39–010 

Calendar No. 796 

108TH CONGRESS REPORT " ! SENATE 2d Session 108–405 

AMENDING THE NATIVE HAWAIIAN HEALTH CARE 

IMPROVEMENT ACT TO REVISE AND EXTEND THAT ACT 

NOVEMBER 10, 2004.—Ordered to be printed 

Filed, under authority of the order of the Senate of October 11, 2004 

Mr. CAMPBELL, from the Committee on Indian Affairs, 

submitted the following 

R E P O R T 

[To accompany S. 702] 

The Committee on Indian Affairs, to which was referred the bill 

(S. 702), a bill to amend the Native Hawaiian Health Care Improvement Act to revise and extend that Act, having considered the 

same, reports favorably thereon without amendment and recommends that the bill do pass. 

PURPOSE

The purpose of S. 702, a bill to provide for the reauthorization 

of the Native Hawaiian Health Care Improvement Act, is to improve the health status of Native Hawaiians through the continuation of a comprehensive health promotion and disease prevention 

effort that involves health education in Native Hawaiian communities, and the provision of health services using health care providers trained in western medicine and traditional Native Hawaiian healers. In areas where there is an underutilization of existing 

health care delivery systems that have the capacity to provide culturally-relevant health care services, S. 702 provides authority for 

the Secretary of the Department of Health and Human Services to 

enter into contracts with Native Hawaiian health care systems to 

provide health care referral services to Native Hawaiian patients. 

S. 702 is intended to assure the continuity of the health care programs that are provided to Native Hawaiians under the authority 

of Public Law 100–579. 

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As enacted in 1988, the Native Hawaiian Health Care Improvement Act is premised upon the findings and recommendations of 

the Native Hawaiian Health Research Consortium report to the 

Secretary of the Department of Health and Human Services of December, 1985. That report clearly indicates that the underutilization of existing health care services by Native Hawaiians can be 

traced to the absence of culturally-relevant services in which traditional Native Hawaiian concepts of healing are lacking, as well as 

to a general perception in the Native Hawaiian community that 

health care services, which are fundamentally based on concepts of 

Western medicine, will not effect the healing or cure of diseases 

and illnesses afflicting Native Hawaiian people. 

HISTORICAL BACKGROUND

The islands that now compose the State of Hawai‘i were governed by a monarchy of Native Hawaiians until 1893. The Native 

Hawaiian government was recognized as an independent sovereign 

nation by foreign governments, and treaty relationships were established with the United States (Treaty of Friendship, Commerce, 

and Navigation of 1849; Treaty of Commercial Reciprocity, January 

30, 1875.) Expanded trade with the United States resulted in increased western influence in the islands, and in 1893, the government of the Kingdom of Hawai‘i was overthrown in an insurrection 

engineered by a group of western businessmen in an effort to secure the annexation of Hawai‘i to the United States. The United 

States minister in Hawai‘i ordered one company of marines and 

two companies of sailors to be landed, and the minister then recognized a new provisional government even before Queen 

Liliuokalani’s lines of defense had surrendered. Although the provisional government sought immediate annexation by the United 

States, President Grover Cleveland refused to submit a treaty of 

annexation to the Senate, finding that the provisional government 

lacked the popular support of the Native Hawaiian population and 

that the government would not have been established but for the 

lawless and unauthorized military intervention of the United 

States (see Pub. L. No. 103–150). Upon the inauguration of William 

McKinley as the new President of the United States in 1897, however, the western businessmen that sought annexation were able to 

change the official U.S. position, and in 1898, Hawai‘i became a 

territory of the United States. 

Prior to European contact, it was estimated that there were 

400,000 Native Hawaiians in the Hawaiian Islands. By 1919, the 

Native Hawaiian population had been reduced to 22,600, and many 

were concluding that the native people of Hawai‘i were a ‘‘dying 

race,’’ (see S. Rep. No. 108–85, at 13–14 (2004)) and that if they 

were to be saved from extinction, they must have the means of regaining their connection to the land, the ‘aina.’ Accordingly, in 

1920, the Hawaiian Homes Commission Act was enacted into law 

by the U.S. Congress, establishing a land base that could serve as 

a permanent homeland for Native Hawaiians and encouraging agricultural pursuits. The Act placed approximately 203,000 acres 

under the jurisdiction of the Hawaiian Homes Commission, a 

branch of the territorial government established for the purpose of 

‘‘rehabilitating’’ persons of at least fifty percent Native Hawaiian 

ancestry through a return to pastoral life. The Act also authorized 

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the Commission to undertake ‘‘activities having to do with the economic and social welfare of the homesteaders.’’ (See generally Hawaiian Homes Commission Act, 42 Stat. 108 (July 9, 1921)) 

Hawai‘i was admitted into the Union of States in 1959. Under 

the Hawaii Admission Act, the title to the lands set aside under 

the Hawaiian Homes Commission Act was transferred from the 

United States to the State of Hawai‘i. The Admissions Act requires 

the State to hold the lands ‘‘as a public trust * * * for the betterment of the conditions of Native Hawaiians * * * and their use for 

any other object shall constitute a breach of trust for which suit 

may be brought by the United States’’ (Hawaii Statehood Admissions Act, Pub. L. No. 86–3, § 5(f), 73 Stat. 4 (Mar. 18, 1959)). 

BACKGROUND

Language contained in the 1984 Supplemental Appropriations 

Act, Public Law 98–396, directed the Department of Health and 

Human Services to conduct a comprehensive study of the health 

care needs of Native Hawaiians. The study was conducted under 

the aegis of Region IX of the Department by a consortium of health 

care providers and professionals from the State of Hawai‘i in a predominantly volunteer effort, organized by Alu Like, Inc., a Native 

Hawaiian organization. An island-wide conference was held in November of 1985 in Honolulu to provide an opportunity for members 

of the Native Hawaiian community to review the study’s findings. 

Recommended changes were incorporated in the final report of the 

Native Hawaiian Health Research Consortium, and the study was 

formally submitted to the Department of Health and Human Services in December of 1985. The Department submitted the report to 

the Congress on July 21, 1986, and the report was referred to the 

Select Committee on Indian Affairs (S. Rep. No. 108–85 (2004)). 

Because the Consortium report’s findings as to the health status 

of Native Hawaiians were compared only to other populations within the State of Hawai‘i, the Select Committee requested that the 

Office of Technology Assessment (OTA), an independent agency of 

the Congress, undertake an analysis of Native Hawaiian health 

statistics as they compared to national data in other United States 

populations. Using the same population projection model that was 

employed in OTA’s April 1986 report on Indian Health Care (U.S. 

Congress, Office of Technology Assessment, Indian Health Care, 

OTA–H–290 (Washington, DC: U.S. Government Printing Office, 

April 1986)) to American Indian and Alaska Native populations, 

and based on additional information provided by the Department 

of Health and the Office of Hawaiian Affairs of the State of 

Hawai‘i, the Office of Technology Assessment report contains the 

following findings: 

The Native Hawaiian population living in Hawai‘i consists of two groups, Hawaiians and part-Hawaiians, who 

are distinctly different in both age distributions and mortality rates. Hawaiians comprise less than five percent of 

the total Native Hawaiian population and are much older 

than the young and growing part-Hawaiian populations. 

Overall, Native Hawaiians have a death rate that is 

thirty-four percent higher than the death rate for the 

United States all races, but this composite masks the great 

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differences that exist between Hawaiians and part-Hawaiians. Hawaiians have a death rate that is 146 percent 

higher than the U.S. all races rate. Part-Hawaiians also 

have a higher death rate, but only 17 percent greater. A 

comparison of age-adjusted death rates for Hawaiians and 

part-Hawaiians reveals that Hawaiians die at a rate 110 

percent higher than part-Hawaiians, and this pattern persists for all except one of the 13 leading causes of death 

that are common to both groups. 

As in the case of the U.S. all races population, Hawaiian 

and part-Hawaiian males have higher death rates than 

their female counterparts. However, when Hawaiian and 

part-Hawaiian males and females are compared to their 

U.S. all races counterparts, females are found to have 

more excess deaths than males. Most of these excess 

deaths are accounted for by diseases of the heart and cancers, with lesser contributions from cerebrovascular diseases and diabetes mellitus. 

Diseases of the heart and cancers account for more than 

half of all deaths in the U.S. all races population, and this 

pattern is also found in both the Hawaiian and part-Hawaiian populations, whether grouped by both sexes or by 

male or female. However, Hawaiians and part-Hawaiians 

have significantly higher death rates than their U.S. all 

races counterparts, with the exception of part-Hawaiian 

males, for whom the death rate from all causes is approximately equal to that of U.S. all races males. 

One disease that is particularly pervasive is diabetes 

mellitus, for which even part-Hawaiian males have a 

death rate 128 percent higher than the rate for U.S. all 

races males. Overall, Native Hawaiians die from diabetes 

at a rate that is 222 percent higher than for the U.S. all 

races. When compared to their U.S. all races counterparts, 

deaths from diabetes mellitus range from 630 percent 

higher for Hawaiian females and 538 percent higher for 

Hawaiian males, to 127 percent higher for part-Hawaiian 

females and 128 percent higher for part-Hawaiian males. 

(Id.) 

These findings clearly establish that the health status of Native 

Hawaiians is significantly worse than that of other U.S. population 

groups, and that in a number of areas, the evidence is compelling 

that Native Hawaiians constitute a population group for whom the 

mortality rate associated with certain diseases exceed that for 

other U.S. populations in alarming proportions. 

Native Hawaiians premise the high mortality rates and the incidence of disease that far exceed that of other populations in the 

United States upon the breakdown of the Hawaiian culture and belief systems, including the banning of the use of traditional healing 

practices, that was brought about by western settlement, as well as 

the influx of western diseases to which the native people of the Hawaiian Islands lacked immunities. 

In 1998, an organization of Native Hawaiian health care providers, Papa Ola Lokahi, updated the health care statistics from 

the original E Ola Mau report. Additionally Papa Ola Lokahi extrapolates the data that the Hawai‘i State Department of Health 

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annually gathers on Native Hawaiians from the Department’s behavioral risk assessment and health surveillance survey. The findings from those assessments revealed that— 

With respect to cancer, Native Hawaiians have the highest cancer mortality rates in the State of Hawai‘i (216.8 

out of every 100,000 male residents and 191.6 out of every 

100,000 female residents), rates that are 21 percent higher 

than that for the total State male population (179.0 out of 

every 100,000 residents) and 64 percent higher than that 

for the total State female population (117.0 per 100,000). 

Native Hawaiian males have the higher cancer mortality 

rates in the State of Hawai‘i for cancers of the lung, colon, 

rectum, colorectum, and for all cancers combined, and the 

highest years of productive life lost from cancer in the 

State of Hawai‘i. Native Hawaiian females have the highest cancer mortality rates in the State of Hawai‘i for cancers of the lung, liver, pancreas, breast, corpus uteri, stomach, colon, rectum, and for all cancers combined. 

With respect to breast cancer, Native Hawaiians have 

the highest mortality rates in the State of Hawai‘i, and nationally Native Hawaiians have the third highest mortality 

rates due to breast cancer. Native Hawaiians have the 

highest mortality rates from cancer of the cervix and lung 

cancer in the State of Hawai‘i, and Native Hawaiian males 

have the third highest mortality rates due to prostate cancer in the State. 

For the year 2000, Native Hawaiians had the highest 

mortality rate due to diabetes mellitus in the State of 

Hawai‘i, with full-blood Hawaiians having a mortality rate 

that is 518 percent higher than the rate for the statewide 

population of all other races. 

In 1990, Native Hawaiians represented 44 percent of all 

asthma cases in the State of Hawai‘i for those 18 years of 

age and younger, and 35 percent of all asthma cases reported, and in 1999, the Native Hawaiian prevalence rate 

for asthma was 69 percent higher than the rate for the 

total statewide population. 

With respect to heart disease, the death rate for Native 

Hawaiians is 68 percent higher than for the entire State 

of Hawai‘i, and Native Hawaiian males have the greatest 

years of productive life lost in the State of Hawai‘i. The 

death rate for Native Hawaiians from hypertension is 84 

percent higher than that for the entire State, and the 

death rate from stroke for Native Hawaiians is 20 percent 

higher than for the entire State. 

Native Hawaiians have the lowest life expectancy of all 

population groups in the State of Hawai‘i. Between 1910 

and 1980, the life expectancy of Native Hawaiians from 

birth has ranged from 5 to 10 years less than that of the 

overall State population average, and the most recent data 

for 1990 indicates that Native Hawaiian life expectancy at 

birth is approximately 5 years less than that of the total 

State population. 

With respect to prenatal care, as of 1998, Native Hawaiian women have the highest prevalence of having had no 

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prenatal care during their first trimester of pregnancy, 

representing 44 percent of all such women statewide. Over 

65 percent of the referrals to Healthy Start in fiscal year 

1996 and 1997 were Native Hawaiian newborns, and in 

every region of the State of Hawai‘i, many Native Hawaiian newborns begin life in a potentially hazardous circumstance. 

In 1996, 45 percent of the live births to Native Hawaiians mothers were infants born to single mothers. Statistics indicated that infants born to single mothers have a 

higher risk of low birth weight and infant mortality. Of all 

low birth weight babies born to single mothers in the State 

of Hawai‘i, 44 percent were Native Hawaiians. 

In 2000, Native Hawaiians had the highest number of 

fetal deaths in Hawai‘i. Twenty-one percent of all fetal 

deaths in the State were associated with expectant Native 

Hawaiian mothers and 37 percent of those Native Hawaiian mothers were under the age of 25 years. 

These and other health status statistics contained in the findings 

section of S. 702 clearly establish that the health care challenges 

that the Native Hawaiian health care systems were established to 

address require reauthorization of the Native Hawaiian Health 

Care Improvement Act. 

NATIVE HAWAIIAN HEALTH CARE MASTER PLAN AND NATIVE

HAWAIIAN HEALTH CARE SYSTEMS

The concepts embodied in S. 702 are the result of the Committee’s work with Native Hawaiian health care professionals and others who are dedicated to improving the health status of Native Hawaiians. It is based on the beliefs of those with whom the Committee has consulted, that to insure that Native Hawaiians are 

able to achieve the healthful harmony of the self (body, mind, and 

spirit) or lokahi, with others and all of nature, and to assure that 

Native Hawaiians are able to function effectively as citizens and 

leaders in their own homeland, there must be a restoration of cultural traditions, an integration of traditional healing methods in 

the health care delivery system, and a collective effort to restore to 

the Native Hawaiian, a sense of self-esteem and self-worth, for his 

or her culture, as well as for the individual. 

E Ola Mau, a group of Native Hawaiian health care professionals, proposed that this effort begin with the development of a 

health care master plan, based on a bio-psycho-socio-cultural-political model that would be aimed at identifying significant events 

and factors related to specific health care needs and issues. E Ola 

Mau proposed that this master plan be implemented at every societal level (individual, household, community, county, and state) in 

the Hawaiian Islands. It is its goal to have this Native Hawaiian 

way of dealing with health, eventually become an institutional part 

of the State’s health policy for both Native Hawaiian and other citizens of the State of Hawai‘i. 

After much debate and careful consideration in the Native Hawaiian community and amongst those concerned with the health 

status of Native Hawaiians, a consensus was reached that Papa 

Ola Lokahi, the Native Hawaiian Health Board, should be the 

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mechanism through which Native Hawaiian health care systems 

would be developed, coordinated, administered, monitored, and continually revised to meet the changing health care needs of the Native Hawaiian population. Papa Ola Lokahi is currently composed 

of five organizations: 

(1) The Office of Hawaiian Affairs, an agency of the State 

which was established pursuant to the authority of amendments made to the Constitution of the State of Hawai‘i in 1978 

to assure the well-being and to advance the interests of Native 

Hawaiians; 

(2) E Ola Mau, a nonprofit organization of Native Hawaiian 

professionals dedicated to insuring that Native Hawaiians 

achieve a healthful harmony of self (body, mind, and spirit) 

with others and all of nature, and become productive citizens 

and leaders in their homeland; 

(3) Alu Like, a Federally-funded Native Hawaiian agency 

that promotes vocational training and the founding of community-based organizations that promote health, education, and 

economic development for Native Hawaiians; 

(4) The University of Hawai‘i; and the 

(5) The Office of Hawaiian Health within the State Department of Health. 

Papa Ola Lokahi has assumed the primary responsibility of overseeing the development and maintenance of a Native Hawaiian 

Comprehensive Health Care Master Plan. Papa Ola Lokahi also is 

the entity responsible for certifying to the Secretary of Health and 

Human Services the qualifications and capabilities of Native Hawaiian organizations that petition the Secretary to carry out, pursuant to contracts with the Secretary, the provisions of the Act. 

The Native Hawaiian Health Care Act of 1988, Pub. L. No. 100– 

579, 102 Stat. 2916, authorized Papa Ola Lokahi, the Native Hawaiian Health Board, to— 

• Designate a chairman and vice-chairman from among its 

member organizations and such other officers as may be 

deemed necessary to carry out its responsibilities under the 

Act; 

• Adopt bylaws and such other internal regulations or procedures as may be deemed necessary to carry out its responsibilities under the Act; 

• Certify to the Secretary that a Native Hawaiian organization meets the definition of ‘‘Native Hawaiian organization’’ as 

set forth in the Act; 

• Certify to the Secretary that a Native Hawaiian organization has the qualifications and capacity to provide the services 

or perform contract requirements pursuant to a contract with 

the Secretary; 

• Oversee the development of a comprehensive Native Hawaiian health care master plan; 

• Assure the conduct of health status and health care needs 

assessments of Native Hawaiian communities desiring to participate in Native Hawaiian health care programs; and 

• Coordinate the activities and functions of all Native Hawaiian organizations operating health care programs pursuant 

to contracts with the Secretary. 

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1The ‘ohana system is based upon the fundamental unit of societal interaction for Native Hawaiians in which a family or an organization is led by a haku (the recognized leader), whose 

function is to coordinate and facilitate the expertise and resources of the various households or 

affiliated organizations in order to accomplish a task or resolve a problem. The households or 

affiliated organizations are in turn led by a po‘o (the head of the household or designated leader 

of the organization). 

The Native Hawaiian Health Care Act of 1988, Pub. L. No. 100– 

579, 102 Stat. 2916 (Oct. 31, 1988) envisions a comprehensive 

health care system that is community-based, building upon the Native Hawaiian ‘ohana system1 and incorporating traditional healing 

(la ‘au lapa ‘au) practices with western medical services to provide 

a health care system that will be culturally sensitive and responsive to the needs of Native Hawaiian communities. 

As originally enacted, Public Law 100–579 authorized the establishment of Native Hawaiian Healing Centers on each of the islands comprising the State of Hawai‘i, upon the acceptance of and 

in consultation with the Native Hawaiian communities on those islands, and wherever possible, using existing health care facilities 

and health care providers now serving the Native Hawaiian communities on those islands. These centers were intended to lead and 

coordinate the development and implementation of a statewide Native Hawaiian health care system which would include: (1) a research and monitoring staff, state-certified neighborhood counselors, outreach workers and health educators, traditional Native 

Hawaiian healers, and Native Hawaiian cultural educators; (2) primary health care providers; (3) primary health care facilities, using 

existing health care facilities where practicable and acceptable to 

the local Native Hawaiian community; (4) participation by the 

State Department of Health, Office of Hawaiian Health in the provision of disease prevention and health promotion programs, as 

well as a multidisciplinary approach to Native Hawaiian health 

care which would include nursing, dental hygiene, nutrition education, maternal and infant child care education; and (5) other Federal, State, county, community, and private organizations and 

agencies that could provide services which meet the health care 

needs of their respective communities. 

The development of the master plan by Papa Ola Lokahi was intended to include: 

(1) Work with Native Hawaiian communities which support 

the establishment of a Native Hawaiian Health Center; 

(2) Conducting a community health needs assessment survey 

for participating communities; 

(3) Facilitating the development, establishment, and effective 

functioning of such Centers on the islands of O‘ahu, Moloka‘i, 

Maui, Hawai‘i, Lana‘i, Kaua‘i and Ni‘ihau; and 

(4) Coordinating the work of relevant agencies and organizations to provide participating communities with: 

(a) Direct health care services and health education, including maternal and child health care and mental health 

care; 

(b) Instruction in the Native Hawaiian language, cultural beliefs, and traditions with an emphasis on health 

concepts and practices; 

(c) Training and education of health care providers and 

educators and cultural educators in health promotion and 

disease prevention; 

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(d) Basic and applied research and monitoring of Native 

Hawaiian health care approaches to validate outcomes and 

create standards of quality care; 

(e) Development of health care services, training and 

education that would have a Native Hawaiian perspective 

as its primary focus; 

(f) Development of Native Hawaiian community health 

counselors, outreach workers, educators, and community 

health aide training programs; 

(g) Prevention-oriented health care services in medical, 

dental, nutrition, mental health, and in other designated 

areas as needs assessments may identify as necessary; 

(h) Data collection related to prevention of diseases and 

illnesses among Native Hawaiians; 

(i) Medical and general health-related research into the 

diseases that are most prevalent among Native Hawaiians; 

(j) Mental health research in areas of mental health 

problems that are most prevalent in the Native Hawaiian 

population; 

(k) Ongoing health planning for further development of 

the Native Hawaiian health care system; and 

(l) The provision of health care referral services when 

certain health care services are not available within the 

Native Hawaiian Health Center. 

Following enactment of the Native Hawaiian Health Care Improvement Act, the Papa Ola Lokahi Board incorporated and began 

working with health care providers on each island on the development of a master plan and an island-specific plan for the provision 

of primary health care and health care referral services. Those involved in the planning effort ultimately determined that the health 

care needs of Native Hawaiians would be better served by the establishment of five Native Hawaiian health care systems which 

could be composed of as many health care centers as might be necessary to serve the health care needs of Native Hawaiians on each 

island. 

Accordingly, Papa Ola Lokahi certified to the Secretary that five 

health care systems qualified as Native Hawaiian organizations for 

purposes of entering into contracts with the Secretary, and plans 

for the provision of primary health care services or health care referral services were submitted to the Secretary in 1990. The first 

contract awards were 13 made in October of 1991, and since that 

time, the health care systems have been engaged not only in the 

implementation of the plans approved by the Secretary, but the 

provision of health care services. The plans for each health care 

system vary according to the availability of and access to existing 

health care resources on each island and the need for health care 

services. Currently, all five Native Hawaiian health care systems 

have become incorporated as 501(c)(3) non-profit health care organizations. 

In general, the capacity to provide critical health care services 

exists only on the island of O‘ahu, and thus, it has long been the 

pattern that if a patient requires hospitalization and complex surgery or treatment, the patient would be referred to a health care 

provider on the island of O‘ahu and would have to incur the costs 

associated with air travel to O‘ahu. However, it is not uncommon 

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that treatment requiring advanced medical technology must be secured in the continental United States. 

The Native Hawaiian Health Care Improvement Act provides authority for the provision of health promotion, disease prevention, 

and primary health care services to Native Hawaiians who reside 

in the State of Hawai‘i. Federal planning funds first became available in July of 1990. However, Papa Ola Lokahi incorporated in 

February 1989 and was able to initiate its organizing activities in 

July 1989 with funds provided by the Hawai‘i State legislature. Between July 1989 and December 1990, informational meetings and 

organizational activities took place throughout the State, resulting 

in the establishment or recognition of the five Native Hawaiian 

health care systems which would assume the responsibility for providing services: (1) Ho‘ola Lahui Hawai‘i for Kaua‘i and Ni‘ihau; (2) 

Ke Ola Mamo for O‘ahu; (3) Na Pu‘uwai for Moloka‘i and Lana‘i; 

(4) Hui No Ke Ola Pono for Maui; and (5) Hui Malama Ola Na 

‘Oiwi for Hawai‘i. Papa Ola Lokahi provided planning funds and 

technical assistance to these five health care systems, which then 

developed their service plans from January through June 1991, applied for funding under the Native Hawaiian Health Care Act in 

July 1991, and were awarded service grants in October of 1991. 

The basic set of services that all five health care systems must 

provide include: (1) outreach services to inform Native Hawaiians 

of the availability of health services; (2) education in health promotion and disease prevention of the Native Hawaiian population 

by Native Hawaiian health care practitioners, community outreach 

workers, counselors, and cultural educators, whenever possible; (3) 

services of physicians, physicians assistants, nurse practitioners or, 

other health professionals; (4) immunizations; (5) prevention and 

control of diabetes, high blood pressure, and otitis media; (6) pregnancy and infant care; and (7) improvement of nutrition. 

In the initial stages, because the five health care systems needed 

to gain experience in managing health services and because of limited funds, each health care system concentrated on outreach, 

health assessments, case management, and disease prevention and 

health promotion activities, with the ultimate objective of providing 

the full range of health and medical services that are available 

through a typical primary health care center, and working with 

traditional healers so that their services would also be more readily 

available to Native Hawaiians. 

Now that the five island-wide Native Hawaiian health care systems are established and engaged in the provision of health care 

services, Papa Ola Lokahi’s role is to provide technical support and 

training to the five health care systems, work with each of the systems to develop a statewide, cooperative Native Hawaiian health 

system, develop research activities and capacities within the five 

health care systems, and evaluate how well the objectives of the 

Native Hawaiian Health Care Improvement Act are being met. 

The goals and objectives, as well as the services provided by each 

of the five Native Hawaiian health care systems is contained in Appendix A of the committee report. 

Through the work of the five Native Hawaiian health care systems, on an annual basis, 20,000 Native Hawaiians continue to 

benefit from the range of health care services provided by the systems. 

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NATIVE HAWAIIAN HEALTH CARE PROFESSIONS SCHOLARSHIPS

The Native Hawaiian Health Care Improvement Act also provides authority for the provision of scholarships to Native Hawaiians who are seeking higher education opportunities in the health 

care professions. The Native Hawaiian Health Scholarship Program has been administered by the Kamehameha Schools, but S. 

702 will transfer administration of these scholarships to Papa Ola 

Lokahi. 

Scholarships awarded thus far have resulted in: bachelors of 

science degrees in nursing, clinical psychology doctoral degrees, 

dentists, dental hygienists, osteopathic physicians, allopathic physicians, masters degrees in public health, masters degrees in social 

work, nurse midwives, nurse practitioners, doctors of psychology, 

and registered nurses. Many of the scholarship recipients have 

completed their studies and their service payback requirements 

and are practicing in the Native Hawaiian community. 

REAUTHORIZATION PROCESS

In order to assure the maximum involvement of Native Hawaiians in the development of a bill to reauthorize the Native Hawaiian Health Care Improvement Act (the Act), from December of 

1997 through January of 1998, eight island ‘aha (island-wide conferences) were held involving more than 1,200 individuals in an effort to identify the principle Native Hawaiian health and wellness 

issues and concerns. In March 1998, a statewide Native Hawaiian 

Health and Wellness Summit, Ka ‘Uhane Lokahi, was held on the 

island of O‘ahu, bringing together more than 600 people to identify 

potential health and wellness issues and concerns. In January 

1999, a Native Hawaiian Health Forum was convened to discuss 

major health care trends and strategies for health care and 

wellness developed by the indigenous peoples of North America and 

Aotearoa (New Zealand). 

In March 1999, the Executive Directors of the Native Hawaiian 

health care systems, the members of the Papa Ola Lokahi Board, 

and the Director of the Native Hawaiian Health Scholarship Program met to review the Act and to incorporate recommendations 

from the ‘aha, the summit, and the health forum for inclusion in 

a bill to reauthorize the Native Hawaiian Health Care Improvement Act. Thereafter, a series of public meetings were held to discuss and review a draft reauthorization bill and based upon the 

comments received, the bill was further refined and then circulated 

in the Native Hawaiian community. A final draft of the bill, incorporating and responding to recommendations received from the Native Hawaiian community, was submitted to the Congress. 

SUMMARY OF MAJOR PROVISIONS

S. 702 extends the existing program authorities of the Act and 

authorizes appropriations in such sums as may be necessary 

through fiscal year 2009. The bill contains extensive findings on 

the current health status of Native Hawaiians including the incidence and mortality rates associated with various forms of cancer, 

diabetes, asthma, circulatory diseases, infectious disease and illness, and injuries, as well as statistics on life expectancy, maternal 

12 

and child health, births, teen pregnancies, fetal mortality, mental 

health, and health professions education and training. 

The bill further refines the role of Papa Ola Lokahi and the Native Hawaiian health care systems, providing authority for the establishment of additional health care systems to serve the islands 

of Lana‘i and Ni‘ihau. The Board of Papa Ola Lokahi has been expanded to include the five Native Hawaiian health care systems, 

the Native Hawaiian Health Task Force, the Hawai‘i State Primary 

Care Association (which represents the community health centers), 

the Native Hawaiian Physicians Association, and such other organizations as the Papa Ola Lokahi Board will admit based upon a 

satisfactory demonstration of a record of contribution to the health 

and well-being of Native Hawaiians. 

The 1992 amendments to the Act adopted the relevant health objectives of the U.S. Surgeon General’s Healthy People 2000 objectives as goals to be met by the Native Hawaiian health care systems. S. 702 establishes new objectives that the Native Hawaiian 

health care systems must meet based on the objectives in the U.S. 

Surgeon General’s Healthy People 2010. 

S. 702 proposes that the providers of health care services, including traditional Native Hawaiian healers, who provide services 

under the aegis of the Native Hawaiian health care systems be 

treated as members of the Public Health Service for purposes of 

Federal Tort Claims Act coverage (28 U.S.C. 1346(b) and 2671– 

2680). 

The bill also provides authorization for Papa Ola Lokahi to carry 

out Native Hawaiian demonstration projects of national significance in areas such as the education of health professionals, the integration of western medicine with complementary health practices 

including traditional Native Hawaiian healing practices, the use of 

tele-wellness and telecommunications in chronic disease management and health promotion and disease prevention, the development of an appropriate model of health care for Native Hawaiians 

and other indigenous people, the development of a centralized data 

base and information system relating to the health care status, 

health care needs, and wellness of Native Hawaiians, and the establishment of a Native Hawaiian Center of Excellence for Nursing 

at the University of Hawai‘i at Hilo, a Native Hawaiian Center of 

Excellence for Mental Health at the University of Hawai‘i at 

Manoa, a Native Hawaiian Center of Excellence for Maternal 

Health and Nutrition at the Waimanalo Health Center, a Native 

Hawaiian Center of Excellence for Research, Training, and Integrated Medicine at Moloka‘i General Hospital, and a Native Hawaiian Center of Excellence for Complementary Health and Health 

Education and Training at the Waianae Coast Comprehensive 

Health Center. 

THE PROVISION OF FEDERAL PROGRAMS TO NATIVE HAWAIIANS

In the exercise of the plenary power vested in the Congress in 

Article I, section 8, clause 3 of the United States Constitution, the 

Congress has exercised its authority to address the conditions of 

the aboriginal, indigenous, native people of the United States, including the aboriginal, indigenous, native people of the states of 

Alaska and Hawai‘i. More than one hundred and sixty Federal 

laws have been enacted to address the conditions of Native HawaiVerDate Aug 04 2004 01:02 Nov 16, 2004 Jkt 039010 PO 00000 Frm 00012 Fmt 6659 Sfmt 6602 E:\HR\OC\SR405.XXX SR405
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2 Id., § 4; Haw. Const., Art. XVI, § 7. 

3 Id., § 5(f); Haw. Const. Art. XII, § 4. 

4 Id., § 5(f); Haw. Const. Art. XII, § 4. 

5 Id. 

ians (see for example, S. Rep. No. 108–85). The authority of the 

Congress to enact legislation to address the conditions of Native 

Hawaiians is set forth more fully in Appendix B to the committee 

report. 

FEDERAL DELEGATION OF AUTHORITY TO THE STATE OF HAWAII

For the past two hundred and ten years, the United States Congress, the Executive Branch, and the U.S. Supreme Court have recognized certain legal rights and protections for America’s indigenous peoples. Since the founding of the United States, Congress 

has exercised a constitutional authority over indigenous affairs and 

has undertaken an enhanced duty of care for America’s indigenous 

peoples. This has been done in recognition of the sovereignty possessed by the native people—a sovereignty which pre-existed the 

formation of the United States. The Congress’ exercise of its constitutional authority is also premised upon the status of the indigenous people as the original inhabitants of this nation who occupied 

and exercised dominion and control over the lands over which the 

United States subsequently acquired jurisdiction. 

The United States has long recognized the existence of a special 

political relationship with the indigenous people of the United 

States. As Native Americans—American Indians, Alaska Natives, 

and Native Hawaiians—the United States has recognized that they 

are entitled to special rights and considerations, and the Congress 

has enacted laws to give expression to the respective legal rights 

and responsibilities of the Federal government and the native people (see for example, S. Rep. No. 108–85). 

From time to time, with the consent of the affected States, the 

Congress has sought to more effectively address the conditions of 

the indigenous people by delegating Federal responsibilities to various states. In 1959, the State of Hawai‘i assumed the Federallydelegated responsibility of administering 203,500 acres of land that 

had been set aside by Congress in 1921 for the benefit of the native 

people of Hawai‘i under the Hawaiian Homes Commission Act.2 In 

addition, the State agreed to the imposition of a public trust upon 

all of the lands ceded to the State upon admission.3 One of the five 

purposes for which the public trust was established is the ‘‘betterment of the conditions of native Hawaiians[.]’’ 4 The Federal authorization for this public trust clearly anticipated that the State’s 

constitution and laws would provide for the manner in which the 

terms of trust would be carried out.5

In 1978, the citizens of the State of Hawai‘i exercised the Federally-delegated authority by amending the State constitution in furtherance of the special relationship with Native Hawaiians. The 

delegates to the 1978 constitutional convention recognized that Native Hawaiians had no other homeland, and thus that the protection of Native Hawaiian subsistence rights to harvest the ocean’s 

resources, to fish the freshwater streams, and to hunt and gather, 

as well as the protection of Native Hawaiians’ rights to exercise 

their rights to self-determination and self-governance, and to preVerDate Aug 04 2004 01:02 Nov 16, 2004 Jkt 039010 PO 00000 Frm 00013 Fmt 6659 Sfmt 6602 E:\HR\OC\SR405.XXX SR405
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serve their culture and language, could only be accomplished within their native homeland, the present State of Hawai‘i. 

Hawai’i’s adoption of amendments to the State constitution to 

fulfill the special relationship with Native Hawaiians is consistent 

with the practice of other states that have established special relationships with the native inhabitants of their areas. Fourteen 

states have extended recognition to Indian tribes that are not recognized by the Federal government, and thirty-two states have established commissions and offices to address matters of policy affecting the indigenous citizenry. 

SECTION-BY-SECTION ANALYSIS

Section 1. Short title 

The title of the Act is the Native Hawaiian Health Care Improvement Reauthorization Act of 2003. 

Section 2. Findings 

Subsection (a) sets forth the findings of the Congress with regard 

to the historical and legal basis for a Federal program designed to 

address the health care needs of Native Hawaiians. Subsection (b) 

sets forth the unmet needs and serious health disparities affecting 

Native Hawaiians, including chronic diseases and illnesses, infectious diseases and illnesses, injuries, dental health, life expectancy, 

maternal and child health, mental health, and health professions 

education and training. 

Section 3. Definitions 

This section sets forth the definitions of terms used in the Act. 

Section 3(1) defines ‘‘Department’’ to mean the Department of 

Health and Human Services. 

Section 3(2) defines ‘‘disease prevention’’ to include immunizations, control of high blood pressure, control of sexually transmittable diseases, the prevention and control of chronic diseases, control of toxic agents, occupational safety and health, injury prevention, fluoridation of water, control of infectious agents, and provision of mental health care. 

Section 3(3) defines ‘‘health promotion’’ to include pregnancy and 

infant care, including prevention of fetal alcohol syndrome, cessation of tobacco smoking, reduction in the misuse of alcohol and 

harmful illicit drugs, improvement of nutrition, improvement in 

physical fitness, family planning, control of stress, reduction of 

major behavioral risk factors and promotion of healthy lifestyle 

practices, and integration of cultural approaches to health and 

well-being. 

Section 3(4) defines ‘‘health service’’ as the services of physicians, 

physician’s assistants, nurse practitioners, nurses, dentists, and 

other health care professionals; diagnostic laboratory and radiologic 

services; preventive health services, including perinatal services, 

well child services, family planning services, nutrition services, 

home health services, sports medicine and athletic training, and 

other enhanced health or wellness services; emergency medical 

services, including first responders, emergency medical technicians, 

and mobile intensive care technicians; transportation services as 

required for adequate patient care; preventive dental services; and 

15 

pharmaceutical and medicament services; mental health services, 

including those of psychologists and social workers; genetic counseling services; health administration services, including those 

services of health program administrators; health research services, including those with advanced degrees in medicine, nursing, 

psychology, social work, and other related health programs; environmental health services, including those provided by epidemiologists, public health officials, medical geographers and medical anthropologists, and those specializing in biological, chemical, and environmental health determinants; primary care services that may 

lead to specialty or tertiary care; and complementary healing practices, including those performed by traditional Native Hawaiian 

healers. 

Section 3(5) defines ‘‘Native Hawaiian’’ as any individual who is 

a descendant of the aboriginal people who, prior to 1778, occupied 

and exercised sovereignty in the area that now constitutes the 

State of Hawaii as evidenced by genealogical records, kama‘aina 

(long-term community residents) witness verification from Native 

Hawaiian kupuna (elders) or birth records of the State of Hawai‘i 

or any State or territory of the United States. 

Section 3(6) defines ‘‘Native Hawaiian health care system’’ as any 

of up to 8 entities that has the following characteristics: is organized under Hawai‘i law; provides or arranges for health services 

for Native Hawaiians in the State; is a public or nonprofit private 

entity; has Native Hawaiians significantly participating in the 

planning, management, provision, monitoring, and evaluation of 

health services; addresses the health care needs of an island’s Native Hawaiian population, and; is recognized by Papa Ola Lokahi 

for the purpose of planning, conducting, or administering programs, 

authorized by this Act for the benefit of Native Hawaiians, and as 

having the qualifications and the capacity to provide the services 

and meet the requirements under the contract each Native Hawaiian health care system enters into with the Secretary or the grant 

each Native Hawaiian health care system receives from the Secretary under this Act. 

Section 3(7) defines ‘‘Native Hawaiian Health Center’’ as an organization that provides primary health care services and which Papa 

Ola Lokahi has certified has met the following criteria: a governing 

board with a membership that has a minimum of fifty-percent 

(50%) Native Hawaiians; has demonstrated cultural competency in 

a predominantly Native Hawaiian community; has a patient population that is either made up of individuals at least fifty-percent of 

whom are Native Hawaiian or serves not less than 2,500 Native 

Hawaiian clients annually. 

Section 3(8) defines ‘‘Native Hawaiian Health Task Force’’ as a 

task force established by the State Council of Hawaiian Homestead 

Associations that implements health and wellness strategies in 

Hawai‘i’s Native Hawaiian communities. 

Section 3(9) defines ‘‘Native Hawaiian organization’’ as a public 

or nonprofit organization that serves Native Hawaiian interests 

and which Papa Ola Lokahi has recognized for purposes of planning, conducting, or administering programs authorized under this 

Act. 

Section 3(10) defines ‘‘Office of Hawaiian Affairs’’ and ‘‘OHA’’ as 

the governmental entity established under the Hawai‘i State ConVerDate Aug 04 2004 01:02 Nov 16, 2004 Jkt 039010 PO 00000 Frm 00015 Fmt 6659 Sfmt 6602 E:\HR\OC\SR405.XXX SR405
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stitution which is charged with the responsibility of formulating 

policy relating to Native Hawaiian affairs. 

Section 3(11) defines ‘‘Papa Ola Lokahi’’ as an organization composed of public and private organizations focusing on improving the 

health status of Native Hawaiians. It is governed by a board, 

whose members may include representatives from: E Ola Mau; the 

Office of Hawaiian Affairs; Alu Like, Inc.; the University of 

Hawai‘i; the Hawai‘i State Department of Health; the Native Hawaiian Health Task Force; Hawai‘i State Primary Care Association; 

Ahahui O Na Kauka; Ho’ola Lahui Hawai‘i (or a health care system 

serving the islands of Kaua‘i or Ni‘ihau); Ke Ola Mamo (or a health 

care system serving the island of O‘ahu); Na Pu‘uwai (or a health 

care system serving the islands of Molokai and Lana‘i); Hui No Ke 

Ola Pono (or a health care system serving the island of Maui); Hui 

Malama Ola Ha ‘Oiwi (or a health care system serving the island 

of Hawai‘i); other Native Hawaiian health care systems that Papa 

Ola Lokahi certifies and recognizes; and such other member organizations as the Board of Papa Ola Lokahi may admit from time to 

time, based upon a satisfactory demonstration of a record of contribution to the health and well-being of Native Hawaiians. However, organizations will not be added to Papa Ola Lokahi if the Secretary determines that an organization has not developed a mission 

statement with clearly defined goals and objectives for its contributions to the Native Hawaiian health care systems and an action 

plan for carrying out those goals and objectives. 

Section 3(12) defines ‘‘Secretary’’ as the Secretary of the U.S. Department of Health and Human Services. 

Section 3(13) defines ‘‘State’’ as the State of Hawai‘i. 

Section 3(14) defines ‘‘traditional Native Hawaiian healer’’ as a 

practitioner who is of Hawaiian ancestry and has the knowledge, 

skills and experience in direct personal health care of individuals, 

and whose knowledge, skills, and experience are based on demonstrated learning of Native Hawaiian healing practices acquired 

by direct practical association with Native Hawaiian elders and the 

oral traditions transmitted from generation to generation. 

Section 4. Declaration of national Native Hawaiian health policy 

This section establishes the policy of the Act. 

Section 4 (a) and (b) establish that it is the United States’ policy, 

in fulfilling its special responsibilities and legal obligations to the 

indigenous people of Hawai‘i which result from the unique and historical relationship between the United States and the indigenous 

people of Hawai‘i, to raise the health status of Native Hawaiians 

to the highest practicable level and to provide existing Native Hawaiian health care programs with the resources necessary to effectuate this policy. Section 4 also expresses Congress’ intent to raise 

Native Hawaiians’ health status by 2010 to at least the standards 

contained within the Surgeon General’s Healthy People 2010, and 

to incorporate within health programs the following activities: integration of cultural approaches to health and well-being; increasing 

the number of health and allied-health care providers who can provide culturally competent care; increasing the use of traditional 

Native Hawaiian foods in peoples’ diets and dietary preferences including those of students and the use of traditional foods in school 

feeding programs; identifying and instituting Native Hawaiian culVerDate Aug 04 2004 01:02 Nov 16, 2004 Jkt 039010 PO 00000 Frm 00016 Fmt 6659 Sfmt 6602 E:\HR\OC\SR405.XXX SR405
17 

tural values and practices within the corporate cultures of organizations and agencies providing health services to Native Hawaiians; facilitating the provision of Native Hawaiian healing practices 

by Native Hawaiian healers for those clients desiring such assistance; supporting training and education activities and programs in 

traditional Native Hawaiian healing practices by Native Hawaiian 

healers; and demonstrating the integration of health services for 

Native Hawaiians, particularly those that integrate mental, physical, and dental services in health care. 

Section 4(c) directs the Secretary to provide the President with 

a report on the progress made toward meeting the national policy 

of the Act which will be included in the President’s report to the 

Congress under section 12. 

Section 5. Comprehensive health care master plan for Native Hawaiians 

Section 5(a)(1) authorizes the Secretary to make a grant or enter 

into a contract with Papa Ola Lokahi for the purpose of coordinating, implementing, and updating the Native Hawaiian comprehensive health care master plan which is designed to promote 

comprehensive health promotion and disease prevention services, 

to maintain and improve Native Hawaiian health status, and to 

support community-based initiatives reflective of holistic health 

care. 

Section 5(a)(2) requires Papa Ola Lokahi and the Office of Hawaiian Affairs to consult with the Native Hawaiian health care systems, the Native Hawaiian health centers, and the Native Hawaiian community in carrying out section 5, and authorizes Papa Ola 

Lokahi and the Office of Hawaiian Affairs to enter into memoranda 

of understanding or agreement to acquire joint funding and for purposes of addressing other issues to accomplish the objectives of this 

section. 

Section 5(a)(3) requires that within eighteen (18) months of the 

Act’s enactment that Papa Ola Lokahi, in cooperation with the Office of Hawaiian Affairs and other appropriate State and Federal 

agencies, prepare and submit a study report to the Congress detailing the impact of current Federal and State health care financing 

mechanisms and policies on Native Hawaiians’ health and wellbeing. The report will include the impact of cultural competency, 

risk assessment data, eligibility requirements and exemptions, reimbursement policies and capitation rates currently in effect for 

service providers, and any other information that may be important 

to improving the health status of Native Hawaiians as it relates to 

health care financing, including barriers to health care. The report’s recommendations will be submitted to the Secretary for review and consultation with Native Hawaiians. 

Section 5(b) authorizes the appropriation of such sums as may be 

necessary to coordinate, implement, and update the master plan 

and to prepare the health care financing study report. 

Section 6. Functions of Papa Ola Lokahi and Office of Hawaiian Affairs 

This section sets forth the functions of Papa Ola Lokahi and 

amends the previous Act to include the Office of Hawaiian Affairs. 

18 

Section 6(a)(1) authorizes Papa Ola Lokahi to carry out the following responsibilities: 

(A) Coordinating, implementing, and updating the comprehensive health care master plan under section 5; 

(B) Training and education of individuals providing health 

services; 

(C) Identifying and researching the diseases that are most 

prevalent among Native Hawaiians, including behavioral, biomedical, epidemiological, and health services; and, 

(D) Developing and maintaining an institutional review 

board for all research projects involving all aspects of Native 

Hawaiian health. 

Section 6(a)(2) authorizes Papa Ola Lokahi to receive special 

project funds that may be appropriated for the purpose of conducting research on the health status of Native Hawaiians or for 

the purpose of addressing the health care needs of Native Hawaiians. 

Section 6(a)(3) authorizes Papa Ola Lokahi to serve as a clearinghouse for the collection and maintenance of data associated with 

the health status of Native Hawaiians; the identification and research into diseases affecting Native Hawaiians; the availability of 

Native Hawaiian project funds, research projects, and publications; 

the collaboration of research in Native Hawaiian health; and the 

timely dissemination of information pertinent to the Native Hawaiian health care systems. 

Section 6(b) requires the Secretary and the Secretaries of other 

Federal departments consult with Papa Ola Lokahi and to provide 

Papa Ola Lokahi and the Office of Hawaiian Affairs with at least 

one annual accounting of funds and services provided in carrying 

out the Act’s policy. This accounting will include, but not be limited 

to, the following: the amount of funds expended explicitly for and 

benefitting Native Hawaiians; the number of Native Hawaiians impacted by these funds; the collaborations made with Native Hawaiian groups and organizations in the expenditure of these funds; 

and the amount of funds used for Federal administrative purposes 

and for the provision of direct services to Native Hawaiians. 

Section 6(c)(1) requires that Papa Ola Lokahi provide annual recommendations to the Secretary regarding the allocation of all 

amounts appropriated under this Act. 

Section 6(c)(2) requires that Papa Ola Lokahi, to the extent possible, coordinate and assist the health care programs and services 

to Native Hawaiians. 

Section 6(c)(3) requires the Secretary to consult with Papa Ola 

Lokahi and make recommendations for Native Hawaiian representation on the President’s Advisory Commission on Asian Americans 

and Pacific Islanders. 

Section 6(d) authorizes Papa Ola Lokahi to act as a statewide infrastructure to provide technical support and coordination of training and technical assistance to the Native Hawaiian health care 

systems and the Native Hawaiian health centers. 

Section 6(e)(1) authorizes Papa Ola Lokahi to enter into agreements or memoranda of understanding with relevant institutions, 

agencies, or organizations that are capable of providing health-related resources or services to the Native Hawaiians, the Native HaVerDate Aug 04 2004 01:02 Nov 16, 2004 Jkt 039010 PO 00000 Frm 00018 Fmt 6659 Sfmt 6602 E:\HR\OC\SR405.XXX SR405
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waiian health care systems, or resources for carrying out the national policy of this Act. 

Section 6(e)(2) addresses health care financing as follows: 

Subsection (A) requires that Federal agencies providing health 

care financing and health care programs consult with Native Hawaiians, Papa Ola Lokahi, and organizations providing Native Hawaiian health care services prior to adopting any policy or regulation which may impact on service provision or health insurance 

coverage. The consultation is to include but not be limited to identifying the impact of proposed policies, rules, or regulations. 

Subsection (B) requires the State of Hawaii to engage in meaningful consultation with Native Hawaiians, Papa Ola Lokahi, and 

organizations providing Native Hawaiian health care services prior 

to making any changes or initiating new programs. 

Subsection (C) authorizes the Office of Hawaiian Affairs, in concert with Papa Ola Lokahi, to develop consultative, contractual, or 

other arrangements with the following: the Centers for Medicare 

and Medicaid Services; the agency of the State which administers 

or supervises the administration of a State plan or waiver approved 

under Title XVIII, XIX, or XXI of the Social Security Act for payment of all or part of the health care services to Native Hawaiians 

who are eligible for medical assistance under such a State plan or 

waiver; or with any other Federal agency or agencies providing Native Hawaiians with full or partial health insurance. Such arrangements may include but are not limited to appropriate reimbursement for health care services including capitation and fee for service rates for Native Hawaiians who are entitled to insurance, scope 

of services provided, or any other matters which enable Native Hawaiians to maximize health insurance benefits provided by Federal 

and State health insurance programs. 

Section 6(e)(3) provides that the Department and other Federal 

agencies that provide health care services may include the services 

of traditional Native Hawaiian healers and traditional healers providing traditional health care practices as defined in section 4 of 

the Indian Health Care Improvement Act (25 U.S.C. 1603). Such 

services are to be exempt from national accreditation reviews. 

Section 7. Native Hawaiian health care 

This section addresses the Secretary’s authority to enter into contracts and grants with Native Hawaiian health care systems for 

the provision of Native Hawaiian health care and health care referral services and the responsibilities of the Native Hawaiian health 

care systems. 

Section 7(a) authorizes the Secretary to consult with Papa Ola 

Lokahi and make grants to or enter into contracts with one or more 

Native Hawaiian health care systems for the purpose of providing 

comprehensive health promotion and disease prevention services, 

as well as health care services to Native Hawaiians who desire and 

are committed to bettering their own health. The Secretary may 

enter into grants or contracts with not more than 8 Native Hawaiian health care systems. 

Section 7(b) authorizes the Secretary to also make a grant to, or 

enter into a contract with, Papa Ola Lokahi for purposes of planning Native Hawaiian health care systems to serve the health 

20 

needs of Native Hawaiian communities on the islands of O‘ahu, 

Moloka‘i, Maui, Hawai‘i, Lana‘i, Kaua‘i, Kaho‘lawe, and Ni‘ihau. 

Section 7(c) specifies that each qualified entity receiving funds 

under section 7(a) must ensure that the following health services 

are either provided or provision is arranged for: outreach services 

to inform and assist Native Hawaiians in accessing health services; 

health promotion and disease prevention education for Native Hawaiians by, wherever possible, Native Hawaiian health care practitioners, community outreach workers, counselors, cultural educators, and other disease prevention providers; services of individuals providing health services; collection of data related to the prevention of diseases and illnesses among Native Hawaiians; and 

support of culturally appropriate activities enhancing health and 

wellness including land-based, water-based, ocean-based, and spiritually-based projects and programs. These services may be provided by traditional Native Hawaiian healers, when appropriate. 

Section 7(d) provides that individuals who provide medical, dental, or other services under subsection (7)(a)(1) for a Native Hawaiian health care system shall be treated as if they were members 

of the Public Health Service and shall be covered under the provisions of section 224 of the Public Health Service Act (42 U.S.C. 

233). 

Section 7(e) requires that a Native Hawaiian health care system 

receiving funds under subsection 7(a) may serve as a Federal loan 

repayment facility. This facility must be designed to enable health 

and allied-health professionals to remit payments to loans provided 

to such professionals under any Federal loan program. 

Section 7(f) specifies that the Secretary may not make a grant or 

enter into a contract as authorized under subsection 7(a) unless the 

qualified entity agrees that the grant or contract amount will not, 

directly or through contract, be expended for the following: health 

care services except as described in section 7(c)(1); the purchase or 

improvement of real property (other than minor remodeling of existing improvements to real property); or the purchase of major 

medical equipment. 

Section 7(g) provides that the Secretary may not make a grant 

or enter into a contract with any qualified entity under subsection 

7(a) unless the qualified entity agrees that, whether health services 

are provided directly or through contract, health services under the 

grant or contract will be provided regardless of payment ability and 

the entity will impose a charge for the delivery of health services 

which will be made according to a public schedule of charges and 

will be adjusted to reflect the income of the individual involved. 

Section 7(h) authorizes the appropriation of sums as may be necessary to carry out the general and planning grant activities and 

health services under subsections 7(a), 7(b), and 7(c) for fiscal years 

2004 through 2009. 

Section 8. Administrative grant for Papa Ola Lokahi 

This section authorizes the Secretary to make a grant or enter 

into a contract with Papa Ola Lokahi for its administrative functions. 

Section 8(a) authorizes the Secretary to make grants to or enter 

into contracts with Papa Ola Lokahi for the following: the coordination, implementation, and appropriate updating of the comprehenVerDate Aug 04 2004 01:02 Nov 16, 2004 Jkt 039010 PO 00000 Frm 00020 Fmt 6659 Sfmt 6602 E:\HR\OC\SR405.XXX SR405
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sive health care master plan; training and education for providers 

of health services; identification of and research into the diseases 

that are most prevalent among Native Hawaiians, including behavioral, biomedical, epidemiological and health services; a clearinghouse function for the collection and maintenance of data associated with the health status of Native Hawaiians, the identification 

of and research into diseases affecting Native Hawaiians, and the 

availability of Native Hawaiian project funds, research projects, 

and publications; the establishment and maintenance of an institutional review board for all health-related research involving Native 

Hawaiians; the coordination of the health care programs and services provided to Native Hawaiians; and the administration of special project funds. 

Section 8(b) authorizes the appropriation of sums as may be necessary to carry out the activities in subsection 8(a) for each of fiscal 

years 2004 through 2009. 

Section 9. Administration of grants and contracts 

This section sets forth the terms and conditions under which the 

Secretary makes grants or enters into contracts. 

Section 9(a) specifies that within any grants made or contracts 

entered include terms and conditions that the Secretary considers 

necessary or appropriate to ensure that the grant or contract objectives are achieved. 

Section 9(b) requires that the Secretary periodically evaluate the 

performance of and compliance with grants and contracts under 

this Act. 

Section 9(c) restricts the Secretary’s authority to make any grant 

or enter into any contract under this Act with an entity unless the 

entity: 

(1) Agrees to establish such procedures for fiscal control and 

fund accounting as may be necessary to ensure proper disbursement and accounting with respect to the grant or contract; 

(2) Agrees to ensure the confidentiality of records maintained 

on individuals receiving health services under the grant or contract; 

(3) With respect to health services provided to any population of Native Hawaiians, a substantial portion of whom has 

a limited ability to speak the English language, has developed 

and has the ability to carry out a reasonable plan to provide 

health services under the grant or contract through individuals 

who are able to communicate with that population in the language of that population and in the most appropriate cultural 

context, and has designated at least one individual, fluent in 

both English and the appropriate language, to assist in carrying out the plan; 

(4) With respect to health services that are covered under 

title XVIII, XIX, or XXI of the Social Security Act, including 

any State plan, or under any other Federal health insurance 

plan, if the entity will provide under the grant or contract any 

such health services directly, the entity has entered into a participation agreement under such plans and the entity is qualified to receive payments under such plan, or if the entity will 

provide under the grant or contract any such health services 

22 

through a contract with an organization, the organization has 

entered into a participation agreement under such plan, and 

the organization is qualified to receive payments under such 

plan; and 

(5) Agrees to submit an annual report to the Secretary and 

to Papa Ola Lokahi that describes the use and costs of health 

services provided under the grant or contract, including the average cost of health services per user, and that provides such 

other information the Secretary determines to be appropriate. 

Section 9(d) addresses the Secretary’s evaluation of contracts entered into by the Secretary. 

Subsection (1) provides that when the Secretary’s evaluation reveals that an entity has not complied with or satisfactorily performed a contract entered into under section 7, that before the contract is renewed the Secretary must attempt to resolve the areas 

of noncompliance or unsatisfactory performance and modify the 

contract to prevent future noncompliance or unsatisfactory performance. 

Subsection (2) provides that if the Secretary determines that the 

noncompliance or unsatisfactory performance cannot be resolved 

and prevented in the future, the Secretary shall not renew that entity’s contract and is authorized to enter into a new section 7 contract with a qualified entity, as defined in section 7(a)(3), that provides services to the same population of Native Hawaiians that was 

served by the entity whose contract was not renewed. 

Subsection (3) specifies that in determining whether to renew an 

entity’s contract under the Act, the Secretary shall consider the results of the evaluations undertaken under the authority of section 

9. 

Subsection (4) specifies that the contracts the Secretary enters 

under this Act must be in accordance with all Federal contracting 

laws and regulations, but that the Secretary has the discretion to 

negotiate contracts without advertising and may be exempt from 

subchapter III of chapter 31, United States Code. 

Subsection (5) specifies that payments made under any contract 

entered into under this Act may be made in advance, by means of 

reimbursement, or in installments and shall be made on such conditions as the Secretary deems necessary to carry out the purposes 

of this Act. 

Section 9(e) provides that for each fiscal year during which an 

entity receives or expends funds pursuant to a grant or contract 

under the Act, that entity is to submit an annual report to the Secretary and to Papa Ola Lokahi on the entity’s activities under the 

grant or contract, the amounts and purposes for which Federal 

funds were expended, and such other information as the Secretary 

may request. The reports and records of any entity concerning any 

grant or contract under this Act shall be subject to audit by the 

Secretary, the Inspector General of the Department of Health and 

Human Services, and the Comptroller General of the United 

States. 

Section 9(f) provides that the Secretary shall allow as a cost of 

any grant made or contract entered into under this Act, the cost 

of an annual private audit by a certified public accountant. 

23 

Section 10. Assignment of personnel 

This section addresses the assignment of personnel by the Secretary. 

Section 10(a) authorizes the Secretary to enter into an agreement 

with Papa Ola Lokahi or any of the Native Hawaiian health care 

systems for assigning personnel from Department of Health and 

Human Services with expertise for the purpose of conducting research or providing comprehensive health promotion and disease 

prevention services to Native Hawaiians. 

Section 10(b) specifies that any personnel assignment the Secretary agrees to under the authority of subsection 10(a) is to be 

treated as an assignment of Federal personnel to a local government that is made in accordance with subchapter VI of chapter 33 

of title 5 of the United States Code. 

Section 11. Native Hawaiian health scholarships and fellowships 

Section 11(a) provides that subject to the availability of funds appropriated under the authority of subsection 11(c), the Secretary is 

to provide funds through a direct grant or a cooperative agreement 

with Papa Ola Lokahi for the purpose of providing scholarship assistance to Native Hawaiian students. 

Section 11(b) provides authority for employees of the Native Hawaiian Health Care Systems and the Native Hawaiian Health Centers to have a priority for these scholarships. 

Section 11(c)(1) specifies that subsection 11(a) is to be provided 

in correspondence with the need for each type of health care professional to serve the Native Hawaiian community as Papa Ola 

Lokahi identifies; to the maximum extent practicable, the Secretary 

is to select scholarship recipients from a list of eligible applicants 

Papa Ola Lokahi submits; the obligated service requirement for 

each scholarship recipient is to be fulfilled through service, in order 

of priority, in any one of the Native Hawaiian health care systems; 

Native Hawaiian health centers; health professions shortage areas, 

medically underserved areas, or geographic areas or facilities similarly designated by the U.S. Public Health Service in the State of 

Hawai‘i; a Native Hawaiian organization that serves a geographical 

area with a significant Native Hawaiian population; any public or 

non-profit organization providing services to Native Hawaiians; or 

any of the uniformed services of the United States. The placement 

service for a scholarship shall assign each Native Hawaiian scholarship recipient to one or more appropriate sites for service in accordance with this section. 

Subsection (E) further specifies that counseling, retention, and 

other support services will be available to scholarship recipients 

and other scholarship and financial aid programs recipients enrolled in appropriate health professions training programs. 

Subsection (F) provides that, after consultation with Papa Ola 

Lokahi, financial assistance may be provided to scholarship recipients while they are fulfilling their service requirement in any one 

of the Native Hawaiian health care systems or Native Hawaiian 

health centers. 

Subsection (G) allows for the provision of scholarships to Native 

Hawaiians who are enrolled in an appropriate distance learning 

program offered by an accredited educational institution. 

24 

Section 11(c)(2) provides that the financial aid provided through 

fellowships may be provided by Papa Ola Lokahi to Native Hawaiian health professionals who are Native Hawaiian community 

health representatives, outreach workers, health program administrators in professional training programs; to Native Hawaiians who 

provide health services; or Native Hawaiians in certificated programs provided by traditional Native Hawaiian healers. The financial assistance may include a stipend or reimbursement for costs 

associated with participating in the program. 

Section 11(c)(3) provides that scholarship recipients in health 

professions designated in section 338A of the Public Health Service 

Act shall have the same rights and benefits of members of the National Health Service Corps while fulfilling their service requirements. 

Section 11(c)(4) provides that the financial assistance provided 

under section 11 shall be deemed ‘‘Qualified Scholarships’’ for purposes of section 117 of the Internal Revenue Code of 1986 (26 

U.S.C.117). 

Section 11(d) authorizes the appropriation of such sums as may 

be necessary for the purpose of funding the scholarship assistance 

under subsections 11(a) and 11(c)(2) for fiscal years 2004 through 

2009. 

Section 12. Report 

This section provides that at the time the budget is submitted, 

the President is to transmit a report to Congress for each fiscal 

year on the progress made in meeting the Act’s objectives. The report should include a review of programs established or assisted 

pursuant to the Act and an assessment and recommendation of additional programs or assistance necessary to provide health services to Native Hawaiians and to ensure a health status for Native 

Hawaiians which are on par with the general population’s health 

services and health status. 

Section 13. Use of Federal Government facilities and sources of supply 

This section authorizes organizations that receive grants or contracts to have access to Federal property and supplies. 

Section 13(a) authorizes the Secretary to allow organizations, in 

carrying out their grants or contracts authorized under the Act, to 

use existing facilities and equipment therein or under the Secretary’s jurisdiction, under such terms and conditions as may be 

agreed upon for their use and maintenance. 

Section 13(b) authorizes the Secretary to donate any personal or 

real property determined to be in excess of the needs of the Department or the General Services Administration to organizations that 

receive contracts or grants for purposes of carrying out such contract or grants. 

Section 13 (c) authorizes the Secretary to acquire excess or surplus Federal government personal or real property for donation to 

organizations that receive grants or contracts under this Act, provided that the Secretary determines that the property is appropriate for the organization’s use for the purpose for which the contract or grant was authorized. 

25 

Section 14. Demonstration projects of national significance 

This section authorizes demonstration projects to improve the 

health status of Native Hawaiians. 

Section 14(a) authorizes the Secretary to consult with Papa Ola 

Lokahi and allocate appropriated amounts under this or any other 

Act to carry out Native Hawaiian demonstration projects of national significance. The project areas of interest may include the 

following: 

(A) The development of a centralized database and information system relating to Native Hawaiian health care status, 

health care needs, and wellness; 

(B) The education of health professionals, and other individuals in higher learning institutions, in health and allied health 

programs in healing practices, including Native Hawaiian healing practices; 

(C) The integration of Western medicine with complementary 

healing practices including traditional Native Hawaiian healing practices; 

(D) The use of tele-wellness and telecommunications in 

chronic and infectious disease management and health promotion and disease prevention; 

(E) The development of appropriate models of health care for 

Native Hawaiians and other indigenous people including the 

provision of culturally competent health services, related activities focusing on wellness concepts, and the development of 

appropriate kupuna care programs, and the development of financial mechanisms and collaborative relationships leading to 

universal access to health care; and 

(F) the establishment of Native Hawaiian Centers of Excellence for Nursing at the University of Hawai‘i at Hilo; for Mental Health at the University of Hawai‘i at Manoa; for Maternal 

Health and Nutrition at the Waimanalo Health Center; and for 

Research, Training, and Integrated Medicine at Moloka‘i General Hospital; and for Complementary Health and Health Education and Training at the Waianae Coast Comprehensive 

Health Center. Papa Ola Lokahi and any centers established 

under this paragraph shall be deemed qualified as Centers of 

Excellence under the Public Health Service Act. 

Section 14(b) provides that funds allocated for demonstration 

projects under subsection 14(a) shall not result in a reduction of 

funds required by the Native Hawaiian health care systems, Native 

Hawaiian Health Centers, the Native Hawaiian Health Scholarship 

Program, or Papa Ola Lokahi to carry out their respective responsibilities under this Act. 

Section 15. Rule of construction 

This section specifies that nothing in this Act will be construed 

to restrict the authority of the State of Hawai‘i to license health 

practitioners. 

Section 16. Compliance with Budget Act 

This section provides that any new spending authority described 

in section 401(c)(2)(A) or (B) of the Congressional Budget Act of 

1974 which is provided under the authority of the Act is to be effecVerDate Aug 04 2004 01:02 Nov 16, 2004 Jkt 039010 PO 00000 Frm 00025 Fmt 6659 Sfmt 6602 E:\HR\OC\SR405.XXX SR405
26 

tive only for any fiscal year to the extent or in such amounts as 

are provided in appropriation Acts. 

Section 17. Severability 

This section specifies that if any provision of the Act or application of any provision of the Act to any person or circumstance is 

held to be invalid, the remainder of the Act will be unaffected. 

LEGISLATIVE HISTORY

S. 702 was introduced on March 25, 2003, by Senator Daniel K. 

Inouye, for himself and Senator Daniel K. Akaka, and was referred 

to the Committee on Indian Affairs. No hearings were held on S. 

702, however, during the 106th Congress, the Committee did hold 

a series of hearings on S. 1929 which is the predecessor bill to S. 

702 and was nearly identical in its provisions to S. 702. Those 

hearings were as follows: Moloka‘i and Kaua‘i (January 18, 2000); 

Maui (January 19, 2000); Hilo, Hawai‘i (January 20, 2000); O‘ahu 

(January 21, 2000); Kona, Hawai‘i and Lana‘i (March 16, 2000). 

COMMITTEE RECOMMENDATION AND TABULATION OF VOTE

The Committee on Indian Affairs, on May 14, 2003, in an open 

business meeting, by a unanimous vote, recommended that the 

Senate pass S. 702, a bill to reauthorize and amend the Native Hawaiian Health Care Improvement Act. 

COST AND BUDGETARY CONSIDERATIONS

The cost estimate for S. 702 as calculated by the Congressional 

Budget Office, is set forth below: 

U.S. CONGRESS, 

CONGRESSIONAL BUDGET OFFICE, 

Washington, DC, June 3, 2003. 

Hon. BEN NIGHTHORSE CAMPBELL, 

Chairman, Committee on Indian Affairs, 

U.S. Senate, Washington, DC. 

DEAR MR. CHAIRMAN: The Congressional Budget Office has prepared the enclosed cost estimate for S. 702, the Native Hawaiian 

Health Care Improvement Reauthorization Act of 2003. 

If you wish further details on this estimate, we will be pleased 

to provide them. The CBO staff contact is Alexis Ahlstrom. 

Sincerely, 

DOUGLAS HOLTZ-EAKIN, 

Director. 

Enclosure. 

S.702—Native Hawaiian Health Care Improvement Reauthorization 

Act of 2003 

Summary: S. 702 would reauthorize the Native Hawaiian Health 

Care Program, funded from within the Health Resources and Services Administration’s Consolidated Health Center Program, 

through 2009. 

The bill would authorize the appropriation of such sums as may 

be necessary for fiscal years 2004 through 2009. Assuming the apVerDate Aug 04 2004 01:02 Nov 16, 2004 Jkt 039010 PO 00000 Frm 00026 Fmt 6659 Sfmt 6602 E:\HR\OC\SR405.XXX SR405
27 

propriation of the necessary amounts, CBO estimates that implementing S. 702 would cost about $5 million in 2004 and $53 million 

over the 2004–2009 period. (That estimate assumes that annual 

appropriations are adjusted for inflation. Without such adjustments, the six-year total would be $50 million.) 

The bill would extend provisions under section 224 of the Public 

Health Service Act to providers in Hawaiian health systems. That 

section authorizes settlements and awards for tort claims to be 

paid out of the Treasury’s Judgment Fund. Those payments are 

considered direct spending, regardless of whether the health program involved is an entitlement program or subject to appropriation. CBO estimates those payments would total less than $500,000 

in 2004 and less than $500,000 over the 2004–2009 period. 

S. 702 contains no private-sector mandates as defined in the Unfunded Mandates Reform Act (UMRA). The bill would require the 

state of Hawaii to consult with Naive Hawaiians, Papa Ola Lokahi 

(an umbrella organization composed of groups involved in Native 

Hawaiian health), and health care organizations that provide services to Native Hawaiians before making policy changes or implementing new programs. That requirement would be an intergovernmental mandate as defined in UMRA, but CBO estimates that the 

costs of the mandate would be minimal and would not exceed the 

threshold established in that act ($59 million in 2003, adjusted annually for inflation). 

Estimated cost to the Federal Government: The estimated budgetary impact of S. 702 is shown in the following table. The costs 

of this legislation would fall within budget functions 550 (health) 

and 800 (general government). 

By fiscal year, in millions of dollars— 

2003 2004 2005 2006 2007 2008 2009 

SPENDING SUBJECT TO APPROPRIATION 1

With Adjustments for Inflation 

Native Hawaiian Health Center Program Spending Under Current Law: 

Budget Authority 2 ............................................................ 9 0 0 0 0 0 0 

Estimated Outlays ............................................................ 7 4 * 0 0 0 0 

Proposed Changes: 

Estimated Authorization Level 3 ....................................... 0 9 9 10 10 10 10 

Estimated Outlays ............................................................ 0 5 9 9 10 10 10 

Native Hawaiian Health Center Program Spending Under S. 

702: 

Estimated Authorization Level .......................................... 9 9 9 10 10 10 10 

Estimated Outlays ............................................................ 7 9 9 9 10 10 10 

1 This bill also would increase direct spending, but by less than $500,000 a year. 

2 The 2003 level is the amount appropriated for that year for the Native Hawaiian Health Care Program. 

3 The proposed changes include annual adjustments for inflation for the bill’s authorizations of ‘‘such sums as necessary.’’ Without such inflation adjustments, the six-year totals of costs would be about $3 million lower. 

Note.—* = less than $500,000. 

Basis of estimate: For the purposes of this estimate, CBO assumes that the bill will be enacted by the end of fiscal year 2003 

and that the necessary appropriations will be provided for each fiscal year. 

Spending subject to appropriation 

Native Hawaiian Health Care Program. S. 702 would authorize 

the appropriation of such sums as necessary for 2004 through 2009 

for the extension of activities carried out under the Native HawaiVerDate Aug 04 2004 01:02 Nov 16, 2004 Jkt 039010 PO 00000 Frm 00027 Fmt 6659 Sfmt 6602 E:\HR\OC\SR405.XXX SR405
28 

ian Health Care Program. These activities include the provision of 

health care at Native Hawaiian health centers and health systems; 

granting scholarships to students dedicated to providing health 

care to Native Hawaiians; administration of the program; and the 

development of strategies to improve the health status of Native 

Hawaiians. The bill would authorize increasing from five to eight 

the number of health systems receiving grants, and would authorize the establishment of a fellowship program for health care workers. 

CBO estimates that these activities could be carried out with 

2003 appropriation levels adjusted for inflation, plus additional 

funding for the increase in the number of health systems receiving 

grants. Those systems would be added to the program gradually 

over the next few years, according to information provided by Papa 

Ola Lokahi. Assuming the appropriation of $9 million in 2004, and 

adjustments for inflation in 2005 through 2009, CBO estimates the 

cost of these provisions would be $5 million in 2004 and $53 million 

over the 2004–2009 period. 

Direct spending 

Under current law, settlements and tort claims arising from the 

actions of licensed heath care providers in federally funded health 

centers are paid from the Treasury’s Judgment Fund. The bill 

would expand that coverage to include tort claims arising from the 

actions of licensed providers within the Native Hawaiian health 

systems, as well as non-licensed providers and traditional Hawaiian health providers. Based on past experience with spending from 

the Judgment Fund for providers covered under section 224, as 

well as information on the number and license status of newly covered providers, CBO estimates the cost of this provision to be less 

than $500,000 in each year and less than $500,000 over the 2004– 

2009 period. 

Impact on state, local, and tribal governments: The bill would require the state of Hawaii to consult with Native Hawaiians, Papa 

Ola Lokahi, and health care organizations that provide services to 

Native Hawaiians before making policy changes or implementing 

new programs. That requirement would be an intergovernmental 

mandate as defined in UMRA, but CBO estimates that the costs of 

the mandate would be minimal and would not exceed the threshold 

established in that act ($59 million in 2003, adjusted annually for 

inflation). 

Impact on the private sector: S. 702 contains no private-sector 

mandates as defined in UMRA. 

Estimate prepared by: Federal Costs: Alexis Ahlstrom; Impact on 

State, Local, and Tribal Governments: David Conway; and Impact 

on the Private Sector: Julie Lee. 

Estimate approved by: Peter H. Fontaine, Deputy Assistant Director for Budget Analysis. 

EXECUTIVE COMMUNICATIONS

The Committee received no communications from the Executive 

branch of government on S. 702. 

29 

REGULATORY AND PAPERWORK IMPACT

Paragraph 11(b) of rule XXVI of the Standing Rules of the Senate requires each report accompanying a bill to evaluate the regulatory and paperwork impact that would be incurred in carrying 

out the bill. The Committee believes that S. 702 will have a minimal impact on regulatory or paperwork requirements. 

CHANGES IN EXISTING LAW

UNITED STATES CODE ANNOTATED 

TITLE 42—THE PUBLIC HEALTH AND WELFARE 

CHAPTER 122—NATIVE HAWAIIAN HEALTH CARE 

§ 11701. Findings 

øThe Congress finds that:¿ (a) GENERAL FINDINGS.—Congress 

finds that— 

(1) Native Hawaiians øcomprise¿ begin their story with the 

Kumulipo, which details the creation and inter-relationship of 

all things, including the evolvement of Native Hawaiians as 

healthy and well people; 

(2) NATIVE HAWAIIANS.— 

(A) are a distinct and unique indigenous people with a 

historical continuity to the original inhabitants of the Hawaiian archipelago øwhose society was organized as a Nation prior to the arrival of the first nonindigenous people 

in 1778¿ within Ke Moananui, the Pacific Ocean; and 

(B) have a distinct society that was first organized almost 

2,000 years ago; 

(3) the health and well-being of Native Hawaiians are intrinsically tied to the deep feelings and attachment of Native Hawaiians to their lands and seas, 

(4) the long-range economic and social changes in 

Hawai‘i over the 19th and early 20th centuries have been 

devastating to the health and well-being of Native Hawaiians; 

(5) Native Hawaiians have never directly relinquished to 

the United States their claims to their inherent sovereignty 

as a people or over their national territory, either through 

their monarchy or through a plebiscite or referendum; 

ø(2) The¿ (6) the Native Hawaiian people are determined to 

preserve, develop and transmit to future generations, øtheir 

ancestral territory, and their cultural identity¿ in accordance 

with their own spiritual and traditional beliefs, their customs, 

practices, language, øand¿ social institutionsø.¿, ancestral territory, and cultural identity; 

(7) in referring to themselves, Native Hawaiians use the term 

‘Kanaka Maoli’, a term frequently used in the 19th century to 

describe the native people of Hawai‘i; 

ø(3)¿ (8) The constitution and statutes of the State of 

Hawai‘iø:¿— 

30 

(A) acknowledge the distinct land rights of Native Hawaiian people as beneficiaries of the public lands trust; 

and 

(B) reaffirm and protect the unique right of the Native 

Hawaiian people to practice and perpetuate their cultural 

and religious customs, beliefs, practices, and languageø.¿; 

ø(4) At¿ (9) at the time of the arrival of the first nonindigenous people in Hawaii in 1778, the Native Hawaiian people 

lived in a highly organized, self-sufficient, subsistence social 

system based on communal land tenure with a sophisticated 

language, culture, and religionø.¿; 

ø(5) A¿ (10) a unified monarchical government of the Hawaiian Islands was established in 1810 under Kamehameha I, the 

first King of Hawaiiø.¿; 

ø(6) Throughout¿ (11) throughout the 19th century øand¿ 

until 1893, the United Statesø:¿— 

(A) recognized the independence of the Hawaiian Nation; 

(B) extended full and complete diplomatic recognition to 

the Hawaiian Government; and 

(C) entered into treaties and conventions with the Hawaiian monarchs to govern commerce and navigation in 

1826, 1842, 1849, 1875, and 1887ø.¿; 

ø(7)¿ (12) øIn the year¿ in 1893, John L. Stevens, the United 

States Minister assigned to the sovereign and independent 

Kingdom of Hawai‘i, øJohn L. Stevens,¿ conspired with a small 

group of non-Hawaiian residents of the Kingdom, including 

citizens of the United States, to overthrow the indigenous and 

lawful øGovernment¿ government of Hawai‘iø.¿; 

ø(8) In¿ (13) in pursuance of that conspiracyø,¿— 

(A) the United States Minister and the naval representative of the United States caused armed ønaval¿ forces of 

the United States Navy to invade the sovereign Hawaiian 

Nation in support of the overthrow of the indigenous and 

lawful Government of Hawai‘i; and 

(B) after that overthrow, the United States Minister 

øthereupon¿ extended diplomatic recognition of a provisional government formed by the conspirators without the 

consent of the native people of Hawai‘i or the lawful Government of Hawai‘i, in violation of— 

(i) treaties between the øtwo nations and of international law.¿ Government of Hawai‘i and the United 

States; and 

(ii) international law, 

ø(9) In¿ (14) in a message to Congress on December 18,1893, 

øthen¿ President Grover Cleveland— 

(A) reported fully and accurately on øthese¿ those illegal 

actionsø,¿; 

(B) øand¿ acknowledged that by øthese¿ those acts, described by the President as acts of war, the government of 

a peaceful and friendly people was overthrownø,¿; and 

(C) øthe President¿ concluded that a ø‘‘¿‘substantial 

wrong has thus been done which a due regard for our national character as well as the rights of the injured people 

required that we should endeavor to repairø’’.¿’; 

31 

ø(10)¿ (15) Queen Lili‘uokalani, the lawful monarch of 

Hawai‘i, and the Hawaiian Patriotic League, representing the 

aboriginal citizens of Hawai‘i, promptly petitioned the United 

States for redress of øthese¿ those wrongs and øfor¿ restoration of the indigenous government of the Hawaiian nation, but 

øthis petition was not acted upon.¿ no action was taken on that 

petition; 

(16) in 1993, Congress enacted Public Law 103–150 (107 

Stat.1510), in which Congress— 

(A) acknowledged the significance of those events; and 

(B) apologized to Native Hawaiians on behalf of the people of the United States for the overthrow of the Kingdom 

of Hawai‘i with the participation of agents and citizens of 

the United States, and the resulting deprivation of the 

rights of Native Hawaiians to self-determination; 

ø(11) In¿ (17) in 1898, the United States— 

(A) annexed Hawai‘i through øthe Newlands¿ Resolution 

No. 55 (commonly known as the ‘Newlands Resolution’) (30 

Stat. 750), without the consent of, or compensation to, the 

indigenous people of Hawai‘i or øtheir¿ the sovereign government øwho were thereby¿ of those people; and 

(B) denied those people the mechanism for expression of 

their inherent sovereignty through self-government and 

self-determinationø,¿ of their lands and ocean 

resourcesø.¿; 

ø(12) Through¿ (18) through the Newlands Resolution and 

the ø1900 Organic Act, the United States¿ Act of April 30, 

1900 (commonly known as the ‘1900 Organic Act’) (31 Stat. 141, 

chapter 339), Congress— 

(A) received ø1.75 million¿ 1,750,000 acres of ølands¿ 

land formerly owned by the Crown and Government of the 

Hawaiian Kingdom; and 

(B) exempted the ølands¿ land from then-existing public 

land laws of the United States by mandating that the revenue and proceeds from øthese lands¿ that land be 

ø‘‘¿‘used solely for the benefit of the inhabitants of the Hawaiian Islands for education and other public purposesø’’¿’, 

thereby establishing a special trust relationship between 

the United States and the inhabitants of Hawai‘iø.¿; 

ø(13) In¿ (19) in 1921, Congress enacted the Hawaiian 

Homes Commission Act, 1920 (42 Stat. 108, chapter 42), 

which— 

(A) designated 200,000 acres of the ceded public ølands¿ 

land for exclusive homesteading by Native Hawaiiansø,¿; 

and 

(B) øthereby affirming¿ affirmed the trust relationship 

between the United States and øthe¿ Native Hawaiians, 

as expressed by øthen¿ Secretary of the Interior Franklin 

K. Lane, who was cited in the Committee Report of the 

øUnited States¿ Committee on Territories of the House of 

Representatives øCommittee on Territories¿ as stating, 

ø‘‘¿‘One thing that impressed me . . . was the fact that 

the natives of the islands øwho are our wards, I should 

say, and¿ . . . for whom in a sense we are trustees, are 

32 

falling off rapidly in numbers and many of them are in 

poverty.ø’’¿’; 

ø(14) In¿ (20) in 1938, øthe United States¿ Congress again 

acknowledged the unique status of the Native Hawaiian people 

by including in the Act of June 20, 1938 (52 Stat. 781ø et 

seq.¿), a provision— 

(A) to lease ølands¿ land within the extension to Native 

Hawaiians; and 

(B) to permit fishing in the area ø‘‘¿‘only by native Hawaiian residents of said area or of adjacent villages and by 

visitors under their guidanceø’’.¿’; 

ø(15) Under¿ (21) under the Act øentitled ‘‘An Act to provide 

for the admission of the State of Hawaii into the Union,’’ approved March 18, 1959 (73 Stat. 4)¿ of March 18, 1959 (48 

U.S.C. prec. 491 note; 73 Stat.4), the United States— 

(A) transferred responsibility for the administration of 

the Hawaiian øHome Lands¿ home lands to the State øof 

Hawai‘i¿; but 

(B) reaffirmed the trust relationship øwhich¿ that existed between the United States and the Native Hawaiian 

people by retaining the exclusive power to enforce the 

trust, including the power to approve land exchangesø,¿ 

and legislative amendments affecting the rights of beneficiaries under øsuch¿ that Actø.¿; 

ø(16) Under¿ (22) under the Act øentitled ‘‘An Act to provide 

for the admission of the State of Hawai‘i into the Union’’, approved March 18, 1959 (73 Stat. 4)¿ referred to in paragraph 

(21), the United States— 

(A) transferred responsibility for administration over 

portions of the ceded public lands trust not retained by the 

United States to the State øof Hawai‘i¿; but 

(B) reaffirmed the trust relationship øwhich¿ that existed between the United States and the Native Hawaiian 

people by retaining the legal responsibility of the State for 

the betterment of the conditions of Native Hawaiians 

under section 5(f) of øthe Act entitled ‘‘An Act to provide 

for the admission of the State of Hawai‘i into the Union’’, 

approved March 18, 1959 (73 Stat. 4, 6).¿ that Act (73 Stat. 

6); 

(23) in 1978, the people of Hawai‘i— 

(A) amended the constitution of Hawai‘i to establish the 

Office of Hawaiian Affairs; and 

(B) assigned to that Office the authority— 

(i) to accept and hold in trust for the Native Hawaiian people real and personal property transferred from 

any source; 

(ii) to receive payments from the State owed to the 

Native Hawaiian people in satisfaction of the pro rata 

share of the proceeds of the public land trust established by section 5(f) of the Act of March 18, 1959 (48 

U.S.C. prec 491 note, 73 Stat. 6); 

(iii) to act as the lead State agency for matters affecting the Native Hawaiian people; and 

(iv) to formulate policy on affairs relating to the Native Hawaiian people; 

33 

ø(17) The¿ (24) the authority of the Congress under the 

øUnited States¿ Constitution to legislate in matters affecting 

the aboriginal or indigenous øpeoples¿ people of the United 

States includes the authority to legislate in matters affecting 

the native øpeoples¿ people of Alaska and Hawai‘iø.¿; 

(25) the United States has recognized the authority of the Native Hawaiian people to continue to work toward an appropriate form of sovereignty, as defined by the Native Hawaiian 

people in provisions set forth in legislation returning the Hawaiian Island of Kaho ‘olawe to custodial management by the 

State in 1994; 

[(18) In] (26) in furtherance of the trust responsibility for the 

betterment of the conditions of Native Hawaiians, the United 

States has established a program for the provision of comprehensive health promotion and disease prevention services to 

maintain and improve the health status of the Hawaiian 

peopleø.¿; 

(27) that program is conducted by the Native Hawaiian 

Health Care Systems, and Papa Ola Lokahi; 

(28) health initiatives implemented by those and other health 

institutions and agencies using Federal assistance have been responsible for reducing the century-old morbidity and mortality 

rates of Native Hawaiian people by— 

(A) providing comprehensive disease prevention; 

(B) health promotion activities; and 

(C) increasing the number of Native Hawaiians in the 

health and allied health professions; 

(29) those accomplishments have been achieved through implementation of— 

(A) the Native Hawaiian Health Care Act of 1988 (Public 

Law 100–579); and 

(B) the reauthorization of that Act under section 9168 of 

the Department of Defense Appropriations Act,1993 (Public 

Law 102–396; 106 Stat. 1948); 

ø(19) This¿ (30) the historical and unique legal relationship 

between the United States and Native Hawaiians has been consistently recognized and affirmed by øthe¿ Congress through 

the enactment of more than 160 Federal laws øwhich¿ that extend to the Native Hawaiian people the same rights and privileges accorded to American Indian, Alaska Native, Eskimo, 

and Aleut communities, including— 

(A) the Native American Programs Act of 1974 ø[42 

U.S.C.A. 2991 et seq.]¿ (42 U.S.C. 2991 et seq.); 

(B) the American Indian Religious Freedom Act ø[42 

U.S.C.A. 1996]¿ (42 U.S.C. 1996); 

(C) the National Museum of the American Indian Act 

ø[20 U.S.C.A. § 80q et seq.]¿ (20 U.S.C. 80q et seq.); and 

(D) the Native American Graves Protection and Repatriation Act ø[25 U.S.C.A. 3001 et seq.].¿ (25 U.S.C. 3001 et 

seq.); 

ø(20) The¿ (31) the United States has [also] recognized and 

reaffirmed the trust relationship to the Native Hawaiian people through legislation øwhich¿ that authorizes the provision of 

services to Native Hawaiians, specificallyø,¿— 

34 

(A) the Older Americans Act of 1965 ø[42 U.S.C.A. 

§ 3001 et seq.],¿ (42 U.S.C. 3001 et seq.); 

(B) the Developmental Disabilities Assistance and Bill of 

Rights Act Amendments of 1987ø,¿ (42 U.S.C. 6000 et 

seq.); 

(C) the Veterans’ Benefits and Services Act of 1988ø,¿ 

(Public Law 100–322); 

(D) the Rehabilitation Act of 1973 ø[29 U.S.C.A. 701 et 

seq.],¿ (29 U.S.C. 701 et seq.); 

(E) the Native Hawaiian Health Care Act of 1988ø,¿ (42 

U.S.C. 11701 et seq.); 

(F) the Health Professions Reauthorization Act of 

1988ø,¿ (Public Law 100–607,102 Stat. 3122); 

(G) the Nursing Shortage Reduction and Education Extension Act of 1988ø,¿ (Public Law 100–607; 102 Stat. 

3153); 

(H) the Handicapped Programs Technical Amendments 

Act of 1988ø,¿ (Public Law 100–630); 

(I) the Indian Health Care Amendments of 1988ø,¿ (Public Law 100–713); and 

(J) the Disadvantaged Minority Health Improvement Act 

of 1990ø.¿ (Public Law 101–527); 

ø(21) The¿ (32) the United States has øalso¿ affirmed øthe¿ 

that historical and unique legal relationship to the Hawaiian 

people by authorizing the provision of services to Native Hawaiians to address problems of alcohol and drug abuse under 

the Anti-Drug Abuse Act of 1986ø.¿ (21 U.S.C. 801 note, Public 

Law 99–570); 

(33) in addition, the United States— 

(A) has recognized that Native Hawaiians, as aboriginal, 

indigenous, native people of Hawai‘i, are a unique population group in Hawai‘i and in the continental United 

States, and 

(B) has so declared in Office of Management and Budget 

Circular 15 in 1997 and Presidential Executive Order No. 

13125, dated June 7, 1999, and 

ø(22) Despite¿ (34) despite øsuch services,¿ the United States 

having expressed in Public Law 103–150 (107 Stat. 1510) its 

commitment to a policy of reconciliation with the Native Hawaiian people for past grievances— 

(A) the unmet health needs of the Native Hawaiian people øare¿ remain severe, and 

(B) the health status of the Native øHawaiians¿ Hawaiian people continues to be far below that of the general 

population of the United States. 

(b) FINDING OF UNMET NEEDS AND HEALTH DISPARITIES.—Congress finds that the unmet needs and serious health disparities that 

adversely affect the Native Hawaiian people include the following: 

(1) CHRONIC DISEASE AND ILLNESS.— (A) CANCER.— (i) IN GENERAL.—With respect to all cancer— 

(I) Native Hawaiians have the highest cancer 

mortality rates in the State (216.8 out of every 

100,000 male residents and 191.6 out of every 

100,000 female residents), rates that are 21 percent 

35 

higher than the rate for the total State male population (179.0 out of every 100,000 residents) and 

64 percent higher than the rate for the total State 

female population (117.0 per 100,000); 

(II) Native Hawaiian males have the highest 

cancer mortality rates in the State for cancers of 

the lung, colon, rectum, and colorectum, and for 

all cancers combined; 

(III) Native Hawaiian females have the highest 

cancer mortality rates in the State for cancers of 

the lung, liver, pancreas, breast, corpus uteri, 

stomach, colon, and rectum, and for all cancers 

combined; 

(IV) Native Hawaiian males have 8.7 years of 

productive life lost as a result of cancer in the 

State, the highest years of productive life lost in 

that State, as compared with 6.4 years for all 

males; and 

(V) Native Hawaiian females have 8.2 years of 

productive life lost as a result of cancer in the 

State as compared with 6.4 years for all females in 

the State; 

(ii) BREAST CANCER.—With respect to breast cancer— 

(I) Native Hawaiians have the highest mortality 

rate in the State from breast cancer (30.79 out of 

every 100,000 residents), a rate that is 33 percent 

higher than that for Caucasian Americans (23.07 

out of every 100,000 residents) and 106 percent 

higher than that for Chinese Americans (14.96 out 

of every 100,000 residents); and 

(II) nationally, Native Hawaiians have the third 

highest mortality rate as a result of breast cancer 

(25.0 out of every 100,000 residents) behind African Americans (31.4 out of every 100,000 residents) and Caucasian Americans (27.0 out of every 

100,000 residents). 

(iii) CANCER OF THE CERVIX.—Native Hawaiians 

have the highest mortality rate as a result of cancer of 

the cervix in the State (3.65 out of every 100,000 residents), followed by Filipino Americans (2.69 out of 

every 100,000 residents) and Caucasian Americans 

(2.61 out of every 100,000 residents). 

(iv) LUNG CANCER.—Native Hawaiian males and females have the highest mortality rates as a result of 

lung cancer in the State, at 74.79 per 100,000 for 

males and 47.84 per 100,000 females, which rates are 

higher than the rates for the total State population by 

48 percent for males and 93 percent for females. 

(v) PROSTATE CANCER.—Native Hawaiian males have 

the third highest mortality rate as a result of prostate 

cancer in the State (21.48 out of every 100,000 residents), with Caucasian Americans having the highest 

mortality rate as a result of prostate cancer (23.96 out 

of every 100,000 residents). 

(B) DIABETES.—With respect to diabetes, in 2000— 

36 

(i) Native Hawaiians had the highest mortality rate 

as a result of diabetes mellitus (38.8 out of every 

100,000 residents) in the State, which rate is 138 percent higher than the statewide rate for all racial 

groups (16.3 out of every 100,000 residents); and 

(ii) full-blood Hawaiians had a mortality rate as a 

result of diabetes mellitus of 93.3 out of every 100,000 

residents, which is 518 percent higher than the rate for 

the statewide population of all other racial groups. 

(C) ASTHMA.—With respect to asthma— 

(i) in 1990, Native Hawaiians comprised 44 percent 

of all asthma cases in the State for those 18 years of 

age and younger, and 35 percent of all asthma cases 

reported, and 

(ii) in 1999, the Native Hawaiian prevalence rate for 

asthma was 129.6 out of every 1,000 residents, which 

was 69 percent higher than the rate for all others combined in the State (76.7 out of every 1,000 residents). 

(D) CIRCULATORY DISEASES.— 

(i) HEART DISEASE.—With respect to heart disease— 

(I) the mortality rate for Native Hawaiians as a 

result of heart disease (372.3 out of every 100,000 

residents) is 68 percent higher than the rate for the 

entire State (221.9 out of every 100,000 residents); 

and 

(II) Native Hawaiian males have the greatest 

years of productive life lost in the State, because 

Native Hawaiian males lose an average of 15.5 

years and Native Hawaiian females lose an average of 8.2 years as a result of heart disease, as 

compared with 7.5 years for all males, and 6.4 

years for all females, in the State. 

(ii) HYPERTENSION.-—With respect to hypertension— 

(I) the mortality rate for Native Hawaiians as a 

result of hypertension (3.5 out of every 100,000 

residents) is 84 percent higher than that for the entire State (1.9 out of every 100,000 residents); 

(II) Native Hawaiians have substantially higher 

prevalence rates of hypertension than— 

(aa) those observed statewide; and and 

(bb) those of any other ethnic group in 

Hawai‘i; and 

(III) the prevalence rate of hypertension for Native Hawaiians is 37.9 percent, 11 percent higher 

than that for all others in the State (34.1 percent). 

(iii) STROKE.—The mortality rate for Native Hawaiians as a result of stroke (72.0 out of every 100,000 

residents) is 20 percent higher than that for the entire 

State (60 out of every 100,000 residents). 

(2) INFECTIOUS DISEASE AND ILLNESS.—With respect to infectious disease and illness— 

(A) in 1998, Native Hawaiians comprised 20 percent of 

all deaths resulting from infectious diseases in the State for 

all ages; and 

37 

(B) the incidence of acquired immune deficiency syndrome for Native Hawaiians is at least twice as high per 

100,000 residents (10.5 percent) than that for any other 

non-Caucasian group in the State. 

(3) INJURIES.—With respect to injuries— 

(A) the mortality rate for Native Hawaiians as a result 

of injuries (32.0 out of every 100,000 residents) is 16 percent higher than that for the entire State (27.5 out of every 

100,000 residents); 

(B) 32 percent of all deaths of individuals between the 

ages of 18 and 24 years of age resulting from injuries were 

Native Hawaiian; and 

(C) the 2 primary causes of Native Hawaiian deaths in 

that age group were motor vehicle accidents (30 percent) 

and intentional self-harm (39 percent). 

(4) DENTAL HEALTH.—With respect to dental health— 

(A) Native Hawaiian children exhibit among the highest 

rates of dental caries in the United States, and the highest 

in the State as compared with the 5 other major ethnic 

groups in the State; 

(B) the average number of decayed or filled primary teeth 

for Native Hawaiian children aged 5 through 9 years was 

4.3, as compared with 3.7 for all children in the State and 

1.9 for all children in the United States; and 

(C) the proportion of Native Hawaiian children aged 5 

through 12 years with unmet dental treatment needs (defined as having active dental caries requiring treatment) is 

40 percent, as compared with 33 percent for all other racial 

groups in the State. 

(5) LIFE EXPECTANCY.—With respect to life expectancy— 

(A) Native Hawaiians have the lowest life expectancy of 

all population groups in the State; 

(B) between 1910 and 1980, the life expectancy of Native 

Hawaiians from birth has ranged from 5 to 10 years less 

than that of the overall State population average, and 

(C) the most recent tables for 1990 show Native Hawaiian life expectancy at birth (74.27 years) to be about 5 years 

less than that of the total State population (78.85 years). 

(6) MATERNAL AND CHILD HEALTH.— 

(A) IN GENERAL.—With respect to maternal and child 

health, for 2000 

(i) 39 percent of all deaths of children under the age 

of 18 years in the State were Native Hawaiian; and 

(ii) perinatal conditions accounted for 38 percent of 

all Native Hawaiian deaths in that age group. 

(B) PRENATAL CARE.—With respect to prenatal care— 

(i) as of 1998, Native Hawaiian women have the 

highest prevalence (24 percent) of having had no prenatal care during the first trimester of pregnancy, as 

compared with the 5 largest ethnic groups in the State; 

(ii) of the mothers in the State who received no prenatal care throughout their pregnancies in 1996, 44 

percent were Native Hawaiian; 

38 

(iii) over 65 percent of the referrals to Healthy Start 

in fiscal years 1996 and 1997 were Native Hawaiian 

newborns; and 

(iv) in every region of the State, many Native Hawaiian newborns begin life in a potentially hazardous circumstance, far higher than any other racial group. 

(C) BIRTHS.—With respect to births— 

(i) in 1996, 45 percent of the live births to Native Hawaiian mothers were infants born to single mothers, a 

circumstance which statistics indicate puts infants at 

higher risk of low birth weight and infant mortality; 

(ii) in 1996, of the births to Native Hawaiian single 

mothers, 8 percent were low birth weight (defined as a 

weight less than 2,500 grams); and 

(iii) of all low birth weight infants born to single 

mothers in the State, 44 percent were Native Hawaiian. 

(D) TEEN PREGNANCIES.—With respect to births— 

(i) in 1993 and 1994, Native Hawaiians had the 

highest percentage of teen (individuals who were less 

than 18 years of age) births (8.1 percent), as compared 

with the rate for all other racial groups in the State 

(3.6 percent); 

(ii) in 1998, nearly 49 percent of all mothers in the 

State under 19 years of age were Native Hawaiian; 

(iii) in 1998, Native Hawaiians comprised 31 percent 

(1,425) of all live births to mothers with medical risk 

factors in the State (4,559); and 

(iv) lower rates of abortion (approximately 33 percent 

lower than for the statewide population) among Hawaiian women may account, in part, for that higher percentage of live births. 

(E) FETAL MORTALITY.—With respect to fetal mortality— 

(i) in 2000, Native Hawaiians had the highest number of fetal deaths in the State; and 

(ii)(I) 21 percent of all fetal deaths in the State were 

associated with expectant Native Hawaiian mothers; 

and 

(II) 37 percent of those Native Hawaiian mothers 

were under the age of 25 years. 

(7) MENTAL HEALTH.— 

(A) ALCOHOL AND DRUG ABUSE.—With respect to alcohol 

and drug abuse— 

(i) Native Hawaiians represent 38 percent of the total 

admissions to substance abuse treatment programs 

funded by the Department of Health, Alcohol, Drugs 

and Other Drugs of the State; 

(ii) in 2000, the prevalence of cigarette smoking by 

Native Hawaiians was 31.0 percent, a rate that is 57 

percent higher than that for the total population in the 

State, which is 19.7 percent;, 

(iii) Native Hawaiians have the highest prevalence 

rate of acute alcohol drinking (19.6 percent), a rate 

that is 40 percent higher than that for the total population in the State; 

39 

(iv) the chronic alcohol drinking rate among Native 

Hawaiians is 54 percent higher than that for all other 

racial groups in the State; 

(v) in 1991, 40 percent of the Native Hawaiian 

adults surveyed reported having used marijuana, as 

compared with 30 percent for all other racial groups in 

the State; and 

(vi) 9 percent of the Native Hawaiian adults surveyed reported that they use or have used marijuana 

within the year preceding the survey, as compared with 

6 percent for all other racial groups in the State. 

(B) CRIME.—With respect to crime— 

(i) in 1998, of the 7,789 arrests that were made for 

property crimes in the State, arrests of Native Hawaiians comprised 23 percent; 

(ii) Native Hawaiians comprised 40 percent of juvenile arrests in 1998, the largest percentage of all juvenile arrests in that year; 

(iii) in the period of 1996 through 1998, the overrepresentation of Native Hawaiian juvenile arrests for 

index crimes and Part II offenses increased by 6 percent and 2 percent, respectively; 

(iv) in 1998, Native Hawaiians represented 22 percent of the 2,423 adults arrested for drug-related offenses in the State; 

(v) Native Hawaiians are overrepresented in the prison population in the State; 

(vi) of the 2,260 incarcerated Native Hawaiians, 70 

percent are between 20 and 40 years of age; 

(vii) in 1995 and 1996, Native Hawaiians comprised 

36.5 percent of the sentenced felon prison population in 

Hawaii, as compared with 20.5 percent for Caucasian 

Americans, 3.7 percent for Japanese Americans, and 6 

percent for Chinese Americans; 

(viii) in 2002, Native Hawaiians comprised 40 percent of the total sentenced felon population in the State, 

as compared with 25 percent for Caucasian Americans, 

12 percent for Filipino Americans, 6 percent for Japanese Americans, and 5 percent for Samoans; and 

(ix) based on anecdotal information from inmates at 

the Halawa Correction Facilities, Native Hawaiians 

are estimated to comprise between 60 and 70 percent of 

all inmates in the State. 

(8) OBESITY.—Native Hawaiians have the highest prevalence 

rate of overweightness and obesity (69.4 percent), a rate that is 

38 percent higher than that for the total State population (50.2 

percent). 

(9) HEALTH PROFESSIONS EDUCATION AND TRAINING.—With 

respect to health professions education and training— 

(A)(i) Native Hawaiians who are at least 25 years of age 

have a comparable rate of high school completion as compared with all people in the State who are at least 25 years 

of age; but 

40 

(ii) the rate of baccalaureate degree achievement among 

Native Hawaiians is 6.9 percent, which is less than the average in the State (15.76 percent); 

(B) Native Hawaiian physicians make up 4 percent of the 

total physician workforce in the State; and 

(C)(i) in fiscal year 1999, Native Hawaiians comprised— 

(I) 9 percent of those individuals who earned Bachelor’s degrees; 

(II) 15 percent of those individuals who earned 2– 

year diplomas; and 

(III) 6 percent of those individuals who earned Master’s degrees; and 

(ii) in 1997, Native Hawaiians comprised less than 1 percent of individuals who earned doctoral degrees at the University of Hawai‘i. 

§ 11702. Declaration of øpolicy¿ National Native Hawaiian 

Health Policy 

(a) øCONGRESS¿ DECLARATION.—øThe¿ Congress øhereby¿ declares that it is the policy of the United States, in fulfillment of 

øits¿ special responsibilities and legal obligations of the United 

States to the indigenous people of Hawaii resulting from the unique 

and historical relationship between the United States and the 

øGovernment of the¿ indigenous people of Hawai‘i— 

(1) to raise the health status of Native Hawaiians to the 

highest øpossible¿ practicable health level; and 

(2) to provide øexisting¿ Native Hawaiian health care programs with all resources necessary to effectuate øthis¿ that 

policy. 

(b) INTENT OF CONGRESS.—It is the intent of the Congress that— 

øthe Nation meet the following health objectives with respect to 

Native Hawaiians by the year 2000:¿ 

(1) øReduce coronary heart disease deaths to no more than 

100 per 100,000.¿ health care programs having a demonstrated 

effect of substantially reducing or eliminating the overrepresentation of Native Hawaiians among those suffering from 

chronic and acute disease and illness, and addressing the 

health needs of Native Hawaiians (including perinatal, early 

child development, and family-based health education needs), 

shall be established and implemented, and 

(2) øReduce stroke deaths to no more than 20 per 100,000.¿ 

the United States— 

(A) raise the health status of Native Hawaiians by the 

year 2010 to at least the levels described in the goals contained within Healthy People 2010 (or successor standards); and 

(B) incorporate within health programs in the United 

States activities defined and identified by Kanaka Maoli, 

such as— 

(i) incorporating and supporting the integration of 

cultural 60 approaches to health and well-being, including programs using traditional practices relating 

to the atmosphere (lewa lani), land (‘aina), water (wai), 

or ocean (kai); 

41 

(ii) increasing the number of Native Hawaiian health 

and allied-health care providers who provide care to or 

have an impact on the health status of Native Hawaiians; 

(iii) increasing the use of traditional Native Hawaiian foods those in— 

(I) the diets and dietary preferences of people, including those of students; and 

(II) school feeding programs; 

(iv) identifying and instituting Native Hawaiian cultural values and practices within the corporate cultures 

of organizations and agencies providing health services 

to Native Hawaiians; 

(v) facilitating the provision of Native Hawaiian 

healing practices by Native Hawaiian healers for individuals desiring that assistance; 

(vi) supporting training and education activities and 

programs in traditional Native Hawaiian healing 

practices by Native Hawaiian healers; and 

(vii) demonstrating the integration of health services 

for Native Hawaiians, particularly those that integrate 

mental, physical, and dental services in health care. 

ø(3) Increase control of high blood pressure to at least 50 

percent of people with high blood pressure. 

ø(4) Reduce blood cholesterol to an average of no more than 

200 mg/dl. 

ø(5) Slow the rise in lung cancer deaths to achieve a rate of 

no more than 42 per 100,000. 

ø(6) Reduce breast cancer deaths to no more than 20.6 per 

100,000 women. 

ø(7) Increase Pap tests every 1 to 3 years to at least 85 percent of women age 18 and older. 

ø(8) Increase fecal occult blood testing every 1 to 2 years to 

at least 50 percent of people age 50 and older. 

ø(9) Reduce diabetes-related deaths to no more than 34 per 

100,000. 

ø(10) Reduce the most severe complications of diabetes as 

follows: 

ø(A) end-stage renal disease to no more than 1.4 in 

1,000; 

ø(B) blindness to no more than 1.4 in 1,000; 

ø(C) lower extremity amputation to no more than 4.9 in 

1,000; 

ø(D) perinatal mortality to no more than 2 percent; and 

ø(E) major congenital malformations to no more than 4 

percent. 

ø(11) Reduce infant mortality to no more than 7 deaths per 

1,000 live births. 

ø(12) Reduce low birth weight to no more than 5 percent of 

live births. 

ø(13) Increase first trimester prenatal care to at least 90 percent of live births. 

ø(14) Reduce teenage pregnancies to no more than 50 per 

1,000 girls age 17 and younger. 

42 

ø(15) Reduce unintended pregnancies to no more than 30 

percent of pregnancies. 

ø(16) Increase to at least 60 percent the proportion of primary care providers who provide age-appropriate preconception 

care and counseling. 

ø(17) Increase years of healthy life to at least 65 years. 

ø(18) Eliminate financial barriers to clinical preventive services. 

ø(19) Increase childhood immunization levels to at least 90 

percent of 2-year-olds. 

ø(20) Reduce the prevalence of dental caries to no more than 

35 percent of children by age 8. 

ø(21) Reduce untreated dental caries so that the proportion 

of children with untreated caries (in permanent or primary 

teeth) is no more than 20 percent among children age 6 

through 8 and no more than 15 percent among adolescents age 

15. 

ø(22) Reduce edentulism to no more than 20 percent in people age 65 and older. 

ø(23) Increase moderate daily physical activity to at least 30 

percent of the population. 

ø(24) Reduce sedentary lifestyles to no more than 15 percent 

of the population. 

ø(25) Reduce overweight to a prevalence of no more than 20 

percent of the population. 

ø(26) Reduce dietary fat intake to an average of 30 percent 

of calories or less. 

ø(27) Increase to at least 75 percent the proportion of primary care providers who provide nutrition assessment and 

counseling or referral to qualified nutritionists or dieticians. 

ø(28) Reduce cigarette smoking prevalence to no more than 

15 percent of adults. 

ø(29) Reduce initiation of smoking to no more than 15 percent by age 20. 

ø(30) Reduce alcohol-related motor vehicle crash deaths to no 

more than 8.5 per 100,000 adjusted for age. 

ø(31) Reduce alcohol use by school children age 12 to 17 to 

less than 13 percent. 

ø(32) Reduce marijuana use by youth age 18 to 25 to less 

than 8 percent. 

ø(33) Reduce cocaine use by youth age 18 to 25 to less than 

3 percent. 

ø(34) Confine HIV infection to no more than 800 per 100,000. 

ø(35) Reduce gonorrhea infections to no more than 225 per 

100,000. 

ø(36) Reduce syphilis infections to no more than 10 per 

100,000. 

ø(37) Reduce significant hearing impairment to a prevalence 

of no more than 82 per 1,000. 

ø(38) Reduce acute middle ear infections among children age 

4 and younger, as measured by days of restricted activity or 

school absenteeism, to no more than 105 days per 100 children. 

ø(39) Reduce indigenous cases of vaccine-preventable diseases as follows: 

43 

ø(A) Diphtheria among individuals age 25 and younger 

to 0; 

ø(B) Tetanus among individuals age 25 and younger to 

0; 

ø(C) Polio (wild-type virus) to 0; 

ø(D) Measles to 0; 

ø(E) Rubella to 0; 

ø(F) Congenital Rubella Syndrome to 0; 

ø(G) Mumps to 500; and 

ø(H) Pertussis to 1,000; and 

ø(40) Reduce significant visual impairment to a prevalence of 

no more than 30 per 1,000.¿ 

(c) REPORT.—The Secretary shall submit to the President, for inclusion in each report required to be øtransmitted¿ submitted to 

øthe¿ Congress under section ø11710 of this title¿ 12, a report on 

the progress made øin each area¿ toward meeting øeach of the objectives described in subsection (b) of this section.¿ the national 

policy described in this section. 

§ 11703. Comprehensive health care master plan for Native 

Hawaiians 

(a) DEVELOPMENT.— (1) IN GENERAL.—The Secretary may make a grant to, or 

enter into a contract with, Papa Ola Lokahi for the purpose of 

coordinating, implementing, and updating a Native Hawaiian 

comprehensive health care master plan that is designed— 

(A) to promote comprehensive health promotion and disease prevention services; 

(B) øand¿ to maintain and improve the health status of 

Native Hawaiians; and øThe master plan shall be based 

upon an assessment of the health care status and health 

care needs of Native Hawaiians. To the extent practicable, 

assessments made as of the date of such grant or contract 

shall be used by Papa Ola Lokahi, except that any such assessment shall be updated as appropriate.¿ 

(C) to support community-based initiatives that are reflective of holistic approaches to health. 

(2) CONSULTATION.— (A) IN GENERAL.—In carrying out this section, Papa Ola 

Lokahi and the Office of Hawaiian Affairs shall consult 

with representatives of— 

(i) the Native Hawaiian health care systems; 

(ii) the Native Hawaiian health centers; and 

(iii) the Native Hawaiian community. 

(B) MEMORANDA OF UNDERSTANDING.—Papa Ola Lokahi 

and the Office of Hawaiian Affairs may enter into memoranda of understanding or agreement for the purpose of acquiring joint funding, and for other such purposes as are 

necessary, to accomplish the objectives of this section. 

(3) HEALTH CARE FINANCING STUDY REPORT.— (A) IN GENERAL.—Not later than 18 months after the 

date of enactment of the Native Hawaiian Health Care Improvement Reauthorization Act of 2003, Papa Ola Lokahi, 

in cooperation with the Office of Hawaiian Affairs and 

other appropriate agencies and organizations in the State 

44 

(including the Department of Health and the Department of 

Human Services of the State) and appropriate Federal 

agencies (including the Centers for Medicare and Medicaid 

Services), shall submit to Congress a report that describes 

the impact of Federal and State health care financing 

mechanisms and policies on the health and well-being of 

Native Hawaiians. 

(B) COMPONENTS.—The report shall include— 

(i) information concerning the impact on Native Hawaiian health and well-being of— 

(I) cultural competency; 

(II) risk assessment data, 

(III) eligibility requirements and exemptions; 

and 

(IV) reimbursement policies and capitation rates 

in effect as of the date of the report for service providers; 

(ii) such other similar information as may be important to improving the health status of Native Hawaiians, as that information relates to health care financing (including barriers to health care); and 

(iii) recommendations for submission to the Secretary, for review and consultation with the Native Hawaiian community. 

(b) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to 

be appropriated such sums as ømay be¿ are necessary to carry out 

subsection (a) øof this section¿. 

§ 11704. Functions of Papa Ola Lokahi and Office of Hawaiian Affairs 

(a) øRESPONSIBILITY¿ IN GENERAL.—Papa Ola Lokahi— 

(1) shall be responsible for øthe¿— ø(1)¿ (A) the coordination, implementation, and updating, as appropriate, of the comprehensive health care master plan ødeveloped pursuant to¿ under section ø11703 of 

this title¿ 5; 

ø(2)¿ (B) the training and education of individuals providing health services øfor the persons described in section 

11705(c)(1)(B) of this title¿; 

ø(3)¿ (C) the identification of and research (including behavioral, biomedical, epidemiological, and health service 

research) into the diseases that are most prevalent among 

Native Hawaiiansø, including behavioral, biomedical, epidemiological, and health services¿; and 

(D) the development and maintenance of an institutional 

review board for all research projects involving all aspects 

of Native Hawaiian health, including behavioral, biomedical, epidemiological, and health service research; 

(2) may receive special project funds (including research endowments under section 736 of the Public Health Service Act 

(42 U.S.C. 293)) made available for the purpose of— 

(A) research on the health status of Native Hawaiians; or 

(B) addressing the health care needs of Native Hawaiians; and 

(3) shall serve as a clearinghouse for— 

45 

(A) the collection and maintenance of data associated 

with the health status of Native Hawaiians; 

(B) the identification and research into diseases affecting 

Native Hawaiians; 

(C) the availability of Native Hawaiian project funds, research projects, and publications; 

(D) the collaboration of research in the area of Native 

Hawaiian health; and 

(E) the timely dissemination of information pertinent to 

the Native Hawaiian health care systems. 

ø(4) the development of an action plan outlining the contributions that each member organization of Papa Ola Lokahi 

will make in carrying out the policy of this chapter.¿ 

ø(b) SPECIAL PROJECT FUNDS.—Papa Ola Lokahi øis authorized 

to¿ may receive special project funds that may be appropriated for 

the purpose of research on the health status of Native Hawaiians 

or for the purpose of addressing the health care needs of Native 

Hawaiians.¿ 

(b) CONSULTATION.— 

(1) IN GENERAL.—The Secretary and the Secretary of each 

other Federal agency shall— 

(A) consult with Papa Ola Lokahi; and 

(B) provide Papa Ola Lokahi and the Office of Hawaiian 

Affairs, at least once annually, an accounting of funds and 

services provided by the Secretary to assist in accomplishing the purposes described in section 4. 

(2) COMPONENTS OF ACCOUNTING.—The accounting under 

paragraph (1)(B) shall include an identification of— 

(A) the amount of funds expended explicitly for and benefiting Native Hawaiians; 

(B) the number of Native Hawaiians affected by those 

funds; 

(C) the collaborations between the applicable Federal 

agency and Native Hawaiian groups and organizations in 

the expenditure of those funds; and 

(D) the amount of funds used for— 

(i) Federal administrative purposes; and 

(ii) the provision of direct services to Native Hawaiians. 

ø(c) CLEARINGHOUSE.—Papa Ola Lokahi shall serve as a clearinghouse for: 

ø(1) the collection and maintenance of data associated with 

the health status of Native Hawaiians; 

ø(2) the identification and research into diseases affecting 

Native Hawaiians; 

ø(3) the availability of Native Hawaiian project funds, research projects and publications; 

ø(4) the collaboration of research in the area of Native Hawaiian health; and 

ø(5) the timely dissemination of information pertinent to the 

Native Hawaiian health care systems.¿ 

(c) FISCAL ALLOCATION AND COORDINATION OF PROGRAMS AND

SERVICES.— 

46 

(1) RECOMMENDATIONS.—Papa Ola Lokahi shall provide annual recommendations to the Secretary with respect to the allocation of all amounts made available under this Act. 

(2) COORDINATION.—Papa Ola Lokahi shall, to the maximum 

extent practicable, coordinate and assist the health care programs and services provided to Native Hawaiians under this 

Act and other Federal laws. 

(3) REPRESENTATION ON COMMISSION.—The Secretary, in consultation with Papa Ola Lokahi, shall make recommendations 

for Native Hawaiian representation on the President’s Advisory 

Commission on Asian Americans and Pacific Islanders. 

ø(d) COORDINATION OF PROGRAMS AND SERVICES.—Papa Ola 

Lokahi shall, to the maximum extent possible, coordinate and assist the health care programs and services provided to Native Hawaiians.¿ 

ø(e)¿ (d) TECHNICAL SUPPORT.—Papa Ola Lokahi shall øact as a¿ 

provide statewide infrastructure to provide technical support and 

coordination of training and technical assistance to— 

(1) the Native Hawaiian health care systems; and 

(2) the Native Hawaiian health centers. 

ø(f)¿ (e) RELATIONSHIPS WITH OTHER AGENCIES.— 

(1) Authority.—Papa Ola Lokahi øis authorized to¿ may enter 

into agreements or memoranda of understanding with relevant 

institutions, agencies, or organizations that are capable of providing— 

(A) health-related resources or services to Native Hawaiians and the Native Hawaiian health care systems; or 

(B) resources or services for the implementation of the national policy described in section 4. 

(2) HEALTH CARE FINANCING.— 

(A) FEDERAL CONSULTATION.— 

(i) IN GENERAL.—Before adopting any policy, rule, or 

regulation that may affect the provision of services or 

health insurance coverage for Native Hawaiians, a 

Federally agency that provides health care financing 

and carries out health care programs (including the 

Centers for Medicare and Medicaid Services) shall consult with representatives of— 

(I) the Native Hawaiian community; 

(II) Papa Ola Lokahi; and 

(III) organizations providing health care services 

to Native Hawaiians in the State. 

(ii) IDENTIFICATION OF EFFECTS.—Any consultation 

by a Federal agency under clause (i) shall include an 

identification of the effect of any policy, rule, or regulation proposed by the Federal agency. 

(B) STATE CONSULTATION.—Before making any change in 

an existing program or implementing any new program relating to Native Hawaiian health, the State shall engage in 

meaningful consultation with representatives of— 

(i) the Native Hawaiian community; 

(ii) Papa Ola Lokahi; and 

(iii) organizations providing health care services to 

Native Hawaiians in the State. 

47 

(C) CONSULTATION ON FEDERAL HEALTH INSURANCE PRO- GRAMS.— 

(i) IN GENERAL.—The Office of Hawaiian Affairs, in 

collaboration with Papa Ola Lokahi, may develop consultative, contractual, or other arrangements, including 

memoranda of understanding or agreement, with— 

(I) the Centers for Medicare and Medicaid Services; 

(II) the agency of the State that administers or 

supervises the administration of the State plan or 

waiver approved under title XVIII, XIX, or XXI of 

the Social Security Act (42 U.S.C. 1395 et seq.) for 

the payment of all or a part of the health care services provided to Native Hawaiians who are eligible 

for medical assistance under the State plan or 

waiver; or 

(III) any other Federal agency providing full or 

partial health insurance to Native Hawaiians. 

(ii) CONTENTS OF ARRANGEMENTS.—An arrangement 

under clause (i) may address— 

(I) appropriate reimbursement for health care 

services, including capitation rates and fee-forservice rates for Native Hawaiians who are entitled to or eligible for insurance; 

(II) the scope of services; or 

(III) other matters that would enable Native Hawaiians to maximize health insurance benefits provided by Federal and State health insurance programs. 

(3) TRADITIONAL HEALERS.— 

(A) IN GENERAL.—The provision of health services under 

any program operated by the Department of another Federal agency (including Department of Veterans Affairs) may 

include the services of— 

(i) traditional Native Hawaiian healers; or 

(ii) traditional healers providing traditional health 

care practices (as those terms are defined in section 4 

of the Indian Health Care Improvement Act (25 U.S.C. 

1603). 

(B) EXEMPTION.—Services described in subparagraph (A) 

shall be exempt from national accreditation reviews, including reviews conducted by— 

(i) the joint Commission on Accreditation of 

Healthcare Organizations; and 

(ii) the Commission on Accreditation of Rehabilitation Facilities. 

§ 11705. Native Hawaiian health care øsystems¿ 

(a) COMPREHENSIVE HEALTH PROMOTION, DISEASE PREVENTION, AND øPRIMARY¿ OTHER HEALTH SERVICES.— (1)ø(A)¿ GRANTS AND CONTRACTS.—The Secretary, in consultation with Papa Ola Lokahi, may make grants to, or enter 

into contracts with 1 or more Native Hawaiian health care systems ø, any qualified entity¿ for the purpose of providing comprehensive health promotion and disease prevention services, 

48 

as well as øprimary¿ other health services, to Native Hawaiians who desire and are committed to bettering their own 

health. 

ø(B)¿ (2) LIMITATION ON NUMBER OF ENTITIES.—øIn making 

grants and entering into contracts under this paragraph, the 

Secretary shall give preference to Native Hawaiian health care 

systems and Native Hawaiian organizations and, to the extent 

feasible, health promotion and disease prevention services 

shall be performed through Native Hawaiian health care systems.¿ The Secretary may make a grant to, or enter into a contract with, not more than 8 Native Hawaiian health care systems under this subsection for any fiscal year. 

ø2¿ (b) PLANNING GRANT OR CONTRACT.—In addition to øparagraph (1)¿ grants and contracts under subsection (a), the Secretary 

may make a grant to, or enter into a contract with, Papa Ola 

Lokahi for the purpose of planning Native Hawaiian health care 

systems to serve the health needs of Native Hawaiian communities 

on each of the islands of O‘ahu, Moloka‘i, Maui, Hawai‘i, Lana‘i, 

Kaua‘i, Kaho‘lawe, and Ni‘ihau in the State øof Hawai‘i¿. 

ø(b) QUALIFIED ENTITY.—An entity is a qualified entity for purposes of subsection (a)(1) of this section if the entity is a Native 

Hawaiian health care system.¿ 

(c) HEALTH SERVICES TO BE PROVIDED.— (1) IN GENERAL.—Each recipient of funds under subsection 

(a)ø(1) of this section shall¿ may provide or arrange for—øthe 

following services:¿ 

(A) outreach services to inform and assist Native Hawaiians øof the availability of¿ in accessing health services; 

(B) education in health promotion and disease prevention øof the¿ for Native øHawaiian population by¿ Hawaiians that, wherever øpossible¿ practicable, is provided by— (i) Native Hawaiian health care practitionersø,¿; 

(ii) community outreach workersø,¿; 

(iii) counselorsø, and¿; 

(iv) cultural educators; and 

(v) other disease prevention providers; 

(C) services of øphysicians, physicians’ assistants, nurse 

practitioners or other health professionals¿ individuals 

providing health services; 

(D) øimmunizations¿ collection of data relating to the 

prevention of diseases and illnesses among Native Hawaiians; and 

(E) øprevention and control of diabetes, high blood pressure, and otitis media;¿ support of culturally appropriate 

activities that enhance health and wellness, including landbased, water-based, ocean-based, and spiritually-based 

projects and programs. 

ø(F) pregnancy and infant care; and 

ø(G) improvement of nutrition. 

ø(2) In addition to the mandatory services under paragraph 

(1), the following services may be provided pursuant to subsection (a)(1) of this section: 

ø(A) identification, treatment, control, and reduction of 

the incidence of preventable illnesses and conditions endemic to Native Hawaiians; 

49 

ø(B) collection of data related to the prevention of diseases and illnesses among Native Hawaiians; and 

ø(C) services within the meaning of the terms ‘‘health 

promotion’’, ‘‘disease prevention’’, and ‘‘primary health 

services’’, as such terms are defined in section 11711 of 

this title, which are not specifically referred to in paragraph (1) of this subsection.¿ 

ø(3)¿ (2) TRADITIONAL HEALERS.—The health care services 

referred to in øparagraphs (1) and (2)¿ paragraph (1) øwhich¿ 

that are provided under grants or contracts under subsection 

(a)ø(1) of this section¿ may be provided by traditional Native 

Hawaiian healers, as appropriate. 

ø(d) LIMITATION OF NUMBER OF ENTITIES.—During a fiscal year, 

the Secretary under this chapter may make a grant to, or hold a 

contract with, not more than 5 Native Hawaiian health care systems.¿ 

(d) FEDERAL TORT CLAIMS ACT.—An individual who provides a 

medical, dental, or other service referred to in subsection (a)(1) for 

a Native Hawaiian health care system, including a provider of a 

traditional Native Hawaiian healing service, shall be— 

(1) treated as if the individual were a member of the Public 

Health Service; and 

(2) subject to section 224 of the Public Health Service Act (42 

U.S.C. 233). 

ø(e) MATCHING FUNDS.— 

ø(1) The Secretary may not make a grant or provide funds 

pursuant to a contract under subsection (a)(1) of this section to 

a Native Hawaiian health care system— 

ø(A) in an amount exceeding 83.3 percent of the costs of 

providing health services under the grant or contract; and 

ø(B) unless the Native Hawaiian health care system 

agrees that the Native Hawaiian health care system or the 

State of Hawai‘i will make available, directly or through 

donations to the Native Hawaiian health care system, nonFederal contributions toward such costs in an amount 

equal to not less than $1 (in cash or in kind under paragraph (2) for each $5 of Federal funds provided in such 

grant or contract. 

ø(2) Non-Federal contributions required in paragraph (1) 

may be in cash or in kind, fairly evaluated, including plant, 

equipment, or services. Amounts provided by the Federal Government or services assisted or subsidized to any significant 

extent by the Federal Government may not be included in determining the amount of such non-Federal contributions. 

ø(3) The Secretary may waive the requirement established in 

paragraph (1) if— 

ø(A) the Native Hawaiian health care system involved is 

a nonprofit private entity described in subsection (b) of 

this section; and 

ø(B) the Secretary, in consultation with Papa Ola 

Lokahi, determines that it is not feasible for the Native 

Hawaiian health care system to comply with such requirement.¿ 

(e) SITE FOR OTHER FEDERAL PAYMENTS.— 

50 

(1) IN GENERAL.—A Native Hawaiian health care system that 

receives funds under subsection (a) may serve as a Federal loan 

repayment facility. 

(2) REMISSION OF PAYMENTS.—A facility described in paragraph (1) shall be designed to enable health and allied-health 

professionals to remit payments with respect to loans provided 

to the professionals under any Federal loan program. 

(f) RESTRICTION ON USE OF GRANT AND CONTRACT FUNDS.— 

The Secretary ømay¿ shall not make a grant to, or enter into 

a contract with, øany¿ an entity under subsection (a) ø(1) of 

this section¿ unless the entity agrees thatø,¿ amounts received 

øpursuant to such subsection¿ under the grant or contract will 

not, directly or through contract, be expended— 

(1) for any øpurpose¿ service other than øthe purposes¿ a 

service described in subsection (c) øof this section¿ (1); 

ø(2) to provide inpatient services; 

ø(3) to make cash payments to intended recipients of health 

services; or¿ 

ø(4)¿ (2) to purchase or improve real property (other than 

minor remodeling of existing improvements to real property); 

or 

(3) to purchase major medical equipment. 

(g) LIMITATION ON CHARGES FOR SERVICES.—The Secretary 

ømay¿ shall not make a grant to, or enter into a contract with, 

øany¿ an entity under subsection (a)ø(1) of this section¿ unless the 

entity agrees that, whether health services are provided directly or 

øthrough¿ under a contract— 

(1) any health øservices¿ service under the grant or contract 

will be provided without regard to the ability of an individual 

receiving the health service to pay for the health øservices¿ 

service; and 

(2) the entity will impose øa charge¿ for the delivery of such 

a health øservices, and such charge¿ service a charge that is— 

(A) øwill be¿ made according to a schedule of charges 

that is made available to the public, and 

(B) øwill be¿ adjusted to reflect the income of the individual involved. 

(h) AUTHORIZATION OF APPROPRIATIONS.— 

(1) GENERAL GRANTS.—There are authorized to be appropriated such sums as ømay be¿ are necessary to carry out subsection (a) for each of fiscal years ø1993¿ 2004 through ø2001¿ 

2009 øto carry out subsection (a)(1) of this section¿. 

(2) PLANNING GRANTS.—There are authorized to be appropriated such sums as ømay be¿ are necessary to carry out subsection ø(a)(2) of this section¿ (b) for each of fiscal years 2004 

through 2009. 

(3) HEALTH SERVICES.—There are authorized to be appropriated such sums as are necessary to carry out subsection (c) 

for each of fiscal years 2004 through 2009. 

§ 11706. Administrative grant for Papa Ola Lokahi 

(a) IN GENERAL.—In addition to any other grant or contract 

under this øchapter¿ Act, the Secretary may make grants to, or 

enter into contracts with, Papa Ola Lokahi for— 

51 

(1) coordination, implementation, and updating (as appropriate) of the comprehensive health care master plan developed 

øpursuant to section 11703 of this title¿ under section 5; 

(2) training and education for øthe persons described in section 11705(c)(1)(B) of this title¿ providers of health services; 

(3) identification of and research øinto the diseases that are 

most prevalent among Native Hawaiians,¿ (including behavioral, biomedical, øepidemiological¿ epidemiologic, and health 

øservices¿ service research) into the diseases that are most prevalent among Native Hawaiians; 

ø(4) the development of an action plan outlining the contributions that each member organization of Papa Ola Lokahi 

will make in carrying out the policy of this chapter;¿ 

ø(5)¿ (4) a clearinghouse function for— 

(A) the collection and maintenance of data associated 

with the health status of Native Hawaiians; 

(B) the identification and research into diseases affecting 

Native Hawaiians; and 

(C) the availability of Native Hawaiian project funds, research projects and publications; 

(5) the establishment and maintenance of an institutional review board for all health-related research involving Native Hawaiians; 

(6) the coordination of the health care programs and services 

provided to Native Hawaiians; and 

(7) the administration of special project funds. 

(b) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to 

be appropriated such sums as ømay be¿ are necessary to carry out 

subsection (a) for each of fiscal years ø1993¿ 2004 through ø2001¿ 

2009 øto carry out 80 subsection (a) of this section¿. 

§ 11707. Administration of grants and contracts 

(a) TERMS AND CONDITIONS.—The Secretary shall include in any 

grant made or contract entered into under this øchapter¿ Act such 

terms and conditions as the Secretary considers necessary or appropriate to ensure that the objectives of øsuch¿ the grant or contract are achieved. 

(b) PERIODIC REVIEW.—The Secretary shall periodically evaluate 

the performance of, and compliance with, grants and contracts 

under this øchapter¿ Act. 

(c) ADMINISTRATIVE REQUIREMENTS.—The Secretary ømay¿ shall 

not make a grant or enter into a contract under this øchapter¿ Act 

with an entity unless the entity— 

(1) agrees to establish such procedures for fiscal control and 

fund accounting as ømay be¿ the Secretary determines are necessary to ensure proper disbursement and accounting with respect to the grant or contract; 

(2) agrees to ensure the confidentiality of records maintained 

on individuals receiving health services under the grant or contract; 

(3) with respect to providing health services to any population of Native Hawaiians, a substantial portion of which has 

a limited ability to speak the English language— 

(A) has developed and has the ability to carry out a reasonable plan to provide health services under the grant or 

52 

contract through individuals who are able to communicate 

with the population involved in the language and cultural 

context that is most appropriate; and 

(B) has designated at least øone¿ 1 individualø,¿ who is 

fluent in øboth¿ English and the appropriate languageø,¿ 

to assist in carrying out the plan; 

(4) with respect to health services that are covered øin the 

plan of the State of Hawai‘i approved¿ under a program under 

title XVIII, XIX, or XXI of the Social Security Act ø42 U.S.C.A. 

§ 1396 et seq.¿ (42 U.S.C. 1395 et seq.) (including any State 

plan), or under any other Federal health insurance plan— 

(A) if the entity will provide under the grant or contract 

any øsuch¿ of those health services directly— 

(i) øthe entity¿ has entered into a participation 

agreement under each such øplans¿ plan; and 

(ii) øthe entity¿ is qualified to receive payments 

under øsuch¿ the plan; and 

(B) if the entity will provide under the grant or contract 

any øsuch¿ of those health services through a contract 

with an organization— 

(i) ensures that the organization has entered into a 

participation agreement under each such plan; and 

(ii) ensures that the organization is qualified to receive payments under øsuch¿ the plan; and 

(5) agrees to submit to the Secretary and øto¿ Papa Ola 

Lokahi an annual report that— 

(A) describes the øutilization¿ use and costs of health 

services provided under the grant or contract (including 

the average cost of health services per user); and 

(B) øthat¿ provides such other information as the Secretary determines to be appropriate. 

(d) CONTRACT EVALUATION.— 

(1) DETERMINATION OF NONCOMPLIANCE.—If, as a result of 

evaluations conducted by the Secretary, the Secretary determines that an entity has not complied with or satisfactorily 

performed a contract entered into under section ø11705 of this 

title¿ 7, the Secretary shall, øprior to¿ before renewing øsuch¿ 

the contractø,¿— 

(A) attempt to resolve the areas of noncompliance or unsatisfactory performance; and 

(B) modify øsuch¿ the contract to prevent future occurrences of [such] the noncompliance or unsatisfactory performance. 

(2) NONRENEWAL.—If the Secretary determines that øsuch¿ 

the noncompliance or unsatisfactory performance described in 

paragraph (1) with respect to an entity cannot be resolved and 

prevented in the future, the Secretary— 

(A) shall not renew øsuch¿ the contract with øsuch¿ the 

entity; and 

(B) øis authorized to¿ may enter into a contract under 

section ø11705 of this title¿ 7 with another entity referred 

to in section ø11705(b)¿ 7(a)(3) øof this title¿ that provides 

services to the same population of Native Hawaiians 

øwhich is¿ served by the entity øwhose contract is¿ the 

53 

contract with which was not renewed by reason of this 

øsubsection¿ paragraph. 

ø(2)¿ (3) CONSIDERATION OF RESULTS.—In determining 

whether to renew a contract entered into with an entity under 

this øchapter¿ Act, the Secretary shall consider the results of 

the øevaluation¿ evaluations conducted under this section. 

ø(3)¿ (4) APPLICATION OF FEDERAL LAWS.—øAll contracts¿ 

Each contract entered into by the Secretary under this øchapter¿ Act shall be in accordance with all Federal contracting 

laws øand¿ (including regulations), except that, in the discretion of the Secretary, such øcontracts¿ a contract may— 

(A) be negotiated without advertising; and 

(B) ømay¿ be exempted from øthe provisions of the Act 

of August 24, 1935 (40 U.S.C. 270a et seq.)¿ subchapter III 

of chapter 31, United States Code. 

ø(4)¿ (5) PAYMENTS.—A øPayments¿ payment made under 

any contract entered into under this øchapter¿ Act— 

(A) may be made— 

(i) in advanceø,¿; 

(ii) by means of reimbursementø,¿; or 

(iii) in installments; and 

(B) shall be made on such conditions as the Secretary 

ødeems¿ determines to be necessary to carry out øthe purposes of¿ this øchapter¿ Act. 

ø(e) LIMITATION ON USE OF FUNDS FOR ADMINISTRATIVE EXPENSES.—Except for grants and contracts under section 11706 of 

this title, the Secretary may not grant to, or enter into a contract 

with, an entity under this chapter unless the entity agrees that the 

entity will not expend more than 10 percent of amounts received 

pursuant to this chapter for the purpose of administering the grant 

or contract.¿ 

ø(f)¿ (e) REPORT.— 

(1) IN GENERAL.—For each fiscal year during which an entity 

receives or expends funds øpursuant to¿ under a grant or contract under this øchapter¿ Act, øsuch¿ the entity shall submit 

to the Secretary and to Papa Ola Lokahi øa quarterly¿ an annual report øon¿ that describes— 

(A) the activities conducted by the entity under the grant 

or contract; 

(B) the amounts and purposes for which Federal funds 

were expended; and 

(C) such other information as the Secretary may request. 

(2) AUDITS.—The reports and records of any entity øwhich 

concern¿ concerning any grant or contract under this øchapter¿ Act shall be subject to audit by— 

(A) the Secretaryø,¿; 

(B) the Inspector General of the Department of Health 

and Human Servicesø,¿; and 

(C) the Comptroller General of the United States. 

ø(g)¿ (f) ANNUAL PRIVATE AUDIT.—The Secretary shall allow as 

a cost of any grant made or contract entered into under this øchapter¿ Act the cost of an annual private audit conducted by a certified 

public accountant to carry out this section. 

54 

§ 11708. Assignment of personnel 

(a) IN GENERAL.—The Secretary øis authorized to¿ may enter 

into an agreement with øany entity under which the Secretary is 

authorized to assign¿ Papa Ola Lokahi or any of the Native Hawaiian health care systems for the assignment of personnel of the Department of Health and Human Services with relevant expertise 

øidentified by such entity to such entity on detail¿ for the øpurposes¿ purpose of— 

(1) conducting research; or 

(2) providing comprehensive health promotion and disease 

prevention services and health services to Native Hawaiians. 

(b) APPLICABLE FEDERAL PERSONNEL PROVISIONS.—Any assignment of personnel made by the Secretary under any agreement entered into under øthe authority of¿ subsection (a) øof this section¿ 

shall be treated as an assignment of Federal personnel to a local 

government that is made in accordance with subchapter VI of chapter 33 of øTitle¿ title 5, United States Code. 

§ 11709. Native Hawaiian health scholarships and Fellowships 

(a) ELIGIBILITY.—Subject to the availability of øfunds¿ amounts 

appropriated under øthe authority of¿ subsection (c) øof this section¿, the Secretary shall provide to Papa Ola Lokahi, through a 

direct grant or a cooperative agreement, funds øthrough a direct 

grant or a cooperative agreement to Papa Ola Lokahi¿ for the purpose of providing scholarship assistance to students who are Native 

Hawaiians.ø—¿ 

ø(1) meet the requirements of section 254l of this title, and 

ø(2) are Native Hawaiians.¿ 

(b) PRIORITY.—A priority for scholarships under subsection (a) 

may be provided to employees of— 

(1) the Native Hawaiian Health Care Systems; and 

(2) the Native Hawaiian Health Centers.— ø(b)¿ (c) TERMS AND CONDITIONS.— (1) SCHOLARSHIP ASSISTANCE.— (A) IN GENERAL.—The scholarship assistance øprovided¿ 

under subsection (a) øof this section¿ shall be provided 

øunder the same terms and subject to the same conditions, 

regulations, and rules that apply to scholarship assistance 

provided under section 254l of this title, provided that—¿ 

in accordance with subparagraphs (B) through (G). 

ø(A)¿ (B) NEED.—øthe¿ The provision of scholarships in 

each type of health øcare¿ profession training shall correspond to the need for each type of health øcare¿ professional øidentified in the Native Hawaiian comprehensive 

health care master plan implemented under section 11703 

of this title¿ to serve the Native Hawaiian øhealth care 

systems¿ community in providing health services, as identified by Papa Ola Lokahiø;¿. 

ø(B) the primary health services covered under the 

scholarship assistance program under this section shall be 

the services included under the definition of that term 

under section 11711(8) of this title;¿ 

(C) ELIGIBLE APPLICANTS.—øto¿ To the maximum extent 

practicable, the Secretary shall select scholarship recipiVerDate Aug 04 2004 01:02 Nov 16, 2004 Jkt 039010 PO 00000 Frm 00054 Fmt 6659 Sfmt 6602 E:\HR\OC\SR405.XXX SR405
55 

ents from a list of eligible applicants submitted by øthe¿ 

Papa øOka¿ Ola Lokahiø;¿. (D) OBLIGATED SERVICE REQUIREMENT.— (i) IN GENERAL.—An øthe¿ obligated service requirement for each scholarship recipient (except for a recipient receiving assistance under paragraph (2)) shall be 

fulfilled through øthe full-time clinical or nonclinical 

practice of the health profession of the scholarship recipient, in an¿ service, in order of priority øthat would 

provide for practice—¿ , in— (I)ø(i) first, in¿ any øone¿ of the øfive¿ Native 

Hawaiian health care systems; øand¿ 

(II) any of the Native Hawaiian health centers; 

(III) 1 or more health professions shortage areas, 

medically underserved areas, or geographic areas 

or facilities similarly designated by the Public 

Health Service in the State; 

(IV) a Native Hawaiian organization that serves 

a geographical area with a significant Native Hawaiian population; 

(V) any public agency or non-profit organization 

providing services to Native Hawaiians; or 

(VI) any of the uniformed services of the United 

States. 

ø(ii) second, in— 

ø(I) a health professional shortage area or medically underserved area located in the State of Hawaii; or 

ø(II) a geographic area or facility that is— 

ø(aa) located in the State of Hawaii; and 

ø(bb) has a designation that is similar to a 

designation described in subclause (I) made 

by the Secretary, acting through the Public 

Health Service;¿ 

(ii) ASSIGNMENT.—The placement service for a scholarship shall assign each Native Hawaiian scholarship 

recipient to 1 or more appropriate sites for service in 

accordance with clause (i). 

(E) COUNSELING, RETENTION, AND SUPPORT SERVICES.— øthe¿ The provision of academic and personal counseling, 

retention and other support services— 

(i) shall not be limited to scholarship recipients ø,¿ 

under this section; and 

(ii) øbut shall also include¿ shall be made available 

to recipients of other scholarship and financial aid programs enrolled in appropriate health professions training programsø,¿. (F) FINANCIAL ASSISTANCE.—øthe obligated service of a 

scholarship recipient shall not be performed by the recipient through membership in the National Health Service 

Corps; and¿ After consultation with Papa Ola Lokahi, financial assistance may be provided to a scholarship recipient during the period that the recipient is fulfilling the 

service requirement of the recipient in any of— 

(i) the Native Hawaiian health care systems; or 

56 

(ii) the Native Hawaiians health centers. 

ø(G) the requirements of sections 254d through 254k of 

this title, section 254m of this title, other than subsection 

(b)(5) of that section, and section 254n of this title applicable to scholarship assistance provided under 254l of this 

title shall not apply to the scholarship assistance provided 

under subsection (a) of this section.¿ 

(G) DISTANCE LEARNING RECIPIENTS.—A scholarship may 

be provided to a Native Hawaiian who is enrolled in an appropriate distance learning program offered by an accredited educational institution. 

ø(2) The Native Hawaiian Health Scholarship program shall 

not be administered by or through the Indian Health Service.¿ 

(2) FELLOWSHIPS.— 

(A) IN GENERAL.—Papa Ola Lokahi may provide financial assistance in the form of a fellowship to a Native Hawaiian health professional who is— 

(i) a Native Hawaiian community health representative, outreach worker, or health program 

administrator in a professional training program; 

(ii) a Native Hawaiian providing health services; 

or 

(iii) a Native Hawaiian enrolled in a certificated 

program provided by traditional Native Hawaiian 

healers in any of the traditional Native Hawaiian 

healing practices (including lomi-lomi, la’au 

lapa’au, and ho’oponopono). 

(B) TYPES OF ASSISTANCE.—Assistance under subparagraph (A) may include a stipend for, or reimbursement for 

costs associated with, participation in a program described 

in that paragraph. 

(3) RIGHTS AND BENEFITS.—An individual who is a health 

professional designated in section 338A of the Public Health 

Service Act (42 U.S.C. 254l) who receives a scholarship under 

this subsection while fulfilling a service requirement under that 

Act shall retain the same rights and benefits as members of the 

National Health Service Corps during the period of service. 

(4) NO INCLUSION OF ASSISTANCE IN GROSS INCOME.—Financial assistance provided under this section shall be considered 

to be qualified scholarships for the purpose of section 117 of the 

Internal Revenue Code of 1986. 

ø(c)¿ (d) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated such sums as ømay be¿ are necessary to 

carry out subsections (a) and (c)(2) for each of fiscal years ø1993¿ 

2004 through ø2001¿ 2009 øfor the purpose of funding the scholarship assistance provided under subsection (a) of this section¿. 

§ 11710. Report 

For each fiscal year, the øThe¿ President shall, at the time at 

which the budget of the United States is submitted under section 

1105 of øTitle¿ title 31, United States Code, submit øfor each fiscal 

year transmit¿ to øthe¿ Congress a report on the progress made in 

meeting the øobjectives¿ purposes of this øchapter¿ Act, including— 

57 

(1) a review of programs established or assisted øpursuant to 

this chapter¿ in accordance with this Act; and 

(2) an assessment of and recommendations øof¿ for additional programs or additional assistance necessary to provide, 

at a minimum, øprovide¿ health services to Native Hawaiians, 

and ensure a health status for Native Hawaiians, øwhich¿ that 

are at a parity with the health services available to, and the 

health status of, the general population. 

SEC. 13. USE OF FEDERAL GOVERNMENT FACILITIES AND SOURCES OF 

SUPPLY 

(a) IN GENERAL.—The Secretary shall permit an organization that 

enters into a contract or receives grant under this Act to use in carrying out projects or activities under the contract or grant all existing facilities under the jurisdiction of the Secretary (including all 

equipment of the facilities), in accordance with such terms and conditions as may be agreed on for the use and maintenance of the facilities or equipment. 

(b) DONATION OF PROPERTY.—The Secretary may donate to an organization that enters into a contract or receives grant under this 

Act, for use in carrying out a project or activity under the contract 

or grant, any personal or real property determined to be in excess 

of the needs of the Department or the General Services Administration. 

(c) ACQUISITION OF SURPLUS PROPERTY.—The Secretary may acquire excess or surplus Federal Government personal or real property for donation to an organization under subsection (b) if the Secretary determines that the property is appropriate for use by the organization for the purpose for which a contract entered into or grant 

received by the organization is authorized under this Act. 

SEC. 14. DEMONSTRATION PROJECTS OF NATIONAL SIGNIFICANCE 

(a) AUTHORITY AND AREAS OF INTEREST.— 

(1) IN GENERAL.—The Secretary, in consultation with Papa 

Ola Lokahi, may allocate amounts made available under this 

Act, or any other Act, to carry out Native Hawaiian demonstration projects of national significance. 

(2) AREAS OF INTEREST.—A demonstration project described 

in paragraph (1) may relate to such areas of interest as— 

(A) the development of a centralized database and information system relating to the health care status, health 

care needs, and wellness of Native Hawaiians; 

(B) the education of health professionals, and other individuals in institutions of higher learning, in health and allied health programs in healing practices, including Native 

Hawaiian healing practices; 

(C) the integration of Western medicine with complementary healing practices, including traditional Native Hawaiian healing practices; 

(D) the use of telewellness and telecommunications in— 

(i) chronic and infectious disease management, and 

(ii) health promotion and disease prevention; 

(E) the development of appropriate models of health care 

for Native Hawaiians and other indigenous people, including— 

58 

(i) the provision of culturally competent health services; 

(ii) related activities focusing on wellness concepts; 

(iii) the development of appropriate kupuna care programs; and 

(iv) the development of financial mechanisms and 

collaborative relationships leading to universal access 

to health care; and 

(F) the establishment of— 

(i) a Native Hawaiian Center of Excellence for Nursing at the University of Hawai‘i at Hilo; 

(ii) a Native Hawaiian Center of Excellence for Mental Health at the University of Hawai‘i at Manoa, 

(iii) a Native Hawaiian Center of Excellence for Maternal Health and Nutrition at the Waimanalo Health 

Center; 

(iv) a Native Hawaiian Center of Excellence for Research, Training, and Integrated Medicine at Molokai 

General Hospital; and 

(v) a Native Hawaiian Center of Excellence for Complementary Health and Health Education and Training at the Waianae Coast Comprehensive Health Center. 

(3) CENTERS OF EXCELLENCE.—Papa Ola Lokahi, and any 

centers established under paragraph (2)(F), shall be considered 

to be qualified as Centers of Excellence under sections 485F and 

903(b)(2)(A) of the Public Health Service Act (42 U.S.C. 287c– 

32, 299a–1). 

(b) NONREDUCTION IN OTHER FUNDING.—The allocation of funds 

for demonstration projects under subsection (a) shall not result in 

any reduction in funds required by the Native Hawaiian health care 

systems, the Native Hawaiian Health Centers, the Native Hawaiian 

Health Scholarship Program, or Papa Ola Lokahi to carry out the 

respective responsibilities of those entities under this Act. 

§ 11711. Definitions 

øFor purposes of this chapter¿ In this Act: 

(1) DEPARTMENT.—The term ‘Department’ means the Department of Health and Human Services. 

ø(1)¿(2) DISEASE PREVENTION.—The term ø‘‘¿‘disease 

preventionø’’¿’ includes— 

(A) immunizationsø,¿; 

(B) control of high blood pressureø,¿; 

(C) control of sexually transmittable diseasesø,¿; 

(D) prevention and control of ødiabetes,¿ chronic diseases; 

(E) control of toxic agentsø,¿; 

(F) occupational safety and healthø,¿; 

(G) øaccident¿ injury preventionø,¿; 

(H) fluoridation of waterø,¿; 

(I) control of infectious agentsø,¿; and 

(J) provision of mental health care. 

ø(2)¿ (3) HEALTH PROMOTION.—The term ø‘‘¿‘health 

promotionø’’¿’ includes— 

59 

(A) pregnancy and infant care, including prevention of 

fetal alcohol syndromeø,¿; 

(B) cessation of tobacco smokingø,¿; 

(C) reduction in the misuse of alcohol and harmful illicit 

drugsø,¿; 

(D) improvement of nutritionø,¿; 

(E) improvement in physical fitnessø,¿; 

(F) family planningø, and¿; 

(G) control of stressø.¿; 

(H) reduction of major behavioral risk factors and promotion of healthy lifestyle practices; and 

(I) integration of cultural approaches to health and wellbeing (including traditional practices relating to the atmosphere (lewa lani), land (’aina), water (wai), and ocean (kai). 

(4) HEALTH SERVICE.—The term ‘health service’ means— 

(A) service provided by a physician, physician’s assistant, 

nurse practitioner, nurse, dentist, or other health professional; 

(B) a diagnostic laboratory or radiologic service, 

(C) a preventive health service (including a perinatal 

service, well child service, family planning service, nutrition service, home health service, sports medicine and athletic training service, and, generally, any service associated 

with enhanced health and wellness); 

(D) emergency medical service, including a service provided by a first responder, emergency medical technician, 

or mobile intensive care technician; 

(E) a transportation service required for adequate patient 

care; 

(F) a preventive dental service, 

(G) a pharmaceutical and medicant service; 

(H) a mental health service, including a service provided 

by a psychologist or social worker; 

(I) a genetic counseling service; 

(J) a health administration service, including a service 

provided by a health program administrator; 

(K) a health research service, including a service provided by an individual with an advanced degree in medicine, nursing, psychology, social work, or any other related 

health program; 

(L) an environmental health service, including a service 

provided by an epidemiologist, public health official, medical geographer, or medical anthropologist, or an individual specializing in biological, chemical, or environmental health determinants; 

(M) a primary care service that may lead to specialty or 

tertiary care; and 

(N) a complementary healing practice, including a practice performed by a traditional Native Hawaiian healer. 

ø(3)¿(5) NATIVE HAWAIIAN.—The term ø‘‘¿‘Native 

Hawaiianø’’¿’ means any individual who is ø—¿ Kanaka Maoli 

(a descendant of the aboriginal people who, prior to 1778, occupied and exercised sovereignty in the area that now constitutes 

the State), as evidenced by— 

60 

(A) øa citizen of the United States, and¿ genealogical 

records; 

(B) øa descendant of the aboriginal people, who prior to 

1778, occupied and exercised sovereignty in the area that 

now constitutes the State of Hawai‘i, as evidenced by—¿ 

kama‘aina witness verification from Native Hawaiian 

Kupuna (elders); or 

ø(i) genealogical records, 

ø(ii) Kupuna (elders) or Kama‘aina (long-term community residents) verification, or¿ 

ø(iii)¿ (C) birth records of the State øof Hawai‘i¿ or 

any other State or territory of the United States. 

ø(4)¿ (6) NATIVE HAWAIIAN HEALTH øCENTER¿ CARE SYSTEM.—The term ø‘‘¿‘Native Hawaiian health øcenter¿ care system’ means øan entity¿ any of up to 8 entities in the State 

that— 

(A) øwhich¿ is organized under the laws of the State øof 

Hawai‘i¿; 

(B) øwhich¿ provides or arranges for the provision of 

health øcare¿ services øthrough practitioners licensed by 

the State of Hawai‘i, where licensure requirements are applicable¿ for Native Hawaiians in the State; 

(C) øwhich¿ is a public or nonprofit private entity ø, 

and¿; 

(D)ø in which¿ has Native øHawaiian health practitioners¿ Hawaiians significantly øparticipate¿ participating in the planning, management, provision, monitoring, and evaluation of health servicesø.¿; 

(E) addresses the health care needs of an island’s Native 

Hawaiian population; and 

(F) is recognized by Papa Ola Lokahi— 

(i) for the purpose of planning, conducting, or administering programs, or portions of programs, authorized by this Act for the benefit of Native Hawaiians; 

and 

(ii) as having the qualifications and the capacity to 

provide the services and meet the requirements under— 

(I) the contract that each Native Hawaiian 

health care system enters into with the Secretary 

under this Act; or 

(II) the grant each Native Hawaiian health care 

system receives from the Secretary under this Act. 

ø(5)¿ (7) øNATIVE HAWAIIAN ORGANIZATION¿ NATIVE HAWAIIAN HEALTH CENTER.—The term ø‘‘¿‘Native Hawaiian øorganization’’¿ Health Center’ means any organizationø—¿ that is a 

primary health care provider that— 

(A) øwhich serves the interests of Native Hawaiians,¿ 

has a governing board composed of individuals, at least 50 

percent of whom are Native Hawaiians; 

(B)ø which is—¿ has demonstrated cultural competency 

in a predominately Native Hawaiian community; 

(C) services a patient population that— (i) ørecognized by Papa Ola Lokahi for the purpose 

of planning, conducting, or administering programs (or 

portions of programs) authorized under this chapter 

61 

for the benefit of Native Hawaiians, and¿ is made up 

of individuals at least 50 percent of whom are Native 

Hawaiian; or 

(ii) øcertified by Papa Ola Lokahi as having the 

qualifications and capacity to provide the services, and 

meet the requirements, under the contract the organization enters into with, or grant the organization receives from, the Secretary under this chapter,¿ has not 

less that 2,500 Native Hawaiians as annual users of 

services; and 

ø(C) in which Native Hawaiian health practitioners 

significantly participate in the planning, management, 

monitoring, and evaluation of health services, and¿ 

(D) øwhich is a public or nonprofit private entity.¿ is recognized by Papa Ola Lokahi has having met each of the 

criteria described in subparagraphs (A) through (C). 

ø(6)¿ (8) NATIVE HAWAIIAN øhealth care system—¿ HEALTH

TASK FORCE.—The term ø‘‘¿‘Native Hawaiian øhealth care system’’¿ Health Task Force’ means øan entity—¿ a task force established by the State Council of Hawaiian Homestead Associations to implement health and wellness strategies in Native Hawaiian communities. 

ø(A) which is organized under the laws of the State of 

Hawai‘i, 

ø(B) which provides or arranges for health care services 

through practitioners licensed by the State of Hawai‘i, 

where licensure requirements are applicable, 

ø(C) which is a public or nonprofit private entity, 

ø(D) in which Native Hawaiian health practitioners significantly participate in the planning, management, monitoring, and evaluation of health care services, 

ø(E) which may be composed of as many Native Hawaiian health centers as necessary to meet the health care 

needs of each island’s Native Hawaiians, and 

ø[(F) which is— 

ø(i) recognized by Papa Ola Lokahi for the purpose 

of planning, conducting, or administering programs, or 

portions of programs, authorized by this chapter for 

the benefit of Native Hawaiians, and 

ø(ii) certified by Papa Ola Lokahi as having the 

qualifications and the capacity to provide the services 

and meet the requirements under the contract the Native Hawaiian health care system enters into with the 

Secretary or the grant the Native Hawaiian health 

care system receives from the Secretary pursuant to 

this chapter.¿ 

ø(7)¿ (9) øPapa ola lokahi—¿ NATIVE HAWAIIAN ORGANIZA- TION.—The term ‘Native Hawaiian organization’ means any organization that— 

(A) øThe term ‘‘Papa Ola Lokahi’’ means an organization 

composed of—¿ serves the interests of Native Hawaiians; 

and 

ø(i) E Ola Mau; 

ø(ii) the Office of Hawaiian Affairs of the State of 

Hawai‘i; 

62 

ø(iii) Alu Like Inc.; 

ø(iv) the University of Hawai‘i; 

ø(v) the Office of Hawaiian Health of the Hawaii 

State Department of Health; 

ø(vi) Ho‘ola Lahui Hawai‘i, or a health care system 

serving the islands of Kaua‘i and Ni‘ihau, and which 

may be composed of as many health care centers as 

are necessary to meet the health care needs of the Native Hawaiians of those islands; 

ø(vii) Ke Ola Mamo, or a health care system serving 

the island of O‘ahu, and which may be composed of as 

many health care centers as are necessary to meet the 

health care needs of the Native Hawaiians of that island; 

ø(viii) Na Pu‘uwai or a health care system serving 

the islands of Moloka‘i and Lana‘i, and which may be 

composed of as many health care centers as are necessary to meet the health care needs of the Native Hawaiians of those islands; 

ø(ix) Hui No Ke Ola Pono, or a health care system 

serving the island of Maui, and which may be composed of as many health care centers as are necessary 

to meet the health care needs of the Native Hawaiians 

of that island; 

ø(x) Hui Malama Ola Ha‘Oiwi or a health care system serving the island of Hawai‘i, and which may be 

composed of as many health care centers as are necessary to meet the health care needs of the Native Hawaiians of that island; and 

ø(xi) such other member organizations as the Board 

of Papa Ola Lokahi may admit from time to time, 

based upon satisfactory demonstration of a record of 

contribution to the health and well-being of Native 

Hawaiians, and upon satisfactory development of a 

mission statement in relation to this chapter, including clearly defined goals and objectives, a 5-year action 

plan outlining the contributions that each organization 

will make in carrying out the policy of this chapter, 

and an estimated budget.¿ 

(B) øSuch term does not include any such organization 

identified in subparagraph (A) if the Secretary determines 

that such organization has not developed a mission statement with clearly defined goals and objectives for the contributions the organization will make to the Native Hawaiian health care systems, and an action plan for carrying 

out those goals and objectives.¿ (i) is recognized by Papa 

Ola Lokahi for planning, conducting, or administering programs authorized under this Act for the benefit of Native 

Hawaiians; and 

(ii) is a public or nonprofit private entity. 

ø(8)¿ (10) øPrimary health services¿ OFFICE OF HAWAIIAN AFFAIRS.—The term ‘Office of Hawaiian Affairs’ means the governmental entity that— 

øThe term ‘‘primary health services’’ means—¿ 

63 

(A) øservices of physicians, physicians’ assistants, nurse 

practitioners, and other health professionals;¿ is established under Article XII, sections 5 and 6 of the Hawai‘i 

State Constitution; and 

(B) ødiagnostic laboratory and radiologic services;¿ 

charged with the responsibility to formulate policy relating 

to the affairs of Native Hawaiians. ø(C) preventive health services (including children’s eye 

and ear examinations to determine the need for vision and 

hearing correction, perinatal services, well child services, 

and family planning services); 

ø(D) emergency medical services; 

ø(E) transportation services as required for adequate patient care; 

ø(F) preventive dental services; and 

ø(G) pharmaceutical service, as may be appropriate for 

particular health centers.¿ 

ø(9)¿ (11) øSECRETARY¿ PAPA OLA LOKAHI.— øThe term ‘‘Secretary’’ means the Secretary of Health and 

Human Services.¿ 

(A) IN GENERAL.—The term ‘‘Papa Ola Lokahi’’ means an 

organization that— 

(i) is composed of public agencies and private organizations focusing on improving the health status of Native Hawaiians; and 

(ii) governed by a board the members of which may 

include representation from— 

(I) E Ola Mau; 

(II) the Office of Hawaiian A airs; 

(III) Alu Like, Inc.; 

(IV) the University of Hawai‘i; 

(V) the Hawai‘i State Department of Health; 

(VI) the Native Hawaiian Health Task Force, 

(VII) the Hawai‘i State Primary Care Association; 

(VIII) Ahahui O Na Kauka, the Native Hawaiian Physicians 

(IX) Ho ‘ola Lahui Hawai‘i, or a health care system serving the islands of Kaua‘i or Ni‘ihau 

(which may be composed of as many health care 

centers as are necessary to meet the health care 

needs of the Native Hawaiians of those islands); 

(X) Ke Ola Mamo, or a health care system serving the island of O‘ahu (which may be composed 

of as many health care centers as are necessary to 

meet the health care needs of the Native Hawaiians of that island); 

(XI) Na Pu‘uwai or a health care system serving 

the islands of Moloka‘i or Lana‘i (which may be 

composed of as many health care centers as are 

necessary to meet the health care needs of the Native Hawaiians of those islands); 

(XII) Hui No Ke Ola Pono, or a health care system serving the island of Maui (which may be 

composed of as many health care centers as are 

64 

necessary to meet the health care needs of the Native Hawaiians of that island); 

(XIII) Hui Malama Ola Na ‘Oiwi, or a health 

care system serving the island of Hawai‘i (which 

may be composed of as many health care centers as 

are necessary to meet the health care needs of the 

Native Hawaiians of that island); 

(XIV) such other Native Hawaiian health care 

systems as are certified and recognized by Papa 

Ola Lokahi in accordance with this Act; and 

(XV) such other member organizations as the 

Board of Papa Ola Lokahi shall admit from time 

to time, based on satisfactory demonstration of a 

record of contribution to the health and well-being 

of Native Hawaiians. 

(B) EXCLUSION.—The term ‘‘Papa Ola Lokahi’’ does not 

include any organization described in subparagraph (A) for 

which the ‘Secretary has made a determination that the organization has not developed a mission statement that includes— 

(i) clearly-defined goals and objectives for the contributions the organization will make to— 

(I) Native Hawaiian health care systems, and 

(II) the national policy described in section 4; 

and 

(ii) an action plan for carrying out those goals and 

objectives. 

ø(10)¿ (12) øTRADITIONAL NATIVE HAWAIIAN HEALER.—¿ SECRETARY.—The term ‘‘Secretary’’ means the Secretary of Health 

and Human Services. 

øThe term ‘‘traditional Native Hawaiian healer’’ means a 

practitioner— 

ø(A) who— 

ø(i) is of Hawaiian ancestry, and 

ø(ii) has the knowledge, skills, and experience in direct personal health care of individuals, and 

ø(B) whose knowledge, skills, and experience are based 

on demonstrated learning of Native Hawaiian healing 

practices acquired by— 

ø(i) direct practical association with Native Hawaiian elders, and 

ø(ii) oral traditions transmitted from generation to 

generation.¿ 

(13) STATE.—The term ‘‘State’’ means the State of Hawai‘i. 

(14) TRADITIONAL NATIVE HAWAIIAN HEALER.—The term ‘‘traditional Native Hawaiian healer’’ means a practitioner— 

(A) who— 

(i) is of Native Hawaiian ancestry; and 

(ii) has the knowledge, skills, and experience in direct personal health care of individuals; and 

(B) the knowledge, skills, and experience of whom are 

based on demonstrated learning of Native Hawaiian healing practices acquired by— 

(i) direct practical association with Native Hawaiian 

elders, and 

65 

(ii) oral traditions transmitted from generation to 

generation. 

§ 11712. Rule of construction 

Nothing in this øchapter¿ Act øshall be construed to restrict¿ restricts the authority of the State øof Hawai‘i¿ to ølicense¿ require 

licensing of, and issue licenses to, health practitioners. 

§ 11713. Compliance with Budget Act 

Any new spending authority ø(¿described in øsubsection (c)(2)¿ 

subparagraph (A) or (B) of section ø651¿ 401(c) (2) of øTitle 2)¿ the 

Congressional Budget Act of 1974 (2 U.S.C. 651 (c) (2)) ø)¿ øwhich¿ 

that is provided under this øchapter¿ Act shall be effective for any 

fiscal year only to such extent or in such amounts as are provided 

for in Acts of appropriation øActs¿. 

§ 11714. Severability 

If any provision of this øchapter¿ Act, or the application of any 

such provision to any person or øcircumstances¿ circumstance, is 

øheld¿ determined by a court of competent jurisdiction to be invalid, 

the remainder of this øchapter¿ Act, and the application of øsuch¿ 

the provision øor amendment¿ to a øpersons or circumstances¿ person or circumstance other than øthose¿ that to which øit¿ the provision is held invalid, shall not be affected øthereby¿ by that holding. 

(67) 

APPENDIX A 

GOALS AND OBJECTIVES AND HEALTH CARE SERVICES PROVIDED BY

THE FIVE NATIVE HAWAIIAN HEALTH CARE SYSTEMS

Islands of Kaua‘i and Ni‘ihau 

To serve the health care needs of Native Hawaiians on the islands of Kaua‘i and Ni‘ihau, Ho‘ola Lahui Hawai‘i is a nonprofit organization dedicated to elevating the health status and overall living conditions of Native Hawaiians. Ho‘ola Lahui Hawaii has established offices in Waimea and Anahola which serve as a base 

from which outreach is provided to the East and West sides of 

Kaua‘i. Service to the island of Ni‘ihau is provided through the office in Waimea. Ho‘ola Lahui Hawaii is working with existing 

health and health-related organizations in an effort to assure access to services for Native Hawaiians that were either inaccessible 

or unacceptable. Ho‘ola Lahui Hawai‘i is organized around the concept of lokahi (unity in all aspects of life) in which they seek to 

maintain a balance of body, mind, and soul. As a community-based 

organization, the concern of Ho‘ola Lahui Hawai‘i for Native Hawaiians grows out of a shared history, for those involved in Ho‘ola 

Lahui Hawai‘i are Native Hawaiian. 

Ho‘ola Lahui Hawai‘i provides health education and teaching on 

cancer, diabetes, hypertension, high cholesterol, gout, hygiene, and 

diet/exercise. Ho‘ola Lahui Hawai‘i also conducts monitoring on 

blood pressure, blood sugar, weight, and diet. Ho‘ola Lahui Hawai‘i 

offers information and referral to outside agencies through case 

management. In addition, Ho‘ola Lahui Hawai‘i is sponsoring the 

traditional Native Hawaiian diet regimen on the island of Kaua‘i. 

Ho‘ola Lahui Hawai‘i completed one diet project in Waimea in conjunction with the State Department of Health and started another 

in Kapa‘a in May of 1992. 

Traditional healing is also an area Ho‘ola Lahui Hawai‘i addresses with sponsorship of a statewide la‘au lapa‘au (training in traditional medicine) in the spring of 1992 in conjunction with E Ola 

Mau and Ka Wai Ola ‘o Kalani. In addition, Ho‘ola Lahui Hawai‘i 

offers lomi lomi (traditional massage therapy). Ho‘ola Lahui 

Hawai‘i intends to expand its services to include health education 

and teaching on sexually-transmitted diseases, family planning, 

maternal and infant care, and alcohol/substance abuse. Ho‘ola 

Lahui Hawai‘i’s plans include establishing a health education component in kindergarten, elementary, and high schools, tailored to 

the physical and psychological needs of the particular age group. 

68 

Island of O‘ahu 

Ke Ola Mamo is committed to improving the health status of Native Hawai‘ians on the island of O‘ahu through the development of 

a system of culturally-competent services that build upon rather 

than duplicate the existing health care service delivery system. 

Through outreach referral and case consultation, Ke Ola Mamo’s 

goal is the empowerment of Native Hawaiian families and individuals to access appropriate health care services; the development of 

partnerships with existing health care services in a collaborative 

effort to improve access to health care; and working with Native 

Hawaiian communities and neighborhoods to assist them in meeting their health care needs. 

In 1986, there were 137,481 Native Hawaiians living on the island of O‘ahu, who comprise approximately two-thirds of the total 

Native Hawaiian population in the entire State of Hawai‘i. The Native Hawaiian population living on O‘ahu can be roughly divided 

into three equal groups by geographic location; those living on the 

leeward coast, including Pearl City; those living on the windward 

and north coasts; and those living in the urban Honolulu complex. 

There are estimated to be at least 20 distinct communities and 

neighborhoods where Native Hawaiian families reside. At the outset of its work, Ke Ola Mamo selected four of these communities 

to develop service delivery projects. Three projects involve rural 

communities: the Waimanalo community, the Wai‘anae community, 

and the Ko‘olauloa community. A fourth project is being proposed 

as a community education and planning process for the urban Honolulu communities with future service implementation proposals. 

Island of Moloka‘i 

The goal of Na Pu‘uwai is to raise the health status of the Native 

Hawaiian residents of the island of Moloka‘i, including Kalaupapa, 

and the island of Lana‘i to the highest possible level and to encourage the maximum participation of Native Hawaiians to achieve this 

goal. The strategy of the program is two-fold: (1) to develop a personalized schedule of recommended health care activities, referred 

to as a ‘‘personalized health care plan’’ for each client; and (2) to 

use case management methodologies as a behavioral intervention 

to assure client adherence to their ‘‘personalized health care plan.’’ 

To implement this strategy, the program: (1) conducts screening 

and enrollment for those who are self-referred, provider-referred, or 

recruited by staff; (2) conducts a health risk appraisal on each enrollee to assess current health maintenance status; (3) develops a 

personalized health care plan with each client, based on recommended primary, secondary, and tertiary health maintenance 

guidelines and the client’s concerns and needs; (4) coordinates and 

provides health promotion and disease prevention programs and 

health screening; (5) provides clinic-based primary health care 

services; (6) provides multi-disciplinary case management services 

as appropriate, to enrolled participants; and (7) reassesses client 

status as dictated in the case management plan and conducts ongoing followup on all clients, case management and non-case management. 

Na’ Pu‘uwai’s service delivery plan provides for (1) direct outpatient care services of a physician and nurse; (2) case manageVerDate Aug 04 2004 01:02 Nov 16, 2004 Jkt 039010 PO 00000 Frm 00068 Fmt 6601 Sfmt 6601 E:\HR\OC\SR405.XXX SR405
69 

ment services of a social worker and multi-disciplinary case management team; (3) direct health education and health screening 

services; and (4) patient followup and outreach services. 

Island of Maui 

Hui No Ke Ola Pono, an association to strengthen and perpetuate life, is Maui’s Native Hawaiian Health Care System, providing 

services that are culturally relevant to Native Hawaiians of Maui, 

including identification, treatment, control, and reduction of the incidence of preventable illnesses and conditions frequently occurring 

in the Native Hawaiian population. The services provided by Hui 

No Ke Ola Pono include health promotion and disease prevention; 

referrals for immunizations; improvement of nutrition; referrals for 

pregnancy and infant care; prevention and control of diabetes, high 

blood pressure, and middle ear infections; community outreach 

services; referrals to physician and nursing services; and education 

on traditional practitioner services. 

In addition, traditional Hawaiian healers provide the following 

services: ho‘oponopono (family or group counseling); la‘au lapa‘au 

(traditional Hawaiian herbal medicine); and lomi lomi (Hawaiian 

massage therapy). 

Island of Hawai‘i 

Hui Malama Ola Na ‘Oiwi (caring for our people) is the Native 

Hawaiian health care system for Native Hawaiians on the Island 

of Hawai‘i. The program mission of Hui Malama Ola Na ‘Oiwi is 

to assist Native Hawaiians in restoring a high quality health care 

system by creating and developing a non-threatening healing environment inclusive of traditional health assistance and to provide 

and facilitate a process of awareness and addressing the health 

needs, both physical and spiritual, of Native Hawaiians. 

Hui Malama’s objectives are to (1) promote physical, emotional, 

and spiritual health and well-being of Native Hawaiians on the island of Hawai‘i; (2) assist and promote personal responsibility 

among Native Hawaiians toward making sound, informed decisions 

which would decrease unhealthy behaviors and reduce morbidity 

and mortality rates; (3) support and advocate the use of health care 

services that come from the traditions of the Native Hawaiian culture and of western science; and (4) work toward the establishment 

of primary health care centers in appropriate locations where quality primary care can be provided and where primary care services 

are not currently available. 

The death rates of Native Hawaiians exceed the death rates for 

all races in the United States caused by diseases of the heart, cancer, strokes, and diabetes. Achieving good health for Native Hawaiians appears difficult, but these diseases can be controlled through 

early detection, proper diet and treatment, and regular exercise. 

Hui Malama Ola Na ‘Oiwi provides the following services: 

(1) Outreach—enrolling participants in the program, assessing their health risk factors, assisting in securing medical insurance where needed, assisting in access to a physician, providing transportation to and from the physician for those who 

need it, and making home visits when necessary; 

70 

(2) Health promotion and disease prevention—providing education regarding the prevention and control of diabetes, high 

blood pressure (hypertension), use of tobacco, alcohol and other 

harmful drugs, sexually transmitted diseases, stress, cancer, 

the importance of sound nutrition habits, regular exercise, and 

proper maternal and infant care practices; 

(3) Primary health services—Hui Malama Ola Na ‘Oiwi assists patients in securing access to the primary health care 

services of a physician, a physician’s assistant, or a nurse practitioner. 

(71) 

6The power of the general government over these remnants of a race once powerful, now weak 

and diminished in numbers, is necessary to their protection. As well as to the safety of those 

among whom they dwell. It must exist in that government, because it never has existed anywhere else, because the theater of its exercise is within the geographical limits of the United 

States * * * From their very weakness and helplessness, so largely due to the course of dealing 

of the Federal government with them, and the treaties in which it has been promised, there 

arises a duty of protection, and with it the power. This has always been recognized by the executive, and by congress, and by this court, whenever the question has arisen.’’ United States v. 

Kagama, 118 U.S. 375 (1886). 7Morton v. Mancari, 427 U.S. 535 (1974). 8Delaware Tribal Business Council v. Weeks, 430 U.S. 73 (1977); United States v. Sioux Nation, 448 U.S. 371 (1980). The rulings of the Supreme Court make clear that neither the conferring of citizenship upon the native people, the allotment of their lands, the lifting of restrictions 

on alienation of native land, the dissolution of a tribe, the emancipation of individual native people, the fact that a group of natives may be only a remnant of a tribe, the lack of continuous 

Federal supervision over the Indians, nor the separation of individual Indians from their tribes 

would divest the Congress of its constitutional authority to address the conditions of the native 

people. Cherokee Nation v. Hitchock, 187 U.S. 294 (1902); United States v. Celestine, 215 U.S. 

278 (1909); Tiger v. Western Inv. Co., 221 U.S. 286 (1911); United States v. Nice, 241 U.S. 591 

(1916); Chippewa Indians v. United States, 307 U.S. 1 (1939); Delaware Tribal Business Council 

v. Weeks, 430 U.S. 73 (1977); United States v. John, 437 U.S. 634 (1979). 9 United States v. Sandoval, 231 U.S. 28 (1913). 

APPENDIX B 

CONSTITUTIONAL SOURCE OF CONGRESSIONAL AUTHORITY

The United States Supreme Court has so often addressed the 

scope of Congress’ constitutional authority to address the conditions of the native people that it is now well-established.6 Although 

the authority has been characterized as ‘‘plenary,’’ 7 the Supreme 

Court has addressed the broad scope of the Congress’ authority.8

It has been held to encompass not only the native people within the 

original territory of the thirteen states but also lands that have 

been subsequently acquired.9

The ensuing course of dealings with the indigenous people has 

varied from group to group, and thus, the only general principles 

that apply to relations with the first inhabitants of this nation is 

that they were dispossessed of their lands, often but not always relocated to other lands set aside for their benefit, and that their subsistence rights to hunt, fish, and gather have been recognized 

under treaties and laws, but not always protected nor preserved. 

Some commentators have suggested that no other group of people 

in America has been singled out so frequently for special treatment, unique legislation, and distinct expressions of Federal policy. 

Although the relationship between the United States and its native 

people is not a history that can be said to have followed a fixed 

course, it is undeniably a history that reveals the special status of 

the indigenous people of this land. American laws recognize that 

the native people do not trace their lineage to common ancestors 

and, from time to time, our laws have in fact discouraged the indigenous people from organizing themselves as ‘‘tribes.’’ But this much 

is true—that for the most part, at any particular time in our hisVerDate Aug 04 2004 01:02 Nov 16, 2004 Jkt 039010 PO 00000 Frm 00071 Fmt 6604 Sfmt 6604 E:\HR\OC\SR405.XXX SR405
72 

10The Records of the Federal Convention of 1787, Volume II, Journal Entry of August 18, 

1787, p. 321. 11The Records of the Federal Convention of 1787, Volume II, Journal Entry of August 22, 

1787, p. 367. 12 In his letter to James Monroe of November 27, 1784, James Madison observes, ‘‘The 

foederal articles give Congs, the exclusive right of managing all affairs with the Indians not 

members of any State, under a proviso, that the Legislative authority, of the State within its 

own limits be not violated. By Indian[s] not members of a State, must be meant those, I conceive 

who do not live within the body of the Society, or whose Persons or property form no objects 

of its laws. In the case of Indians of this description the only restraint on Congress is imposed 

by the Legislative authority of the State.’’ The Founders’ Constitution, Volume Two, Preamble 

through Article 1, Section 8, Clause 4, p. 529, James Madison to James Monroe, 27 Nov. 1784, 

Papers 8:156–57; See also, James Monroe to James Madison, 15 Nov. 1784, Madison Papers 

8:140. 13The term ‘‘aborigines’’ is defined as ‘‘the earliest inhabitants of a country, those of whom 

no original is to be traced,’’ and the term ‘‘tribe’’ is defined as ‘‘a distinct body of the people 

as divided by family or fortune, or any other characteristic.’’ A Dictionary of the English Language (Samuel Johnson ed., 1755). The annotations accompanying the term ‘‘Indian’’ in the 1901 

Oxford dictionary indicates the use of the term as far back as 1553. Oxford English Dictionary 

(James A.H. Murray ed., 1901). 

tory, the laws of the United States have attempted to treat the native people, regardless of their genealogical origins and their political organization, in a consistent manner. 

Organization as a Tribe and the Scope of Constitutional Authority 

It has been suggested that the scope of constitutional authority 

vested in the Congress is constrained by the manner in which the 

native people organize themselves. Under this theory, if the native 

people are not organized as tribes, then the Congress lacks the authority to enact laws and the President is without authority to establish policies affecting the native people of the United States. 

However, the original language proposed for inclusion in the Constitution made no reference to ‘‘tribes’’ but instead proposed that 

the Congress be vested with the authority ‘‘to regulate affairs with 

the Indians as well within as without the limits of the United 

States.’’ 10 A further refinement suggested that the language read 

‘‘and with Indians, within the Limits of any State, not subject to 

the laws thereofø.¿’’.11

The exchanges of correspondence between James Monroe and 

James Madison concerning the construction of what was to become 

Article I, Section 8, Clause 3 of the Constitution make no reference 

to Indian tribes, but they do discuss Indians.12 Nor is the term ‘‘Indian tribe’’ found in any dictionaries of the late eighteenth century, 

although the terms ‘‘aborigines’’ and ‘‘tribe’’ are defined.’’ 13

Native Hawaiians and the Meaning of ‘‘Indian’’ 

Whether the reference was to ‘‘aborigines’’ or to ‘‘Indians’’, the 

Framers of the Constitution did not import a meaning to those 

terms as a limitation upon the authority of Congress, but as descriptions of the native people who occupied and possessed the 

lands that were later to become the United States—whether those 

lands lay within the boundaries of the original thirteen colonies, or 

any subsequently acquired territories. This construction is consistent with more than two hundred Federal statutes which establish that the aboriginal inhabitants of America are a class of people 

known as ‘‘Native Americans’’ and that this class includes three 

groups—American Indians, Alaska Natives and Native Hawaiians. 

The unique native peoples of Alaska have been recognized as ‘‘Indian’’ and as ‘‘tribes’’ for four hundred years. The Founders’ underVerDate Aug 04 2004 01:02 Nov 16, 2004 Jkt 039010 PO 00000 Frm 00072 Fmt 6604 Sfmt 6604 E:\HR\OC\SR405.XXX SR405
73 

standing of the ‘‘Eskimaux’’ as Indian tribes, and Congress’ recognition of its power over Alaska Natives ever since the passage of the 

Fourteenth Amendment and the acquisition of the Alaskan territory, help illuminate Congress’ power over, and responsibility for, 

all Native American peoples. 

The treatment of Alaskan Eskimos is particularly instructive because the Eskimo peoples are linguistically, culturally, and ancestrally distinct from other American ‘‘Indians.’’ Many modern scholars do not use the word ‘‘Indian’’ to describe Eskimos or the word 

‘‘tribe’’ to describe their nomadic family groups and villages. The 

Framers, however, recognized no such technical distinctions. In the 

common understanding of the time, Eskimos, like Native Hawaiians, were aboriginal peoples; they were therefore ‘‘Indians.’’ Their 

separate communities of kind and kin were ‘‘tribes.’’ Congress’ special power over these aboriginal peoples is beyond serious challenge. 

During the Founding Era, and during the Constitutional Convention, the terms ‘‘Indian’’ and ‘‘tribe’’ were used to encompass the 

tremendous diversity of aboriginal peoples of the New World and 

the wide range of their social and political organizations. The 

Founding generation knew and dealt with Indian tribes living in 

small, familial clans and in large, confederated empires. Native 

Alaska villages and Native Hawaiians residing in their aboriginal 

lands (i.e., the small islands that comprise the State of Hawaii) are 

‘‘Indian Tribes’’ as that phrase was used by the Founders. The 

Framers drafted the Constitution not to limit Congress’ power over 

Indians, but to make clear the supremacy of Congress’ power over 

Indian affairs. The Congress has exercised the power to promote 

the welfare of all Native American peoples, and to foster the everevolving means and methods of self-governance as exercised by Native people. 

This history is accurately reflected in nearly two centuries of 

U.S. Supreme Court jurisprudence. Beginning with Chief Justice 

Marshall, the Supreme Court has recognized the power of the 

United States to provide for the welfare, and to promote the selfgovernance, of Indian peoples. This recognition of the right of the 

indigenous, native people of the United States to self-determination 

and self-governance is part of the structure of America’s complex 

multi-sovereign system of governance. 

In the language and understanding of the Founders, ‘‘tribes’’ or 

‘‘peoples’’ did not lose their identity as such when conquered or 

ruled by kings. Like other Native American people, Native Hawaiians lived for thousands of years as ‘‘tribes,’’ then as confederations 

of tribes, now as conquered tribes. All aboriginal peoples of the 

New World were ‘‘Indians.’’ That is what it meant to be an ‘‘Indian.’’ The Founders knew that Columbus had not landed in India 

or the Indies; Columbus’s navigational error had been corrected, 

but his malapropism had survived. And so, in the words of one of 

the earliest English books about America, the native people were 

74 

14Gonzalo Fernandez de Oviego y Valdez, De la natural hystoria de las Indias (1526), trans. 

by R. Eden (1955), in E. Arber, ed., The First Three English Books on America (Birmingham, 

Eng., 1885) (emphasis added). 15 Robert F. Berkhofer, Jr., The White Man’s Indian 16 (1979). 16 Jefferson, Notes, at 221. 17See, e.g., Treaty with the Six Nations, Oct. 22, 1784 (treaty with the many tribes of Senecas, 

Mohawks, Onondagas, Cayugas, Oneida and Tuscarora), in C.J. Kappler, ed., Indian Affairs: 

Laws and Treaties 2:5–6; Treaty of Treaty of Forth McIntosh, Jan. 21, 1785 (treaty with the 

Wiandot, Delaware, Chippewa, and Ottawa ‘‘and all their tribes’’), in id. at 2:6–8; Treaty of 

Hopewell, Nov. 28, 1785 (treaty with all the ‘‘tribes’’ of the Cherokee), in id. at 2:8–11. 

‘‘Indians,’’ for the simple reason that ‘‘so caule wee all nations of 

the new founde lands.’’ 14

The Founding generation used ‘‘tribes’’ to denote peoples of like 

kind or kin. As used in the Constitution, the word ‘‘tribe’’ does not 

refer to some specific type of government or social organization. All 

Native American peoples were ‘‘tribes,’’ whether they lived in villages or spread out in vast federations or empires. ‘‘Tribe’’ and ‘‘nation’’ were used to refer not to governments, but to groups of people 

recognizing a common membership or identity as such. Application 

of the biblical concept of ‘‘tribes’’ to the ‘‘Indians’’ reflected the understanding that the natives of the New World were not one people, but many ‘‘peoples,’’ ‘‘nations,’’ or ‘‘tribes’’—terms used interchangeably well into the Nineteenth Century.15

The Founders had seen analogies to the complex tribal history of 

the Bible. The Founders knew the native peoples evolved, united 

and divided in ever shifting forms of government. The native peoples had formed ‘‘powerful confederac[ies],’’ tribes united under 

common chiefs, and federations of tribes joined with other federations.16 The colonies and the States under the Articles of Confederation had repeatedly dealt with vast federations of tribes, including the ‘‘Six Nations’’ in the north and the ‘‘Five Civilized Tribes’’ 

in the south.17 The Indian peoples were ‘‘tribes’’ not because they 

formed any particular organization, but because they recognized 

themselves as distinct peoples, with cultures, languages and societies separate from each other and from the European invaders. 

As Jefferson’s ‘‘Notes on the State of Virginia’’ and other contemporary works show, the division of the world into ‘‘European settlers’’ and ‘‘Indians’’ was not essentially racial. The Indians were 

not a race, they were many peoples, thought to share diverse ancestry with peoples all over the world. The distinction between European and Native American peoples was political. The European 

settlers (who arrived with Royal charters) recognized the ‘‘aboriginal peoples’’ as separate nations—separate sovereigns with whom 

they would have to deal as one nation to another. Before and after 

the Constitution, the new settlers treated the Indian peoples as 

separate nations, with whom they made war, peace and treaties. 

The treatment of the aboriginal peoples under the Constitution was 

systematically and structurally distinct from the inhumane and 

unendurable treatment accorded to ‘‘slaves.’’ This distinctive nation-to-nation relationship survived the settlement of the West, the 

Civil War Amendments to the Constitution, and two hundred years 

of Congressional action and judicial construction. 

History of the Origins of the Constitutional Term ‘‘Tribe’’ 

The Articles of Confederation gave the Continental Congress 

power over relations with the Indians only so long as Congress’ 

75 

18 Articles of Confederation, Art. X, March l, 1778. 19Federalist 42, in XIV Documentary History of the Ratification of the Constitution (J. 

Kaminiski, ed., 1983) (‘‘Documentary History’’), XV: 431. 20 Notes of James Madison,’’ June 19, 1787, in The Records of the Federal Convention of 1787, 

at 3:316 (Max Farrand, rev. ed. 1966) [hereafter, ‘‘Federal Convention’’] (‘‘By the federal articles, 

transactions with the Indians appertain to Congress. Yet in several instances, the States have 

entered into treaties & wars with them’’); see also, id. at 325–26. 21 2 Federal Convention, at 321, 324; see also id. at 143 (Rutledge noted that ‘‘Indian affairs’’ 

should be added to Congress’ powers). 22 Id. at 367. Similarly, since Indians did not pay tax, the proposal to exclude ‘‘Indians not 

taxed’’ from the apportionment clause was accepted without discussion. 23 Id. at 481. 

dealings with Indians within a State did not ‘‘infringe’’ that State’s 

legislative power. This created constant friction over where the 

States’ power ended and Congress’ power began. The sole stated 

purpose of the Indian terms of the new Constitution was to eliminate any uncertainty as to Congress’ supremacy. The Framers intended to grant Congress broad, supreme authority to regulate Indian affairs. The two references to ‘‘Indians’’ in the Constitution 

generated virtually no debate at any time in the Constitutional 

Convention. That relations with the Indians should be one of the 

Federal powers appears to have been universally accepted. The 

Framers sought only to make clear that Congress’ power here was 

supreme. 

The Articles had given the Continental Congress ‘‘sole and exclusive right and power’’ of regulating relations with Indians who 

were ‘‘not members of any of the states, provided that the legislative right of any state within its own limits be not infringed or violated.’’ 18 As Madison explained, this language created two major 

problems. First, no one knew when or whether Indians were ‘‘members of states’’; second, the grant to Congress of ‘‘sole and exclusive 

power,’’ so long as Congress did not ‘‘intrud[e] on the internal 

right’’ of States was ‘‘utterly incomprehensible.’’ The provision had 

been a source of ‘‘frequent perplexity and contention in the federal 

councils.’’ 19 Capitalizing on the uncertainty, several states (Georgia, New York and North Carolina) had infringed Congress’ power 

by making their own arrangements with local Indians. As a result, 

during the Constitutional Convention and Ratification, Georgia was 

in armed conflict, and on the verge of war, with the powerful Creek 

Nation. 

The only debate on the issue in the Convention focused on the 

need for federal supremacy over the states. Madison objected early 

on to the ‘‘New Jersey Plan’’ on the ground that it failed to bar 

states from encroaching on Congress’ power over ‘‘transactions with 

the Indians.’’ 20 In August, Madison proposed that Congress be 

given the power ‘‘[t]o regulate affairs with the Indians as well within as without the limits of the United States.’’ 21 Madison’s proposal 

was submitted to the Committee on Detail without discussion. The 

Committee on Detail recommended that power over Indians be 

dealt with in the Commerce clause, which would provide Congress 

with power over commerce ‘‘with the Indians, within the limits of 

any State, not subject to the laws thereof.’’ The proposal provoked 

no debate. 22 On August 31st, the Convention referred various 

‘‘parts of the Constitution’’ (including the Commerce Clause) to a 

‘‘Committee of eleven,’’ including Madison. 23 Without recorded discussion, the Committee recommended that the language be simVerDate Aug 04 2004 01:02 Nov 16, 2004 Jkt 039010 PO 00000 Frm 00075 Fmt 6604 Sfmt 6602 E:\HR\OC\SR405.XXX SR405
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24 Id. at 493, 496–97, 503 (emphasis added). 25See id. at 495. The language appears in the final version. Id at 569, 595. 26Federalist 40, in Documentary History, XV: 406. (Constitution represents ‘‘expansion on the 

principles which are found in the articles of confederation,’’ which gave Congress power over 

‘‘trade with the Indians’’); Federal Farmer, October 8, 1787, in id. at XIV: 24 (under the new 

Constitution, federal government has power over ‘‘all foreign concerns, causes arising on the 

seas, to commerce, imports, armies, navies, Indian affairs’’); Federal Farmer, October 10, 1787, 

in id. at 30, 35 (federal power over ‘‘foreign concerns, commerce, impost, all causes arising on 

the seas, peace and war, and Indian affairs’’). The Federal Farmer Letters are considered ‘‘one 

of the most significant publications of the ratification debate.’’ Id. at 14. 27Madison, Federalist 42, in Documentary History XIV: 430–31. 28 ‘‘An Act to regulate trade and intercourse with the Indian tribes,’’ July 22, 1790, ch. 33, 

Sec. 4, 1 Stat. 137, in 1 Doc. Hist. of the First Federal Congress, 1789–1791 (De Pauw, ed., 

1972) (‘‘First Federal Congress’’), at 440. 29Madison, Federalist 40, in Documentary History, XV: 406. 30Washington, Instructions to the Commissioners for Southern Indians, August 29, 1789, in 

2 First Federal Congress, at 207 (emphasis added). 

plified to commerce ‘‘with the Indian tribes.’’ 24 The Convention accepted the recommendation without debate or dissent. 25

As noted above, the debate in the Convention focused solely on 

making clear the supremacy of Congress’ power. During the ratification debates, the new Constitution was defended on the ground 

that it gave Congress power over ‘‘Indian affairs’’ and ‘‘trade with 

the Indians.’’ 26 In the only extended discussion of the issue during 

ratification, Madison used the phrases ‘‘commerce with the Indian 

tribes’’ and ‘‘trade with Indians’’ interchangeably; Madison explained that the purpose of the new provision was to eliminate the 

limitation on Congress’ power over trade with the Indians living 

within the States. 27 The notion that the reference to ‘‘tribes’’ was 

a limit on Congress’ ability to deal with the native peoples is without support in history and is contrary to the only expressions of the 

Framers’ original intent. The Constitution gave Congress power 

over the Indian peoples, however and wherever it found them. 

The First Federal Congress treated the Constitution as granting 

broad power to regulate ‘‘trade and intercourse’’ with ‘‘Indians,’’ 

‘‘Indian tribes,’’ ‘‘nations of Indians,’’ and ‘‘Indian country.’’ 28 Congress understood its power to ‘‘operate immediately on the persons 

and interests of individual citizens.’’ 29 The actions of the new government also show that even when the Framers knew nothing 

about the organization of Indian peoples, they nevertheless intended to assert Federal power over those peoples. Shortly after 

taking office, President Washington gave instructions to Commissioners to negotiate with the Creeks. It was, as noted, the war between the Creeks and Georgia that had fostered the apparently 

universal conclusion that the new Federal government must be 

given supremacy over Indian affairs. Washington instructed the 

Commissioners to determine the nature of the Creek’s political divisions and governments, including ‘‘[t]he number of each division’’; 

‘‘[t]he number of Towns in each District’’; ‘‘[t]he names, Characters 

and residence of the most influential Chiefs—and . . . their grades 

of influence.’’ And, most tellingly, the Commissioners were to learn 

‘‘[t]he kinds of Government (if any) of the Towns, Districts, and Nation.’’ 30 Washington, like other Founders, did not know how the 

Creek lived and how they governed themselves. But however the 

Indian peoples lived, and however they governed themselves, they 

were still Indian peoples and they were still subject to the supreme 

power of the Federal government over Indian tribes. 

77 

31Thomas Jefferson, ‘‘Instructions to Captain Lewis,’’ June 20, 1803, in Jefferson, Writings, 

supra, at 1126, 1128. 32Similar limiting language occurs in the Equal Protection Clause. 

President Jefferson gave similar instructions to Lewis and Clark. 

When they encountered unknown Indian peoples, the explorers 

were to learn the ‘‘names of the nations’’; ‘‘their relations with 

other tribes or nations’’; their ‘‘language, traditions, monuments’’; 

and the ‘‘peculiarities in their laws, customs & dispositions.’’ 31 Like 

Washington, Jefferson knew there was much he and his fellow citizens did not know about the ‘‘Indian’’ peoples; but he intended to 

find out and to assert Federal authority over whatever he found. 

Fourteenth Amendment to the United States Constitution 

It is inconceivable anyone thought that if Washington’s Commissioners or Lewis and Clark found a native people living without 

‘‘chiefs,’’ like many Eskimo, or under a King like Montezuma or Kamehameha, these people would be beyond Congress’ power over Indian ‘‘tribes’’ or nations. Nor did the Framers of the Fourteenth 

Amendment intend to eliminate Congress’ special power to adopt 

legislation singling out and favoring Indians; they did not intend 

to alter the nation-to-nation relationships between the United 

States and the Indian peoples created by the Constitution. Indeed, 

the Framers of the Amendment were at pains to make certain that 

they preserved that structure. 

‘‘Indians’’ are expressly singled out for special treatment by the 

text of the Amendment. In order to eliminate the morally repugnant language which counted slaves as three-fifths persons, the 

Framers of the Fourteenth Amendment redrafted the apportionment clause. The Framers deleted the ‘‘three-fifths persons,’’ but 

retained the express exclusion of ‘‘Indians not subject to tax’’ 

(Amend. XIV, Sec. 1), because, while they intended to wipe out the 

badges and incidents of slavery, they intended to preserve the special relationship between the United States and the Indian people. 

Before and after the Amendment, Indians were not citizens of the 

United States, they did not have the right to vote, they did not 

count for purposes of apportionment, but they were subject to special legislation in furtherance of Congress’ historic trust responsibilities. 

The only debate during the drafting and ratification of the Fourteenth Amendment was not about whether the special relationship 

with the Indian people should be preserved, but about how to make 

certain it was preserved. When one Senator suggested that specific 

reference be made excluding ‘‘Indians’’ from the citizenship clause, 

the Senator presenting the clause argued this was unnecessary. 

The Amendment provided citizenship only to persons ‘‘within the 

jurisdiction’’ of the United States,32 and Indian nations were treated like alien peoples not fully within the jurisdiction of the government: 

in the very Constitution itself there is a provision that 

Congress shall have power to regulate commerce, not only 

with foreign nations and among the States, but also with 

Indian tribes. That clause, in my judgment, presents a full 

78 

33 Cong. Globe, 39th Congress, 1st Sess. 2895. 34See, e.g., Remarks of Sen. Doolittle, Cong. Globe, 39th Cong., 1st Sess., 2895–2896 (1866) 

(‘‘[Senator Howard] declares his purpose to be not to include Indians within this constitutional 

amendment. In purpose I agree with him. I do not intend to include them. My purpose is to 

exclude them’’). 35 Congress expressed the same intent in the Civil Rights Act that same year. The Act, granting citizenship to the emancipated slaves, specifically excluded ‘‘Indians not taxed.’’ Civil Rights 

Act, ch. 31, 14 Stat. 27 (1866). 36 Cherokee Nation v. Georgia, 30 U.S. (5 Pet.) 1, 16 (1831). 37 Id., at 17. 38Johnson v. McIntosh, 21 U.S. (8 Wheat.) 543, 572–74 (1823). 39See Worcester v. Georgia, 31 U.S. (6 Pet.) 515, 561 (1832). 40 Cherokee Nation, 30 U.S. (5 Pet.) at 17–18; Worcester, 31 U.S. (6 Pet.) at 558–59. 41See Worcester, 31 U.S. (6 Pet.) at 560–61; accord Cherokee Nation, 30 U.S. (5 Pet.) at 16 

(‘‘[t]hey look to our government for protection, rely upon its kindness and its power; appeal to 

it for relief to their wants’’). 42Johnson, 21 U.S. (8 Wheat.) at 572–74; Worcester, 31 U.S. (6 Pet.) at 544 (1832) (Indians 

are ‘‘those already in possession [of land], either as aboriginal occupants, or as occupants by virtue of a discovery made before the memory of man’’). See also Johnson, 21 U.S. (8 Wheat.) at 

575 (Indians in French Canada); id. at 581 (Indians in Nova Scotia); Id. at 584–87 (Indians in 

Virginia, Kentucky, the Louisiana Purchase, and Florida). Marshall noted the United States had 

dealt with variously organized ‘‘tribes’’ or ‘‘confederacies.’’ See id. at 546–49. 43Worcester, 31 U.S. (6 Pet.) at 559, 561. See also Cherokee Nation, 30 U.S. (5 Pet.) at 20 

(‘‘an Indian tribe or nation within the United States’’); Johnson, 21 U.S. (8 Wheat.) At 590 (‘‘the 

tribes of Indians inhabiting this country’’). 

and complete recognition of the national character of the 

Indian tribes.33

Congress debated what language to adopt in order to make certain that the special status of the Indian tribes was preserved.34

There was no support for, or consideration given to, eliminating the 

special relationship between the United States and the Indian peoples. The uniform intent was to preserve Congress’ ability to decide 

when Indians would be granted citizenship, when Indians would be 

taxed, and when Indians would be subject to special legislation.35

For nearly two hundred years, the Supreme Court has recognized 

the political distinction the Constitution draws between ‘‘Indian 

tribes’’ and all other people. The early opinions of Chief Justice 

John Marshall reflect the original intent of the Framers and lay 

the groundwork for the Supreme Court’s jurisprudence. Marshall 

wrote that ‘‘[t]he condition of the Indians in relation to the United 

States is perhaps unlike that of any other two people in existence.’’ 36 With deliberate irony, he called the Indian tribes ‘‘domestic dependent nations.’’ 37 The Indian peoples had surrendered 

‘‘their rights to complete sovereignty,’’ 38, and yet they continued to 

be ‘‘nations’’ that governed themselves.39

Marshall knew that the constitutional text reflected this preexisting nation-to-nation relationship. The Indian Commerce 

Clause, U.S. Const. art. I., § 3, cl. 8, and the Treaty Clause, art. II, 

§ 2, cl. 2, granted Congress broad power to regulate Indian affairs. 

These provisions permitted the United States to fulfill its obligations to the dependent Indian ‘‘nations’’ that were its ‘‘wards.’’ 40 As 

‘‘guardian,’’ Congress had both the obligation and the power to 

enact legislation protecting the Indian nations.41

Marshall defined ‘‘Indians’’ broadly to include all of the ‘‘original 

inhabitants’’ or ‘‘natives’’ who occupied America when it was discovered by ‘‘the great nations of Europe.’’ 42 He also conceived of 

‘‘tribes’’ in broad, inclusive terms. He used ‘‘tribe’’ and ‘‘nation’’ 

interchangeably: A ‘‘tribe or nation,’’ he noted, ‘‘means a people distinct from others’’—a ‘‘distinct community.’’ 43 Like the Founders, 

Marshall defined an ‘‘Indian tribe’’ as nothing more than a commuVerDate Aug 04 2004 01:02 Nov 16, 2004 Jkt 039010 PO 00000 Frm 00078 Fmt 6604 Sfmt 6602 E:\HR\OC\SR405.XXX SR405
79 

44 Id., at 559. 45 Id., at 559–60. 46See, e.g., Montoya v. United States, 180 U.S. 261, 266 (1901) (‘‘a body of Indians of the same 

or a similar race, united in a community under one leadership or government, and inhabiting 

a particular though sometimes ill-defined territory’’); United States v. Candelaria, 271 U.S. 432, 

442 (1926); see Oklahoma Tax Comm’n v. Sac & Fox Nation, 508 U.S. 114, 123 (1993); United 

States v. Antelope, 430 U.S. 641, 647 n.7 (1977) (individuals ‘‘anthropologically’’ classified an Indians may be outside Congress’s Indian commerce power if they sever relations with tribe). 47 United States v. Antelope, 430 U.S. 641, 646–47 (1977). 48 Id., at 646. 49 Antelope, 430 U.S. at 646; see Fisher v. District Court, 424 U.S. 382, 389 (1976); Mancari, 

417 U.S. at 553–54; see also Sac & Fox Nation, 508 U.S. at 123; United States v. Mazurie, 419 

U.S. 544, 557 (1975). 50Santa Clara Pueblo v. Martinez, 436 U.S. 49, 72 n.32 (1978); Cherokee Intermarriage Cases, 

203 U.S. 76, 95 (1906); Boff v. Burney, 168 U.S. 218, 222–23 (1897). 51See Indian Policy Report at 108–09 (‘‘the tribe, as a political institution, has primary responsibility to determine tribal membership for purposes of voting in tribal elections * * * and 

other rights arising from tribal membership. Many tribal provisions call for one-fourth degree 

of blood of the particular tribe but tribal provisions vary widely. A few tribes require as much 

as one-half degree of tribal blood * * *’’); accord Felix S. Cohen, Handbook of Federal Indian 

Law 22–23 & n.27 (1982 ed.). 

nity, large or small, of descendants of the peoples who inhabited 

the New World before the Europeans. 

Although the aboriginal ‘‘tribes’’ or ‘‘nations’’ or ‘‘peoples’’ were 

defined in part by common ancestry, their constitutional significance lay in their separate existence as ‘‘independent political communities,’’ 44. The ‘‘race’’ of Indian peoples was constitutionally irrelevant. Native peoples were ‘‘nations,’’ 45 and the relationship between the United States and the natives reflected a political settlement between conquered and conquering nations. 

The Supreme Court has kept faith with Marshall’s conception. 

The Indian nations have always been defined by ancestry and political affiliation. In the native cultures, the two are inextricably 

intertwined. The Supreme Court’s definition is legal, and the Native American’s self-definition is historic, religious or cultural; but 

the two reduce to the same elements: ‘‘Indians’’ are (1) the descendants of aboriginal peoples who (ii) belong to some Native American 

‘‘people,’’ ‘‘nation,’’ ‘‘tribe,’’ or ‘‘community,’’ as the founding generation understood those terms.46

These interwoven qualifications reflect the Supreme Court’s consistent understanding that constitutionally-relevant Indian status, 

while based in part on ancestry, is a political classification.47 It is 

an individual’s membership in a ‘‘political community’’ of Indians— 

even a community in the making—and not solely his or her racial 

identity, that brings him or her within Congress’ broad authority 

to regulate Indian affairs.48

Indian Tribes and Blood Quantum 

Nor does the use of blood quantum as part of the formula to determine who is and is not a Native American constitute impermissible ‘‘racial’’ discrimination. The Supreme Court has repeatedly 

made clear that Indian tribes are the political and familial heirs to 

‘‘once-sovereign political communities’’—not ‘‘racial groups.’’ 49 The 

Court has long recognized that a tribe’s ‘‘right to determine its own 

membership’’ is ‘‘central to its existence as an independent political 

community.’’ 50 From time immemorial, Native American communities have defined themselves at least in part by family and ancestry.51 Kinship and ancestry is part of what it means to be an ‘‘Indian.’’ Indians by ancestry or blood is what the Framers meant by 

80 

52 Id., 437 U.S. at 646. 53 Id. at 650 (quoting 25 U.S.C. Sec. 479). 54 Alaska Chapter v. Pierce, 694 F.2d 1162, 1168–69 n. 10 (9th Cir.1982) (noting absence of 

other practicable methods, like tribal rolls or proximity to reservations). 55 Kagama, 118 U.S. 375, 384–85 (1886) (emphasis added); See Seminole Nation v. United 

States, 316 U.S. 286, 296 (1942) (the government owes a ‘‘distinctive obligation of trust’’ to Indians). 56See Greater New Orleans Broadcasting Assn v. United States, 527 U.S. 173, 193 (1999) (recognizing ‘‘special federal interest in protecting the welfare of Native Americans’’). 

‘‘Indians.’’ It is what Chief Justice Marshall meant by ‘‘Indians.’’ It 

is what the Framers of the Fourteenth Amendment meant by ‘‘Indians.’’ This central conception of ‘‘Indian’’ identity is woven into the 

Constitution and the entire body of law that has grown up in reliance on that conception. 

Congressional authority to use such traditional requirements for 

tribal membership or benefits has never been doubted. In United 

States v. John, the Supreme Court approved Congress’ establishment of an Indian reservation for the benefit of ‘‘Chocktaw Indians 

of one-half or more Indian blood, resident in Mississippi.’’ 52 The 

Court unhesitatingly applied the definition of ‘‘Indian’’ that appears 

in the Indian Reorganization Act, which has governed Indian tribes 

since 1934: ‘‘all other persons of one-half or more Indian blood.’’ 53

Similarly, the Alaska Native Claims Settlement Act’s use of a blood 

quantum formula as one factor in determining ‘‘native’’ status is a 

valid method of defining those belonging to the group eligible for 

statutory benefits, and the use of the blood quantum ‘‘does not detract from the political nature of the classification.’’ 54 The use of 

blood ties is integral to the nature of the political deal struck between the conquering Europeans and the native peoples, as they 

set out to maintain partially separate existences while inhabiting 

the same country. 

This is not to suggest, however, that the Constitution imposes 

any minimum blood quantum requirement for tribal membership, 

and suggestions to the contrary have no legal or historical basis. 

The constitutional text and historic relationship gives Congress 

not just the ‘‘right’’ to discriminate between Native Americans and 

others, but the responsibility to do so. As the Supreme Court has 

long recognized, from the relationship between these former sovereign peoples and the ‘‘superior nation’’ that conquered them 

arises ‘‘the power and the duty’’ of the United States to ‘‘exercis[e] 

a fostering care and protection over all dependent Indian communities within its borders. . . .’’ 55 Recently, the Supreme Court acknowledged the continued significance of this historic trust relationship.56

Like the 556 Indian tribes currently recognized by the United 

States, Native Hawaiians are a group of people defined by their 

common descent from an ancestral class, each forming a distinct 

polity and having a unique historical existence. Any contemporary 

group whose members are defined by their lineal descendancy from 

a historically-defined class will necessarily share an ethnic identity 

with the original members of the historical class, even though 

intermarriage may attenuate the degree of blood quantum shared 

by the original historical class members. Nevertheless, a definition 

that is based primarily on the historical uniqueness of the original 

class is no more race-based than the definition of those who are 

81 

57 72 U.S. 737 (1866). 58 Id., 72 U.S. at 755–57. 59See United States v. Joseph, 94 U.S. (4 Otto.) 614, 616 (1877). 60 United States v. Sandoval, 231 U.S. 28, 46–47 (1913); Candelaria, 271 U.S. at 439–40, 442– 

43. 61Sandoval, 231 U.S. at 46; accord Tiger v. Western Inv. Co., 221 U.S. 286, 315 (1911). 62 437 U.S. 634 (1978). 63 Id., 437 U.S. at 652–53. 64 Id., at 650 n.20, 652–53. 65 United States v. Holliday, 70 U.S. (3 Wall.) 407, 417 (1865) (regulation of ‘‘commerce with 

the Indian tribes means’’ regulation of ‘‘commerce with the individuals composing those tribes’’); 

see Morton v. Ruiz, 415 U.S. 199, 230–38 (1974) (addressing the scope of federal Indian welfare 

benefits for individuals living in Indian communities); Mancari, 417 U.S. at 551–55. 

members or citizens of the historic Indian tribes that greeted the 

first Europeans immigrants to this nation’s shores. 

The Supreme Court has repeatedly applied the concepts of ‘‘Indian’’ and ‘‘tribe’’ to a wide variety of Native American communities, recognizing the constant evolution of Native community life 

and that the questions of whether and how to treat with these 

changing communities are assigned by the Constitution to Congress. In The Kansas Indians,57, the Court recognized that the 

Ohio Shawnees remained a ‘‘tribe,’’ even though tribal property 

was no longer owned communally and the tribe had abandoned Indian customs ‘‘owing to the proximity of their white neighbors.’’ 58

Fifty years later, the Supreme Court approved a similar tribal 

designation for the Pueblo Indians of New Mexico. After long experience under Spanish rule, the Pueblo Indians seemed little like 

the ‘‘savages’’ of James Fennimore Cooper. The Pueblo Indians 

lived in villages with organized municipal governments; they cultivated the soil and raised livestock; they spoke Spanish, worshiped 

in the Roman Catholic Church; and prior to the acquisition of New 

Mexico by the United States, they enjoyed full Mexican citizenship.59 Nevertheless, the Pueblo Indians lived in ‘‘distinctly Indian 

communities,’’ and Congress acted properly under the Indian Commerce Clause in determining that they were ‘‘dependent communities entitled to its aid and protection, like other Indian tribes.’’ 60

For Native American ‘‘communities,’’ the Court held that ‘‘the questions whether, to what extent, and for what time they shall be recognized and dealt with as dependent tribes requiring the guardianship and protection of the United States are to be determined by 

Congress. . . .’’ 61

As indicated above, sixty years later, in United States v. John,62

the Supreme Court recognized Congress’ authority to establish a 

reservation for the benefit of Choctaw Indians in Mississippi, even 

though (1) they were ‘‘merely a remnant of a larger group of Indians’’ that had moved to Oklahoma; (2) ‘‘federal supervision over 

them had not been continuous’’; and (3) they had resided in Mississippi for more than a century and had become fully integrated 

into the political and social life of the State.63 The Mississippi 

Choctaw were Indians. They had recently organized into a distinctly Indian community. The Court therefore deferred to Congress’ determination that they were a ‘‘tribe for the purposes of 

Federal Indian law.’’ 64

Similarly, the Supreme Court has recognized Congress’ broad authority to deal with individual ‘‘Indians.’’ 65 or large organizations 

82 

66See Cherokee Nation v. Journeycake, 155 U.S. 196 (1894) (Delaware Indians entitled to 

rights of Cherokee Nation which Delawares had joined); United States v. Blackfeather, 155 U.S. 

218 (1894) (same for Shawnee). 67See John, 437 U.S. at 652–53; Moe v. Confederated Salish & Kootenai Tribes, 425 U.S. 463, 

480 (1976). 68 Although the Alaska natives’ situation is ‘‘distinctly different from that of other American 

Indians,’’ Alaska Chapter, 694 F.2d at 1168–69 n.101, see Metlakatla Indian Community v. Egan, 369 U.S. 45, 50–51 (1962), it is ‘‘well established’’ that Athabascan Indians, Eskimos, and 

Aleuts are ‘‘dependent Indian people’’ within the meaning of the Constitution. Alaska Pacific 

Fisheries v. United States, 248 U.S. 78, 87–89 (1918); see also Pence v. Kleppe, 529 F.2d 135, 

138–39 n.5 (9th Cir. 1976) (‘‘Indian’’ means ‘‘the aborigines of America’’ and includes Eskimos 

and Aleuts in Alaska); United States v. Native Village of Unalakleet, 411 F.2d 1255, 1256–57 

(Ct. Cl. 1969) (‘‘Eskimos and Aleuts are Alaskan aborigines’’ and, therefore, ‘‘Indians’’). 69Santa Clara Pueblo v. Martinez, 436 U.S. 49, 72 n.32 (1978). 70See, e.g., Stuart Minor Benjamin, Equal Protection and the Special relationship: The Case 

of Native Hawaiians, 106 Yale L.J. 537, 607–8 & n.287 (1996) (discussing this argument, while 

noting that ‘‘[i]nclusion of some Westerners would not necessarily defeat a claim of tribal status’’ 

as the Supreme Court has never directly addressed the question, and noting that ‘‘some Indian 

tribes included Westerners. . . .’’. 71See, e.g., United States v. Rogers, 45 U.S. (4 How.) 567 (1846); Boff v. Burney, 168 U.S. 

218 (1897); Daniel Red Bird v. United States, 203 U.S. 76 (1906). 72Public Law No. 129, §§ 1–4, 34 Stat. 137, 137–38 (April 26, 1906) (setting forth enrollment 

criteria for members of the Choctaw, Chickasaw, Cherokee, Creek and Seminole Tribes of Oklahoma). 

comprised of numerous ‘‘tribes.’’ 66 Congress may recognize new aggregations of Native Americans, so long as such legislation is rationally related to the fulfillment of Congress’ trust obligation to 

the historic Indian peoples.67 Congress’ treatment of the Alaska native people—including the establishment of unique regional corporations whose shareholders comprise numerous Native villages— 

has properly been upheld as within Congress’ special power over 

and responsibility for the Native American peoples.68

Citizens of the Kingdom of Hawai‘i 

Contrary to well-established principles of Federal-Indian law 

that recognize the right of a tribe to determine its own members 

as a fundamental aspect of the tribe’s sovereignty,69 some have argued that the Kingdom of Hawai‘i somehow lost its ‘‘native’’ character because some non-Hawaiians became naturalized citizens of 

the Kingdom. This argument is used as the basis for asserting that 

Native Hawaiians cannot now be ‘‘recognized’’ as a native group 

with which the United States may maintain a special legal and political relationship.70 However, as evident from the preceding discussion of Supreme Court rulings and precedent, this argument 

lacks any constitutional basis. The Supreme Court has often decided cases relating to the status of non-Indians who had become 

members or citizens of Indian tribes,71 but the Court has never 

suggested that a tribal law that provides for the membership or 

citizenship in the tribe of previously non-tribal members renders 

those tribes or their modern-day successors ineligible for recognition as having a special legal and political relationship with the 

United States pursuant to the Indian Commerce Clause. Similarly, 

opposition to the recognition of a Native Hawaiian governing entity 

premised upon the attenuation of the blood quantum of its citizens 

lacks any historical or constitutional basis. 

Many contemporary tribes define their citizenship or membership based upon lineal descendancy from a tribal roll, and the Congress has from time to time established criteria for membership in 

certain tribes.72 What neither the Congress nor the Supreme Court 

83 

73See 25 CFR Part 83. 74William W. Quinn, Jr., Federal Acknowledgment of American Indian Tribes: The Historical 

Development of a Legal Concept, 34 Am. J. Leg. Hist. 331, 332 (1990) (citing 48 Stat. 984 (1934) 

(codified as amended at 25 U.S.C. §§ 461 et seq.)); see generally, William W. Quinn, Jr., Federal 

Acknowledgment of American Indian Tribes: Authority, Judicial Interposition, and 25 CFR § 83, 

17 Am. Indian L. Rev. 37 (1992); L.R. Weatherhead, What is an ‘‘Indian Tribe’’?—The Question 

of Tribal Existence, 8 Am. Indian L. Rev. 1 (1980). 75 25 CFR, Part 83. Quinn 1992, at 40–41. 76See 25 CFR §§ 83.1, 83.3 (administrative process available only to groups within the ‘‘continental United States,’’ defined as the ‘‘contiguous 48 states and Alaska’’). Native Hawaiians 

have twice sought unsuccessfully to challenge their exclusion from this process. Price v. State 

of Hawaii, 764 F.2d 623 (9th Cir. 1985); Kahawaiolaa v. Norton, 222 F. Supp. 2d 1213 (D. Haw. 

2002). 

has done is to suggest that the Constitution imposes a blood quantum limitation or requirement on tribal citizenship. 

The Significance of ‘‘Federal Recognition’’ 

It is important to recognize that the legal distinctions that have 

been drawn in contemporary times between Indian tribes that are 

‘‘acknowledged’’ by the Department of the Interior 73 or ‘‘recognized’’ 

by the Congress—tribes that have a direct government-to-government relationship with the United States and are thereby eligible 

for various Federal benefits—and Native American groups that are 

not so recognized and have no such government-to-government relationship, is a relatively recent phenomenon. ‘‘[A] close scrutiny of 

the various executive orders, Congressional legislation, departmental policies, Solicitor’s opinions, and judicial decisions since 

1783 . . . discloses an astonishing oblivion of the need for an express declaration or statement regarding which Indian tribes were 

to be recognized, until the enactment of the Wheeler-Howard (Indian Reorganization) Act of 1934,’’ 74 thirteen years after the enactment of the Hawaiian Homes Commission Act. In fact, there was 

no systematic procedure by which a Native American group could 

petition the United States for recognition until 1978, when regulations were promulgated to implement the Federal Acknowledgment 

process.75

An administrative process for the acknowledgment of Native 

groups by the United States that was established almost twenty 

years after Hawaians admission to the Union could not have informed the provisions of the Hawaiian Homes Commission Act nor 

the Hawai‘i Admission Act and it is thus not surprising that the 

language of those Acts do not conform neatly with categorizations 

that had yet to be developed. 

Although the authority of Congress to formally ‘‘recognize’’ tribes 

through legislation is unquestioned, the Department of the Interior’s regulations associated with the administrative process for the 

acknowledgment of tribes pursuant to 25 CFR Part 83 exclude Native Hawaiians from that process, and thus legislation is the only 

mechanism available to Native Hawaiians.76 The present legislation thus establishes no precedent applicable to groups eligible to 

apply for recognition under the existing administrative framework. 

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