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44–280—PDF 2007

S. HRG. 110–520

KEEPING AMERICA’S PROMISE:

HEALTH CARE AND CHILD WELFARE

SERVICES FOR NATIVE AMERICANS

HEARING

BEFORE THE

COMMITTEE ON FINANCE

UNITED STATES SENATE

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

MARCH 22, 2007

(

Printed for the use of the Committee on Finance

COMMITTEE ON FINANCE

MAX BAUCUS, Montana, Chairman

JOHN D. ROCKEFELLER IV, West Virginia

KENT CONRAD, North Dakota

JEFF BINGAMAN, New Mexico

JOHN F. KERRY, Massachusetts

BLANCHE L. LINCOLN, Arkansas

RON WYDEN, Oregon

CHARLES E. SCHUMER, New York

DEBBIE STABENOW, Michigan

MARIA CANTWELL, Washington

KEN SALAZAR, Colorado

CHUCK GRASSLEY, Iowa

ORRIN G. HATCH, Utah

TRENT LOTT, Mississippi

OLYMPIA J. SNOWE, Maine

JON KYL, Arizona

CRAIG THOMAS, Wyoming

GORDON SMITH, Oregon

JIM BUNNING, Kentucky

MIKE CRAPO, Idaho

PAT ROBERTS, Kansas

RUSSELL SULLIVAN, Staff Director

KOLAN DAVIS, Republican Staff Director and Chief Counsel

(II)

C O N T E N T S

OPENING STATEMENTS

Page

Baucus, Hon. Max, a U.S. Senator from Montana, chairman, Committee

on Finance ............................................................................................................ 1

Grassley, Hon. Chuck, a U.S. Senator from Iowa ................................................. 3

WITNESSES

Venne, Carl, chairman, Crow Nation; chairman, Montana/Wyoming Tribal

Leaders Council; and president, Council of Large Land-Based Tribes, Crow

Agency, MT ........................................................................................................... 4

Davidson, Valerie, Esq., senior director, Legal and Intergovernmental Affairs,

Alaska Native Tribal Health Consortium, Anchorage, AK ............................... 7

Holt, Linda, secretary, Suquamish Tribal Council and chair, Northwest Portland Area Indian Health Board, Suquamish, WA ............................................. 9

Bear King, Connie R., enrolled member, Standing Rock Sioux Tribe and

Government Affairs Associate, National Indian Child Welfare Association,

Portland, OR ......................................................................................................... 12

ALPHABETICAL LISTING AND APPENDIX MATERIAL

Baucus, Hon. Max:

Opening statement ........................................................................................... 1

Bear King, Connie R.:

Testimony .......................................................................................................... 12

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

Bingaman, Hon. Jeff:

Prepared statement .......................................................................................... 35

Davidson, Valerie, Esq.:

Testimony .......................................................................................................... 7

Prepared statement .......................................................................................... 38

Response to a question from Senator Bingaman ........................................... 48

Grassley, Hon. Chuck:

Opening statement ........................................................................................... 3

Holt, Linda:

Testimony .......................................................................................................... 9

Prepared statement .......................................................................................... 51

Responses to questions from Senator Bingaman ........................................... 62

Smith, Hon. Gordon H.:

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

Venne, Carl:

Testimony .......................................................................................................... 4

Prepared statement .......................................................................................... 67

COMMUNICATIONS

Child Welfare League of America (CWLA) ............................................................ 79

Forman, Jonathan Barry ........................................................................................ 84

National Indian Health Board (NIHB) .................................................................. 102

(III)

(1)

KEEPING AMERICA’S PROMISE:

HEALTH CARE AND CHILD WELFARE

SERVICES FOR NATIVE AMERICANS

THURSDAY, MARCH 22, 2007

U.S. SENATE,

COMMITTEE ON FINANCE,

Washington, DC.

The hearing was convened, pursuant to notice, at 10:06 a.m., in

room SD–215, Dirksen Senate Office Building, Hon. Max Baucus

(chairman of the committee) presiding.

Present: Senators Bingaman, Salazar, Grassley, and Thomas.

OPENING STATEMENT OF HON. MAX BAUCUS, A U.S. SENATOR

FROM MONTANA, CHAIRMAN, COMMITTEE ON FINANCE

The CHAIRMAN. The hearing will come to order.

A chief and Indian wise man named Shinguaconse once respectfully addressed a government official, and he said, ‘‘My father, you

have made promises to me and to my children. If the promises had

been made by a person of no standing, I would not be surprised to

see his promises fail. But you, who are so great in riches and

power, I’m astonished that I do not see your promises fulfilled.’’

We would be ashamed if Shinguaconse were here today. America

is great in riches and power, but our health care promises to America’s original inhabitants remain unfulfilled.

In 1976, Congress made promises when it passed the Indian

Health Care Improvement Act, known as IHCIA. IHCIA provided

critical funding and improvements to ensure that our Nation’s first

people get access to health care.

But for the last 13 years, Native Americans have been waiting

for Congress to fulfill these promises. For the last 13 years, we

have seen Congress fail to reauthorize the law. As a result, the current funding level for the Indian Health Service system is only 52

to 60 percent of the need. That means that, in any given year, by

the month of June, the only patients who can receive treatment in

Indian Health Service hospitals are those with conditions that

‘‘threaten life and limb.’’

Listen to the story of one 25-year-old Native American, a veteran

of the Gulf War. He was diagnosed with a problem that required

removal of his gall bladder. Now, gall bladder removal has become

a pretty routine procedure. But this young man could not be referred for surgery in an Indian Health Service hospital. His condition did not ‘‘threaten life or limb,’’ so he had to wait.

2

So his gall bladder became inflamed. His kidneys and other organs shut down. Because of this needless delay, he will be on dialysis for the rest of his life. We can trace that result back to a lack

of adequate funding for his care.

Listen to some other results of inadequate health care funding in

Indian country: Native Americans younger than 25 years of age die

at a rate three times of that nationwide; Native Americans are

three times more likely to die in accidents; Native Americans are

four times more likely to die from diabetes; and Native Americans

are 7.5 times more likely to die from tuberculosis.

As well in Indian country, methamphetamine abuse is at an alltime high, so today we will also examine the links between substance abuse and the tribal child welfare system. In Montana, twothirds of child welfare cases are related to substance abuse, primarily meth.

The child welfare system is also languishing because of inadequate funding. The system also suffers from a lack of culturally

appropriate approaches to help tribal children find loving, permanent homes.

I am proud to have worked last year with Senator Grassley, Senator Rockefeller, Senator Hatch, and Senator Snowe to pass the

Child and Family Services Improvement Act of 2006.

This act provides $140 million over 5 years to fund competitive

grants to encourage collaboration and innovation across the country. These grants will help families to heal from addiction and

these grants will help to keep children from entering the child welfare system.

There is still much work to do. More than a third of foster children in Montana are Native American. Across America, most of the

Native American children in foster care are under the jurisdiction

of tribal courts. But Native American tribes that administer their

own child welfare systems are not eligible for title IV–E funds to

run their programs.

We also need to think creatively about allowing children and loving family members the option of subsidized guardianship. Nearly

20,000 foster children who cannot return to their parents have

found safe, permanent homes with relatives.

We owe the first inhabitants of this great Nation medical care

consistent with the medical care found in mainstream hospitals

and clinics. We also owe their children a child welfare system that

works for them. We must do all we can to help provide that help.

Last year, Congress came close to reauthorizing IHCIA. Three

committees favorably reported bills. The Finance Committee, in a

bipartisan effort, yielded the ‘‘Medicare, Medicaid and SCHIP Indian Health Care Improvement Act of 2006.’’ So, this year let us

complete the job.

Let us heed the call of Shinguaconse. Let us act like a Nation

‘‘great in riches and power,’’ and let us fulfill our health care promises to the first Americans, and to the children.

Senator Grassley?

3

OPENING STATEMENT OF HON. CHUCK GRASSLEY,

A U.S. SENATOR FROM IOWA

Senator GRASSLEY. Thank you very much. I thank the Chairman

for calling this meeting and reflect upon the hard work that we did

on similar legislation last year that got out of this committee

unanimously.

We spent a long time working with the Committee on Indian Affairs to get it out, and it was all done in a bipartisan way, and I

think we will continue that same way this time.

I want to also, Mr. Chairman, recognize Ms. Bear King, who is

not from Iowa right now, but has had Iowa connections for a long

period of time. I want to recognize her and welcome her here, as

well as the other witnesses.

In 2003, the Commission on Civil Rights reported that ‘‘American

Indian youths are twice as likely to commit suicide, 630 percent

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

from tuberculosis, 318 percent more likely to die from diabetes, and

204 percent more likely to suffer accidental deaths compared with

other groups.’’

Yet, with the Indian Health Service and tribal health care delivery sites funded at less than 60 percent of the cost of providing

health care to their patients, we are not doing enough to close the

gap on the health disparities faced by Native Americans. The answer is for us to pass, then, the bill already referred to: the Indian

Health Care Improvement Act.

Last year, the Finance Committee passed the Medicare, Medicaid

and SCHIP Indian Health Care Improvement Act. The bill contained the provisions of the larger Indian Health Care Improvement Act that were in the Finance Committee’s jurisdiction.

That legislation allowed the tribes to use money from Medicare

and Medicaid to maximize improvement of their health care. That

legislation provided increased outreach for Indian tribes to assist

Native Americans in applying for Medicaid and SCHIP.

In addition, the legislation that was reported last year provided

relief for Indians for Medicaid cost sharing or premiums, if that Indian comes to Medicaid by contract or referral from the Indian

Health Service.

Our legislation last session required reporting of data, the status

of their health care, and efforts being made to upgrade facilities

that may not be in compliance with the Social Security Act. There

were valuable reporting requirements that would aid us then in the

future to ensure that we are providing quality care to Native Americans.

The Indian Affairs Committee has started the process through

the legislation introduced there for this Congress. I know, working

with Chairman Baucus, that we are committed to moving our bill

through the Finance Committee again this session. As he knows,

I look forward to working with him.

I also look forward to efforts to continue the bipartisan work on

improvements to the child welfare system. I recognize the importance to tribes of being able to apply directly to HHS for foster care

funds. I have supported similar provisions in the past, and I am

also interested in kinship care.

4

I am pleased that my State of Iowa has approved a waiver that

supports subsidized guardianship. While I am mindful of the fiscal

constraints and the needs to address the overall issue of child welfare financing, I am supportive of efforts to more broadly subsidize

family guardianships.

We have an important agenda to accomplish in this committee

when it comes to welfare issues generally, and specifically Indian

health today. It is good that we are having this hearing to start

this process again, and I think it will be an easier process this

time.

The CHAIRMAN. I think so. Right. Thank you, Senator Grassley.

I would now like to introduce our witnesses. First, I am very

proud to introduce the chairman of the Crow, Chairman Carl

Venne. Chairman Venne is also chairman of the Montana/Wyoming

Tribal Leaders Council, and president of the Council of Large

Land-Based Tribes.

I do not know your name, Mr. Chairman, in native Crow, but I

do know, translated to English, it means One Who Crosses the Big

River and Becomes a Leader. I think that is very apt for you. You

come back to Washington many times. I do not know a tribal leader who works harder for his people than you. We see you many

times. I just want, personally, to tell you how much I deeply appreciate your deep commitment to your people.

We will also hear from Valerie Davidson. Ms. Davidson is senior

director of Legal and Intergovernmental Affairs at the Alaska Native Tribal Health Consortium based in Anchorage, AK. Welcome,

Ms. Davidson. You have traveled a long way to come here.

Next, Ms. Linda Holt. She is secretary of the Suquamish Tribal

Council and legislative liaison to the State and Federal Governments. The Suquamish Tribe is located, of course, in the State of

Washington and is the tribe of the great Chief Seattle.

Finally, Connie Bear King. Ms. King is an enrolled member of

the Standing Rock Sioux Tribe and also the Government Affairs

Associate for the National Indian Child Welfare Association. Ms.

Bear King is from Sioux City, IA. Thank you very much.

Chairman Venne, you are first.

STATEMENT OF CARL VENNE, CHAIRMAN, CROW NATION;

CHAIRMAN, MONTANA/WYOMING TRIBAL LEADERS COUNCIL; AND PRESIDENT, COUNCIL OF LARGE LAND-BASED

TRIBES, CROW AGENCY, MT

Mr. VENNE. Thank you. Good morning, Chairman Baucus, Vice

Chairman Grassley, and honorable members of the Senate Finance

Committee. I am Carl Venne, chairman of the Crow tribe, chairman of the Montana/Wyoming Tribal Leaders, and president of

Large Land-Based Tribes.

I am honored to be here today to provide testimony on the critical need to adopt the Indian Health Care Improvement Act. The

Council of Large Land-Based Tribes is a national organization of

tribes with land bases of over 100,000 acres.

The large land-based tribes continue to suffer from traditional

Indian reservation issues, including poverty, high unemployment,

joblessness, lack of housing, and, most critically, substandard

health care.

5

While the discussion about the Indian Health Care Improvement

Act continues, I would like to tell you real-life stories about the impact of substandard, deplorable health care on my home reservation.

One of the stories is, a little Crow girl was diagnosed with a rare

cancer in one eye at age 5 months. She had to have the eye removed and have an artificial eye that must be replaced as she

grows. She is now 5 years old and needs a new artificial eye.

But because it is not a life-or-limb illness, Contract Health Service will not approve of the cost for the eye. Her parents both recently became employed and make just enough to be ineligible for

Medicare. Without the new artificial eye this little girl will be disfigured, but it is unlikely her parents will be able to afford it on

their own. That is only one story.

You know, the mission statement of Indian Health is to ensure

adequate health care, to promote healthy communities, and to protect tribal sovereignty. Without sufficient funding, this mission is

meaningless.

Health care for American Indians is a treaty right. We, as tribes,

have given, and given, and given to this mighty country of ours.

Take my tribe, for instance. It owned all of the Powder River

Basin, 38 million acres.

Today, we only own 2.5 million acres. But look at the billions of

dollars that have been taken from the land because of large resources. Look at all the dams in Montana. Where were they built?

On Indian reservations.

What did we receive as Indian tribes when the Federal Government has made hundreds of millions of dollars and we were only

paid $5.5 million and the land was condemned? However, we suffer

from great health disparities, we suffer from higher rates of chronic

disease, including diabetes, heart disease, cancer, suicide, and one

of the highest infant mortality rates in the world in the Great

Plains.

I think there is a misconception all over the United States about

Indian tribes. There are the haves and the have-nots. We are not,

especially in the Great Plains and in Montana, not gaming tribes.

We do not receive gaming revenues.

You see in the papers where gaming tribes are buying and investing throughout America. We on the Great Plains and in Montana do not have that opportunity. So, we are very diverse between

Indian tribes. The majority of Indian tribes live in the Great Plains

and the Rocky Mountain region.

The biggest land bases are with these tribes, and the population

is with these tribes. So there is a lot of misconception about Indians. While the President’s budget increased in every line item, the

Indian Health Service budget increase is not enough to even the

deplorable status of health care.

The President’s $1.4-billion budget request falls far below the fiscal year 2006 needs-based budget, indicating at least $19.7 billion

is necessary for adequate health care.

The present budget allows Indian Health Service to meet only 60

percent of the need. In 2003, the Indian health budget allowed

$2,130 per person, while the general public expenditure for the

6

U.S. population was $5,065, per capita. But in Montana, it is only

$1,688 that was expended on tribal members in the Billings area.

You know, Indians, we joke about things. I think that is how we

control our depression. Come June 1, Indian Health Service is out

of money to provide money for Indian tribes for health care. We

joke about that and we say, don’t get sick after June 1. It is not

right.

The billions of dollars that this country spends in foreign aid—

I look at the budget as a tribal leader. You know, the Montana

area or the Billings area is $40 million in the red, but yet we give

$40 million to BLM to take care of some wild horses, which we do

not ride and we do not eat. Let us set priorities in government

today where these needs are met. The human needs of this country

and the morals of this country are very important to its Indians.

Looking at the proposed budget this year, take the African nations. They are asking 3 times more to fund them, when, if you go

down the First Avenue in Billings, MT and you see the homeless

women and children standing outside, what are we really thinking

about in this country? We should be serving our people. We are

your constituents. I also have constituents.

What are we really doing in America today? It is very sad to see

these things, especially in Indian country, and it is deplorable. But

it is time for Indian tribes to start speaking up. It is time to start

doing things for all of our people.

Do I need Kevin Costner to show another ‘‘Dances With Wolves’’

in order to bring the Indian problems out to the general public

today, or go on ‘‘Larry King Live’’? No, I do not think so. It is time

for all of us to work together.

You know, 70 percent of tribal members enlist in the service during war time. That is a fact. Eighteen percent of all the branches

of services are Indians today. I alone have 52 young men and

women in Iraq and Afghanistan today.

You know, the bullets do not say, that guy is white, that guy is

red, or that guy is black. We are all in it together, and we need

to work together as a people, as great Americans, great Montanans,

and great Indians. We have supported everything that this great

country has asked.

Give us a chance to dream like Martin Luther King dreamed for

his people. We want the American dream of building our own

homes, having jobs. We have unemployment rates of 47 percent. If

40 percent of Americans today were unemployed, you would see

riots in the streets of Washington, DC and all the big cities.

Montana enjoys a 2.7-percent unemployment rate, but on reservations—my reservation has the lowest unemployment rate, and

that is 47 percent. But look at all the reservations within Montana,

it is over 50 percent.

What can we do as Americans? We need to sit down and work

together. I know the reauthorization bill was stopped by the Justice

Department. Why can we not sit across the table and discuss these

things and get things done for all of America?

The CHAIRMAN. You make very good points, Mr. Chairman. I

really appreciate that very, very much. Thank you.

[The prepared statement of Mr. Venne appears in the appendix.]

The CHAIRMAN. Ms. Davidson?

7

STATEMENT OF VALERIE DAVIDSON, ESQ., SENIOR DIRECTOR,

LEGAL AND INTERGOVERNMENTAL AFFAIRS, ALASKA NATIVE TRIBAL HEALTH CONSORTIUM, ANCHORAGE, AK

Ms. DAVIDSON. Good morning, Chairman Baucus, Ranking Member Grassley, and honorable members of the Senate Finance Committee. ‘‘Ochwiana,’’ or thank you for the opportunity to testify

about the importance of Medicaid, Medicare and SCHIP funding for

the Indian Health system.

I should introduce myself properly: Wiinga Nurraraluugua Amill

amarnan-llu. Yupiugua-Mamterillermiu. Aanaka kwigillingsurmianguq ataka Portera Washington macmilloq. My In ̃upiaq Eskimo

names are: Nurraralaq Aanaka Millimoquinon. Feel free to call me

Valerie Davidson; it is a little bit easier to pronounce.

The CHAIRMAN. What language is that?

Ms. DAVIDSON. In ̃upiaq Eskimo.

The CHAIRMAN. In ̃upiaq?

Ms. DAVIDSON. It is the best language in the world. [Laughter.]

The CHAIRMAN. All right. Thank you. I am not going to argue

with you. [Laughter.]

Ms. DAVIDSON. I serve as the chair of the tribal technical advisory group to the Centers for Medicare and Medicaid Services, and

I recently served as a non-voting member of the Medicaid Commission.

In its final report, one of the things that the Medicaid Commission did is endorse the provisions that were passed by this committee in S. 3524, the ‘‘Medicaid, Medicare, and SCHIP Indian

Health Care Improvement Act of 2006.’’

I wanted to express my special appreciation to this committee in

what has been probably the highlight of this long, long effort to be

able to get the Indian Health Care Improvement Act reauthorized.

I have served on the National Steering Committee since its beginning. I cannot even remember how many years ago. I think it

has been about 7, 8, or 9, but it feels like about 20.

It has been my great privilege to work for the Yukon-Kuskokwim

Health Corporation in southwest Alaska, an area about the size of

the State of Oregon, 75,000 square miles, with no roads connecting

any communities. Health care is provided in 50 small villages, and

access to care is truly a problem, where the only way you can get

to the closest hospital is by anywhere between a $300 to an $800

round-trip plane ticket.

I currently work for the Alaska Native Tribal Health Consortium, and we provide State-wide services that were previously provided by the Indian Health Service.

Let me tell you a little bit about Alaska and Alaska natives. We

represent about 19 or 20 percent of Alaska’s population. Our median age is about 23.6 years, and that is because, traditionally, we

get married right after high school and have children in our communities.

We get married early and our children are quite young. We have

incredibly high poverty rates and unemployment, as high as 75 or

80 percent in some of our communities, and income generally will

stretch to provide for the sustainability for about 15 family members.

8

I am not going to talk about some of the health disparities that

were already mentioned by the members of this committee, as well

as other folks, but I did want to talk a little bit about some of the

Medicaid, Medicare, and SCHIP provisions.

If you look at those kinds of things, which I will just refer to now

as third party reimbursement, there are really two critical roles

that it plays in the delivery of health care to American Indians and

Alaska natives.

The first role that it plays is that it supplements a source of

health care that the Indian Health system cannot provide itself,

and which contract health care also cannot pay for.

The second is, it also provides a critical source of revenue to be

able to sustain the Indian Health system, when we know it is only

funded at 60 percent of the level of need. If it costs $1,000 to provide care to a patient and the Indian Health system only funds $600 of that, where does that remaining

$400 come from? It has to come from third party reimbursement,

otherwise we would have to be forced to close our doors.

In the first category, Medicaid pays for services that are not currently available widely in the Indian Health system, and it pays for

things like long-term care, pays for the continuum of care, and the

advancement of health systems that we know that the rest of the

country benefits from, like long-term care.

There are other provisions that I can maybe talk about a little

bit later if I have more time, but let me turn back a little bit to

sustainability. We know that the current system does not pay for,

as you mentioned, substance abuse services adequately, other kinds

of behavioral health services, and basic access to medical care.

One of the things that Medicaid does is, it pays for the difference

in that gap. The only way that American Indians and Alaska natives currently have access to those services is when Medicaid,

SCHIP, or Medicare pays for those services.

The new provisions that increase outreach and enrollment are

critical to our people, and here is an example. The citizenship

issues that are included in the bill are really critical, and here is

one example in Indian country.

In the region that I am from, there is only one place in this

75,000-square-mile area to be able to get a State-issued ID, and

that is in the big, giant city of Bethel that has about 6,000 people.

Here is the challenge: in many communities you have to buy a

$200 to an $800 round-trip plane ticket just to be able to go there

to be able to get that State-issued ID, and that DMV office, last

year, was closed for 10 months out of the last year, and there were

families who showed up to be able to satisfy that citizenship requirement and paid a lot of money, money that they simply did not

have, to be able to protect their eligibility for Medicaid, and the

door was not even open, and nobody could tell them when in the

next year it could possibly be open. We know that, as resources get

tighter, individual American Indians and the Indian Health system

that provides their care will feel the impact more than any.

You may ask, why? Well, the reasons are pretty simple. We are

disproportionately eligible for Medicaid because, as we said, we

have the highest rates of unemployment and we have the lowest

income levels.

9

We have some of the poorest health status and the greatest

health disparities, and we live in rural and frontier communities

where access to care is a problem, and we have a high cost of providing care and a high cost of living, which means that limited incomes get stretched even further.

What that really means is, when our people finally do get the

care that they need, they have traveled further with money they

simply do not have, they are sicker than the average person, and

they are seen in clinics and hospitals that have fewer resources

than any other facility in the country, that also, because of their

rural nature, have a higher cost of providing care.

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

[The prepared statement of Ms. Davidson appears in the appendix.]

The CHAIRMAN. Ms. Holt?

STATEMENT OF LINDA HOLT, SECRETARY, SUQUAMISH TRIBAL COUNCIL AND CHAIR, NORTHWEST PORTLAND AREA INDIAN HEALTH BOARD, SUQUAMISH, WA

Ms. HOLT. Hello. Good morning, Chairman Baucus, Ranking

Member Grassley, and members of the committee. My name is

Linda Holt. I am a Suquamish Tribal Council member from Washington State, and I bring you greetings from the Suquamish Tribe.

I also serve as chair of the Northwest Portland Area Indian

Health Board and am a member of the National Indian Health

Board.

The Northwest Portland Area Indian Health Board is an organization that represents 43 tribes in the States of Idaho, Oregon, and

Washington. I also serve as the Portland area representative on the

National Steering Committee for the Indian Health Care Improvement Act. I would like to thank you for holding this hearing today,

and I am honored to be here.

I commend the Finance Committee for its work on the Indian

Health Care Improvement Act in the last Congressional session.

The provisions that the committee passed will allow us to address

the significant health disparities that Indian people face.

I truly hope that we can get this bill passed in this session and

look forward to your continued support. Medicare and Medicaid

have become critically important to the health of Indian people.

Indian expenditures in Medicaid and Medicare constitute a very

small share of overall costs in these programs. For example, it is

estimated that Medicaid accounts for almost 20 percent of the IHS

budget, but less than one-half percent of the overall Medicaid expenditures go to the Indian Health program.

I want to stress this fact, since there were challenges against

some of the provisions contained in title IV in the Indian Health

Care Improvement Act. The Medicare and Medicaid programs are

very important to the viability of the Indian Health system. Many

Indian Health programs would go bankrupt without these collections due to the chronic under-funding of the Indian Health system.

Today I want to talk to you also about health facilities and their

relationship to Medicare and Medicaid reimbursements, which

allow our health programs to maintain services. These reimburseVerDate 11-MAY-2000 15:01 Oct 06, 2008 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6633 44280.000 SFIN1 PsN: SFIN1
10

ments are vital to our Indian Health programs and allow tribally

operated programs to maximize the Contract Health Service budgets.

Unfortunately, if you happen to be a tribal member from a CHSdependent area, you do not have the same access to health care as

other Indian people within the Indian Health system. Where I

come from in the Portland area, we have no hospitals or inpatient

facilities.

All specialty care that is normally provided in a hospital is purchased through the CHS program. This program applies strict eligibility rules and uses a medical priority system that requires all

services to be preauthorized or they will not be paid.

Because we have no hospitals, our health programs often begin

the year on Priority One status. This means that only emergent

and acute care services are covered in order to prevent the immediate death or impairment of health. Our programs begin the fiscal

year clearing the backlog of denied or deferred services from the

previous fiscal year.

You may have heard the term Chairman Venne used, do not get

sick in June or you will not receive CHS health care. Well, in the

Portland area this term does not hold true, as our programs often

begin the fiscal year on Priority One status, so you should not get

sick at all.

While those areas that have hospitals face the same issues as

CHS-dependent areas, they are not as extreme. The reason for this

is simple. Hospitals have medical staff that can provide a number

of services that are routinely purchased through the CHS program.

Hospital-based systems internalize the costs associated with providing health care that CHS-dependent areas cannot. They are also

able to provide more services, since they save unobligated CHS dollars that would have normally been used to purchase such specialty

care.

It is remarkable that most Americans in this country receive

health services in the most modern facilities with state-of-the-art

equipment; however, Indian people do not. Our clinics in the northwest are notable exceptions, most on the average of 40 to 50 years

old. A clinic on the Coleville Reservation in Washington State is

over 70 years old.

In other northwest tribal communities, clinics are housed in mobile homes. Not only are the clinics old, they simply are inadequate

to provide health services. They are often too small, equipment is

outdated, and the staff is forced to make do as best they can.

Section 301 of the Indian Health Care Improvement Act establishes authority for the IHS to develop a facility construction priority system. This system is used to evaluate and rank health facility construction projects.

Successful projects have provided funding for construction and a

recurring staffing package by Congress. The staffing packages are

significant with respect to the ability of a facility to seek third

party reimbursements under the Medicare and Medicaid programs.

CHS-dependent areas do not enjoy the same benefits as hospitalbased systems and are not as able to collect as much third party

reimbursements.

11

This is very true for IHS areas with large hospitals and health

clinics that have been built with staffing packages under the priority system. This creates health service disparities within our own

Indian Health system, and it is wrong.

I want to draw your attention to some graphs and maps that are

included in my written testimony. On page 7, I include a graph

that shows the effect of staffing new facilities on the IHS budget

increases since 1995.

The graph shows that staffing, over the past 5 years, has significantly cut into the IHS budget increase by roughly 50 percent. This

means that two to three tribes that are fortunate to get a new facility get half of the IHS budget increase, while 550 other tribes must

share the remaining 50 percent.

The graphs on pages 7 and 8 show the amount of funding that

has been allocated within the IHS system under the current priority system. Clearly, you can see there are five to six areas that

do not benefit equally in funding under the current system. Three

areas have never benefitted from an inpatient hospital or outpatient clinic built under the current priority system.

Finally, I want to draw your attention to maps on pages 9 and

10. These maps clearly demonstrate that facility construction

projects since 1991 have been centered around five to six IHS

areas. The map on page 9 shows that there has not been one inpatient hospital built in the Bemidji, California, Nashville, and Portland areas under this system.

The map on page 10 shows that there has not been one outpatient clinic built in the California, Nashville, and Portland areas

under this system, yet there are 24 tribes in the Nashville area,

43 tribes in the Portland area, 34 tribes in Bemidji, and over 75

tribes in California.

The provisions of section 301 of the Indian Health Care Improvement Act are very concerning for northwest tribes. While there is

generally consensus among tribes on most provisions of the Indian

Health Care Improvement Act, there is not, on section 301. It is

critical that this issue be addressed before enacting this bill into

law.

Section 301 includes a grandfathering that will protect all construction projects on the current priority list. The language contained in section 301 was carried over from current law and developed through tribal consultation, which responded to tribal needs

and concerns in 1999.

However, given recent changes in the construction priority system, the language is now out of date. Over the last 3 years, IHS

and tribes have worked to develop a new facilities priority system.

If this bill language is passed, it will prevent IHS from implementing this priority system.

The reason for this is, due to the grandfathering provision, it is

estimated, at the current rate of appropriations, it will take 20 to

30 years to clear the current project list.

The grandfathering provision will prevent the new system from

being implemented. In our written testimony, we provide the committee with a compromise to establish an area distribution methodology for facilities construction.

12

We further recommend language changes in other provisions of

section 301. We have provided the committee staff with these recommendations and are available to discuss our recommendations

with staff.

I would, further, like to add as a note that we have been waiting

3 years for the Medicare-like rates that have been finalized, and we

still have not received them in final form.

The CHAIRMAN. I am going to have to ask you to summarize your

testimony as well as you can.

Ms. HOLT. All right. I just want to note that we have estimated that it would save the IHS budget about $25 million a year just

to get the Medicare-like rates and be able to have that.

I want to thank the members of the committee for allowing me

to be here today. As stated, the Portland area is willing to step forward with any help that we can provide.

The CHAIRMAN. Thank you very, very much.

[The prepared statement of Ms. Holt appears in the appendix.]

The CHAIRMAN. Ms. Bear King?

STATEMENT OF CONNIE R. BEAR KING, ENROLLED MEMBER,

STANDING ROCK SIOUX TRIBE AND GOVERNMENT AFFAIRS

ASSOCIATE, NATIONAL INDIAN CHILD WELFARE ASSOCIATION, PORTLAND, OR

Ms. BEAR KING. Good morning. Thank you, Chairman Baucus,

Ranking Member Grassley, and the other members of the committee, for giving me the opportunity to share with you my experience and insight into the methods of improving child welfare services to American Indian and Alaska Native children.

I also want to thank the committee for their support of direct

funding for tribal child welfare services, as evidenced by the inclusion of tribal title IV–E provisions in the foster care and adoption

assistance and welfare reform reauthorization bills in the 108th

and 109th Congresses.

We also would like to thank the committee for its work to support increases in funding for eligible tribes under the Promoting

Safe and Stable Families program during the last Congress.

My name is Connie Bear King, and I am a Hunkpapa Lakota.

I am an enrolled member of the Standing Rock Sioux Tribe in

South Dakota and North Dakota. For the last 10 years until this

February, I lived and worked in Sioux City, IA.

As the executive director for the Sioux City Indian Education

Committee, I came in contact with many of the community’s Indian

families and became aware of a lot of the major issues that families

were struggling with.

While working with many of its community families, I saw that

many of them had experiences with the local child welfare system

either as a parent whose child had been removed, or as a prospective relative placement for a child.

The local child welfare system did not understand many of our

tribal communities and, many times, opted for non-relative placement of these native children, especially when relatives did not

want to adopt.

During that time period, Iowa was placing 10 percent or fewer

of its children in foster care with relatives, and placement options

13

for relatives were very limited. Nearby tribes, of which many of the

Sioux City Indian community were members, were also working actively to participate in child welfare cases by offering placement

and other services.

Regina Little Beaver, the director of the Human Services for the

Winnebago Tribe of Nebraska along the Iowa border, told me that

her ability to assist the Iowa Department of Human Services was

often predicated upon the resources that were available to her.

In many cases, she said the tribe did want to bring the children

home to be with their relatives, but she was not able to do that because she did not have the resources to do it. She said this was in

spite of the fact that her tribe does have a title IV–E agreement

with the State of Nebraska.

The agreement does not allow the tribe to access all of the title

IV–E funding that was available to the State and required that the

tribal title IV–E be under State court jurisdiction.

I have also been able to learn from other tribal human service

directors, such as Arlene Templer at Salish-Kootenai Tribe in Montana. In her discussions with our organization and before this committee last year, she shared some of the issues she faces, such as

methamphetamine abuse.

In trying to protect and find permanency for tribal children

under her care, she notes that, although her tribe has a title IV–

E agreement with Montana, the State insists the tribes adhere to

State policies that are not part of the Federal title IV–E program.

One of these prohibits the tribes from seeking Federal IV–E reimbursement for IV–E eligible children who are being transferred

from another State and placed in foster or adoptive homes on the

reservation in Montana.

Arlene has said that this severely limits her ability to assist

other States in finding an appropriate placement for Salish and

Kootenai children living off the reservation and does not enable her

or the tribe to bring them back to be placed with relatives on the

reservation.

Arlene also said that if the tribe was allowed to apply for, and

operate, the program directly from the Federal Government, she

could serve additional children that she is not currently able to

service and provide and design programs that will more effectively

meet the needs of her community.

Arlene is also working with the State of Montana to secure access for her relative caregivers to the State’s subsidized guardianship waiver program. In one case, a tribal member who was providing care for her niece and nephew was asked to participate in

the State’s subsidized guardian waiver program.

Unfortunately, they were not selected, and they were placed in

the control group, which meant that her guardianship placement

would be ineligible to receive any subsidy. The aunt had very limited income, and she told the program should could not care for the

children without a subsidy or support and then had to return the

children back to the foster care program and system, where Arlene

says they will likely stay until they age out.

I ask, what are the common findings of these experiences? First

is the need to give more support to relatives as caregivers. In my

upbringing, I was taught that family relationships were the most

14

important relationships that I would ever have in my life. We

strengthen our tribal families and honor the important connections

of our tribal children when we can support our extended families

as caregivers.

Second, we need to ensure that people with the most extensive

knowledge and skills regarding native children and their families

are available to help, and that is the tribes and the community.

Tribal governments throughout the Nation are struggling to keep

their families together whenever appropriate and to be able to provide permanency for their children, children who have so many factors that put them at risk for removal from their homes.

I urge you, please consider the power of supporting our dream in

helping Native American children and families to continue that

journey of well-being and permanency.

Thank you.

[The prepared statement of Ms. Bear King appears in the appendix.]

The CHAIRMAN. Thank you very much, Ms. Bear King. That is

very effective.

I have a couple, three points to make here. Number one, I think

the inadequate funding is an outrage in health care. I mean, the

life-and-limb restriction is unconscionable, in my judgment. We

have to figure out some way to solve that and prevent that from

happening at the very top.

There are just too many stories of too many people who do not

get proper care because of that limitation. You, Ms. Holt, said that

in your area of the country it starts earlier than it does in some

other areas of the country, mid-year. It should not happen at all,

regardless.

I do not know how many dollars it is going to take, but we have

to find a way to get that solved just as quickly as we possibly can,

in my judgment. It just bothers me to no end. Again, it is just unconscionable, totally unconscionable, in my judgment. We will get

at that. I have to figure out a way to solve that one.

Next, though, the IHCIA Act. You, Ms. Holt, suggested some

changes in section 301. What I would like to do is, just generally,

hear from all four of you the degree to which you think IHCIA

should be reauthorized the way it is, or the degree to which you

think there are some changes, major changes, you think should be

made.

I do not have a lot of time; other Senators may have similar

questions. But I would just like to go down just very briefly and

start with you, Chairman Venne, whether you like it the way it is,

the reauthorization as it is contemplated, or would you suggest a

couple, three major changes. If you could limit your remarks to

about a minute, because that is about all the time I have, and

going down here, please.

Mr. VENNE. I think you put it well when you started out, that

you know the problems in stuff like this. But the biggest thing is

probably the money situation. The priorities of money going elsewhere, I think Congress needs to sit down and make those priorities. It is very important.

The budgets that are requested are only 60 percent of the needs

in Indian country, and that is very important to us. One example

15

is, because of the fact, without the money, doctors working in our

hospital are leaving because they cannot practice good health care.

It creates a problem between the patient and the doctor because

they are dedicated people to provide good health and they cannot

do that. They are starting to leave the Indian Health Service also.

The CHAIRMAN. All right. Thank you.

Ms. Davidson?

Ms. DAVIDSON. Although I am happy with the way the bill reads

in terms of Medicaid and Medicare provisions, I guess if I could

change one thing, since you asked——

The CHAIRMAN. I asked.

Ms. DAVIDSON. I would really like to see that the increases that

are available for Medicaid patients and Medicare patients, the

mandatory medical inflation rates, be included when Congress

funds the Indian Health Service budget.

Some may ask, well, why is that? I guess if you go back to before

any of us were alive, way back to our forefathers—and because I

am a woman I have to say foremothers—that there were promises

that were made. Our forefathers and foremothers made promises of

peace in exchange of land in order for the promise of prepaid

health care, for education, for health, for housing, et cetera. And

for American Indians and Alaska Natives, this really is a sacred

promise and it is one that cannot be breached.

The CHAIRMAN. Just so I understand, the change would be what,

again?

Ms. DAVIDSON. I guess I would encourage that there would be a

provision in the bill that mandates mandatory medical inflation increases for the IHS budget.

The CHAIRMAN. Okay.

Ms. DAVIDSON. And also that we have full access to Medicaid,

Medicare, and SCHIP. When a patient presents at a facility, they

do not necessarily care whether the payment is coming from IHS

or CMS or wherever.

The CHAIRMAN. Right. Right.

Ms. DAVIDSON. That patient just needs help and they need care.

The promises that were made many, many years ago were promises made by the past presidents of these great United States, and

every single employee of the United States, whether they work for

the Indian Health Service, or whether they work for CMS, or

whether they work for HRSA, should be able to carry out the promises of that agreement that was made many years ago.

The CHAIRMAN. All right. My time is about expired.

Ms. Holt, briefly. Very briefly, please.

Ms. HOLT. Sure. As I stated earlier, the Portland area would certainly like to see the revision, and requests the revision in section

301. We are working under a system, a health care system, that

has been totally inequitable to Indian country as a whole. We

should not have inequities within that system that favors tribes

over other tribes.

The CHAIRMAN. Right.

Ms. HOLT. And so we would ask for the revision in section 301.

We also would like, for consideration, having the language taken

out as IHS being the payor of last resort. As stated by Ms. Davidson and Chairman Venne, this is a treaty obligation and a fiduVerDate 11-MAY-2000 15:01 Oct 06, 2008 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6633 44280.000 SFIN1 PsN: SFIN1
16

ciary responsibility that the Federal Government has to provide

health care. We should not have to put up with the payor of last

resort provision.

The CHAIRMAN. Thank you very much.

Ms. Bear King?

Ms. BEAR KING. Yes. Chairman Baucus, I am here primarily to

speak to child welfare issues.

The CHAIRMAN. So you would like the guardianship provision

changed.

Ms. BEAR KING. Yes. Yes.

The CHAIRMAN. As well as IV–E.

Ms. BEAR KING. That is correct.

The CHAIRMAN. Right. Changed.

Ms. BEAR KING. But I would definitely defer to the experts here.

The CHAIRMAN. All right. Good. I agree with you on those two

points. Thank you.

Ms. BEAR KING. Thank you.

The CHAIRMAN. Senator Bingaman?

Senator BINGAMAN. Thank you, Mr. Chairman. Let me just start

by saying thanks for having the hearing. I agree with you that the

funding disparities are a very major inequity that we need to try

to correct.

We have a chart here that makes the point that many of these

witnesses have made and that you made in your opening statement. It shows the per capita funding or health care expenditures

per user through the Indian Health Service, through Medicare,

through Medicaid. You can see this bottom line, which is the blue

line.

Two big problems with it. Number one, it is less than half the

level of expenditure that any of the other lines are. Second, it is

flat. It does not go up. That is our big problem with Indian health

care.

Part of the solution, of course, is getting the Indian Health Care

Improvement Act reauthorized, and clearly we need to get that

done, and quickly. But the other part, of course, is getting funding.

There are only two parts of the Federal budget which provide

health care services that are not entitlements. One is veterans

care, the other is Indian health care. Both of those have been suffering as a result of the fact that they are not entitlements and

Medicare goes up, and Medicaid goes up, and these programs do

not. So, it is a serious problem.

Let me ask just one question. Ms. Davidson, we had a real problem in my State with this newly enacted Medicaid citizenship documentation requirement. You somewhat alluded to that in your

statement.

I think the estimate is, we lost as many as 10,000 children from

the Medicaid program because of the inability to document their

citizenship. I gather this is a problem that you encountered in

Alaska as well.

Ms. DAVIDSON. Thank you, Senator Bingaman. It actually is a

problem. It is a problem everywhere. I think it is a darn shame,

if I may be so bold, that a provision that was enacted under the

Medicare Modernization Act that was designed to protect and conserve those Medicaid resources from non-citizens of the United

17

States, it is a shame that that provision is most impacting this

country’s first people, people who were here first, who should be

able to use tribal enrollment cards as proof of citizenship.

When we meet with folks who designed the regulations for how

that is implemented and we ask the question, why is that, the answer we get is because, well, some tribes are along the borders of

Mexico and Canada.

Well, it just does not make sense to engineer 99 percent of a solution to address 1 percent of the problem. So you take care of the

1 percent—or probably less than 1 percent—of the problem by creating a problem for 99.9 percent of the rest of the country. It just

does not make sense.

Senator BINGAMAN. So you do not think these individuals who

have tribal enrollment cards up in Alaska are illegal immigrants?

Ms. DAVIDSON. No. In fact, one of those people, my grandmother,

who died 2 years ago—in fact, 2 years ago today—did not have a

birth certificate. On our Tribal Technical Advisory Group, one of

the technical advisors, who is young, in her 40s, is from Navajo and

she herself does not have a birth certificate and was wondering

about how many other people in her reservation are in that same

situation. This is not just an elder problem—this is people of our

younger generation’s age.

We are at a point where we know that American Indians and

Alaska Natives are under-enrolled, and we should be doing everything we can, extending outreach and enrollment, everything within our power to be able to reach more people, not setting up barriers to be able to have access to health care and access to enrollment. That just does not make sense.

Senator BINGAMAN. All right. Well, thank you. I will stop with

that, Mr. Chairman.

The CHAIRMAN. Thank you very much, Senator.

Senator Thomas?

Senator THOMAS. Thank you, Mr. Chairman. Thank you for holding this hearing. As you know, I am Vice Chairman of the Indian

Affairs Committee, and so this is very interesting. We have talked

about it on our committee. Certainly I am encouraged by the

amount of increased participation in Medicare and Medicaid, in

that I think that has been a change.

By the way, the citizen thing, the law was changed last year. It

has not been implemented yet entirely, but we have tried to deal

with that, so that will be taken into account soon.

I do indicate that Medicare/Medicaid now is estimated, this year, to be up to $625 million with the tribes, which is a great increase.

It was only $88 million back in 1990. So, there is a great deal of

increase, and that is a good thing, because those are eligible programs that all citizens of this country are eligible for.

Chief, how many patients on your reservation are enrolled, or

what percentage are enrolled in Medicare and Medicaid?

Mr. VENNE. We have 11,600 Crows. Medicaid and Medicare,

probably only about 20 percent are enrolled because of the problems of signing up people, and then to have the State verify it. It

takes a long time for them to verify it.

When their office, from Crow, is over 70 miles away in Forsyth,

we do not know if it gets off their desk or what the holdup is, but

18

the State is responsible for that, for certification. So, consequently

we have a lot of people who are not Medicaid——

Senator THOMAS. Isn’t that something we ought to resolve, and

get somebody to come to the reservation if you have to, to get them

signed up? That is not a difficult thing to do, you know.

Mr. VENNE. No. But I think tribes should be given the authority

to verify people on Medicaid and Medicare, because we all have the

know-how to do it, and how to follow Federal guidelines. We contract with the Federal Government every day, and we should be afforded that opportunity.

Senator THOMAS. Ms. Davidson, what is the payor of last resort

rule, and why is it needed for Indian health care?

Ms. DAVIDSON. The payor of last resort rule basically requires

that if there is an alternate payor, whether it is Medicaid, Medicare, SCHIP, or private insurance, that those payors must pay first

before the resources are taken out of the budget that is allocated

to that facility.

Senator THOMAS. All right. That is not a bad thing, is it?

Ms. DAVIDSON. It depends on whether you are standing from the

provider’s perspective or the patient’s perspective, I think. I think

that is a good thing, that it allows us to be able to access additional

resources, to be able to get those resources in, to be able to round

out the funding for an already under-funded system.

But I think one of the things that other members of this panel

indicated is that barriers to being able to access those resources

can have a crippling effect on our ability to be able to get increased

funds. For example, the law requires that IHS is not allowed to

subtract the amount that we get from Medicaid and Medicare in

their annual budget request, but we see it happen every single

year.

So as we are doing our part to be able to get additional third

party revenues for additional administrative costs, what we are

seeing is that the IHS budget, those funds are actually coming off

the top of the IHS request.

Senator THOMAS. All right.

Ms. Holt, you talked about construction and so on. It takes 20

to 30 years to clear the current projects. Are Federal dollars the

only source for construction of facilities?

Ms. HOLT. On that list, yes.

Senator THOMAS. Well, I mean, for all the reservations. We have

a community health center we are building in Wyoming, some community health centers, with the cooperation of the tribes and the

local communities, and things of that kind.

Ms. HOLT. And a lot of tribes are having to do that. They are

having to redirect dollars that could be used for education, or for

detention facilities, or justice systems. They are having to redirect

those monies to meet the health care needs, and that just should

not happen. That is not right.

It is the Federal Government’s responsibility to provide that

health care and to provide the facilities, and the Federal Government should meet that obligation. At the rate of appropriations

that have been happening, it is estimated that it will take 20 to

30 years to clear the current list.

Senator THOMAS. All right. My time has expired. Thank you.

19

The CHAIRMAN. Thank you, Senator.

Senator Salazar?

Senator SALAZAR. Thank you very much, Chairman Baucus, for

focusing on this issue. I very much agree with you and Senator

Bingaman that the funding disparity is unconscionable. I am hopeful that we can work together to see how we can address that funding disparity this year.

I believe this hearing provides us a very important forum to discuss the critical issues that are facing Indian country across our

country, including the health and child welfare system.

In my State of Colorado, we have about 51,000 Native Americans

who reside in my State. While many belong to, and reside, on the

two reservations in southwestern Colorado, we also have about

22,000 Native Americans who live in the city of Denver and the

Denver metropolitan area.

The Native American communities are a vital part of Colorado’s

history, culture, heritage, and economy. In fact, the oldest known

continuous residents of Colorado are the Utes, who were there long

before my family came in and settled that area in 1851.

Currently, the Ute Mountain Ute and Southern Ute tribes are effectively led by Chairman Manuel Hart and Chairman Clement

Frost. I know them both. I am proud of their work. I meet with

them often to discuss issues at the reservation.

Whether it is combatting crime and the methamphetamine epidemic, we are striving to provide health care, housing, and educational services to their tribal members. Chairman Hart and

Chairman Frost are hard at work, but their resources are stretched

thin.

I want to ask a question of you. That is, one of the troublesome

statistics in terms of health care in Indian country is the fact that

Native Americans are, I understand, 6 times more likely to die

from an alcohol-related disease than other people. That is an astounding statistic, in my view: 6 times more likely to die from an

alcohol-related disease than other people.

What do you think we can do in terms of a push on health care

to try to address that chronic problem that we have in Indian country? Whoever wants to respond to that question, please go ahead.

Ms. HOLT. Thank you, Senator Salazar. It is another epidemic in

Indian country, just like methamphetamine is an epidemic in Indian country. It was a disease that was brought into Indian country 100 years or so ago.

Unfortunately—given the poverty status, as Ms. Davidson testified to, the unemployment rates, and the ruralness of most reservations—there is nothing to do. There is nothing for the kids to do,

so they look to entertain themselves.

I firmly believe that Native Americans suffer from post-traumatic

stress disorder because of the trauma that they have faced

throughout the centuries, and continue to face, and that this also

leads to the depression that alcohol suppresses in a lot of people.

Senator SALAZAR. Let me ask you whether there are programs

out there somewhere within Indian country, with all the reservations, that have been proven to be effective in dealing with the

issue. Do we have models out there that we could try to push to

deal with the issue?

20

Ms. HOLT. Yes. Yes, we do.

Senator SALAZAR. Chief?

Mr. VENNE. Thank you, Senator. I developed a program for our

reservation for alcohol and drug abuse that is strictly a cultural

program where my people talk Indian, we go in the sweats, we

have a circle, we burn sweet sage.

We also go fasting on the highest mountains within Montana. It

is a spiritual thing. Plus, we are educating them in the history of

the Crow, where they know who they are, and to be proud of who

they are and to be proud of where they live.

Senator SALAZAR. And has that worked at your reservation?

Have the alcohol abuse rates dropped in the reservation because of

your program?

Mr. VENNE. Yes. I can safely say we have about a 70-percent success rate.

Senator SALAZAR. A 70-percent success rate. That is impressive.

Ms. Davidson?

Ms. DAVIDSON. There are actually examples of programs that are

working throughout Indian country. What we have seen is, the

most effective programs are programs that are close to home, that

are culturally appropriate, and provide the full spectrum of the

continuum of care.

I mean, even if we have access to a treatment program, when

you send that person away, what happens when they come back?

If they do not have a continuum of care, then that person is going

to fall right back into the same patterns all over again.

A program that we developed in Alaska is called Behavioral

Health Aid Program, and it is built on the very successful Community Health Aid Program in which we train local tribal members

who speak the language to be able to do a 2-year program through

the University of Alaska to be able to be cross-trained in——

Senator SALAZAR. And it has been an effective program then?

Ms. DAVIDSON. Yes, it has. To be able to provide both mental

health and substance abuse services at the village level. Because

the problem is, when the services are only available hundreds of

miles away, you lose all those kids.

Senator SALAZAR. I agree.

Let me just thank the panel for your excellent testimony. My

time is up. Thank you, Chairman Baucus.

The CHAIRMAN. Thank you, Senator.

Senator Snowe?

Senator SNOWE. Thank you, Mr. Chairman.

I want to thank all of you as well for your participation here

today. I know, having recently met with Maine’s Native American

tribes, first and foremost, is the issue of funding for health care,

and the disparities are really simply unacceptable. That is something that we really have to address as one of the foremost critical

issues.

I joined Senator Clinton in offering the Kinship Caregiver Act

that does provide for subsidized guardianship, because I think that

is a very important avenue to pursue. It may be, obviously, very

beneficial to the Native American populations.

In my State, for example, they have used State-only funds to

support subsidized guardianship. I do not know if any of your

21

States have done anything similar in that regard. Has any other

State done that? I mean, it is an option. Obviously, it should be a

Federal partnership. Hopefully we can pass this legislation to give

that kind of support.

What is deeply troubling as well is the health status of Native

Americans. I know, for example, in the State of Maine, the issue

of diabetes, which again is inconceivable that the rates could be so

high, not only for Maine’s population, but the Native American

population.

The fact is, the prevalence of diabetes has tripled in the State of

Maine, and the rate of diabetes in the Native American tribes in

the State of Maine is 4 times as great as the general Maine population.

So, it is stunning that we are facing such a situation, and that

is why I think that these health care programs become so instrumental, in my estimation, and we certainly have to do far more

than we are obviously doing now.

One of the ways I wanted to explore with you this morning is,

is there any partnership with the States, through the Medicare and

the SCHIP program, to encourage enrollment among Native Americans? Have you had that experience? Do you know what your

States are doing in that regard? Mr. Venne?

Mr. VENNE. It has been talked about, but the actual action of

doing something is not there in enrolling people. I think to sum everything up, you know, we had the great scandal of the Walter

Reed Hospital over the past 2 weeks. The Indian Health Service is

a bigger scandal, if the Senators look into it. That is why we are

here. I think it is very serious.

Senator SNOWE. Yes. I could not agree with you more.

Ms. Davidson?

Ms. DAVIDSON. I think there are some States that have really

great relationships with tribes in which they do more active enrollment and outreach. One of the critical aspects of being able to provide that is the Medicaid Administrative Match program, which allows tribes to be able to enter into agreements with States to be

able to do some of those outreach and enrollment efforts.

Unfortunately, a lot of work was done by the TTAG, the Tribal

Technical Advisory Group to the CMS administrator, which worked

on developing regulations and clarifying of the law and the regulation that tribes and tribal organizations are able to access that program. And no sooner had we gotten that clarity from CMS, then

right after that regulations came out that basically—the end result

is, it would preclude many tribal organizations and tribes from

being able to participate in Medicaid administrative match because

of the taxing requirement that the new proposed rule imposes. We

have been assured, in our meetings with folks from CMS, that that

was not the intent, that we are supposed to still be able to access

that. But that is not how the current regulation is written.

Senator SNOWE. I see. When were those regulations issued?

Ms. DAVIDSON. I think the comments were due March.

Senator SNOWE. Oh. So very recent.

Ms. DAVIDSON. March 18. Yes. Very, very recent.

Senator SNOWE. All right.

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Ms. DAVIDSON. And then there are other examples. It seems like

sometimes we take one big step forward, and then we take two

giant steps back. There is an example that was raised earlier by

Chairman Holt for the Medicare-like rates.

Congress passed Medicare-like rates years ago. It would basically

allow that, when a tribal member or American Indian/Alaska Native IHS beneficiary needs to use Contract Health Services for a

level of service that the IHS cannot provide itself, you contract

with another hospital to provide that care, and the law prevents

the hospital from charging any more than what Medicare would

pay.

Those regulations were supposed to be done 2 years ago and was

somewhere stuck between the Office of the Secretary, the IHS, and

CMS, and we have been languishing for 2 years. First it was at

IHS, then they signed off, then it was at CMS, then they signed

off, and then it went to the Secretary’s office and they signed off,

and now it is going all the way back through again.

It was supposed to be enacted 2 years ago. It was supposed to be in effect 2 years ago. We have lost at least $75 million of buying

power of Contract Health. Basically, those are Federal taxpayer

dollars, $75 million that have basically been flushed down the

‘‘cuhn’’ because we are sort of like the unwanted stepchild between

two Federal agencies.

We are like the child of divorced parents, where one rule applies

when we are at mommy IHS’s house and one rule applies when we

are at daddy CMS’s house, and we are stuck in the middle, just

trying to navigate whose rules apply when and where, and the end

result is, we are not getting the services that we need.

Senator SNOWE. That is obviously something, Mr. Chairman, we

ought to explore and try to address, and particularly the CMS, and

obviously this issue as well, on the Medicare program. But, definitely we ought to do it because that is an avenue that should be

open to you without obstruction. Thank you.

The CHAIRMAN. I want to thank the witnesses. You have been

very, very good. This is compelling testimony. Frankly, it puts a lot

of burden back on our shoulders now to help solve a lot of these

problems that you have pointed out.

I will pretty much end where I began. The funding is just an outrage. It is up to us to find a way to solve that. Thank you very

much. We will continue to work with you very aggressively. I want

to do something about this.

Thank you very much. And thank you, Mr. Chairman, and thank

you all.

The hearing is adjourned.

[Whereupon, at 11:20 a.m., the hearing was concluded.]

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A P P E N D I X

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