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S. HRG. 111–525 

EXPANDING DENTAL HEALTH CARE IN INDIAN 

COUNTRY; 

PROMISES MADE, PROMISES BROKEN: THE 

IMPACT OF CHRONIC UNDERFUNDING OF 

CONTRACT HEALTH SERVICES 

HEARING 

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

DECEMBER 3, 2009 

Printed for the use of the Committee on Indian Affairs 

( 

(II) 

COMMITTEE ON INDIAN AFFAIRS 

BYRON L. DORGAN, North Dakota, Chairman 

JOHN BARRASSO, Wyoming, Vice Chairman 

DANIEL K. INOUYE, Hawaii 

KENT CONRAD, North Dakota 

DANIEL K. AKAKA, Hawaii 

TIM JOHNSON, South Dakota 

MARIA CANTWELL, Washington 

JON TESTER, Montana 

TOM UDALL, New Mexico 

AL FRANKEN, Minnesota 

JOHN MCCAIN, Arizona 

LISA MURKOWSKI, Alaska 

TOM COBURN, M.D., Oklahoma 

MIKE CRAPO, Idaho 

MIKE JOHANNS, Nebraska 

ALLISON C. BINNEY, Majority Staff Director and Chief Counsel 

DAVID A. MULLON JR., Minority Staff Director and Chief Counsel 

(III) 

C O N T E N T S 

Page 

Hearing—Expanding Dental Health Care in Indian Country—held on 

December 13, 2009 ............................................................................................ 1 

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

Statement of Senator Franken ............................................................................... 21 

Prepared statement .......................................................................................... 23 

Statement of Senator Murkowski ........................................................................... 18 

WITNESSES

Dotomain, Evangelyn ‘‘Angel’’, President/CEO, Alaska Native Health Board ... 6 

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

Tankersley, D.D.S., Ronald L., President, American Dental Association 

(ADA) ..................................................................................................................... 1 

Prepared statement with attachment ............................................................. 3 

Tarren, Patricia, Staff Pediatric Dentist, Department of Dentistry, Hennepin 

County Medical Center ........................................................................................ 14 

Prepared statement .......................................................................................... 16 

APPENDIX

Batliner, Terry, DDS, MBA, prepared statement ................................................. 38 

Pew Children’s Dental Campaign, prepared statement with attachment .......... 25 

Response to written questions submitted to Patricia Tarren, BDS by: 

Hon. Byron L. Dorgan ...................................................................................... 40 

Hon. Al Franken ............................................................................................... 41 

Response to written questions submitted by Hon. Lisa Murkowski to 

Ronald L. Tankersley, D.D.S. .............................................................................. 39 

Shoshone-Bannock Tribes—Fort Hall Business Council, prepared statement ... 37 

Hearing—Promises Made, Promises Broken: The Impact of Chronic 

Underfunding of Contract Health Services—held on December 13, 

2009 ....................................................................................................................... 43 

Statement of Senator Dorgan ................................................................................. 43 

Statement of Senator Murkowski ........................................................................... 54 

WITNESSES

Peercy, Mickey, Executive Director of Health Services, Choctaw Nation of 

Oklahoma .............................................................................................................. 67 

Prepared statement .......................................................................................... 69 

Roubideaux, Yvette, M.D., M.P.H., Director, Indian Health Service, U.S. Department of Health and Human Services; accompanied by Randy Grinnell, 

Deputy Director, and Carl Harper, Director, Office of Resource Access and 

Partnerships ......................................................................................................... 44 

Prepared statement .......................................................................................... 46 

Whidden, Connie, Health Director, Seminole Tribe of Florida ............................ 56 

Prepared statement with attachments ........................................................... 57 

APPENDIX

Kennedy, Hon. Cheryle, Chairwoman, Confederated Tribes of the Grand 

Ronde Community of Oregon, prepared statement ........................................... 92 

Northwest Portland Area Indian Health Board, prepared statement ................. 77 

Shirley, Jr., Dr. Joe, President, Navajo Nation, prepared statement ................. 87 

(1) 

EXPANDING DENTAL HEALTH CARE IN 

INDIAN COUNTRY 

THURSDAY, DECEMBER 3, 2009 

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

The Committee met, pursuant to notice, at 2:41 p.m. in room 

628, Dirksen Senate Office Building, Hon. Byron L. Dorgan, 

Chairman of the Committee, presiding. 

OPENING STATEMENT OF HON. BYRON L. DORGAN, 

U.S. SENATOR FROM NORTH DAKOTA 

The CHAIRMAN. We will now convene the hearings. We have two 

hearings, and as I indicated previously, we thank all of you. 

The first hearing is on expanding dental health care in Indian 

Country. And what we are going to do is begin with the witnesses 

for that hearing. 

Dr. Ronald Tankersley is with us, a dentist from the American 

Dental Association, President, actually; Ms. Evangelyn ‘‘Angel’’ 

Dotomain, the President and CEO of Alaska Native Health Board; 

Dr. Patricia Tarren, Staff Pediatric Dentist, Department of Dentistry at Hennepin County Medical Center in Minneapolis. 

If the three of you will take your seats, we will begin testimony. 

When it is required for us to be present at the vote, we will go to 

the end of the first vote, then cast the beginning of the second vote 

and be back as quickly as we can. 

We have two items on our hearing list today. The first is on dental health care and the second is on contract health services. So we 

want to try to get through these in reasonable time, and I appreciate the cooperation of everyone. 

Dr. Tankersley, you are President of the American Dental Association. We are pleased that you are here and your entire statement will be a part of the permanent record, so you may summarize. Why don’t you proceed? 

STATEMENT OF RONALD L. TANKERSLEY, D.D.S., PRESIDENT, 

AMERICAN DENTAL ASSOCIATION (ADA) 

Dr. TANKERSLEY. Mr. Chairman and Members of the Committee, 

I am Ron Tankersley, President of the American Dental Association, which represents 157,000 dentists across the Country. I am 

a practicing oral and maxillofacial surgeon in Newport News, Virginia. 

2 

Let me begin by thanking you for your efforts to reauthorize the 

Indian Health Care Improvement Act which contains so many important provisions to improve the health of American Indians and 

Alaska Natives. Enactment is long overdue. 

I have been asked to appear before you to discuss our position 

on whether to expand the new dental health aide therapist position, which is currently being tested in frontier Alaska, into other 

areas of the Country. 

You know from our previous testimony that the ADA does not 

support delegating surgical procedures to those without the comprehensive education of dentists. So we are opposed to Congress expanding the Alaska therapist model. 

To us, it is not a matter of whether similar providers exist in 

other countries. The U.S. has higher education standards than 

many other countries, and currently in this Country, surgical services are not delegated to any health care provider with just two 

years of post-high school education. Even nurse practitioners who 

have six years of higher education and training are not given surgical privileges. 

The real question is whether establishing such a position, with 

the attending challenges of recruiting, educating, training, supervising and regulating such providers, is the best solution for improving access to oral health in the tribal areas. 

Furthermore, we believe that recent events make expanding that 

model even less necessary than in the past. Specifically, the drastic 

shortage of dentists in the Indian Health Services is finally being 

addressed. This year alone, there will be 70 additional dentists providing care in tribal areas. With one more year of similar recruiting 

success, the shortage of dentists in IHS could actually be eliminated. No other action could have more significant impact upon increasing access to surgical oral health care in tribal areas with profound needs. 

The ADA has played a critical role in this success. Working with 

the Indian Health Service to create a fund for dental summer extern programs and lobbying to increase student loan repayments 

for dentists hired by the Service or the tribes. Last year, over 300 

dental students applied for 150 openings for the extern program. 

This year, the ADA successfully advocated for increased funding 

to double the number of summer dental externs in 2010. We believe that this will lead to more young dentists choosing to work 

in tribal areas, reducing even further the need to look for other 

models to provide surgical dental care. 

That said, we agree with many others that innovations in the 

dental team could help increase access to dental services in underserved areas, including tribal lands. For example, the expanded 

function dental assistant model has been used with great success 

in the United States military. We also strongly support the creation of new innovative dental workforce models that parallel that 

of medical community health aides. 

The ADA is currently funding and pilot testing such a model, the 

Community Dental Health Coordinator. We call that the CDHC. 

Our initial classes of CDHCs will work in rural, urban and tribal 

areas. These allied dental personnel come from the under-served 

communities in which they will work. They are trained to provide 

3 

1See attachment for additional ADA activities on behalf of IHS/tribal oral health. 

community-focused oral health promotion, prevention and coordination of care. 

And importantly for this discussion, the CDHC Program will be 

independently evaluated during the pilot phase before the program 

is actually replicated in other areas. 

We all agree that American Indians and Alaska Natives deserve 

access to the same oral health care as the rest of the population. 

Accordingly, the ADA asks Congress to focus on eliminating dentist 

shortages and supporting workforce innovations that increase efficiency and focus on prevention, while still ensuring that the people 

who need surgical care receive that care from fully trained dentists. 

Thank you. I appreciate the opportunity to speak. 

[The prepared statement of Dr. Tankersley follows:] 

PREPARED STATEMENT OF RONALD L. TANKERSLEY, D.D.S., PRESIDENT, AMERICAN

DENTAL ASSOCIATION (ADA) 

Mr. Chairman and Members of the Committee: 

I am Dr. Ron Tankersley, president of the American Dental Association (ADA), 

which represents 157,000 dentists around the country. I am a practicing oral and 

maxillofacial surgeon from Newport News, Virginia. 

Let me begin by thanking you for your efforts to reauthorize the Indian Health 

Care Improvement Act. Enactment of this legislation, which contains so many important provisions to improve the health of American Indians and Alaska Natives, 

is long, long overdue. 

I have been asked to appear before you to discuss our position on whether to expand the new dental health aide therapist position currently being tested in frontier 

Alaska into other areas of the country. You know from previous ADA committee testimony that the ADA does not support delegating surgical dental procedures to 

those without the comprehensive education of dentists. So, we are opposed to Congress expanding the Alaska therapist model. 

To us, it’s not a matter of whether similar providers exist in other countries. The 

United States has higher educational requirements than many other countries. Currently in this country, surgical services are not delegated to any healthcare providers with just two years of post-high-school training. Even nurse practitioners, 

with six years of education and training, are not given surgical privileges. 

The real question is whether establishing such a position, with the attending challenges of recruiting, educating, training, supervising, and regulating such providers, 

is the best solution for improving access to oral health care in tribal areas. 

Furthermore, we believe that recent events make expanding that model even less 

necessary than in the past. Specifically, the drastic shortage of dentists in the Indian Health Service (IHS) is finally being addressed—this year alone there will be 

70 additional dentists providing care in tribal areas. With one more year of similar 

recruiting success, the shortage of dentists in the IHS could be eliminated. No other 

action could have a more significant impact upon increasing access to surgical oral 

healthcare in tribal areas with profound need. 

The ADA has played a critical role in this success, working with the IHS to create 

and fund a dental summer extern program and lobbying to increase student loan 

repayments for dentists hired by the Service or tribes. Last year, over 300 dental 

students applied for 150 openings in the extern program. This year, ADA successfully advocated for increased funding to double the number of summer dental 

externs in 2010. We believe that this will lead to more young dentists choosing to 

work in tribal areas, reducing even further the need to look for other models to provide surgical dental care. 1

We agree with many that innovations in the dental team could help increase access to dental services in underserved areas, including tribal lands. For example, 

the expanded function dental assistant model that has been used with great success 

by the U.S. military. We also strongly support the creation of new innovative dental 

workforce models that parallel that of medical community health aides. The ADA 

is currently funding and pilot testing one such model, the Community Dental 

Health Coordinator (CDHC). 

4 

2 Alaska (Bristol Bay Area Health Corporation/Togiak), Arizona (Hopi Health Care Center/ 

Pollaca), Maine (Presque Isle), Minnesota (Cass Lake, Red Lake and White Earth Health Centers), New Mexico (Taos-Picuris Health Center), North Dakota (Belcourt and Fort Yates), South 

Dakota (Pine Ridge, Rosebud and Wagner) and Wisconsin (Menominee Tribal Clinic/Keshena). 

Our initial classes of CDHCs will work in rural, urban, and tribal areas. These 

allied dental personnel come from the underserved communities in which they will 

work and who will provide community-focused oral health promotion, prevention, 

and coordination of dental care. And importantly, for this discussion, the CDHC program will be independently evaluated during the pilot phase before the program is 

replicated in other areas. 

To qualify for a CDHC credential, an individual will have to be a high school 

graduate and complete a 12 month series of classes, with 3–6 months of on-site 

practice depending on the student’s prior experience. The individual will have to be 

trained at a Commission on Dental Accreditation (CODA) approved training site. 

Working under a dentist’s supervision in health and community settings (such as 

schools, churches, senior citizen centers, and Head Start programs) and with people 

who have similar ethnic and cultural backgrounds, CDHCs will: 

• Provide individual preventive services, such as screenings, fluoride treatments, 

placement of sealants, and simple teeth cleanings. 

• Place temporary fillings in preparation for restorative care by a dentist. 

• Help patients and/or their caregivers navigate through the maze of health and 

dental systems to assure timely access to care and to help prevent reoccurrence 

of the Deamonte Driver tragedy. 

• Collect information to assist the dentist in the triage of patients, which will enhance delivery system effectiveness and efficiency. 

• Overcome the barriers to seeking care by working with community leaders to 

promote oral health literacy and nutritional literacy and to address additional 

social and environmental barriers, such as assistance with transportation issues 

and enrollment in publicly funded programs. 

We all agree that American Indians and Native Alaskans deserve access to the 

same oral health care as the rest of the population. Accordingly, the ADA asks Congress to focus on eliminating dentist shortages and supporting workforce innovations that increase efficiency and focus on prevention while still ensuring that people who need surgical care still receive that care from fully trained dentists. 

Thank you. 

Attachment 

American Dental Association’s American Indian/Alaska Native Activities 

The ADA is the founding member of the ‘‘Friends of Indian Health’’, which works 

to ensure adequate funding for the Indian Health Service and tribal health programs, including oral health care services. And each year the ADA aggressively lobbies the United States Congress to ensure the dental health programs funded by 

the Indian Health Service (IHS) receive adequate appropriations dollars. In addition: 

American Indian/Alaska Native (AI/AN) Dental Placement Program 

In 2005, the ADA hired a full time staffer to develop a volunteer dentist program 

for Indian Country. To date, volunteer dentists have served at 13 sites in eight 

states, including North Dakota. 2 In Minnesota we have sent 17 dentists on 19 trips. 

In November 2009, the ADA sponsored a team of eight prosthodontists, who travelled to Taos-Picuris Health Center (NM) for one week to provide full and partial 

dentures to local patients. The ADA continues to recruit, assign and coordinate volunteer dentists and dental students to serve at Indian Service (IHS) and/or tribal 

clinics. 

Indian Health Service Externship Program Support 

Since 2008, the ADA has financially sponsored 18 dental students who provided 

practical support for upper classmen who are participating in the IHS externship 

program. This provided the chance for more dental students to participate in the 

IHS dental extern program, a key recruitment activity. The current vacancy rate for 

IHS dentists has dropped from 140 last year to 67 today. We believe that some of 

that success is due to the IHS summer extern program. Last year over 300 dental 

students applied for 150 openings. The IHS has reported that their positive summer 

experience makes them great ambassadors to their dental school colleagues. As a 

5 

3Stakeholder Groups: (1) Indian Health Service Area Dental Officers and Headquarters Personnel, (2) State Dental Societies, (3) Local Tribal Health Programs, (4) American Dental Association, (5) Indian Health Service Dental/Clinical/Preventive Support Programs and Other Local 

Programs, (6) Specialty and Special Interest Oral Health and General Health Care Organizations, (7) Regional Health Boards and Philanthropic Organizations, (8) Dental Education. 

result of this program the ADA successfully advocated for additional funding in FY 

2010 to double the number of summer dental externs. 

Summit on American Indian/Alaska Native Oral Health Access 

In 2007, the ADA hosted the Summit, which included more than 100 participants, 

public and private interests, from tribal organizations, local communities, state dental societies, dental educators, specialty organizations, the U.S. Public Health Service, philanthropy and the Association. 3 The Summit focused around the question, 

‘‘What are we going to do, both individually and collectively, to improve access to 

dental treatment and prevention strategies that address the oral health of American 

Indian and Alaskan Native people? ’’ 

At the conclusion of the Summit, all participants agreed to work on activities related to the following seven AI/AN oral health focus areas: 

1. Creating a new paradigm for improving the dental workforce; 

2. developing collaborative strategies for lobbying, funding, policy making, etc.; 

3. designing research and implementing ‘‘best practices’’ for the prevention of 

oral disease, including early childhood caries; 

4. fostering broader community involvement to identify oral health issues and 

their solutions; 

5. advocating for a fully funded IHS/Tribal/Urban (ITU) dental program; 

6. building trust among the partners/communities of interest; and 

7. encouraging meaningful tribal empowerment in oral health policy making. 

American Indian/Alaska Native Strategic Workgroup 

The AI/AN Strategic Workgroup is comprised of leaders for the action team areas 

identified during the 2007 Summit. The Workgroup continues to meet two times per 

year to foster and maintain collaborations for effective advocacy, research, policies 

and programs at the local, regional and national levels, resulting in: (1) increased 

access to oral health care, (2) reduced oral health disparities, and (3) improved prevention of oral disease. One outcome of this continued effort was a FY 2009 joint 

appropriations request seeking $1 million for research into the unique causes and 

needed new treatments for tooth decay among AI/AN children. The Strategic 

Workgroup also identified a long term funding plan for the IHS dental program. The 

ADA conveyed that message in an April 2009 letter to President Obama. Tribal 

members of the AI/AN Strategic Workshop planned to work with their organizations 

to send similar letters to the Administration. 

Symposium on Early Childhood Caries in American Indian and Alaska Native Children 

In October 2009, the ADA co-hosted, with the IHS, the Symposium on Early 

Childhood Caries (ECC) in American Indian and Alaska Native (AI/AN) Children. 

The Symposium was attended by national and international ECC experts; Indian 

Health Service dental, pediatric and child development personnel; and local tribal 

representatives. There was a consensus among Symposium participants that early 

childhood caries among AI/AN children represents a different disease from that experienced by other populations of children: it starts earlier, follows a more aggressive course, results in a much higher burden of disease for the children and their 

families, and has been refractory to many years of determined efforts to control it 

using intervention strategies found effective in other populations. Control of ECC 

among AI/AN children thus requires new approaches which are likely to be 

multimodal in nature with an enhanced emphasis on the infectious etiology of the 

disease. It will also require development of new metrics with which we can better 

characterize the disease and measure the effectiveness of new prevention approaches. Symposium participants intend to present a research agenda to the National Institute of Dental and Craniofacial Research and similar entities. 

Pathways Into Health 

In 2008 and 2009, the ADA co-sponsored the Pathways Into Health (PIH) annual 

conference. PIH is a grassroots collaboration of more than 150 individuals and organizations dedicated to improving the health, health care and health care education 

of American Indians and Alaska Natives. PIH recognizes that an important factor 

6 

to improving the number of health care providers serving in Indian country is to 

‘‘grow your own’’ and has developed distance education and mentoring programs to 

ensure that AI/AN students succeed in becoming health care providers. ADA personnel serve on the PIH advisory committee. 

Society of American Indian Dentists (SAID) 

Dr. Lindsey Robinson, ADA CAPIR Council chair represented the ADA at the Society of American Indian Dentists’ annual meeting, April 30-May 3, 2009 at University of California, Los Angeles. Dr. Robinson gave a presentation about ADA access 

to care activities, highlighting advocacy and programs for AI/AN populations. 

ADA Institute for Diversity in Leadership 

Two Summit participants; Dr. Alyssa York, dental director, Inter Tribal Council 

of Arizona and Ruth Bol, secretary/treasurer, SAID; were accepted to participate in 

the ADA’s Institute for Diversity in Leadership, a three-part personal leadership 

training program designed to enhance the leadership skills of dentists who belong 

to racial, ethnic and/or gender backgrounds that have been traditionally underrepresented in leadership roles in the profession. 

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

Evangelyn Dotomain? Thanks for being here and you may proceed. 

STATEMENT OF EVANGELYN ‘‘ANGEL’’ DOTOMAIN, 

PRESIDENT/CEO, ALASKA NATIVE HEALTH BOARD 

Ms. DOTOMAIN. Good afternoon and thank you for the opportunity to testify today. I am honored to be here. My name is Angel 

Dotomain. It is much easier. I am President and CEO of the Alaska 

Native Health Board. 

In response to extensive dental health needs and high dental vacancy rates, the Alaska Dental Health Aide Therapist Program 

began in 2003. It is part of the Community Health Aide Program, 

which is authorized under Section 119 of the Indian Health Care 

Improvement Act. 

Following the CHAP model, the DHAT Program selects individuals from rural Alaska communities to be trained and certified to 

practice under general supervision of dentists in the Alaska Tribal 

Health System. 

Alaska Native children and adolescents suffer dental caries rates 

at 2.5 times greater than the general U.S. child and adolescent 

population. This, combined with a vacancy rate of 25 percent and 

30 percent turnover rates in dentists, has developed into a serious 

problem in Alaska dental care. 

Indian Country, in fact, has about half the number of dentists 

per capita, at 33 per 100,000. With the number of dentists expected 

to decline, there is clearly not an adequate supply in the distribution of dentists to meet the basic dental health needs of America’s 

first people. Dental therapists can help to fill the gap to provide 

desperately needed services where dental services are limited or do 

not exist at all. 

At a time when Indian Country lags behind the rest of the Country in access to service, isn’t it time for us to be at the forefront 

of the health care delivery model? The DHAT Program, if expanded, would allow for that to happen in our Country, and for the 

first time, American Indians and Alaska Natives would be the first 

to benefit from a positive health care change. 

The Alaska DHAT Training Program is modeled after the New 

Zealand National School of Dentistry in Otago. New Zealand’s denVerDate Nov 24 2008 12:57 Jun 30, 2010 Jkt 057096 PO 00000 Frm 00010 Fmt 6633 Sfmt 6601 S:\DOCS\57096.TXT JACK PsN: JACKF
7 

tal therapists have been highly valued for over 80 years. In fact, 

over 14,000 dental therapists operate in over 53 countries worldwide, including Canada, The Netherlands, Australia, Great Britain 

and Malaysia. The United States is the only industrialized nation 

without a mid-level dental provider available to its citizens. 

Alaska’s DHATs receive extensive training, certification, continuing education and clinical reviews to ensure that their skills 

are of the highest quality. In 2007, the Alaska Native Tribal 

Health Consortium and the University of Washington’s MEDEX 

Program opened DENTEX, the first DHAT training center in the 

United States. 

The DENTEX Program is extremely rigorous. Students receive 

2,400 hours of training over two years, spending one year in Anchorage and one year in Bethel. They utilize the same textbooks as 

dental students. DHATs are trained with the same high quality 

level of care dentists would, within their limited scope. 

DHATs are trained to provide oral health education, preventive 

services, fillings, and uncomplicated extractions to preserve function and address pain and infection. In addition to their two-year 

training, DHATs are required to perform at least a 400-hour preceptorship program with their supervising dentist. 

Only after the DHAT completes that clinical preceptorship are 

they eligible for certification. Each DHAT must apply for and receive certification to the Indian Health Service Community Health 

Aide Program Certification Board. DHATs must be recertified 

every two years, which includes multiple direct observation of skills 

and complete 24 continuing education hours per two-year period. 

There are currently 10 practicing DHATs who were trained in 

New Zealand, and three who were trained at the DENTEX Program. There are 14 in DENTEX training and on December 11th 

will graduate seven more. 

In recent independent studies, DHAT skills were assessed to determine if they are on par with dentist-provided services and quality of care. The results of an early study noted that the program 

deserves not only to continue, but to expand. In a recent pilot 

study, there was found to be no significant difference between irreversible dental treatment provided by DHATs in comparison to 

dentists, and no significant difference in reportable events. 

Like the community health aide, the DHAT has become an essential part of dental health delivery in the Alaska Tribal Health 

System. Their ability to provide culturally appropriate high quality 

care has increased Alaska Native access to proper dental services 

and prevention activities. 

It is exciting to see that other parts of the United States are 

looking at a dental mid-level model. DHATs are an innovative solution to the inadequate numbers of licensed dentists practicing in 

under-served areas, not just in rural Alaska. Because of this, we 

respectfully recommend this Committee urge the Indian Health 

Service to include DHAT Program funding in their funding request 

for future years. 

In addition to seeing DHATs provide services, the Alaska Native 

Health Board is excited to see upcoming preliminary results of a 

study commissioned by philanthropic organizations which will determine the DHATs Program implementation integrity and conduct 

8 

a health outcome assessment addressing safety, quality and patient-oriented outcomes. The study started in the spring of 2009 

and preliminary results are expected in the summer of 2010. 

It has come to our attention that the current philanthropic evaluation meets all but one evaluation request set aside for review by 

the Secretary of Health and Human Services. Thus, we also respectfully recommend that the Committee utilize the current study 

for all of the needs of evaluation noted, rather than commissioning 

a new study. 

With that, I thank you for your time and I am open for questions. 

[The prepared statement of Ms. Dotomain follows:] 

PREPARED STATEMENT OF EVANGELYN ‘‘ANGEL’’ DOTOMAIN, PRESIDENT/CEO, ALASKA

NATIVE HEALTH BOARD


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The CHAIRMAN. Well, thank you very much, Ms. Dotomain. I perhaps should have asked Senator Murkowski whether she wanted 

to say a word because you are from Alaska, I know. 

All right. We have I think about four minutes left to the end of 

this vote. So I think what we should do is go vote and come back. 

I want to recognize Senator Franken, who wishes to make a comment as he introduces a colleague from Minnesota. 

We will stand in recess for about 15 minutes, no more than 15 

minutes. 

[Recess.] 

The CHAIRMAN. I will call the hearing back to order. 

Senator Franken? 


1203a6.eps
14 

Senator FRANKEN. Thank you, Mr. Chairman. 

I want to introduce Dr. Patricia Tarren. 

Thank you, Dr. Tarren, for traveling all the way from Minnesota. 

I know it is a great hardship. I am kidding about that. It is not 

so bad and I do it all the time. 

Dr. Tarren is a pediatric dentist at the Hennepin County Medical 

Center, which is a great safety net hospital about four blocks from 

my house. And you have first-hand experience supporting mid-level 

dental providers and serving patients who face serious barriers to 

dental care, and we thank you for being here today. 

STATEMENT OF PATRICIA TARREN, STAFF PEDIATRIC 

DENTIST, DEPARTMENT OF DENTISTRY, HENNEPIN COUNTY 

MEDICAL CENTER 

Dr. TARREN. Good afternoon, Chairman Dorgan, Members of the 

Committee. My name is Patricia Tarren. I am a pediatric dentist 

at Hennepin County Medical Center. 

I am here to testify regarding the amendment that Senator Dorgan had proposed restricting further expansion of dental therapists 

on Indian lands and prevent the Indian Health Services from providing or covering dental therapist services. 

I am really glad to hear that he is going to be working with Senator Franken on the amendment that he had proposed, but is now 

withdrawn, to remove that restriction. 

Hennepin County Medical Center is a large safety net hospital 

in Minneapolis, Minnesota. We provide dental care for patients 

who are medically compromised, those with special needs, and the 

socio-economically disadvantaged. We see the medical complications that arise from dental neglect, causing considerable pain, suffering, as well as costly hospitalizations. 

When I graduated from dental school in England in 1974, I 

worked with four dental therapists and recognized their ability to 

provide safe, high quality dental treatment for our patients. I was 

a member of the Oral Health Practitioner Work Group that reported to the Minnesota legislature to facilitate enactment of Minnesota’s dental therapy law this year. 

I serve on the Curriculum Advisory Committee for Metropolitan 

State University’s Advanced Dental Therapy Program. In my hospital position, I observe the professionalism of the dental hygienists 

I have trained in expanded functions, delivering local anesthetic 

and placing fillings. 

Since the inception of the dental therapist in 1921, they have 

been evaluated worldwide. Dozens of peer-reviewed studies have 

shown that they improve access, reduce costs, provide excellent 

quality of care, and do not put patients at risk. 

They provide commitment to their community and can work 

under general supervision of the dentist, who need not be present. 

Their scope of practice is limited to certain procedures which they 

are trained to perform to the same level of clinical competence as 

a dentist. 

The benefit of a dental therapist improving access to care may 

well depend on them working in places impossible to recruit and 

staff permanently with dentists. This is particularly evident on Indian lands. For example, on the Red Lake Indian Reservation in 

15 

Minnesota, the dental hygienist struggles to find care for children 

with extreme dental neglect. Various intermittent volunteer and 

training programs using private dentists and dental students have 

not provided an effective solution. 

Further, it has been demonstrated that American Indians have 

better health outcomes when culturally appropriate services are 

available. The dental health aide therapists, DHATs, who provide 

dental care in the bush for Alaska tribes have had a positive impact on oral health and are appreciated by their patients. They 

triage patients so the neediest are prioritized for the dentist’s arrival. They are instrumental in directing patients who need evacuation by air for emergency care. 

Dr. Bolin, a consultant and instructor with the DENTEX Anchorage Training Program, supervises DHAT students in the bush 

where he continues to see very good technical work as they perform 

simple procedures within a narrow scope of practice. The results of 

his pilot study are reported in the Journal of the American Dental 

Association. A full evaluation of the DHAT Program is currently 

underway, funded by the Kellogg Foundation. 

So, given the successful introduction of the Alaska DHATs, tribes 

in other States should be allowed to evaluate the data when published, and determine for themselves whether to utilize DHATs, 

rather than using this restrictive legislation to deny them that possibility. 

For the benefit of all members of society, the mark of a true medical professional is to advance the science of their profession. We 

should, therefore, be open to the possibility of different models of 

allied dental professionals, just as our medical colleagues have 

done with nurse practitioners and physician assistants, for example. 

In conclusion, to increase access for under-served patients, allow 

us to follow our medical colleagues and expand our dental workforce to include well trained professional dental therapists who will 

provide appropriate care within their scope of practice, and allow 

their supervising dentist to practice at the top of their license. 

Please do not perpetuate the status quo where the best care is reserved for those with means and there is little or no care for the 

rest. 

I urge you to support Senator Franken’s amendment to remove 

the restrictive language and allow the option of dental therapists 

to improve dental care in Indian Country. 

And thank you for this opportunity to testify. 

[The prepared statement of Dr. Tarren follows:] 

16 

PREPARED STATEMENT OF PATRICIA TARREN, STAFF PEDIATRIC DENTIST, 

DEPARTMENT OF DENTISTRY, HENNEPIN COUNTY MEDICAL CENTER


1203b1.eps
17 

The CHAIRMAN. Ms. Tarren, thank you very much. We appreciate 

your coming to testify. 

Let me just say at the outset, my notion of this is that we have 

responsibilities to provide health care for Native Americans. I have 

never been very interested in saying to the IHS it is okay if you 

don’t provide full dental service. You can do something less because 

we are short of money, so hire people that aren’t qualified to be 

dentists to do bona fide dental work. So that has been my notion. 

Why let them off the hook? Why not say let’s spend the money necessary to give the First Americans the kind of dental treatment 

that we have said that they would get in trust agreements and 

treaties and so on? 

On the other hand, I recognize that in Alaska, you won’t find a 

dentist around population centers, so they have created a separate 

kind of dental health aide therapist and apparently quite successful for providing services in the areas where there would be no 

service. 

So the question I have is this. The testimony by Dr. Tankersley, 

you talk about your support of the creation of a new innovative 


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dental workforce that parallels the medical community health 

aides. You are pilot testing a community dental health coordinator. 

How does that particular position that you are now training, how 

does that relate to the DHAT, the dental health therapist that exists in Alaska? What might be the difference between those two 

levels? 

Dr. TANKERSLEY. Well, the community dental health coordinator 

is more like a medical model. You know, like a physician’s assistant or whatever. In other words, they are not doing surgical services, but there are many, many services that they do which are preventive, triage, and that sort of thing. 

The DHAT model in Alaska, and once again, one of the problems 

is with multiple DHAT models. But the DHAT model in Alaska is 

doing surgical services. They are extracting teeth and doing things 

like that, and that is the problem. 

As a surgeon, I can tell you there is no such thing as a routine 

extraction until it is done. You just never know what you are going 

to run into. You know, you can run into the area around a nerve. 

You can get excessive bleeding and that sort of thing. So that is 

our concern is having unsupervised surgery done by someone, you 

know, who admittedly could have good technical training. 

The CHAIRMAN. All right. 

Let me call on Senator Murkowski and then call on Senator 

Franken. 

Senator Murkowski? 

STATEMENT OF HON. LISA MURKOWSKI, 

U.S. SENATOR FROM ALASKA 

Senator MURKOWSKI. Thank you, Mr. Chairman. I appreciate the 

hearing. 

I want to welcome you, Angel. It is good to see you and I appreciate your leadership on this issue and your leadership as the CEO 

of the Alaska Native Health Board. 

Some of the comments that have been made here today, Dr. 

Tankersley has indicated that the effort that is underway now 

within the ADA is to help eliminate the shortage that we all acknowledge exists out there in terms of the dentists, the practitioners. And you have indicated that as many as 70 additional dentists may be in the pipeline coming into IHS. 

Angel, I am going to ask you this question because so much of 

our problem is not that there not dentists that are being trained 

on a daily basis coming out of dental school. It is our ability to get 

them into these villages on a more than once a year for one week 

or two week basis. And this has been our challenge and how we 

as a very remote, very large State have come to this mid-model 

that has been developed, the DHAT model. 

Your family comes from Shaktoolik. How many folks live in 

Shaktoolik now? 

Ms. DOTOMAIN. As of last week, probably about 212. 

Senator MURKOWSKI. About 212. How often do the people of 

Shaktoolik see a dentist come to the village? 

Ms. DOTOMAIN. Once a year. 

Senator MURKOWSKI. And how long would that individual be 

there to care for the residents? 

19 

Ms. DOTOMAIN. One week. 

Senator MURKOWSKI. So you get one week. So your five-year-old 

child or your 23-year-old young woman or you are an elder, and 

you have dental care that is provided to you for one week. I 

shouldn’t say dental care provided for one week because you get 

your time slot with the dentist that is there. Our challenge has always been how we get these professionals. 

Now, earlier in the audience there were three friends from 

Kotzebue, and I was asking them as we took our break. I said, how 

many DHATs do we have in Kotzebue now? And I am told that we 

have two, and I was also reminded that both of these individuals 

were born and raised in Kotzebue. We have now trained them and 

they have come back home. 

I have had a chance to visit with the DENTEX program and the 

individuals there that are going through there. You ask them 

where they are from, and one is from Chevak and one is from Hooper and one is from Quinhagak. And their desire is to go back to 

their village. 

So what we are doing is we are not sending people out to a dental school in Oklahoma or Minnesota, and hoping that they come 

back home. We are growing our own. And I think this is one of the 

facets of the DHAT Program that I think is resulting in a level of 

success. 

Dr. Tankersley, you mentioned the concern about the unsupervised surgery. And I think we have all recognized that that is kind 

of where the angst comes. When you are extracting teeth, that is 

a permanent issue, as opposed to putting fluoride on a child’s teeth. 

Can you explain, Angel, how the mentoring process works within 

the program? If you have a DHAT in a village who does have to 

work a procedure, are they totally on their own? Can you just explain for the panel here? 

Ms. DOTOMAIN. Absolutely not. They are in constant contact and 

communication with their supervising dentist. 

Senator MURKOWSKI. And what does that mean? Tell us. 

Ms. DOTOMAIN. What happen is the dental health aid therapist 

actually works under the license and supervision of their supervising dentist, usually someone located, for instance, in Unalakleet, 

which is 40 miles from my home town of Shaktoolik, there is a dental health aide therapist, Aurora Johnson. Born and raised in Unalakleet, she was able to go to the program in New Zealand and 

come home. 

And she works under the license of a dentist in Nome, with the 

Norton Sound Health Corporation. They are in constant communication with their supervising dentist, and the agreement between 

the supervising dentist and the dental health aide therapist actually can sometimes limit the already limited scope of practice of the 

dental health aide therapist. 

So they come out of the DENTEX Program with a certain scope 

of training, and then they spend at least 400 hours with their supervising dentist in the preceptorship program. And during that 

time, they can either continue to limit the scope of practice so there 

is an agreement between the supervising dentist and the DHAT of 

what their scope of practice will be, based on how the supervising 

dentist feels their skills are. 

20 

Aurora Johnson could be in contact with her supervising dentist 

three to six times a day, either on the phone, via email, or through 

the Alaska Federal Health Care Axis Network Telemedicine Program. She is able to send films to her supervising dentist if she is 

unsure of or wants to just refer, consult with her supervising dentist. She has the option and opportunity to do that at any point in 

time during her day. 

Senator MURKOWSKI. Thank you. 

Dr. Tarren, I think you used the words ‘‘culturally appropriate’’ 

services, and you indicated that you think American Indians have 

better outcomes, and you have also cited to the DHAT Program in 

Alaska, where we have seen the benefits. 

How significant do you feel that is as we are trying to develop 

these mid-levels to respond to what clearly is a need in my State 

and in the Lower 48 with American Indians? 

Dr. TARREN. I think it is extremely important for the practitioner 

to develop the trust of their patients. And for example, if I came 

into Alaska and worked for two weeks in one of the villages, I 

would probably be viewed with some suspicion, and I know that my 

giving, for example, advice to a family about diet and their child 

would not be received as well as if Angel were giving them the 

exact same information. 

And in our hospital at Hennepin County Medical Center, we see 

many patients of different ethnicities. For example, I have learned 

to speak Spanish so that I can more readily gain the trust of my 

Spanish-speaking families so that they will believe me when I am 

trying to divert their dietary practices from harmful practices, for 

example. 

Senator MURKOWSKI. I appreciate you bringing that up because 

I think one of the things that we have recognized, particularly with 

children, is that if it is somebody that is in your village, someone 

that is in your community who is giving you guidance, giving you 

counsel, telling you, you know, are you brushing, who sees you in 

your school or in the store, that is kind of a constant reminder. 

You mention the issue of trust, which is so important, but I think 

also just having that presence within the community on a daily 

basis, somebody that lives there, someone that is one of us I think 

makes such a big difference. 

And Dr. Tankersley, I so appreciate what the American Dental 

Association is doing and their efforts. And I truly believe that there 

has been a greatly stepped up effort to get more dentists out into 

all aspects of rural America, and I applaud you on that. 

I think that the example that is underway in Alaska does demonstrate that we can be working cooperatively to fill in some of 

these gaps, so I appreciate your willingness to work with us on 

that. 

I have well exceeded my time, Mr. Chairman. I appreciate your 

indulgence. 

The CHAIRMAN. Thank you very much. 

Senator Franken? 

21 

STATEMENT OF HON. AL FRANKEN, 

U.S. SENATOR FROM MINNESOTA 

Senator FRANKEN. Thank you, Mr. Chairman. 

Thank you, Senator Murkowski, for talking about the DHAT Program in Alaska and a lot of the successes of it. 

I would like to ask Dr. Tarren, in your career as a dentist, and 

I knew you were a pediatric dentist. I just said pediatrician. Have 

you seen a dental therapist give substandard care? 

Dr. TARREN. I have not. I was in England last year and visited 

two training programs, and continue to be very impressed by the 

level of education that is received, the competence, the commitment, the dedication among the students, who are learning dental 

therapy, and then going out in to the community to a practice situation, a community clinic, and again seeing the high level of professionalism. 

And the fact that their patients really appreciate the standard of 

care that they are getting to the point where a dental therapist 

who recognizes that a procedure would be beyond her scope of capability and wants to refer that patient to the supervising dentist, 

the patient is a little bit disappointed and would rather have the 

dental therapist provide the care. 

Senator FRANKEN. And I think that I would argue the most substandard is offering no care at all. Would you agree with that? 

Dr. TARREN. Completely. 

Senator FRANKEN. Now, have you worked on Red Lake Reservation? 

Dr. TARREN. Unfortunately, no. 

Senator FRANKEN. Do you know anyone who has? 

Dr. TARREN. I know the dental hygienist that works there, and 

I know that they are desperately short of access to dental care. For 

example, they send patients down to the Twin Cities, children who 

need care, who have extensive dental needs and would most benefit 

from care under general anesthesia. And that is 250 miles. It is a 

long way to bring a small child. 

Senator FRANKEN. Ms. Dotomain, do you see any reason why 

other locations that are suffering from a lack of dental care 

shouldn’t use a mid-level dental provider model similar to what you 

use in Alaska? 

Ms. DOTOMAIN. No, none at all. 

Senator FRANKEN. Dr. Tankersley, shouldn’t everyone have access to dental care? 

Dr. TANKERSLEY. We believe they should. 

Senator FRANKEN. Okay. In your testimony, you said something 

interesting. You said this year alone, there will be 70 additional 

dentists providing care in tribal areas. That was your recruitment. 

And then you went on to say, with one more year of similar recruiting success, the shortage of dentists in the IHS could be eliminated. 

Dr. TANKERSLEY. Yes. 

Senator FRANKEN. Do you know how many dentists there are in 

the IHS? 

Dr. TANKERSLEY. I don’t know the total, but I think the number 

that the IHS, you know, wants is low, as it is in some military situations. 

22 

Senator FRANKEN. I am sorry. I didn’t understand. 

Dr. TANKERSLEY. Yes, I don’t know the total of dentists in IHS. 

No, I don’t. 

Senator FRANKEN. Well, the numbers don’t seem to make any 

sense to me. Do you know what the shortage is? 

Dr. TANKERSLEY. Well, the IHS has a quota just like military 

does for how many posts they have. And for years, there has been 

an inability to recruit dentists in IHS. In the last short period of 

time, we have been much more successful because of some of these 

programs that we have instituted in getting dentists to—— 

Senator FRANKEN. Okay. Well, if you don’t know how many dentists there are in the IHS, and you said that recruiting 70 more 

could eliminate the shortage, I don’t know how you could make 

that statement. 

Dr. TANKERSLEY. Because there are—— 

Senator FRANKEN. There are 600 dentists in the IHS. Do you 

how much of a shortfall there is? 

Dr. TANKERSLEY. Yes, the shortfall at this point is about another 

70 dentists, and they have—— 

Senator FRANKEN. No, it is not. The shortfall that I have seen 

is about 25 percent. 

And do you know what the turnover rate is? 

Dr. TANKERSLEY. I don’t know the statistics, but the turnover 

rate is high. 

Senator FRANKEN. So when you said that with one more year of 

similar recruiting success, the shortage of dentists in the IHS could 

be eliminated, why did you use the word ‘‘could’’ ? 

Dr. TANKERSLEY. Because there is no way we know that it will 

be eliminated. 

Senator FRANKEN. Why did you even bother to say it? Because 

the turnover rate is about 30 percent, sir. 

Dr. TANKERSLEY. Yes, but because there is a—for the first time 

in many years, there is a positive trend to actually get dentists into 

the Indian Health Service. 

Senator FRANKEN. Well, your positive trend was 70, which to my 

calculation is like 11 or 12 percent. And if we have a 24 percent 

shortfall and we have a 30 percent turnover, I don’t see how 70 

new recruits can possibly eliminate the shortage. And so it just 

bothers me that—I mean, I think we agree that people need dental 

care. 

Dr. TANKERSLEY. We do. 

Senator FRANKEN. And I understand that the ADA represents 

dentists and you want people who you represent to do this work, 

and I applaud dentists who do this. But we have a model here that 

seems to be working, and we have a shortfall in Indian Country. 

And it could do a lot of people a lot of good. And I wouldn’t mind 

if you could meet that shortfall. I would love it. But it doesn’t seem 

to me that from your testimony that your testimony is convincing 

at all. 

And what I want to do is make sure that kids in Indian Country 

don’t have rotting teeth. That is my responsibility. 

Thank you. 

Thank you, Mr. Chairman. 

[The prepared statement of Senator Franken follows:] 

23 

PREPARED STATEMENT OF HON. AL FRANKEN, U.S. SENATOR FROM MINNESOTA

Thank you Mr. Chairman. It is an honor to be here today, and I thank you for 

holding this hearing on such a critical and timely topic for our nation and particularly Minnesotans. 

Last summer, Minnesota became the first state to pass legislation to create a 

training option for mid-level dental health practitioners to be licensed. The goal was 

providing more basic services to underserved rural populations in the state. Underserved areas including reservations where there are teeth literally rotting in the 

mouths of children because they don’t have dentists to take care of them. 

Physician assistants and nurse practitioners have become accepted and valuable 

parts of the health care model. There is no reason that areas other than Alaska 

shouldn’t have the option to add dental health aid therapists to the dental care 

model. Particularly in locations where there has been such a historically hard time 

in getting dentists to work. The bill we craft today should be permissive to reasonable options, not dictating because of special interests. 

Over 50 countries, such as England, Canada and Australia are using mid-level 

dental practitioners to improve access and lower costs. Research has shown these 

programs are both safe and effective. Not a single study has shown these programs 

to be unsafe. Yet the American Dental Association has repeatedly tried to block efforts to have mid-level providers help Americans improve their dental health. The 

ADA fought the Alaska program. When the program was implemented they filed a 

lawsuit to stop it. The ADA was vehemently against the Minnesota legislation. And 

now they are lobbying to take away the chance to duplicate a good program in 

places where it’s needed most. 

We are talking today about teeth rotting in the mouth of children because of a 

lack of dental care. How can this possibly be acceptable? 

I am looking forward to hearing from the people who have come here to testify 

on this crucial topic, particularly Dr. Patricia Tarren, from the Hennepin County 

Medical Center in the great state of Minnesota. But I’d also like to point out that 

we won’t be hearing today from the people who have the most to lose. People on 

the reservations who have some of the worst dental health of anyone in our country. 

People who, at the same time, have some of the worst access to dental care. Those 

are the people who would most benefit from a mid-level dental provider. Those are 

the people that will continue to have poor dental health and poor access to dental 

care if we deny them this opportunity. 

The CHAIRMAN. Senator Franken, thank you very much. 

This is an issue that has had some previous attention by this 

Committee, again thanks to the work of Senator Murkowski and 

others. Senator Franken has brought the issue to us again, and I 

think caused us to have a discussion that is probably long overdue. 

I appreciate the testimony by all three of you. We are going to 

work on this Committee to think our way through this in a way 

that reaches a good result. 

My interest, I think the interest of everyone on this Committee, 

is for good dental care for American Indians who have been promised good dental care. I have seen circumstances myself of one dentist working in an old trailer house serving 5,000 people on an Indian reservation. That is not good dental care. Most of the dental 

care there was to simply have a patient show up and pull the 

tooth. So we expect better, demand better, and I think this discussion will be helpful going forward. 

And Senator Franken, I appreciate you requesting this hearing. 

Senator MURKOWSKI. Mr. Chairman? 

The CHAIRMAN. Yes, Senator Murkowski? 

Senator MURKOWSKI. Can you let me ask one quick question of 

Dr. Tankersley? 

Is there an effort within the ADA to specifically recruit American 

Indians, Alaska Natives into the dental profession? Do you have a 

specific outreach to them, and if so could you speak to that? 

24 

Dr. TANKERSLEY. You know, we have pipeline projects, and that 

is difficult and there is an effort to do that, and it is meeting with 

some success. 

Senator MURKOWSKI. Can you define when you say it is meeting 

with success? How far along are you in the process? 

Dr. TANKERSLEY. Well, you know, it is a low percentage. I don’t 

know, do you know the percentage? We can supply it. I know it is 

an—— 

Senator MURKOWSKI. I would be curious to know what that is. 

Dr. TANKERSLEY. The reason I know is because our Board of 

Trustees deals with this all the time, and it is a major issue, not 

just with Indians, but with other ethnic groups, too. 

And if I have permission to say something, I would like to say 

most of the conversation of what has been done is exactly what our 

community dental health coordinator does—you know, the cultural 

competence, the prevention, they can get people out of pain. And 

the difference in approach probably is that we would like to see the 

Indian Health Service have better resources so that they could 

have dentists to come in to do the actual surgical procedures. 

Now, we are aware of stories like a dentist shows up once a year, 

but that is not necessary. I mean, if you have proper resources in 

medicine and dentistry, there are lots of people that can come into 

areas once a week or once a month. And so it is just a matter of 

having the appropriate resources to get the dentist in to do the surgical procedures. 

Thank you. 

The CHAIRMAN. Dr. Tankersley, thank you. 

Angel Dotomain, thank you. 

Patricia Tarren, we appreciate your being here. 

That closes this portion of the hearing. 

[Whereupon, at 3:48 p.m., the Committee was recessed, to reconvene the same day.] 

(25) 

A P P E N D I X 

PREPARED STATEMENT OF THE PEW CHILDREN’S DENTAL CAMPAIGN

The Pew Children’s Dental Campaign would like to thank the Committee Chairman for holding this important and timely hearing. 

The Pew Children’s Dental Campaign is working to ensure that more children receive dental care and benefit from policies proven to prevent tooth decay. We are 

mounting a national campaign to raise awareness of the problem, recruit influential 

leaders to call for change, and showcase states that have made progress and can 

serve as models for pragmatic, cost-effective reform. 

Pew believes children should see a dentist when needed, and when possible. However, we recognize it is not always possible. Therefore, Pew supports state innovations that show promise in improving access to preventive and restorative services 

for children who cannot access care. Pew supports state efforts to expand the existing dental health care team with new providers, as well as using current providers 

to the extent of their training. 

The Campaign supports dental workforce innovations based on five key principles: 

1.) Proposals for new workforce models should be based on research and evidence. 

2.) Models should be based on a careful analysis of the state’s particular experience and needs. 

3.) The duties and scope of practice of new providers should be designed to 

address the needs and problems identified in the state’s analysis. 

4.) New dental providers should be adequately educated to perform their 

scope of services competently. 

5.) States should adopt the least restrictive level of supervision that maintains patient safety. 

The DHAT program in Alaska meets each of these criteria. 

To prevent tribes in the other 49 states—who have the legal standing as sovereign 

nations—from even assessing the viability of this model as a solution to their lack 

of access to dental care is counterproductive. 

Our country is facing a critical lack of access to dental care. A shortage of dentists—especially in low-income, inner-city and rural communities—constitutes a national crisis, particularly for children. 

There is a consistent shortage of dentists in rural and underserved areas, including tribal lands. The ADA has acknowledged a geographic maldistribution of dentists, with too few locating in rural, isolated, and underserved areas. 

During economic downturns, it is always easier to recruit dentists for the IHS and 

other safety net settings. However, once the economy improves, the vacancy rate always goes up. Generally speaking, about one quarter of rural safety net clinic openings for dentists are unfilled, and the percentage is higher in rural areas. 

Expanding the dental workforce to include therapists is a cost-effective investment that can help extend essential health services to all Americans. Therefore, the 

Pew Children’s Dental Campaign supports the DHAT program and does not support 

preemptively restricting the tools available to communities in the other parts of the 

United States to address their dental health needs. 

26 

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PREPARED STATEMENT OF THE SHOSHONE-BANNOCK TRIBES—FORT HALL BUSINESS

COUNCIL, PREPARED STATEMENT

Fort Hall Indian Health Service Dental Department Needs 


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PREPARED STATEMENT OF TERRY BATLINER, DDS, MBA 

I am writing as a private citizen. The following opinions are strictly my own and 

not necessarily those of my employer, The University of Colorado Denver (UCD) or 

any other group with which I am affiliated. 

I am a dentist and a member of the American Dental Association (ADA). I occupy 

the positions of Associate Dean at the UCD School of Dental Medicine and Associate 

Professor in the Colorado School of Public Health. More importantly, I am a member 

of the Cherokee Nation of Oklahoma and I care deeply about the health of Indian 

people. That is why I adamantly disagree with ADA’s effort to thwart the expansion 

of the Dental Health Aid Therapist (DHAT) program outside of Alaska. 

Earlier in my career I spent 8 years in the Indian Health Service, 5 years in 

South Dakota and 3 years in the Northwest. It was depressing to treat child after 

child with early childhood caries (ECC), knowing that there were at least 5 more 

kids needing care for every one we treated. My current work takes me back to the 

Pine Ridge reservation and to the Navajo Nation in Arizona. The situation has not 

improved and has, in fact, gotten worse. This is not merely my opinion. At a recent 

national meeting of ECC investigators it was agreed the problem has gotten far 

worse in Indian Country. The majority of kids at age 3 in Indian communities have 

significant and often severe untreated dental decay. Why? Well one reason is clearly 

the lack of access to preventive, restorative and even emergent dental services. 

In the U.S., it is generally agreed that a child with a painful and abscessed tooth 

is a dental emergency. That is simply not the case in Indian Country. I recently 


1203d2.eps
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learned the following fact from some current IHS dentists: A dental emergency is 

defined differently because there are just too many kids with these problems and 

too few dentists to treat them. Only kids with severe facial infections are considered 

true emergencies because the risk of dire complications is very high. In Indian 

Country, a child in pain is not an emergency. This must change! 

The Indian Health Service cannot fill the large number of dental vacancies they 

currently have and even if they could, there would still be too few dentists to serve 

the needs of Indian people. The DHAT provides some hope for Indian communities. 

If local people can be trained and supported, they will be more likely to stay in their 

communities and provide needed emergent, preventive and restorative care to their 

fellow community members. This would help to reduce the number of children in 

pain and perhaps lead to some leveling in the definition of a dental emergency. If 

the DHAT program expands, perhaps more Indian children will grow up free of dental pain. 

I respectfully urge you to act now to remove the language in the present draft 

of the Indian Health Care Improvement Act that would effectively restrict the expansion of the DHAT program for Indian communities outside of Alaska. It is sad 

that the ADA has taken a stand that places the economic concerns of dentists over 

the severe dental needs of Indian people. Please help those in the most need, our 

Indian children. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. LISA MURKOWSKI TO

RONALD L. TANKERSLEY, D.D.S. 

Question. Is there an effort within the ADA to specifically recruit American Indians, Alaska Natives into the dental profession? Do you have a specific outreach to 

them, and if so could you speak to that? 

Answer. The ADA has been involved in a variety of activities to attract and recruit minorities, including American Indian/Alaska Native (AI/AN) students, to a career in dentistry. Knowing that just one approach is not enough, the ADA has employed a variety of strategies. 

We formed the Committee on Career Guidance and Diversity Activities which is 

made up of representatives from the national and student chapters of the Society 

of American Indian Dentists (SAID), the National Dental Association (NDA), the 

Hispanic Dental Association (HDA), the American Dental Education Association 

(ADEA), the American Student Dental Association (ASDA), the National Association 

of Advisors to the Health Professions (NAAHP) and the Colgate-Palmolive Company. 

Committee members collaborate on joint efforts to attract students from underrepresented groups including AI/AN students, such as: 

• Attending and exhibiting at the annual SAID Conference to distribute career 

resources and materials aimed at attracting AI/AN students to careers in dentistry. 

• Supporting and collaborating with community-based organizations such as 

Learning for Life Health Careers Exploring organization in their outreach activities promoting dentistry as a profession to students from diverse of backgrounds. 

• Publicizing the need for a diverse profession. For example, Dr. George BlueSpruce, former committee member and founder of the SAID, wrote an article 

titled, ‘‘The Need for American Indian Dentists’’, which is on the Career Resources landing page of ADA.org at http://www.ada.org/public/careers/ 

beadentist/index.asp#need. 

The ADA initiated the Student Ambassador Program which is made-up of representatives from the Society of American Indian Dentists (SAID) Student Chapter, 

National Association of Advisors to the Health Professions (NAAHP), the American 

Student Dental Association (ASDA), the Student National Dental Association 

(SNDA), the Hispanic Student Dental Association (HSDA), the American Dental 

Education Association (ADEA) Council of Students. The Ambassador Program is a 

student-driven recruitment process in which dental students take the lead in organizing and conducting introduction to dentistry get-acquainted programs with an 

emphasis on recruiting underrepresented students to the profession. 

The five student representatives plan an annual meeting where they share information on their national student peer-to-peer recruiting outreach strategies and programs. Specifically, the 2009 SAID Student Chapter representative detailed the support and resources for AI/AN students interested in dentistry and encouraged other 

ambassadors (including AI/AN students) to model the best practices presented at 

40 

1 Nash, D et al. Dental Therapists: A Global Perspective. Int Dent J. April 2008 58 (2): 61– 

70. 2Support for the Alaska Dental Health Aide Therapist and Other Innovative Programs for 

Underserved Populations.Policy date: 11/8/2006 http://www.apha.org/advocacy/policy/ 

policysearch/default.htm?id=1328. 3Dental Health Aide Program Improves Access to Oral Health Care for Rural Alaska Native 

People. AHRQ Innovations exchange. June 2008, updated Nov. 2009; http:// 

www.innnovations.ahrq.gov/content.aspx?=1840. 4Training New Dental Health Providers in the U.S.: Executive summary prepared for 

W.K.Kellogg Foundation, Burton L. Edelstein DDS MPH, Dec. 2009. 5 Bolin K. Assessment of Treatment Provided by Dental Health Aide Therapists in Alaska: A 

Pilot Study. J Amer Dent Assoc. Nov. 2008; 139: 1530–1535. 6 Evaluation to Measure Effectiveness of Oral Health Care Model in Rural Alaska Native Villages. W.K. Kellogg Foundation press release 7/15 2008 http://www.wkkf.org/default.aspx?tabid=1147&CID=432&NID=259&newsitem=4. 7Patkotak, E. Dental aides remedy lax care in villages. Anchorage Daily News (AK): Voice 

of the Times. June 8, 2005. 

the meeting. A CD containing the recruiting programs presented at the 2009 Ambassador Meeting, including the information targeting AI/AN students, was made 

available to all participants at this year’s program. 

The ADA has established a mentoring program with information specifically for 

AI/AN students on the ADA webpage at http://www.ada.org/public/careers/ 

beadentist/college.asp linking interested students with AI/AN students via the Arizona School of Dentistry and Oral Health SAID Student Chapter site. The site includes ‘‘A Day in the Life’’ series,’’ a newly revised feature of ADA.org, which highlights an American Indian new dentist working at the Yukon-Kuskokwim Health 

Corporation Dental Clinic in Bethel, Alaska. A portrait of her day-to-day activities 

in working in the clinic and in the surrounding Alaskan villages is detailed at: 

http://www.ada.org/public/careers/beadentist/dayldamon.asp. The ADA.org site 

also has information on IHS, scholarships and other resources to encourage AI/AK 

students to consider a career in dentistry. 

In addition to peer—peer recruitment strategies, collaborative ventures with community organizations, dental societies are also encouraged to liaison locally with a 

variety of community resources/organizations across the country as exemplified in 

a resource kit highlighting ‘‘best practices’’ in dental society initiated outreach efforts. 

The ADA is committed to these and future programs to increase the number of 

AI/AN dentists.’’ 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. BYRON L. DORGAN TO

PATRICIA TARREN, BDS 

Question. During the hearing, it was said that opposition to the dental health aide 

therapist program in Alaska was related to concern about therapists performing irreversible procedures without the proper training. Can you recommend or describe 

ways that programs for mid-level dental health providers could address this concern? Do you think that there are advantages to having access to mid-level dental 

health providers even if the providers cannot do surgical procedures? 

Answer. There have been 5 years of positive experience with Dental Health Aide 

Therapists (DHATs) in Alaska (as well as utilization of a similar model in New Zealand since 1921) where the education and experiential training received by the graduates prepares them to practice in the Alaskan bush including performing extractions, with the authorization of their supervising dentist. They are educated in a certified program with professional supervision in a narrowly focused, 

competency based, primary care curriculum. The DHAT must meet the same standard of care for procedures they perform as that expected of a dentist. Following 

graduation, they have 400 hours of direct supervision in preceptorship with their 

supervising dentist, and their scope of practice is based on their demonstration of 

clinical skill. They undergo continued quality assessment and assurance by their supervising dentist and receive annual education and recertification. Ongoing, independent evaluation of DHAT clinical competency has shown that DHATs provide 

competent, safe care. 1, 2, 3, 4, 5, 6 They are well received and appreciated in their communities as highlighted in an editorial by Elise Patkotak in the Anchorage Daily 

News, June 2005: ‘‘People need ongoing treatment to take care of long- and shortterm problems. A dentist in a village for a couple of weeks doesn’t meet that need.’’ 7

It must be emphasized that the DHAT works under the license and supervision 

of a dentist. They have the constant ability for daily contact, as frequently as needed, by telemedicine with the supervising dentist, who retains control over proceVerDate Nov 24 2008 12:57 Jun 30, 2010 Jkt 057096 PO 00000 Frm 00044 Fmt 6601 Sfmt 6621 S:\DOCS\57096.TXT JACK PsN: JACKF
41 

8 Indian Health Service: IHS Impressions, Quarterly Newsletter Vol. 6, Issue 2. Public Health 

Dentistry—Creating Access for the Underserved: An interview with RADM Christopher G. 

Halliday, Chief dental Officer, USPHS. 9 Indian health Service website: The Indian health Service Dental Program, and employment 

opportunities accessed 12/3/2009. 

dures performed by the DHAT. Teledentistry, for example, utilizing intraoral cameras, digital x-rays, and electronic health records allow the dentist to view in ‘‘realtime’’ the patient’s medical history, any lab results, clinical and radiographic findings and consult with attending dentist to confirm the diagnosis, treatment plan, 

and authorize treatment as well as offer guidance throughout the procedure. The 

usefulness in utilizing teledentistry to support the services and minimize complications of DHATs or a similar model of mid-level practioner, such as the dental therapist, is underscored by the published statement of RADM Halliday, chief dental officer USPHS, ‘‘The fact that many Indian Health Service dental facilities are in remote locations underscores the need for strong commitment to technology in delivering care. . . IHS has made large financial commitments over last several 

decades . . . in emerging technologies in the health field. . . IHS remote sites in 

Alaska often utilize telemedicine/teledentistry to consult with oral health providers. . . This is being increasingly integrated into remote facilities in the lower 

48 states as well. All new clinics are equipped with digital imaging technology 

which IHS has used for many years.’’ 8

It was interesting to hear Dr Yvette Roubideaux’s testimony (which followed 

ours), when questioned by Sen. Murkowski about expanding the use of DHATs, 

she responded that the IHS ‘‘has not taken a formal position... but it is 

a great program.’’ 

It is noteworthy that in his testimony, Dr Tankersley stated, ‘‘Performing surgical 

services.there’s no such thing as a routine extraction until it’s done, for example a 

root wrapped around the nerve or excessive bleeding. . .’’ This complication can be 

avoided by triaging the procedure with the supervising dentist, discussing potential 

complications before beginning the procedure, receiving authorization to carry out 

the procedure and having a robust system in place for management of any complication for example, stabilize the patient and transport them to a facility where treatment can be completed. In his testimony Dr Tankersley stated, in regard to 

the DHAT, ‘‘Admittedly they could have good technical training.’’ 

In my opinion, removing the ability of the DHAT to perform nonsurgical extractions will dilute their potential benefit but will not negate their usefulness. According to Burton Edelstein in his report to the Kellogg Foundation ‘‘the primary goal 

of instituting dental therapists is to expand the availability of basic dental services 

to socially disadvantaged subpopulations who are now inadequately served. A second goal is to establish a diverse cadre of caregivers whose social, experiential and 

language attributes are a better match for targeted underserved populations than 

those of current dentists. The proportion of procedures now delivered exclusively by 

dentists that could potentially be delegated to dental therapists is substantial: 75 

percent for general dentists and 79 percent for pediatric dentists’’. 4

A published on the IHS website, there are approximately 380 IHS dentists. As 

of 12/3/2009, there were 108 vacancies with 56 available for immediate employment 

now. 9

According to Dr. Tankersley’s testimony, ‘‘The number of dentists that the IHS 

wants is low, as in the military... the inability to recruit for years... turnover 

rate is high... but we are showing a positive trend recruiting new graduates.’’ 

In my opinion, this strengthens the argument for utilizing DHATs or other 

models of dental therapists in Indian country. As Sen. Murkowksi stated, (in 

Alaska) ‘‘we are growing our own DHAT graduates who return to their community, 

high level of commitment to serve.’’ They are a proven model providing safe, effective, culturally sensitive dental care for individuals who lack access to care. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. AL FRANKEN TO

PATRICIA TARREN, BDS 

Question. Dr. Tankersley said during questioning that their Community Dental 

Health Aide Coordinator (CDHC) model is a better option than the Dental Health 

Aide Therapist (DHAT) currently being used in Alaska for improving dental care 

through the Indian Health Service. As a dentist, do you agree with that assessment? 

Dr. Tankersley also asserted that the CDHC is more similar to the medical model 

of a Physician Assistant. Again, as a dentist, do you believe this is true? 

42 

10 ADA website: The ADA CDHC Program: frequently asked questions. Sept. 2009. 11 U.S. Bureau of Labor Statistics, Occupational Outlook handbook, 2008–2009 Edition. 

Answer. I disagree with Dr. Tankersley’s assertions. While the Community Dental 

Health Coordinator (CDHC) may prove to be a useful adjunct in providing preventive dental services and coordination of dental care, it is a new, untested model. 

It is more comparable to the community health worker (CHW) and pales in comparison to the educational background and scope of services of the Physician Assistant 

(PA) which is a well proven model. The CDHC cannot perform anywhere near 

the range of services of the PA or DHAT. According to the ADA, the CDHC will 

work in health and community settings, assist the dentist in triaging patients, and 

address social, environmental and health literacy issues facing the community. They 

will educate community members on preventive oral health care and assist them in 

developing goals to promote and manage their personal oral health care. Helping 

patients navigate their way through the complex maze of health and dental care 

systems to obtain care will be an important role of the CDHC. To date there have 

been no graduates of the ADA’s CDHC program. 10

According to the U.S. Bureau of Labor Statistics PAs receive 2 years of training 

in accredited programs (admission to many programs requires at least 2 years of 

college and some health care experience. Most applicants have a bachelor or master’s degree due to the competitive applicant pool). The PA passes a national exam 

to become licensed. Employment growth is high as PAs are increasingly utilized to 

contain costs. PAs practice medicine under supervision of physicians and surgeons: 

diagnostic, therapeutic, preventive. They treat minor injuries—suturing, splinting 

and casting, take medical histories, examine and treat patients, order and interpret 

lab tests, xrays and make diagnoses, record progress notes, instruct and counsel patients, order and carry out therapy. They have prescribing privileges. They may 

make house calls, work in hospitals and nursing homes. Also, those who specialize 

in surgery provide preoperative and postoperative care and may work as 1st or 2nd 

assistant during major surgery. They may be the principle care providers in 

rural or inner city clinics where the doctor is present 1 or 2 days/week. Their 

duties are determined by supervising doctor and state law. 11

The DHAT more readily resembles the PA or the nurse practitioner than 

the CDHC. The CDHC is envisioned to provide limited preventive and palliative 

care and extensive care coordination services—which will be a useful member of the 

oral health care delivery team, but with a very much limited scope of practice compared to the DHAT. 

(43) 

PROMISES MADE, PROMISES BROKEN: THE 

IMPACT OF CHRONIC UNDERFUNDING OF 

CONTRACT HEALTH SERVICES 

THURSDAY, DECEMBER 3, 2009 

U.S. SENATE, 

COMMITTEE ON INDIAN AFFAIRS, 

Washington, DC. 

The Committee met, pursuant to notice, at 3:49 p.m. in room 

628, Dirksen Senate Building, Hon. Byron L. Dorgan, Chairman of 

the Committee, presiding. 

OPENING STATEMENT OF HON. BYRON L. DORGAN, 

U.S. SENATOR FROM NORTH DAKOTA 

The CHAIRMAN. I want to call to the dais Dr. Yvette Roubideaux. 

Dr. Roubideaux, you have been extraordinarily patient and I appreciate that. I know you have taken much of your afternoon. Perhaps it was helpful as well to be here during the discussion of the 

Indian health care bill and dental health care. 

I would like to ask your permission. I know that we normally 

don’t do this, but I would like to ask your permission to bring the 

other two witnesses to sit at the table while you are there. That 

way we can go from you to the other two witnesses, then have 

questions of all three. 

Would that be satisfactory to you? 

Dr. ROUBIDEAUX. Sure. 

The CHAIRMAN. All right. 

Ms. Connie Whidden and Mr. Mickey Peercy, we will ask questions of Dr. Roubideaux first, but then I will be able to excuse her 

and let her be on her way. 

Dr. Roubideaux is the Director of the Indian Health Service, and 

this discussion is on the impact of chronic underfunding of Contract Health Services. We want to revisit this issue because we are 

beginning to try to look at some more interesting ways to improve 

this Contract Health Service program. 

So Dr. Roubideaux, what we will do is have you testify, ask you 

questions, and allow you to be on your way. You have been very 

generous with your time. 

Following that, I will ask Connie Whidden to testify and Mickey 

Peercy. 

Dr. Roubideaux, you may proceed. 

44 

STATEMENT OF YVETTE ROUBIDEAUX, M.D., M.P.H., 

DIRECTOR, INDIAN HEALTH SERVICE, U.S. DEPARTMENT 

OF HEALTH AND HUMAN SERVICES; ACCOMPANIED BY 

RANDY GRINNELL, DEPUTY DIRECTOR, AND CARL HARPER, 

DIRECTOR, OFFICE OF RESOURCE ACCESS AND 

PARTNERSHIPS 

Dr. ROUBIDEAUX. Great. Thank you so much, Mr. Chairman and 

Members of the Committee. 

Good afternoon. I am Dr. Yvette Roubideaux, the Director of the 

Indian Health Service. Today, I am accompanied by Mr. Randy 

Grinnell, the Deputy Director, and Mr. Carl Harper, the Director 

of the Office of Resource Access and Partnerships. I am pleased to 

have the opportunity to testify on the Indian Health Service’s Contract Health Services program. 

The Contract Health Services Program, or CHS Program, serves 

a critical function in the Indian Health Service since patients often 

have medical needs that cannot be met with available services in 

our facilities. IHS provides direct care in its systems of hospitals, 

clinics and health stations based on what resources, providers and 

equipment are available to each facility with our annual appropriation for direct services. The CHS Program was developed to purchase additional health care services for patients when the local facility is unable to provide needed services. 

Our health care providers first identify the needs for referrals 

based on medical need, and then we review what resources might 

be available to pay for this referral, either through the Contract 

Health Services Program or through other third-party resources. 

Many programs report that funding these referrals can be a challenge because their CHS annual budget does not cover all referrals. 

Therefore, the CHS Program has been designed to pay first for the 

most urgent medical referrals when funding is limited. 

Based on preliminary area and service unit reports, we estimate 

that approximately 360 million services were denied and deferred 

in 2008. In fiscal year 2009, the Contract Health Services Program 

was funded at $635 million with over 50 percent administered by 

tribes under Indian self-determination compacts or contracts. In 

fiscal year 2010, the CHS budget is $779 million, and increase of 

$144 million or 23 percent. 

CHS programs are administered locally through our IHS and 

tribal operating units, 163 of them. The funds are provided through 

the 12 IHS area offices which in turn provide resource distribution, 

program monitoring and evaluation activities, and technical support. Less than two percent of the CHS funds are retained at headquarters. 

CHS payments within budget limitations may be made for referrals to community health care providers in situations where the direct care facility does not provide the required health care services, 

the direct care facility has more demand for the services than it 

has the capacity to provide, or the patient must be taken to the 

nearest emergency services facility. 

Referring patients to the CHS Program depends on the direct 

services available. In a particular IHS or tribal facility in locations 

where there is limited or no access to in-patient emergency or speVerDate Nov 24 2008 12:57 Jun 30, 2010 Jkt 057096 PO 00000 Frm 00048 Fmt 6601 Sfmt 6601 S:\DOCS\57096.TXT JACK PsN: JACKF
45 

cialty care in IHS or tribal health care facilities, patients must depend on CHS to address their health care needs. 

However, all of our facilities and programs are dependent on 

CHS and third-party coverage among IHS beneficiaries for the 

medical services they are unable to provide. 

It is important to understand that the CHS Program does not 

function as an insurance program with a guaranteed benefits package. The CHS Program only covers those services provided to patients who meet the eligibility and other requirements and only 

when funds are available. 

Many facilities have CHS funds available only for more urgent 

and high-priority cases, and all utilize a priority system to approve 

the most medically urgent cases first. When CHS funding is depleted, CHS payments are not authorized. 

It is also important to note that when CHS funding is not available to authorize payment for a referral, that does not mean that 

the referral is not medically necessary. If a medical provider identifies a need to refer a patient, we assume the referral is medically 

necessary. The challenge we have in many cases is finding funding 

to pay for these referrals with our annual appropriation for the 

CHS Program. 

Some patients and community health providers often believe that 

IHS does or should provide coverage and payments for all American Indians and Alaska Natives that present for services. So it is 

not uncommon for providers to expect payment in cases where CHS 

requirements are not met or when funding is not available. We constantly have to work with our health care provider partners in the 

private sector and our patients to educate them on our CHS requirements and procedures so that they better understand and can 

work with us in our efforts to fulfill our mission within available 

resources. 

In terms of the distribution of Contract Health Services funding, 

CHS funding is distributed to local service units in two ways. A 

fixed amount, called the base funding, does not change over the 

years except for adjustments in inflation and population growth if 

it is included in the annual appropriation; and second, by new increases in annual appropriations. 

Now, in 2001, a work group called the CHS Allocation Work 

Group, comprised of IHS and tribal representatives from the 12 

IHS areas, developed a new formula to distribute funding beyond 

the base amount made available for CHS in the annual appropriation. The formula emphasizes four factors: inflation, depending on 

the prevailing OMB inflation rate; user population to address population growth; regional and geographic cost variances; and access 

to care to the nearest health facility. 

Any new CHS funding in the annual appropriation is distributed 

to the areas based on this methodology. 

As the new Director of the Indian Health Service, I have heard 

from tribes that one of their top priorities for internal IHS reform 

is to discuss improvements in the Contract Health Services Program, which may include a discussion of how we distribute these 

resources and how we do business. 

I plan to ask tribes if they want to continue to use this 2001 formula for new program increases or whether they would like to disVerDate Nov 24 2008 12:57 Jun 30, 2010 Jkt 057096 PO 00000 Frm 00049 Fmt 6601 Sfmt 6601 S:\DOCS\57096.TXT JACK PsN: JACKF
46 

cuss changes in the formula, but I believe it is important to discuss 

any changes to the CHS Program and its funding distribution in 

consultation and partnership with tribes. Any formula or changes 

to it may be more advantageous to some areas compared to others. 

So my primary concern is to ensure that any proposed changes to 

the formula are as fair as possible to all our patients and health 

programs. 

Now, the most common complaint we receive about the program 

is why do we not pay for all of our medical referrals. The most important principle that drives this policy is that IHS cannot incur 

costs which would exceed our available resources. So we follow a 

series of regulatory and other requirements to guide approval and 

payment. 

Our medical providers first identify medically needed referrals. 

Then the CHS Program determines whether IHS can authorize 

payment for such referrals. 

In my written testimony, I have included a number of reasons 

why payment for Contract Health Services may be denied or deferred, such as not meeting eligibility, patient has alternative resources, IHS is the payer of last resort, prior approval was not obtained, notification was not made, services could have been provided in IHS or tribal programs, or the services don’t fall within 

medical priority levels when funding is limited. 

So again, while our providers make medically needed referrals, 

IHS cannot incur costs which would exceed available resources. So 

unfortunately, the CHS annual budget does not cover all referrals. 

Finally, we realize the importance of making maximum use of 

available CHS funding, and we are focusing on improvements in 

the ways we do business in the overall CHS program. 

I also look forward to consulting with tribes on how to improve 

the CHS Program now that they have formally indicated to me 

that it is a priority for internal IHS reform. 

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

opportunity to testify on the Contract Health Services Program 

serving American Indians and Alaska Natives. I would be happy to 

answer any questions you may have. 

[The prepared statement of Dr. Roubideaux follows:] 

PREPARED STATEMENT OF YVETTE ROUBIDEAUX, M.D., M.P.H., DIRECTOR, INDIAN

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

Overview of Indian Health Service Program 

As you know, the Indian Health Service plays a unique role in the Department 

of Health and Human Service because it is a health care system that was established to meet the federal trust responsibility to provide health care to American 

Indians and Alaska Natives. The mission of the Indian Health Service is to raise 

the physical, mental, social, and spiritual health of American Indians and Alaska 

Natives to the highest level. The IHS provides high-quality, comprehensive primary 

care and public health services through a system of IHS, Tribal, and Urban operated facilities and programs based on treaties, judicial determinations, and acts of 

Congress. This Indian health system provides services to nearly 1.5 million American Indians and Alaska Natives through hospitals, health centers, and clinics located in 35 States, often representing the only source of health care for many American Indian and Alaska Native individuals, especially for those who live in the most 

remote and poverty-stricken areas of the United States. IHS provides a wide array 

of clinical, preventive, and public health services, within a single system for American Indians and Alaska Natives. The purchase of health care from private providers through the Contract Health Services program is also an integral component 

47 

of the health system for services unavailable in IHS and Tribal facilities or, in some 

cases, in lieu of IHS or Tribal health care programs. 

Overview of the Contract Health Services Program 

The Contract Health Services (CHS) program serves a critical function in the IHS 

since patients often have medical needs that cannot be met with available services 

in our facilities. IHS provides direct care in its system of hospitals, clinics and 

health stations based on what resources, providers and equipment are available to 

each facility with our annual appropriation for direct services. The CHS program 

was developed to purchase additional health care services for patients when the 

local facility is unable to provide needed services. Our health care providers identify 

needs for referrals based on medical need, and then we review what resources might 

be available to pay for this referral either through the CHS program or through 

other third party resources. Many programs report funding these referrals, however, 

can be a challenge because their CHS annual budget does not cover all referrals. 

Therefore, the CHS program has been designed to pay first for urgent medical referrals. 

Based on preliminary Area and Service Unit reports, we estimate that approximately $360 million services were denied and deferred in 2008. In FY 2009, the 

CHS program was funded at $635 million, with over 50 percent administered by 

Tribes under Indian Self Determination contracts or compacts. In FY 2010 the CHS 

budget is $779 million, an increase of $144 million or 23 percent. CHS programs 

are administered locally through 163 IHS and Tribal Operating Units (OU). The 

funds are provided to the 12 IHS Area Offices which in turn provide resource distribution, program monitoring and evaluation activities, and technical support to 

Federal and Tribal OUs (local level). Less than 2 percent of CHS funds are retained 

at Headquarters to administer the Fiscal Intermediary contract and Quality Assurance Fund. 

CHS payments, within budget limitations, may be made for referrals to community healthcare providers in situations where: 

• There is a designated service area where no IHS or Tribal direct care facility 

exists; 

• The direct care facility does not provide the required health care services; 

• The direct care facility has more demand for services than it has capacity to 

provide; and/or 

• The patient must be taken to the nearest Emergency Services facility with a 

valid medical emergency. 

Referring patients to the CHS program depends on the direct services available 

in a particular IHS or tribal facility. The CHS and direct care programs are complementary; some locations with larger IHS eligible populations have facilities, 

equipment, and staff to provide more sophisticated medical care. IHS and Tribes 

provide direct medical care at nearly 700 different locations. Emergency room and 

inpatient care is provided directly in 46 locations, and a limited number of our largest medical facilities do provide secondary medical services (such as family practice 

medicine) but none provide tertiary care (such as burn units or specialized care). 

With the exception of one hospital in Alaska, IHS and Tribal hospitals have an average daily patient census of fewer than 45 patients, most with a census of 5 or fewer 

patients. Twenty of the hospitals have operating rooms. In locations where there is 

no access to inpatient, emergency or specialty care in IHS or tribal healthcare facilities, patients must depend on CHS to address their health care needs. Those direct 

care programs with the most sophisticated capabilities have, per capita, the smallest 

CHS programs and vice versa. However, all of our facilities and programs are dependent on CHS and third party coverage among IHS beneficiaries for the medical 

services that they are unable to provide. 

It is important to understand that the CHS program does not function as an insurance program with a guaranteed benefit package. The CHS program only covers 

those services provided to patients who meet CHS eligibility and other requirements, and only when funds are available. Many facilities have CHS funds available 

only for more urgent and high priority cases and all utilize a strict priority system 

to approve the most urgent cases first. When CHS funding is depleted, CHS payments are not authorized. 

It is also important to note that when CHS funding is not available to authorize 

payment for a referral that does not mean that the referral is not medically necessary. If a medical provider identifies a need to refer a patient, we assume the referral is medically necessary. The challenge we have, in many cases, is finding funding to pay for these referrals with our annual appropriation for the CHS program. 

48 

Many of our patients have no health care coverage outside of services received 

from the IHS or Tribal health programs, approximately 40 percent based on the Resource Patient Management System patient registration enrollment data. However, 

many of these patients access health care through local community hospital emergency rooms and in other ways. Some patients and community health care providers 

often believe that IHS does or should provide coverage and/or payments for all 

American Indians and Alaska Natives that present for services, so it is not uncommon for providers to expect payment from the IHS or Tribal CHS program even in 

cases where CHS requirements are not met or CHS funding is not available. Patients who access care without meeting CHS requirements are responsible for payment for those services. We constantly have to work with our health care provider 

partners in the private sector and our patients to educate them on our CHS requirements and procedures so that they better understand and can work with us in our 

efforts to fulfill our mission within available resources, including our CHS resources. 

Distribution of CHS Funding Increases 

CHS funding is used to maintain previously existing levels of CHS patient care 

services. This fixed amount is called ‘‘BASE’’ funding. This base funding was originally established based on health care needs and availability of resources for each 

designated population within an area and is not necessarily based on a funding formula. Consequently, the established historical funding base or ‘‘fixed amount’’ does 

not change over the years except for adjustments due to inflation and population 

growth if included in the annual appropriation. 

In 2001, the CHS Allocation Workgroup (CHSAWG) comprised of IHS and Tribal 

representatives from the 12 IHS Areas developed a new formula to distribute funding beyond the base amount made available for CHS in the annual IHS appropriation. The Workgroup-developed formula for allocation of new CHS funding emphasizes the four following factors: 

• Inflation funding based on each Area’s base of the prevailing OMB inflation 

rate; 

• User population to address population growth; 

• Regional and geographical cost variances; and 

• Access to care to the nearest healthcare facility 

Any new CHS funding distribution to the Areas is based on this methodology, 

which is expressed mathematically as follows: 

As the new Director of the Indian Health Service, I have heard from tribes that 

one of their top priorities for internal IHS reform is to discuss improvements in the 

CHS program, which may include a discussion of how we distribute CHS program 

resources. I plan to ask tribes if they want to continue to use this 2001 formula for 

new program increases or whether they would like to discuss changes to the formula. I believe it is important to discuss any changes to the CHS program and its 

funding distribution in consultation and partnership with tribes. Any formula, or 

changes to it, may be more advantageous to some Areas compared with others. My 

primary concern is to assure that any proposed changes to the formula are as fair 

as possible to all our patients and health programs. 

Reasons Services are Not Covered by CHS 

The CHS requirements and how we conduct the business of the CHS program are 

important but complex matters and I would like to discuss them now in greater detail. The most common complaint we receive about the program is why we do not 

pay for all medical referrals. The most important principle that drives policy in this 

case is that IHS cannot incur costs which would exceed available resources. The 

CHS program follows a series of regulatory and other requirements to guide approval and payment of CHS services. Our medical providers identify medically necessary referrals. The CHS program determines whether IHS authorizes payment for 

such referrals. 

Payment for contract health care services may be denied (and the referral care 

may be denied or deferred) for the following reasons: 


1203d3.eps
49 

1.) Patient does not meet CHS eligibility requirements; 

2.) Patient is eligible for alternate resources and IHS is the payer of last resort; 

3.) Prior approval was not obtained for non-emergency services; 

4.) Notification was not made to the IHS or tribal program within the required 

time frames after emergency services were received (generally within 72 hours, 

or within 30 days in certain cases); 

5.) Services could have been provided at an IHS or Tribal facility; or 

6.) Services do not fall within medical priority levels for which funding is available. 

Eligibility 

In general, to be eligible for CHS, an individual must be of Indian descent from 

a federally recognized Tribe, belong to and live in the Indian community served by 

the local facilities and programs, or maintain close economic and social ties with 

said Indian community in a Contract Health Services Delivery Area (CHSDA). If the 

person moves away from their CHSDA, even to a county contiguous to their home 

reservation, they are eligible for all available direct care services but are generally 

not eligible for CHS. Given the limited amount of funding available for CHS, the 

CHSDA rules were implemented to ensure that the funding for CHS was prioritized 

for patients that live in the specified areas. 

When the individual is not eligible for CHS, the IHS cannot pay for referred medical care, even when it is medically necessary, and the patient and provider must 

be informed of this circumstance. The CHS program educates patients on the eligibility requirements for CHS, by interviewing them and by posting the eligibility criteria in the patient waiting rooms and in the local newspapers. The CHS program 

assists these patients by attempting to locate available healthcare services within 

the community at no cost or minimal cost to them. Patients who do not meet CHS 

eligibility requirements are responsible for their health care expenses from other 

providers. If patients have other healthcare resources, such as Medicare, Medicaid 

or private insurance, the third party insurer must pay for the services because IHS 

is the payer of last resort. CHS programs work with the patient to determine if 

those other resources can pay for referrals. Some non-IHS providers have expectations that IHS will be the primary payer for all American Indian and Alaska Native 

patients, whether or not they are eligible to receive care through the CHS program. 

This can lead to strained relationships with local community health care providers 

when payment for medical services are denied by the CHS program leaving the nonIHS providers without compensation if a patient does not have alternate healthcare 

resources such as insurance. While we do everything we can to inform local health 

care providers of the process for authorization of CHS payments for medical referrals from IHS, misunderstandings sometimes still occur. 

Payor of Last Resort Rule 

By regulation, the Indian Health Service is the payor of last resort (42 C.F.R. 

136.61), and therefore the CHS program must ensure that all alternate resources 

that are available and accessible such as Medicare, Medicaid, Children’s Health Insurance Program (CHIP), private insurance, etc., are used before CHS funds can be 

expended. IHS and Tribal facilities are also considered an alternate resource; therefore, CHS funds may not be expended for services reasonably accessible and available at IHS or tribal facilities. As a part of our business practices, both patients and 

outside healthcare providers are informed of the payor of last resort rule, as well 

as other CHS requirements, and we work with all patients to identify any third 

party or alternate resources to help pay for their referrals. This is particularly important when we do not have CHS funding available—patients can still obtain referred services using their other health coverage. This is why we encourage our providers to identify the need for referrals based on medical necessity, not on availability of funding. Sometimes a patient can be scheduled for a referral by IHS with 

an understanding that their health insurance, Medicare, Medicaid, or the CHIP will 

pay for it when we don’t have CHS funding or the patient is not eligible for CHS 

funding. 

Maximizing Alternate Resources 

The CHS program maximizes the use of alternate resources, such as Medicare 

and Medicaid, which increases the program’s purchasing power of existing dollars. 

The IHS works closely with the Centers for Medicare & Medicaid Services (CMS) 

to provide outreach and education to the populations we serve to ensure that eligible 

patients are signed up for Medicare, Medicaid, and CHIP. On February 4, 2009 the 

President signed into law the Children’s Health Insurance Program Reauthorization 

50 

Act of 2009 (CHIPRA, P.L. 111–3). CHIPRA provides $100 million over five years 

to fund outreach and enrollment efforts that increase coverage of eligible children 

in Medicaid and CHIP. Ten percent of these funds are set aside for grants to the 

IHS providers, Urban Indian Organizations, and certain Tribes and Tribal organizations that operate their own health programs for outreach to, and enrollment of, 

children who are Indians. The IHS trains staff and educates patients to maximize 

the enrollment of eligible American Indian and Alaska Natives in CMS and private 

insurance programs. Enrolling patients in these programs frees up existing funds 

to be used for CHS referrals/payments. 

Medical Priorities 

CHS regulations permit the establishment of medical priorities that rank referrals 

or requests for payment when funding is limited, as is frequently the case. There 

are five categories of care within the medical priority system: ranging from Emergency (threat to life, limb and senses) to chronic care services. Medical Priority V 

is considered Excluded Services and would not normally be funded. The medical priority categories are as follows: 

1. Emergency—threat to life, limb, senses e.g., auto accidents, cardiac episodes. 

2. Preventive Care Services e.g., diagnostic tests, lab, x-rays. 

3. Primary and Secondary Care Services e.g., family practice medicine, chronic 

disease management. 

4. Chronic Tertiary and Extended Care Services e.g., skilled nursing care. 

It is important to note that this priority system is only used to rank referrals in 

order of medical priority for payment when resources are limited. It does not imply 

that these referrals are not medically necessary. It assures that we are targeting 

limited resources to the patients most in need of care based on their medical condition, not other factors. 

If the medical condition does not meet medical priorities, the proposed care is 

identified as a CHS deferred service. In the event funds become available, the care 

may be provided at a later date. Again, the IHS cannot incur costs which would exceed the amount of available resources. 

Unified Financial Management System (UFMS) 

The IHS implemented the accounting system (UFMS) in accordance with HHS 

Departmental policy. Prior to implementation of UFMS, the CHS program experienced some challenges in paying providers for authorized referrals; but, we anticipate full implementation of UFMS will mitigate these issues. Making timely payments to community healthcare providers is a priority for us, and we continue to 

look for ways to improve the process. We provided training on this new system prior 

to implementation and continue to train our staff in not only this system but the 

overall management of the CHS program. It is important to note that the issue of 

not paying for referrals that are not authorized is a separate issue. 

Catastrophic Health Emergency Fund (CHEF)—Purpose and Intent 

The CHS program also includes a Catastrophic Health Emergency Fund which 

pays for high cost cases over a threshold of $25,000, as authorized by the Indian 

Health Care Improvement Act (Public Law 94–437), as amended. In FY 2007, the 

CHEF was funded at $18 million and was depleted before the end of the fiscal year. 

In FY 2009, the CHEF program was funded at $31 million and provided funds for 

1,223 high cost cases and was depleted in August. The CHEF is funded at $48 million in FY 2010, an increase of over 100 percent from the FY 2007 level. The CHEF 

cases are funded on a ‘‘first-come-first served’’ basis. When CHEF cannot cover a 

particular high cost case, the responsibility for payment reverts back to the referral 

facility for payment purposes. 

Medicare-Like Rates (MLR) 

The passage of Section 506 of the Medicare Prescription Drug, Improvement, and 

Modernization Act of 2003 established a requirement that Medicare participating 

hospitals accept IHS, Tribal and Urban Indian Health programs’ reimbursement 

rates set forth in regulations and based on Medicare payment methodologies. As is 

the case for health programs of the Department of Defense and certain Department 

of Veterans Affairs health programs, rates are established by regulation based on 

what Medicare pays for similar services. These reimbursement rates are typically 

about 60–70 percent of full billed charges. These rates are established by regulation, 

based on what Medicare pays for similar services, and are typically about 60–70 

percent of full billed charges. The individual physicians and other practitioners paid 

under Medicare Part B are not included in this provision. The savings derived from 

51 

the Medicare-like rates allow Indian healthcare programs to purchase additional 

health care services for American Indians and Alaska Natives, than would otherwise 

be the case. Since the regulation became effective in July of 2007, we have heard 

from several Tribes experiencing increased purchasing power due to payment savings, and expect the Medicare-like rate payment savings to continue. IHS Federallyoperated programs have experienced fewer saving because most had already negotiated provider contracts with payment rates at, or near, the level of the Medicare 

rates. However, the federally-operated programs benefit from the guarantee of reasonable rates that the regulation provides. Area Office CHS staff continue their efforts to negotiate contracts with other providers not covered by the MLR to achieve 

the most cost-effective payment rates possible. 

We realize the importance of making maximum use of available CHS funding and 

we are focused on improvements in the ways we do business in the overall CHS program. We work to ensure that staff maximizes the use of alternate resources, assist 

eligible patient to enroll in other types of health coverage, apply the Medicare-like 

rates, negotiate lower reimbursement rates for services not covered under MLR, and 

apply medical priorities and other CHS requirements strictly and fairly. For many 

years, the program also has implemented managed care practices in an effort to 

maximize resources. We focus our efforts on cost-effective strategies for our CHS 

cases such as improved case management and utilization of telemedicine. We are 

working diligently to recruit and retain providers to provide more direct care in our 

facilities, thus reducing the demand on CHS. We are also working to improve the 

CHS systems and processes by utilizing the electronic health record and the new 

UFMS system. And, we continue to build partnerships with our non-IHS healthcare 

providers through local and national meetings. I also look forward to consulting 

with tribes on how to improve the CHS program now that they have formally indicated to me that it is a priority for Internal IHS reform. 

Mr. Chairman, this concludes my statement. Thank you for the opportunity to testify on the Contract Health Services programs serving American Indians and Alaska 

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

The CHAIRMAN. Dr. Roubideaux, thank you very much. You described a couple of things: one, a shortage of money in the aggregate to cover all of the needs. I think you indicated in your testimony 360 million services were denied and deferred in 2008. And 

my guess is there are some American Indians out there whose 

credit is destroyed because likely they got the service, had no 

money, only to discover that Contract Health won’t pay. They are 

supposed to pay. Their credit rating is trashed, and it goes to a collection service. 

I mean, that is the awful part of this. The first part is the lack 

of funding generally to do what we have promised to do in Contract 

Health. And the second is the issue of the formula. And so you described what you are going to do with the formula. You are going 

to begin a consultation with tribes. I think that makes a lot of 

sense in terms of how you would distribute funding for Contract 

Health. 

But let me ask you just a general question. If you had your will 

and your ability to do whatever you wanted to the Contract Health 

Service to make it work, to keep the promise to American Indians, 

what would that be? 

Dr. ROUBIDEAUX. Well, personally if I had my wish, I would find 

funding so we could pay for all of the referrals. But you know, personally I don’t have that much money. 

In terms of the Indian Health Service, I think it is important for 

us to do two things, is to consult with tribes on how we distribute 

the funding, and the second thing is for us to look at how we do 

business. 

I really think there is a lot of ways that we can improve the way 

we do our program. For example, we can better assist patients in 

52 

understanding why we have to look at the payment for the referral. 

We can do a lot of work with our local health care providers to 

make sure they understand the rules, so that there are no misunderstandings about who is going to pay. We can better look at 

how we are monitoring our costs and making sure that we are negotiating good rates, making sure that we are processing the claims 

in a timely manner, and making sure that we are trying to do what 

we can to get the patients their medically necessary referrals. 

The CHAIRMAN. Let me ask you about the process. Let’s assume 

that a woman on the Standing Rock Indian Reservation presents 

herself to the Indian Health Service clinic and she has a knee condition that is unbelievably painful, bone on bone, impossible to 

walk and so on. And I assume that that is referred because the referral would mean that they can’t treat that at that Indian Health 

Service clinic at Fort Yates, North Dakota. 

So the person is referred to an orthopedic surgeon in one of the 

hospitals in Bismarck, but I also assume that is not a priority one 

or two, right? It is not life or limb. 

Dr. ROUBIDEAUX. Well, yes, if a patient comes in and is seen by 

the medical provider, the medical provider assesses them and 

makes a diagnosis of, you know, knee pain. And then if the facility 

doesn’t have an orthopedic surgeon, then the medical provider 

writes out a referral to an orthopedic doctor. Then the patient is 

instructed to take the referral to our Contract Health Services office, and then our Contract Health Services office looks at that referral and tries to help figure out, okay, first does the patient have 

other resources that might be able to pay for that? And second, do 

we have enough funding to pay for it with our Contract Health 

Services Program? If we don’t, then they have to consider that referral with all the other referrals according to medical priority. 

The CHAIRMAN. But they are prioritizing their referrals. Is the 

situation I described, a desperate need for an orthopedic doctor to 

address this unbelievable pain of bone on bone in the knee, is that 

considered a priority one on most reservations? 

Dr. ROUBIDEAUX. Well, it depends. If the person couldn’t walk, it 

could be sort of life and limb. But if the person can still walk, it 

may be in a different priority category. And it depends on the 

availability of funding. If funds are not available for that category 

that it fits into, then it wouldn’t be paid for. 

The CHAIRMAN. And even if it is a priority one life and limb, if 

it is let’s say June and the contract health funds are exhausted, 

then what happens? 

Dr. ROUBIDEAUX. Well, it depends on the facility because in some 

facilities, the funds last longer or can pay for more referrals versus 

others, depending on all the other resources in terms of alternate 

resources like Medicare and Medicaid available. But it could be a 

case where funding is limited and this particular referral doesn’t 

meet the highest medical priority that we can pay for. So in that 

fact, the patient would not be able to have a referral. 

The CHAIRMAN. But my question is, this person shows up at the 

Contract Health office and it is June. Don’t get sick after June because there is zero money. What happens at that point? If there is 

zero money, there is no referral? 

53 

Dr. ROUBIDEAUX. Well, if there is not funding available for the 

level of priority of that referral, then the case could either be denied or deferred. And what some facilities do is that they have 

these referrals and they meet weekly with medical providers and 

try to figure out which cases meet the highest priority. So unfortunately, some patients may have to wait to get that referral paid for. 

The CHAIRMAN. We had testimony before this Committee. I know 

anecdotal testimony sometimes you can’t draw a more general conclusion from it. A doctor, an orthopedic doctor testified before this 

Committee about a woman who came to him having been treated 

at the Indian Health Service, with an unbelievably painful knee 

condition, almost unable to walk because it was bone on bone. And 

the treatment at the Indian Health Service was to wrap the knee 

in cabbage leaves for four days. 

Of course, that produced no pain relief at all, so she showed up 

then at the Bismarck Hospital to the person that came to testify. 

The person testifying said this is a woman who was living with 

pain that almost no one should have had to live with, and wrapping a knee in cabbage leaves is not going to address a serious orthopedic problem. 

The reason I ask these questions is I think almost certainly 

someone at an Indian Health Service clinic someone with a serious 

orthopedic problem is not going to get help there. In most cases you 

don’t have an orthopedic surgeon or orthopedic doctor at that clinic, 

so it gets referred. And the question is, who pays for it, under what 

conditions does it get paid for. 

And I think the biggest issue for us is to try to figure out, not 

just how do you increase the aggregate amount of money, but how 

do you, on serious medical issues that must be referred. Because 

if they can’t be handled by the Indian Health Service clinic, how 

do you keep the promise to that Native American who was promised health care. The Native American discovers that that promise 

means only optional health care if someone decides to give you the 

go sign as opposed to the stop sign when you stop at the Contract 

Health office? 

And we are trying to work through, a number of us on this Committee, trying to work through a reform proposal on Contract 

Health or some sort of pilot project. We just can’t continue doing 

this. It is not fair to say to somebody who is desperately ill or desperately in need of attention, it is June and your tribe has run out 

of Contract Health funds. 

That is just not fair and that is, we have heard on the Floor of 

the Senate all kinds of discussion about rationing of health care. 

I know exactly rationing goes on and so do you. The rationing went 

on when 360 million worth of care that was required, necessary, 

was not able to be compensated, denied and deferred. 

So, I mean, that is rationing. And it is not on the front pages because nobody pays very much attention, which I think is shameful. 

You have taken over this job. It is a big job. All of us want to work 

with you in every possible way because we want you to succeed. If 

you succeed, Native Americans will receive the full flower of the 

promise that was given to them. 

So, Senator Murkowski? 

54 

STATEMENT OF HON. LISA MURKOWSKI, 

U.S. SENATOR FROM ALASKA 

Senator MURKOWSKI. Thanks, Mr. Chairman. 

Interesting discussion about how it actually works, not in theory, 

but in practice. And as you say, I mean, this is rationing in action. 

This is one of our government-run health care plans, and when you 

don’t fully fund it, as we do not within IHS, we see what happens. 

To know that, well, if you get sick after June when those Contract Health funds have run out, you are out of luck, if not unlike 

what many veterans in the State of Alaska face within the V.A. 

system. If you happen to live in the right place, you can get those 

services. But if you are in a village and you have no way to get 

to town, so to speak, those services that were promised you, whether you are a veteran or whether you are an Alaska Native/American Indian, are not available to you. That is rationing in all-capital 

letters here. 

Some of the Alaska Native health leaders have raised concerns 

with me about reopening the Contract Health Services distribution. 

I understand that the tribes are very much divided on this distribution formula, and as long as we have this chronic under-funding, they are going to be continue to be divided on the formulas. 

We recognize that the negotiated rulemaking process is by nature a very contentious process, and I would hope that we don’t put 

the tribes in the position of battling over limited or scarce funds. 

I want to ask you, Dr. Roubideaux, whether or not the IHS keeps 

track of the chronic under-funding of Contract Health Services. 

How do you know what your unfunded balance is, I guess, if I can 

frame it that way? Do you keep track? 

Dr. ROUBIDEAUX. Yes. In the Contract Health Services Program, 

we do track with the Indian Health Service programs what number 

of cases are denied and deferred, so that we can have an estimate 

of the numbers of cases that we were not able to fund. 

Senator MURKOWSKI. And as you prepare for the budget coming 

up here, do you plan on requesting funds to address the shortfall? 

Dr. ROUBIDEAUX. Well, it is clear that the amount of resources 

we have to pay for referrals is not adequate. 

Senator MURKOWSKI. It doesn’t work. 

Dr. ROUBIDEAUX. Yes. So as we look at our budget formulation 

process, the first thing we look at is the recommendations from our 

tribes. And our tribes have indicated that more funding for Contract Health Services is a priority, so we do take that—— 

Senator MURKOWSKI. Is a priority or their number one priority? 

Have they specified? 

Dr. ROUBIDEAUX. Yes, they do list the priorities in their budget 

formulation recommendations, and I know that it is in the top 

three, for sure. They also have other top priorities that include the 

Indian Health Care Improvement Fund and improve contract support costs. But Contract Health Services is indicated as one of their 

top priorities and we fully consider that as we develop our budgets. 

Senator MURKOWSKI. Well, I would hope that you would. I would 

hope that you would take a very critical look and review as to what 

the chronic under-funding has been. We recognize that these are 

difficult budget times, but as the Chairman has noted not only 

today, but on many, many other occasions when I have sat at the 

55 

dais with him, this is an issue that would be unacceptable anywhere else, and yet somehow, some way in Indian Country it is 

just allowed to continue. The IHS budget is just, when it comes to 

Contract Health support costs, it just hasn’t been funded. And we 

hear the stories of the consequences. 

A little bit off-subject, but knowing that you were here during 

the discussion about the dental health therapists, has the IHS 

taken a position on the expansion of the DHAT Program? 

Dr. ROUBIDEAUX. The Department of Health and Human Services has not taken a formal position on that issue, but we are reviewing the various positions. 

Senator MURKOWSKI. Have you had a chance yourself to observe 

what we have been able to do with the DHAT Program in Alaska? 

Dr. ROUBIDEAUX. Yes, I have. I think it is a great program. 

Senator MURKOWSKI. Well, I appreciate your attention to it. I do 

think we recognize that we have worked hard to be out front in developing a model that will not only work in a very remote place like 

Alaska, but that can be used in other parts of the Country if we 

do it right. I think we have a pretty good model up there, and we 

are saying we are open to the rest of the world to take a look at 

it, review this, assess it. We are happy to share all that we know 

of it, but we think that we have something very good and very positive coming in and we would certainly encourage the support from 

IHS on this. 

Dr. ROUBIDEAUX. Well, I look forward to traveling to Alaska and 

learning more about their programs. I actually was scheduled to be 

there this week until the hearing was scheduled. So I look forward 

to going there. 

Senator MURKOWSKI. Oh, darn it. I was going to get her up there 

in December. 

[Laughter.] 

Dr. ROUBIDEAUX. So as soon as I can, I will go and visit Alaska. 

But I want to reassure all the Members of the Committee that related to the Contract Health Services Program, we believe that the 

referrals that are made are medically necessary and that our patients deserve the highest quality of care. And as the Director of 

the Indian Health Service, I am committed to working in partnership with our tribes to look in our budget formulation to make Contract Health Services a priority, as the tribes want us to, and also 

to look at how we do the business of the Contract Health Services 

Program to make sure that as many patients can get these referrals as efficiently as possible. 

Senator MURKOWSKI. I appreciate that and look forward to your 

visit to Alaska. Thank you. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Dr. Roubideaux, thank you very much. We will 

excuse you. I know you have other things to do, and we appreciate 

your patience today. Thank you for coming. 

Dr. ROUBIDEAUX. Thank you very much. 

The CHAIRMAN. Next, we will hear from Connie Whidden, who is 

the Health Director of the Seminole Tribe in Florida, Hollywood, 

Florida; and Mr. Mickey Peercy, the Executive Director of the 

Health Services of the Choctaw Nation of Oklahoma in Durant, 

Oklahoma. 

56 

Let me thank the two of you for your patience as well. 

You may proceed, Ms. Whidden. Thank you. 

STATEMENT OF CONNIE WHIDDEN, HEALTH DIRECTOR, 

SEMINOLE TRIBE OF FLORIDA 

Ms. WHIDDEN. Thank you for the opportunity to be here today. 

My name is Connie Whidden. I am a member of the Seminole Tribe 

of Florida and have served as its Health Director for 15 years. I 

have been asked to provide testimony on the tribe’s experience with 

Contract Health Service Program. 

Under a self-governance compact with the IHS, the Seminole 

Tribe offers primary care programs at the ambulatory clinics located on our reservation. We also operate the CHS programs. CHS 

funding nationwide is extremely inadequate. Last year, the Seminole Tribe received approximately $1.9 million for its CHS Program. The tribe supplements these CHS funds significantly to ensure that eligible tribal members receive the care they need. 

To address the unmet need, the tribe created and administers a 

supplemental self-funded CHS member health plan. Eligibility is 

limited to tribal members and descendants who are eligible for the 

CHS Program. Consistent with the IHS regulations, all beneficiaries must enroll in other programs for which they are eligible, 

such as Medicare and Medicaid, in order to be eligible for services. 

After our supplemental plan was established, Medicare paid first 

for care to tribal members enrolled in Medicare. But approximately 

18 months ago, Medicare began denying claims from patients covered by our supplemental plan. For example, one of our tribal 

members who is enrolled in Medicare is in end-stage renal disease 

and is undergoing dialysis treatment. Medicare approved the claim 

early in the treatment, but then started to deny payments, asserting that the patient has another resource, namely the tribe’s supplemental plan which Medicare erroneously concluded was an employment-based plan. The patient has appealed the denied claims. 

In the meantime, the tribe has paid the provider more than 

$500,000 to assure that the patient has continued access to dialysis 

service. Two weeks ago, tribal officials met with the Director of 

CMS Financial Services Group. We explained that the tribe’s CHS 

supplemental health plan is not an employment-based group health 

plan, so the secondary payment rules are not a basis for denial of 

Medicare payments. 

We explained that the tribe’s plan supplements the CHS Program. Federal regulations require that all alternate resources must 

be used before the CHS Program will be responsible for any payment. The Director agreed to consult with IHS officials before making a final determination on the tribe’s request to correct the denied Medicare claim. We understand that these conversations have 

begun. 

Mr. Chairman, the real issue here is whether the Federal Government will honor its trust responsibility to pay for medically necessary services provided to tribal members through the CHS Program as administered by the Seminole Tribe. If Medicare fails to 

pay, it will be yet another broken promise to Indian people. 

To truly fulfill the United States’ trust responsibility to Indian 

people for health care, the CHS Program should be an entitlement 

57 

program. Until that happens, however, we urge Congress to assure 

that the Federal Government does not further abrogate its trust responsibility. If existing laws can be interpreted to allow CMS to 

deny Medicare benefits on this basis, then the law need to be clarified to assure that this practice does not continue. 

I hope that CMS will quickly determine that Medicare is a primary payer for the Seminole tribal members whose claim has been 

denied. If it does not, I look forward to working with this Committee and Congress to address this issue. 

Thank you for the opportunity to testify today. My staff and I 

will be happy to answer any questions you may have. 

[The prepared statement of Ms. Whidden follows:] 

PREPARED STATEMENT OF CONNIE WHIDDEN, HEALTH DIRECTOR, SEMINOLE TRIBE OF

FLORIDA


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The CHAIRMAN. Ms. Whidden, thank you very much for being 

here, and your testimony. 

Mr. Peercy, you may proceed. 

STATEMENT OF MICKEY PEERCY, EXECUTIVE DIRECTOR OF 

HEALTH SERVICES, CHOCTAW NATION OF OKLAHOMA 

Mr. PEERCY. Thank you, sir. I have a voice problem so I am going 

to be sucking water as we go, but I wanted to thank the Committee 

for the invitation. I am Mickey Peercy, Choctaw Nation of Oklahoma, Executive Director of Health. 

Choctaw Nation covers 10.5 counties in Southeast Oklahoma, 

very rural there. We have a 37-bed hospital and eight ambulatory 


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68 

clinics that cover a space about the size of Vermont. We have about 

200,000 primary patient visits per year, a user population of about 

40,000, as well as about 520 births. 

Today, I am going to speak to you as a clinical social worker, so 

it is not going to be a lot of empirical stuff, but it is, with 25 years 

of experience in working with tribal health programs and working 

with Indian Health Service, I am sorry that Dr. Roubideaux left. 

I think she had read my testimony and felt like I had insulted her 

in my testimony. That wasn’t the intent at all, and she and I get 

along real well, so we will work through that. 

I am not going to describe to you what Contract Health is. I 

think that Dr. Roubideaux did a great job of doing that. You folks 

on this distinguished panel know what CHS is. You know it is rationed care. You also know CHS is woefully under-funded, as well 

as all of IHS. 

We applaud Chief Pyle. I wanted to make sure that you knew we 

applaud the movement that Congress is making this year and 2010 

with the $144 million increase. We ask that that be done at least 

in a lump sum next year or in a five-year increment so at least that 

same amount of significant money. There has to be significant 

money put in the system. 

I think what Dr. Roubideaux might have had an issue with is I 

wanted to contrast a little bit of what Indian Health Service, how 

they run CHS, and how tribal-operated programs, specifically Choctaw’s, would run. 

And my observation is that Government employees, not just Indian Health Service, have a real problem dealing with private sector individuals. Keep in mind, CHS is private sector-driven. It is 

outside of the Indian Health Service. It is outside of V.A. We go 

from our primary care facility to that next level, which is private 

sector. And when government and private sector get together, it 

doesn’t hardly ever work out, the two different mind-sets. And that 

is what I think the issue is with, especially with Indian Health 

Service. And again, I have been around it for many years in terms 

of the issues that, you know, the staff in Indian Health Service, 

they are good people, but they have rules, regulations. They have 

this new USMF system that I guess all the Government has, that 

you can’t, which is cumbersome, it takes forever, the rules, the regulations that take forever. 

On the other side, and I guess just to talk a little bit about the 

private sector, those folks expect to be paid. You know, they are 

running their own business. They are running their own labs. They 

are running their own radiology services. They expect to be paid, 

and they don’t want to wait for a year to be paid, and they don’t 

want to wait six months. If you make a referral, they expect to be 

paid within a reasonable time. 

It is really tough in the world of government to get something 

like that done, and I think that is a real drawback for the Service. 

In most cases, in my experience, Federal employees always have, 

and I think you heard Dr. Roubideaux say, you know, it is Federal. 

We don’t have deficit spending. If we run out of money, we run out 

of money. And Feds, in my experience, tend to use that, if you are 

dealing with private sector folks and payment folks, you always can 

say, we are the Government. 

69 

In contrast with the tribally-operated program, you know, if our 

system turned down somebody for CHS in McAlester, Oklahoma, I 

am probably going to see that person at the next community meeting. And I am probably going to see that person. They are family. 

They are community family and they are voters for the tribe. 

So I do think that tribal programs are better able to operate CHS 

programs, have it easier because we can go out to that doc, and if 

I have a doc that needs to be paid within a short period of time, 

we can do a quick check in about three days. You know, so we can 

function better with the private sector, whether that be hospitals, 

diagnostic labs or anybody else, than the Indian Health Service. 

We have that advantage. Plus that is our family. 

And I know my time has run out, so I will try to speed up real 

quickly, sir. 

What we would like to see and what we are starting to do at 

Choctaw, instead of—I know Dr. Roubideaux mentioned the lady 

you mentioned would go to the CHS office—and a lot of what or 

would have been in CHS offices are those clerks who take that information and they look at it. What we try to do and what we are 

trying to do is turn our people into case managers, instead of saying no and writing the letter and sending the letter out. 

We are trying to case manage, make sure that we sit down with 

them, make sure we explore those resources, make sure we get 

back to them. There is a way of saying no to someone without sending a letter. And there is a way of putting somebody on a list and 

continuing to work with them. 

So we are trying to change the scope of our Contract Health 

Service to a case management, and try to change the name of it. 

And I would like to see us work, tribes with IHS, in maybe taking 

a look at developing that model. 

One thing I also wanted to mention, when Dr. Roubideaux was 

talking about, I think the question was asked about deferred and 

denials. That is a list, but in my experience over the years, when 

doctors don’t think that service is going to be paid, they don’t send 

a referral. So you don’t have a denied and referral. So I think the 

number of denieds and deferrals are probably under-tabulated. 

And with that, I will just make quick recommendations. The finance piece, encourage Indian Health Service and tribes to look for 

best practices and let us work together not on the funding methodology, but on how we deal with best practices in taking care of our 

patients, and how we deal with the private sector. I think the funding methodology was put in place, I worked on that work group in 

2001, and it was put together. But this is the first year that that 

methodology ever hit. There was never ever enough funding to 

make that methodology work. So I would suggest we leave that in 

place. 

And I would just answer questions. 

[The prepared statement of Mr. Peercy follows:] 

PREPARED STATEMENT OF MICKEY PEERCY, EXECUTIVE DIRECTOR OF HEALTH

SERVICES, CHOCTAW NATION OF OKLAHOMA

Good Morning Chairman Dorgan, Vice-Chairman Barasso and distinguished 

Members of this Committee. On behalf of Chief Gregory E. Pyle, of the Great Choctaw Nation of Oklahoma, I extend to you the support of the people of the Choctaw 

Nation to work with you in addressing the priority issues of Native American peoVerDate Nov 24 2008 12:57 Jun 30, 2010 Jkt 057096 PO 00000 Frm 00073 Fmt 6601 Sfmt 6621 S:\DOCS\57096.TXT JACK PsN: JACKF
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ples. Thank you for inviting the Choctaw Nation to provide testimony on the desperate need for contract health services funding. 

The Choctaw Nation of Oklahoma is and American Indian Tribe organized pursuant to the provisions of the Indian Reorganization Act of June 26, 1936–49. 

Stat.1967. and is federally recognized by the United States Government through the 

Secretary of the Interior. The Choctaw Nation of Oklahoma consists of ten and onehalf counties in the southeastern part of Oklahoma and is bordered on the east by 

the State of Arkansas, on the south by the Red River, on the north by the South 

Canadian, Canadian and Arkansas Rivers, and on the west by a line slightly west 

of Durant that runs north to the South Canadian River. 

We have been operating under a compact of Self-Governance since 1995 in the Indian Health Service/Department of Health and Human Services and in the Bureau 

of Indian Affairs/Department of the Interior since 1996. The Choctaw Nation of 

Oklahoma believes that responsibility for achieving self-sufficiency rests with the 

governing body of the Tribe. It is the Tribal Council’s responsibility to assist the 

community in its ability to implement an economic development strategy and to 

plan, organize and direct Tribal resources in a comprehensive manner which results 

in self-sufficiency. The Tribal Council recognizes the need to strengthen the Nation’s 

economy, with primary efforts being focused on the creation of additional job opportunities through promotion and development. By planning and developing its own 

programs and building a strong economic base, the Choctaw Nation of Oklahoma 

applies its own fiscal, natural, and human resources to develop self-sufficiency. 

These efforts can only succeed through strong governance, sound economic development and positive social development. 

Issue 

Contract Health Service (CHS) is the most complex and dysfunctional service delivered by the Indian Health Service, Tribally Operated Health Program (IT) health 

care delivery program. CHS is designed to refer patients and reimburse providers 

outside the IT system for medical services provided to American Indians/Alaska Natives (AIAN) patients. CHS services consist of those services not provided by the IT 

hospitals and clinics. The Congress is aware of what CHS is designed to do. The 

question is how it can be improved. 

The most logical way to fix the contract health problem is to provide adequate 

funding for the IT system. The Congress is also aware of the marginal funding level 

for ITs overall, and specifically in this line item. 2010 appropriations level for CHS 

is a positive step and needs to be continued, with that type of increase for the next 

5 years. At this point, we know that some tribal health programs receive assistance 

in their health programs budget, some specific to CHS, from their tribal governments. Not all tribes have the developed and economic development base that allows 

this support. Also, in most cases these tribal funds are not recurring and cannot be 

counted on long term. Significant federal funding over the next several years is critical. 

An important aspect of CHS that has been difficult for the Indian Health Service 

to work with is the private sector relationship. Administrators and Providers must 

work in a collaborative effort with hospitals, clinics, imaging services, diagnostic 

labs and doctors who provide services in a whole different world than the IT system. 

As much as providing quality service, they are driven by the bottom line, the reimbursement. They expect to be paid for their service. 

Federal employees in the Indian Health Service do not, and will not ever, fully 

understand the private sector concept. They have always had the ability to fall back 

on the federal system. In most cases federal employees do not concern themselves 

with the private sector providers who refuse to see our patients because they are 

either not getting paid or have to wait as much as a year for payment. The antideficiency act is always there. This is not to say that federal staff are bad, they are 

just always going to err on the side of the government. It is in their DNA. 

Whether you receive, in some cases, a life or limb saving procedure should never 

be determined on the basis of if you called in within 72 hours of an incident or hospitalization, or whether the committee could not meet on a certain day, or if it is 

after July 1, and the funds are gone. We must provide case management. 

Many Tribally Operated Health Programs have reached out to private sector specialty care facilities and providers and have formed strong partnerships with them 

to include: quality of care issues, authorization/referrals, and expectation of payments. In addition, Tribally Operated Programs own the responsibility of the patient. The patient is family, a community member and a voter. It is imperative that 

they are treated with respect, even if the funds are not available for a service; the 

way this is conveyed to a patient is important. We are changing the scope of work 

for our staff members that work in the CHS environment. It not acceptable to just 

71 

say ‘‘No’’. This staff will be trained in Case Management. All staff must be trained 

to work with outside vendors and most importantly with our patients. 

There are ‘‘best practice models’’ for CHS out there within the Tribally Operated 

Programs. They are not perfect, as we are all underfunded. We need to share those 

models, and others have to be ready to listen. 

Recommendations 

2010 appropriations for CHS was a good faith beginning for Congress. Additional 

fiscal support of at least at the 2010 level should continue for the next 5 years. 

Strongly encourage the Indian Health Service to explore some ‘‘best practice models’’ of tribal programs around the areas of customer service, collaboration with referral sources, case management and fund management. 

Currently the Senate Committee on Indian Affairs is working on S. 1790, Reauthorization of the Indian Health Care Improvement Act. There are two sections 

within that legislation that are controversial. Section 131, proposes a negotiated 

rule-making process to develop a distribution formula for the CHS program. The 

Choctaw Nation of Oklahoma strongly recommends that this provision be deleted. 

A funding formula was developed in 1999 through consultation with Tribal leaders. 

It is ironic that 2010 is the first year that a CHS increase has contained enough 

resources to trigger this funding methodology. Section 192 of S. 1790 proposes establishing a new Contract Health Service Delivery Area (CHSDA) for North and South 

Dakota. We fear that if this happens the result could be an attempt to shift funds 

from one Area to another which will have a tendency to pit tribe against tribe. We 

ask that this provision not be allowed to proceed. 

Establish a regular hearing before this Committee to ensure progress. 

The Choctaw Nation of Oklahoma strongly requests that Congress respect the 

sovereignty of Tribal Governments in defining their citizens. We are defined by the 

Dawes Commission and our Constitution. 

Conclusion 

There is no ‘‘magic bullet’’ fix for the underfunding of Contract Health. The issue 

critically affects all Tribes. The Choctaw Nation of Oklahoma strongly urges this 

Committee, and the entire Congress to work with Tribes and with each other to 

remedy this long-standing problem. We stand ready to assist the Committee in any 

way we can. 

On behalf of the Choctaw Nation of Oklahoma, and Chief Gregory E. Pyle, I appreciate the opportunity to offer our Tribe’s views on the needs of the Contract 

Health Services system. 

Thank you for allowing me to testify today. 

The CHAIRMAN. Mr. Peercy, you just indicated that doctors, I assume you are talking about doctors at the IHS. 

Mr. PEERCY. At the clinic. 

The CHAIRMAN. The IHS clinics, will decide not to defer if they 

think it is going to be turned down anyway. Is that correct? 

Mr. PEERCY. True. 

The CHAIRMAN. So you think that perhaps we are getting less 

than accurate information about how much Contract Health Services are denied because some was just not referred that probably 

should be just because the doctor says this isn’t going to happen. 

Mr. PEERCY. Yes, sir. 

The CHAIRMAN. Tell me about your notion of case management. 

I mean, you are talking about case management. Describe what 

you mean by that. I mean, if someone comes in with a medical condition and there is no money in Contract Health Service, what does 

case management mean to a pain? 

Mr. PEERCY. Case management has to do with really doing an assessment on the socioeconomic side of that patient in terms of are 

there really any resources out there? Is there, if it is a medication, 

is there a needy meds number you can call? There are many pharmaceutical companies who will provide medications. That may not 

be in our formulary. There are many foundations out there. There 

72 

is St. Jude’s. There are many places that people can sit with and 

say, well, we can’t go this way; let’s go this way. 

And you know, Choctaw CHS folks weren’t trained that way 

until a couple of years ago, and we are trying to start training 

them. The thing comes in, do they meet the eligibility, are they living in our geographical area, did it come within 72 hours of when 

it was supposed to, was a phone call made. And I heard Dr. 

Roubideaux, it is right—mention A, B, C, D, C. How many things 

kept people out? 

Well, we are trying to look for things that get people in. 

The CHAIRMAN. All right. I mean, case management is not a substitute for the health care. Your case management is a way to try 

to find a road into the health care system. 

Mr. PEERCY. Yes, sir. 

The CHAIRMAN. Ms. Whidden, how many members of the tribe 

that you represent? 

Ms. WHIDDEN. We have approximately 3,500 enrolled members 

and another 200 descendants of the Seminole Tribe that we provide 

services to. 

The CHAIRMAN. You described that the tribe set up a supplemental system that would be available to assist those who need 

help when the Contract Health money is not available. And then 

you indicated those who are Medicare-eligible would have Medicare 

billed, which I understand. Medicare would be billed for the procedure first, and Medicare was paying that, and then decided, no, we 

are not going to pay it. This is because the supplemental system 

the tribe set up means that Medicare doesn’t have to pay it. The 

supplemental system should be called upon first. 

Has anyone done a legal analysis of that? I mean, tell me, how 

did you discover this? They just began denying claims? 

Ms. WHIDDEN. Yes, it did. We worked at the local, when it was 

first denied, we worked at the local and regional offices trying to 

resolve this and trying to see why it had been paid, and now all 

of a sudden it was being denied. And I think in my presentation, 

they said something about reason such-and-such number, which 

turned out to be they thought that our tribal members had insurance which was employment insurance, and that was not the case. 

So after 18 months of back and forth, a couple of weeks ago we 

came up to Baltimore, met with the CMS people and that is when 

we began to see what the differences were and we did tell them 

that it is not an insurance plan; that it is a supplement to CHS. 

The CHAIRMAN. Is it now resolved or not? 

Ms. WHIDDEN. No. It is not. 

The CHAIRMAN. Okay. Does your tribe run out of Contract Health 

Service money in the year? 

Ms. WHIDDEN. Yes. 

The CHAIRMAN. When? 

Ms. WHIDDEN. By the end of the first quarter. 

The CHAIRMAN. So at the end of the first three months of the 

year, you are out of Contract Health Service money? 

Ms. WHIDDEN. Yes. 

The CHAIRMAN. And then someone who goes to, do you have a 

clinic, the IHS clinic on the reservation? 

Ms. WHIDDEN. Yes. 

73 

The CHAIRMAN. And someone goes to that clinic tomorrow morning and they have any number of problems that cause them great 

pain. It is likely the doctor onsite would want to refer to a specialist, perhaps, and that referral would then probably go to a contract health office on your reservation? 

Ms. WHIDDEN. Yes. 

The CHAIRMAN. And they would show up and the contract health 

office would say no money here on contract health; that is exhausted. 

Ms. WHIDDEN. No, we don’t even let our patient know that CHS 

funding has been exhausted. 

The CHAIRMAN. You immediately grab them in the supplemental 

program? 

Ms. WHIDDEN. Yes. 

The CHAIRMAN. And if they are Medicare-eligible, you move 

them—— 

Ms. WHIDDEN. Yes, and he talked about case management. We 

have medical social workers who know when our elder population 

will turn 65 and they start working with our clients or our patient 

to make sure that they are enrolled with Medicare. 

The CHAIRMAN. Now, why do you think that you run out of 

money at the end of the first quarter? I mean, that is pretty dramatic under-funding, isn’t it, on contract health? 

Ms. WHIDDEN. Yes. 

The CHAIRMAN. Mr. Peercy, when do you run out of money, or 

don’t you? 

Mr. PEERCY. We are fairly fortunate with economic development. We get about $5 million from the line item of CHS, and then the 

tribe supplements $7 million. So we have about $12 million. And 

we would run out of money without the tribal improvement. 

We are fortunate also where we are at. It is about 87 percent to 90 percent Choctaw, and so those $7 million from the tribal side 

are specific to Choctaw members, and the Federal money certainly 

takes care of Choctaws and other members. 

The CHAIRMAN. How many members of the Choctaw Nation? Do 

you have an enrolled—— 

Mr. PEERCY. Yes, nationwide there is about 200,000. Within the 

10.5 counties, there is probably 60,000. 

The CHAIRMAN. Is that recognized, 60,000? 

Mr. PEERCY. Yes, sir. 

The CHAIRMAN. That is recognized as a separate tribe, a separate 

tribal entity? 

Mr. PEERCY. It is all Choctaw Nation. 

The CHAIRMAN. Okay. 

Mr. PEERCY. Yes, 200,000, and only about 60,000 live in the 10.5 

counties. 

The CHAIRMAN. I understand. 

Well, what we are trying to think through is how to do this differently. I mean, clearly contract health is a process by which if we 

have provided a guarantee, and we have actually signed treaties to 

say we promise, and have trust responsibilities to say we are going 

to take care of this population with respect to their health care. 

We put together an Indian health system, IHS. They establish 

clinics. Those clinics are staffed with certain health professionals, 

74 

and then the tribal member will go to that clinic. And if that clinic 

is not able to address that health care need, there would be a referral to some other facility, and that will be paid by contract health. 

That is the purpose of contract health, to be the facilitator, the 

funding facilitator to move to a specialist or another facility where 

the health care they need would be made available to them. 

The dilemma is if we have reservations that are running out of 

funding at the end of the first quarter. Some reservations don’t 

have extra revenues and can’t put together a supplemental program, Mr. Peercy, you have described. 

Mr. PEERCY. True. 

The CHAIRMAN. That means that the person that comes in is 

going to be told no. Or perhaps the person will find their way nonetheless to a hospital thinking it is going to be paid, and then have 

their credit rating ruined because they get the health care and it 

doesn’t get paid. This happens all too often, where a person’s credit 

rating is ruined. 

And so we have got to find some reform approach to Contract 

Health. This is the purpose of this discussion with Dr. Roubideaux 

and to hear your perspectives as well, to try to evaluate. 

If you know what doesn’t work, and we know what doesn’t work, 

and that is dramatically under-funding Contract Health. Then 

what is it that can work other than just funding up to a certain 

level? Are there other ways? You mentioned case management and 

other efforts that could improve the system. I agree, and certainly 

the Indian Health Service itself can be improved in many ways. 

But can this particular piece of public policy, Contract Health 

Services, be reformed and improved? Or do we just continue with 

the model we have and continue to under-fund it? This means 

there is actual deliberate rationing going on. Notwithstanding, I 

am not suggesting that people at the start of the year say, you 

know what? Let’s ration health care. But deliberate in the sense 

that everyone knows it is under-funded. If it is under-funded, then 

we have a population in this Country that are recipients of fullscale health care rationing. I find this abominable, especially inasmuch as the entire government has made a written promise. 

So we are just trying very hard to address this. 

Mr. Peercy? 

Mr. PEERCY. Yes, sir. I think so. I think with funding and with 

additional funding and being able to deal with the private sector 

on a closer basis, more collaboration, knowing that we are always 

going to have rationed care. I don’t see the day ever there that we 

are going to pay for heart and lung transplants. You know, but I 

don’t know how many private sector insurance things pay for that, 

either. 

But there ought to be a way that we can get through priorities 

one and two. 

The CHAIRMAN. Yes. 

Mr. PEERCY. You know, we don’t want to do orthodontics. You 

know, we are not talking orthodontics. We are talking that basic 

priorities one and two, and not the cosmetics, not the orthodontics, 

but what we consider the—— 

Ms. WHIDDEN. The very basic health care of Indian people. 

75 

Mr. PEERCY. The very basic health care. But I do think with a 

combination of adequate funding and, you know, we are not talking 

breaking the bank, but I mean better case management of individual Indian patients who come in. Have enough staff to, when a 

doc in my clinic makes a referral, that person goes right to them, 

and some of what Dr. Roubideaux mentioned, but also make sure 

you have done everything that you can to make sure that person 

has looked for those alternate resources and let them know right 

up front. Don’t let them go out to that doc with the assumption 

that it is going to get paid for when it is not. 

The CHAIRMAN. Well, let me thank both of you for traveling to 

Washington, D.C. and for having the patience to spend most of 

your afternoon with us. We are going to work on, as you witnessed 

today, we passed out the Indian Health Care Improvement Act. 

The next step for us is to work on some reform pieces that follow 

it. 

The Health Care Improvement Act does make some positive, constructive changes, but it is not the major reform. We are now working on reform, and some reforms for the Contract Health Services. 

Your contributions and your testimony will be very helpful. 

So we thank you very much for being here. 

Mr. PEERCY. Thank you, sir. 

Ms. WHIDDEN. Thank you. 

The CHAIRMAN. This hearing is adjourned. 

[Whereupon, at 4:48 p.m., the Committee was adjourned.] 

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A P P E N D I X 

PREPARED STATEMENT OF THE NORTHWEST PORTLAND AREA INDIAN HEALTH BOARD


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PREPARED STATEMENT OF DR. JOE SHIRLEY, JR., PRESIDENT, NAVAJO NATION


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PREPARED STATEMENT OF HON. CHERYLE KENNEDY, CHAIRWOMAN, CONFEDERATED

TRIBES OF THE GRAND RONDE COMMUNITY OF OREGON

Chairman Dorgan, Vice Chairman Barrasso, Members of the Senate Indian Affairs Committee, my name is Cheryle Kennedy and I am the Chairwoman of the 

Confederated Tribes of the Grand Ronde Community of Oregon. 

I appreciate the Chairman holding this hearing to focus attention on such a significant issue to Indian Country. Contract Health Services (CHS), a critical line 

item in the Indian Health Service budget that pays for hospital and specialty care, 

is severely under-funded. Under-funding CHS not only impacts the more than 5,000 

Grand Ronde tribal members, but Indian Country as a whole. 

First, I want to thank you Chairman Dorgan for your leadership in addressing 

the many issues facing Indian Country. Your commitment to increasing funding for 

health care, economic and infrastructure development, crime and gang prevention 

and other Native priorities is very much welcomed and appreciated. 

Notwithstanding the significant increase in funding provided to CHS in FY 2010, 

there is still much to be done. I come from a restored tribe. I was a young girl when 

Congress passed the Western Oregon Indian Termination Act ending the federal 

recognition of all western Oregon tribes, including Grand Ronde. For most Grand 

Ronde people, termination meant a loss of home, identity, and services from the 

Federal Government. After 30 years of hard work and perseverance by tribal members, the Grand Ronde people convinced Congress in 1983 to reverse its ill-fated termination decision and restore Grand Ronde’s federal recognition. 

My testimony today is shaped in part by a 30-year career as a health administrator working to improve the access and quality of health care to native people and, 


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more importantly, as someone who personally experienced the immediate injustices 

of termination and has lived long enough to witness and chronicle its long-term consequences. 

I will focus my testimony today on a topic of great importance to me and my tribe, 

the severe under-funding of CHS and the significant impacts of this under-funding 

on terminated tribes. 

As you would expect, termination forced the vast majority of Grand Ronde tribal 

members to leave the reservation in search of work and sustenance. While today 

many tribal members are returning to the reservation, Grand Ronde has tribal 

members living across the United States and around the world. 

Health care to eligible beneficiaries who reside in our six-county service area is 

provided out of the Grand Ronde Health and Wellness Center, a health care facility 

built, financed, and owned by the tribe on the Grand Ronde Reservation. The tribe 

first contracted with the Indian Health Service (IHS) in 1986 and began running 

a CHS program. In 1995, the tribe and IHS entered into a self-governance agreement under Title V of the Indian Self-Determination and Education Assistance Act. 

Like many other tribes, we have struggled to achieve and maintain a high level of 

health care service, despite chronic under-funding, especially of CHS funds. 

The CHS budget is the most important budget item for the Grand Ronde Health 

and Wellness Center as there are no hospitals in the Portland Area, unlike most 

other IHS areas. This is significant because inpatient hospitals are able to provide 

services that outpatient clinics cannot. 

This gap in services is otherwise borne by a tribe’s CHS funds. Due to the lack 

of facilities to deliver health services, Grand Ronde has no choice but to purchase 

specialty care from the private sector. It is important to understand that the CHS 

program does not function as an insurance program with a guaranteed benefit package. When CHS funding is depleted, CHS payments are not authorized. The CHS 

program only covers those services provided to patients who meet CHS eligibility 

and regulatory requirements, and only when funds are available. Nationally, the 

CHS program represents 19 percent of the total health services account. In the 

Northwest, the CHS program represents 30 percent of the Portland Area Office’s 

budget. 

When tribes run out of CHS funds during the fiscal year, many tribal members 

put off important medical care and procedures until funding is again available. 

Sadly, this creates undue illness and members are sometimes lost due to untimely 

diagnoses, due solely on the lack of funding. This process also creates a huge burden 

at the beginning of the fiscal year on the CHS budget and in many cases cost more 

money as the delay in care magnifies the problems associated with most diseases. 

The good news is that the solution is simple: fund the IHS at a needs-based level. 

When Grand Ronde took over the delivery of health care services, our goal was 

simple: to provide the best possible health care to our people. We wanted to provide 

a continuum of care to our patients that would include as many possible health 

services in one location as possible so that the care provided by physicians who are 

providers that could be integrated and coordinated. The challenge Grand Ronde has 

faced in providing health services to its members is an illustration of the impact 

that CHS under-funding and IHS under-funding in general has on tribal health programs and tribal sovereignty. 

Since restoration, the tribe has worked diligently to develop the foundation necessary to sustain a viable community. We have invested in excess of one hundred 

million dollars to date toward this effort. However, to accomplish our ultimate objective requires an additional investment of hundreds of millions of dollars in areas 

such as: health care, land acquisition, physical infrastructure, support services for 

children and families, and other resources which promote a sustainable community 

and provide a reasonable opportunity for our people to realize social and economic 

stability and progress. 

Through treaties, the tribes of this nation pre-paid for health care with their land 

and resources. I request the members of this Committee and all of Congress to fulfill 

the treaty obligations of this nation by establishing the funding levels of the Indian 

Health Service based on the true health care needs of Indian people. 

Æ