?

Mr. VANDERWAGEN. For those that are in uniforms, the bonuses

and cost of living allowances are consistent with those provided to

the other uniformed services.

The CHAIRMAN. But what happens when there is no comparable

category to tie it in in certain areas?

Mr. VANDERWAGEN. Well, we have a variety of disciplines, for instance, where there are no such bonus opportunities or other inducements that we might provide, and that presents us with difficulty.

For instance, in nursing there really are no real financial incentives like that provided through the DOD, so we don’t have much

to offer on our side, either, for those that are in uniform.
9

The CHAIRMAN. For many, many years DOD has been most reluctant to have joint operations with the VA, and, as a result, we have

had VA hospitals and DOD hospitals. But now, with the cold war

over, many of our military hospitals have been destined to be

closed, and in order to keep them open some have become joint operations with the VA—for example, in Hawaii. And the Hawaii operation is a model operation.

Would you consider, where it is feasible, to have DOD have a

joint operation with IHS?

Mr. VANDERWAGEN. I believe that there are opportunities like

that—for instance, in western Oklahoma. There are other locations

where there may be DOD facilities where, if tribal and urban people had effective policy involvement in the development of those relationships, I think we would be very interested in adding DOD

into the partnership.

The CHAIRMAN. Mr. Bird, would that be acceptable to Native

Americans?

Mr. BIRD. Well, I think it is something that one has to approach

very carefully, because I think there is some concern in terms of

most Indian populations that they’re going to end up losing out

when anything like this is explored.

I know in New Mexico, drawing on my 20 years of experience in

the IHS in the Albuquerque area, that there had been initial discussion back about 10 years ago about negotiating some sort of an

approach with the VA there in Albuquerque, and, as I best recall,

some of the tribes were concerned and actually kind of put a stop

to that because they felt like we would—the tribes, in fact, would

be losing out in some form or fashion.

I don’t know if that was based on any real threat to the services

that were provided, but I think that there is that perception out

there in the community that somehow it will diminish—possibly diminish the Federal Government’s role and responsibility to tribes.

But I know that that is a concern.

I think, given the times that we are looking at and the impact,

the adverse impact of lack of services for Indian people and Indian

populations that’s occurring today, I think some tribes might be

more open to considering those options.

The CHAIRMAN. We will be thinking about that.

Mr. Vanderwagen, is there any partnering or collaboration between IHS and non-Federal agencies whenever there is a shortage

of specialties?

Mr. VANDERWAGEN. Yes; I’m glad you asked that, because, while

Michael is here representing the Friends and he was unable to sort

of, in his prepared testimony, speak to some of the activities with

them—for instance, the American College of OB/GYN routinely assists us in two ways. One is they will go out with us and do field

site visits to assess the quality of care, needed improvements in patient safety, protections, medication error management, and that

sort of thing, but they also have a program to provide OB/GYN specialists to assist us in locations where we have special needs.

The American Dental Association also has done very similar

kinds of site visitation with us and assisted us on a variety of clinical care needs, as well.
10

American Academy of Pediatrics—a variety of these professional

organizations that constitute the Friends of Indian Health have

been tremendously helpful, both to the tribal programs and to the

Federal programs. I don’t know that we have been able to link with

the urban programs as effectively as we might with these kind of

professional supports, and that’s certainly an area where we could

work with the Friends of Indian Health to expand that relationship.

The CHAIRMAN. We have an issue on the Federal Tort Claims

Act.

Mr. BIRD. Mr. Chairman?

The CHAIRMAN. Yes?

Mr. BIRD. Might I share some thoughts?

The CHAIRMAN. Sure.

Mr. BIRD. I wanted to mention that the American Public Health

Association has, since I became president of the association, has

been much more involved and much more engaged. There is, in

fact, an American Indian and Alaska Native, Native Hawaiian

Caucus, which has a 20-year history of association with the American Public Health Association. At our annual meeting this year in

Atlanta, which typically draws about 13,000 participants, for the

first time in 128 years there will be a plenary session on dealing

with indigenous health. We’re attempting to have four representatives from Native populations. Actually, there will be a Native Hawaiian physician who will be part of that program and a Canadian

representative and someone from South America to look at focusing

attention on indigenous health internationally, as well as within

this country.

The CHAIRMAN. All right. Thank you.

May I now go to tort claims? Is it true that the Department of

Health and Human Services can only approve settlements of less

than $25,000?

Mr. HILL. Yes; it is.

The CHAIRMAN. And yet you have testified that the median

amount is $1 million?

Mr. HILL. That is correct.

The CHAIRMAN. Then what should we do? Is something wrong

there?

Mr. HILL. Well, the current process allows them to settle for those claims that are less than $25,000, but it does allow the Department of Justice to handle claims in excess of that.

The CHAIRMAN. Then what happens?

Mr. MALCOLM. I think that’s correct. Some agencies have looked

at whether that cap should be increased, kind of adjusting for inflation type of methodology, given the increase in the claim amount.

Is the $25,000 gap still a reasonable amount for them to have that

authority?

The CHAIRMAN. How does it compare with the VA hospitals? Is

there a cap also for veterans going to VA hospitals?

Mr. MALCOLM. The restriction of the $25,000 would be for the entire Federal Government, except where the Department of Justice

has delegated a higher settlement authority. The VA has been delegated the authority to settle FTCA claims up to $200,000.

The CHAIRMAN. Is that the same with DOD hospitals?
11

Mr. MALCOLM. To my knowledge it is the same, but I’d have to

confirm that.

The CHAIRMAN. It is the same?

Mr. MALCOLM. To my knowledge it is the same.

The CHAIRMAN. Dr. Vanderwagen?

Mr. VANDERWAGEN. Yes; I agree with him. My understanding is

that that’s a Federal-wide cap that independent agencies, short of

litigation going to the Department of Justice, have placed on them

for just settlement.

The CHAIRMAN. And what has been the experience with the Justice Department?

Mr. VANDERWAGEN. In general, our experience has been mixed.

Without getting too lengthy, we do an extensive quality review

process of any cases brought involving patient care, in particular,

and the Department of Justice has not been actively involved in

that review process with us, and there are times when we believe

that decisions are made despite the review process that weighs on

the merit of the case, and that has been of some concern to providers, because if Justice proceeds, despite the fact that the Quality

Review Panel does not believe there’s merit against that individual,

they end up reported to the Practitioner Data Bank, whether they

were viewed as really having culpability or not, and that’s a problem from the provider perspective, not speaking about the fiduciary

responsibility of the Government here, but provider concerns.

The CHAIRMAN. Is it because of this situation that you are not

able to fully utilize volunteers?

Mr. VANDERWAGEN. That is part of the situation. The other circumstance, you may be aware there was a malpractice suit brought

in a tribal court in New Mexico, and while the tribal council immediately rejected trying that case within tribal court, it created conflict in the State of New Mexico over jurisdictional concerns, and

the insurance malpractice carriers for many providers, particularly

the pediatricians and obstetricians, since they were the two specialties involved in the case, have been real reticent to counsel their

members, their insured providers to practice. In fact, they’ve discouraged them from practicing in reservation environments.

The CHAIRMAN. And before I call upon the vice chairman, one

final question. Is there any medical school that specializes on Indian health? For example, you pointed out that there are problems

that you just discovered. Are there any medical schools that specialize on Indian health?

Mr. VANDERWAGEN. Sir, I believe there are one-half dozen institutions nationwide who really have shown tremendous commitment

and involvement in Indian communities through their participation

with tribes, as well as their participation with providers. Those

schools actually have developed a coalition now to explore ways

that they might more effectively support Indian health issues.

Without getting too extensive about it, it ranges from Hopkins

here in the east to the University of Washington to the southwest,

where Arizona and New Mexico have had real interests in Indian

health, and, of course, the University of Hawaii has trained a large

number of masters in public health and supported Indian health

concerns. So there are a variety of schools that have been very

helpful.
12

The CHAIRMAN. Thank you very much.

Mr. Bird, the staff will be working with you on your recommendations.

Mr. BIRD. Thank you.

The CHAIRMAN. Mr. Vice Chairman.

Senator CAMPBELL. Thank you, Mr. Chairman.

While listening to your questions I was just musing to myself

about some of the people that I know who have been sick who have

needed help. I tell you, you take an average elder in an Indian

tribe who is not a very ‘‘sophisticated’’ person, a person that is close

to the land and close to their culture, and you start talking to them

when they come in about fiduciary responsibilities and the legal

ramifications and tort reform or tort problems and punitive damages and all that, I think they’re probably not going to understand.

All they know is they’re sick and need help. Somewhere we’ve got

to find a way to bridge that, you know, and give them more help.

I was interested in the chairman’s question about if there’s a

DOD program that you work with, and I was thinking of one that

has worked out really well. It’s not directly with DOD, Mr. Chairman, but Fitzsimmons Military Hospital, as you know, in Denver

was a few years ago turned over to the University of Colorado.

They, in turn, with our help and funding from the Federal Government, are building an American Indian diabetes center there now

for research and treatment, too, of diabetes among Indian people,

so I think there’s some precedent set, maybe not a direct relationship, but through working with local universities there are, I think,

some real opportunities.

Let me just scatter some of these questions around. You talked

earlier, Dr. Vanderwagen, about the recruitment program. As I understand from Mr. Hill, there is a problem with retention, too.

What is the reason? Is it low pay? Do they just go on to better

things? Do they get burnout from too many hours, like people in

the medical profession often do?

Mr. VANDERWAGEN. Well, I think it is a combination of those factors. I mean, entry level for a pharmacist, let’s say, in Indian

health, they have to accept 30 percent lesser pay to come to work

for us than if they went to work for one of the retail chains in an

urban setting, so the pay is an issue.

Second, obviously, if they’re working in isolated environments

where spouses don’t have the ability to get a job and so on, those

factors play in.

The concern, as I suggested earlier, about the severe rationing of

the system that Mr. Bird referred to and that you just spoke to

about an elder seeking service plays on providers severely. When

you continually have to pull people out of the river and you do not

have the opportunity to figure out how they got there in the first

place because you’re just so busy trying to meet that flow, after a

while you do become tired. There’s no question about it.

I was just out in the Dakotas last week, and clearly that was a

message that I heard.

Senator CAMPBELL. Do most of them go to jobs in the private sector or just quit altogether?
13

Mr. VANDERWAGEN. It’s a combination of those factors that you

spoke to, and I think it is problematic to try and address each of

those.

Senator CAMPBELL. Let me ask again, the ones that do leave, do

most of them go into the private sector or just burn out and do

something else?

Mr. VANDERWAGEN. I think the majority of the people who leave

our system will go to another health care environment, just one

that meets their needs individually.

Senator CAMPBELL. When you do recruiting, do you do that on

the reservation?

Mr. VANDERWAGEN. The scholarship program, if you look at it

that way, yes, we do recruit that way. For certain jobs, skills that

are available in the community, that’s clearly where we would recruit. That’s part of the reason why 75 percent of the staff out

there are Indian people. We recruit from Indian communities for

Indian communities.

Senator CAMPBELL. We have tried to increase the IHS budget.

We’ve put this year, I believe, $78 million more into the budget

than was in last year. It’s probably still not enough. But does some

of that get to the salaries of the people that are in training?

Mr. VANDERWAGEN. Yes, sir; In fact, the highest priority that the

tribes, the urbans, and the Federal people developing the budget—

the highest priority was let’s make sure that the Pay Act for Federal employees and pay increases for tribal and urban employees

get covered. That has been the highest priority for expenditure.

Senator CAMPBELL. Let me ask you just a question or two about

the urban Indian community. Mr. Bird, you know, a person—an Indian person—gets sick in Albuquerque, it’s not a long-distance trip

usually to go back to the Pueblos. A lot of them are pretty close.

But our biggest city is Denver, we have roughly 25,000 Indian people who live in Denver. The nearest Indian clinic, reservation clinic, is I guess about 250 miles away, the Southern Ute clinic way

down at the end of the State. They can’t just go home when they

get sick. They’ve got to go downtown.

Do you do any interaction working with local health clinics for

Indian people that need help that can’t go home? Or do you do any

kind of an outreach program so that Indian people know where

they can go if they’re in the city and need help?

Mr. BIRD. Yes; well, without getting too wordy, we do fund 34

urban Indian programs whose primary mission has been initially

to institute an outreach process and provide a way to coherently

assist Indian patients. Some of those now have expanded into fullyfunctioning, ambulatory, primary care facilities. In fact, 14 of them

are now federally-qualified health care facilities under the HCFA

guidelines. So that is exactly what the intent of the act, as we understood it, title V was, and that’s what we’ve tried to work with

the urban programs to accomplish.

Senator CAMPBELL. I see.

Mr. Hill, what’s the average time that claims are settled now?

Mr. HILL. We don’t have a general timeframe. The process is basically when the claim is filed HHS has 6 months to decide, and

certainly a number of those are spilling over that 6-month period,
14

but after the 6-month period expires the claimant can then go and

file suit in court to get it settled.

Senator CAMPBELL. What’s the longest you would say it takes to

get a claim settled?

Mr. HILL. We found five claims that were filed in fiscal year 1997

that were still pending. That makes them almost 4 years old.

Senator CAMPBELL. Dr. Vanderwagen, you know, there has been

some discussion. In fact, there is a bill in to elevate the IHS director to Assistant Secretary in the HHS. Would that be a priority in

the Indian health community?

Dr. VANDERWAGEN. In consultation with the tribes and the urban

folks, that clearly, from their perspective, is a priority to elevate

the director to an Assistant Secretary level.

Senator CAMPBELL. Do you have a personal view on it?

Mr. VANDERWAGEN. I think there are real pluses in terms of the

kind of partnership and access to a wide range of departmental

programs that could be facilitated—for example, alcohol programs

that cross the Department and other kinds of health programs.

There appears to be some merit in the proposal from that perspective.

Senator CAMPBELL. There are two demonstration programs, Dr.

Vanderwagen, in Oklahoma that are, as I understand, operated a

little differently from the normal programs in the IHS that I understand are very successful. How are they different and what

makes them so successful?

Mr. VANDERWAGEN. Well, thank you for asking. Those are interesting and, I think, unique programs.

In the past, Congress provided authority for those programs to

not only be dealt with under title V as urban programs, but to be

dealt with as service units under the Federal process. That means

that they could access resources not only limited to the title V

budget authority but to all the other budget authorities within the

agency—hospitals and clinics, mental health, et cetera.

The plus side of that has been that it has allowed them to expand and become more comprehensive using IHS funds in addressing the health needs of individual urban Indians in Tulsa and

Oklahoma City, and therefore reduce the requirement for them to

seek funding from other sources, to some degree.

Senator CAMPBELL. There’s supposed to be a report made on

those demonstration projects, too, as I understand it. Is that report

finished? I’m told it is.

Mr. VANDERWAGEN. Yes, sir.

Senator CAMPBELL. And when are we going to get a copy of that

report.

Mr. VANDERWAGEN. I would have to check on that, but I could

provide you an answer for the record, sir, as to when that would

be available. I’m just ignorant at the moment of that.

Senator CAMPBELL. To your knowledge is there any opposition to

launching more programs along the lines of those demonstration

programs?

Mr. VANDERWAGEN. It is a complicated issue with regards to tribal sovereignty and the responsibilities and authorities of tribal governments vis-a-vis individual Indians who may be in urban settings

and how those programs access resources. This is a real difficult
15

issue, not just involving Oklahoma and Tulsa, but I think all of the

Indian health system at this point, the balance between tribal government and the government-to-government relationship and the

needs of individual Indian people who happen to live in urban settings. It’s very difficult.

Senator CAMPBELL. Well, if they have been successful, there is a

good possibility that we could expand that program, then.

Mr. Bird, tell me a little bit more about this. Which organization

participated in this, as you called it, ‘‘Friends Organization.’’

Mr. BIRD. Yes.

Senator CAMPBELL. What’s their interest in the Indian health

field?

Mr. BIRD. Well, their interest is in seeing that, in fact, the needs

of American Indian and Alaska Native people are better met, and

there is—it’s a broad coalition, as was mentioned before, of the

American Dental Association, American Association of Colleges of

Nursing, American Hospital Association, American——

Senator CAMPBELL. All of them have some health connection?

Mr. BIRD. Yes; all involved in the health arena. I will submit a

copy. I do have a list of the members of Friends of Indian Health.

Senator CAMPBELL. Great. Please submit a copy of that. We’ll try

to make that a part of the record.

Did you go out and recruit those people to help, or is that something they put together themselves and volunteered to do?

Mr. BIRD. It’s actually something that the American Dental Association put together, has been active for a number of years because

of their interest and their recognition of the fact that there’s great

disparity in American Indian and Alaska Native communities.

Senator CAMPBELL. I see.

Mr. BIRD. And they are to be commended because they are a very

active, viable group, and at their behest I am here today.

Senator CAMPBELL. Okay. Swell.

Thank you, Mr. Chairman.

The CHAIRMAN. I thank you very much.

I have a few more questions.

Mr. Vanderwagen, do you have any thoughts on Mr. Bird’s recommendation on having Indian volunteers be on the same par as

Peace Corps workers and others?

Mr. VANDERWAGEN. Well, that’s a refreshing notion and one that

we have not explored, but it certainly seems to have some merit.

Again, bringing people in, we believe that our mission and the

work that we do is such a blessing in life that if we bring those

people in we’re likely to keep them for longer than just a simple,

short-term stint.

The CHAIRMAN. Will you have your staff look at Mr. Bird’s recommendations and give us your thoughts on this?

Mr. VANDERWAGEN. Yes, sir; I will.

The CHAIRMAN. Are you aware of other federally-sponsored loan

repayment programs that are tax free?

Mr. VANDERWAGEN. I believe that there have been programs

funded through the Health Resources and Services Administration

that has had some tax-free loan repayment components, but I may

be wrong about that, but that’s what comes to mind.
16

The CHAIRMAN. Then you do not mind if you are on a level playing field?

Mr. VANDERWAGEN. If we’d get back onto a level playing field I’d

be real happy.

The CHAIRMAN. Well, Mr. Bird, it appears that you have a few

allies here.

Mr. BIRD. I’m glad to hear that.

The CHAIRMAN. Now may I ask Mr. Hill a few questions. Does

the Tort Claims Act provide malpractice coverage for retired providers who practice on a part-time basis for a contractor?

These questions are asked because I have had letters from Indian country.

Mr. MALCOLM. Yes, Mr. Chairman; the Federal regulations that

were issued on this—it’s 25 CFR, part 900, subpart M talks about

the types of people, both for medical and non-medical claims, that

are covered. It specifically states that temporary employees, if they

are working under a self-determination contract for a tribe, would

have tort claim coverage.

The CHAIRMAN. They are covered?

Mr. MALCOLM. Yes; if they are performing a service under a selfdetermination contract.

The CHAIRMAN. Now, does this act also provide coverage for medical specialists, as well as primary care providers?

Mr. MALCOLM. I believe so. Again, depending on—a lot of very

legal technical terms apply to this area, and that’s why there’s a

lot of confusion, and the Department of Justice basically has to

make determinations on a case-by-case basis.

If the specialist, again, is working at the tribal facility, then

clearly there would be that coverage. If that specialist is basically

at a hospital in town that’s not a tribal facility, there would be

questions about the coverage in that case.

Again, it’s the function that is being performed. If it’s being performed under the tribal contract, there would be coverage either for

full time, part time, or volunteers. When tribal members are getting care from people outside of that contract, then there would be

questions about the coverage.

The CHAIRMAN. Does it make any difference as to the venue of

the care in the tribal hospital or some other hospital?

Mr. MALCOLM. Yes; it would. If that person is not directly working under the contract, there would be—that would be an issue.

The CHAIRMAN. Mr. Hill, you indicated that volunteers working

at a tribal facility will have tort claim coverage?

Mr. HILL. That is correct, as long as they’re working under a contract.

The CHAIRMAN. Dr. Vanderwagen suggested that, because of this

tort claim issue, volunteers are reluctant to sign up. How are these

claims examined that involve volunteers?

Mr. HILL. I can’t answer that. Of the 114 claims that we identified, none of them involved volunteers, so I’m not sure it has been

tested yet.

Mr. VANDERWAGEN. If I may, Senator, it’s a climate of anxiety

that is not fully assuaged by Justice approach of decision on a caseby-case basis, and many providers are unwilling to accept the sort

of verbal assurance that, ‘‘Oh, yes, you will be covered, but we re-
17

serve the right on a case-by-case to approach these issues,’’ and it

is that lack of absolute certainty that is chilling for many people,

particularly in light of their private insurance carrier counseling

them that they are entering into an extremely risky environment.

So the cases really have not been directly challenged. It is more

a climate of concern and anxiety that we’re trying to attend to on

these matters.

The CHAIRMAN. Mr. Hill, do you have any response to that?

Mr. HILL. No. That’s correct. We would agree with that. We

would note there are some other special coverage provisions that

apply. For example, in California, where you have a lot of contracting the California Indian Rural Health Board basically provides

services there, and then they have subcontractors. As a general

rule, under FTCA subcontractors would not be covered; however,

Congress has made special provisions for California that those subcontractors will be covered.

We did find, during the 3 years we looked at, that there were 10

claims from subcontractors of the California Indian Rural Health

Board that had been provided coverage. So there are other special

mechanisms in there for IHS programs, and we did find that those

are working as they should be.

The CHAIRMAN. Then do you feel that the problem expressed by

Dr. Vanderwagen can be resolved or addressed legislatively?

Mr. MALCOLM. I don’t believe so. Part of the problem is, again,

as Dr. Vanderwagen mentioned, there is a large amount of confusion and misunderstanding about the coverage, and a lot of the

legal questions about who is covered and who is not covered, that

actually hinges on State law. So, depending on the location of

where the incident occurred, the Justice Department or HHS, the

Office of General Counsel, will look to the State law as far as the

definition of who is an employee and what functions that person

has to be performing to be considered an employee, so the State

law is the controlling issue there historically, so that’s what they

look to and that’s why there could be differences from State to

State, and that’s a case-by-case basis.

The CHAIRMAN. Are volunteers at VA or DOD hospitals treated

the same?

Mr. MALCOLM. Our study didn’t really include VA and DOD, so

I’ll have to—we’d have to look into that further.

The CHAIRMAN. My final question on urban Indian programs has

to do with a letter that was received by the staff. Are urban in

health care centers deemed to be ordering agents of the IHS for the

purchase of pharmaceuticals?

Mr. VANDERWAGEN. In general they have not been direct participants in the special purchasing arrangements that we have

through the VA, the prime vendor, which gets the absolute lowest

cost. The 638 relationships provide us the authority to do that, and

the majority—obviously, the urban programs are generally under

the buy-Indian provision, and they’ve not been included with the

VA purchasing arrangements to date.

The CHAIRMAN. Is there any reason for that?

Mr. VANDERWAGEN. Primarily revolving around the authority, in

their view, being Federal, and 638 qualifying tribes as Federal, as
18

it does in many other environments, but the buy-Indian contracting

not viewed in the same way by the Veterans folks.

The CHAIRMAN. Can this matter be resolved internally?

Mr. VANDERWAGEN. We are working on it and we think we might

be able to get a solution, but that’s certainly something we can report to you on.

The CHAIRMAN. Mr. Bird, are you satisfied?

Mr. BIRD. Yes.

The CHAIRMAN. Your negotiations are bearing fruit?

Mr. BIRD. We need more trees.

The CHAIRMAN. Well, we’ll try our best, sir.

Mr. BIRD. Thank you.

The CHAIRMAN. We have a few more questions we’d like to submit, if we may, and receive your response.

Senator CAMPBELL. May I ask one more?

The CHAIRMAN. Yes, please.

Senator CAMPBELL. Let me ask one final question, Mr. Chairman. Since you had mentioned Peace Corps, originally when Peace

Corps was set up it dealt with helping people in foreign countries.

There was another program called ‘‘Vista’’ that was very similar,

but it was more domestic oriented, and Vista workers at that time

some years ago actually were working on reservations.

I don’t know if Vista program is still in effect or if it has been

superseded by Americorps or some of these other groups such as

the National Health Care Service Corps or so on, but do any of

these groups take part in the Indian health profession, Dr.

Vanderwagen? Or do you work with any of those groups at all?

Mr. VANDERWAGEN. No; we really have not had formal relationships with them, and an interesting idea that we have not explored.

Senator CAMPBELL. Do you have the legislative authority now to

be able to work with them, or do you need something from us in

order to do it?

Mr. VANDERWAGEN. Well, I’d have to defer to our legislative people on that, but we could certainly provide an answer back to you

on that question.

Senator CAMPBELL. Would you find out for us, because it seems

to me that there are a lot of good-willed, hard-working people that

want to help out there, and if we could get them involved with you

so you could utilize some of their folks, I think it would be good

for you and maybe good for Indian country, too. Find out if we need

to do something legislatively or if you can just go ahead and do it.

And if you can, I would encourage you to do it.

Dr. VANDERWAGEN. We’ll do.

Senator CAMPBELL. Thank you.

Thank you, Mr. Chairman.

The CHAIRMAN. All right. Thank you very much, gentlemen.

Mr. VANDERWAGEN. Thank you.

Mr. HILL. Thank you.

Mr. BIRD. Thank you.

The CHAIRMAN. Before I call upon the next panel, without objection the opening statement of Senator Kent Conrad will be made

part of the record.

[Prepared statement of Senator Conrad appears in appendix.]
19

The CHAIRMAN. And now may I call upon the second panel: The

president of the National Council of Urban Indian Health, Robert

Hall; the health director of the American Indian Community House

in New York, Anthony Hunter; the executive director of the Missoula Indian Center of Missoula, MT, Carole Meyers; the executive

director of the Native American Health Center, Oakland, CA, Martin Waukazoo; and the executive director of the Denver Indian

Health and Family Services, Incorporated, of Denver, Kay

Culbertson.

May I call upon President Hall.

STATEMENT OF ROBERT HALL, PRESIDENT, NATIONAL

COUNCIL OF URBAN INDIAN HEALTH, WASHINGTON, DC

Mr. HALL. Thank you, Mr. Chairman, Mr. Vice chairman, and

also for the Senator of my home State, Senator Conrad, when he

was in here for a while. My name is Robert Hall. I am the president of the National Council of Urban Indian Health and a member

of the Three Affiliated Tribes from Fort Berthold, ND. My tribal

heritage is Arikara and Hidatsa. The third tribe up there is

Mandan. I also have some prepared remarks I have submitted for

the record. I am also the executive director of the South Dakota

Urban Indian Health Clinics. I wish to thank you for this opportunity to address the committee on the reauthorization of the Indian Health Care Improvement Act, S. 212.

I’d like to take a moment to introduce you to our new executive

director for the National Council of Urban Indian Health, a lady

I think you are very familiar with, Beverly Russell. We’re very

pleased for the training she received while she was interning with

you.

The CHAIRMAN. She’s a good lady.

Mr. HALL. Yes.

The CUIH is the only membership organization representing

urban Indian health programs. Our members provide a wide range

of health services and care, ranging from information and outreach

to full clinics. We provide referral services in 34 cities, not counting

the new program in Hawaii, to a population of approximately 332

urban Indians. We are often the main source of health care and

health information for these urban Indians. According to the 1990

census, 58 percent of American Indians lived in urban areas. We

expect that number to be well over 60 percent in the 2000 census

results.

Like their reservation counterparts, urban Indians historically

suffer from poor health and substandard health care services.

In 1976, Congress passed the Indian Health Care Improvement

Act. The original purpose of this act, as set forth in a contemporaneous report, was to,

raise the status of health care for American Indians and Alaska Natives over a

7-year period to a level equal to that enjoyed by other American citizens.

It has been 25 years since Congress committed to raising the status of Indian health care and 18 years since the deadline has

passed for achieving the goal of equality with other Americans, and

yet Indians, whether reservation or urban, continue to occupy the

lowest rung on the American health care ladder.
20

Although the road to equal health care still appears to be a long

one for Indians, the CUIH—the National Council of Urban Indian

Health—believes that S. 212 is a step in the right direction. As a

general matter, NCUIH supports S. 212, although we do recommend certain changes to maintain Congress’ commitment to

urban Indians.

The Indian Health Care Improvement Act currently provides

that it is the policy of the United States to achieve the highest possible health care for both Indians and urban Indians; however, S.

212 does not contain a reference to urban Indians in its equivalent

paragraphs. Deleting urban Indians from this policy statement, especially since ‘‘urban Indian’’ is a defined term in the legislation,

could imply that the Congress no longer considers the health status

of urban Indians to be a national priority.

NCUIH strongly urges the restoration of ‘‘urban Indian’’ to section 3, paragraphs 1 and 2, of S. 212.

NCUIH is generally satisfied with the definition of ‘‘urban Indian’’ in S. 212, although certain language in the definition appears

to limit its coverage to title V of the legislation. Urban Indians are

referred to in other titles of this legislation; therefore, this limiting

language should be removed.

NCUIH supports an amendment to S. 212 that would grant

urban Indian health programs the same 100 percent Federal medical assistance percentage as is currently enjoyed by IHS facilities

and IHS 638 contractors.

Like IHS facilities, urban Indian programs exist because of the

Federal responsibility in the Indian health care area. We should be

treated the same as IHS for the purposes of FMAP, and we would

like to thank the chairman for his support in introducing FMAP

legislation.

NCUIH supports expanded authority in funding for urban Indian

health programs in the area of pharmaceutical services. Such expanded authority would result in an immediate elevation of the

quality of care for these communities, especially the elderly.

NCUIH supports the establishment of the National Bipartisan

Indian Health Care Entitlement Commission. The work of this

commission will help provide the basis for a rational and effective

approach to Indian health care well into the 21st century.

Although addressed in other Senate legislation, we would like

you to know that NCUIH strongly supports the elevation of the director of the IHS to Assistant Secretary for Indian health. Too

often Native voices are lost in the national clamor over health care

policy and funding. Elevating this position would greatly strengthen the voice of Indian country, whether in the halls of Health and

Human Services, the corridors of Congress, or wherever the health

care debate occurs.

In fiscal year 2001 urban Indian health programs received 1.14

percent of the total IHS budget, although urban Indians constituted at least 50 percent of the total American Indian population.

NCUIH acknowledges that there are some sound reasons why

the lion’s share of the IHS budget should go to reservation Indians;

however, the health of Indian people in urban areas affects the

health of Indian people on reservations and vice versa. Disease
21

knows no boundaries. NCUIH strongly believes that the health

problems associated with the Indian population can be successfully

combated if there is significant funding directed at the urban Indian population, as well as reservation population. To address this

need, NCUIH has asked for a $5 million increase in the urban Indian health line item in its 2002 budget.

NCUIH also supports the establishment of a 5-percent set-aside

of the IHS diabetes funding to be provided to urban Indian diabetes programs, and we would like to acknowledge the vice chairman

for his strong letter directing that.

In the chart in front, you will see a history of IHS funding and

urban Indian health funding from 1979. You will notice in 1979 our

funding comprised 1.48 percent of the total IHS budget, and you

can see from the graph we’re back down into a dive in falling behind, not even maintaining. And you also are very aware that the

IHS budget isn’t maintaining a level track with increased cost.

America is nowhere near the lofty goals set by the Congress in

1976 of achieving equal health care for American Indians. Whether

reservation or urban, NCUIH challenges this committee to think in

terms of that goal as it considers reauthorization of the Indian

Health Care Improvement Act.

NCUIH thanks this committee for this opportunity to provide

testimony on S. 212, and we strongly urge positive action on the

matters we are addressing today.

I would like to take this opportunity to thank both the majority

staff in the committee and the minority staff in the committee for

being very cooperative and helpful in establishing this hearing and

in working with our members.

Thank you.

The CHAIRMAN. I thank you very much, Mr. Hall.

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

The CHAIRMAN. May I now call upon Mr. Hunter.

STATEMENT OF ANTHONY HUNTER, HEALTH DIRECTOR,

AMERICAN INDIAN COMMUNITY HOUSE, NEW YORK, NY

Mr. HUNTER. Good morning, Mr. Chairman and members of the

committee. We want to thank you for inviting us to testify at this

important hearing on urban Indian health programs. We would

also like to recognize and thank you for your support of our programs over the years.

With your permission, I will submit my written testimony and

make additional verbal comments.

I’d like to familiarize you with the American Indian Community

House because we have not only health programs but also cultural

enrichment programs. We use an innovative approach in order to

combine these to meet our community’s needs.

The American Indian Community House is a 501(C)(3) not-forprofit organization serving the health, social service, and cultural

needs of Native Americans residing in New York City. AICH was

founded in 1969 by Native American volunteers as a communitybased organization mandated to improve the status of Native

Americans and to foster inter-cultural understanding.

Since its inception, AICH has grown into a multi-faceted social

support agency, cultural center, and it has a staff of 35.
22

AICH membership is currently composed of Native Americans

from over 80 different tribes and represents a service population,

according to the 2000 census figures, of 59,000 Native Americans

who reside in the greater New York City metropolitan area.

Native American migration between urban centers and reservations demonstrates the inter-relatedness of all Native Americans,

and from this reality emerges the recognition that our issues and

concerns are truly shared.

The AICH philosophy is that solutions can be shared, as well.

AICH uses an innovative approach in combining the objectives of

our social service and cultural enrichment programs to meet that

community’s multi-faceted needs.

AICH provides programs in job training, placement, health services referral and advocacy, HIV referral, case management, and

counseling programs for alcoholism, substance abuse, and mental

health. AICH also sponsors programs in cultural enrichment

through a performing arts program and the only Indian-owned and

-operated Native American gallery museum in New York City.

These programs are important to us, because a large percent of our

population comes to New York City specifically because they are involved in the performing and visual arts.

A secondary but no less important focus of AICH is to educate

the general public about contemporary as well as historic American

Indian issues and peoples. Some of the departments that I spoke

about—and I’ll give you a little more detail, if I may, on those— our HIV/AIDS project, for example. In response to the increasing

numbers of Native Americans living with HIV and AIDS, the HIV/

AIDS project provides community prevention, outreach, education,

and information, targeted outreach to individuals at risk, and services to those infected. The project offers referral to drug and alcohol

programs, sexually transmitted disease clinics, test sites, general

health and mental health care facilities.

They also offer services for gay and lesbian Native people. At one

of our recent community meetings, it was our understanding that

we need to expand our services for gay and lesbian Native people

living in New York, and that it’s not just HIV and AIDS that our

agency needs to be concerned about when serving that population.

Case management services are also offered and provided in New

York City, as well as program offices in Buffalo, Syracuse,

Riverhead, and the Akwesasne Mohawk Reservation.

AICH is actually very unique, I believe, as one of the urban programs in that we offer services also on the reservation. We have

historically offered also Department of Labor services on the

Shinnecock Reservation in eastern Long Island.

The employment and training funding by DOL provides educational services as well as training focused on preparing an individual for the job market. Interview skills, resume writing, computer training, referrals to outside job training facilities, limited

tuition and support for higher education, and job placement assistance are among those services. We are beginning a process of becoming a training facility registered with the New York State Education Department.

Our health department is staffed by community health representatives, or CHRs, and their work includes health education,
23

medical and dental referrals, community outreach, and the development of Native American specific health oriented materials.

The Health Department’s alcohol and substance abuse program

services strongly focus on group and individual counseling. These

programs offer a sense of community support as the Native American people seek to begin and maintain their recovery.

Spiritual and cultural support are integral parts of the programs,

as well as our education and prevention activities, and other programs within the Health Department include mental health, the

AICH Youth Council and Theater Project, our daily food and clothing bank, and hot lunches for community members.

According to our recent behavioral risk factor survey sponsored

by IHS and Centers for Disease Control, prevalent in our population are risk factors associated with heavy cigarette smoking,

sedentary lifestyle, acute alcohol use, and drinking while driving.

Using AICH’s innovative approach in combining health prevention

and cultural activities, we will now design prevention programs

specifically addressing these behaviors using the visual and performing arts.

As part of the Health Department, we have a Women’s Wellness

Circle project, and it is specifically for Native women. Utilizing innovative and cultural-specific strategies again here in this program, the project works to develop a network between AICH,

health institutions, other front-line providers, and Native women in

the community. The project provides accessible satellite screening

and health information through mobile units, develops Native educational performance pieces, holds monthly wellness circles for Native women to share access concerns and to provide preventive

health education.

The AICH gallery museum is the only Native American owned

and operated gallery in New York City. It exhibits the finest in

contemporary and traditional art in every media by both emerging

and established Native American artists. The gallery presents a

minimum of four exhibitions a year and presents artists’ lectures

and forums on contemporary Native arts and issues.

The artwork on exhibit is often for sale, and we charge only a

small commission on those sales.

Our Performing Arts Department, which is actually part of our

Department of Labor program, they’ve actually been very liberal

with us in the way we operate and the way we combine programming, and the Department of Labor, or what is now the WIA—

Workforce Investment Act program—is really the backbone of our

organization over the years, since we first received Federal funding

in 1975.

The Performing Arts Department coordinates various cultural activities featuring Native American performing arts and promotes

and assists all Native ensembles, such as Spiderwoman Theatre,

Thunderbird American Indian Dancers, Coatlicue Theatre, and

Ulali. The Department provides referrals for Native storytellers,

musicians, and lecturers. It acts as a non-paid booking agent for

Native actors, dancers, and models, and provides rehearsal space

and technical assistance to Native American artists.

We have a main stage that we have as a moveable space within

our agency that seats up to 150 people during performances.
24

We also have a legal service project for Native Americans in our

community, which is actually a joint project between AICH and the

American Indian Law Alliance. The legal services project is in its

fourth year of providing free legal referral services to Native Americans. The project assists with all types of legal matters for Native

people in an urban environment, including but not limited to housing, Indian Child Welfare Act, and Jay treaty issues. The Jay Treaty, as a matter of fact, has been something that the American Indian Law Alliance has been looking at very closely, and they’re developing further information on this.

In our population we have a large number of Indians that come

from Canada, and since they are eligible to receive services in the

United States, we advocate for that service for them by not only

attending hearings on their eligibility requirements, but also doing

outreach with departments such as Social Security Administration

to educate them and their workers about the eligibility of Canadian

Indians living and residing in the United States.

On behalf of the Native American community of the New York

City metropolitan area, I’d like to thank you for your consideration,

and as you go about considering the needs of urban Indians I’d like

to just mention that some of the most important issues that we

have are support of the Jay Treaty and its rights. We’re also having an urban planning meeting coming up in August that will be

attended by representatives of IHS, the Health Care Financing Administration, our State alcohol program, and the Bureau of Managed Care Planning to help AICH decide how it can move forward

in its licensing and third-party billing process.

And, of course, the Indian Health Care Improvement Act reauthorization is an integral part of AICH’s future and its ability to

serve its community.

Thank you.

The CHAIRMAN. I thank you very much, Mr. Hunter.

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

The CHAIRMAN. Ms. Meyers.

STATEMENT OF CAROLE MEYERS, EXECUTIVE DIRECTOR,

MISSOULA INDIAN CENTER, MISSOULA, MT

Ms. MEYERS. Thank you. Honorable Chairman, committee members, my name is Carole Meyers. I’m the executive director for the

Missoula Indian Center, Missoula, MT. I am an enrolled member

of the Blackfeet Tribe and a descendent of the Oneida and Seneca.

I want to thank you for this opportunity to come before you today.

Missoula Indian Center is a nonprofit organization. It has been

in existence in Missoula, MT, for the past 31 years. The organization has assisted with health referrals to the 3,100 Native Americans that reside in that area. We have approximately 65 tribal representation throughout the Nation that come to our community. It’s

also the home of the University of Montana, of which many of our

Native American clients come and attend.

Montana has seven reservations, and of the reservations there

are 11 different Native American tribes represented in each area.

When Native Americans leave their home reservation and move

to an urban area such as Missoula, they face many obstacles. One

of the most noticeable is their health coverage. Once they leave the
25

reservation and live in an urban area for more than 180 days, they

lose their health coverage through the IHS.

Some of the programs that we provide through our program is

immunization, health promotion and disease prevention, AIDS, alcohol and mental health, diabetes, and our chemical dependency

programs.

Missoula Indian Center is governed by a 7-member board of directors, of which 51 percent must be Native American. Missoula Indian Center is organized under two major programs, which is our

health program and our chemical dependency. We have 11 full-time

staff and one part-time mental health counselor.

Health issues that surround our Native American clients range

from diabetes to the common cold. With our agency as a health referral organization, many of our clients see up to three to five different health providers in the course of a year. With this inconsistency of health providers, there is not a medical health history that

follows our clients as they go to their medical provider. This creates

more confusion and lack of medical knowledge of a client’s history.

Many times, because lack of funding, clients will be referred to at

a point of emergency in their situation. There is little prevention

health coverage, such as yearly physicals or dental checkups.

Missoula Indian Center’s health program provides quarterly clinics that cover the basic health issues, which in itself is an excellent

program but a significant problem that we are faced with is if a

client comes up with a problem through their medical checkup, we

cannot provide the resources to do the maintenance or followup,

such as when they do a blood screening. If they come back and

there is an issue that they need to do followup with a medical doctor, we basically have to tell them they have to go back to the reservation or seek medical assistance on their own.

It is safe to say that 80 to 90 percent of our clients do not have

health coverage or insurance.

The Missoula Indian Center had 8,865 encounters this past year.

These encounters are community members who accessed the center

for medical issues, drug and alcohol counseling, all the way up to

utilizing the telephone. We are looked upon as a one-stop agency

for many of our needs other than medical.

Other issues besides health issues that our clients face are housing, employment, school, K–12 and higher education, law enforcement, and food.

Presently, we contract with the health agencies such as Partnership Health at a reduced cost for our doctors’ visits. This enables

health funds to cover more clients over the course of 1 year, but

this does not address the client’s need for medical followup or

maintenance, as I discussed earlier.

When a client needs to have a prescription filled, we are able to

transport them to St. Ignatious, which is located on the Flathead

Indian Reservation. This entails a 90-mile round trip. Because of

the Salish and Kootenai tribal policies, clients have to physically

present themselves at the pharmacy in order for their prescription

to be filled. This creates hardship with our clients for two reasons:

No. 1, they may not have a vehicle to transport themselves up; and,

No. 2, they may not have gas to put in their vehicle to make the

90-mile round trip.
26

Other services that we seek for our clients to try to utilize on the

Flathead Reservation is the dental clinic, but in order for a client

to be seen they have to leave the Missoula area at 7 in the morning

to be there at 8 a.m. to be seen in an emergency dental situation.

Once again, for them to utilize it, it is an emergency, either a

toothache or some type of infection. There’s no or little prevention

for our dental.

In our chemical dependency programs we offer intensive outpatient and standard outpatient groups and some individual counseling. Our programs are Montana State certified, so we’re able to

see non-Native American clients, which we do some billing with

that particular population.

Our programs are spiritually and culturally themed, and many

of the agencies other than our programs that provide counseling

make comment that the uniqueness of the counseling sessions do

help with the holistic approach with recovery of the addiction, and

they have been noted for this in the State of Montana.

When clients come in to utilize these alcohol programs, they not

only bring their addiction but they bring many, many health problems, and we are seeing more diabetics in this course of our target

population in this area.

I want to just interject this personal note. My father who is 82

years old has been a diabetic since the mid 1970’s. My mother is

79 years old and she has been diagnosed with diabetes for the last

15 years. My father is a World War II veteran, has been an admirer of yourself, Senator Inouye, and this Commission for many

years and thinks of you as a champion on issues that pertain to

the American Indian. He has made comment that he would like to

leave the reservation, but because of the lack of health coverage in

the urban areas he is unable to leave the hospital in Browning,

Montana, because that is his life support for he and my mother.

I want to thank you for your time for listening and reading my

testimony. It has been a privilege and an honor to come before you

with my thoughts and ideas. Each and every day Native Americans

are faced with issues and problems of health, employment, and

education. I sincerely hope with my testimony that our issues have

been personalized. Survival on a day-to-day basis for Native American people is a very real issue.

Thank you.

The CHAIRMAN. Thank you very much, Ms. Meyers.

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

The CHAIRMAN. May I now recognize Mr. Waukazoo.

STATEMENT OF MARTIN WAUKAZOO, EXECUTIVE DIRECTOR,

NATIVE AMERICAN HEALTH CENTER, OAKLAND, CA

Mr. WAUKAZOO. Thank you, Mr. Chairman and Mr. Vice Chairman. My name is Marty Waukazoo, and I am an enrolled member

of the Rosebud Sioux Tribe in South Dakota. I was born and raised

in South Dakota. I moved to California in 1973 and have been the

executive director of the Urban Indian Health Board since 1982.

My wife and I have three children and two grandchildren. My wife,

Helen, is the executive director of the Friendship House Association of American Indians in San Francisco, which is an alcohol an

drug rehabilitation center partially funded by the IHS.
27

The American Indian community in the Bay area organized and

incorporated the Urban Indian Health Board in 1972 to open the

first Native American health center in San Francisco. In 1976, a

second clinic was opened in Oakland, CA. Today, the Native American Health Centers are a full-service clinic with locations in Oakland and San Francisco, dedicated to making health services available to the American Indian community of the five Bay area counties—Marin, Contra Costa, San Mateo, Alameda, and San Francisco.

The services we offer include medical, dental, mental health, nutrition, community health education, youth services, and women,

infants and children program, or WIC program.

In 1983, the urban Indian Health Board had an annual operating

budget of $827,000, with 17 employees. Of this amount, 90 percent

was funded through grants and contracts from IHS. Today our annual operating budget is $7.1 million, with 120 employees. Of that,

14 percent or $960,000 is through grants and contracts from the

IHS. Of the 120 employees we have, 65 percent are American Indian. For every dollar that the IHS invests in us, we are able to

leverage six additional dollars.

We are much more than just a medical clinic. We are also the

cultural hub of the Bay area. When an Indian person comes to the

Bay area looking for jobs from the reservations, coming to the

urban area for training, the first question they ask is where is the

clinic, because they know that’s where you can renew friendships,

get acquainted, and find someone who can connect you up with

other services.

Within the Bay area Indian community there is a social service

network. When I, as a Lakota or a Sioux and someone from my

State comes to visit us in the area, when they walk up to me and

they find me I’m obligated to help that individual navigate through

the city system or through the local health care delivery system,

so it is really a point of access for our community that we serve

over and beyond that of just a health clinic.

As I said, the Native American Health Center in the Bay area

is one of the largest, if not the largest, employer of American Indians in the Bay area. We not only offer employment opportunities,

but we also do dental assistant training, medical assistant training,

clerical training. We do training within our organization. Many of

our employees are former patients of our clinic. It was very important for us that we have that balance of having that opportunity

and giving preference, not only Indian preference, but also preference to those people who are patients of the Native American

Health Center, and we have been very successful over the years.

Just last Saturday we awarded four scholarships—not big scholarships, $1,000 each, but we made those awards by raising funds.

We raised $7,000 by having the staff talent show, food sales

throughout the previous year. We felt it was important that we,

ourselves, award scholarships. We have two students going to junior college in the local area. One Indian student will be going to

Harvard this fall. So we’re very proud of what our community has

done in the area of not waiting for things to happen to us, but

being on the offense and doing things for our community.
28

Last year our medical clinic saw over 4,800 patients, with over

16,800 visits. Of our patients, 98 percent meet the Federal poverty

level guidelines.

The services we provide reflect our community’s expanded definition of health—that health of an individual depends upon the

health of the community. If we have a healthy community, we’ll

have healthy individuals within our community.

I would like to outline some of the critical issues facing our clinics today—issues that ultimately impact the health of our community in the Bay area.

Back in 1985 we bought a building in east Oakland, a four-story,

20,000-square-foot building. We bought that building at a time

when the market was very low. Today, we have filled up that building—four floors offering comprehensive services. Again, we also

have set up a fitness center, a gym on the first floor as part of our

preventive efforts.

The issues of providing health care has increased significantly

over the years. Pharmacy costs for us have increased by 34 percent

from fiscal year 1999 to fiscal year 2000. According to our medical

director, 20 percent of our medical users are diabetic—20 percent

of our medical users are diabetic. A diabetic with high sugar, high

cholesterol, and high blood pressure, a very common combination,

can average $3,000 per year in drug costs. Just 40 such patients

for a clinic like ours can cost us $120,000 a year, or close to 13 percent of the total IHS funding that we do receive.

Capital needs for our clinic have been and continue to be a major

issue for us. We have been located at 56 Julian Avenue since 1972.

We lost that lease this year. Our lease rent at the 56 Julian site

was $6,500 last year [sic]. We moved to a new location a 11⁄2blocks

down on Cap Street. Our rent has increased to $20,000 a year—

a month. From $6,500 to $20,000 a month. The market has gone

up and exploded in the urban areas.

We are currently at full or near capacity in our medical clinics

and our dental clinics. Poor design, inefficient and inadequate technology has also been an issue that we have to struggle with. We’ve

had to obtain additional funding from within private foundations

and corporations in order to buy the needed computer equipment

to at least continue to participate in the local health care delivery

system in Alameda County and in San Francisco.

Health insurance premiums for employees—we have 120 employees. Our health insurance premiums have increased by 28 percent

in the last 3 years.

The California energy crisis is also having a major impact on us.

These costs have increased by 40 percent over previous years.

Another critical issue that’s going to impact our ability to provide

primary care in the next year or two is something very positive in

our community. The Friendship House Association of American Indians will be building an 80-bed alcohol and drug treatment center

in San Francisco. Through a partnership with the city of San Francisco, they were able to obtain funding to buy property in the Mission District to build this 80-bed facility. That is great. There is a

need there. That 80-bed facility is going to become a regional treatment center for not only California but for the western United

States.
29

The Friendship House already has agreements with tribes in

California and throughout the western United States for those people to come into the urban area to get their treatment for alcohol

and substance abuse. The problem for us is that we have to provide

the health care for them, and, as you know, those people that are

in recovery do need a lot of health care as they go about turning

their life around. How do I know that? Because 22 years ago I went

through the Friendship House. For 1 decade I was homeless on the

streets of Oakland and San Francisco. I entered the Friendship

House in 1980, March 12, 1980. This past year I celebrated another

year of sobriety. These urban programs do work.

A financial challenge for us is to find the funding and the financing to provide care for these people. When I went to the treatment

center in March 1980, I had to go next door to get my TB test and

also to get screened for my physical exam, and also my dental services. I can always remember that, how they treated me there. After

coming off the streets of Oakland and San Francisco and coming

into the urban area, how they treated me—they treated me as if

I was someone important. I was just 30 days into the program, into

the treatment, having gone through detox and going through the

first 30 days. My efforts today are just an attempt to repay back

what they gave me as an urban program 22 years ago.

The challenge for us in urban country, again, is the challenge

that we have to take on as urban Indian programs, is to build that

relationship with the tribes at the reservations. There has been

miscommunications, misunderstandings. We can get along individually, but somehow we don’t get along as communities and groups.

We need to work on that. We are uniquely positioned in the State

of California, working with the California Rural Indian Health

Board, trying to put together their statewide HMO plan. It is a

unique opportunity for us in urban country to partner up with the

tribes and urban programs.

Many of our people do return. We are young. When the relocation programs took place in the 1960’s and 1970’s, we were a young

community. Those people in the urban areas were only in their

early twenties. Today, we are seeing more grandparents, more

grandfathers, grandmothers. We are seeing an elderly population

starting to emerge. Those of us who are in our fifties now are

grandmas and grandpas. What comes along with that is increased

cost, increased needs in our community.

I’d like to thank you for the opportunity to give you my testimony and appreciate all that this committee has done for Indian

people throughout the Nation—my relatives—and we look forward

to improving the health care of our people together. We will work

on those things and we will do everything possible in the local

areas to help improve the future for the next generation.

Thank you.

The CHAIRMAN. I thank you very much, Mr. Waukazoo, for your

very inspiring statement.

[Prepared statement of Mr. Waukazoo appears in appendix]

The CHAIRMAN. May I now call upon Ms. Culbertson.
30

STATEMENT OF KAY CULBERTSON, EXECUTIVE DIRECTOR,

DENVER INDIAN HEALTH AND FAMILY SERVICES, INC., DENVER, CO

Ms. CULBERTSON. Good morning, Chairman Inouye and Vice

Chairman Campbell. I’m very excited to be here, and I feel honored

because I wasn’t supposed to be on the presenting committee, so

my testimony was very hurried.

My name is Kay Culbertson. I am an enrolled member of the

Fort Peck Assiniboine/Sioux Tribes from Poplar, MT, and today I

want to talk to you about Denver Indian Health and Family Services. I think I am going to show you a different perspective of

urban Indian health than Mr. Waukazoo did. I didn’t realize that

they had 100-some employees. I knew that they had a beautiful facility but didn’t realize it was so large. So, as we say in Assiniboine, I’m going to give you the ‘‘oonshaka’’ story.

I want to talk about Denver. Like Oakland and San Francisco,

Denver was a relocation center for urban Indians or for Indians

moving off of the reservation. There’s also many Air Force bases

and military bases in the area, so a lot of people that moved to

Denver ended up staying there and raising their families there.

Like San Francisco and Oakland, we also see second- and thirdgeneration urban Indian people, but they still have their ties with

their reservation, and I would like to talk about that a little bit because my family is still very close to our people back home, and I’m

very anxious to go back home tomorrow because our family will be

coming out of mourning on Saturday for my uncle that was killed

in an accident on the Northern Cheyenne Reservation and then my

grandmother that passed away last year.

One of the things that brought people to Denver was that hope

for a better future. Like all of the places, you know, we all thought

that—well, my parents moved there when I was 6 years old—that

we’d improve our lives, that their children would grow up free from

racism and grow up in a better environment and have opportunities that they didn’t have on the reservation.

I want to talk a little bit about Denver. We’re located right in

the heart of Indian country. I mean, you fly into Denver, there’s

conferences there all the time. There’s several national organizations with National Indian Health Board, Native American Rights

Fund, the American Indian College Fund, but as far as Indian

country goes we’re pretty isolated.

You talked about us being 250 miles away from the Southern

Ute Reservation. That’s true. And we don’t see very many people

from Southern Ute. It’s too beautiful to leave there, I think, and

to come to Denver. But we primarily see Lakota people, Sioux people. That’s 60 percent of our population, and another 30 percent are

the Navajo people.

The closest Indian hospitals, like I said in my testimony, are in

Albuquerque and probably in Rapid City, so that’s quite a long

haul for people to go if they need any kind of medical services that

we can’t handle.

We were incorporated in 1978. We started out with two employees, and they were little ladies that worked in the community and

met with hospital people and when Indian people came to them

and needed help they helped them get into medical appointments
31

or they helped them get to their medical appointment. They worked

with them to find dentists. It was a very sort of hodgepodge way

of providing services in the Denver area.

We started to grow. Actually, we were part of the Indian Center,

Denver Native Americans United, when we started, and we moved

away from the Indian Center and incorporated in 1978 as Denver

Indian Health Board, now known as Denver Indian Health and

Family Services. We had a full-scale clinic at one point with 21 employees, not to a point that Marty’s program was, but quite, quite

extensive for the Denver area. We had an agreement with the Denver Health System to provide services, and, unfortunately, a lot of

the people that we see don’t have health insurance. Of the population that we see now, 70 percent don’t have health insurance. I’m

sure that it was as high or higher then, because there weren’t the

Medicaid programs and the CHIP programs that they have now.

And the people that were insured, the Indian people that came to

our clinic actually put a burden on our clinic and we ended up having a huge debt with Denver Health and had to close our clinic operations for the organization in 1991.

We then entered into a small agreement with a community

health clinic, but all along we’d hear the community people say, ‘‘This isn’t our community. Where is our clinic? We want our clinic

back.’’ And so we started to work on that.

In 1998 our board had a planning retreat, and they decided that,

come hell or high water, we were going to have a clinic back in our

community, and so we started out really small. Very fortunately,

we found this young Indian doctor that was just so excited to be

providing services and was fresh out of medical school and wanted

to work for us, and she came and she helped us get our clinic licensed, so that was a big step for us. She could only work for us

20 hours a week. Unfortunately, her husband was also a doctor

and—well, fortunate for them, unfortunate for us—and they ended

up moving to Billings, and we lost a fine doctor, a dedicated person,

so we had to backtrack and start to look at how we could continue

to provide services.

Eventually, we decided that we would go with the least-expensive method of providing medical services for our community, and

that was through a nurse practitioner. We felt that a nurse practitioner gave us what we needed—a lot of health education—but they

can do everything a doctor can do as long as they are supervised

by a doctor, except for surgery, of course, and so that’s the mode

we are in now. We have a volunteer physician that oversees our

family nurse practitioner. We do well child checks, acute emergencies, immunizations, women’s health, and abuse physicals—anything that you don’t have to go to the hospital for specialty care

like x rays or casts or anything like that.

Let me talk about our community.

We serve people from Adams, Arapahoe, Boulder, Denver, Douglas, Jefferson, and Gilpin Counties. That’s a pretty large area, if

you look at Denver metropolitan area. But we do see people that

come from the reservations, particularly during March Pow-wow—

you know, the things that are going on in the community we seem

to see a lot of people that come off the reservation, or if they’re visiting their family. I can’t tell you how many times people have
32

come and needed prescriptions through our offices or need to get

something refilled because they forgot it at home or they ran out,

and so they come to us looking for those services.

Denver’s population is fairly young. We have a median age of

30.2. A lot of older people don’t stay in Denver, and I think it has

a lot to do with their health benefits and such that they move home

to the reservation because it is easier for them to receive services.

If they are fortunate to have health insurance, then they’ll stay,

but we have a very small elderly population.

The annual income of a person that comes into our organization is $7,452, and it is kind of crazy. We wonder why we have so many

people that aren’t on Medicaid or the other programs, but we realize that they come to us thinking that they have a right to health

care—as Indian people, they have a right to health care, and that

they should be able to go to any place and receive the services that

they would on the reservation.

Beyond our medical clinic, we also offer a community health program that is sort of our hodgepodge of everything. It helps with

getting people prescriptions. We help pay for people’s prescriptions.

They also work very hard to sign up people on Medicaid and CHIP,

because one of the things we try to stress is that you cannot afford

to live in Denver if you do not have health insurance. One trip to

the hospital will wipe you out.

We have a new diabetes program, and we’d like to thank you for

the additional funds. In addition to our management of glucose and

keeping an eye and making sure that our diabetics are keeping

their glucose levels in check, we are going to start offering new exercise programs and teaming up with different things in the community so that we have a more active community.

We also have a behavioral health program, and that’s for mental

health and substance abuse counseling. It’s a very small program.

We are in need of psychiatric backup for a lot of the things that

we provide.

We have Victims of Crime Act program, where we do case management, work very closely with the area victims’ programs.

Some of the challenges that I’d like to talk to you about for Denver Indian Health—and I see them as things that can’t be overcome—is that one of the things, unlike Marty’s program, is our

board has really struggled with is entertaining becoming a 330 program or a Federally-qualified health center or a national health

service core provider because we don’t want to lose our identity as

an Indian provider. Right now 99 percent of the people we see are

enrolled members of Federally-recognized tribes, and so we are

very proud of that, and we don’t want to lose that. We don’t want

to lose that complexion of our community.

We also see that part of it would include additional things that

we don’t know we could handle, and that would be signing up with

an HMO and having 24-hour coverage and those type of things that

we haven’t been able to do now, so it really limits our ability in

third-party billing and we have a lot of work to go on there.

As we have said, IHS, as a whole, is funded very low, but urban

programs get the bottom of the barrel. One of the things that I’d

like to mention that is very important to us is dental care. There’s

only one urban Indian health program that has funding for the
33

dental program, and that’s in Albuquerque, and that’s just this

year that they’ve received the funding.

We take 10 slots a month for emergency dental people, and we’ve

got a 3-month waiting list. I mean, I don’t know how many people

can plan their emergencies for their dental visits, but it is very difficult. And alot of the providers in Denver don’t accept Medicaid

patients, so we’re getting people that have the insurance but they

have nowhere to go, and that has been really hard.

A little boy was in my clinic the other day and we were looking

for a pedodontist to send him to because he was deathly afraid of

the dentist. We don’t usually deal with children. We usually refer

them somewhere else. But they wouldn’t accept him, either, because his family hadn’t signed up for Medicaid. And so we were

looking, and I think they found a pedodontist the other day for

him, and hopefully his dental care is taken care of.

One of the problems we have is hiring and retaining qualified

professionals. Dr. Vanderwagen talked about 30 percent lower pay

rates for doctors or people that go into the tribal centers or into

IHS. We can’t even begin to match the salaries that IHS provides

or the tribal facilities. I have calls from people calling about the diabetes positions that I have open, and they’re, like, ‘‘Well, I can’t

afford to move there. I’d really like to move there, but you don’t

pay enough.’’ And it’s, like, ‘‘Well, our budget doesn’t allow for us

to be able to go much higher than this.’’ And, unfortunately, we’re

not able to attract them because we don’t have the benefits package that IHS has.

So yes, urban programs are eligible for the scholarship repayment programs, but it is very limited because they really have to

take a much more decreased salary to come and work for an urban

program than they do with a tribe or with a IHS facility.

I’ll go very quickly now.

Denver Indian Health and Family Services would like to support

the Indian Health Care Improvement Act. We’ve testified on that

before, of our support.

We’d also like to support the elevation of the director of IHS to

Assistant Secretary for IHS. We think that through his innovation

we’ll be able to access other grants through SAMHSA and different

programs other than IHS, and hopefully, with his speaking with

one voice theme for the Indian Health Care Improvement Act and

working with urban programs, that we’ll begin to see urban programs included in some of the funding mechanisms. Right now a

lot of things are just for tribal programs or for tribal organizations.

Denver Indian Health and Family Services supports section 535

of the amendment to the Social Security Act to clarify that Indian

women with breast and cervical cancer who are eligible for health

services provided under a medical program of the IHS or a tribal

organization are included in the eligibility category of breast or cervical cancer patients added by the Breast and Cervical Prevention

Treatment Act of 2000. Again, that’s an example that the urban

programs will not be included in that and the urban Indians will

be left out.

We’d also like to support the demonstration projects. We’ve heard

good things. We would like to see the report. But we think that

that is one way for programs that are isolated or that want to keep
34

their identity as Indian providers to be able to go on and do that,

so we strongly support the funding of further demonstration

projects.

I want to close with a story. And I want to thank you for the opportunity to provide testimony today. As I was saying, I was working on my testimony last minute. My son is very active in the local

Native lacrosse program. It’s a neat program. There’s about 25

families that participate in this program on a regular basis.

I was sitting there at the park with my laptop out typing and

working on this, and this mother that I have been friends with

through the year came up to me and said, ‘‘Kay, what are you

working on?’’ And I said, ‘‘Well, I’m working on some testimony.’’ And I didn’t want to give her a lot of information because I didn’t

really want to intimidate her in any way. And she said, ‘‘Are you

an attorney?’’ And I said, ‘‘No.’’ I said, ‘‘I’m the director of Denver

Indian Health,’’ and she said, ‘‘You are?’’ And I said, ‘‘Yeah.’’ And

she said, ‘‘What are you testifying on?’’ I said, ‘‘Urban Indian

health issues.’’ And she said, ‘‘I have a story for you.’’ She’s diabetic and she was pregnant with a set of twins and so

she was high-risk with her diabetes and also with a set of twins.

Her family had told her, ‘‘Laura, go home. Go home and have your

babies on the reservation because then you won’t have this huge

bill when you go out.’’ Well, Laura didn’t want to go home. She

wanted to have her children where she lived, and so she stayed in

Denver, without realizing what would happen. She had the babies.

I don’t know what hospital she had them at. But they were in intensive care for quite some time.

At the time they released her and her children, Laura left the hospital with a $45,000 bill, and she told me, ‘‘You know, we

couldn’t afford it. We couldn’t do it.’’ But she said, ‘‘I had to have

my babies. They needed this care.’’ So they ended up filing bankruptcy, and they’ve never recovered.

They’ve never recovered from this. And I’m sure that Laura is not

the only person in our community that has had those problems or

had to face that type of situation.

She asked me, she said, ‘‘Will you tell my story?’’ And I said,

‘‘Yes, I will.’’

I hope that in the future you will be able to give some answers

to people like Laura and provide us with additional funding for

urban programs.

Thank you.

The CHAIRMAN. I thank you very much, Ms. Culbertson. We will

try to help your friend.

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

The CHAIRMAN. Mr. Hall, what is your definition of an urban Indian health center? What services are they required to provide? Is

there any standard?

Mr. HALL. There are basically three levels currently existing,

with the highest being the comprehensive like Marty’s program,

where you provide a multitude of services. The second level would

be limited direct, much like Kay’s program, where you provide partial services. And the third level is the outreach and referral, where

when people come to you for advice and how to find other services

that might be available.
35

The CHAIRMAN. How many full-service clinics are there in urban

Indian health centers?

Mr. HALL. I think there’s currently 14 that qualify for FQHC.

There are 10 limited direct service programs and ten outreach and

referral.

The CHAIRMAN. If I may ask the directors of the centers, how do

you determine your beneficiaries or your clients or your members?

Do they have to be enrolled members of tribes?

Ms. CULBERTSON. Every program is different. Denver Indian

Health and Family Services, because we don’t have a State-recognized tribe in Colorado, do not serve any State-recognized members

at this time.

When people come into our clinic, we ask them to bring their documentation either of tribal enrollment, or we will tell them, because there’s so much inter-marriage in the urban areas, that they

are able to collect the CDIBs, and if they can come up with onequarter degree of Indian blood from the federally-recognized tribe

we will serve them.

But I know that everybody else has different—— The CHAIRMAN. Does one have to have one-quarter blood quantum?

Ms. CULBERTSON. Yes; and then we do get the people from tribes

such as the Cherokee where we get in 1/124th or something like

that, but we will serve regardless of blood quantum for tribal members.

The CHAIRMAN. How is it done in Oakland?

Mr. WAUKAZOO. Self-identified.

The CHAIRMAN. What?

Mr. WAUKAZOO. Self-identified.

Ms. MEYERS. In Missoula they are enrolled member of the recognized tribe or State, and are a descendent of an enrolled member.

If they can prove a descendence through the lineage, then we will

be able to provide services for them.

Mr. HUNTER. In New York City, Mr. Chairman, we use the definition as it is written in the Indian Health Care Improvement Act

in the current legislation, and that applies to our health services.

Our other programs have different requirements, but for our health

services we use that definition.

We were also able to convince the State, in its managed care

planning process, to accept that definition for exemptions to mandatory managed care in the State.

The CHAIRMAN. Mr. Hall, how many individuals receive services

from these health centers?

Mr. HALL. In any one fiscal year it is approximately 100,000 Native Americans. If you compute that over a 3-year period, as we do

for the IHS user population, it averages about 175,000.

I would like to point out that, of those 14 comprehensive clinics,

we’ve only got two that are about the size of Marty’s. Most of us

are the size of mine, which is just under $1 million of total program.

The CHAIRMAN. From your experience and from statistics that

you have gathered, what is the major health problem? Alcoholism?

Mr. HALL. They’re very much similar with reservation. Diabetes

is a very high concern. In my program we service well over 500 dia-
36

betics in our three urban clinics. Another high need, of course, is

alcohol program, alcohol treatment money. We have high incidence

of obesity and blood pressure problems. We have high incidence of

other related physical structure problems because of that.

The CHAIRMAN. Now, you have been here all morning and you

have listened to the testimony of the IHS. Are you satisfied with

your relationship with IHS?

Mr. HALL. Are you asking anybody in particular or all of us in

general?

Mr. WAUKAZOO. Could be better. Some of the—no. No, we are

not. In some ways really dissatisfied with the formulas that they

use. Some of the formulas that they use for additional funding,

such as diabetes, was merely division. It doesn’t take into account

service population. It doesn’t take into account level of need. Division. Diabetes funding that just came down was, as I understand

it, divided by the number of programs at two levels. So our center,

with two clinics, they treat us like one clinic. We have the overhead

at the San Francisco clinic, overhead costs in the East Bay, and

we’re treated as one clinic. If both of our clinics were stand-alone,

they would probably be within the top ten urban clinics in the Nation largest. But the funding that comes down comes down based

on, from what I gather over my 20 years, division is the formula

being used.

Mr. HALL. There are a couple of other things, as was alluded to

earlier. There is direct service, IHS-provided service. There’s 638-

provided service by tribal groups who operate under the 638 authority. And the authority that allows us as urban programs is the

buy-Indian authority. There are inconsistencies throughout IHS in

how we are treated through that buy-Indian authority, and we’re

trying to work as a national organization in making more uniform.

We’re satisfied with a lot of our relationship with IHS and being

involved in consultation and having input into several of the policies, but it is still the bottom line. We are a very tiny portion of

the budget process. We’re a very tiny voice in any consultation

issue, often one voice among up to 50, 60 representatives. And so

in the end, as you can see from the recommendations, our budgets

have been the last to be fully supported, and so we’ve got some concerns about those kinds of things.

They’re fixable. We have some concerns.

Mr. HUNTER. A lot of that also has to do—and I’ll refer back to

Dr. Vanderwagen’s testimony, in which he mentioned several times

that authority is not granted. They just don’t have the authority

to do some of the things for urban programs that we need, and so

this is why certain parts of the Indian Health Care Improvement

Act are so important, because it will give the authority that we

need in order to partake of some of the services and available resources that are out there.

Ms. CULBERTSON. It becomes a tenuous relationship. I don’t

think that anybody is saying that they want to lose their relationship with IHS, but I think that what we’d like is some of the benefits and the luxuries that tribes and IHS share in, such as the Federal Tort Claims Act. We’re not eligible for that and so we have to

pay for malpractice when we become direct service providers. I

think that’s one of the things we need to look at.
37

Another thing is that they expect certain things from the urban

Indian health programs, and a lot of times they expect us to function like IHS facilities or tribal facilities with the limited funding

that we have. My operating budget is only about $400,000, so trying to provide all the things that IHS provides, requires is sometimes overwhelming, and so I think that there needs to be some

sort of different look at how the urban programs can get their funding increased, get some of the benefits the tribes have, and also

provide some support for us.

The CHAIRMAN. Montana?

Ms. MEYERS. I would like to see a more workable relationship

with IHS. I grew up with IHS, and I would like to see, as an urban

setting—and I put it on a personal note. I’ve tried to convince my

parents to come live with me in Missoula, but because of the limited health coverage that they would receive in Missoula their

hands are tied. They would love to come and spend time with me

and live in an area that they enjoy, but because of the lack of coverage of their medical needs it is totally impossible.

The CHAIRMAN. The first panel spent some time discussing tort

claims, malpractice. Is that a matter of major concern to the urban

Indian health centers?

Mr. HALL. If we fully participated under that protection, it would

save each one of us high malpractice insurance costs. We all have

to maintain high liability once we start providing direct service for

that. Again, its because of the authority. Because we’re not 638, it

doesn’t apply to a buy-Indian provider, so technically right now, according to what is legislated, we wouldn’t be able to participate in

it. There would have to be some enabling legislation that would

allow us to be covered by that.

The CHAIRMAN. What is the cost of insurance in Denver?

Ms. CULBERTSON. Well, for us our insurance is running about $800 a year, but we have a very good relationship with a nonprofit

group that provides the malpractice insurance for us. And because

we have such limited services, our malpractice insurance isn’t as

high.

If we opened up our doors to OB, to prenatal care, our costs

would skyrocket and we wouldn’t be able to afford those services.

So the malpractice really determines on what you offer, and

probably the best guess is Marty’s malpractice, because they are a

comprehensive center and are probably the closest to what an IHS

facility would be, how much their malpractice insurance costs.

The CHAIRMAN. How is it in Oakland?

Mr. WAUKAZOO. I don’t have that figure in front of me right now.

The CHAIRMAN. Any figures from Montana?

Ms. MEYERS. Because we are a health outreach referral, we considered and looked at when we do become a clinic—and that’s one

of our goals, to become a clinic for our area. That is one issue that

has been discussed among staff and our board of directors is the

cost of malpractice insurance, which if we don’t come under this

claim, the Tort Claims Act, then we will be looking at high insurance in that area.

The CHAIRMAN. Anything in New York?

Mr. HUNTER. Very similar situation in New York, sir. We are an

outreach and referral. We do direct counseling services, and on oc-
38

casion some of our counselors in the past have insisted that there

be coverage provided. We don’t have it in our budgets, and so

they’ve had to purchase their own malpractice insurance.

The CHAIRMAN. Mr. Hunter, I would gather that most of your

beneficiaries are from outside New York?

Mr. HUNTER. Yes; a large segment of the population is Mohawk

from the two reservations in upstate New York. A large population

is from eastern Long Island from Shinnecock and the Unkechaug

Reservation. Shinnecock is about 90 miles east. That’s where my

family is. And Cherokee people are also a large number. In our Department of Labor statistics, I just noticed in reviewing those that

Navajo is also well represented in New York City.

The CHAIRMAN. And for Montana the population is from that

area?

Ms. MEYERS. The biggest population that we serve are the Blackfeet, and it goes on down to the Flathead, which is Salish and

Kootenai, Asinniboine. All the 11 tribes that live in the State of

Montana do come to the Missoula area, plus nationwide we have

Navajos from the southwest, Apache that do come up to attend the

University of Montana, and we have a variety.

The CHAIRMAN. How is it in Oakland?

Mr. WAUKAZOO. The largest group of tribes that we provide service for are the California tribes. Individually largest group is the

Navajo, Lakota, Pomo, Cherokee, Apache, Paiute, Blackfeet, Choctaw, and Chippewa, in that order.

The CHAIRMAN. Denver?

Ms. CULBERTSON. Well, as I said before, 64 percent of the people

we see are from the Sioux tribes, and then 30 percent are Navajo,

and then it is a whole mixture. The one tribe we rarely, rarely see

are the Southern Utes and the people from our home State.

The CHAIRMAN. Well, I thank you.

May I now call upon the vice chairman.

Senator CAMPBELL. Thank you, Mr. Chairman. We have a conference in another 15 minutes or so, so I’m going to submit most

of my questions in writing, if that’s acceptable.

I might just ask Kay, does Rosalie Tall Bull work with you?

Ms. CULBERTSON. No; Gloria works for me. She’s my community

health specialist. But Rosalie works for National Indian Health

Board.

Senator CAMPBELL. Okay. She’s my sister. I don’t know if you

knew that.

Ms. CULBERTSON. Yes; I knew.

Senator CAMPBELL. Tell her hello for me. You see her more than

I do.

Ms. CULBERTSON. I’ve got alot of friends that know you.

Senator CAMPBELL. Yes; alot of relatives.

Carol, does Henrietta Whiteman still run the Native American

studies program up there at Missoula?

Ms. MEYERS. No; unfortunately, Bozeman got her.

Senator CAMPBELL. Bozeman? Oh.

Ms. MEYERS. And so she’s down in the Bozeman area at MSU.

Senator CAMPBELL. I see. Well, she’s not my sister. She’s my

cousin.

Ms. MEYERS. Okay. That’s good.
39

Senator CAMPBELL. You can tell her hello if you see her, too. I

don’t have any relatives in anybody else’s area that’s testifying, but

they brought up some really interesting questions, Mr. Chairman.

I’m probably not going to get into them. We just won’t have the

time.

But Mr. Waukazoo really I thought alluded to something really

important, and that is that when you talk about Indian healing it’s

just not a matter of giving them pills and Band-Aids. It’s a form

of holistic healing. So much of Indian healing has to do with their

spiritual feeling and their cultural feeling about being in balance

with their surroundings and so on.

I think that when you talk about all the activities you have in

your center, your health center, and Mr. Hunter’s too, in New York,

superficially you might say, ‘‘Well, what do those have to do with

health?’’ But they have a lot to do with health with Indians, and

I think they are really worth pursuing and worth expanding, too,

if you can do this.

Obviously there’s a question of how to finance all those things,

and that’s what I wanted to ask you. You must have a pretty large

staff to do all those different activities you do. Is that all done with

donations and volunteerism?

Mr. WAUKAZOO. It’s done with a lot of dedication and commitment on the part of the staff. And I agree with you 100 percent

about health care—it’s much more than just providing health care

externally in the western model.

You know, when I was growing up in South Dakota my parents

used to tell me, ‘‘Get out of the house. Go out and play.’’ Today parents are saying, ‘‘Stay in the house.’’ Senator CAMPBELL. Yes; you’ll get sick.

Mr. WAUKAZOO. ‘‘Don’t go outside.’’ So now we have a generation

who is growing up. I coach the Grasshoppers. We have a tribal athletic program, part of our clinic. The Grasshoppers are first and

second graders, little guys. I coach them. We haven’t won a game

in 2 years, but that’s not important. [Laughter.]

Senator CAMPBELL. You’re developing character.

Mr. WAUKAZOO. What’s very important is that they’re out there

getting active and they’re learning that they’re at risk for diabetes.

But they can’t even run up and down the court three or four times

without getting tired. We get ahead by two or three points at the

end of the first quarter but we loose by the end of the game because they’re all tired.

How do we do it with financing? Well, health care is local. We

spend a lot of time and a lot of energy at the local level. The local

level and the State and the county delivery system have a responsibility also.

Our greatest concern is we’re seeing a larger and larger group of

those uninsured, those individuals that are not eligible for Medicare, Medicaid, Medical in our State.

Then we also look in that other option in partnering up with different other organizations. We will be building a youth development center in the next year which will incorporate a gymnasium,

performing arts studio, fitness center, and it’s really about the next

generation because that’s our largest population. If we can get in

front of this diabetes and these other health problems, you know,
40

instead of trying to pull them out of the stream, go upriver and

build or repair that bridge to keep them from falling into that.

That’s the initiative that we’ve taken.

We’re quite proud of the fact that our physicians both have been

with us for over 18 years. Our dentist has been with us for 25

years. My assistant director has been with me for 16 years.

Senator CAMPBELL. That’s a commitment.

Mr. WAUKAZOO. And, following my father’s advice 20 years ago

when I took this job, he said, ‘‘The best place to be when you don’t

know anything is in charge.’’ [Laughter.]

Senator CAMPBELL. That’s why we’re here. [Laughter.]

Mr. Chairman, years ago I asked an old man who was a halfbrother to my grandmother, I went over to visit him one time and

he had a really bad cold and I asked him why Indian people have

such health problems now that they didn’t have in the olden days,

and he gave me an interesting answer. He said, ‘‘Because look

what we’re living in.’’ I don’t remember the exact words, it has

been so many years ago, but he pointed out in the olden times Indian people lived with nature. In the case of the Plains people, all

of their structures were round. The sweat lodge, the tepee, and so

on, were all round to reflect the circle of nature, the circle of life.

And he said that when they were moved into square houses it was

kind of an affront to the natural way of living and he thought that

their health problems went up when that lifestyle changed and living in square things instead of round things.

As I began to reflect on that, almost all Indian housing, whether

it was the Plains tribes or the Southwest tribes in the desert or no

matter where, the northeast, their structures were round. Maybe

he knew something we didn’t know. But that’s what his belief

was—kind of an old-time belief about why health problems go up

if you’re out of tune with nature.

Mr. Hall, I remember we had the infamous tobacco settlement

debate here a few years ago and this committee certainly went to

bat for the Indian tribes being included in that tobacco settlement.

In fact, the current Secretary of the Interior came back and testified. She was the attorney general for Colorado then. She testified

to help us make sure there were Indian provisions in that settlement.

The thing fell apart because, typical of the Senate, we went off

in 100 different directions and we couldn’t get anything passed.

But States did, as you know, go ahead and sue tobacco companies

and reached some settlements.

Do urban Indian centers have access to any of the settlement

funds that went into States? Do you know?

Mr. HALL. That varies by St. Montana I know gets a little bit per

each urban center. In South Dakota we got zip.

Senator CAMPBELL. You got zip.

Mr. HALL. All of South Dakota’s money went to tax relief. California—I believe you guys participated in that a little bit. But it

varied by State.

Senator CAMPBELL. State by State. There was no negotiated

agreement with the States and tribes.

Another question, Mr. Hall. Some Indian centers access community health center funding. Denver does not, I understand. Is the
41

reason because you would have to accept anyone? Oakland does, I

guess. You would have to accept anyone, regardless of whether

they were Indian or not if you accept those funds?

Mr. HALL. A little bit of it is that reason. The other part of it

is that those clinics pretty much operate as a clinic in a dominant

society. Where the access is is from our people feeling uncomfortable in those kind of environments. For example, in the State of

South Dakota the family planning office has made three major efforts to reach Native American women in the past 10 years. This

July 1 they finally contracted with us for a very small contract to

reach out to Native American women, and in the past 10 years

they haven’t increased their numbers at all, and we’ve already submitted 25 names in less than 1 month. So it’s a matter of where

Indian people feel comfortable getting their service.

It’s not just a matter of their being resistant. We have to understand this whole cultural history of being Indian in this country is

like being an outsider in any environment, especially when you get

up in places like South Dakota. So it’s not just that, it’s also the

recognition that Indian health care is a Federal responsibility, so

many State offices and stuff are not inviting to Indian people.

Another part of the issue is it is run very much in a time constrained manner. If you’re late with an appointment, just like with

TANF, you end up getting on sanctions, and when you don’t have

gas for the car or your babysitter is not there, boomadee,

boomadee, boomadee, you’re late. And so people get very reluctant

to do that, just like a lot of our people that qualify for Medicaid.

We have to push and push and push to get them to jump through

the hoops of applying for it because of a perception and in many

instances the reality of being discriminated against in that application process.

So when you take a full look at how our people have bumped into

walls getting service in various dominant society options, it really

ends up being no option.

Senator CAMPBELL. Sure.

Mr. HALL. In Sioux Falls, for example, I’ve had several OB/GYN

people tell us that they see a young lady or a young woman when

she finds out she’s pregnant and again when she calls in the emergency room having a baby because of that limited sense of comfort

with the dominant society’s provisions.

Senator CAMPBELL. I understand that.

Mr. HALL. Sorry for the long answer, but it was——

Senator CAMPBELL. No; that’s all right. I appreciate it.

Mr. Waukazoo, as I understand it, you—what did you say? The

people that come into the clinic self identify? Is that the word you

used?

Mr. WAUKAZOO. Yes.

Senator CAMPBELL. That means if they come in and they say,

‘‘I’m Indian and I need help,’’ you go ahead and help them?

Mr. WAUKAZOO. Yes.

Senator CAMPBELL. You don’t ask them for an enrollment number or anything?

Mr. WAUKAZOO. No; they self identify as American Indians.

Senator CAMPBELL. Dealing with health service, then, how do

you handle a mixed family? A guy comes in and says, ‘‘I’m Indian.’’
42

His wife says, ‘‘I’m not.’’ And they’ve got a couple of kids with

them. Do you say, ‘‘Well, we can help you but not her?’’ How do

you deal with that?

Mr. WAUKAZOO. That’s what’s in the family.

Senator CAMPBELL. Okay. So if he identifies, his whole family

then is—— Mr. WAUKAZOO. Yes; the community—you know, in the Bay

area—in urban areas the community is spread out but it is very

highly connected. It’s well known. It’s just like on the reservation.

You know who is on the reservation.

Senator CAMPBELL. You generally know because you’ve seen

them at activities—— Mr. WAUKAZOO. Yes.

Senator CAMPBELL [continuing]. And they participate in the community.

Mr. WAUKAZOO. Yes; right.

Senator CAMPBELL. I see.

Mr. WAUKAZOO. And that decision generally is within the family

as far as where the health care is going to be taken care of, so we

don’t get into that part of it.

Senator CAMPBELL. I see.

I think, in the essence of time, Mr. Chairman, I’ll submit the rest

of my questions in writing, if I could ask the panel to respond.

Thank you, Mr. Chairman.

The CHAIRMAN. I will also join you in submitting questions, if I

may.

A final question. In the Native Hawaiian Health Improvement

Act, there is a provision for traditional Native healers and traditional Native Hawaiian healers are officially recognized by the Government of the United States. They are compensated for their services.

Are Native American Indians interested in having this act provide for traditional Native healers? I do not want to tell you what

to do, because I believe in you telling us what to do.

Mr. HALL. I just came from the Aberdeen Area Tribal Chairman’s

Health Board meeting, where they spoke of this very issue. They

had a healer from the Navajo Reservation that is part of the

Shiprock, I believe—no, excuse me, Winslow service unit. Some of

the requirements you have to go through to become billable under

Medicaid are so stringent that most of the healers feel they are

stepping outside of their cultural powers to participate in that, so

most of them, as it is now structured, are not reimbursable.

From the conversation of the Navajo people and from the Lakota

people and others up in the Aberdeen area, if that provision you’re

describing could be applied without having to do all of the hoops,

they’d very much appreciate it.

IHS, as a whole, is being very receptive to utilizing traditional

healers, and I think the tribes, but we don’t all speak for the tribes.

I can only speak from that experience.

The CHAIRMAN. Any objections?

Mr. WAUKAZOO. I would just say that it would be a decision that

I would prefer to have the tribes make, and if the decision is yes,

then we would be very supportive. But, you know, sometimes we

have to, in urban programs, kind of step back and follow the tribes.
43

The CHAIRMAN. I think your position is correct. We will most certainly discuss this matter with tribal leaders.

Before we adjourn, I would like to note the presence of Dr.

Vanderwagen. He has been sitting here all morning, and if you

have been to Senate hearings you will note that Government witnesses oftentimes testify and leave immediately, but he has been

here and listening to your testimony, and I think all of us owe him

a great debt of gratitude. I commend you, sir, for doing that.

[Applause.]

The CHAIRMAN. He was good enough to sit here to listen to your

concerns, if you had any.

With that, I thank you all for patiently waiting. Your testimony

is very much appreciated. It has been inspiring and moving.

Thank you.

[Whereupon, at 12:20 p.m., the committee was adjourned, to reconvene at the call of the Chair.]

(45)

APPENDIX

ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD

PREPARED STATEMENT OF HON. KENT CONRAD, U.S. SENATOR FROM NORTH DAKOTA

Mr. Chairman, thank you for holding today’s hearing on the personnel and urban

Indian provisions of the Indian Health Care Improvement Act.

Senator Dorgan and I chaired a field hearing last August in North Dakota to consider this legislation. I can attest to the fact that tribes in my State believe changes

need to be made to the way health care is delivered throughout Indian country.

This bill is one of the most important pieces of legislation being considered by this

committee. Tribes in North Dakota have told me time and again that health care

is their top priority. Without healthy people, all other endeavors will be less successful.

I am pleased that the committee has worked so closely with tribes in putting together this important bill. I hope we are nearly to the point where we can pass this

legislation and allow health care improvements to move forward throughout Indian

country.

This is especially important for the growing number of young Native Americans.

We need a greater emphasis on prevention of disease and injury overall, but especially with respect to young people. Wellness and nutrition training, teaching young

people to stay away from drugs, tobacco, and alcohol, and greater attention to the

mental well-being of young people are all goals that I believe we should embrace.

Greater access to medical care, both rural and urban, and more health care personnel throughout the system are vital to reaching those goals.

Mr. Chairman, thank you for holding this hearing today.

PREPARED STATEMENT OF HON. TOM DASCHLE, U.S. SENATOR FROM SOUTH DAKOTA

Mr. Chairman, thank you for the opportunity to testify on one of the most important issues before this committee—our commitment to provide quality health care

for American Indians and Alaska Natives. As you know, the Indian Health Service

[IHS] is in far too many cases unable to provide even basic health services to American Indians and Alaska Natives. We are failing to uphold a promise we made many

years ago in Federal-tribal treaties as well as Federal statute.

The IHS is tasked with providing full health coverage and care for American Indians and Alaska Natives, but is so underfunded that patients are routinely denied

care that most of us take for granted and, in many cases, call essential. The budget

for clinical services is so inadequate that Indian patients are frequently subjected

to a ‘‘life or limb’’ test. Unless their condition is life-threatening or they risk losing

a limb, their treatment is deferred for higher priority cases; by the time they become

a priority, there are often no funds left to pay for the treatment.

As devastating as the problem is for Native American patients and the tribal governments struggling to address their people’s health needs, the problem does not

end there. IHS often contracts with non-IHS facilities to provide care that cannot

be provided at local IHS clinics and hospitals, due either to the complicated nature
46

of the needed service or a lack of funds. These non-IHS facilities often receive no

reimbursement for the services they provide and, as a result, face serious budget

shortfalls of their own. In 1999 alone, IHS issued 20,000 contract health service denials, leaving the contract facilities without any reimbursement.

A compelling example of the impact of this underfunding is the inability of many

tribes to provide emergency medical services [EMS] to their residents. IHS uses its

authority through the Indian Self-Determination and Education Assistance Act of

1975 to contract EMS to tribes. Throughout Indian country, however, ambulance

service is funded at only 47 percent of the determined need. On the Rosebud Reservation in South Dakota, the funding for EMS is depleted by mid-year. The Rosebud Sioux Tribe’s EMS contractors respond to 425 calls per month. The local IHS

facility does not have an obstetrical or surgical unit, so all high-risk pregnancies

and surgeries have to be transferred by the EMS providers to private hospitals located 180 to 260 miles from the reservation. When the tribe’s funds for EMS are

depleted, other local providers are often called to respond to emergency transport

needs. Consequently, local EMS providers experience serious financial difficulties

because there are no funds left to reimburse them. Ultimately, this situation can

result in discontinuation of ambulance services in a rural area.

I attempted to address the crisis created by this serious, chronic underfunding of

IHS by offering an amendment to the fiscal year 2002 budget resolution. The

amendment called for a $4.2-billion increase for the fiscal year 2002 clinical services

budget of the IHS. This amendment passed the Senate, but was not included in the

bill that returned from conference. I again attempted to address this situation in

the Interior Appropriations bill, but it appears that we will be unable to do that

at this time due to the inadequate budget allocation facing the Interior Appropriations Subcommittee.

It seems Congress has grown so accustomed to inadequate IHS funding that we

are failing to recognize the extraordinary tragedy tribal people are facing. The problem seems so big that we are almost afraid to tackle it. But we cannot afford to

shirk our responsibility.

One reason the problem seems so intractable is that IHS funding—and, in turn,

health care for Native Americans—depends on the vicissitudes of the appropriations

process. The budget for IHS has been so underfunded for so long, our annual appropriations process may never allow us to increase it enough to adequately address

the health needs of American Indians and Alaska Natives. The magnitude of the

increase I requested is evidence of this point: For fiscal year 2002, I requested a

$4.2-billion increase to the $1.8 billion budgeted for IHS clinical services. This 233

percent increase is based on two conservative estimates of the amount needed to

adequately fund the provision of basic clinical services: The tribal needs budget and

the level of need funding budget, developed by the tribes and IHS respectively.

It is time to change the way we fund our commitment to provide health services

to American Indians and Alaska Natives. This Federal responsibility was codified

by treaties and laws dating from 1787 and required under the trust responsibility

of the United States to the tribes. It is clear that, in a historic and moral context,

American Indians and Alaska Natives are entitled to receive adequate health services from the Federal Government. Why then, are they not getting it?

What some may not know is that health care for Indians is not delivered as an

entitlement. I have come to believe it is time to consider changing the funding

mechanism for IHS from a domestic discretionary program to an entitlement. Unless we can demonstrate a renewed commitment to Indian health care in the budget

and appropriations process, granting entitlement status may be the only way we

will live up to our obligation. I understand the political challenges that this entails.

For Indian people, however, this is not a. question of politics. It is a question of history and obligation. It is a question of health and life.

If Indian health were moved from a domestic discretionary program to an entitlement program, it would no longer shoulder the burden of balancing the Nation’s

budget, along with other discretionary programs. We would have to develop a new

process to quantify Indian health based on services and beneficiaries. Funding

would be guaranteed.

I wholeheartedly support, therefore, the provision in the Indian Health Care Improvement Act which establishes a National Bipartisan Commission on Indian

Health Care Entitlement. I look forward to the Commission’s report, and to continuing the discussion of this critical issue.

I would like to bring to your attention another critical issue impacting IHS’s ability to provide health care services. The IHS experiences enormous difficulties in recruiting and retaining health professionals. In 1999, in the Sisseton Indian Health

Service unit, there were 34 different physicians providing medical care in four funded provider positions. This high turnover rate significantly erodes the IHS’s ability
47

to provide high quality health care services and continuity of care. We must address

this issue because, without health care professionals, health care services cannot be

delivered.

The Sicangu Sioux on the Rosebud Indian Reservation in South Dakota recently

built a beautiful new hospital and health care center. While in many ways they are

equipped to provide state-of-the-art care, they are unable to retain health care professionals. As a result, their brand new delivery and surgery rooms stand empty,

and individuals living on the reservation are forced to travel long distances to receive these vital services.

There are many documented reasons for the difficulty recruiting and retaining

IHS health professionals, including low pay, lack of suitable housing, isolation, and

an overwhelming workload. Some health care professionals do not want to practice

long-term in chronically underfunded, crowded and outdated facilities that lack essential equipment. I am pleased that S. 212 includes an array of excellent programs

to improve the ability of the IHS to recruit and retain health care professionals.

There is, however, one issue that is not addressed in S. 212: Medical license reciprocity for HIS physicians.

IHS physicians, as a condition of employment, must hold a license in at lease one

State. Since they are Federal employees, this license should guarantee their ability

to work as an IHS physician in any State. This concept is called ‘‘reciprocity’’. In

South Dakota, IHS physicians are granted reciprocity and allowed to practice under

a license issued from a different State. Their scope of practice, however, is limited;

they are not allowed to practice outside of an IHS facility. This limitation is extremely frustrating, since, due to severe underfunding of the IHS, many areas do

not have IHS facilities, such as hospitals, nursing homes, or specialized clinics.

Many physicians prefer to follow their patients throughout the systems of care. If

an IHS patient is transferred from an IHS facility to a non-IHS facility for inpatient

care, for example, the IHS physician is currently forced to turn over the care to a

non-IHS physician, who may not even know the patient.

Given the many challenges IHS faces in recruiting physicians, I firmly believe we

should not create another barrier. The inability of IHS physicians to practice outside

the bricks and mortar of an IHS facility has led to the resignation of too many IHS

physicians. I hope we can find a way to remove this barrier as we move forward

with S. 212.

I was pleased to see that S. 212 continues an emphasis on programs to comprehensively address substance abuse and Fetal Alcohol Syndrome [FAS]. According

to IHS, the 1994–95 age adjusted death rate for alcoholism in the IHS Service Area

was more than six times that of the general population. Yet, treatment services for

Native Americans remain severely inadequate.

Programs to address FAS are particularly crucial. FAS is the leading preventable

cause of mental retardation in the United States and the No. 1 cause of preventable

birth defects. Although the exact prevalence of this disorder is unknown, studies

have estimated that 3 out of 1,000 Native American children are born with FAS,

and many more with less severe alcohol-related impairments.

These statistics highlight the urgent need for increased access to residential treatment services for women of childbearing age. In the Pine Ridge area of South Dakota, there is currently a five-month wait for IHS residential substance abuse treatment programs. This means that if an alcoholic woman learns she is pregnant and

is motivated enough to request treatment, she would probably be more than 6

months into her pregnancy before a bed was available. By this time, her unborn

child could be severely and permanently damaged.

We need to ensure that when a pregnant woman walks in the door to ask for help

with her drinking, help is available. In addition, we need to do all we can to educate

Native American women, as well as professionals who serve the Native American

community [as well as the non-Native community], about FAS and the dangers of

drinking while pregnant. And we need to ensure that when these approaches have

failed and a child is born with FAS, that child has access to the medical, educational, and social services he or she needs.

In closing, I would like to thank the chairman, the vice chairman and the entire

committee for their dedication to improving the health of American Indians and

Alaska Natives. S. 212 is a comprehensive reauthorization of the Indian Health

Care Improvement Act, and, when enacted and if adequately funded, will go a long

way toward reducing the disparities in health outcomes between Native and other

Americans. It saddens me to know that the mortality rate for American Indians and

Alaska Natives is higher than for all races in the United States, and life expectancy

is the lowest. I commend you for your efforts to eliminate these disparities and live

up to our commitment to provide health services to American Indians and Alaska

Natives.
48

PREPARED STATEMENT OF DR. WILLIAM C. VANDERWAGEN, ACTING CHIEF MEDICAL

OFFICER, INDIAN HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES

Good morning, Mr. Chairman and members of the committee. I am Dr. William

C. Vanderwagen, acting chief medical officer, Indian Health Service [IHS], Department of Health and Human Services.

I am pleased to be here this morning to testify before the Senate Indian Affairs

Committee about two important areas within the IHS service responsibilities.

The first issue of health manpower, providing and retaining sufficient health professionals for our health care delivery system, is one shared by the country overall.

The second matter concerns the operation and challenges facing the urban Indian

health programs.

In meeting our goals, the IHS has adhered to its policy of working with our tribal

and urban partners and constituents, on key decisions and actions. Efforts to improve program delivery of services are greatly improved by such consultation and

cooperation.

The IHS health care delivery system is comprised of 49 hospitals, 219 health centers, 7 school health centers and 293 health stations. The American Indian and

Alaska Native eligible population, in fiscal year 2000 was approximately 1.51 million. This service population is increasing at a rate of about 23 percent per year,

and this estimate exclude’s the effect of the additions of new tribes. *[Trends 1998–

99]

Patient admissions into our IRS, tribal and contract general hospitals, in fiscal

year 1997, were about 85,000. Main causes for admission were births and pregnancy

complications. The 2 ambulatory statistics in fiscal year 1997 show over 7.3 million

medical visits provided through the IHS-funded operations.

There, are additional data to be found in our IHS 1998–99 Trends publication,

but the main purpose of this review is to provide the backdrop against which much

of our discussions will take place this morning.

It is to the credit of our personnel, health professionals and others, that all of our

IHS and tribally operated health facilities had achieved accreditation by the Joint

Commission on Accreditation of Health Care, Organizations [JCAHCO]. This rating

was true as of January 20, 1999.

To fulfill our primary goal of ensuring that we achieve the highest possible health

status among American Indians and Alaska Natives, the health professions activities are critical but could be tested over the next 5 years. The IHS could lose a substantial number of its staff for a variety of reasons, including age-eligible retirement

and the fulfillment of service obligations.

As of the end of June 2001, nearly 22 percent of our 13,000 Federal employees,

throughout the whole system, had 20 or more years of service. Within the health

professions, 18 percent of the 8,600 health-related employees in the 600 personnel

series, in which most of the health professionals are found, are in the 20-plus years

category. Finally, of the three most numerous health professions, nurses, pharmacists, and dentists, all of these groups have more than 12 percent of their staffs

in this group age-eligible retirement category. Physicians have 8 percent of all of

our IHS physicians are in the 20-plus years category.

Our plans for addressing this pending situation include the institution of even

more vigorous recruitment efforts and a greatly increased emphasis on retention.

Such activities include:

1. Increased advertising in professional journals.

2. Increased Health Educational Institution Recruitment Visits.

3. Increased web-based Advertising.

Retention has been a major factor in reaching our current status. The average

length of service for all IHS employees is just over 12 years. For those in the 600

series, it is just over 11 years.

Of our four most numerous professions, nurses have the longest average length

of service, at nearly 11 years. Physicians, with 8 years, have the shortest, while dentists and pharmacists average just over 9 years each. The difficulty, however, is that

we lose many of our new recruits before they have served 5 years. Therefore, retention of new employees must remain a priority.

These difficulties in retention include culture and transition issues, within rural

and often disadvantaged communities. Additionally, the competition for such qualified individuals is huge. Many of these professionals are often approached by other

health care institutions with more attractive employee benefits packages and placements. This situation, of competing health care systems, is only going to grow in

future years as our population, national and in Indian communities continue to live

longer and more productive lives.
49

Our scholarship and loan repayment programs offer us the opportunity to attract

highly qualified staff. In fiscal year 2000, 37 new scholarships were awarded to participants in two undergraduate scholarship programs in the Health Professions with

46 extensions. Forty-five new awards were made in the Preparatory Pregraduate

scholarship program with 61 extensions, and 60 new awards were made to students

in a health professions graduate programs with 287 extensions.

In fiscal year 1996, the average debt load of a new loan repayment program participant was S32,000. In fiscal year 2000, it was $64,000. We anticipate that this

individual debt load will be even higher this year.

Such educational financial assistance, in turn, assures the IHS of a service commitment by the individual who receives such aid. Service ‘‘payback’’ commitment

can range from 2 to 4 years. Once such commitment is completed, an individual may

have private practice goals or family obligations that preclude their further employment within the Indian health care system.

Today 62.3 percent of all American Indians and Alaska Natives identified in the

1990 Census reside off-reservation. This figure represents 1.39 million of the 2.24

million American Indian/Alaska Natives identified in the 1990 Census updated by

Indian Health Service. The updated 1994 Census identifies 1.3 million [58 percent]

of the American Indian/Alaska Natives residing in urban areas. For comparison purposes the Indian Health Service total service population is 1.4 million with active

users at 1.2 million. This figure includes 427,100 eligible urban Indian active users

who reside in geographic locations with access to an Indian Health Service or Tribal

facility.

In 1976 Congress passed the Indian Health Care Improvement Act [IHCIA] [Public Law 94–437]. Title V of the [IHCIA] targeted specific funding for the development of supporting health programs for American Indians/Alaska Natives residing

in urban areas. Since passage of this landmark legislation, amendments to title V

have strengthened Urban Indian Health programs [UIHPs] to expand to direct medical services, alcohol services, mental health services, HIV services, and health promotion and disease prevention services. [Public Law 100–713, Public Law 101–630,

Public Law 102–573].

The UIHPs consist of 34 nonprofit 501 (C)(3) programs nationwide funded through

grants and contracts from the Indian Health Service, under title V of IHCIA, Public

Law 94–437, as amended. Sixteen [16] of the 34 programs receive Medicaid reimbursement as Federally Qualified Health Centers [FQHCs) and others receive fee

for service under Medicaid for allowable services, that is, behavioral services, transportation, et cetera. The other programs are automatically eligible by law but may

not provide all of the necessary primary care service requirements mandated by

FQHC legislation. Over $10 million are generated in other revenue sources.

In the Omnibus Budget Reconciliation Act [OBRA] of 1993, title V of the IHCIA,

and tribal 638 self-governance programs were added to the list of specific programs

automatically eligible as FQHCs. The range of contract and grant funded programs

below are provided in facilities owned or leased by the Urban organizations. Pursuant to title V, the Indian Health Service is required by law to conduct an annual

program review using various-programs standards of Indian Health Service and to

provide technical assistance to the Urban Indian Health Programs.

The range of Indian Health Service/Urban grant and contract programs services

can include: Information, outreach and referral, dental services, comprehensive primary care services, limited primary care services, community health, substance

abuse [outpatient and inpatient services], behavioral health services, immunizations, HIV activities, Health Promotion and Disease prevention, and other health

programs funded through other State and Federal, and local resources, for example,

WIC, Social Services, Medicaid, Maternal Child Health.

Sixteen [16] of the 34 programs are certified as Federally Qualified Health Centers. The other programs are automatically eligible by law but may not provide all

of the necessary primary care service requirements mandated by FQHC legislation.

Today the Indian Health Service provides funding to the 36 [34 title V of the

lHCIA and two demonstration programs] urban Indian health centers and to 10

urban Indian alcohol programs. The urban Indian health programs, range from comprehensive primary care centers to referral and information stations. In fiscal year

2001 Congress appropriated $29,843 million for Urban Indian Health. These centers

continue to receive funding as well, from a variety of other Federal, state and private sources.

Mr. Chairman, this concludes my prepared statement, I will be happy to respond

to any questions you and other committee members may have.
50

PREPARED STATEMENT OF MICHAEL E. BIRD, PRESIDENT, AMERICAN PUBLIC HEALTH

ASSOCIATION

Mr. Chairman and members of the committee, I am Michael Bird, president of

the American Public Health Association. However, today, I am representing the

Friends of Indian Health, a coalition of over 40 health organizations and individuals. The Friends were formed in 1997 to improve the funding and delivery of

health services to American Indians and Alaska Natives [AVAN].

We thank you for the opportunity to testify today and to comment on health care

personnel issues that we think could be addressed in the Reauthorization of the Indian Health Care Improvement Act, S. 212. While the individual members of the

Friends have profession specific concerns we are united on the need to improve the

recruitment and retention of health care providers in the IHS.

A member of the Friends recently sought care from the Phoenix Indian Medical

Center [PIMC]. For a 1 o’clock doctor’s appointment, he left his home at 11 a.m.,

arriving at the PIMC at noon. Having been there before, he knew that he needed

to arrive an hour before his appointment because patients are seen on a ‘‘first come,

first serve’’ basis . . . even though he had a scheduled appointment. At this facility,

the patient to doctor ratio is overwhelming. Not only does it serve Indian patients

from the Phoenix city limits but also patients from the adjacent reservations that

do not have inpatient services are brought in by vans. The patient was eventually

seen but also told that his back condition had worsened and would probably need

surgery for several herniated discs. However, because of a lack of orthopedists at

the PIMC he was unable to schedule a consultation until September 27. The patient’s check up took all afternoon; he returned home at 5 p.m.

This experience is not unique. There is a disparity in access to care throughout

the Indian health care system. For example:

• In fiscal year 1998, there were 74 physicians per 100,000 AI/AN beneficiaries,

compared to 242 per 100,000 in the overall U.S. population;

• In fiscal year 1998, there were 232 registered nurses per 100,000 AI/AN beneficiaries, compared to 876.2 per 100,000 in the overall U.S. population;

• In fiscal year 1998, there were 289 public health nurses in the IHS. This represents a ratio of 19.8 per 100,000 AVAN beneficiaries;

• In fiscal year 2000, there were 21 IHS psychiatrists;

• In fiscal year 2000, there were 63 IHS psychologists;

• In fiscal year 2001, there were 19 podiatrists to treat the more than 60,000 AI/

AN diagnosed with diabetes;

• In fiscal year 2001, there are 11 vacancies for optometrists. Unless these positions are filled, 27,500 patients will not receive care;

• In fiscal year 1998, the dentist to AI/AN beneficiary ratio was 1:2,793 compared

to 1:1,743 for the overall U.S. population; and,

• In fiscal year 1999 there were only 20 registered dietitians per 100,000 AI/AN

beneficiaries.

Another way to view this situation is to compare the IHS to the Veterans Administration. For example, the Carle T. Hayden Veterans Medical Center and the PIMC

are within a mile of each other in central Phoenix. The total number of outpatient

visits at the VA facility was 8,339, compared to 14,400 at the PIMC, a difference

of 6,060. The VA employs 9.5 psychologists, while the PIMC employs 4 psychologists. The total number of behavioral staff at the VA was 75.5, as compared to the

17 behavioral staff at the PIMC.

While the disparity to access to care is most pronounced in the IHS, it will not

be long before the rest of the country will see similar problems. Various health professions are already experiencing or expect to experience shortages in the near future. For example:

• According to the American Hospital Association’s June 2001 TrendWatch,

126,000 nurses are currently needed to fill vacancies at our nation’s hospitals.

Today, fully 75 percent of all hospital personnel vacancies are for nurses;

• According to a study by Dr. Peter Buerhaus and colleagues published in the

Journal of the American Medical Association [June 14, 2000], the United States

will experience a 20-percent shortage in the number of nurses needed in the

United States health care system by the year 2020. This translates into a shortage of more than 400,000 RNS nationwide;

• In the next 20 years, 85,000 dentists will retire and only 81,000 will replace

them;
51

• The June 2001 TrendWatch also reports that hospitals have a 21-percent vacancy rate for pharmacists; and • Podiatry has experienced a nearly 50 percent reduction in its applicant pool

since the 1990’s. In addition, the number of graduates is also dropping. This is

occurring when most States have only 1 to 4 podiatrists per every 100,000 citizens. Federal estimates recommend 6.2 podiatrists per 100,000.

The Friends believes that by improving access to treatment and preventive services the IRS will be able to make significant strides in reducing health disparities

and morbidity and mortality rates in the AI/AN population. Evidence of this was

demonstrated by the placement of a full time podiatrist with the Winnebago and

Omaha tribes. During his 4-year tenure, the average annual 16 leg amputations fell

to zero. Not only did this improve the daily living and quality of life for tribal members and their families but there was a considerable cost savings also. On the average, medical and surgical costs associated with leg amputations can average $40,000

a piece. This one podiatrist saved the tribes over $2 million in surgical expenses

during his tenure.

But the IHS needs to move quickly to better recruit and retain health care providers now. If the Administration waits too long then in the near future when competition for health care providers throughout the country becomes more intense, the IRS

will not be able to compete for these workers. In order for that to happen, Congress

needs to make it easier for the IHS to recruit health care providers.

Suggested Solutions;

1. Loan Repayment

The most successful recruiting tool that the IHS has is loan repayment. A few

years ago, following recruitment visits to dental schools, the IHS dental branch received 100 calls from interested graduating seniors. However, almost every caller

asked about the availability of loan repayment. When they learned that it was minimal, actual applications fell to just over 30. Loan repayment is an excellent recruiting tool. Of the 19 podiatrists serving in the IHS, 13 are receiving loan repayment.

Most health professionals have incurred heavy debt loads during their education.

The average debt load of the 272 people entering the IHS last year was $64,000.

But that figure understates several individual professions:

• The average student debt for physicians is $95,000;

• The average student debt for optometrists is over $100,000;

• The average student debt for dentists is $100,000 [this does not include undergraduate debts]; and

• The average student debt for podiatrists is $110,000.

As part of the Friends fiscal year 2002 appropriations request, we requested that the IHS loan repayment budget be raised to $34 million. This is an increase of $17

million and would allow the IHS to double its workforce. The IHS could further extend this funding if Congress were to make these loans tax-free. Under the current

system, Congress not only pays health care providers an annual sum of $20,000 but

also pays an additional 20 percent of that amount for taxes. Therefore, $3.4 million

goes to the Internal Revenue Service. If the loans were tax free, this would allow

the IHS to hire 170 more providers. Just doubling the number of IHS dentists getting loan repayment would mean that 53,000 more dental visits could be scheduled

each year. The Friends recommends that the committee include a provision in S.

212 to make the loans tax-free.

2. Loan Deferment

Under the Higher Education Act, volunteers or members of various health and

Federal programs do not have to repay the principal of, or the interest on, any student loan under the Act for 3 years. This includes members of the

• Armed Forces,

• Peace Corps,

• Domestic Volunteer Service,

• Full time nurse or medical technicians providing health services, or

• Full time employees of a public or private nonprofit child or family service agency who is providing, or supervising services to high-risk children from low-income communities.

Health care personnel working in the IHS or for tribes are noticeably absent from

this list. Consequently, recent graduates must begin immediate repayment of debt

upon graduation, when their net incomes are at their lowest. For some, that monthly payment can be over $1,000. Faced with this burden, many health care professionals cannot afford to join the IHS, whether as Commissioned Corps, Tribal hires

or urban hires. For those who do take the risk of joining while waiting to be accepted for loan repayment, many soon discover that they cannot make ends meet be-
52

cause of their enormous debt load and leave the IHS to accept more lucrative opportunities. Therefore, the Friends recommends that the Committee correct this omission in S. 212 in order to improve the recruitment and retention of IHS health professionals.

The need for a robust loan repayment and deferment program is especially critical

when one considers that the IHS pay scale lags far behind the private sector. For

example, in 1998, the average net income among general practice dentists that graduated less than 10 years ago was $141,690, while the newly graduated dentist in

the Commissioned Corps earned slightly more than $50,000. Similarly, the average

annual income for IHS pediatricians is nearly $40,000 less than for pediatricians

in the private practice. This occurs despite the fact that one-third of the AI/AN population is under the age of 15.

3. Housing for Health Care Providers

Another important aspect of recruiting health care personnel is adequate housing.

At some sites, health care providers have reported it is discouraging to have to live

in housing that is ‘‘worse than college dorms.’’ The American Dental Association reported to Congress, following a 1997-site visit, that a dentist was leaving a remote

site because of the unlivable conditions of her mobile home. No suitable housing

could be found to retain her services. In some areas, health care providers are forced

to live miles away, often in other States, in order to find decent housing for themselves and their families. The Friends believes that the IHS needs to assess its staff

quarters and develop a consistent approach to replacing or building new staff quarters. Therefore, the Friends recommends that committee include a study of staff

quarters and a proposal for addressing the situation in S. 212.

4. Exit Interviews:

As the IHS approaches the next decade and must compete for health personnel

with the rest of the country, the Friends believes that it would be very helpful to

require exit interviews of departing employees. Determining whether staff are leaving because of non-competitive salaries, high debt burden, inadequate housing,

spousal needs or a lack of an ‘‘esprit de corps’’ would be essential to quickly making

corrections to prevent others from leaving. The Friends has heard anecdotal stories

that because of the Government Performance and Results Act [GPRA] that midlevel

support personnel have been lost and paperwork burdens have increased. These

changes directly impact on patient care. They decrease the number of patients that

can be treated and reduce prevention education programs which help to keep down

the level of disease. Health care providers feel overburdened which leads to bum out

and retention problems. For example, the financial resources in the IHS are at 40

percent of that need to provide mental health services. Most Service Units and Tribal programs are operated with one or two providers, who provide primarily crisisrelated services with little backup due to the isolated, rural nature of their practice.

Not surprisingly, professional burnout leads to rapid turnover, adversely affecting

the availability of a single backup psychiatrist, let alone the essentials of an adequate, cost-effective mental health program. Maintaining strong patient-provider relationships is essential to good care, but if the provider doesn’t stay long enough

to form such a bond, it undermines the care and prognosis of the patient.

Increasing the Use of Students and Volunteers

The IHS employs approximately 500 pharmacists. Many of them joined the IHS

after completing a residency at IHS sites. The pharmacists have 11 IHS sites where

students can do their residencies. Interestingly, new pharmacist hires have a better

retention rate than other health care professionals during the first 5 years of working for the IHS. While the Friends cannot state for sure that this is due to the students’ early exposure to the IHS we recognize that such a program offers great opportunities. We would like to see the IHS work with other professional organizations

and education groups to create similar programs. We believe that this would help

to ease the provider shortage on a short-term basis when the students are at the

sites and possibly in the long run for recruitment efforts.

In addition, the Friends would like to see the IHS explore ways to recruit active

and retiring health care professionals interested in providing care on a part-time or

temporary basis. For example, the American Academy of Pediatrics has received

more than 300 requests from active physicians for information about its Locum

Tenens program, a national initiative that identifies short-term pediatric opportunities at IHS sites. Additional, we believe that many other providers are not ready

to completely retire and would be willing to volunteer a week, a few days a month

or even 6 months of their services. Their experience and expertise, particularly specialists like OB/GYNs, psychiatrists, oral surgeons, and orthopedic surgeons are in

high demand. However, in order to make use of these professionals the IHS needs

to create a program where such volunteers can be recruited, enter easily without

a lot of paperwork, provide adequate housing and assure the volunteers that liabil-
53

ity would not be problem. The Friends recommends that the committee include in

S. 212 a pilot project to create such a program in consultation with professional organizations. Individual members of the Friends would be pleased to work with the

IHS on such a project.

Thank you Mr. Chairman and members of the committee for offering the Friends

of Indian Health the opportunity to testify today on the Indian Health Care Improvement Act. We hope we have provided the committee with thoughtful suggestions and we will try to answer any questions you might have.

FRIENDS OF INDIAN HEALTH

AIDS Action

American Academy of Child & Adolescent Psychiatry

American Academy of Family Physicians

American Academy of Ophthalmology

American Academy of Pediatrics

American Academy of Pediatric Dentistry

American Academy of Physicians Assistants

American Association of Colleges of Nursing

American Association of Colleges of Osteopathic Medicine

American Association of Colleges of Pharmacy

American Association of Colleges of Podiatric Medicine

American Association of Dental Schools

American Cancer Society

American College of Obstetricians and Gynecologists

American College of Osteopathic Family Physicians

American College of Physicians

American Dental Association

American Diabetes Association

American Dietetic Association

American Geriatrics Society

American Hospital Association

American Medical Association

American Nurses Association

American Occupational Therapy Association

American Optometric Association

American Osteopathic Association

American Pharmaceutical Association

American Podiatric Medical Association

American Psychiatric Association

American Psychological Association

American Public Health Association

Arizona Academy of Family Physicians

Association of Schools of Public Health

Friends Committee on National Legislation

National Kidney Foundation

National Rural Health Association

National Native American AIDS Prevention Center

George Blue Spruce, D.D.S.

Ward Robinson, M.D.

William Treviranus, D.O.

James Zuckerman, M.D., Harvard Medical School

PREPARED STATEMENT OF CAROLE MEYERS, EXECUTIVE DIRECTOR, MISSOULA INDIAN

CENTER, MISSOULA, MT

Honorable Chairman and committee members, my name is Carole Meyers, executive director for the Missoula Indian Center, Missoula, MT. I am an enrolled member of the Blackfeet Tribe and also a descendent of the Oneida and Seneca Tribes.

I would like at this time and thank you for this opportunity to testify before your

committee on the issues of urban health problems in Missoula, MT.

The Missoula Indian Center is a Non-Profit 301 c. (3) organization and has been

in existence in Missoula, MT since April 1970. This organization has assisted the

Native American community in Missoula for thirty-one (31) years as a health referral agency. The population of Native American’s in the Missoula Community is approximately 3,100 people with, 65 tribal representations from across the Nation.

Missoula, MT has a population of 74,000, home of the University of Montana, which
54

many of the Native American people who move to Missoula attend the University

system. Montana has seven (7) reservations and there are eleven (11) different

tribes that live in each area. When Native American’s leave their home reservation

and move to an urban area, such as Missoula, they face many obstacles. One of the

most noticeable is their health coverage. Once they live in an urban area for 180

days, they loss all of their Indian Health Service coverage.

I want to go on record that I fully support the passage of Indian Health Care Improvement Act Reauthorization of 2001 S. 212. This reauthorization of this bill

would allow Native American people to receive the necessary health coverage to

enjoy a long and healthy life.

The definition of ‘‘Urban Indian’’ means any individual who resides in an urban

center and who-(A) regardless of whether such individual lives on or near a reservation, is a member of a tribe, band or other organized group of Indians, including

those tribes, bands, or groups terminated since 1940 and those tribes, bands or

groups that are recognized by the States in which they reside, or who is a descendant, in the first or second degree, of any such member.

This definition needs to part of the Indian Health Care Improvement Act. In order

for the Urban Indians to receive adequate funding; we need to be recognized as our

own unique group of Indian people. Living away from the reservation does create

different situations.

Below is a listing of the program the Missoula Indian Center provides:

Indian Health Service

Immunization Health Promotion/Disease

Prevention AIDS

Alcohol

Mental Health

Diabetes

Adolescence Substance Abuse Program

Health

Chemical Dependency Program

Missoula County

Alcohol

State of Montana

Alcohol

Tobacco

The Missoula Indian Center is governed body by a 7-member Board of Directors,

of which, 51 percent, must be Native American. The Missoula Indian Center is organized under two major programs; the Health Programs and the Chemical Dependency Programs. There are 11 full-time staff and one part-time Mental Health Counselor.

The health issues that surround the Native American population range from diabetes to the common cold.

With our agency as a health referral organization, many of our clients may see

as many as three (3) to five (5) different health providers in a course of 1 year. With

this inconsistency of health providers, there is not a medical history that follows the

clients. This creates more confusion and lack of medical knowledge of the client’s

history. Many times, because of lack of funding, clients will be referred to at the

point of emergency medical attention. There is very little prevention health care,

such as a yearly physical or dental check-ups.

The Missoula Indian Center’s Health program provides quarterly clinics that

cover basic health issues. Which, in itself is an excellent program activity. But a

significant problem the Health program faces is, if a client has a medical problem

we do not have the resources to provide the medical follow up that is necessary. For

example, at our quarterly, clients are provided with a blood screening, this is a very

through medical screening. If a client’s medical report comes back as an issue, they

are basically on his or her own to seek medical assistance. It is a safe estimate that

80 percent to 90 percent of our clients do not have medical insurance so they look

to us for their medical needs but we do not have the funding resources to help them

in their crisis. The only thing we can advise them if to go back to their home reservation to seek medical help but some require a 6-month waiting period for residency purposes.

The Missoula Indian Center had 8,865 encounters this past year. These encounters are community members who access the center for medical issues, drug and alcohol counseling to utilizing the telephone. We are looked upon as a ‘‘One-Stop’’

agency for many needs other than medical. Other prevalent issues besides the

health are: No. 1, housing; No. 2, employment; No. 3, school (K–12 and Higher Edu-
55

cation); No. 4, law enforcement and; No. 5, food. These are a few that we see on

a daily base if not weekly.

The center staff networks with other agencies within the Missoula community,

such as Office of Public Assistance, Casey Family Foundation, Youth Court, Adult

Parole and Probation, Pre-Release Center, Missoula County School District, Missoula Food Bank, Public Health Clinic, Now Care, Missoula Housing Authority,

Human Resources, City Police Department and Missoula County Sheriffs Department, just to mention a few. Networking within the community is important because many of our Native American clients utilize those agencies and if there are

issues that clients face, we can advocate for them. The Missoula Indian Center offers ‘‘In-Service’’ training for those agencies that want a better understanding the

type of services we provide.

Presently, we contract with other health agencies, such as Partnership Health

Clinic at a reduced cost for a doctor’s visit. This enables Health funds to cover more

clients over the course of a year. But this does not address a client’s need for medical followup or maintenance.

When a client needs to have a prescription filled, we are able to transport them

to St. Ignatius on certain days, located on the Flathead Indian Reservation, which

is a 90-mile round trip. Because of the Salish and Kootenia Tribal policies, clients

have to physically present themselves to pick up their medication. This creates some

hardship on our clients due to the fact that they may not have transportation to

drive to St. Ignatius or money to purchase gas for their car. When the health staff

transports, this takes them away from their regular workday.

The other service clients can utilize is the dental clinic. But in order for a client

to be seen, it has to be an emergency and they have to be at the dental office by

8 a.m. in order to be seen by a dentist. This means, the client has to leave Missoula

by 7 a.m. in order to have dental care. And once again, by the time they need emergency dental, it is a tooth ache or some type of infection and it is in a crisis setting.

Plus, this trip can and is often dangerous drive to St. Ignatius because of the hazardous weather conditions Montana has during the winter months.

As you can read in my testimony, there are many factors that play in to affect

when it comes to the health issues of Native Americans living in an urban area.

Native American’s leave their home reservation for many reasons. The most prevalent is education. Trying to achieve a higher education degree is of the utmost importance from many. This enables individuals to have a better life style, achieve a

goal not too many Native Americans have been able to accomplish in the past. But

in order for them to achieve this goal, they have to move to an urban area to attend

a 4-year higher education institution. At times, it can be very difficult in the sense

they experience ‘‘culture shock’’ when they move to an urban location. The transition

period for adjustment can be up to 1 year to feel comfortable and cope with many

of the difficulties they encounter. Within the capacity of my job, I have seen many

Native American’s try to better themselves and their families but at times when

they are faced with medical problems or other issues and no where to turn, the only

alternative would be for them to move back home and at times, the cycle poverty

or frustration continues.

The Chemical Dependency programs the center offers are Intensive Outpatient

and Standard Outpatient with some group/individual counseling sessions. Since

these programs are Montana State Certified that enables them to apply for other

funding through State and County programs. Not only the Native American clients

utilize these programs, the non-Native American’s attend these sessions. The type

of programs the center offers has a Native American/spirituality theme and many

of the clients who participate have commented that a ‘‘wholelistic’’ approach to their

addictive issues has benefited them with their recovery. The Missoula Indian Center

is the only program in the Missoula area that offers this type of services. Other programs in the Missoula area have recognized the spirituality of these Chemical Dependency counseling sessions and have commented the uniqueness of them.

The health programs assist with the Chemical Dependency clients. They offer HIV

testing and counseling, Hepatitis-C testing, and encourage them to attend the quarterly clinics they offer. Many of them not only come in with an addiction problem

but as well noted stems into many health issues.

Diabetes is a prevalent health issue that is on the rise with many of the recovery

alcoholic. One incident that comes to mind is a pre-release client utilizing the Chemical Dependency program complained of having a blister on his foot. The pre-release

staff accompanying him that day thought it was not a big deal but I told her that

a blister on a diabetic could be fatal. She was not aware of the significant problems

that Native American diabetics face everyday with their disease. I offered to have

the health staff come to the Pre-Release Center and provide their staff with an ‘‘InService’’ on the health issues of diabetic clients.
56

I want to thank you for your time for listening and reading my testimony; it has

been a privilege and honor to come before you with my thoughts and ideas. Each

and everyday Native American’s are faced with issues and problems of health, employment, and education. I sincerely hope with my testimony that our issues have

been personalized and ‘‘survival’’ on day-to-day bases for the Native American people is a very real issue.

PREPARED STATEMENT OF MARTIN WAUKAZOO, EXECUTIVE DIRECTOR, URBAN

HEALTH BOARD, INC., NATIVE AMERICAN HEALTH CENTERS SAN FRANCISCO AND

OAKLAND, CA

Although the majority of Native Americans live in urban settings, most Federal

funding for Native health care and community initiatives goes to those who continue

to live on reservations. The basic medical and dental needs of urban Indians are

unmet in addition to other areas including mental health, substance abuse, HIV/

AIDS prevention and treatment, diabetes prevention and treatment, and capital

needs. Urban Indian Health Board, Inc. was established in 1972 to address the

health needs of the urban Indian population of the San Francisco Bay Area. In that

year, Indian Health Services [IHS] funding comprised ninety percent of our operating budget. Today, IHS grants amount to only 14 percent of our total funding. Our

success in fundraising and in service delivery can be attributed to decades of sacrifice and persistence. However, consistent funding is becoming more difficult to

achieve when costs rise faster than the needs of our service population.

Our service area is the five counties of the San Francisco Bay Area including Alameda, Contra Costa, Marin, San Francisco, and San Mateo Counties. Preliminary

Census 2000 figures show nearly 80,000 Native American/Alaska Native and multirace/Native individuals reside in these five counties. The Bay Area has one of the

largest concentrations of urban Indians in the country.

Urban Indian Health Board, Inc. is a nonprofit 501(c)(3) community health care

provider operating two licensed clinics, one in San Francisco, since 1972, and one

in Oakland, since 1983. We employ 120 health workers. Our operating budget for

the current year is $7.1 million. The Board of Directors is composed entirely of Native Americans and serves on a volunteer basis.

Ninety-eight percent of Native American patients served meet the Federal poverty

level guidelines. In 2000, the medical clinic saw over 4,800 patients with over 16,800

visits. Many of our patients are members of tribes from across the United States

with the largest number representing California tribes, Navajo, Lakota, Pomo, Cherokee, Apache, Paiute, Blackfeet, Choctaw, and Chippewa.

Our services reflect our expanded definition of health: The health of an individual

depends upon the health of a community. Since our agency is one of the few Native

organizations in the Bay Area, we are in a unique position to directly impact our

community’s health. Thus, we function as far more than a medical clinic. As part

of our mission to contribute to the health and growth of our community, we offer

adult and pediatric services in our two clinic settings; women’s health care; prenatal

care; a WIC program; comprehensive dental care; mental health services including

substance abuse counseling; fitness and nutrition counseling; health education and

outreach; and a variety of youth initiatives through our Native American Youth

Services program.

We believe health is whole-body and community-based. Urban Indians feel a sense

of isolation and disconnect from the broader community. As a health service provider, we step in to try to ameliorate that feeling of isolation among our community

members. Our clients are disproportionately young, poor [nearly every client in 2000

was below the poverty line, with fully 13 percent at 200 percent or more below poverty level], and impacted by physical and mental health issues specific to a people

that has suffered cultural and physical dislocation and decades of poverty. Disparities have arisen in disease and mortality rates between Native peoples and the general population. We believe these disparities are due to the consequences of poverty

and cultural dislocation, with urban environments like our own only exacerbating

the lack of family and traditional support systems.

We face several overlapping challenges: Those specific to urban Native populations, and those specific to the Bay Area. For instance, the rate of substance abuse

is higher for urban Native Americans than for any other ethnic group, while the

rate of HIV/AIDS among Native Americans is higher in the Bay Area than in any

other Native service area. In the five counties, we estimate that over 75 percent of

Native American families suffer from substance abuse, domestic violence, and mental illnesses. Additionally, we believe that over 50 percent of urban Native American

children are emotionally disturbed or at high risk for mental illness, substance
57

abuse, and delinquency. The suicide rate for Native American teenagers is higher

than for any other group.

Another challenge we face is a disproportionate rate of diabetes. In a local study

we conducted last year, we found that two-thirds of the adults and youth in the

study group fell into the nutritionally poor to very poor category. This correlates

with our experience that the most common physical problems facing our patients are

diabetes, heart disease, obesity and chemical dependency. Poor dietary practices and

lack of exercise contribute directly to heart disease and the development of diabetes.

Urban Indian Health Board’s operates two licensed clinics but we are treated by

Indian Health Services as one entity for funding, programmatic and evaluative procedures. Although there are 34 urban Indian clinics in the nation, our clinics are

counted as one site. Funds for urban clinics for some programs are distributed now

via a simple method of division between the 34 urban sites across the country that

serve Native Americans.

We advocate that the formula for distribution be redrawn to coincide with the

number of Native people in the service area and that area’s cost of living. This determination would far more accurately reflect the costs of providing care to those

in need. For instance, additional money for diabetes care was recently distributed,

yet our clinics received only a tiny portion of that funding despite the fact that a

full twenty percent of our 18,000 patient visits were due to diabetes.

There is no urban clinic IHS funding available for capital needs. Our agency is

stretched beyond our limits as we struggle to meet the increasing demand for services. Presently, we are at full capacity and need immediate capital funds. Existing

facility problems such as poor design, insufficient exam rooms, inadequate information systems and technology, and limited access for the handicapped result in the

inefficient provision of services. Capital investments in urban Indian health centers

will increase access to primary and preventive health care.

The cost of providing health has increased significantly over the years. Pharmacy

costs, which accounted for 44 percent of health care costs nationwide last year, is

growing much faster than other components of health care. Providing this benefit

for indigent patients has become an overwhelming financial drain on our clinics.

Our clinics’ pharmacy costs increased by 34 percent from fiscal years 1998–99 to

1999–2000. Pharmacy costs have skyrocketed so significantly that they directly reduce our ability to provide primary care services, as we must devote more of the

IHS funding to cover the cost of prescription drugs.

Health insurance premiums for our employees have also increased dramatically

over the past 3 years. The premium rate for our clinic has increased by 28 percent

in the past 3 years. The increase in health insurance premiums directly reduces the

clinics’ ability to provide primary care services. As we spend more money to provide

health insurance for our employees, there are fewer funds available to provide care.

The California energy crisis is also having a major impact on our clinics. Our clinics’ utility costs have increased by approximately 40 percent this fiscal year. Finally,

workforce issues have also had a tremendous impact on our clinics. Our clinics’ ability to provide quality health care is limited by the number of health care professionals that we are able to hire and retain. Often, salaries are not competitive

enough to attract various health care professionals. In addition, vacancies directly

limit the resources that we have to serve our community.

A disproportionate number of Native Americans are ineligible for any subsidized

insurance programs. Our clinic has struggled to respond to the ever-increasing demand for our services, particularly by uninsured patients who have no other system

of health care to utilize. Furthermore, as we enroll more children into health insurance programs, we are seeing changes in the patient mix that reflect an older population facing more chronic diseases, with the need for acute care and a greater number of pharmaceuticals. We are now seeing a greater number of patients with chronic conditions requiring more than one visit and a greater amount of health care

services resulting in increased costs. Because the number of uninsured patients

seeking care at our health centers continues to increase, urban Indian health clinics

need additional funding to cover the ongoing health costs of serving more indigent

patients and patients that have more expensive health care needs.

Ninety-eight percent of our clinic patients are low-income and approximately 60

percent are uninsured. In the past 3 years, we have seen a 10-percent increase in

older uninsured patients. This older population faces a greater amount of chronic

conditions, requiring more acute care, a greater number of pharmaceuticals and

more than one visit. Our data also shows a 30-percent increase in patient visits per

year in the last 3 years. This data likely reflects an increase in clinic patients that

are needlessly suffering from chronic conditions/diseases.

In response, our clinics for the past 2 years have been working on a diabetes management initiative. While physicians play a key role in diabetes management, other
58

health care professionals including health educators, community health workers,

nurses, case managers, and nutritionists are crucial to assisting patients in their

disease management by helping individuals learn self-management skills and assisting patients to make behavioral changes in their lifestyle.

In conclusion, our community clinic is a strong and vibrant organization committed to providing the highest quality of care for our community. As an urban Indian

clinic we must be creative and resourceful to weave available funding opportunities

to address the need of our community. We have developed linkages with the system

of health care in the broader community in the San Francisco Bay Area while at

the same time build alliances with other IHS funded urban programs. For example,

we have a working partnership with the Friendship House of American Indians of

San Francisco who is developing an 80-bed residential treatment facility, the first

major development project in the Indian community of the Bay Area. We are also

working with Friendship House to build a 75,000 square foot Youth Development

Center in Oakland, a project which is in pre-development with anticipated site control within the next 30 days.

These projects in our community continue to underscore the need for greater investment in our community. Many times we fall through the cracks and remain unrecognized within the broader discussions of Indian issues. Although I.H.S. funding

only composes 14 percent of our total operating budget, for every one dollar invested

by IHS we are able to leverage another $6 from other sources.

We have several recommendations which address the level of need in our community and will ultimately increase the level of care for our patients. A funding augmentation is required to provide immediate ‘‘pharmacy relief to allow the our clinics

to maintain their capacity for primary care visits. A special augmentation is also

required that would provide our clinics with relief from health insurance premium

increases. With soaring energy costs already making a tremendous impact upon our

operating costs, we would recommend and allocation to offset increased energy costs

and provide our clinics with additional funds to address the shortage of health care

professionals in our clinics. The demographics of our patient population is everchanging along with the cost of care. We recommend an adjustment in the funding

formula that would take into consideration the higher health care costs to clinics

given the changing patient mix. With an increasingly older patient population, we

require Increased funding to cover costs for patients participating in chronic disease

management initiatives. Although we strive to provide a high level of care, capital

needs in our facilities is at an all-time high, we strongly recommend allocations of

funding to address greatly needed capital and facility improvement needs. Finally,

we recommend funding for regional and culturally competent approaches to diabetes

prevention and treatment, substance abuse prevention and care, youth violence prevention and HIV/AIDS prevention and treatment.

We would like to thank the committee for allowing us this opportunity to share

with you our concerns, our successes and our recommendations. Our ability to provide quality care for our unique community is directly affected by your work and

your commitment. We are fortunate for the opportunity. Thank you.

PREPARED STATEMENT OF KAY CULBERTSON, EXECUTIVE DIRECTOR, DENVER INDIAN

HEALTH AND FAMILY SERVICES

Good morning Chairman Inouye, Vice Chairman Campbell and other distinguished committee members. My name is Kay Culbertson, I am an enrolled member

of the Fort Peck Assiniboine/Sioux Tribes located in Poplar, MT. I serve on the

board of directors for the National Council of Urban Indian Health and I am the

Executive Director for Denver Indian Health and Family Services [DIHFS] located

in Denver, CO. On behalf of the Denver Indian Community, I would like to thank

you for the opportunity to provide testimony regarding health issues of Indians who

reside off reservation and the Urban Indian Programs that serve them. There are

currently 34 urban Indian health programs located throughout the United States,

with each program offering a variety of medical service through many creative and

innovative delivery types. Today, my focus will be on Denver Indian Health and

Family Services.

In the past, Denver attracted Indian people for a variety of reasons. Denver was

one of the original sites for relocation of Indian people from their home reservations.

A segment of Denver’s Indian population is a result of Indian men and women who

settled here after serving in the armed forces. Another segment came to Denver because there was a Bureau of Indian Affairs office located in the area. Many Indian

people moved from the reservation to the Denver area with the hope of attaining

the ‘‘American Dream’’. And today, Denver continues to be a hub for Indian people.
59

Denver’s Indian population is estimated at 25,000 and is comprised of people who

have lived in Denver for over 30 years producing second and are third generation

Denver natives as well as those who are transient and move to and from the reservation on a regular basis. The universal reason for moving continues to be ‘‘Hope

for a better future’’. Although Denver is centrally located within ‘‘Indian country’’ and many national

Indian organizations are headquartered in Denver, it is isolated from tribal health

and Indian Health Service services, the closest Indian health facility in Colorado is

located on the Southern Ute Reservation, an 8-hour, drive. The nearest Indian

Health Service Hospitals are in Rapid City, SD and Albuquerque, NM. Unlike other

urban health programs we do not have the ability to utilize other Indian health facilities to meet the gaps in services.

Denver Indian Health and Family Services was created as the result of a needs

assessment conducted by the Denver Native Americans United. Denver Indian

Health and Family Services was incorporated in 1978, as a non-profit Indian organization and received funding from the Indian Health Service to provide outreach and

referral services to the Indian community. With a staff of two people, the agency

gathered and provided information to Indian people in accessing health care in the

Denver metropolitan area. Eventually, DIHFS began to provide limited health care

through volunteer nurses and doctors and grew into a full scale clinic entering into

an agreement with Denver Health and Human Services. The number of uninsured

and the inability to charge American Indian patients placed a much larger financial

burden on the organization and clinic services were discontinued in 1991. Unfortunately, the health care needs of the community exceeded the funding limits of the

agency. In 1996, DIHFS entered into an agreement with a local community clinic

to provide services at a limited cost; however, the agency could only allow two visits

per year and the patients were responsible for their own laboratory and x ray costs.

This arrangement made it difficult to provide health care to persons with chronic

medical problems such as diabetes. The community voiced the need for additional

health care. Not just any health care but health care that was culturally sensitive

and available through an Indian organization or provider.

At a 1998 strategic planning retreat the DIHFS board of directors planted the

seeds to begin the process of providing medical services to the Indian community

onsite. The board of directors stressed the importance of taking slow steps to providing health care. The board of directors insisted that the services be provided by

DIHFS, that patients would receive more health education, that the delivery of services be provided in a manner that was comfortable to Indian patients, that the financial pitfalls of the past be avoided and that we maintain our identity as an Indian provider and an Indian clinic. In March 1999, a young Indian physician, Dr.

Lori Kobrine, took on the task of laying the foundation for our clinic. Through her

efforts our clinic met the requirements for state licensure. She worked 20 hours a

week providing limited medical services to the community. Now our clinic continues

to grow. Since May 2000 our clinic has been staffed with a full time nurse practitioner and a volunteer physician who provide medical services on a full time basis

to the community. The medical services include immunizations, acute emergencies,

well child physicals, physicals, women’s basic health, diabetes management and

screening and other health services that do not require a specialist or that are not

life threatening. DIHFS also provides mental health and substance abuse counseling, substance abuse prevention, case management services for victims of crime, energy assistance, diabetes case management, prescription assistance, emergency dental, and referrals to meet other community health needs.

The cachement area for DIHFS includes Adams, Arapahoe, Boulder, Denver,

Douglas, Jefferson, and Gilpin counties. However, we also serve people who travel

from as far as Pueblo and Aspen. There is also an increase in services during peak

months of March, June, July, and August for persons who are visiting during the

annual March Pow-wow or who are staying with relatives over the summer. DIHFS

is located in southwest Denver near the old Fort Logan facility. Although located

outside of central Denver, DIHFS is conveniently located near the Denver Indian

Center and Denver Indian Family Resource Center, making referrals to other Indian organizations and coordination of case services much easier for Indian clients.

The Denver Indian community is fairly young population with the median age of

30.2 as compared to 34.5 for all other races. The majority of DIHFS clientele are

single parent heads of household. The average income reported by DIHFS patients

is $621 per 4 month or $7,452 per year. Seventy-three percent of DIHFS patients

do not have health insurance.

The Medical Clinic provides onsite services through a family nurse practitioner.

Appointments are scheduled for 1 hour at time to allow for intense patient education regarding their presenting problem. The most common diseases treated in the
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clinic are diabetes, hypertension and dental pain. Wellness screening services include women’s health, family planning, men’s health, well child checks and education.

The Community Health Program is the most often utilized program is the agency.

DIHFS assists with prescriptions purchases, energy bills, adult emergency dental

through a contract dentist, referrals for denture purchases, transportation, tribal enrollment for patients, optical exams and glasses and many other health related

problems. Education regarding the importance of health insurance [private or public] is stressed in the Community Health Program. We currently have a Denver

Health Authority navigator stationed at our office to assist Indian people with access the Denver Health system and walk clients through the enrollment procedure

for the State Child Health Plan and Medicaid.

Our Diabetes Program is staffed by a Certified Diabetes Educator and has focused

on bringing traditional foods back into our diets. The focus has been on the Plains

Indian diet with additional research on Southwest Indian traditional diet. Diabetic

patients are provided with free glucometers, and strips to encourage regular checking of glucose levels. The project also assists diabetic patients with special eye

exams, podiatry checks, shoe inserts, shoes, glasses and medications.

Behavioral Health services include mental health and substance abuse counseling

and youth substance abuse prevention support in area schools. The program assists

with antabuse physicals and medication, psychological evaluations and court support. The outpatient and women’s counseling program are the only American Indian

programs in the Denver area that are licensed through the Colorado Department

of Health, Alcohol and Drug Abuse Division.

Victims of Crime Act funds a small case management project for Indian victims

of crime. The Bureau of Justice Statistics released a report in February 1999 detailing the rates of victimization for Indian people. The study found that American Indians were victims of violence at twice the rate of the U.S. population, that rates of

violence are higher than any other group in every age group, and that alcohol was

more often involved in crimes against American Indian persons at double the rate

of any other race. These are sobering statistics.

As you can see DIHFS has accomplished a great deal with the limited amount

of funding; that is received and the limitations of our community. We have learned

to build relationships with other programs and meet some but not all of the gaps

in service delivery to American Indian people living in the Denver area.

In providing services we have encountered barriers that tribes may not face. If

we accept Medicaid, become a National Health Service Corp provider, federally

Qualified Health Center or a 330 Community Health Center our services must be

open to all people. This places a strain on our identity as an Indian clinic.

Seventy-three percent of the patients seen in our clinic do not have insurance because they are underemployed, have recently moved to the area, the employer does

not provide health benefits or they do not qualify for any other health benefits.

Often Indian people who come to an urban area have a misconception that urban

Indian health programs are virtually the same as the Indian Health Service or tribal health programs on the reservation and may not elect to sign up for health care

benefits. Indian people assume that IHS is everywhere. DIHFS does not currently

have an affiliation with a health maintenance organization [HMO] because we have

neither 24 hour coverage nor hospital admission privileges. These issues also do not

allow us to generate third party billing from Medicaid because the State of Colorado

contracts with HMO’s to provide services to the Medicaid beneficiaries. The patients

who have health insurance do not utilize their providers due to the expense of copay amounts or deductibles, they enjoy receiving services at the Indian clinic or wait

times for visits are not as long.

Indian Health Service is severely under funded as a whole, but urban Indian programs receive the least amount of funding. If urban programs were f1mded at the

same amount and provided the core services of a tribal or IHS facilities, American

Indians living off reservation would have access to comprehensive health care.

Dental services are limited. DIHFS is limited to 10 emergency dental appointments a month. The dental waiting list is months long. Affordable dental care is

difficult to find, even for persons with private or public insurance. Very few dentists

accept Medicaid patients. Only one urban program has received funding from the

Indian Health Service for dental services.

Hiring and retaining quality professionals has been difficult. DIHFS has an operating budget of $430,000. The medical field is highly competitive in the Denver area

and we are not always able to compete with other health facilities for staff. DIHFS

does have the opportunity to provide IHS scholarship recipients with payback opportunities and although there has been much interest to work in Denver, we are not
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able to provide them with a salary and benefit package that is commensurate with

tribal and IHS staff positions of the same level.

Denver Indian Health and Family Services supports S. 212 a bill to amend the

Indian Health Care Improvement Act. We strongly support inclusion of urban Indian health programs in title IV, Access to Health Care.

Denver Indian Health and Family Services also supports S. 214 a bill to elevate

the position of Director of Indian Health Service to the Assistant Secretary for Indian Health. Through the leadership of Dr. Michael Trujillo and his concept of

‘‘Speaking with One Voice’’ there has been an increase in support from both tribal

leaders and Indian Health Service professionals to address the needs of tribal members who live off reservation. The elevation of the Director to Assistant Secretary

will benefit both tribes and urban programs in their ability to access other Department of Health and Human Service programs as well as to bring to the forefront

the severe disparities in health for Indian people as a whole.

Denver Indian Health and Family Services also supports S. 535 a bill to amend

the Social Security Act to clarify that Indian women with breast or cervical cancer

who are eligible for health services provided under a medical care program of the

Indian Health Services or a tribal organization are included in the eligibility category of breast or cervical cancer patients added by the Breast and Cervical Cancer

Prevention and Treatment Act of 2000. We recommend that urban Indian health

programs also be included in the eligibility category. During my testimony to the

Senate Committee on Indian Affairs in March 2000 regarding the Indian Health

Care Improvement Act, I relayed a story of a woman with breast cancer who did

not have insurance and had no way of receiving services. Her only option was to

return to the reservation and hope that Indian Health Service would extend coverage to her. We may be able to avoid these scenarios if urban Indian health programs are included in S. 535.

Denver Indian Health and Family Services also strongly recommends that the feasibility of additional demonstration projects such as those located in Tulsa and

Oklahoma City be funded. We recommend that one site be funded in an area that

is isolated from other IHS or tribal facilities. It is recommended that the project include provisions for comprehensive medical, dental, and hospital services.

Once again, thank you for the opportunity to testify on behalf Denver Indian

Health and Family Services. I would like to close my testimony with the following

story:

My son is active with the local Native Lacrosse Program. There are approximately

25 Indian families who regularly participate in this most worthwhile sport. The program not only promotes exercise and culture but also serves as an informal social

support system for parents while the youth practice. I was writing my testimony

for today when a young mother named Laura inquired about my work. I told her

that I was working on addressing urban Indian health issues to the Senate Committee on Indian Affairs. She became very excited and went into great length about the

need for more comprehensive health care for Indian people in Denver. She told me

of the birth of her twin children and how her diabetes had caused complications in

the pregnancy. The young family did not have health insurance because of layoffs

and they were not eligible for other services. She was told by her family to go home

to Oklahoma and have her twins at the Indian hospital but she chose to stay because they could not afford to travel back home. She gave birth to her children at

an area hospital. The twins were kept in intensive care for an extended amount of

time. After the twins were released from the hospital the family was presented with

a $45,000-hospital bill, a bill that they would never be able to satisfy. The family

had to file for bankruptcy and today continues to suffer from the effects of that action. Laura asked me why she was not allowed to have the same medical care as

her brothers and sisters who live on the reservation, why was there not an IHS facility for people in Denver? She asked that I tell you this story today. I hope that

in the near future I will be able to tell Laura that you heard her questions and provided the Denver Indian community with additional health care resources.

PREPARED STATEMENT OF WAYNE TAYLOR, JR., CHAIRMAN, HOPI TRIBE

Thank you, Chairman Inouye, Vice Chairman Campbell, and other distinguished

members of the Senate Committee on Indian Affairs for allowing the Hopi Tribe to

provide testimony on S. 212, legislation to reauthorize the Indian Health Care Improvement Act. We are grateful for your continued attention to improving health

care services for all Native Americans.

The Hopi Tribe looks to Congress as the ultimate Federal trust authority. Vested

in your authority is the ability to ensure the provision of quality health services for
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all Native Americans. We value your counsel and depend in no small measure on

your assistance in establishing an array of health services of critical importance to

all tribes.

I would like to provide the Hopi Tribe’s comments on four provisions of title II

of S. 212 dealing with medical services covered by the Indian Health Service [IHS].

Each of these four provisions addresses a service area that is critical for the improvement of the health status of the Hopi people, and we strongly urge the committee to enact the strongest possible provisions in these areas during the 107th Congress.

The Hopi Tribe strongly supports requiring the Secretary of Health and Human

Services, through the IHS or Indian tribes or tribal organizations, to provide mammography screening for Indian women at an appropriate frequency under national

standards and consistent with those established for the Medicare program. It is essential to the improvement of the health and survival of Indian women that the IHS

and tribes be able to significantly increase the availability of early screening, diagnosis and treatment.

One- and 5-year breast cancer survival rates are significantly lower among Southwestern American Indian women compared with non-Hispanic whites, despite the

lower rates of breast cancer observed in the Indian population. One of the major

factors contributing to this poor rate of survival is the later stage at which breast

cancer is diagnosed in the Indian population.

The reduction in breast cancer mortality when screening mammography is available to American Indian populations is estimated at 27.9 percent. Among populations whose disease is more advanced when it is first diagnosed, as among Southwestern American Indian women, the reduction in mortality with screening mammography increases another estimated 26.4 percent.

The 1993 ‘‘Healthy Hopi Women Survey’’ of 559 women on the Hopi Reservation

confirmed the lack of knowledge about breast cancer screening. Only 55.7 percent

of these women had knowledge of a mammogram procedure, and less than 20 percent knew when women should begin to have screening exams. Only 61 percent of

the women surveyed reported having annual clinical breast exams as recommended

by the American Cancer Society—less than one-half of the women 40 years and

older had ever had a mammogram and only 26.4 percent had one in the 2 years

preceding the survey. The results were similar for women age 50 and older—less

than 25 percent of those women had both a mammogram and a clinical breast exam

in the 2 years preceding the survey. The survey confirmed that the proportion of

women receiving screening mammography and clinical breast examinations is significantly lower than the rate proposed in the Year 2000 goals.

The Hopi Tribe Breast and Cervical Cancer Early Detection Program currently

provides breast screening services to women 40 years and older. The program works

in collaboration with Indian Health Service to provide mammography services to

women who are seen through the program or through Indian Health Service. At this

time, Indian Health Service is unable to cover the cost of services for mammography

services and will provide women with mammography service only when it is necessary. Often times, many women who are covered under Indian Health Service for

mammography services are already at high risk for cancer. The Hopi Tribal Breast

and Cervical Cancer Early Detection Program currently covers the cost of mammography service for all women who reside on the Hopi Reservation and who are eligible through the program. Women who are not eligible through the program are unable to receive a mammogram unless they pay for the cost or have private insurance

to cover the cost.

To date, 48 percent of enrolled Hopi women ages 40 and over have been screened

through the Hopi Tribal Breast and Cervical grant program. Although nearly onehalf of the women in this age category have been screened, there is still a need to

screen the other 52 percent of the population. While the Breast and Cervical Early

Detection provides breast and cervical screening to all women, services are limited

due to the lack of a full-time women’s health provider as well as the availability

of space for services.

With additional funds available to provide screening services, the Hopi Tribe will

be able to screen all women regardless of their eligibility through the program. The

program will also be able to hire a full-time physician to provide screening services

to women on a daily basis and eliminate the waiting time of 3 months for a women’s

health exam. Outreach and awareness in the community is essential, as many Native American women do not understand the importance of early detection. The

Hopi Tribe needs additional funding to increase our ability to provide preventative

breast and cervical cancer services, thereby decreasing the cancer rate for native

women and improving the chance of survival for women who suffer breast or cervical cancer.
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The Hopi Tribe also strongly supports the ‘‘Native American Breast and Cervical

Cancer Treatment Technical Amendment Act of 2001’’ introduced by Senator Jeff

Bingaman [D–NM], which would correct an oversight made by Congress when it enacted the Breast and Cervical Cancer Prevention and Treatment Act of 2000. Senator Bingaman’s bill [S. 535] would ensure that Indian women with breast and cervical cancer who are eligible to received health services from the IHS or a tribe or

tribal organization will be included in the optional Medicaid eligibility category of

breast and cervical cancer patients added by the 2000 legislation. Without this legislation, Indian women who are diagnosed with breast or cervical cancer through the

CDC program may still find themselves ineligible for coverage of any treatment

services. We strongly urge the committee to support the prompt enactment of this

legislation.

The Hopi Tribe is also strongly supportive of the provisions of S. 212 to require

the Secretary, acting through the IHS or tribes or tribal organizations, to provide

funds for appropriate patient travel costs, including transportation by ambulance,

specialized vehicle or private vehicle, or by air transportation or such other means

as may be available when ground transportation is infeasible.

We have presented testimony to the committee in the past regarding the difficulty

of providing necessary emergency medical transportation services on geographically

remote reservations such as ours. Insufficient funding for adequate staffing and outdated equipment has left our existing emergency medical service [EMS] team constantly struggling to provide services. While they do a wonderful job, our EMS personnel are stressed for time and lack the equipment necessary to perform certain

lifesaving functions. Our program lacks the resources to staff the program according

to industry standards for the time and distances involved in rural transport.

The closing of reservation hospitals in Indian country and replacing them with

ambulatory care centers and consolidating medical services adds to the burden on

emergency medical services teams and magnifies the importance of providing necessary emergency and non-emergency transport. Patients must now travel longer

distances for necessary inpatient care, requiring highly trained personnel as escorts

and more advanced equipment. Thus, the change health care system itself is increasing the critical role of emergency transportation and advanced life support care

yet the system has failed to provide the financial resources necessary to meet the

need, resulting in a growing gap in the continuum of health care.

We applaud the committee’s effort to require the Secretary to provide funds for

patient travel costs. However, we remain concerned that our tribe and others will

have difficulty purchasing the high-cost emergency vehicles and equipment needed

to provide these services. Further, given the historical under-funding of IHS contract health services, we are very concerned that simply requiring the Secretary to

pay for these added costs from already inadequate funds would ultimately fail to

address the problem. We urge the committee to address these concerns as it addresses the legislation.

We are very pleased that the committee bill recognizes the need to address health

care related services such as long-term care, home- and community-based services

including homemaker/home health aide services, and assisted living services. The

Hopi Tribe, like many others, faces serious challenges in providing necessary health

care for our aging population.

Respect and care for our elders is one of the fundamental elements of Hopi culture

and heritage. As a result, the traditional Hopi concept of family care-giving includes

a cohesive community that emphasizes the desire to keep all members at home—

where elders are able to remain active members of the community and participate

in the care of close and extended family members. Since 1978, IHS and Bureau of

Indian Affairs [BIA] statistics indicate that Hopi has maintained the lowest nursing

home placements of all the 19 Arizona Tribes. In this context, it is critical for the

tribe to establish and maintain services that are locally available and accessible to

our elders.

Currently, about 25 to 30 Hopi members reside in respite care facilities located

in Phoenix, Flagstaff, and Payton. It is difficult for family members to travel these

significant distances to visit their elders, and the elders themselves feel cutoff from

their family and community. To remedy this situation, the tribe is seeking funding

support from the State of Arizona to establish Senior Centers in 3 of the 12 Hopi

reservation villages. We have also initiated planning for an on-reservation long-term

and respite care facility. However, there remains a significant need for planning, design, engineering and construction funding.

The geographical remoteness of our reservation and language barriers have also

made it difficult to access many State services. Service providers must currently

travel 4 hours from their Phoenix office to provide care for Hopi seniors, and even

then they are available for a limited time. All of our elderly are Hopi-speaking with
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limited proficiency in English, and they are often discouraged from applying for

state or Federal services because of the communications barrier that exists between

them and their service providers. We are investigating the possibility of establishing

a local, on reservation office in partnership the State agencies and recruiting and

training Hopi-speaking providers to reach a broader client population.

Since 1978 the Hopi Tribe has contracted with the IHS to participate in the Community Health Representative [CHR] program. There are currently more than 325

Hopi seniors in all 12 reservation villages receiving services ranging from patient

care and monitoring to case management, education and counseling, and disease

prevention. It is crucial that Congress continue to support and increase funding for

this important support program.

In conclusion, thank you again for allowing the Hopi Tribe to present this testimony. We look forward to working with you during the course of your deliberations

on legislation reauthorizing and enhancing the programs provided through Indian

Health Care Improvement Act. I would be pleased to respond fully to any request

for additional information.
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