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THE INDIAN HEALTH CARE

IMPROVEMENT ACT

AMENDMENTS OF 2007

HEARING

BEFORE THE

SUBCOMMITTEE ON HEALTH

OF THE

COMMITTEE ON ENERGY AND

COMMERCE

HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

ON

H.R. 1328

JUNE 7, 2007

Serial No. 110–54

(

Printed for the use of the Committee on Energy and Commerce

energycommerce.house.gov

COMMITTEE ON ENERGY AND COMMERCE

JOHN D. DINGELL, Michigan, Chairman

HENRY A. WAXMAN, California

EDWARD J. MARKEY, Massachusetts

RICK BOUCHER, Virginia

EDOLPHUS TOWNS, New York

FRANK PALLONE, JR., New Jersey

BART GORDON, Tennessee

BOBBY L. RUSH, Illinois

ANNA G. ESHOO, California

BART STUPAK, Michigan

ELIOT L. ENGEL, New York

ALBERT R. WYNN, Maryland

GENE GREEN, Texas

DIANA DEGETTE, Colorado

Vice Chairman

LOIS CAPPS, California

MIKE DOYLE, Pennsylvania

JANE HARMAN, California

TOM ALLEN, Maine

JAN SCHAKOWSKY, Illinois

HILDA L. SOLIS, California

CHARLES A. GONZALEZ, Texas

JAY INSLEE, Washington

TAMMY BALDWIN, Wisconsin

MIKE ROSS, Arkansas

DARLENE HOOLEY, Oregon

ANTHONY D. WEINER, New York

JIM MATHESON, Utah

G.K. BUTTERFIELD, North Carolina

CHARLIE MELANCON, Louisiana

JOHN BARROW, Georgia

BARON P. HILL, Indiana

JOE BARTON, Texas

Ranking Member

RALPH M. HALL, Texas

J. DENNIS HASTERT, Illinois

FRED UPTON, Michigan

CLIFF STEARNS, Florida

NATHAN DEAL, Georgia

ED WHITFIELD, Kentucky

BARBARA CUBIN, Wyoming

JOHN SHIMKUS, Illinois

HEATHER WILSON, New Mexico

JOHN B. SHADEGG, Arizona

CHARLES W. ‘‘CHIP’’ PICKERING,

Mississippi

VITO FOSSELLA, New York

STEVE BUYER, Indiana

GEORGE RADANOVICH, California

JOSEPH R. PITTS, Pennsylvania

MARY BONO, California

GREG WALDEN, Oregon

LEE TERRY, Nebraska

MIKE FERGUSON, New Jersey

MIKE ROGERS, Michigan

SUE WILKINS MYRICK, North Carolina

JOHN SULLIVAN, Oklahoma

TIM MURPHY, Pennsylvania

MICHAEL C. BURGESS, Texas

MARSHA BLACKBURN, Tennessee

PROFESSIONAL STAFF

DENNIS B. FITZGIBBONS, Chief of Staff

GREGG A. ROTHSCHILD, Chief Counsel

SHARON E. DAVIS, Chief Clerk

BUD ALBRIGHT, Minority Staff Director

(II)

(III)

SUBCOMMITTEE ON HEALTH

FRANK PALLONE, JR., New Jersey, Chairman

HENRY A. WAXMAN, California

EDOLPHUS TOWNS, New York

BART GORDON, Tennessee

ANNA G. ESHOO, California

GENE GREEN, Texas

Vice Chairman

DIANA DEGETTE, Colorado

LOIS CAPPS, California

TOM ALLEN, Maine

TAMMY BALDWIN, Wisconsin

ELIOT L. ENGEL, New York

JAN SCHAKOWSKY, Illinois

HILDA L. SOLIS, California

MIKE ROSS, Arkansas

DARLENE HOOLEY, Oregon

ANTHONY D. WEINER, New York

JIM MATHESON, Utah

JOHN D. DINGELL, Michigan (ex officio)

NATHAN DEAL, Georgia,

Ranking Member

RALPH M. HALL, Texas

BARBARA CUBIN, Wyoming

HEATHER WILSON, New Mexico

JOHN B. SHADEGG, Arizona

STEVE BUYER, Indiana

JOSEPH R. PITTS, Pennsylvania

MIKE FERGUSON, New Jersey

MIKE ROGERS, Michigan

SUE WILKINS MYRICK, North Carolina

JOHN SULLIVAN, Oklahoma

TIM MURPHY, Pennsylvania

MICHAEL C. BURGESS, Texas

MARSHA BLACKBURN, Tennessee

JOE BARTON, Texas (ex officio)

(V)

C O N T E N T S

Page

Hon. Frank Pallone, Jr., a Representative in Congress from the State of

New Jersey, opening statement .......................................................................... 1

Hon. Nathan Deal, a Representative in Congress from the State of Georgia,

opening statement ................................................................................................ 3

Hon. Hilda L. Solis, a Representative in Congress from the State of California, opening statement ........................................................................................ 4

Hon. Heather Wilson, a Representative in Congress from the State of New

Mexico, opening statement .................................................................................. 4

Hon. Darlene Hooley, a Representative in Congress from the State of Oregon,

opening statement ................................................................................................ 6

Hon. Jan Schakowsky, a Representative in Congress from the State of Illinois, opening statement ....................................................................................... 7

Hon. John D. Dingell, a Representative in Congress from the State of Michigan, prepared statement ...................................................................................... 8

Hon. Jim Matheson, a Representative in Congress from the State of Utah,

prepared statement .............................................................................................. 8

Hon. Michael C. Burgess, a Representative in Congress from the State of

Texas, prepared statement .................................................................................. 8

WITNESSES

Charles W. Grim, D.D.S., Assistant Surgeon General; Director, Indian Health

Service ................................................................................................................... 9

Prepared statement .......................................................................................... 11

James Crouch, executive director, California Rural Indian Health Board, Incorporated ............................................................................................................. 25

Prepared statement .......................................................................................... 28

Ralph Forquera, executive director, Seattle Indian Health Board ...................... 37

Prepared statement .......................................................................................... 40

Ken B. Lucero, Pueblo of Zia .................................................................................. 47

Prepared statement .......................................................................................... 49

Rachel A. Joseph, co-chair, National Steering Committee for the Reauthorization of the Indian Health Care Improvement Act; National Indian Health

Board ..................................................................................................................... 62

Prepared statement .......................................................................................... 64

SUBMITTED MATERIAL

Joe Garcia, chairman, All Indian Pueblo Council, statement .............................. 81

Rudy Shije, governor, Pueblo of Zia, statement .................................................... 83

A Joint Memorial Endorsing the Reauthorization of the Federal Indian

Health Care Improvement Act ............................................................................ 84

(1)

H.R. 1328, THE INDIAN HEALTH CARE

IMPROVEMENT ACT AMENDMENTS OF 2007

THURSDAY, JUNE 7, 2007

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON HEALTH, COMMITTEE ON ENERGY AND COMMERCE, Washington, DC.

The subcommittee met, pursuant to call, at 11:12 a.m., in room

2322 of the Rayburn House Office Building, Hon. Frank Pallone,

Jr. (chairman) presiding.

Members present: Representatives Schakowsky, Solis, Hooley,

Matheson, Deal, Sullivan, Wilson, and Burgess.

Staff present: William Garner, Amy Hall, Bobby Clark, Nandan

Kerkeremeth, Chad Grant, Melissa Sidman, and Ken Keremath.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY

Mr. PALLONE. I call the meeting of the subcommittee to order,

and I want to apologize for being so late. Unfortunately, we have

so much to do in a short week here, and I wanted to make sure

that we did in fact have this hearing on the Indian Health Care

Improvement Act, but we are kind of fitting it in between a bunch

of other things.

The hearing today is on H.R. 1328, the Indian Health Care Improvement Act amendments of 2007 and I recognize myself initially

for an opening statement.

This is a bill that I introduced earlier this year with Representatives Nick Rahall and Don Young to reauthorize the Indian Health

Care Improvement Act. Let me start by saying that I think this

hearing is long overdue. The Indian Health Care Improvement Act

expired 7 years ago in 2000. While there have been several attempts to reauthorize the legislation in previous Congresses, sadly

none has been successful. In fact, this is the first time since the

law expired that a hearing has been held in the Energy and Commerce Committee on reauthorizing it, and as someone who is very

familiar with Native American issues, and particularly the health

care issues they face, let me be the first to say that the failure of

Congress to reauthorize the Indian Health Care Improvement Act

had a very real impact, negative impact on Indian communities. I

have no doubt that lives have actually been lost due to inaction,

and it is my hope that my colleagues on the subcommittee will

walk away from today’s hearing understanding that Indian Country can no longer afford to wait. The unmet health needs of AmerVerDate 11-SEP-98 09:38 Oct 08, 2008 Jkt 000000 PO 00000 Frm 00006 Fmt 6633 Sfmt 6633 Q:\DOCS\110-54 SCOM1 PsN: SCOM1
2

ican Indians and Alaskan Natives are alarmingly severe and grow

worse every day that we fail to act.

The statistics speak for themselves. Native Americans suffer disproportionately from almost every condition or disease when compared to the general population from obesity to diabetes and heart

disease to HIV/AIDS. All are epidemics that are ravaging American

Indian communities, which have too few resources to respond. A

large part of the problem is that American Indians have greater

difficulty in accessing quality health care services. For far too many

years there has been a growing divide between the health care

services afforded Native American communities and other segments of the population. In example after example, Native Americans do not receive the level of service comparable to other Americans, and I think the most shocking example that often comes to

my mind is that we currently spend nearly twice the amount on

health care services for Federal prisoners than we do for Native

Americans, and I think that is unconscionable, especially given our

trust responsibility to provide Native Americans with health care

services according to the numerous treaties and agreements we

have signed with them.

Native Americans have great difficulty in accessing the most

simplest of services which many of us take for granted such as primary medical care, dental and vision services. Lengthy wait times,

distant locations and transportation challenges act as significant

barriers to receiving care. According to the GAO, Native Americans

could expect to wait between 2 and 6 months or have to travel between 60 and 90 miles to receive certain services, and needless to

say, specialty services are even harder to come by in Indian country. I can’t imagine that any of us would tolerate such conditions

so why should we expect Native Americans to do so.

This critical piece of legislation will help improve access to health

care for the nearly 2 million Native Americans in this country. Specifically, the bill would improve the supply of health professionals

in the Indian health system by creating new opportunities for

American Indians and Alaskan Natives to pursue health careers. It

would facilitate the construction and maintenance of safe water

and sewage facilities and of hospitals, clinics and other health facilities and provide funding for urban Indian health programs as

well, and these are just a few of the provisions in the bill that will

help improve the current Indian health care system.

I mentioned in the beginning of my statement that I think today’s hearing is long overdue and is a much-needed step towards

accomplishing our goal of reauthorizing this important legislation.

Even though it has been 7 years since we have been trying to do

this, I am still pretty optimistic, but I just want to stress that it

is going to take a lot of hard work. We want the administration’s

position. In the past, as you know, we have waited until the second

year or the end of the Congress to try to address this and then

found out that there were objections by the administration or that

there was difficulty with the other body. So we are trying to start

out early. The bill already passed out of the Resources Committee

and I think that we are going to take on the responsibility, and I

will ask our ranking member that we really want to sit down with

the administration, sit down on both sides of the aisle and come up

3

with a bill that can pass, and I don’t mean just pass the House,

come to conference with the Senate, and be signed by the President. But that is not going to be easy to do, but I am making that

commitment that that is what we are going to do. We are not just

passing this out of here to some other committee or to the floor.

We are passing this out of here with a bill that we think can be

signed by the President. That is our goal.

There is quote from Lone Man of the Teton Sioux Indians that

I was reminded of recently. It is, ‘‘I have seen that in any great

undertaking, it is not enough for a man to depend simply on himself,’’ and so what I am saying is, we need everybody to help us out

here. We need the tribes, we need the administration, we need the

health advocates, but we are going to move forward, and I just

want to thank our witnesses. I think it will be a good hearing but

we have got a lot of work to do.

With that, I will yield to our ranking member, Mr. Deal.

OPENING STATEMENT OF HON. NATHAN DEAL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF GEORGIA

Mr. DEAL. Thank you, Mr. Chairman. I share your concern and

interest in this issue and I am thankful that we got a referral on

this legislation so that our committee can have some input into it.

I look forward to the witnesses’ testimony as we examine the proposed legislation, and hopefully, their input will allow us to make

this legislation workable.

One aspect of the legislation that is before us though was always

of concern and importance to my friend and a friend of everyone

on this committee, the late Congressman Charlie Norwood. Charlie

always expressed reservations regarding certain procedures that

were being performed by dental health aides and dental health

therapists in Alaska, and I recognize the unique dental health

needs presented by the rural nature of Alaska, and I understand

that this has led to the use of the therapists there. However, Dr.

Norwood always raised an important concern about the irreversible

nature of some of the procedures performed by these therapists,

and I believe that Dr. Grim, who is one of our witnesses, is a dentist and I would be interested in hearing his opinion on this particular subject.

I am also especially concerned with how the legislation before us

addresses the Medicaid and SCHIP programs. Nominal cost-sharing or co-payments have a role to play in these programs and I am

concerned about any legislation that removes this flexibility. I understand H.R. 1328 contains other provisions which deal with the

Medicaid and SCHIP and I hope our witnesses could speak to some

of the changes that are being proposed.

Again, I look forward to the testimony of the witnesses, I welcome them here, and I yield back my time, Mr. Chairman.

Mr. PALLONE. Thank you, Mr. Deal.

The gentlewoman from California, Ms. Solis. You don’t want to

go next?

Ms. SOLIS. No.

Mr. PALLONE. It is order of seniority before the gavel, and then

after the gavel, it is based on who shows up, and if I could compliment the gentlewoman from California because I know that she

4

took the lead on this whole issue of health care disparities and

worked with the Native American Caucus and Hispanic Caucus

and she has really been a champion on that.

I yield to the gentlewoman.

OPENING STATEMENT OF HON. HILDA L. SOLIS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA

Ms. SOLIS. Thank you, Mr. Chairman, and I am delighted to be

here and to hear our witnesses today. It is true that the Native

American population, in my opinion, has been sorely underserved

for many, many years. I represent Los Angeles County, and we

have, I believe, services provided to about 155,000 Native Americans who come through our one and only facility there in L.A.

County. If you think about L.A. County, you are talking about well

over 11 to 12 million people and those individuals that do come

through are self-identified. There are so many more that are not

even aware of services so this is a very timely piece of legislation,

and I want to thank our chairman and all the members and people

like myself who really understand that there is a really urgent

need to increase services. We should not be in a predicament where

the President is saying there is no value to these programs, and

we continue to see chronic illnesses come before us here when we

hear about them and the cost to society overall. I just think that

that is an assault on our communities and especially communities

of color where we are the populations that are continuing to grow.

I just want to say I am very excited to hear the witnesses today

and know that there is a lot of issues that are at hand, one of

which I think is having an adverse effect on many of our patients

right now that receive Medicaid to show verification, verification

from our tribes that they are eligible for this assistance. In many

cases we have people that were born there on the reservation and

may not have the appropriate paperwork or processes available to

help establish their legitimacy.

So those are really important issues that we need to address, and

I applaud those witnesses and the chairman and members that are

supportive of this legislation. Thank you.

Mr. PALLONE. Thank you.

The gentlewoman from New Mexico.

OPENING STATEMENT OF HON. HEATHER WILSON, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW MEXICO

Mrs. WILSON. Thank you, Mr. Chairman. This is a very important day in Indian Country. I look back at when the last time was

that this committee held a hearing on Indian health care and it

was actually 1991. At least that is the latest one that we can find,

so this day is long overdue, from my perspective.

The Indian Health Care Improvement Act was first enacted in

1976, and as the chairman said, the authorization expired almost

7 years ago. This bill of which I am a cosponsor will help address

the high rates of diabetes by helping tribes identify and reduce the

incidence of diabetes. It directs the IHS to screen all Indians receiving services for diabetes. It tries to improve nutrition programs

5

and exercise programs, authorizes dialysis programs and creates

diabetes control officers in each IHS area office. It modernizes the

Indian health care system, and while I still don’t think it is perfect

and there may be some things we need to change as we move it

forward, I am very proud to be a cosponsor of legislation that establishes scholarships and loan programs to encourage Indians to

go into the health profession. It authorizes construction and renovation of medical facilities, and frankly, our medical facilities in

Indian Country, there is a $3 billion backlog in construction of

medical facilities in Indian Country, and at the current rate of expenditure, it is going to take 120 years to overcome that backlog.

It improves services for urban Indians, about 48,000 of whom live

in the greater Albuquerque area, and it creates new programs for

substance abuse, for youth suicide prevention, for mental health

care, for comprehensive behavioral health care and treatment programs. The truth is that teen suicide rates among American Indians is three times higher than the national average. The life expectancy among American Indians is 6 years less than the general

population and diabetes is increasing. This legislation will matter

tremendously to the 173,000 Indians who live in New Mexico and

the 48,000 who live in the greater Albuquerque area.

It is my pleasure today to have a member of the Pueblo of Zia

here, and I wanted to particularly welcome him. He will be part of

the second panel. Ken Lucero is the chair of the All Indian Pueblo

Council Health Committee and he has become since his involvement in public life from the Pueblo of Zia one of the State’s leaders

in health care and health policy with respect to Indians, and I

wanted to thank him for coming all the way from New Mexico

today to testify and to represent the All Indian Pueblo Council and

the 19 pueblos in New Mexico so that their voice is heard on this

issue.

I also wanted to welcome Ken’s dad, the former governor of Zia

Pueblo. Gilbert Lucero is here. Sir, I wanted to thank you for coming. We are honored by your presence.

Chairman Pallone, thank you for your leadership in introducing

this bill. I really would like to see this bill brought to a markup

before our July 4 recess. I agree with you that we need to get this

moving and out of the House so that we get legislation to the President’s desk and get this job done. The Resources Committee passed

it through their committee on April 25. I think it has one more stop

to go after it sees us but we need to move this legislation forward,

get the job done and get the signature by the President of the

United States. It will be a great advancement for Indian health

care. There is more needed to reduce the disparities in health status and address the health concerns of Indian people, and we need

to work not only on this bill but to make sure that the appropriations are there to accomplish the goals set out in this piece of legislation.

I thank you, Mr. Chairman.

Mr. PALLONE. Thank you, but I have a word of caution: we are

not going to be able to do this by July 4 recess. I wish I could but

we just have so many things to do with PDUFA and SCHIP and

everything else that I can’t make that commitment. We wanted to

6

get the hearing in but I don’t think we are going to be able to mark

it up that quickly.

We have two votes, 12 minutes left on the first one and then the

second one is a 5-minute. I would like to get a couple of these in

but I don’t know if we can get all three in, so we will start with

Ms. Hooley.

OPENING STATEMENT OF HON. DARLENE HOOLEY, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF OREGON

Ms. HOOLEY. Thank you, Mr. Chairman.

I particularly want to express my appreciation for your strong

leadership on Native American health issues. You have long been

recognized as a champion on those issues. With your continued

leadership on the Indian Health Care Improvement Act, I hope

that we can finally pass this important piece of legislation. Our

tribes have been waiting since 1999 while we have been considering reauthorization of this act. This bill takes an important step to

help fulfill our promise and our obligation to provide health care

for American Indians and Alaskan Natives.

To understand the sense of the need for this legislation, we need

to look no further than to the disconcerting statistics about health

care outcomes for Native Americans. A 2004 report on the health

of American Indians reads that Native Americans are 770 percent

more likely to die from alcoholism, 650 percent more likely to die

from TB, 420 percent more likely to die from diabetes, 280 percent

more likely to die from accidents, and 52 percent more likely to die

from pneumonia or influenza than the rest of the population. Those

statistics are not acceptable and demonstrate a clear need to take

proactive measures to improve health care for our tribes. The Indian Health Care Improvement Act will do just that and help our

tribes meet their health care needs.

First, I believe the inclusion of health IT provisions will help

modernize our Indian health care system. The promotion of home

and community-based services will also provide American Indians

with access to the type of services long available outside the Indian

health care system. Moreover, the elevation of the Director of the

Indian Health Services to assistant secretary should give the Director the enhanced authority needed to improve these appalling

health care statistics for Native Americans that I noted earlier.

Those are just a few of the provisions I know the Northwest Portland Area Indian Health Board and our tribes in Oregon see as

particularly important to improving health care for Native Americans.

Finally, I understand that there is a tribal leader meeting later

this afternoon to work on the facilities construction concerns that

arose in the Resources Committee markup of the bill. I want to

commend Chairman Rahall and his staff for convening this meeting so that tribes can work together toward a positive outcome on

this matter. I believe a fair and equitable compromise is obtainable

to ensure that tribes throughout the country have access to construction funds they need to enhance their health care infrastructure. This is an important issue not only for our tribes in Oregon

but for all tribes and we look forward to a favorable outcome from

today’s meeting.

7

I thank you, Mr. Chairman. I yield back.

Mr. PALLONE. Thank you.

The gentlewoman from Illinois.

OPENING STATEMENT OF HON. JAN SCHAKOWSKY, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS

Ms. SCHAKOWSKY. Thank you, Chairman Pallone, for holding this

hearing today and I know that you have made it a priority to reauthorize the Indian Health Care Improvement Act. I appreciate the

hard work on your part toward that goal.

As Kenneth Scott, who is the director of the Indian Health Service Center of Chicago, puts it, the Indian Health Care Act has

meant the difference between life and death for many of the 4.1

million American Indians and Alaska Natives living in the United

States and has meant the world to those who are able to benefit

from of the 34 urban Indian health programs. As the director of

this program, Mr. Scott knows the importance of supporting these

Indian health projects which serve approximately 330 Indians living in urban areas. I have the American Indian Center in my district in uptown Chicago and this is a very, very important service

organization. The Bush administration zero-funded the urban Indian health centers because they thought community health centers could accomplish what they are doing but we know that that

is not true and so this bill, H.R. 1328, does authorize funding for

urban Indian health centers, and the community health centers

have stated they are unable to cover the needs of urban Indians.

I look forward to hearing from our witnesses today. I am eager

to hear your particular insight into the prevailing health care

needs of Native Americans and Alaskan Native populations.

Though we have made improvements to the delivery of health care

for this population, current funding meets just half of the existing

need. In fact, when compared with the general U.S. population, the

American Indian and Native Alaskan population faces downright

dismal health outlooks, and you have heard those statistics today,

and while the rest of the Nation’s health care infrastructure continues to evolve and modernize, we should take care to bring the

American Indian and Alaskan Native system up to date including

the integration of electronic health records. This effort should also

include reinforcing the workforce available to staff these facilities.

I am glad to see the initiatives in this bill that focus on scholarship

programs and loan repayment programs that will help increase the

number of American Indian and Native Alaskan medical professionals able to work on reservations and in urban Indian health

service programs. Making a commitment to improving both the infrastructure and workforce needs of the Indian health service is

paramount to improving access. I look forward to working with all

of you toward that goal.

Thank you. I yield back.

Mr. PALLONE. Thank you.

The gentleman from Utah.

Mr. MATHESON. Mr. Chairman, in the interest of time, I will just

submit a written statement for the record.

Mr. PALLONE. Thank you. Any other statements for the record

will be accepted at this time.

8

[The prepared statements follow:]

PREPARED STATEMENT OF HON. JOHN D. DINGELL, A REPRESENTATIVE IN CONGRESS

FROM THE STATE OF MICHIGAN

Thank you, Chairman Pallone. I thank our distinguished witnesses for appearing

before the subcommittee to discuss the reauthorization of the Indian Health Care

Improvement Act. I also wish to acknowledge the leadership of my friend, Chairman

Pallone, for expediting this bill’s consideration before the committee. I look forward

to working on this important legislation to ensure that Indian Health Services has

the resources to respond to the complex needs of American Indian and Alaskan Native communities.

For nearly a decade, Congress has considered the reauthorization of the Indian

Health Care Improvement Act. Proposals have been offered in each of the past four

Congresses, yet a reauthorization bill has never passed. Congress simply has not

given sufficient priority and attention to reauthorizing this Act, even though this

legislation would ensure that American Indians and Alaskan Natives receive the

critical health care needed in their communities.

As this legislation moves forward, we want to meet several goals: improving tribal

participation in negotiated rule-making, providing and strengthening needed health

services, and addressing ongoing concerns about reimbursement provisions for Medicaid and other Federal programs.

When their lands were originally ceded, the Federal Government promised that

these Native Americans would receive decent healthcare services. Unless we address

the serious deficiencies in the current Indian Health Service programs, especially

as they relate to accessing mental health services and urban health centers, we

have failed to make good on our promise to the American Indian and Alaskan Native people.

Again, thank you Mr. Chairman for holding this hearing. I look forward to the

testimony of our witnesses.

PREPARED STATEMENT OF HON. JIM MATHESON, A REPRESENTATIVE IN CONGRESS

FROM THE STATE OF UTAH

Thank you, Chairman Pallone and Ranking Member Deal.

I want to thank you for holding this hearing today on H.R. 1328, the Indian

Health Care Improvement Act of 2007. As a Member of Congress representing part

of the Navajo Nation, the largest geographic Native American tribal land holding

in the United States, I have had the opportunity to visit health care facilities in

Utah and in Arizona. Moreover, more than 29,000 individuals in Utah are members

of one of at least 35 different Native American tribes, which is why I am so concerned about improving access to health care on tribal lands.

Congress made many promises to Native Americans when it passed the Indian

Health Care Improvement Act in 1976. Although that bill provided critical funding

and allowed for improved access to health care for Native Americans, anyone who

has been to the Navajo Nation—or to other tribal lands across this country—knows

that Native Americans are still waiting for Congress to fulfill unkept promises. The

current funding level for the Indian Health Service system has fallen short of the

critical need. I commend you, Mr. Chairman, for sponsoring this legislation and

making it a priority for this committee.

I am very supportive of Indian health services and particularly supportive of the

Indian Health Service’s Urban Indian Health Program (UIHP). As you may know,

the UIHP provides funding for 34 non-profit, Indian-controlled and operated urban

health programs across the nation. These centers are uniquely qualified to provide

culturally appropriate primary health care services and outreach to urban Indians.

I look forward to learning more from our distinguished panel and working with

the Committee to pass this vital piece of legislation.

Thank you, Mr. Chairman.

PREPARED STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE IN

CONGRESS FROM THE STATE OF TEXAS

A major concern I have regarding the Indian Health Care Improvement Act is its

continuance of the Community Health Aide/Practitioner (CHAP) created by the

Alaska Dental Health Aide Program. Understanding that in frontier and rural areas

it can be difficult to staff clinics with full-time dentists, I don’t believe the way to

address that gap in care is by using dental health aide therapists that have a lower

9

standard of training to irreversible procedures. By allowing the CHAP dental health

aid therapist program to continue, I believe that IHCIA misses an opportunity to

make an improvement to the dental workforce in rural and frontier areas. I hope

we can work together to come up with a more workable solution that places as high

a priority on access as it does on quality health outcomes.

This is by far a perfect bill and I have additional concerns with H.R. 1328’s Medicaid and SCHIP provisions, but I look forward to hearing from both panels today.

I hope that this committee can work together and move the Indian Health Service

forward and improve health care for hundreds of thousands of Americans.

Mr. PALLONE.We will stand in recess for these two votes. We will

probably be back maybe 20 minutes or so and then we will start

with Dr. Grim. Thank you.

[Recess.]

Mr. PALLONE. The subcommittee will reconvene and we will now

turn to our witness. Dr. Grim, do you want to come up here? I will

introduce you. This is Dr. Charles W. Grim, who is Assistant Surgeon General and Director of the Indian Health Service. I welcome

you for being here with us. Do you want to tell us who else you

have with you?

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

SURGEON GENERAL; DIRECTOR, INDIAN HEALTH SERVICE

Dr. GRIM. First, let me say thank you for holding the hearing.

It is an honor to be before this committee. As Congresswoman Wilson pointed out, it has been a while since we have had an opportunity to testify before this subcommittee and we were excited to

be able to do that. My name is Dr. Charles Grim. I am the director

of the Indian Health Service and I am accompanied today by Mr.

Robert McSwain, my deputy director for the agency; Dr. Rick

Olson, who is our director for the Office of Clinical and Preventive

Services; and Mr. Ron Ferguson, who is our director for the Division of Sanitation Facilities Construction. As you know, this is a

very large bill with a lot of issues and so I have tried to bring a

number of our subject matter experts, depending on what level of

detail you all want to get in on discussing the bill.

As I said before, we are very pleased to appear before this committee to discuss the reauthorization of the Indian Health Care Improvement Act and I, like many of your colleagues, am very appreciative that you called this hearing. This landmark legislation

forms the very backbone of the system through which Federal

health programs serve American Indians and Alaskan Natives and

it encourages participation of eligible American Indians and Alaskan Natives in these and other programs.

Two major statutes are at the core of the Federal Government’s

responsibility for meeting the health needs: the Snyder Act of 1921,

Public Law 67–85, and the Indian Health Care Improvement Act,

Public Law 94–437. As you know, this act was originally authorized

in 1976. It was enacted to implement the Federal responsibility for

the care and education of the Indian people by improving the services and facilities of Federal Indian health programs and encouraging maximum participation of Indians in such programs. Like the

Snyder Act, the Indian Health Care Improvement Act provides the

authority for the programs of the Federal Government to deliver

health services to Indian people but it also provides additional

10

guidance in several areas. It contains specific language that addresses the recruitment and retention of health professionals serving Indian communities, the provision of health services, the construction, replacement and repair of health care facilities, access to

health services and the provision of health services for urban Indian people. Since enactment of the Indian Health Care Improvement Act in 1976, Congress has substantially expanded the statutory authority for programs and activities in order to keep pace

with the changes in health care services and the administration of

those services.

Federal funding for the Act has contributed billions of dollars to

improve the health status of American Indians and Alaskan Natives and much progress has been made, particularly in the areas

of infant and maternal mortality. The Department under this administration’s leadership has reactivated a very important council

called the Interdepartmental Council on Native American Affairs.

It allows for consistent HHS policy when working with the more

than 560 federally recognized tribe, and I serve as the council’s vice

chairman.

In January 2005, the Department completed work ushering

through a revised HHS tribal consultation policy involving tribal

leaders in the process. The policy further emphasizes the unique

government-to-government relationship between Indian tribes and

the Federal Government and assists in improving services to the

Indian community through better communications. Consultation

takes place at different levels including the active participation of

tribes in the development of the Department’s annual budget request. For fiscal year 2008, tribes identified population growth and

increases in the cost to providing health care as their top budget

priorities and IHS’s 2008 budget request included an increase of

$88 million for those items.

While many of the HHS agencies are important to and work

closely with tribes, perhaps one of the most important or most significant agency is the Center for Medicare and Medicaid Services.

CMS has formed a technical tribal advisory group to provide tribes

a vehicle for communicating concerns and comments to CMS on

Medicare, Medicaid and SCHIP policies that impact their members,

and the IHS has been vigilant about improving outcomes for Indian

children and families with diabetes by increasing education and

physical activity programs aimed at preventing and addressing the

needs of those susceptible to or struggling with the potentially disabling disease. In addition, there is a tribal leaders diabetes committee that continues to meet several times a year at the direction

of myself to review information on the special diabetes program for

Indian activities and to provide general recommendations to the

IHS. While the Department hasn’t been a passive observer of the

health needs, we do recognize that health disparities do exist

among the population and are among some of the highest in the

Nation for certain diseases and that improvements in access to IHS

and other Federal and private sector programs will result in improved health status for Indian people.

We are here today to discuss the reauthorization of this Act and

its impact on programs and services provided for in current law.

The Department is supportive of the reauthorization and supports

11

provisions that maintain or increase the Secretary’s flexibility to

work with tribes and to increase the availability of health care. We

are anxious to work with this committee to make progress in moving a program supportive of existing authority while maintaining

the Secretary’s flexibility to effectively manage the IHS program.

However, in the last bill reported by this committee last year, there

continued to be provisions which would negatively impact our ability to provide needed access to services. Such provisions establish

program mandates and burdensome requirements that could or

would divert resources from important programs. To the extent

that those provisions are included in the newly introduced legislation, we hope to work with you to continue to address the concerns.

On behalf of Secretary Leavitt, we commit to work with this committee and others toward the passage of the Indian Health Care

Improvement Act proposal that all stakeholders can support. My

staff and I will be happy to answer any questions you may have

regarding our statement.

[The prepared statement of Dr. Grim follows:]

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

Mr. Chairman and members of the committee:

Good Morning. I am Dr. Charles W. Grim, Director of the Indian Health Service.

Today I am accompanied by Mr. Robert McSwain, Deputy Director of the IHS, Mr.

Gary Hartz, Director, Environmental Health and Engineering, and Dr. Richard

Olson, Director, Office of Clinical and Preventive Services. We are pleased to have

the opportunity to testify on the reauthorization of the Indian Health Care Improvement Act.

This landmark legislation forms the backbone of the system through which Federal health programs serve American Indians/Alaska Natives and encourages participation of eligible American Indians/Alaska Natives in these and other programs.

The IHS provides health services to more than 1.8 million federally-recognized

American Indians/Alaska Natives through a system of IHS, tribal, and urban (I/T/

U) health programs governed by judicial decisions and statutes. The mission of the

agency is to raise the physical, mental, social, and spiritual health of American Indian/Alaska Natives to the highest level, in partnership with the population we

serve. The agency goal is to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to the service population. Our duty is to uphold the Federal Government’s responsibility to promote

healthy American Indian and Alaska Native people, communities, and cultures and

to honor the inherent sovereign rights of Tribes.

Two major statutes are at the core of the Federal Government’s responsibility for

meeting the health needs of American Indians/Alaska Natives: The Snyder Act of

1921, P.L.67–85, and the Indian Health Care Improvement Act (IHCIA), P.L. 94–

437, as amended. The Snyder Act authorized regular appropriations for ′′the relief

of distress and conservation of health′′ of American Indians/Alaska Natives. The

IHCIA was enacted ′′to implement the Federal responsibility for the care and education of the Indian people by improving the services and facilities of Federal Indian

health programs and encouraging maximum participation of Indians in such programs.′′ Like the Snyder Act, the IHCIA provides the authority for the Federal Government programs that deliver health services to Indian people, but it also provides

additional guidance in several areas. The IHCIA contains specific language addressing the recruitment and retention of health professionals serving Indian communities; the provision of health services; the construction, replacement, and repair of

health care facilities; access to health services; and, the provision of health services

for urban Indian people.

DHHS ACTIVITIES

Federal funding for the IHCIA has contributed billions of dollars to improve the

health status of American Indians/Alaska Natives. And, much progress has been

made particularly in the areas of infant and maternal mortality.

The Department under this administration’s leadership reactivated the

Intradepartmental Council on Native American Affairs (ICNAA) to provide for a

12

consistent HHS policy when working with the more than 560 federally recognized

Tribes. This Council’s vice chairperson is the IHS Director, giving us a highly visible

role within the Department on Indian policy.

In January 2005 the Department completed work ushering through a revised

HHS Tribal consultation policy and involving Tribal leaders in the process. This policy further emphasizes the unique government-to-government relationship between

Indian Tribes and the Federal Government and assists in improving services to the

Indian community through better communications. Consultation may take place at

many different levels. To ensure the active participation of Tribes in the development of the Department’s budget request, an HHS-wide budget consultation session

is held annually. This meeting provides Tribes with an opportunity to meet directly

with leadership from all Department agencies and identify their priorities for upcoming program requests. For fiscal year 2008, Tribes identified population growth

and increases in the cost of providing health care as their top budget priorities and

IHS’s fiscal year 2008 budget request included an increase of $88 million for these

items.

Through the Centers for Medicare & Medicaid Services (CMS), a Technical Tribal

Advisory Group was established which provides Tribes with a vehicle for communicating concerns and comments to CMS on Medicare, Medicaid and SCHIP policies

impacting their members. And, the IHS has been vigilant about improving outcomes

for Indian children and families with diabetes by increasing education and physical

activity programs aimed at preventing and addressing the needs of those susceptible

to, or struggling with, this potentially disabling disease. In addition, a Tribal Leaders Diabetes Committee continues to meet several times a year at the direction of

the IHS Director to review information on the progress of the Special Diabetes Program for Indians activities and to provide general recommendations to IHS.

It is clear the Department has not been a passive observer of the health needs

of eligible American Indians/Alaska Natives. Yet, we recognize that health disparities among this population do exist and are among some of the highest in the Nation for certain diseases (e.g., alcoholism, cardiovascular disease, diabetes, and injuries), and that improvements in access to IHS and other Federal and private sector

programs will result in improved health status for Indian people.

The IHCIA was enacted to provide primary and preventive services in recognition

of the Federal Government’s unique relationship with members of federally recognized Tribes. Members of federally recognized Tribes and their descendants are also

eligible for other Federal health programs (such as Medicare, Medicaid and SCHIP)

on the same basis as other Americans, and many also receive health care through

employer-sponsored or other healthcare coverage.

It is within the context of current law and programs that we turn our attention

to reauthorization of the Indian Health Care Improvement Act.

REAUTHORIZATION

We are here today to discuss reauthorization of the IHCIA, and its impact on programs and services provided for in current law. In December 2006, the Department

submitted to the Senate Indian Affairs Committee comments on proposed legislation

under consideration by the 109th Congress (S.1057). Those comments also reflected

concerns in the House bill (H.R.5312) and are the basis for our testimony today. Any

changes introduced by the bill under review in the 110th Congress (H.R.1328) are

being considered as we fully review the legislation. Improving access to healthcare

for all eligible American Indians and Alaska Natives is a priority for all those involved in the administration of the IHS program. We have worked with this committee in the past and we have made progress in moving toward a program supportive

of existing authority while maintaining the Secretary’s flexibility to effectively manage the IHS program. However, in the last bill, H.R. 5312, there continued to be

provisions which could negatively impact our ability to provide needed access to

services. Such provisions established program mandates and burdensome requirements that could, or would, divert resources from important services. To the extent

that those provisions are included in the new legislation, we hope to work with you

to continue to address these concerns.

The Department is supportive of reauthorization of the IHCIA and supports provisions that maintain or increase the Secretary’s flexibility to work with Tribes, and

to increase the availability of health care. Committee leadership previously responded to some concerns raised about certain provisions and some of the changes

went a long way toward improving the Secretary’s ability to effectively manage the

program within current budgetary resources.

I would like to note for you today our particular interest in provisions previously

reported out of this Committee.

13

OVERARCHING CONCERNS

We have a number of general objections to the language, including, expanded requirements for negotiated rulemaking and consultation; new requirements using

‘‘shall’’ instead of ‘‘may’’; use of the term ‘‘funding’’ in place of ‘‘grant’’; expansion

of authorities for Urban Indian Organizations; new permissive authorities; provisions governing traditional health care practices; new reporting requirements; establishment of the Bipartisan Commission on Indian Health Care; and new provisions

that contemplate the Secretary exercising authority through the Service, Tribes and

Tribal Organizations which is not tied to agreements entered into under the Indian

Self-Determination and Education Assistance Act (ISDEAA). In addition, we have

some concerns about modifying current law with respect to Medicaid and the State

Children’s Health Insurance Program (SCHIP) and, in some cases, we believe maintaining the current structure of Medicaid and the State Children’s Health Insurance

Program (SCHIP) preserves access, delivery, efficiency, and quality of services to

American Indians.

We also have some more specific comments on proposals we have previously reviewed for comment.

In the area of behavioral health, proposed title VII provisions provided for the

needs of Indian women and youth and expands behavioral health services to include

a much needed child sexual abuse and prevention treatment program. The Department supports this effort, but opposes language in sections 121, 201, 205, 208, 213,

704, 706, 711(b) and 712 that requires the establishment or expansion of specific

additional services. The Department should be given the flexibility to provide for

services in a manner that supports the priorities of Tribes and IHS, and to address

specific needs within IHS overall budgetary levels.

REPORTING REQUIREMENTS

H.R. 1328 contains various new requirements for reporting to Congress, including

requirements for specific information to be included within the President’s Budget

and new annual reports to Congress. The IHS and HHS will work with Congress

to provide the most complete and relevant information on IHS programs, activities,

and performance and other Indian health matters. However, we recommend striking

language that requires additional specificity about what should be included in the

President’s Budget request and imposes new requirements for annual reports.

FACILITIES

Sanitation facilities construction is conducted in 38 States with federally recognized Tribes who take ownership of the facilities to operate and maintain them once

completed. IHS and Tribes operate 49 hospitals, 247 health centers, 5 school health

centers, over 2000 units of staff housing, and 309 health stations, satellite clinics,

and Alaska village clinics supporting the delivery of health care to Indian people.

HEALTH CARE FACILITIES NEEDS ASSESSMENT & REPORT

One provision in last year’s bill, section 301(d) (1), required Government Accountability Office (GAO) to complete a report, after consultation with Tribes, on the

needs for health care facilities construction, including renovation and expansion

needs. However, efforts are currently underway to develop a complete description

of need similar to what would have been required by the bill. The IHS plan is to

base our future facilities construction priority system methodology application on a

more complete listing of tribal and Federal facilities needs for delivery of health care

services funded through the IHS. We will continue to explore with the Tribes less

resource intensive means for acquiring and updating the information that would be

required in these reports.

We recommend the deletion of the reference to the Government Accountability Office undertaking the report because it would be redundant of and a setback for

IHS’s current efforts to develop an improved facilities construction methodology.

RETROACTIVE FUNDING OF JOINT VENTURE CONSTRUCTION PROJECTS

In last year’s bill, section 311(a)(1) would permit a tribe that has ′′begun but not

completed′′ the process of acquisition or construction of a facility to participate in

the Joint Venture Program, regardless of government involvement or lack thereof

in the facility acquisition. A Joint Venture Program agreement implies that all parties have participated in the development of a plan and have arrived at some kind

of consensus regarding the actions to be taken. By permitting a tribe that has

′′begun or substantially completed′′ the process of acquisition or construction, the

14

proposed provisions could force IHS to commit the government to support already

completed actions that have not included the government in the review and approval process. We are concerned that this language could put the government in

the position of accepting space that is inefficient or ineffective to operate. We, therefore, would oppose such a provision.

SANITATION FACILITIES DEFICIENCY DEFINITIONS

Another section 302(h) (4) would provide ambiguous definitions of the sanitation

deficiencies used to identify and prioritize water and sewer projects in Indian country. As previously proposed ‘‘deficiency level III’’ could be interpreted to mean all

methods of service delivery (including methods where water and sewer service is

provided by hauling rather than through piping systems directly into the home) are

adequate to meet the level III requirements and only the operating condition, such

as frequent service interruptions, makes that facility deficient. This description assumes that water haul delivery systems and piped systems provide a similar level

of service. We believe it is important to distinguish between the two.

In addition, the definition for deficiency level V and deficiency level IV, though

phrased differently, have essentially the same meaning. Level IV should refer to an

individual home or community lacking either water or wastewater facilities, whereas, level V should refer to an individual home or community lacking both water and

wastewater facilities.

We recommend retaining current law to distinguish the various levels of deficiencies which determine the allocation of existing resources.

THRESHOLD CRITERIA FOR SMALL AMBULATORY PROGRAM

Yet another section 305(b) (1) would amend current law to set two minimum

thresholds for the Small Ambulatory Program - one for number of patient visits and

another for the number of eligible Indians. In order to be eligible for the Small Ambulatory Program under the previously proposed criteria, a facility must provide at

least 150 patient visits annually in a service area with no fewer than 1500 eligible

Indians. Aside from the fact that these are both minimum thresholds and so somewhat contradictory, the proposed provisions would make implementation difficult.

First, the IHS cannot validate patient visits unless the applicant participates in the

Resource Patient Management System (RPMS). Since some tribes do not participate

in the RPMS, it is difficult to ensure a fair evaluation of all applicants. Second, the

term ′′eligible Indians′′ refers to the census population figures, which cannot be verified, since they are based on the individual’s statement regarding ethnicity.

NEW NEGOTIATED RULEMAKING AND CONSULTATION REQUIREMENTS

In addition, we are concerned about the requirements for negotiated rulemaking

and increased requirements for consultation in the bill because of the high cost and

staff time associated with this approach. We are committed to our on-going consultation with Tribes under current Executive Orders, as well as using the authority

of Chapter V of title 5, United States Code (commonly known as the Administrative

Procedures Act) to promulgate regulations where necessary to carry out IHCIA.

The comments expressed today in this testimony do not represent a comprehensive list of our current concerns. And, we will continue reviewing H.R.1328 for any

provisions that might be addressed.

I reiterate our commitment to working with you to reauthorize the Indian Health

Care Improvement Act, and the strengthening of Indian health care programs. And

we will continue to work with the Committee, other Committees of Congress, and

representatives of Indian country to develop a bill that all stakeholders in these important programs can support. Again, I appreciate the opportunity to appear before

you today to discuss reauthorization of the Indian Health Care Improvement Act

and I will answer any questions that you may have at this time. Thank you.

Mr. PALLONE. Thank you, Doctor. Before I recognize myself for

questions, I just wanted to say that your statement becomes part

of the hearing record and you may, if you want, submit additional

brief and pertinent statements in writing either in response to our

questions or other things that you might want to bring in.

Dr. GRIM. Thank you, Mr. Chairman.

15

Mr. PALLONE. And I will recognize myself for some questions and

then we will go to the other members.

As you heard me say in my opening statement, I am very frustrated over the fact that we—I say ‘‘we’’ collectively—the tribes,

myself, many of the members have been working on this legislation

essentially for more than 7 years and we haven’t been successful,

and I am not trying to point the finger because I am sure everybody can take some of the blame but it does seem that every time

at the end of the 2-year session when we are close to getting something done that we get the administration coming in with some

new objection, and it might be from HHS or it might be from the

Department of Justice. That is certainly what happened last year

at the end of the last Congress. And of course, what I am trying

to do is avoid that this year. That is why we got it out of Resources.

That is why we are here early. And as I said before, I would like

to report a bill out of even the subcommittee that the President

could sign. So you have got to give me some help here, first of all.

I would like to have a commitment from you that the administration will work with us in good faith to reauthorize the bill this

year, meaning 2007, if you would make that commitment.

Dr. GRIM. As you couldn’t make a commitment by July 4, I am

not sure about 2007, but I can tell you that we are very, very close

within the Department to getting the comments on the bill to you.

They are going through some final stages of clearances right now

and we have made comments on the prior Senate bill that I think

gave a lot of guidance and a number of those things were changed

in the bill that you introduced so we can be very, very close to giving you some comments that I think you can work on.

Mr. PALLONE. When do you expect to give us those comments?

Dr. GRIM. I will have to get back to you for that on the record

but they won’t come in in the 12th hour at the end of the second

year.

Mr. PALLONE. How about a month?

Dr. GRIM. It depends how many back-and-forths there are but

the Department is close to getting them——

Mr. PALLONE. Well, if you could get them to us within the next

month, frankly I would be happy.

Dr. GRIM. We will try to do everything we can to do that.

Mr. PALLONE. OK. Now, just briefly, because I know we don’t

have a lot of time, but did you want to comment on why we have

this problem? It does seem like at the end we always get more objections. Is there some process thing that we need to address here

to change so that it doesn’t happen again and so that we move

things quicker? You might not have an answer but I just——

Dr. GRIM. I would just say that we have all learned through the

process that this it is a complex bill. It has a lot of sections and

it touches a lot of other departments besides HHS. In a hearing

that I testified before the Senate recently, who also had the Department of Justice. The Department of Justice committed as well

to getting their comments and we are trying to——

Mr. PALLONE. Well, I think you hit on the point. I think since

so many other departments are involved, maybe one thing I could

ask you to do is to take it upon yourself to get back to us and tell

us who within the administration other than HHS might have to

16

comment on this because I don’t want to see HHS comments, then

Justice and then we find somebody else has to, so maybe that is

one way you can help me get back to me with whoever you think

we need to have see this so that we can get everybody’s comments.

Dr. GRIM. We are trying to gather all those in for you too. We

are trying to make it a comprehensive set of concerns that will

come forward.

Mr. PALLONE. That would address all the administration’s departments?

Dr. GRIM. As much as can know at this time, yes, sir.

Mr. PALLONE. All right. Now, you mentioned objections to various

provisions in the bill. Do you want to tell us what you support?

What provisions in it right now would you support?

Dr. GRIM. There are a huge amount of provisions that we support

and I don’t know that I could go through them all, and I am assuming the committee has seen some of our comments on the previous bill and a lot of those were on the requirements, a lot of new

requirements for reports that hadn’t been done in the past that

would draw resources away for a large——

Mr. PALLONE. Well, tell us as much as you can what you can support at this time as best you can.

Dr. GRIM. There are a lot of responses that we have made in the

past that express concerns that have been addressed in areas of

new requirements like negotiated rulemaking and consultation.

There were a lot of requirements for negotiated rulemaking and

consultation and a number of those have removed. There were

some new and expensive requirements that have also been addressed, and we appreciate those responses to allow the Secretary

to maintain flexibility to the greatest extent possible. I noted the

reporting requirements that we felt were labor and time intensive

and we note that there is at least one instance where such a requirement was addressed in this bill. One provision that restricted

the Secretary’s authority in the development of regulations also appears to have been addressed under section 802 in regulations, and

we realize that was a very important accommodation that you all

made. It will ensure that our resources are focused and prioritized

by those most closely involved in program administration. Also,

there were several provisions in the bill that we had made comments on, those comments that went in in December to the Senate

that have been revised in this version of the bill. And so there have

been numerous things that have already been addressed and——

Mr. PALLONE. Well, maybe again if you would in writing get back

to us to tell us what you support, OK? Because I think you tell us

what you don’t like but I would like to know more about what you

think you support at this time.

All right. My time has run out. I recognize the gentlewoman from

New Mexico.

Mrs. WILSON. Thank you, Mr. Chairman. I neglected to do so in

my opening statement, but I would like to ask for unanimous consent to include in the record a letter of support for this legislation

from the Pueblo of Zia, from the All Indian Pueblo Council, and

from the New Mexico State Legislature.

Mr. PALLONE. Without objection, so ordered.

Mrs. WILSON. Thank you, Mr. Chairman.

17

Doctor, the Acoma-Canoncito-Laguna Hospital in New Mexico is

running a $4.6 million deficit, many believe due to poor management by the Indian Health Service. Apparently, individuals, IHS

officials that are overseeing the hospital apparently were allowed

to borrow some $2 million from another service unit within the Albuquerque area without the knowledge of tribal leaders and they

owe about $2 million more in other contracted services. Our delegation from New Mexico has written to you several times on this matter, most recently in January of this year, without a response from

your Department. What are the procedures that IHS uses to periodically review the financial situation of each facility, and what do

you intend to do about the ACL Hospital?

Dr. GRIM. The regional leadership in each area on a regular

basis, and it varies by region, have what are called governing board

meetings with each facility, with each service unit within the region. That is one of the requirements under the Joint Commission

on the Accreditation of Health Care Organizations and part of the

things that they review at that time are financial transactions as

well as other sorts of activities in the hospital. It has been a multiple-year process that we have been working on with ACL to try

to address the issue. I personally have met with the tribal leadership and other congressional leadership about the situation going

on out there. The tribe asked us to do a review of that program

and asked that we include more members from their tribes. We

had three Federal representatives on that review team. That report, the draft copy of that report has been shared with tribal leadership. They have asked for some changes to be made to it. We are

also considering—and also Congressman Pearce, one of his senior

staff came out and toured the facility and then went back to our

regional office and we provided them with significant amount of financial information that went back a number of years.

Mrs. WILSON. Have you provided that financial information to

the tribe? Because as I understand it, the preliminary report did

not include financial information. The tribe has asked for it and we

still haven’t gotten a response to our request for that information

that we put in writing to you in January.

Dr. GRIM. I guess you would have to ask the tribe that. I am assuming that that information has been shared. We sent out a large

amount of information. But what people wanted it to be was better

organized over a multiple-year period, and that was some of the information that was shared with the Congressman’s office recently

and so we do now have the data in what we think——

Mrs. WILSON. Well, you have not shared that information with

this Congresswoman’s office and I would remind you that that hospital does not just serve constituents from one congressional district, and if I sign a letter, I generally expect a response, and we

have not gotten a response from the IHS and I would ask you to

address that issue. You obviously can’t address it here today, but

we are not getting sufficient information and neither is the tribe,

and there is obviously a problem there and I would ask you to put

some attention on it.

Dr. GRIM. I apologize that you haven’t gotten a response yet, and

we will get you one as soon as possible.

18

Mrs. WILSON. There is also a problem, as I understand it, regarding the ability of dentists and others to volunteer with the IHS,

and I understand there are some barriers that are in place. I understand you have a volunteer dentist program that you put in

place last year but the participation has been low because of the

burdensome credentialing requirements and process. As I understand it, there is no centralized system at IHS for credentialing

and that volunteer dentists have to be re-credentialed each year.

They have to fill out more paperwork for each clinic in which the

practice. What do you recommend here to straighten out this process?

Dr. GRIM. I am going to make some preliminary comments and

then I am going to let Dr. Olson speak to it a little bit more. The

credentialing requirements that are placed upon our providers are

not requirements that the Indian Health Service has placed upon

them. Those are requirements that we have to meet to maintain

our accreditation through the Joint Commission on the Accreditation of Health Care Organizations. Our hospitals and clinics go

through that process.

Mrs. WILSON. It is my understanding that the military has a centralized credentialing process. Do they not have to be accredited?

Dr. GRIM. I am not sure if the military maintains that accreditation or not. Rick, do you want to——

Dr. OLSON. I don’t know that I can answer whether the military

does. I can talk some about the central credentialing program if

you wish.

Dr. GRIM. Go ahead.

Dr. OLSON. OK. As Dr. Grim said, all Indian Health Service facilities are either Joint Commission accredited, certified by CMS or

accredited by the Accreditation Association for Ambulatory Health

Care Centers, and to meet those standards, which are to meet

quality-of-care standards, we credential and privilege all providers,

primary providers who work in our facilities so all physicians, all

dentists, psychologists, various other ancillary staff who work in

our facilities are all credentialed and privileged by standard providers in all our facilities and that includes all hospitals in the United

States and large health care organizations that have a

credentialing system. This has to be done every 2 years so all of

our providers are re-credentialed every 2 years. I am sure they do

that in the military. They certainly do that in the VA. I just don’t

know the military’s system that well. What the centralized

credentialing system does for the military and it probably makes

a lot more sense for the military because their providers are deployed frequently. Their providers move form base to base every

few years or so. In the Indian Health Service, we want our providers to stay in a location generally. A few folks move but most will

stay and that is for continuity of care. Our patients want to see

their physician, not somebody new every time.

Mrs. WILSON. This isn’t an issue of continuity in the community.

This is how do we credential—we have volunteer dentists who

want to volunteer, pediatricians who want to volunteer, psychologists who want to volunteer, but there is, as I understand it, no

centralized credentialing system at IHS. Do you think that is a

19

problem or are you just going to continue on with the same system

you have?

Dr. OLSON. Well, I don’t think that the centralization meets the

issue at all. We did talk with the American Dental Association, the

American College of OB/GYN, American Academy of Pediatrics

folks last summer when we were aware of the report requirement,

and one of the big issues that they identified which we are in the

process of fixing now is to have one credentialed application form

across our whole system. Now, that is at IHS facilities. Tribes run

their own programs and so if they want to use our form, that is

fine, but if a volunteer goes to a tribal program like in Alaska, that

is not an IHS issue at all, but we are simplifying. We are going to

make it Web-based application form and that can be transported

from location to location so they don’t have to fill out a form. But

they still have to be re-credentialed and it is the same way in the

military. What the centralized credentialing system basically does

is have a repository electronically where different locations can go

in and get the credentials that have been verified but then they

still have to review the credentials and then review the privileging

application. Privileges have to do with what we allow in a facility,

and it is based on two things. One is the expertise and training of

the provider. The other is the capacity of the facility to support

that provider, and just to give you a brief anecdote to understand——

Mr. PALLONE. You have to be brief because we are like almost

twice the amount of time here, so——

Dr. OLSON. All right. I am a physician and internist. I did a lot

of cancer chemotherapy. I had the training and expertise to do that

at my hospital, a small rural hospital in Oklahoma where I was for

11 years, but the facility didn’t have the capacity to support me

and so what we did to develop that capacity, we had to send off

nurses and pharmacists in order to support the chemotherapy program and then I got the privileges to do that and ran a program

for 8 years like that. So capacity of the facility is unique from facility to facility. So at every location where a provider goes, whether

they are a physician, a dentist, a volunteer, we have to credential

and privilege at each location and then we have to re-credential

every 2 years for all providers whether they are volunteers or not.

Mrs. WILSON. Thank you, Mr. Chairman.

Mr. PALLONE. Sure. Ms. Solis.

Ms. SOLIS. Thank you, Mr. Chairman.

I want to direct my questions to Dr. Grim, and I will just ask

you, how many people are actually served by the Urban Indian

Health Care Program?

Dr. GRIM. I will have to get back to you with that number.

Ms. SOLIS. You don’t have an estimate?

Dr. GRIM. The last number that I have was 150,000 but that was

for a hearing a year ago. I just want to double-check and make

sure that that is still accurate for you, and we will submit it for

the record.

Ms. SOLIS. And can you break that down by State?

Dr. GRIM. We can break it down, yes, by State.

Ms. SOLIS. Thank you. One of the questions I have is, what

would happen if these services were not available any longer, espeVerDate 11-SEP-98 09:38 Oct 08, 2008 Jkt 000000 PO 00000 Frm 00024 Fmt 6633 Sfmt 6633 Q:\DOCS\110-54 SCOM1 PsN: SCOM1
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cially again in urban settings? And look at the case in Los Angeles

and if you could just elaborate.

Dr. GRIM. I can elaborate some on that.

Ms. SOLIS. Where would the patients go, for example? Who would

provide them with care?

Dr. GRIM. Well, the Indian Health Service funds about 34 such

programs and our average funding for those programs is about 50

percent. It ranges from about 15 percent of their base funding to

in some programs 100 percent. Some of the programs are only outreach and referral programs so they provide no direct services

whatsoever, and others are full-blown ambulatory care clinics and

so part of what I am saying is that not all the programs would

close down without our funding. They have a lot of other grants

and other resources. Some of them would have to close down, those

that rely on us 100 percent, and the administration’s view when it

made that recommendation in the past is that some of the statistics that were cited by Congressman Pallone about the per capita

funding in Indian Health Service, we redirected the funding from

the Urban Indian Health Program to all of the hospitals and clinics

that are on or near reservations that have in many cases there is

no other place to go except an Indian Health Service location, and

we would have——

Ms. SOLIS. I don’t have a lot of time so I am going to interrupt.

I would like to get information specifically on what impacts that

would have in Los Angeles County. We only have one center there

in Los Angeles downtown and we have got a vast number of urban

Native Americans that I don’t even believe are fully aware that

there is a program that exists, and I would like to know how that

money is being spent there. And then secondly, something I raised

earlier was with respect to the new requirement to show proof of

citizenship or some documentation. I know we are going to hear

from a witness later about restrictions that are currently placed on

tribes and I believe, and you can correct me, that there are only

five tribes that have recognized status of showing acceptable proof

of citizenship, so is that true? Is that correct?

Dr. GRIM. I know it is a very small number of tribes. I don’t

know the exact number. We can get that for the record.

Ms. SOLIS. So a vast number of the Native American population

would not be eligible for assistance because they are not designated

as one of those——

Dr. GRIM. No, that is not true, and right now CMS is currently

in the process of reviewing comments. I have gotten over 1,400

comments on that particular regulation about——

Ms. SOLIS. Is there a need to change that regulation?

Dr. GRIM. Well, they are in the process of writing it right now.

In fact, I submitted a comment myself about some of the concerns

that Indian tribes had and the fact that some of their especially

older membership might not have——

Ms. SOLIS. Will you share that with the committee?

Dr. GRIM. Sure. And the regulations are in the process of being

developed finally right now and the issues that you are raising may

be dealt with. I am just not sure yet.

Ms. SOLIS. With respect to community health aides, I know that

there is such a program that exists right now providing culturally

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competent care in Alaska. Would it behoove us to maybe look at

how that can be expanded to serve communities like Los Angeles

and other, say, mega urban areas where you have a very diverse

population that might be able to benefit from information outreach

campaigns and just prevention?

Dr. GRIM. I believe if I am interpreting your question right, I believe some of the concerns have been addressed in some language

that we worked with one of the other committees where the program that is going on in Alaska right now would operate for a period of years and be evaluated. It is under evaluation right now,

and at the end of that evaluation period we would take another

look at it and see about applicability to the lower 48.

Ms. SOLIS. One of the issues that I am concerned with is the fact

that there are so many cultural barriers, language barriers in accessing health care overall, particularly for Native Americans as

well as Latinos, and in Los Angeles we have those communities

intermixing very often and sometimes it is hard to identify and

separate who is Latin American and who is Native American, and

one of the things that I would like to see is that these kinds of programs are actually extended in urban areas, whether it be Chicago,

New York or Los Angeles County, Arizona, and places such as that.

One last thing, Mr. Chairman, I want to bring up is, I really believe that when we are talking about health care and prevention,

that we really need to go a step farther because we hear so many

instances on the reservation where many of our Native American

families are affected by groundwater contamination, different types

of contaminants that are there that are remnants in their home

and in their environment and what kind of steps could we take

possibly through programs like this and others that might be able

to help provide more information on prevention and what to look

for because I can see where there is really a lack of information

available to the people on the reservation. Thank you.

Mr. PALLONE. Thank you.

Mr. Sullivan of Oklahoma.

Mr. SULLIVAN. Thank you, Mr. Chairman, and thank you, Mr.

Grim, for your being here today at the panel. As an Oklahoma native and a member of the Cherokee Nation, I know you understand

the health challenges facing Native Americans in our State and

Nation and we appreciate the job you do to serve the health care

needs of Indian Country. In Oklahoma, we have 37 federally recognized tribes with each different challenges with respect to assessing and delivering quality health care. As a vice chairman of the

Congressional Native American Caucus, I am deeply concerned

with the status of Indian health care in America and their access

to care. We know that nationally American Indians and Alaskan

Natives have three times the rate of diabetes and up to three times

the rate of suicide. In addition, Native Americans also have among

the highest rate of cardiovascular disease. IHS recently estimated

that more than two-thirds of the health care that is needed for

American Indians is being denied. In your review, what are the

barriers to access to care that Native Americans are experiencing

and how would reauthorization of H.R. 1328 improve access to

tribes? And also along those lines, if you can comment on prevention. I think prevention in health care, when you look at health

22

care is very important. We seem to deal mainly with chronic illnesses and not as much on the front end with prevention like I

think we should, and especially in the Native American populations it is no different really than many others. What is being

done, like I said, with diabetes prevention, drug addiction, alcoholism and also mental illness?

Dr. GRIM. We are focusing very heavily on all those areas you

mentioned actually. We have major initiatives going on in prevention, in behavioral health and chronic care management. We have

all over the country programs that tribes have run both because of

the special diabetes program for Indian monies as well as appropriated funds through Congress of prevention initiatives. One of

the things we are trying to do now is to integrate those three programs. We are working with an institute out of Massachusetts

called the Institute for Health Care Improvement on a chronic care

collaborative to change and re-engineer our system in the way we

deliver chronic care. You talked about barriers to access to care

and prevention is one component. If we could stop some of the disease from occurring, it would allow more people to access the types

of care that they do need. Everyone I think in the country has realized that. We have and certainly tribes have and so as we integrate

these three initiatives, better management of chronic care patients,

dealing with the behavioral health issues that there are in our population. Suicide was mentioned, high alcoholism rates. Methamphetamine is on the rise in our population, and really a lot of

those things are education and prevention are some of the keys to

dealing with them, and those are some of the key things that we

are focusing on right now. So I would say that No. 1, the authorities that we have are allowing us to do those things, and I am very

excited that Congress is interested in focusing on prevention in this

bill.

Mr. SULLIVAN. Well, for Native Americans suffering from the disease of alcoholism, can they go to a residential treatment facility

now?

Dr. GRIM. We have limited residential treatment facilities. We

have 11 of them right now, and right now those are focused on

youth or youth residential treatment centers. For adults, some

tribes have started residential treatment programs for adults.

Right now the Agency has no residential treatment programs for

adults, and if we do send them for care, it is using our contract

health service dollars to refer them out to a private facility. So that

is a gap in access, if you will, for the adult population.

Mr. SULLIVAN. Do you think it would be important to get some

treatment facilities for them?

Dr. GRIM. The adults could use them, as I said, but they are not

going without care right now. Those that need the care if we are

able to refer them out, we do it with contract health service dollars

into the private sector where facilities exist. Perhaps one of the bigger complaints we get though from tribes is that we do have to

send them away. They are sent away to some location and then

they come back. There is nowhere close. In some places we send

them to other States.

Mr. SULLIVAN. I bet you are not sending them to Betty Ford, are

you?

23

Dr. GRIM. I wouldn’t swear we are not but I could get that information.

Mr. SULLIVAN. Well, I think that is important that we get some

access to that. And also, what about mental illness? What are you

doing about that?

Dr. GRIM. One of the line items in our budget is mental health

and so a large majority of our facilities provide mental health services. They are often times in the smaller facilities triage sort of

care only, kind of emergent-type care. We have tested some models

and some larger facilities of on-demand-type care that seem to be

working successfully and I guess one of the things I would want

to point out is that we are constantly looking at best practice

things that are going on, evidence-based best practice things in the

medical sector, and as we can bring them into our system, we are

doing that. There is mental health care available out there. Is it

available for everyone that needs it? No, sir.

Mr. SULLIVAN. All right. Thank you, sir.

Mr. PALLONE. Thank you.

The gentlewoman from Illinois.

Ms. SCHAKOWSKY. Thank you very much, Mr. Chairman. I was

concerned that you seemed reluctant to say that within a month

that you could respond to some of the questions. I don’t know, it

seems like a reasonable amount of time. Do you think it is likely

that you will be able to?

Dr. GRIM. I think it is likely that we can have it within a month.

I am just not going to promise it on the record today.

Ms. SCHAKOWSKY. Is it your intention to stay for the second

panel?

Dr. GRIM. I didn’t know I was going to be here this late so I have

an appointment with my boss, but if the Congress requests that I

stay, I will stay.

Ms. SCHAKOWSKY. Well, I always think it is a good idea that the

people who are actually dealing with these programs hear all the

testimony, so if you could, I think it would be a good idea.

Dr. GRIM. Ninety percent of the time, I do that, but I am just

not sure today.

Ms. SCHAKOWSKY. In developing your concerns and your testimony, did you do this at all in consultation with any representatives of the tribes and the deliverers of the health care to the Native American population?

Dr. GRIM. In preparing my——

Ms. SCHAKOWSKY. Your testimony today. Are your concerns that

you listed reflective of what we may hear from the providers of the

services?

Dr. GRIM. These are administration’s concerns. I think you are

going to hear some different things from the second panel. They

would like to see things perhaps left in the bill that the administration would like to see removed and again the primary concerns

are to leave flexibility for the Secretary, to not put new requirements and reporting provisions in that would take funds away from

the delivery of care.

Ms. SCHAKOWSKY. One of the top priorities of the chairman of the

full committee, Mr. Dingell, and I would say of our health subcommittee as well is the SCHIP program, and I notice that in your

24

testimony you have some concerns about SCHIP. You don’t elaborate on those concerns. What is your concern?

Dr. GRIM. Well, one of the concerns of the SCHIP reauthorization

is that—and I guess let me first say that one of the concerns is that

there are SCHIP-type issues in the Indian Health Care Improvement Act and the administration would prefer to deal with SCHIP

in the SCHIP reauthorization, so that is probably the first and the

biggest concern. The other concern is the expansion that some

States have done with SCHIP to go beyond some of the initial intent of it to cover adults and we think refocusing the efforts to between 100 and 200 percent of the poverty level, focusing back on

children would be an immense help to our population. Much of our

population falls into that 100 to 200 percent of the Federal poverty

level and so those are examples of some of the concerns that we

are dealing with, reauthorization of another bill within our bill and

then a refocusing of the efforts on what the initial intent was.

Ms. SCHAKOWSKY. When you say our population, then are you

saying that you think you are reflecting what your population, that

is, the Native American population would agree that it should not

include adults and it should focus only on 100 to 200 percent of

poverty level?

Dr. GRIM. I was not trying to characterize that my population

would think that, no, that we serve only that. We have a significant amount of population that falls in the 100 to 200 percent

range and to the extent that expansions beyond that dilute what

is available in the way of either services or eligibility to that group,

that it would hurt the coverage within our population group.

Ms. SCHAKOWSKY. Unless more money were allocated for it. And

with respect to Medicaid, you say you have concerns and you are

not only talking about dollars, you say the current structure of

Medicaid. What is the problem with Medicaid?

Dr. GRIM. I would like to get that to you in writing for the

record.

Ms. SCHAKOWSKY. As I said, the American Indian Center in Chicago is located within my district, and the health center is really

struggling. It is one of those 34. I would really like to arrive at a

place where we could work with you to bolster those rather than

this notion that other health care facilities or federally qualified

health centers could address that population. All of our FQHCs are

struggling with being overloaded and it would seem to me that this

one, which is culturally sensitive, which has the capacity to do the

kind of outreach we need to the Native American community could

be helped. I am wondering if there are ways that we could work

together to make sure that this particular facility could continue to

exist and even flourish.

Dr. GRIM. We are willing to work with you. We have an Office

of Urban Indian Health. I don’t have the specifics on the type of

funding that the center in Chicago gets but we either have that or

can get that and we can work with you, Congresswoman, on that.

Ms. SCHAKOWSKY. Well, if you would take a look at that particular center and get back to me and perhaps we could set up a meeting with its director, Ken Scott, and talk about what we can do.

25

Dr. GRIM. Our director for the Office of Urban Indian Health

happens to be in the room today, so she heard that from you and

we will make sure we do that.

Ms. SCHAKOWSKY. Great. Thank you.

I yield back, Mr. Chairman.

Mr. PALLONE. Thank you. Hopefully you won’t leave but before

you step down from the panel, I just want to emphasize again that

it is obvious that there are a lot of disagreements with the administration on this bill and I really would like to get those all on the

table and try to iron them out and see that we can come to a consensus because we want a bill that is going to pass, that is going

to come to conference with the Senate and go to the President.

There are going to be differences but we would like to work them

out but we can’t work them out unless we have them all on the

table, so I appreciate the fact that you are going to try to get us

all these objections as well as what you support within the next

month, and also that you are going to try to be sort of a clearinghouse for other departments or agencies, because that is just as important.

So thank you again. We have a lot of work to do. Thank you.

Dr. GRIM. Thank you, Congressman.

Mr. PALLONE. And I will ask the second panel to come forward.

Welcome to all of you. Thank you for being here. Let me introduce

each of you from my left to right. First we have James Crouch, who

is executive director of the California Rural Indian Health Board,

and then we have Mr. Ralph Forquera, who is executive director

of the Seattle Indian Health Board, and then Mr. Ken Lucero, who

is from the Pueblo of Zia, and then we have Rachel Joseph, who

is co-chair of the National Steering Committee for the Reauthorization of the Indian Health Care Improvement Act and also representing the National Indian Health Board. Good to see you again

as well.

As I said before, your statements will be part of the hearing

record and each of you may in the discretion of the committee submit additional pertinent comments either in response to our questions or on your own, if you like, and I will start with Mr. Crouch.

STATEMENT OF JAMES CROUCH, EXECUTIVE DIRECTOR,

CALIFORNIA RURAL INDIAN HEALTH BOARD, INCORPORATED

Mr. CROUCH. Thank you very much. My name is Jim Crouch, executive director, California Rural Indian Health Board. I am proud

to serve in that position for the last 20 years. I am presenting on

behalf of California Rural Indian Health Board, its 12 member tribal health programs providing services to over 44,000 American Indians. I would like to keep my comments essentially focused on the

new title II Medicare, Medicaid and SCHIP provisions. CRIHB is

totally supportive of the entire bill. We are very pleased to have it

in this committee again.

The Indian Health Service is a discretionarily funded Federal

program. It is not an entitlement program. There could be no

greater flexibility than is already provided in the Indian Health

Service under the appropriations processes. The role of the health

bill is to give them guidance to better meet the needs of the Indian

community, and when this bill first passed in 1976, really the most

26

exciting part of it was the joint funding that responded from including the right of IHS facilities to bill the Social Security-based

programs. A lot has changed in that time. Today the CMS programs provide about a third of the operating budget of the Indian

Health Service. When you all think about the underfunded nature

of the Indian Health Service, you are including through the level

of need funded methodology participation and dollars from the

CMS provides so when we say IHS is underfunded, typically that

includes the contribution of the Center for Medicare and Medicaid

Services programs.

What does this bill do that is new? It newly enfranchises tribal

providers and IHS facilities to bill for not only programs at CMS

but also for furnishing items, and as I stated in my written testimony, such critical things as wheelchairs, diabetic test equipment

and strips would be therefore included that are currently problematic at this point. It also addresses the issue of outreach. Having

access to an entitlement program coverage like Medicaid or SCHIP,

Medicare, simply isn’t real until you actually are enrolled, and

without increased efforts on enrollment and outreach, which this

bill provides, we will continue to have underutilization of particularly the Medicaid program in Indian Country. I can’t believe that

the Indian Health Service in fact would oppose or CMS would oppose any kind of increase in that work.

The real heart of the Medicaid provisions and the SCHIP provisions in this bill which are perhaps somewhat controversial for

some is the issue of providing access to health care without premiums and co-pays. I would suggest that this is important for making that access real. I would like to share with you some material

that was not in my written testimony about low access to health

care. In California a few years ago, we did some research that

matched by education, geography and Medicaid category of eligibility over 22,000 Indian people and compared them to non-Hispanic white population exactly matched by the same geography and

age categories. What we learned from that is Medicaid coverage

doesn’t mean access. The actual visit counts were very different between those two populations. The pattern of providers that were

seen were different and we were looking at both IHS tribal and

non-IHS-funded providers because it is a payment study. And most

importantly, the Indian received only 85 cents for every dollar expended on their similarly situated non-Hispanic white population.

Why is that? It is in part because the geography is much greater.

We couldn’t actually match point by point for geography. It is also

because of barriers that relate to accessing Medicaid through a

share of cost arrangement. I would also point out that we looked

at a broader study, looking at access to hospital-based services. The

Indian community when we looked at just the rate of gross hospitalizations for all payers, and I would add non-payment of debt,

if you have a problem in Canoncito with the payment of CHS dollars being reduced, that is true generally in Indian Country. Looking at bad debt, Medicaid payment and IHS payment, which in

California was very little, overall hospitalization rates differed

greatly between the non-Hispanic whites and the Indian population. American Indian women were getting to the hospital at a

27

52 percent higher rate than the other community and the men a

more shocking 72 percent.

Lastly, I would like to particularly point out the issue of access

to primary care. That is where we will make real progress in

health care. This bill allows by expanding coverage and participation in Medicare, Medicaid and SCHIP. It will allow us to hopefully

address some of these bad statistics. American Indian women are

treated at the hospital level with ambulatory care sensitive diagnoses 106 percent of the rate of non-Hispanic white women in the

same age, same sex and same geography in the State of California.

It is documented over a university-level 3-year study. The ambulatory sensitive diagnostic rate for men is a whopping 136 percent of

the non-Hispanic white rate for the same age and sex category.

This research documents a lack of access. The Indian Health Care

Improvement Act, particularly the title II new provisions, will improve the utilization of Medicare, Medicaid and SCHIP in Indian

County. It will facilitate Indian program participation as providers

and it will facilitate Indian enrollment as individuals. I urge that

you support this bill and work for its speedy passage.

[The prepared statement of Mr. Crouch follows:]

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32

33

34

35

36

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Mr. PALLONE. Thank you, Mr. Crouch.

Mr. Forquera, I know I am mispronouncing it probably.

Mr. FORQUERA. It is Forquera. Just think of four carrots and——

Mr. PALLONE. I am glad that Ms. Solis left because she corrects

me on my Spanish pronunciations.

Mr. FORQUERA. It is OK. No problem. In my bio, I don’t know if

you noticed, but I try to put it into phonetics so that people can

remember it.

Mr. PALLONE. OK. Thanks.

STATEMENT OF RALPH FORQUERA, EXECUTIVE DIRECTOR,

SEATTLE INDIAN HEALTH BOARD

Mr. FORQUERA. Mr. Chairman, thank you for allowing me to be

here today, and thanks for inviting me and to have a representative from the urban Indian health side of the aisle here to speak

on the issue. My name is Ralph Forquera. I am the executive director for the Seattle Indian Health Board. I am an enrolled member

of the Juaneno Band of California Mission Indians. It is a Staterecognized Indian tribe from the San Juan Capistrano area of

southern California, and it is a great pleasure for me to be here.

The Seattle Indian Health Board is one of the 34 urban Indian

health programs along with the Chicago program and the one in

Albuquerque as well as 32 other cities around the country that

have urban Indian programs in them. I have been working in the

field of urban Indian health for the last 25 years, first in San Diego

where I served as the executive director for their program for 8

years and for the last 17 years I have been at the Seattle program

in Seattle, Washington. My agency is a fairly comprehensive organization. It was one of the first funded by the Indian Health Service even prior to the Indian Health Care Improvement Act. We received our first Indian health resources in 1972 as part of the old

OEO equal opportunities program, so we have been engaged with

the Indian health program for quite a long period of time. We provide direct health care services to about 7,000 individuals a year,

about 4,000 of whom are American Indians or Alaskan Native. The

majority of our non-native people that we see tend to be family

members of American Indian or Alaskan Native families. A lot of

the cities Indian people live in mixed environments; mixed households, they marry into mixed racial backgrounds, and we try to

take care of families as opposed to individuals through our organization. As we talk about health promotion and health prevention,

you really need to talk about families. Talking about individuals is

helpful but you really need to address the entire comprehensive nature of the environment in which these people live in order to be

able to affect them, and that is really the kind of work that we try

to do. Through our outreach and education programs, we interact

with probably another 4,000 or 5,000 individuals, so we think that

we see somewhere around 10,000 Indian people a year, interacting

with them in Seattle. Seattle has a population of about 35,000 Indian people so about a third of the population.

Through our Urban Indian Health Institute, which we created in

2000, which is a research arm that we created, we have been able

to finally document for the first time the fact that there are significant health disparities among the urban Indian population. That

38

information has helped us, I believe, to interact with other agencies

of the Federal Government including the CDC and the NIH and

others to try to get them to recognize the fact that this is a population of people with severe health disparities that have not been

engaged in a lot of the health disparities initiatives around the

country. The majority of those resources have gone to larger ethnic

populations, primarily Hispanic and black populations, which have

great needs for those kinds of services and there is an assumption

that the Indian Health Service is taking care of the needs of Indian

people so therefore Indian people that are not directly under the

auspices of the Indian Health Service are oftentimes left out of that

debate and so one of the initiatives that we tried to do through the

Institute was to document this information, get this information in

the hands of policymakers in hopes that that would translate into

resources for our population.

The Urban Indian Health Program has also received a lot of resources from sources other than the Indian Health Service itself.

In fact, we believe that we leverage about two to one the amount

of resource that we get from the Indian Health Service for outside

resources, primarily from local, State and other Federal programs

and some private dollars. My organization, for example, the Indian

Health Service resource that we get represents about 31 percent of

our financing. The rest of it comes through a variety of different

programs. I think we are managing somewhere around 35 or 40

different grants and contracts in a given year, so as you can tell,

that takes an awful lot of administrative time and overhead as well

as somebody was talking earlier about IT. Having a fairly comprehensive technological base to the work that you do is critically

important in our operations in order to be able to manage both the

numbers as well as the finances of those kinds of organizations to

be able to report appropriately.

The urban Indian population is a very diverse population. We

serve enrolled members of federally recognized tribes, which is a

significant portion of the people that we see who are living in cities. We also see members of State-recognized tribes. There are 41

States in the country that recognize Indian tribes. I believe there

is one in New Jersey. There are descendants of early Indian people

who were displaced as a result of adoption back in the early part

of the 1920’s and 1930’s. It has been very interesting for me to find

a lot of Indian people living in Seattle who know that they were

Indian but didn’t grow up in that kind of environment, and one of

the things that we work with, believe it or not, is the Mormon

Church, who has a very big genealogical center in Seattle, as well

as the archives in Seattle, the local archives, to help people try to

link themselves back to their native culture, and it is amazing to

me in terms of just this idea of health promotion and health improvement how getting people linked back to their heritage has

such a profound effect on their mental health, recognizing the fact

that they are native and they truly are native and then having that

linked somehow to some kind of documentation is an amazing

thing to witness. There is also a growing number of Indian people

who we serve who are Indians of mixed race or of mixed tribal

background who are not eligible necessarily for services at their

tribal reservation sites anymore, and those individuals are native

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people who also deserve and need assistance, and that is something

that the urban Indian programs can provide.

Indians in most metropolitan areas are geographically dispersed.

They don’t live in one particular community so doing the work that

we do is very challenging because we are having to do a lot more

of the outreach that you were talking about earlier, a lot more case

finding. We do a lot of cultural events in the community as a way

of kind of gathering people together so we can communicate with

them about the needs that they might have, and at those events

we often do health screenings and other kinds of activities in order

to be able to gauge where the people are at and hopefully focus

them on services.

As you know, the Indian Health Service primarily serves Indians

that live on and near reservations, which we think is an appropriate role for them. Title V was intentionally created as a way of

providing core resources and core assistance to local Indian communities so that they could organize themselves in order to be able to

develop health services, and that is exactly what we have done. I

think that the contribution that the Congress makes of $34 million

to the urban Indian programs is a very wise investment. I think

that we have been able to leverage those resources and provide a

comprehensive set of services in many cities around the country

that would not be possible without the help of the Indian Health

Service being that foundation on which to build

As you know, the Bush administration has been trying to zero

out the Urban Indian Health Program and I really wanted to take

the opportunity to recognize the leadership of Congresswoman Wilson from New Mexico. She and our Congressman from Seattle, Jim

McDermott, took a leadership role in authoring a letter to get that

money reinstated and we are very fortunate that it was done for

the 2007 year. And Mr. Dicks also from Washington State has been

very generous in making sure that that funding continues for the

2008 year.

We also really believe that the Urban Indian Health Program, as

has been stated on several occasions here today, really has

amassed an understanding and a knowledge of the urban Indian

community——

Mr. PALLONE. I was so interested in what you were saying that

I didn’t realize you are 3 minutes over so you have to wrap up.

Mr. FORQUERA. I will wrap up.

Mr. PALLONE. All right.

Mr. FORQUERA. Basically I just wanted to say that the urban Indian programs have really amassed an awful lot of information and

knowledge about the urban Indian communities and know how to

serve those communities better than anybody, and even if they

weren’t, even if the community health centers could step forward

and provide the services, they really couldn’t provide the cultural

and the connectedness that I think is necessary to engage the people in the health care process and I think that that is the real key

to our work.

Thanks for the opportunity to be here. I appreciate your inviting

me.

[The prepared statement of Mr. Forquera follows:]

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Mr. PALLONE. Mr. Lucero.

STATEMENT OF KEN B. LUCERO, PUEBLO OF ZIA

Mr. LUCERO. Good morning and thank you, Chairman Pallone,

Ranking Member Congressman Deal, and members of the Subcommittee on Health. My name is Ken Lucero and I am a councilman from the Pueblo of Zia. I am here on behalf of the men,

women and children of Zia Pueblo and the All Indian Pueblo Council. I would like to thank Congresswoman Wilson for her invitation

to address the subcommittee of the Energy and Commerce committee. Her recognition of the need for the Pueblo Nations in New

Mexico to articulate their needs concerning health care is greatly

appreciated. Thank you on behalf of the Pueblo of Zia and the All

Indian Pueblo Council.

My message is simple. The Indian Health Care Improvement Act

must be amended and reauthorized in order to bring the Indian

health system into the 21st century. The Act expired in fiscal year

2000 and since then American Indian and Alaskan Native leaders

have petitioned Congress to reauthorize the Act so that Indian

health care may be modernized and disparities in Indian health

can be positively addressed. Tribal leader after tribal leader has

come before you to bare their souls and share the tragedies endured by their people and yet the requests have not been granted,

so today I add my voice to those honorable tribal leaders that have

come before me in calling for the reauthorization of the Indian

Health Care Improvement Act.

In 2003, the U.S. Commission on Civil Rights issued ‘‘A Quiet

Crisis: Federal Funding and Unmet Needs in Indian Country.’’

This report highlighted the Federal Government’s failure to provide

adequate funding and meet trust obligations. Among the Commission report’s findings, Native Americans are 318 percent more likely to die from diabetes, 630 percent more likely to die from alcoholism and 658 percent more likely to die from tuberculosis. Members

of the committee, these statistics are gathered from tribal communities. These are our grandparents, our grandchildren, mothers and

daughters, fathers and sons. These statistics are real.

I understand that it is difficult for this committee and your fellow members of Congress to identify with the stories and the data

buried in the mountains of testimony provided on behalf of this

Act. So for just a minute, I would like for you to pretend that the

House of Representatives is a pueblo in New Mexico and that the

Senate represents the groups of other Americans. Picture your fellow lawmakers as members of your community. You are all somehow related and you view each other as a large extended community. How would this report affect your community? In the case of

diabetes, if one Senator died from complications of the disease, you

could expect 14 of your members to also die from diabetes. If one

Senator died from alcoholism, 27 of you are expected to do the

same within your membership. And finally, if one member of the

Senate dies from tuberculosis, 28 of your colleagues will meet the

same fate. I think this room would look much the same if that were

to be the case as it does now.

If this committee can keep this example in mind while listening

to my testimony and the testimony of the rest of the panel today,

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I hope that Congress can gain a better appreciation for the urgency

of our message. In New Mexico, the State’s 205,000 Native Americans have the highest rates of death for diabetes, alcoholism, pneumonia and influenza. Our children suffer the highest rates of behavioral health risks such as substance abuse, smoking, illicit drug

use and obesity and the five major regions for outpatient care at

IHS facilities are diabetes, respiratory infections, hypertensive disease, well-child care and prenatal health care. With such a demand

for the important health care services, it is disheartening to report

that the IHS health care programs are being ended completely or

being drastically reduced. Santa Fe Indian Health Service no

longer provides birthing services. The Albuquerque Indian Health

Services are severely limited due to the lack of adequate funding,

as the Congresswoman Wilson knows very well.

Now, while full and adequate Federal funding is extremely important, it is also important that the United States provide the

quantity and quality of health services which will permit the

health status of Indians to be raised to the highest possible level

and to encourage maximum participation of Indians in the planning and management of their health care services. H.R. 1328 will

pave the way and redefine the existing health care delivery system

for American Indians and Alaska Natives and to bring that health

care system into the 21st century.

In conclusion, the Indian Health Service services 1.8 million federally recognized American Indians and Alaskan Natives. The 1.8

million represents less than 1 percent of the United States population. Now, with this comparatively small service population, the

Indian Health Service should be the gold standard of health care

in the United States. The potential is there. Through the combined

efforts of tribes, Congress and the executive branch, we can provide

serious, meaningful benefits to Indian Country and to this country

as a whole.

Mr. Chairman, members of this committee, I strongly encourage

you to take this opportunity to raise the standards of health care

provided by the Indian Health Service and to begin the work to ensure that American Indians receive the best possible health care.

I ask that the committee for unanimous support of H.R. 1328 and

passage at the earliest possible date. Thank you.

[The prepared statement of Mr. Lucero follows:]

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Mr. PALLONE. Thank you.

Ms. Joseph, thank you for being here.

STATEMENT OF RACHEL A. JOSEPH, CO-CHAIR, NATIONAL

STEERING COMMITTEE FOR THE REAUTHORIZATION OF

THE INDIAN HEALTH CARE IMPROVEMENT ACT; NATIONAL

INDIAN HEALTH BOARD

Ms. JOSEPH. Good afternoon, Mr. Chairman, members of the subcommittee. I am Rachel Joseph, co-chair of the National Steering

Committee for the Reauthorization of the Indian Health Care Improvement Act. I am also testifying on behalf of the National Indian Health Board, a national Indian organization that advocates

health issues on behalf of all Indian tribes. Thank you for this opportunity to testify in support of H.R. 1328.

In 1999, the director of the Indian Health Service established the

National Steering Committee comprised of tribal representatives

from across the country and the national health organizations.

Since then the steering committee and the National Indian Health

Board have led reauthorization efforts, have accommodated administration and congressional concerns through endless compromises

and reached consensus on key policy issues. We are guided by the

principle of no regression from current law and protection of tribal

interests. As you are aware, we will continue with that effort this

afternoon when we meet with congressional staff to address facilities issues in section 301. As Congresswoman Heather Wilson articulated, we have not had the opportunity to update our reauthorization for over 14 years. Modernization is essential for our health

care systems.

Indian tribes ceded over 400 million acres of land based on government promises including promises of health care. The U.S. Commission on Civil Rights in its 2003 report ‘‘A Quiet Crisis’’ found

that the Federal Government has not lived up to its promise to provide adequate health care. The U.S. Commission on Civil Rights in

its 2004 report ‘‘Broken Promises’’ evaluating the Native American

health care system, found tremendous disparities as already articulated by Congresswoman Hooley. The travesty in our health conditions is knowing that the majority of illnesses and deaths from disease are preventable. Additional funding and contemporary programmatic approaches are necessary.

One of the key provisions in H.R. 1328 is the elevation of the Indian Health Service director. We believe an assistant secretary is

essential to advocate for health care issues and certainly budget increases. In 2007 at consultation, tribal officials implored HHS officials to be an advocate, and there was no response, and so we feel

that there was no commitment and the plea falls on deaf ears. We

feel that an assistant secretary would be a point to oversee. For example, the issue related to regulations implementing section 506

from the Medicare Modernization Act of 2003 languished in the Department for years and just this week those regulations were published. We believe the regs bounce back and forth between IHS,

CMS and HSS because of lack of ownership by someone for the regulation. We strongly support the behavioral health programs.

Mr. Chairman, I appreciate your question to the administration

about when we might see their views. I quickly reviewed their tesVerDate 11-SEP-98 09:38 Oct 08, 2008 Jkt 000000 PO 00000 Frm 00067 Fmt 6633 Sfmt 6633 Q:\DOCS\110-54 SCOM1 PsN: SCOM1
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timony this morning and their objection to section 712 in the behavioral health just astounds me, and we would appreciate any assistance you can give us to get a grip on what their objection is.

Tribal leadership felt strongly because of the substance abuse epidemic in our communities that we needed to address fetal alcohol

disorders and just one excerpt from that is to develop, print and

disseminate education and prevention materials on fetal alcohol

disorders. We have a hard time understanding what the objection

to this authorization is, so your assistance will be greatly appreciated.

The issue related to ‘‘shalls’’ and ‘‘mays’’ it seems to me that the

testimony is somewhat outdated. We made a commitment to scale

back ‘‘shalls’’ and ‘‘mays’’ and the only new ‘‘shalls,’’ and I believe

there is two is something that congressional staff supported and

felt needed to be included in the bill and we agree with that.

The issue of funding in place of grants, that was addressed a couple of generations ago in updating and addressing concerns. So we

will do anything we can to work with you, other Members of Congress and the administration. We met with Laura Ott on April 17.

Laura is the Deputy Assistant Secretary for Health Legislation and

respectfully requested that we see their views before the markup

in the Senate Indian Affairs Committee which has already been

done on May 10 and reported unanimously or reported out. We

think that because of the tremendous disparity in health care indicators we need to get this reauthorization soon.

Last year one of our respected and esteemed colleagues, Dr. Taylor Mackenzie, former president of the Navajo Nation, who served

on the steering committee with us from the very beginning, in his

drive and effort to keep us encouraged, leaned over and he said,

‘‘Rachel, do you think this will pass in our lifetime?’’ and we chuckled. It is not funny anymore. We lost Dr. Mackenzie a couple

months ago. So to us, the challenges of providing health care are

always present and always constant. Our proposal to provide assisted living long-term health care to our elders is essential. Tribal

leaders feel strongly about having to send our grandparents and

our aunties and uncles so far away from the reservation to receive

necessary health care and certainly limited visitation opportunities

for families. We think this kind of modernization and update is essential and certainly what is provided in other communities in our

country.

Thank you for your efforts on our behalf, and we stand willing

and able to do anything we can to move this legislation this year.

Thank you again for this opportunity.

[The prepared statement of Ms. Joseph follows:]

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Mr. PALLONE. Thank you so much. I am going to start with questions from myself and I have one question for each of you and I

have 5 minutes, so I am going to try to be brief here.

I wanted to ask Mr. Crouch, first of all, I know and I think everyone knows that pursuant to the trust responsibility, theoretically you shouldn’t be paying anything. There shouldn’t be any copays, any premiums, any contribution—I guess one could argue—

from the tribes at all because the obligation of the Federal Government from the way I understand it; is that the trust responsibility

is 100 percent to pay for health care. But we know that is not the

reality but that should be the reality. So I just wanted to ask you,

Mr. Crouch, about the co-pays. In the bill there are no Medicaid

co-pays or anything of that nature. What are the consequences of

having co-pays or expenditures for Medicaid specifically? What are

the consequences out there right now because that is the case?

Mr. CROUCH. The consequences of the co-pays, it is a barrier to

care. You already have barriers to care that are based on geography, people traveling further. You have barriers to care being on

the poverty and the cost of providing that transportation. When

you have premiums and co-pays, you are adding another barrier to

prevent access to care. What I tried to show in my numbers was

that we have already documented under-access to care, low access

to care for a population whose health status is well documented as

being very poor. It is sort of like having—if Indian health was a

fire, you would want to put the hose right where the fire is. The

low health status is on flame, creating barriers so the fire truck

can’t get there. The patient can’t get to the service. The clinic can’t

provide the service. It doesn’t make sense.

Mr. PALLONE. All right. I appreciate that. I am just trying to

move on.

Mr. CROUCH. Sure.

Mr. PALLONE. Mr. Forquera, you talked about contributions from

outside the Federal Government. I have been to some of the reservations where because they may have a little money, they actually have to build the complete facilities from scratch, which again

I think is not right. Just comment a little bit on what the tribes

themselves have had to contribute on their own. You mentioned

State and maybe others but a lot of cases the tribes themselves are

contributing significant amounts of resources to health care. How

extensive is that?

Mr. FORQUERA. For the urban programs or just——

Mr. PALLONE. No, just in general.

Mr. FORQUERA. In general, I don’t know off the top of my head,

but I would venture to say that more and more of the tribes are

having to pick up more and more of the cost of health care because

the appropriations dollar just isn’t maintained, and those tribes

that have the luxury of having a few resources available to them

I think are making those contributions. I know some of the tribes

in California have certainly invested in facilities and other kinds

of things. The question becomes one of the use of those resources

for the health care which should be taken care of, and the fact that

there are other needs on those reservations that should be taken

care of and where do you prioritize your dollar. Health care fortunately for most of us is seen as one of those fundamental resources

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that are necessary and so I think that people tend to want to

prioritize that, and I know a lot of the tribal communities are doing

so.

Mr. PALLONE. And they really shouldn’t have to.

I wanted to ask Mr. Lucero, we really haven’t had much testimony about the negative impact of not reauthorizing. Do you just

want to comment briefly on the fact that we keep waiting to reauthorize this bill? What are the negative impacts of the fact that we

haven’t done the reauthorization for 7 years? And you only have a

minute, but——

Mr. LUCERO. OK. Well, I think the biggest impact is that we are

not able to move into the 21st century. A lot of the programs have

been held in shackles—that is the only thing I can think of right

now—and they are not able to expand or to implement innovative

ideas. One of the questions you asked about facilities is, tribes are

being forced to go to the State and fortunately in New Mexico we

have a good working relationship with the State and so we have

been appropriated funds by the State to assist in building facilities.

We are interested in participating with IHS, which is section 310,

IHS tribal joint venture, and that is one of the programs that is

within the Indian Health Care Improvement Act that the reauthorization will also assist with innovative ideas and moving into telehealth and new modern means of providing health care.

Mr. PALLONE. All right. Thank you.

And then Ms. Joseph, I know we could talk all afternoon. I wanted to ask you about the lack of providers available to Native Americans and the need for innovative solutions such as the community

health aid program. In the Resources Committee, I was amazed

when the gentleman said that there were only 400 or 500 Native

American doctors in the country. I couldn’t believe that. Do you

just want to comment on what we should be doing to address the

fact that there aren’t enough Native American providers, whether

it be doctors, nurses and what to do about that?

Ms. JOSEPH. Thank you, Mr. Chairman, for that question, because I wanted to make a comment on Ranking Member Deal’s

question about the community health aid program. I will just take

you back a little bit. For whatever circumstances, there were times

in our lives—use me, for example. I had an uncle who had an extracted tooth—my mom was sweet and kind and just couldn’t deal

with that—with a pair of pliers and an auntie tied another tooth

to a string, do the old open the door thing and pull that. In Alaska

in some communities, a dentist only comes once a year. Hopefully

it is once a year. And through the community health program, and

extensive at least 2-year training, we provide opportunities for

emergency care to be provided under the supervision of a dentist.

That particular language authorizing that or at least clarifying

that was addressed. The concerns raised by I think Congressman

Norwood and the American Dental Association was addressed before the bill was marked up and reported out of the Resources

Committee last year and that compromise was facilitated by Congressman Don Young. So through the opportunity to provide creative ways of providing health care through telemedicine and other

ways is one way and we certainly look toward some of those innovative approaches in the reauthorization.

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Mr. PALLONE. OK. Thank you. Mrs. Wilson.

Mrs. WILSON. Thank you, Mr. Chairman.

Mr. Lucero, thank you again for being here. You mentioned in

your testimony that the Santa Fe hospital is no longer providing

OB/GYN services, and of course, you also mentioned cutbacks in

the Albuquerque and Santa Fe areas. I wonder if you could expand

on that and particularly what does that mean for a family in

Nambay? Where do they get their OB/GYN care, if they can’t get

it at the Santa Fe Indian Hospital?

Mr. LUCERO. As far as where they are getting their OB/GYN, I

think a lot of what is happening is, they are being referred to the

St. Vincent’s Hospital there in Santa Fe and are relying on contract

health services, and again, we all know and have testified about

the lack of funding in contract health services and that everybody

is on a priority one, and so a lot of those dollars have to go or are

taken away from other services to provide that when in fact they

should be provided through the hospital clinics in the Santa Fe

service unit.

Mrs. WILSON. Would you like to expand at all on the funding

issues in Albuquerque and Santa Fe and what you are seeing?

Mr. LUCERO. Yes, please. There was testimony offered by Senator

Jeff Bingaman before the Senate Finance Committee on March 22

and he indicated about how over the years that the Medicaid and

Medicare funding has continued to increase and per capita spending had grown nearly $8,000 through Medicare and $4,500 through

Medicaid while the IHS national average for funding remained almost flat at $2,100. Now, in the Albuquerque area, those funding

disparities are even greater. It would take an additional $48 million to achieve even the IHS national average of $2,130, and if Congress were to bring the Albuquerque up to the U.S. average per

capita for health expenditures, which is $6,423, it would require an

additional $380 million in order to even get us up to that level. So

those are kind of the numbers that we have available.

Mrs. WILSON. Ms. Joseph, a question for you on health education.

Are there things that we can do either in the—as I understand it,

there is a medical education program and there may be some caps

on slots for, I think it is referred to as GME, in the Medicare or

Medicaid programs. Are there changes to that program that we can

make to increase the number of doctors who might be allowed to

practice out in Indian Country or is the IHS able to tap into that

pool of doctors under the GME program? Are you aware of that at

all?

Ms. JOSEPH. I am not sure if they can tap into it or not but definitely if we can, we should. We can look into that because it seems

to me we are always recruiting. There is a tremendous shortage of

doctors and nurses in particular.

Mrs. WILSON. Because I have heard that there is some kind of

a barrier there that makes it more difficult for residents to practice

out in Indian Country, and if there is and there is a way to fix

that, then I think we should and I would certainly appreciate your

input on that. And finally, Mr. Crouch, I did have a question for

you on telemedicine. I understand that there are some projects in

California on telehealth and telemedicine and I wonder if you

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ion on whether the telehealth provisions in this bill might help facilitate an improved telemedicine network in the IHS.

Mr. CROUCH. Those provisions would be helpful. If you think

about California Indian Country, basically it is four times larger

than Navajo but it has about one-eighth the population spread over

that geography so it is very thinly distributed from the north of the

State all the way to the south, so it covers the entire State. The

Telemedicine Program that started initially with some philanthropic funds is often the case in California. The Indian Health

Service is working with a number of tribal health programs where

they are doing some I believe entry-level work, first starting out

with diagnosing retinopathy in the eye with cameras, now moving

into issues around dermatology and psychiatry. All of those are

services that are easily sort of set up. Telemedicine is much more

expansive in use in other areas such as Alaska and the Phoenix

area is actually working on a project that would cover a lot of Arizona and Nevada. It does have promise. The fact that those services are billable through Medicaid is very critical to those services

being continued because the Indian Health Service is indeed underfunded.

Mrs. WILSON. Thank you, Mr. Chairman.

Mr. PALLONE. I know a vote has been called so we are going to

have to end, but I did want to ask a couple things and then if the

gentlewoman from New Mexico would like to add something, she

could, and then we are going to have to end because we have some

votes.

Mr. Crouch, these Medicaid citizenship documentation requirements that were in the Deficit Reduction Act last year that says

that States are prohibited from receiving Federal Medicaid reimbursement for individuals who have not provided documentation.

Ms. Schakowsky got into it a little bit. Current Medicaid practice

states that tribal documents from only five tribes are acceptable

proof of citizenship but now we have this provision in the bill that

changes that. Would you comment on whether you think that is

going to address this problem sufficiently, what we put in the bill?

Mr. CROUCH. The bill language is superior to what is the case as

we speak. When the new requirement to document citizenship

came down, it seems almost oxymoronic that proof of tribal membership would suffice for this really low level need of documentation. I am a member of the CMS KTAG. We have had extensive

review of this issue and the reality is that there are five tribes that

have been granted over through history the opportunity to document citizenship. The rules that they follow don’t exist. In other

words, the rules at CMS that expects them to standards, I guess,

whatever, CMS can’t define, cannot find. Our language in the bill

would make it clear that proof of tribal membership would be proof

of citizenship, and for those tribes that do exist on borders but do

have members who are not citizens, the Secretary would work with

them to develop additional criteria so that those portions of their

tribes would be identifiable to Medicaid and therefore not receive

services.

Mr. PALLONE. So like use the Tohono Odham, in other words,

that language isn’t going to help the guys that are in Mexico——

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Mr. CROUCH. It depends on how the Secretary rules. So I guess

if you think about this rule coming down at a later date, one would

only guess how it might change. Currently, the citizens of Tohono

Odham, who are not citizens of the United States because of their

residence on the reservation but south of the border would be excluded because they would not be able to document citizenship.

Mr. PALLONE. They have the option of becoming citizens though,

right? They have that right?

Mr. CROUCH. Sure.

Mr. PALLONE. But they still because they’re not citizens would

not be eligible?

Mr. CROUCH. The Tohono Odham existed exactly where it is before the Gadston purchase. If you look at a map of Arizona from

about 1880——

Mr. PALLONE. I know the history a little bit but what I am saying is, the problem is, even though they have a right to citizenship,

and they are federally enrolled with the Interior Department, because they are not citizens, they are still not eligible because of the

Act. Is that the way you read it?

Mr. CROUCH. The way I read it right now, they would not be eligible, and if the bill passed, it is possible that they would be eligible not as—they wouldn’t be made citizens but they would be

eligibilized for Medicaid.

Mr. PALLONE. They would be?

Mr. CROUCH. Yes.

Mr. PALLONE. All right. So the way you read this bill, we would

be able to correct all these situations that have come up as far as

we know?

Mr. CROUCH. As I read the bill as a member of KTAG, we firmly

support this language.

Mr. PALLONE. All right. Thank you very much. I know we are always in a rush around here and it was important that we have the

hearing today because we do want to move to markup and so I

know it has been expedited somewhat but it is better that we at

least did it, and I think we got some answers and hopefully we will

get some more, and we do intend to move to markup as quickly as

we can. Thank you very much and I appreciate all of your being

here. If you have additional responses to our questions or things

you want to put in the record, please do so. We will certainly take

that letter. And I appreciate you all being here, and we will adjourn the hearing. Thank you.

[Whereupon, at 1:40 p.m., the subcommittee was adjourned.]

[Material submitted for inclusion in the record follows:]

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