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74–845 2012

H.R. 2708, THE INDIAN HEALTH CARE 

IMPROVEMENT ACT AMENDMENTS OF 2009 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

OCTOBER 20, 2009 

Serial No. 111–74 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 


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COMMITTEE ON ENERGY AND COMMERCE 

HENRY A. WAXMAN, California, Chairman 

JOHN D. DINGELL, Michigan 

Chairman Emeritus 

EDWARD J. MARKEY, Massachusetts 

RICK BOUCHER, Virginia 

FRANK PALLONE, JR., New Jersey 

BART GORDON, Tennessee 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

BART STUPAK, Michigan 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

Vice Chairman 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANE HARMAN, California 

TOM ALLEN, Maine 

JANICE D. SCHAKOWSKY, Illinois 

CHARLES A. GONZALEZ, Texas 

JAY INSLEE, Washington 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

ANTHONY D. WEINER, New York 

JIM MATHESON, Utah 

G.K. BUTTERFIELD, North Carolina 

CHARLIE MELANCON, Louisiana 

JOHN BARROW, Georgia 

BARON P. HILL, Indiana 

DORIS O. MATSUI, California 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

CHRISTOPHER S. MURPHY, Connecticut 

ZACHARY T. SPACE, Ohio 

JERRY MCNERNEY, California 

BETTY SUTTON, Ohio 

BRUCE L. BRALEY, Iowa 

PETER WELCH, Vermont 

JOE BARTON, Texas 

Ranking Member 

RALPH M. HALL, Texas 

FRED UPTON, Michigan 

CLIFF STEARNS, Florida 

NATHAN DEAL, Georgia 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOHN B. SHADEGG, Arizona 

ROY BLUNT, Missouri 

STEVE BUYER, Indiana 

GEORGE RADANOVICH, California 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO MACK, California 

GREG WALDEN, Oregon 

LEE TERRY, Nebraska 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

PHIL GINGREY, Georgia 

STEVE SCALISE, Louisiana 

(II) 


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(III) 

SUBCOMMITTEE ON HEALTH

FRANK PALLONE, JR., New Jersey, Chairman 

JOHN D. DINGELL, Michigan 

BART GORDON, Tennessee 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

JAN SCHAKOWSKY, Illinois 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

ANTHONY D. WEINER, New York 

JIM MATHESON, Utah 

JANE HARMAN, California 

CHARLES A. GONZALEZ, Texas 

JOHN BARROW, Georgia 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

CHRISTOPHER S. MURPHY, Connecticut 

ZACHARY T. SPACE, Ohio 

BETTY SUTTON, Ohio 

BRUCE L. BRALEY, Iowa 

NATHAN DEAL, Georgia, 

Ranking Member 

RALPH M. HALL, Texas 

BARBARA CUBIN, Wyoming 

JOHN B. SHADEGG, Arizona 

STEVE BUYER, Indiana 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO MACK, California 

MIKE FERGUSON, New Jersey 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 


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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. Donna M. Christensen, a Representative in Congress from the Virgin 

Islands, opening statement ................................................................................. 4 

Hon. Tammy Baldwin, a Representative in Congress from the State of Wisconsin, opening statement ................................................................................... 5 

Hon. Joe Barton, a Representative in Congress from the State of Texas, 

prepared statement .............................................................................................. 58 

WITNESSES

Yvette Roubideaux, M.D., M.P.H., Director, Indian Health Service ................... 6 

Prepared statement .......................................................................................... 9 

Jefferson Keel, Lieutenant Governor of the Chickasaw Nation And PresidentElect of the National Congress of American Indians ........................................ 19 

Prepared statement .......................................................................................... 21 

Rachel Joseph, Co-Chair, National Tribal Steering Committee for the Reauthorization of the Indian Health Care Improvement Act ................................. 23 

Prepared statement .......................................................................................... 25 

Andrew Joseph, Jr., Chairman, Human Services Committee, Direct Services 

Tribe Advisory Committee ................................................................................... 34 

Prepared statement .......................................................................................... 36 

Patrick Rock, M.D., Executive Director, Indian Health Board of Minneapolis, 

President-Elect, National Council Urban Indian Health .................................. 41 

Prepared statement .......................................................................................... 43 

SUBMITTED MATERIAL

Statement of California Rural Indian Health Board, Inc. .................................... 62 

Statement of Dale E. Kildee, M.C. ......................................................................... 63 

Table, National Indian Health Board, Details of Grants Received, 2009 ........... 64 


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(1) 

H.R. 2708, THE INDIAN HEALTH CARE 

IMPROVEMENT ACT AMENDMENTS OF 2009 

TUESDAY, OCTOBER 20, 2009 

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

The Subcommittee met, pursuant to call, at 2:10 p.m., in Room 

2318 of the Rayburn House Office Building, Hon. Frank Pallone, 

Jr. [Chairman of the Subcommittee] presiding. 

Members present: Representatives Pallone, Schakowsky, Baldwin, Christensen and Shimkus. 

Staff present: Andy Schneider, Chief Health Counsel; Bobby 

Clark, Policy Advisor; Alli Corr, Special Assistant; Mitchell Smiley, 

Special Assistant; Matt Eisenberg, Staff Assistant; Brandon Clark, 

Minority Professional Staff; Aarti Shah, Minority Counsel; and 

Chad Grant, Minority Legislative Analyst. 

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

Mr. PALLONE. The hearing of the Health Subcommittee is called 

to order and today we are having a hearing on H.R. 2708, the Indian Health Care Improvement Act Amendments of 2009. And I 

will yield to myself for an opening statement initially and then we 

will get to the other members. 

For over the past 10 months our country has been engaged in an 

important debate about how to reform our nation’s healthcare system. But what few people realize is that for over the past 10 years 

a similar debate has been going on in Indian country as well as in 

Congress about how to reform the healthcare system that serves 

American Indians and Alaska Natives. Since 1999, legislation has 

been pending before the Congress to reauthorize the Indian Health 

Care Improvement Act which is the cornerstone legal authority for 

the provision of healthcare to American Indians and Alaska Natives. I know for those testifying before us today and for many of 

those in the audience, it is well known that the Federal Government has a legal, and I would say moral responsibility to provide 

free and quality healthcare to this country’s Native peoples. 

This responsibility often referred to as the trust responsibility is 

born from a legal doctrine consisting of various treaties, contract 

and court decisions. Putting all the legal aspects aside, I think the 

trust responsibility can be summed up by saying that something is 

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tarily given—that they voluntarily gave to the United States or 

were forcefully taken as well as the atrocities that were committed 

against their peoples. And what is owed to them is a pledge from 

this government to ensure that their wellbeing is taken care of 

after centuries of mistreatment. But the Federal Government has 

consistently failed to live up to this responsibility in almost every 

aspect. They have mismanaged the lands that they hold in trust for 

Native peoples and American Indian students struggle to receive a 

proper education that is on par with their peers who are non-Indian, and most important, the quality of healthcare services available to American Indians certainly falls well-below the rest of the 

general population which in turn has resulted in worse outcomes 

for Native communities. 

Now, I can’t tell you how many times I have recited the statistics 

I am going to now give you and I am sure everyone in this room 

has heard them too many times as well but I do want everyone to 

understand what is at stake. For Native Americans ages 15 to 44 

years, mortality rates are more than twice those of the general population, and American Indians and Alaska Natives have substantially higher rates of disease than the rest of the U.S. population. 

Based on recent statistics, American Indians and Alaska Natives 

have seven times the rate of tuberculosis, more than six times the 

rate of alcoholism, nearly three times the rate of diabetes and a 62 

percent higher rate of suicide. The Indian Health Service also estimates that more than two-thirds of healthcare that is needed for 

American Indians and Alaska Natives is simply denied. 

Over the course of the health reform debate, some opponents 

have used these statistics and pointed to the Indian Health Service 

as an example of the failures that would occur under a government-run healthcare system. I even had this in some of my town 

meetings but these portrayals of the IHS are unfortunate, gratuitous and misleading. The IHS has not failed. Rather the Federal 

Government has historically failed to properly fund the IHS. A 

2004 report on Native American health issued by the U.S. Commission on Civil Rights found that inadequate Federal funding was the 

major obstacle to eliminating disparities in Native American 

healthcare. The report stated that annual increases in funding for 

the Indian Health Service did not include adjustments for inflation 

or population growth and were significantly less than those allocated to other arms of the Department of Health and Human Services. And this is an important point, in being less is spent on providing healthcare to American Indians per capita than any other 

subpopulation. In fact, we spend more money to provide healthcare 

to Federal inmates than we do for American Indians and I think 

that is probably the most shocking statistic of all. 

We have made some headway in recent months. Provisions relating to Indian health were included in legislation enacted earlier 

this year including CHIP or SCHIP as I call it and the ARRA, the 

Recovery Act or the Stimulus Bill. In both bills we were able to include provisions that would improve outreach in enrollment of 

American Indians eligible for Medicaid and CHIP. In addition, the 

Recovery Act included a substantial increase in funding for the Indian Health Service and in May of this year the IHS released 500 

million of those funds to be used for health facilities construction 


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or maintenance and improvements, health information technology, 

sanitation facilities, construction and health equipment that will 

help improve healthcare in Indian country. 

In addition to these funds, President Obama proposed a 13 percent increase for the IHS in his fiscal year 2010 budget proposal, 

and I am happy to say that both the House and the Senate are on 

track to approve the level of funding requested by the President or 

even exceed it. Simply by adequately funding the Indian Health 

Service we can substantially increase the health and well-being of 

Native communities. But we can’t simply say we are going to increase funding for the IHS and call it a day because it is not just 

a matter of funding. It is a matter of making sure these programs 

work well and can meet the needs that are present in those communities. The bill we are looking at today would make important 

changes to the delivery of healthcare services in Indian communities to make sure needs are being met. That is why we must 

make sure this bill is passed this Congress. It has languished 

around here for far too long. 

I want to say I think many of you know that this effort to try 

to include as much of the Indian Health Care Improvement Act in 

various legislation as well as in the healthcare reform bill that is 

moving is an ongoing effort, and we are still trying to do that as 

much as possible. But I do think that we needed a hearing today 

because whatever isn’t included obviously we would like to move as 

separate legislation if that becomes necessary and so having the 

hearing today is which is a legislative hearing as our effort to continue down that path as quickly as possible. 

I want to thank our witnesses for testifying. We have some new 

faces including Dr. Yvette Roubideaux, who is the new Director of 

the IHS. We also have some returning witnesses including Rachel 

Joseph, who is the co-chair of the National Tribal Steering Committee to reauthorize the Indian Health Care Improvement Act, 

and thank you, Rachel, for all you have done on this bill. So I want 

to welcome our witnesses. 

And I will now—well, I was going to recognize—I will have to 

recognize Mr. Shimkus for an opening statement if he likes. 

Mr. SHIMKUS. Thank you, Mr. Chairman, and I want to welcome 

our guests here, also. I want to first apologize. This is a day when 

I conduct a monthly tour for Army veterans and their families at 

the Capitol which I am already 15 minutes late for so but I wanted 

to make sure that the hearing got off on time with members from 

the Minority Party here too to welcome you and I look forward to 

your testimony. 

The only point that we will add to this debate and it has been 

a debate in the last reauthorization, and it was addressed in the 

Senate legislation and we have this debate now with the overall 

healthcare reform, is the issue of taxpayer funds that would go to 

abortion and abortion services. There are many of us who will 

not—will want us to maintain the position of the Hyde language 

amendment which has been very important in the past legislation. 

It is under challenge today and so it is important for you all to 

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crats, who will make—want to really ensure that taxpayer dollars 

not go for those specific type services. 

So with that, I appreciate the time, Mr. Chairman. I apologize 

for departing but I have dual commitments. 

Mr. PALLONE. Thank you. Donna, the gentlewoman from the Virgin Islands, Ms. Christensen, who has actually both the two both 

of my colleagues who are here today have had major roles in pushing this legislation. So I appreciate both of your being here and all 

that you have done. 

The gentlewoman from the Virgin Islands. 

OPENING STATEMENT OF HON. DONNA M. CHRISTENSEN, A 

REPRESENTATIVE IN CONGRESS FROM THE VIRGIN ISLANDS 

Mrs. CHRISTENSEN. Thank you. Thank you, Mr. Chairman, and 

thank you for holding this hearing. 

You know, preparing for this hearing today just rekindled my indignation over the way indigenous people of this country have been 

treated. I don’t think it even rises to the level of benign neglect. 

It really can’t when one looks at the tragic impact it has had on 

individuals, families, tribes and Native populations over the centuries. But H.R. 2708, the Indian Health Care Improvement Act 

Amendments of 2009 is a good and welcome start however it just 

scratches the surface. 

Disease, illness or in the converse, health and wellbeing don’t 

exist in a vacuum. They are the consequences of genetics to some 

degree, and behavior as well, but the most influential factor is the 

environment, for the environment affects behavior for sure and can 

even have some impact on the genetics. Given the deterioration of 

the environment in which Native people are now confined to, there 

are extremely poor health, no life expectancy and adverse health 

behavior resulting in high rates of injuries, suicide, alcoholism and 

other substance abuse would be expected outcomes of any population group. 

Having had no change in Indian Health Service provisions since 

1976 despite the dire health indicators and given the many advances of health knowledge and technology is truly a shame. The 

fact that we have not been able to pass a reauthorization since 

2001 is also unacceptable. So I am glad that we are having this 

hearing today following on the one in the Committee on Natural 

Resources where the chairman and I are both also members and 

I am also pleased that in addition to the provisions in CHIP and 

ARRA that H.R. 3200 includes some eye care provisions and I am 

proud to say that the tri-caucus has included eye care provisions 

in our health equity bill and that we have fully included concerns 

of our American Indian, Alaskan and Hawaiian Native brothers 

and sisters in our efforts and our initiatives. But these can only be 

considered first steps in the effort that we owe to these first members of the American family. 

So I look forward to working with you, Chairman Pallone and 

Ranking Member Deal, to make sure that the Indian Health Care 

Improvement Act Amendments of 2009 are finally passed in 2009. 

So thank you for holding this hearing. Thank you to the witnesses 

who are here with us today, not only for being here but for all of 


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the work that you have done over the years to improve upon the 

bill that we have before us today. 

Thank you. I yield back the balance of my time. 

Mr. PALLONE. Thank you. 

The gentlewoman from Wisconsin, Ms. Baldwin. 

OPENING STATEMENT OF HON. TAMMY BALDWIN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF WISCONSIN 

Ms. BALDWIN. Thank you, Mr. Chairman. Thank you for convening us and convening this hearing on The Indian Health Improvements Act. I know that this is a major priority for you, Mr. 

Chairman, and for this subcommittee and I am eager to lend my 

support and help achieve the goal of reauthorization during this 

Congress. 

One of my primary concerns like the gentlelady from the U.S. 

Virgin Islands, one of my primary concerns is the stark disparities 

experienced by minority populations in the United States in the 

healthcare system and with healthcare outcome and access. The 

American Indian and Alaska Native people have long experienced 

lower health status when compared with other Americans, and a 

recent report from the Agency for Health Research and Quality 

outlined a number of areas in which American Indians and Alaska 

Natives lag behind others and the specific areas where these disparities are growing worse. The report uses a number of measures 

to assess access to care including prenatal care, rate of preventative screening and other basic services that are key to preventing 

illness and disease. 

One of the most alarming and difficult issues to address is the 

rampant spread of diabetes in Indian country. Lack of public 

health initiatives leave families without the information they need 

to get healthy and to stay healthy, and diabetes ends up being a 

persistent chronic disease that costs the Indian Health Service an 

extraordinary amount of money but much more importantly too 

many Native Americans their lives. 

That is why I am especially proud of a facility I want to boast 

about it in the district that I represent run by the Ho-Chunk Nation. The House of Wellness is a state-of-the-art facility designed 

to offer a full range of health services with the focus on prevention 

and wellness. It is a fitness and aquatic facility featuring a range 

of programs designed to promote exercise, a professionally trained 

staff, indoor walking track and studio lifestyle classes. The House 

of Wellness also offers childcare services for parents who need a little bit of time to take care of their own health and it also offers 

a health clinic and pharmacy services to help meet the needs of the 

community, both Native and non-Native. Through promotion of exercise and helping people of all ages focus on prevention, facilities 

like this one can change the health trajectory of many Native 

American families. 

The Indian Health Service also provides vital water and sanitation assistance to members of the Ho-Chunk Nation. As you know, 

ensuring that housing is safe and provides access to safe and clean 

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we have languished so long without reauthorizing this incredibly 

important legislation. I want to thank our witnesses here today 

who will help us understand how much more pressing the need becomes with each passing day. 

Again, Mr. Chairman, thank you for convening this hearing and 

I also must apologize. I am going to be skipping between two simultaneous hearings this afternoon but I hope to be here as long 

as I can to hear your testimony. 

Mr. PALLONE. Thank you. 

And we will now move to our witnesses and on our first panel 

we have the Director of the Indian Health Service, Yvette 

Roubideaux, thank you for being here today. I guess I normally say 

that we have 5 minutes but since you are the only witness, I am 

not going to worry about it too much but thank you and if you 

would like to begin. 

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

DIRECTOR, INDIAN HEALTH SERVICE 

Dr. ROUBIDEAUX. Thank you, Mr. Chairman and members of the 

committee. 

Good afternoon. My name is Dr. Yvette Roubideaux and I am the 

new Director at the Indian Health Service. I am accompanied by 

Mr. Randy Grinnell, the Deputy Director of the Indian Health 

Service. I am really pleased to have this opportunity to testify on 

H.R. 2708, the Indian Health Care Improvement Act Amendments 

of 2009. I am looking forward to working with you to ensure passage of this important authorizing legislation for the Indian Health 

Service. 

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

the Department of Health and Human Services because it is a 

healthcare system that was established to meet the Federal Trust 

Responsibility to provide healthcare for American Indians and 

Alaska Natives. The mission of the Indian Health Service is a partnership with the American Indian and Alaska Native people to 

raise the physical, mental, social and spiritual health to the highest level. The Indian Health Service provides high quality, comprehensive primary care and public health services through a system of IHS, tribal and urban operated facilities to nearly 1.5 million American Indian and Alaska Natives through hospitals, health 

centers, clinics located in 35 States. However, meeting the mission 

of the Indian Health Service has become increasingly challenging 

over time. Population growth, increased demand for services, rising 

medical costs and the growing burden of chronic disease have place 

significant strain on the system. 

In the opening statement of my confirmation hearing before the 

Senate Committee on Indian Affairs, I stated that despite these 

challenges I see evidence of hope and change. I have worked on a 

variety of projects and national initiatives over the past 16 years 

that have shown me the great potential that exists to improve access and quality of healthcare. I know that thousands of dedicated 

and committed career staff in the Indian Health System work hard 

everyday to provide healthcare to their patients in the face of all 

these challenges and I have seen support from tribes and Congress 

for change and improvement in the Indian Health Service. I believe 


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we are at a unique moment in time where we have the opportunity 

to take great strides towards fulfilling the mission of the Indian 

Health Service and improving the health of American Indian and 

Alaska Natives. 

President Obama’s commitment to improve healthcare for American Indian and Alaska Native people is reflected by a significant 

funding increase for the Indian Health Services you mentioned and 

the fiscal year 2010 budget. While the President, the Secretary and 

I all understand that money alone is not the whole answer, the significant increase in resources for IHS recommended in the President’s budget is essential for the agency to increase services and 

effectively fulfill its mission. 

Now is the time to begin the important work of bringing change 

to the Indian Health Service to improve healthcare quality, to modernize and upgrade IHS facilities, to expand health promotion and 

disease prevention, and to ensure that American Indians and Alaska Natives are able to get the healthcare that they deserve. Passage of the Indian Health Care Improvement Act will be an important step towards these goals. The Department strongly supports 

reauthorization of the Indian Health Care Improvement Act and 

supports the effort to ensure that IHS is able to meet the 

healthcare needs of American Indians and Alaska Natives and 

takes into account increased tribal administration of health programs. It is within this context today that we offer our views on 

H.R. 2708. We will provide a few comments today and we will provide additional comments once we have had an opportunity to conduct complete review of this important reauthorizing legislation. 

First, we note that the authority for the Catastrophic Health 

Emergency Fund or CHEF fund included in title 2 of the existing 

authority has actually been excluded from this bill. We recommend 

its inclusion because the CHEF program is a key component of the 

contract health program administered by the IHS and tribal health 

programs. CHEF provides funding for high-cost cases which cannot 

be absorbed by local service units contract healthcare programs. 

Our next comments are in title 1. IHS offers health profession 

scholarships to American Indian and Alaska Native students who 

agree to sign a legal contract agreeing to a service obligation upon 

completion of their health professional training. Unfortunately, a 

small number of students default on their service obligation. We 

believe the determination of whether to discharge or suspend a defaulted obligation should remain entrusted as is under current law 

to a review board charged with making impartial case by case decisions based on a detailed review of the requests. We recommend 

that the new consultation requirement in this section of title 1 be 

dropped. Defaulting on this obligation is a serious breach of a legal 

contract and a resolution must be decided in an impartial manner. 

The IHS also offers a loan repayment program to health professionals who agree to work in areas of high vacancy or need and a 

list of priority sites is developed each year. In title 1, H.R. 2708 

changes current law to require the Secretary to approve loan repayment of where it is not withstanding the priority ranking of positions for which there is a need or a vacancy required under the 

section. This modification means that award and approvals would 

be based on other priorities undermining the development of our 


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annual priority list. So to keep the intent of the loan repayment 

program consistent with the goal of improving recruitment and retention of health professionals in areas of high vacancy or need, we 

recommend the term notwithstanding be replaced by terms consistent with the priority list. 

My next comments are on title 3, the sanitations facility deficiency definitions. H.R. 2708 would provide ambiguous definitions 

of sanitation deficiencies used to identify and prioritize water and 

sewer projects in Indian country. Our written testimony provides 

examples of the problems with these definitions. We recommend retaining current law to distinguish the various levels of deficiencies 

which determine allocating existing resources. 

In addition to the comments I have made today on certain provisions of H.R. 2708 there will be additional comments once we have 

had an opportunity to conduct a complete review of this important 

reauthorizing legislation. Mr. Chairman, that concludes my testimony. I appreciate the opportunity to appear before you to discuss 

the reauthorization of the Indian Health Care Improvement Act of 

2009. We are committed to working with you to ensure the reauthorization of this key legislative authority. I will be happy to answer any questions that you have. Thank you. 

[The prepared statement of Dr. Roubideaux follows:] 


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Mr. PALLONE. Thank you and now we will take questions from 

the panel. I will start with myself. 

First of all let me thank you for actually getting specific because 

unfortunately and I know it sounds partisan but in the previous 

administration we—I don’t remember any of the open testimony at 

all being, you know, specific about the bill. And I also appreciate 

the fact that you are going to get back to us quickly because as I 

said I would like to see as much of this included in the healthcare 

reform as possible and so, you know, as we move with that whatever comments we can get from the administration will be very important, you know, over the next few weeks or the next few 

months. 

I want to try to get in three questions here quickly if I can. You 

know, obviously this legislation has languished for many years in 

Congress so could you tell us why it is so important to reauthorized 

the Act and what are the consequences to the IHS and those who 

rely upon it that we have other than if we continued not to reauthorize? 

Dr. ROUBIDEAUX. Well, reauthorization of the Indian Health Care 

Improvement Act is extremely important. It is important to our patients and our tribes because they view it as their version of 

healthcare reform and what the Act does is modernizes and updates the Indian Health Service so that we can provide better care 

for the patients that we serve. The consequences of not acting are 

that again are our patients and tribes are waiting for this important legislation to be reauthorized so we strongly support its passage. 

Mr. PALLONE. OK and then the second question, you know, I 

wanted to thank you and for the President obviously for making, 

you know, the additional funding available that is in the budget. 

Clearly, that is very important but IHS doesn’t rely solely on its 

annual appropriations to finance services to tribes. It collects reimbursements from Medicare/Medicaid and private payer so how important is it to make sure that tribal members are enrolled in other 

public programs like Medicare and Medicaid or private insurance 

when they are eligible for such coverage? And what types of barriers do tribal members face in enrolling in these other programs? 

How can we overcome those barriers that exist? 

Dr. ROUBIDEAUX. Right, well, as I had stated the resources that 

we have available in the Indian Health System make it difficult for 

us to meet our mission and so we rely on the ability of serving patients who have other resources in terms of insurance or Medicare 

and Medicaid coverage. Third party reimbursements from these 

sources are extremely important. For some of our facilities, over 

half of their operating budget comes from third party reimbursements so they serve an extremely important source of care for us. 

I think some of the barriers that we have to having some of our 

patients enroll in these forms of coverage is that the paperwork can 

be confusing. There may be a misunderstanding of why they need 

to provide the information that they do for the applications. And 

with regard to private insurance, I think that for many of our patients they just can’t afford to pay the premiums or can’t afford to 

pay the co-pays. That is why a national health reform provides an 


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opportunity to perhaps American Indians and Alaska Natives have 

access to better coverage as well. 

Mr. PALLONE. Thank you. And then my third question was about 

the, you know, some of the changes. I know you were able to offer 

us some of the administration’s positions on organizational structural changes and you said you are going to get back to us with 

more which again, I would appreciate as soon as possible. But did 

you want to talk a little more about any of these organizational 

structural changes, say particularly the elevation of the IHS Director to the position of assistant secretary because that is the important part of this legislation for a long time? 

Dr. ROUBIDEAUX. Right, we understand that the proposal to elevate the Director of the Indian Health Service to an assistant secretary level is extremely important to our tribes and it has been 

a recommendation by them because they would like their 

healthcare needs to be addressed at the highest levels in the Department. I am working with the Secretary and her staff on exploring this issue and once we receive—once we develop a position on 

it we will let you know but we definitely understand that the 

health needs of American Indians and Alaska Natives need to be 

addressed at the highest levels in the Department of Health and 

Human Services and we are committed to that. 

Mr. PALLONE. And that is obviously one that if you could get 

back to us as quickly as possible. Thank you. 

The gentlewoman from the Virgin Islands, Ms. Christensen. 

Mrs. CHRISTENSEN. Thank you, Mr. Chairman, and welcome, Dr. 

Roubideaux. I missed you at the first hearing. 

My first question refers to some of the recommendations that Dr. 

Rock has made that the urban Indians be restored in section 1 and 

6 of section 3 be included in the women’s health section and in the 

section that deals with payments under Medicare and Medicaid 

and SCHIP. Would your office be supporting those recommendations again? Are you aware of them? 

Dr. ROUBIDEAUX. Well, while I can’t comment on the specific provisions of the bill I can tell you that we are supportive of the needs 

of urban American Indians and Alaska Natives. We know that 

many of our American Indians and Alaska Native people choose to 

leave the reservation and go to urban areas but unfortunately that 

leaves them in many cases uncovered by the Indian Health Service. 

So fortunately in some communities we do have the 34 Urban Indian Health programs that are funded by the Indian Health Service and those programs are supported by title 5 of this particular 

Act, and certainly other provisions apply to them as well. So we 

recognize these clinics as extremely important sources of 

healthcare for Native people who go to urban areas. Especially because it is the only source of culturally appropriate care that they 

can receive in urban areas and these places often help them have 

a sense of community and a sense of home while they are away 

from the reservations. And so with regard to the specific provisions 

what we will include that in our review but we are very supportive 

of generally doing what we can to support the urban Indian population. 

Mrs. CHRISTENSEN. Thank you. The bill has provisions to help 

and recruit and retain health professionals and I believe that the 


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best providers are those from our community—from the community 

themselves. In the African-American community the biggest barrier 

to achieving that kind of diversity in the health workforce is the 

K through 12. I know this is not specifically related to the bill but 

is there some commensurate thing from the initiative happening 

with K through 12 to ensure that this provision to train and recruit 

them and retrain perhaps Native American providers would not be 

an empty promise? 

Dr. ROUBIDEAUX. Well, there are a number of programs that are 

already funded by various agencies to deal with the health professional shortages in our communities. One program that we find is 

the Indians Into Medicine program that looks at recruiting young 

American Indians and Alaska Native individuals into the health 

professions. We have a site in North Dakota and we also have a 

site in Arizona and those address the K through 12 population to 

try to get them interested in science careers. One of the most innovative projects that we have been involved with is the diabetes and 

science and education project in tribal schools that was developed 

in partnership with the National Institute of Diabetes, Digestive 

and Kidney Diseases. And a curriculum was developed by tribal 

colleges to be given to students in the K through 12 grades to expose them to science but using diabetes as the example not only 

to expose them to the science of the disease but also how to be 

healthy and in that process helps them learn about health professional careers and we are very excited that curriculum is just now 

available and will be disseminated throughout Indian country. So 

I think there is some opportunities to improve the exposure of students to science and to health careers in our communities but we 

clearly need more efforts. 

Mrs. CHRISTENSEN. Thanks. The bill makes reference to under 

sanitation facilities the inordinately high incidence of disease, injury and illness directly attributed to the absence or inadequacy of 

sanitation facilities. And it also says that the long term cost is far 

greater than the short term cost of providing those sanitation facilities. Is the bill language strong enough to provide the services that 

would be needed in terms of the sanitation to create those savings 

not only in money but in terms of illness and lives? 

Dr. ROUBIDEAUX. Well, one of the important functions of the Indian Health Service is to provide sanitation facilities. The Indian 

Health Care Improvement Act has provided the foundation for 

that. With this bill we have discussed some problems that in the 

definitions of how they are defining those. 

Mrs. CHRISTENSEN. Right. 

Dr. ROUBIDEAUX. And I think that reauthorization of this bill is 

important in terms of what services we could provide for our communities. 

Mrs. CHRISTENSEN. Thank you. 

Thank you, Mr. Chairman. 

Mr. PALLONE. Thank you and thanks so much for your testimony. I appreciate it. 

Dr. ROUBIDEAUX. Thank you. 

Mr. PALLONE. Good luck with everything. 

Dr. ROUBIDEAUX. Thank you very much. 

Mr. PALLONE. I would ask the second panel to come forward. 


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Our second panel has four witnesses and I will introduce them 

starting on my left is the Honorable Jefferson Keel who is Lieutenant Governor of the Chickasaw Nation and President-Elect of the 

National Congress of American Indians. And then is Rachel Joseph 

who is Co-Chair of the National Tribal Steering Committee for the 

Reauthorization of the Indian Health Care Improvement Act. And 

then we have another Joseph, Andrew Joseph, Jr. who is Chairman 

of the Human Services Committee, Direct Services Tribe Advisory 

Committee. And finally, Dr. Patrick Rock who is Executive Director 

of Indian Health Board of Minneapolis and President-Elect of the 

National Council of Urban Indian Health. Thank you for being here 

and thank you for all that you have done over the years on this 

legislation. 

As I said, you know, we have 5 minutes but there is not a lot 

going on today so we are not going to stick to that too much and 

we will start with Mr. Keel. 

STATEMENTS OF HONORABLE JEFFERSON KEEL, LIEUTENANT GOVERNOR OF THE CHICKASAW NATION AND PRESIDENT-ELECT OF THE NATIONAL CONGRESS OF AMERICAN 

INDIANS; RACHEL JOSEPH, CO-CHAIR, NATIONAL TRIBAL 

STEERING COMMITTEE FOR THE REAUTHORIZATION OF 

THE INDIAN HEALTH CARE IMPROVEMENT ACT; ANDREW 

JOSEPH, JR., CHAIRMAN, HUMAN SERVICES COMMITTEE, DIRECT SERVICES TRIBE ADVISORY COMMITTEE; AND PATRICK ROCK, M.D., EXECUTIVE DIRECTOR, INDIAN HEALTH 

BOARD OF MINNEAPOLIS, PRESIDENT-ELECT, NATIONAL 

COUNCIL URBAN INDIAN HEALTH 

STATEMENT OF JEFFERSON KEEL 

Mr. KEEL. Thank you, Mr. Chairman. 

Good afternoon and first I want to begin by just saying as the 

President of the National Congress of American Indians I am honored to be asked to present testimony to our friends at the Health 

Subcommittee of the Energy and Commerce Committee. On behalf 

of the National Congress of American Indians I greatly appreciate 

the opportunity to again provide comments and support for a 

House bill on the Indian Health Care Improvement Act. 

I want to begin by thanking you Congressman Pallone for your 

continued efforts to improve the healthcare services delivered to 

American Indians and Alaska Natives. The Indian country extends 

its thanks for your hard work over the last several years on the 

Indian Health Care Improvement Act. We appreciate all that you 

and the committee have done. Now it is time to get this bill out 

of committee and passed by the full House of Representatives. 

My colleagues today will be providing you testimony on duty, 

rights and obligations for Indian health. They will also provide you 

with the shocking statistics on health disparities in our communities and why the reauthorization is so desperately is needed, all 

of which the committee is very familiar with. What I would like to 

do today is simple. I would like to ask the committee to set a 

schedule and procedure for when the bill will be passed and enacted. 


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Over the last 10 years, NCAI has worked side-by-side with the 

National Steering Committee for the Reauthorization of the Indian 

Health Care Improvement Act and the National Indian Health 

Board for the same procedures. We work with numerous committee 

staff on drafting language, watch leadership in the House change 

and have seen two Presidents come and go in office. With each 

passing year there seems to be a new must-pass priority and the 

Indian Health Care is relegated to the sidelines. The nation is now 

focused on reforming the health insurance industry. As with the 

rest of the country, this issue is of critical importance to tribes and 

we support the efforts of the Obama Administration and Congress. 

Speaker Pelosi and Mr. Pallone have recognized the importance of 

protecting and preserving the Indian healthcare delivery system 

during this reform effort and the National Congress of American 

Indians thanks you for your commitment to Indian country. 

The Indian Health Service as you well know is in need of updates and modernization. The current House Bill H.R. 2708 is a 

starting point for reforming the IHS. As with the national health 

reform bills its goal is to provide cost-saving features for healthcare 

delivery by shifting the healthcare delivery paradigm in the IHS to 

preventative health. Indian country has been waiting for and asking for these updates for over 10 years. We do not believe the national health insurance reform should be used as an excuse for 

abandoning the effort to reauthorize the Indian Health Care Improvement Act. We now come before the committee to ask for an 

assurance that as the nation moves forward with health reform the 

Indian country will be included and our bill the Indian Health Care 

Improvement Act will be passed. What I ask again to the committee is, what is your strategy for passing the Indian country’s 

health modernization bill? The National Congress of American Indians knows what this committee can do when it sets its mind to 

it. We all saw how quickly you came together to write and pass the 

Affordable Health Choices Act. We witnessed the hard work of the 

staff in drafting the Indian protections needed within that bill and 

the dedication of the committee in passing those key provisions. We 

now ask that that same enthusiasm and commitment be provided 

for the Indian Health Care Improvement Act. 

The National Congress of American Indians stands ready as I do 

and I am sure the other members of this panel do to do whatever 

it takes to get this bill passed. Again, thank you for this opportunity and I look forward to working with you for passage of this 

important bill. Thank you. 

[The prepared statement of Mr. Keel follows:] 


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Mr. PALLONE. Thank you, Mr. Keel. 

Ms. Joseph. 

STATEMENT OF RACHEL JOSEPH 

Ms. RACHEL JOSEPH. Good afternoon, Mr. Chairman, and distinguished members of the committee. 

I am Rachel Joseph, Shoshone Paiute of the Lone Pine PaiuteShoshone Tribe of California and Co-Chair of the National Steering 

Committee for the Reauthorization of the Indian Health Care Improvement Act, the NSC. I appreciate the opportunity to testify 

today and to state our strong support for H.R. 2708. On behalf of 

the NSC and National Indian Health Board, we appreciate your ongoing support for improving healthcare for Indians. I also acknowledge the contribution of tribal leaders who have served on the NSC 

over the past 10 years. 

The foundation of our participation in this reauthorization is 

based on two principles. One, that the legislation allow no regression from current law and that the healthcare system be modernized and strengthened. 

In the Chairman’s opening statement he recited the health status and the statistics of our population. No other segment of the 

American population experiences greater health disparities than 

the American Indian and Alaska Native populations. The heartbreaking aspect of these statistics is the knowledge that a majority 

of illnesses and deaths are preventable if additional funding and 

modern programmatic approaches to healthcare were available. Despite two centuries of treaties and promises, American Indians and 

Alaska Natives endure health conditions and a level of healthcare 

that would be unacceptable to most Americans. 

Today I respectfully request Congress to fulfill our nation’s responsibilities to Indian people by reauthorizing the Indian Health 

Care Improvement Act this year. The Indian Health Care Improvement Act also needs to be a permanent law, thus we urge the committee to amend H.R. 2708 to remove the sunset dates and permanently authorize appropriations for the Act’s programs. Our request 

for a permanent authorization is not unique. Congress has permanently authorized other Federal Indian Laws such as The Snyder 

Act, The Indian Self-Determination and Education Assistance Act 

and other laws which I listed in my written testimony. 

There are many provisions in the bill which embody the improvements needed for the Indian healthcare system. I would like to 

highlight just three of them. Section 208 recognizes a need for tribal epidemiology centers to be expressly authorized to access the 

data they need to monitor the incidents of diseases in Indian communities and to help tribes in urban Indian organization design 

programs to attack those diseases. Complete fulfillment of this mission requires epicenters to operate like public health authorities 

and to access Indian country data compiled by HHS agencies. 

Secondly, we strongly support the bill’s revisions to current law 

authorizing a comprehensive system of behavioral health programs. 

Title 7 authorizes the integration of programs for mental health, 

social services, domestic and child abuse, youth suicide and substance abuse. Attacking these chronic problems is vital to improve 


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the quality of life in Indian country and strengthening Indian families. 

Lastly, section 807 addresses a serious issue in Indian country 

when tribes are compelled to try to fill the funding gap by expanding direct services, augmenting contract healthcare, paying premiums for Medicare part B and D, and developing self-insurance 

plans for their members. Unfortunately, the tax consequence of 

such efforts are unclear. Section 807 will clarify that these benefits 

are tax-exempt as they should be. They were prepaid through the 

cessation of over 400 million acres of tribal lands and other resources. American Indians and Alaska Native people are entitled to 

healthcare and should not be taxed when their tribes step in to assist them in obtaining care. 

While the NSC is extremely supportive of this bill there are a 

few provisions that require revision and additional provisions we 

would like to see inserted into the bill. Our proposals are outlined 

in the section by section revisions document which was included 

with my written testimony submitted for the record. 

I would like to conclude by sharing my personal observations and 

experiences with this reauthorization which have been the most 

positive and uplifting experience in my life and at the same time 

the most frustrating experience. During the consultation with the 

tribes that began in 1998 and continued through 1999, tribal leaders across the country made some strong commitments that we 

would spend long hard hours—no cell phones was one of my ground 

rules which was pretty exciting as the tribes developed consensus 

on the proposal that we submitted to Congress. We believe that 

consensus was necessary so that, you know, we would not be in a 

divide and conquer position but as you balance the diverse and the 

varied needs of our tribes it was a tremendous project and undertaking and we did it and we have been able to maintain consensus 

through all these years. 

The disappointment part of course is that our job is not done. Mr. 

Chairman, we appreciate your sponsorship of this bill and we particularly appreciate our relationship that we have been able to 

have. Excuse the—no pun intended, frank and forthright discussions about the need for reauthorization and we are fortunate that 

we have that kind of communication. I also would be remiss if I 

did not acknowledge the support and ongoing efforts of Chairmen 

Rayhall, Waxman and Rangel and former Chairman Don Young 

and Dingell and of course Chairman George Miller who has never 

wavered in his support since he first introduced Indian Health 

Care Improvement Act when he was chairman of the Natural Resources Committee. Together with our many sponsors who have 

consistently stayed with us throughout the years, there is no reason in our view that this legislation should not be enacted this 

year. 

I would be happy to respond to any questions that you have and 

look forward to working with you to get this job done. Thank you. 

[The prepared statement of Ms. Rachel Joseph follows:] 


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Mr. PALLONE. Thank you. 

Mr. Andrew Joseph. 

STATEMENT OF ANDREW JOSEPH, JR. 

Mr. ANDREW JOSEPH. Chairman Pallone and distinguished members of the committee. 

My name is Badger in my language. I am Andrew Joseph, Jr. I 

Chair the Health and Human Services Committee of the Colville 

Federated Tribes. I Chair the Portland Area Indian Health Board 

and the Vice-Chair for IHS–DST, Direct Service Tribes. 

Thank you for inviting the Direct Service Tribes to testify today. 

The Direct Service Tribes are tribes that have decided to receive 

their healthcare services directly from the IHS. The Direct Service 

Tribes consider the decision as an exercise of self-determination 

and the fulfillment of the Federal Trust Responsibility. Out of 564 

federally recognized tribes, IHS provides direct healthcare services 

for over 100 tribes and accounts for over 50 percent of the total 

IHS population served. Since 1999 tribes have been seeking reauthorization of the Indian Health Care Improvement Act. However 

for reasons it is difficult to understand, passage of the Indian 

Health Care Improvement Act Reauthorization Bill has been obstructed each year by concerns of unrelated non-Indian issues. I 

hope the committee will work with us to ensure that this bill is not 

sidetracked this year and the bill is passed as soon as possible. 

For the Indian people, Federal responsibility to provide health 

services represents a prepaid right. Tribes hold and affirm that the 

treaties with the Federal Government ensure that healthcare will 

be delivered effectively in our communities to exchange for the millions of acres of valuable land that are ancestors ceded. Today the 

Indian Health Care Improvement Act continues to be a vital important policy with—that honors these treaties and serves as a foundation for delivery of healthcare to Indian people. 

I would like to speak on a few provisions of H.R. 2708 that would 

have significant impact for Direct Service Tribes. First, section 212 

provides express authority for IHS and tribes to operate hospice, 

long term care, assisted living programs to supply health services 

in homes and community-based settings. All such delivery methods 

are common in the rest of the country but are rare in Indian country. 

Second, the elevation of the IHS director as an assistant secretary level that is in the Department of Health and Human Services would be a strong step in creating a direct link to address the 

needs of tribes especially Direct Service Tribes. With an assistant 

secretary position, the collaborative efforts of tribes and IHS would 

be enhanced through true government to government dialog. 

Additional recommendations—in my remaining time, I also 

would like to touch on two recommendations for H.R. 2708, permanent authorization of the Indian Health Care Improvement Act. 

The process of having the Indian Health Care Improvement Act authorized has been long. Tribes have invested into the process for 

over 10 years. As a tribal leader I need to justify the resources of 

my—that my tribe puts into trips to Washington, D.C. I know that 

these vital resources could be put towards critical patient care, 

however I and my tribe also understand the importance of ensuring 


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that the Indian Health Care Improvement Act is reauthorized. To 

honor our treaties and to ensure the continual authority for our 

healthcare system, the bill should be amended to ensure that the 

authorization for appropriations is permanent. 

Establishing an office of Direct Service Tribes, H.R. 2708 should 

also be amended to include the establishment of an office of Direct 

Service Tribes located within the proposed office of assistant secretary. The responsibilities of this office would honor the relationship with tribes by providing technical support to Direct Service 

Tribes in serving as a point of contact for tribal consultation. 

I wish to thank the committee for the opportunity to provide 

these comments and I will be pleased to answer any questions the 

committee may have. Thank you. 

[The prepared statement of Mr. Andrew Joseph follows:] 


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Mr. PALLONE. Thank you. 

Dr. Rock. 

STATEMENT OF PATRICK ROCK, M.D. 

Dr. ROCK. Thank you. Good afternoon. 

My name is Dr. Patrick Rock, Leech Lake Band enrollee and also 

the President-Elect for the National Council of Urban Indian 

Health, and also the CEO of my organization called the Minneapolis Indian Health Board. 

On behalf of the National Council of Urban Indian Health and 

the 9,000 patient visits that my clinic serves annually, I would like 

to thank Representative Pallone for introducing this important bill. 

I would also like to thank the subcommittee for holding this hearing. 

The Urban Indian Health Program serves over 150,000 American 

Indians and Alaska Natives annually through 36 urban Indian programs across the county. It is a comprehensive health delivery system that integrates public health, preventative health measures, 

behavioral health and primary care services. The urban Indian programs providing health services are at various levels of services dependent upon the needs of the community and the funding. Our 

programs are both innovative and cost effective. As a whole, the 

urban Indian health program leverages $2 for every dollar of Indian health service investment. 

We are also a unique system of care designed to fulfill the trust 

responsibility to Indian people living in urban areas. Congress has 

repeatedly stated that the government’s trust responsibility extends to American Indians and Alaska Natives living away from 

their tribal homes. From the original Snyder Act of 1921 to the Indian Health Care Improvement Act Congress has affirmed and reaffirmed its commitment to ensure that trust responsibility to Indian people is met regardless of where they reside. 

Despite this commitment, the trust responsibility to Indian people has not been fully met. The Indian healthcare delivery system 

is innovative and well-situated to address the health disparities 

suffered by Indian people in a comprehensive, culturally appropriate manner. However, the Indian health delivery system needs 

full funding and modernization promised by this bill in order to 

meet its mission. 

H.R. 2708 provides a number of new tools and updates for the 

Indian health providers. These programs and modernizations will 

help the Indian health delivery system tackle the serious health 

disparities facing our people. 

I would like to take the opportunity to highlight three provisions 

that I believe will greatly benefit urban Indian health providers 

such as myself. First, in section 515, conferring with urban Indians, in order to—in order of the trust responsibility to urban Indians are fully met, urban Indians need the opportunity promised by 

this section to discuss the health needs of urban Indians with the 

Federal Government. 

Second, section 521, authorization for urban Indian organizations, H.R. 2708 creates tools and programs to address behavioral 

health disparities suffered by Indian people, especially with regard 

to Indian youth suicide. This provision assures that urban Indian 


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programs will have such programs available through them through 

title 5 of IHCIA. 

Third, section 522, health information technology, health information technology is the future of health delivery. Any provider 

that does not develop HIT infrastructures and systems now will be 

behind the advances of medicine to the detriment of their patients. 

This provision assures that title 5 programs will have the support 

and the opportunities they need. 

There are also three revisions that the National Council of Urban 

Indian Health seeks. First, NCUIH strongly supports the National 

Steering Committee’s recommendation that IHCIA be made permanent Federal law. There are several major laws which Congress 

has permanently authorized. We believe that the time has come to 

give IHCIA the same permanency. 

Second, NCUIH also asks the committee to restore urban Indians 

to section 3, the Declaration of National Indian Health Policy. Removing urban Indians from this provision is a regression from current law. By not including urban Indians, Congress opens the door 

to inferences that it no longer believes that the trust responsibility 

extends to urban Indians. We believe that dropping urban Indians 

from this provision was done in error and ask the committee to restore urban Indians. 

Third, NCUIH asks the committee to restore urban Indians to 

section 201 of title 2. These provisions pertain to third-party billing, a critical necessity for any health provider. Including urban Indians in this section would greatly help urban Indian organizations 

strengthen their third-party billing capacity which could be a difference between fiscal stability and instability for many programs. 

As President-Elect of the National Council of Urban Indian 

Health and the CEO of Minneapolis Indian Health Board, I would 

like to give Representative Pallone, the committee and the sponsor 

of the H.R. 2708 my deepest and most sincere thanks for producing 

this bill. H.R. 2708 provides the necessary modernization for Indian health delivery system and all Indian health providers from 

the Indian health service to urban Indian health providers will 

benefit greatly from this passage. While there are few provisions— 

important provisions for urban Indians that NCUIH feels should be 

reconsidered we believe that this bill truly reflects the priorities of 

tribes and of urban Indian health programs. 

Thank you. 

[The prepared statement of Dr. Rock follows:] 


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Mr. PALLONE. Thank you, Dr. Rock. 

And we will take questions from myself initially and then my colleague from the Virgin Islands. 

Let me address some of the things you mentioned. First, Mr. 

Keel talked about schedule and procedure for moving the bill and 

I would just, you know, like to reiterate what I said before which 

is that, you know, I would like to see as much of this included in 

the larger healthcare reform as possible, and so it may very well 

be that until we know where we are going with that in the next 

few weeks that, you know, we would have to wait until that is sort 

of resolved. 

And then I wanted to mention with regard to Ms. Joseph, I am 

very much supportive of what you suggested about not taxing 

health benefits provided by tribes. I mean my view of going back 

to what I said in the opening statement is that, you know, since 

we have a responsibility on the part of the Federal Government to 

provide healthcare completely for Native Americans, if and we are 

not doing it, if the tribes set in to make up for that difference it 

is even more outrageous to consider taxing them for it when we are 

supposed to be providing the benefit completely. So I have sent letters to IRS and of course, you know, co-sponsored the legislation 

that would change—that would make it clear that they are not taxable. Now, that is the Ways and Means issue as you know. It 

doesn’t actually come before this committee but it is something 

that we are mindful of as well, you know, as we move forward with 

the healthcare reform. 

I wanted to ask you because several of you mentioned about the, 

you know, making the Act permanent and I was going to ask Ms. 

Joseph initially, I mean there is some precedent for that especially 

with respect to Indian law but tell me in a little more detail why 

you think there is a need for permanent authorization. I mean why 

is that needed as a—I mean normally we don’t do it so would be 

your justification? 

Ms. RACHEL JOSEPH. Well, thank you, Mr. Chairman, for the 

question. 

I think after this long 10-year experience of course, you know, 

the expenditure of resources that Chairman Joseph spoke to, we 

certainly, you know, don’t want to have to go through that exercise. 

But more importantly, we think if we have a permanent authorization and Congress we know can revisit that and revise and amend 

it as necessary, we think that in the future we would have an opportunity to focus on one or two or three issues that need to be addressed, and have some extensive conversations and dialog spent 

on those issues, and we think that we should do more of that. 

Mr. PALLONE. OK, I wanted to ask Mr. Joseph a different question and that is about long term care services. You raised that in 

your testimony and this is something that I am very interested in, 

you know. There is probably not going to be much in the healthcare 

reform, the larger healthcare reform on that because of the expense 

but I am curious to know more about, you know, those long term 

care supports and services provided in Indian country. I mean how 

are the American Indian elders provided long term care now and 

how would the revised authority under this bill change the delivery 

of care? 


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Mr. ANDREW JOSEPH. Honorable Mr. Pallone, right now our tribe 

we have—the Colville tribe has a rest home. We have a area agency on aging and we have some of the people that take care of our 

elders at home. Some of our elders, you know, because of sanitation 

reasons need to be cared for 24 hours a day, you know, everyday 

of the year. And, you know, we all would like to take our last 

breath in our own home but for some of us, you know, we are not 

able to do that. Some people are really physically impaired and 

some elders are trying to take care of elders. So what we would like 

to be able to do is figure out, you know, put an amendment in the 

bill that would be able to help us, you know, take care of our elders. The Makah tribe has elders in rest homes that are over an 

hour, an hour and a half away from their reservation. In order to 

be able to go and visit them it is a long commute. And by having 

this in the bill, we can provide that care for ourselves and it would 

provide jobs and it would be allowed for if we can bill through IHS 

an Indian counter-rate through Medicaid or Medicare. To me, our 

convalescence and our elder rest home is culturally run. We have 

our cultural ceremonies there and our elders feel more at home 

there. 

Mr. PALLONE. Well, that is what I was going to ask you. I would 

imagine your biggest concern is that if, you know, elders have to 

be taken to a nursing home or some institution off the reservation 

is that very common now amongst tribes? I imagine you try to prevent that but is that—is it very common that they have to actually 

go to a, you know, or what I call a mainstream nursing home off 

the reservation? 

Mr. ANDREW JOSEPH. Because of the lack of sufficient funding for 

IHS, a lot of our elders become into more of a critical need by the 

time they, you know, find that their illnesses take them to a rest 

home facility and because it is not in the bill right now tribes 

aren’t able to really, you know, help fund, you know, for those services to build their own and take care of their own. 

Mr. PALLONE. All right, thank you. 

Let me just ask Dr. Rock, you of course talked about the urban 

Indian health program primarily and you mentioned that the 

urban Indian health program and how the last Administration 

tried to eliminate it from the bill. Of course, I never quite understood that. Can you talk about how that urban Indian program 

why it is so important that it stays in place and needs to be expanded the way this bill proposes? And, you know, we hear various 

things that there are more and more, you know, Native Americans 

that are moving off reservations, living in cities but then we also 

hear that a lot of them are coming back. Well, maybe that is less 

so now with the recession or maybe more so, I don’t know. I mean 

I guess it depends upon whether there is economic opportunities on 

the reservation but do you want to comment on that in terms of, 

you know, particularly now with the recession or where we are 

going in the next few years? 

Dr. ROCK. Certainly, well that makes two of us that we didn’t 

understand why we were zeroed out to begin with but we play a 

really important part as far as this healthcare system that Indian 

Health Service provides. We see a number of patients that are either in transition that are moving in and through the Twin Cities, 


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specifically my program the Twin Cities, Minneapolis and Saint 

Paul. People are looking for work. I see a number of patients of 

mine, I still practice medicine, that have lost their jobs that have 

no insurance and they have absolutely nowhere to go. They have 

no access to care. Even though we—our clinic is right smack in the 

middle of several hospitals, we have the university system there. 

We have a couple of private hospital systems there that offer clinical services too, but our patients feel like they don’t have the access there because they don’t have the funding to pay for 

healthcare, and we often see folks that come in that have really advanced disease. They are diabetes, take for example, is to the point 

to where now they are starting to see kidney problems or eye problems and we try our best to get people to the care they need but 

we are often at that level of where we are just putting a Band-Aid 

on something that could be addressed more appropriately if the 

funding sources were there. 

Mr. PALLONE. Has the recession resulted in more people moving 

back to the reservation, moving off or both? Is there—I mean I 

know I am asking you anecdotally but? 

Dr. ROCK. Yes, that is exactly right. It is just through my anecdotal experience of seeing patients one-on-one everyday. We do see 

a number of folks that are just moving to the Twin Cities looking 

for opportunities for work. Again, some statistics that we see these 

days that are 60 percent of Native populations live in urban settings and I will be interested to see what the new census data will 

show as we head into the census as to what that is now currently 

but anecdotally, I have a number of patients who have lost their 

jobs. I have had one gentleman who worked in the foundry, lost his 

job, his insurance. He was a Native man. He was enrolled in the 

White Earth Band of Ojibwe in Northern Minnesota, and his wife 

recently—was recently diagnosed with cancer so she was—the family was struggling, and let alone him losing his job and presenting 

to me with new onset congestive heart failure which requires, of 

course, treatment and therapies that he couldn’t afford. So that is 

one person that I see but everyday, everyday we are open we see 

this. 

Mr. PALLONE. OK, thank you very much. Thank all of you. 

Before I move to our other panels, let me just ask unanimous 

consent that a statement from Congressman Dale Kildee and also 

from the California Rural Indian Health Board, if those would be 

entered into the record, and without objection, so ordered. 

The gentlewoman from the Virgin Islands. 

Mrs. CHRISTENSEN. Thank you again, Mr. Chairman. 

President Keel, just from the frustration that hint in your testimony I would imagine that you support the permanent reauthorization of IHCIA? 

Mr. KEEL. Absolutely, yes, I do. 

Mrs. CHRISTENSEN. Thank you. I just wanted to get your—that 

on the record. 

And, Dr. Rock, you talked about HIT and the importance of improving healthcare but do you see this technology as being really 

important to linking the urban Indian to the tribes and to services? 

Do you think that it can be assistance because I understand that 

we don’t even know how many American Indians are living in 


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urban centers and the difficulties that they have when they need 

services? 

Dr. ROCK. I think it does have a potential. I know the current 

thought behind health information technology is the key word of 

interoperability of how the system is actually going to work together, and we have an invested interest also from an urban standpoint of being part of that system. We think that we could provide 

really a real high quality of care to our patients with the utilization 

of a system as well even cutting our costs as far as healthcare if 

we have an interoperable system and a system that is workable 

with their providers. 

Mrs. CHRISTENSEN. Well, I was on Homeland Security before I 

came to Energy and Commerce and interoperability is something 

that we are still working on over there and that has been what, 

7 years. 

Let me see, I guess let me see who I would ask, Ms. Joseph, 

maybe or anyone can really answer this. I am a strong believer and 

supporter of primary prevention and the high prevalence of deaths 

from injury, from auto accidents, from suicide has always been 

something that I have been concerned about. And I notice similar 

patterns in not only in the American Indian but the Alaska Natives 

and I wonder if—I don’t think that just treating something to the 

use of alcoholism is enough because there are all kinds of conditions as I said in my opening statement but is there anywhere that 

you can see that we could do something within this reauthorization 

that would address maybe some of the social determinants as well. 

We talked about the modernization of approaches of medicine and 

to me one of the more the newer, some of the newer thinking is 

about the social determinants to health. But does anybody have 

any—to what would you attribute the high prevalence of death and 

injury and suicide on the reservation and how could we better address that? 

Ms. RACHEL JOSEPH. Well, we always—I hesitate to say, of 

course we need more money and but we need more money for one 

thing. We are opposing a comprehensive approach to behavioral 

health which addresses a number of those issues you raise and we 

think, you know, with a comprehensive approach we are able to use 

our money more efficiently which would be some. I do believe that 

some of the safety funding related to ambulances and so forth and 

so on, that comes through another agency and HHS and through 

the States, and some States, you know, have a better working relationship with their tribes and some don’t. So some of that, you 

know, accident prevention, you know, auto accidents. 

Mrs. CHRISTENSEN. Services when you have had an accident. 

Ms. RACHEL JOSEPH. Yes, that money needs to flow directly to 

the tribes and not through the States. 

Mrs. CHRISTENSEN. Is there enough in the bill that supports the 

traditional healers or is there a need for us to incorporate the traditional healers more in this legislation? 

Ms. RACHEL JOSEPH. Yes, there—thank you, Councilman, there 

is language in the bill that addresses traditional healers and it is, 

you know, a tribe by tribe situation and patient by patient and, you 

know, as the patients and the doctors view that traditional healing 

as necessary, there is authorization to provide for that. 


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Mrs. CHRISTENSEN. So you are satisfied with it with the way it 

is treated in 2708? 

Ms. RACHEL JOSEPH. We are satisfied with it. We do have a little 

definition recommendation that we would like to, you know, we 

would like to include in a revision. 

Mrs. CHRISTENSEN. OK, I don’t have any further questions, Mr. 

Chairman. 

Mr. PALLONE. Thank you. 

The gentlewoman from Illinois, Ms. Schakowsky. 

Ms. SCHAKOWSKY. Thank you. 

First, let me apologize for coming in at the last minute but I 

didn’t want to miss the opportunity to let you all know that I am 

a big supporter of the Indian Health Care Improvement Act 

amendments and I am a partner with you in trying to get better 

healthcare. 

I am from Chicago where in my district there is the American 

Indian Center and in my Chicago office, which isn’t far from there, 

I have a star quilt that was given to me by the Chicago Indian 

Health Service, and I work very closely with them and, you know, 

want to make sure that the resources that are needed are always 

available. The organization does operate a health clinic, conducts 

education and outreach in diabetes, provides home visits to people 

with diabetes to ensure they are managing the disease correctly. In 

Illinois, there is about 73,000 American Indian and Alaska Natives 

and the really there is a big concentration in my district. So I just 

really wanted to congratulate you on your advocacy on the good 

work that you have been doing and to make sure that I didn’t miss 

the opportunity to tell you that I am grateful for your advocacy, for 

the care that you provide and for the chance to work with you to 

make it even better. 

Thank you. I yield back. 

Mr. PALLONE. Thank you and thank you all. I know this was 

short hearing today but I don’t—I want you to know that doesn’t 

in any way take away from, you know, our efforts to try to move 

this bill or as I said before, include it in the larger healthcare reform. And I know all of you have been playing a major role in all 

of this and will continue to as we move forward over the next few 

weeks. 

Did you have a question? Sure. 

Mr. ANDREW JOSEPH. Chairman Pallone, Dr. Roubideaux talked 

about the CHEF and not being included in this and to me it is really important that it be included into the bill. One of the reasons 

why is we are in the CHS dependent area and are—my tribe’s reservation is in a remote location as some of the Alaska Native villages and some of the other Direct Service Tribes are in remote locations, and by not having that in the bill, I would be afraid that 

we would be losing a whole lot more lives. The distance that our 

people have to travel to get to a hospital facility, if we don’t have 

hospitals in our area, you know, we have a real need for these 

funds. My own grandbaby had to be heart flighted out a little over 

a year ago into to Spokane and that cost over $10,000. That is 

where the CHEF funds money comes into play. It is almost like 

sending our troops to war and not paying for the helicopters to 


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bring them in, you know, once they get wounded. So it is really important. 

Mr. PALLONE. Now, I am glad you brought it up and my assistant tells me that that was basically a drafting error and we are 

conscious of it and we are going to try to correct it, you know, as 

we move along because I know how important it is so thank you 

for bringing it to our attention again. 

All right, thanks very much and we do intend to move forward. 

Thank you. 

[Whereupon, at 3:25 p.m., the Subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 


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