U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Printing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001

40–848 PDF 2008

S. HRG. 110–332

NOMINATION OF ROBERT G. MCSWAIN TO BE

DIRECTOR OF THE INDIAN HEALTH SERVICE

HEARING

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS 

UNITED STATES SENATE

ONE HUNDRED TENTH CONGRESS

SECOND SESSION

FEBRUARY 7, 2008

Printed for the use of the Committee on Indian Affairs

(

(II)

COMMITTEE ON INDIAN AFFAIRS 

BYRON L. DORGAN, North Dakota, Chairman 

LISA MURKOWSKI, Alaska, Vice Chairman 

DANIEL K. INOUYE, Hawaii 

KENT CONRAD, North Dakota 

DANIEL K. AKAKA, Hawaii 

TIM JOHNSON, South Dakota 

MARIA CANTWELL, Washington 

CLAIRE MCCASKILL, Missouri 

JON TESTER, Montana 

JOHN MCCAIN, Arizona 

TOM COBURN, M.D., Oklahoma 

JOHN BARRASSO, Wyoming 

PETE V. DOMENICI, New Mexico 

GORDON H. SMITH, Oregon 

RICHARD BURR, North Carolina 

ALLISON C. BINNEY, Majority Staff Director and Chief Counsel 

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

(III)

C O N T E N T S 

Page 

Hearing held on February 7, 2008 ......................................................................... 1

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

Statement of Senator Murkowski ........................................................................... 2

Statement of Senator Smith ................................................................................... 6

WITNESSES

McSwain, Robert G., Nominee to be Director of the Indian Health Service, 

U.S. Department of Health and Human Services ............................................. 7

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

Biographical information ................................................................................. 11

Van Huss, Hon. Jacquie Davis, Chairperson, North Fork Rancheria of Mono 

Indians of California ............................................................................................ 4

Prepared statement .......................................................................................... 5

APPENDIX

Barrasso, Hon. John, U.S. Senator from Wyoming, prepared statement ........... 27

Letters of support: 

California Rural Indian Health Board, Inc. ................................................... 29

National Indian Health Board ......................................................................... 28

Toiyabe Indian Health Project, Inc. ................................................................ 30

Response to written questions submitted to Robert G. McSwain by: 

Hon. John Barrasso .......................................................................................... 33

Hon. Maria Cantwell ........................................................................................ 33

Hon. Tom A. Coburn, M.D. .............................................................................. 31

Hon. Tim Johnson ............................................................................................ 36

Hon. Gordon H. Smith ..................................................................................... 30

(1)

NOMINATION OF ROBERT G. MCSWAIN TO BE 

DIRECTOR OF THE INDIAN HEALTH SERVICE 

THURSDAY, FEBRUARY 7, 2008

U.S. SENATE, 

COMMITTEE ON INDIAN AFFAIRS, 

Washington, D.C. 

The Committee met, pursuant to notice, at 9:30 a.m. in room 

628, Dirksen Senate Office Building, Hon. Byron L. Dorgan, Chairman of the Committee, presiding. 

OPENING STATEMENT OF HON. BYRON L. DORGAN,

U.S. SENATOR FROM NORTH DAKOTA 

The CHAIRMAN. We will call the hearing to order. This is a hearing of the Indian Affairs Committee of the United States Senate. 

Today, the Committee takes another important and necessary 

step in fulfilling its commitment to try to improve Indian health 

care by considering the nomination of Robert McSwain to be the 

Director of the Indian Health Service. 

We talk a lot in this Committee about the challenges and what 

needs to be done. We talk about the statistics: American Indians 

die at higher rates than other Americans from tuberculosis, 600 

percent higher; alcoholism, 510 percent higher; diabetes, nearly 

double; suicide, 60 percent higher. 

But as we rattle off these numbers, it is important to understand 

we are talking about individuals, people struggling to deal with 

their health care needs. When we talk about the 1.9 million Indian 

Health Service patients, we are referring to a group of people in 

this country who have been afflicted often with very chronic health 

conditions. A group who, in exchange for land and other possessions that they once had, secured federally-sponsored health care, 

a trust responsibility and beyond that, in many cases, a treaty commitment from the Federal Government. 

It is our responsibility, it seems to me, to keep this promise and 

to provide the First Americans with quality health care, and to do 

so with accountability, efficiency and compassion. Accountability is 

a major theme that we are going to talk about in regards to the 

Indian Health Service today. I would say that I think there are 

some wonderful, dedicated professional people who have committed 

their lives to the Indian Health Service. I have seen them, I have 

watched them work and I commend them. 

I also believe that the Indian Health Service in some other areas 

is a Federal agency whose arteries are clogged with bureaucracy, 

2

inefficiency, ineffectiveness, and in some cases desperately in need 

of reform. 

We also face a circumstance where about 40 percent of the health 

care needs of American Indians is unmet. That means we have 

health care rationing, which would be scandalous in most areas, 

but seems to be the norm with respect to delivering health care to 

American Indians. 

We need to do much, much better than that. My hope is that Mr. 

McSwain, as the leader of the Indian Health Service, will begin to 

be able to effect some of these reforms. I am terribly disappointed 

with the President’s budget, once again. I don’t think the President 

or the Congress has done their obligation to meet our responsibility, our trust responsibility for Indian health care for many, 

many, years. My hope is that one day we can look back with some 

pride to say that we did what was required of us and what we have 

previously promised: to provide health care to Native Americans. 

Today we will focus on the confirmation of Robert McSwain. On 

December 18th, President Bush sent Mr. McSwain’s nomination to 

the full Senate. Mr. McSwain has worked in the Indian Health 

Service for 24 years in various capacities. In the field of Indian 

health itself, he has worked for 36 years. He is a member of the 

North Fork Rancheria of Mono Indians of California. The Committee has received statements of support for Mr. McSwain’s nomination from the California Rural Indian Health Board, that is the 

organization that Mr. McSwain served as executive director in the 

mid-1970s, before being tapped to be the IHS California area office 

director. 

The National Indian Health Board, the non-profit organization 

whose membership is made up of each of the Indian Health Service 

areas, also has issued statements of support. I ask consent that 

these and other letters regarding this nomination will be included 

as a record of today’s hearing. Without objection, that will be done. 

Also, I understand that Mr. McSwain is a cousin to Ms. Rachel 

Joseph, who is Co-Chair of the National Steering Committee to Authorize Indian Health Care. She has provided tremendous assistance to this Committee in our attempt to reauthorize the Indian 

Health Care bill. Before I recognize the Vice Chair of the Committee, I want to state the process for moving forward with this 

nomination. Today we will have an opportunity to hear from Mr. 

McSwain and to ask some questions. Once the Committee has received responses, including responses from questions we submit, we 

will report out the nomination at the next scheduled business 

meeting. 

Senator Murkowski. 

STATEMENT OF HON. LISA MURKOWSKI,

U.S. SENATOR FROM ALASKA 

Senator MURKOWSKI. Thank you, Mr. Chairman. 

Good morning, and I want to thank you for moving very quickly 

to the confirmation hearing of Mr. McSwain. When we learned 

back in September that Dr. Grim had withdrawn his nomination, 

I was one of those that expressed great regret. We had a good experience with Dr. Grim in the State of Alaska. But I am very pleased 

that the President has nominated another very dedicated Native 

3

American for what I think we all acknowledge is a very difficult, 

very challenging job. 

You have indicated, Mr. Chairman, in your opening remarks, 

some of the statistics that we deal with that we face as a committee here in trying to advance in a positive way, not only the 

health care needs, but so many of the issues that face Indian Country. We are reminded on the one hand of the very negative statistics. But as I have had an opportunity to point out on the Floor, 

as we have worked to advance the Indian Health Care reauthorization, we do have some good stories, we do have some good progress 

to report in Indian health. 

I have mentioned before the tele-medicine that we are able to 

bring into some of our bush communities and into the reservations, 

some of the sanitation facilities in the remote villages where we are 

making some progress and helping to reduce the mortality rates. 

But again, as you point out, the challenges that face far too many 

are oftentimes insurmountable. We face a time of stringent budgets 

where the directive ‘‘don’t get sick after June’’ continues to be a 

very chilling reminder that the Indian Health care system has fallen far, far short of what its beneficiaries deserve. 

You have mentioned the overwhelming disease rates. These are 

despite the dedicated efforts of Indian health professionals. We continue to experience far too many unnecessary deaths, amputations, 

the pain caused by diabetes. We remain haunted by the youth suicides, the unsolved murders, the rapes of countless Native women. 

We have said, and you certainly, Mr. Chairman, have said that the 

painful truth is that we still have third world conditions existing 

in many of our Nation’s Indian and Alaska Native communities. 

So you have to ask the question, to our nominee, why, Mr. 

McSwain, would you want to take on this job, knowing the difficulties, knowing what you are facing with the disease rates, the funding levels, even knowing that there is obviously going to be a 

change of Administration? I have heard it expressed that anyone 

intelligent enough for this job is probably too smart to accept it. 

But I believe that your intelligence and that of many of our past 

IHS directors is unquestionable. 

But your presence before us today I think speaks greatly to your 

dedication to Indian health, to improving the lives of Indian and 

Alaska Native people and to tribal sovereignty and to self-governance. 

With that, Mr. Chairman, I would like to speak to the specifics 

of Mr. McSwain and introduce him to the Committee, if I may. We 

had a very good conversation a couple days ago in my office about 

Mr. McSwain’s mission, his vision and his pledge for Indian health. 

As you noted from the biography that was submitted to the Committee, Mr. McSwain has worked for the IHS since 1976. He reminded me that he began work for the IHS at the same time that 

the Indian Health Care Act was authorized. You have noted it has 

been a long time, clearly a long time within IHS that Mr. McSwain 

has given his service. 

During that time, he has received numerous awards, most notably the President’s Rank Award for meritorious service in 2004 and 

the President’s Rank Award for distinguished service in 2006. It 

appears that you have held nearly every managerial position availVerDate 0ct 09 2002 09:08 Apr 03, 2008 Jkt 040848 PO 00000 Frm 00007 Fmt 6633 Sfmt 6633 S:\DOCS\40848.TXT JACK PsN: JACKF
4

able in IHS: area director in California, special advisor to the IHS 

director, various positions in the IHS in the areas of management, 

human resources, manpower, deputy director of IHS and then now 

appointed to be acting director. 

In my conversation with Mr. McSwain, I noted that he was quite 

proud of his long and distinguished career with IHS, but he was 

also proud, and I think rightly so, of his time spent working for 

tribal health programs from 1971 to 1974 as the director of the 

Central Valley Indian Health, and then in 1974 to 1976, he served 

as the executive director of the California Rural Indian Health 

Board in Sacramento. Mr. McSwain comes from Indian Country 

and it is too Indian Country that he has remained dedicated. He 

comes from the North Fork Rancheria of Mono Indians in California, proudly supported by his people and his chairperson, 

Jacquie Davis Van Huss, who is here with us today and will provide her remarks for Mr. McSwain. We greatly appreciate that. 

Mr. McSwain was raised by his grandparents who instilled in 

him Indian values which gave him the perseverance, the character, 

to carry him through his career. Mr. McSwain has convinced me 

that if confirmed, he will remain committed to supporting tribal 

self-governance and self-determination. As many know here in the 

room today, self-governance is working successfully, particularly in 

Alaska, and I expect that success to continue under Mr. McSwain’s 

command. 

Moreover, he is committed to the mission of the Indian Health 

Service, which as we have heard many, many times before, is to 

raise the physical, mental, social and spiritual health of American 

Indians and Alaska Natives to its highest level. That mission cannot be accomplished without the help of tribal leaders and of this 

Congress. 

Between his time with the tribal health programs and his time 

with the IHS, Mr. McSwain dedicated about 27 years of his life to 

improving the health of Native people. That, Mr. Chairman, and to 

those here, that is really a lot of on-the-job training for this very 

challenging appointment. I have no doubt he will need to draw on 

those years of experience to carry him through the tough times 

that he will experience as Director if confirmed. 

With that, Mr. Chairman, I thank you and I look forward to 

hearing from Mr. McSwain this morning, and hopefully to an expeditious process. Thank you. 

The CHAIRMAN. Thank you very much. 

We will hear from the Honorable Jacquie Van Huss, Chairperson 

of the North Fork Rancheria, North Fork, California. Ms. Van 

Huss, thank you very much. You may proceed. 

STATEMENT OF HON. JACQUIE DAVIS VAN HUSS,

CHAIRPERSON, NORTH FORK RANCHERIA OF MONO

INDIANS OF CALIFORNIA 

Ms. VAN HUSS. Good morning, Chairman Dorgan, Madam Vice 

Chair Murkowski and the distinguished members of the Senate 

Committee on Indian Affairs. My name is Jacquie Davis Van Huss, 

and I am the Tribal Chairperson for the North Fork Rancheria of 

Mono Indians, which is the largest restored tribe in California. 

Joining me today is our Tribal Council Secretary, Katrina Lewis. 

5

I am delighted to be here for several reasons. I am privileged to 

bring you greetings from each of our 1,680 tribal citizens who share 

their immense pride as I come forward to introduce and express 

support for and confidence in one of our enrolled tribal citizens, 

Robert G. McSwain, or Bob, as we know and love him. 

For nearly three years, Bob has proven himself at the highest 

levels of leadership at Indian Health Services, first as IHS Deputy 

Director, then as Acting IHS Director. His nomination now to be 

permanent Director of Indian Health Services serves as both tribute and testimony to his capabilities and to his commitment to improve the health conditions of all American Indians. 

Mr. Mike Leavitt, Secretary of Health and Human Services, had 

the following to say about Bob upon assumption of his current role 

as Acting Director in September of 2007: ‘‘I am pleased that Bob 

has taken on this position. Over this 30-year career in the Department, Bob has played a pivotal role, most recently sharing responsibility with the IHS Director for managing a $4 billion national 

health care delivery program. His leadership has helped ensure 

that IHS is able to provide top quality preventive, curative and 

community care to approximately 1.9 million American Indians and 

Alaska Natives. During his tenure, Bob has received two Presidential Rank Awards for distinguished and meritorious service. I 

am confident he will continue to provide strong leadership for the 

IHS in serving as its Acting Director.’’

The North Fork Rancheria takes health management seriously, 

having helped create and manage innovative programs such as a 

multi-tribal Temporary Assistance for Needy Families program, 

and the multi-county Central Valley Indian Health, Incorporated, 

in which Bob first started his health career. From this perspective, 

we too have full confidence in Bob’s ability to lead, manage and advocate effectively on behalf of the Nation’s American Indians and 

Alaska Natives in hospitals, clinics and other settings throughout 

the United States. 

The State of California is home to one-fifth of the federally-recognized tribal governments in the United States. Mr. Robert G. 

McSwain brings a unique perspective to this high Federal position 

as both a Native son of California and someone who has literally 

worked his way up to the highest levels of Government. We believe 

this experience and perspective will serve Mr. McSwain well as he 

represents the diversity and richness of both American Indian 

health and tribal sovereignty concerns and needs. 

We believe that Mr. Robert G. McSwain, our esteemed tribal citizen, will serve the position of Director of Indian Health Services 

with great honor and distinction. 

With this said, I have the honor to introduce my tribal citizen, 

Mr. Robert G. McSwain. 

[The prepared statement of Ms. Van Huss follows:]

PREPARED STATEMENT OF HON. JACQUIE DAVIS VAN HUSS, CHAIRPERSON, NORTH

FORK RANCHERIA OF MONO INDIANS OF CALIFORNIA

Good morning Chairman Dorgan, Vice Chairman Murkowski and distinguished 

members of the Senate Committee on Indian Affairs. 

My name is Jacquie Davis Van Huss and I am Chairperson of the North Fork 

Rancheria of Mono Indians of California, which is the largest restored tribe in California. Joining me today is our Vice-Chairperson Elaine Fink and our Secretary 

6

Katrina Lewis. I am delighted and honored to be here for several reasons. I am privileged to bring you greetings from each of our 1680 tribal citizens who share their 

immense pride today as I come forward to introduce and express support for and 

confidence in one of our enrolled Tribal citizens, Robert G. McSwain, or ‘‘Bob’’ as 

we know and love him. 

For nearly three years Bob has proven himself at the highest levels of leadership 

at the Indian Health Services, first as IHS Deputy Director then as Acting IHS Director. His nomination now to be permanent Director of the Indian Health Services 

serves as both tribute and testimony to his capabilities and to his commitment to 

improve the health conditions of all American Indians. 

Mr. Mike Leavitt, Secretary of Health and Human Services, had the following to 

say about Bob upon the assumption of his current role as Acting Director in September, 2007:

‘‘I am pleased that Bob has taken on this position . . .. Over his 30-year career 

in the Department, Bob has played a pivotal role, most recently sharing responsibility with the IHS Director for managing a $4 billion national health care delivery program. His leadership has helped ensure that the IHS is able to provide top quality preventive, curative, and community care to approximately 1.9 

million American Indians and Alaska Natives. During his tenure, Bob has received two Presidential Rank Awards for Distinguished and Meritorious service. 

I am confident he will continue to provide strong leadership for the IHS in serving as its Acting Director.’’

The North Fork Rancheria takes health management seriously, having helped create and manage innovative programs such as a multi-tribal Temporary Assistance 

for Needy Families program and the multi-county Central Valley Indian Health, Incorporated. From this perspective, we too have full confidence in Bob’s ability to 

lead, manage, and advocate effectively on behalf of the nation’s American Indians 

and Alaska Natives in hospitals, clinics, and other settings throughout the United 

States. 

The State of California is home to one-fifth of the federally recognized tribal governments in the United States. Mr. Robert G. McSwain brings a unique perspective 

to this high federal position as both a native son of California and someone who has 

literally worked his way up to the highest levels of government. We believe this experience and perspective will serve Mr. McSwain well as he represents the diversity 

and richness of both American Indian health and tribal sovereignty concerns and 

needs. 

We believe that Mr. Robert G. McSwain, our esteemed Tribal Citizen, will serve 

the position of Director of Indian Health Services with great honor and distinction. 

With this said, I have the honor to introduce, our Tribal Citizen, Mr. Robert G. 

McSwain.

The CHAIRMAN. Madam Chairperson, thank you very much for 

traveling here from California to provide that statement. 

Ms. VAN HUSS. We are very honored to be here, and we highly 

support Mr. McSwain. 

The CHAIRMAN. We got that impression from your testimony. 

[Laughter.] 

The CHAIRMAN. We appreciate it very much. 

Ms. VAN HUSS. Thank you. 

The CHAIRMAN. Mr. McSwain, would you please come forward? 

Mr. McSwain, we welcome you to the Committee. I am going to 

call on you for a statement in just a moment, but I wanted to recognize Senator Smith, who has arrived,if you have anything you 

wish to say. 

STATEMENT OF HON. GORDON H. SMITH,

U.S. SENATOR FROM OREGON 

Senator SMITH. Thank you, Mr. Chairman, Vice Chair Murkowski, for providing the Senate Committee on Indian Affairs with 

an opportunity to hold a confirmation hearing for Robert McSwain. 

7

The issue of Indian health care is critical in the State of Oregon. 

Whether at my annual tribal summit or visiting tribal lands 

throughout Oregon, I always hear how important access to quality 

health care is to Indian Country. 

The Indian Health Care Improvement Act brings us closer to fulfilling the need, and I thank the Chairman and Vice Chair and 

their staffs for working to advance the bill. I look forward to its 

passage on the Floor, and its swift passage. While I recognize this 

bill as a step in the right direction, I am concerned that in its current form,the bill maintains an inequity in the distribution of 

health facility construction funds. Currently, this fund favors a few 

tribes and a few States, while the majority of tribes, including 

those in Oregon, have never received agency funds to build a hospital. 

I would like to take this opportunity to hear from Mr. McSwain 

whether the Indian Health Services would have the statutory authority under the Indian Health Care Improvement Act to implement an area distribution fund that would equally distribute a portion of health facility construction funds to all IHS regions across 

the Country. I am not trying to require the creation of an area distribution fund. That decision must rest with the agency, the tribes 

and their budget situation. 

I do, however, want to ensure that the agency is not legislatively 

precluded from implementing this fund if it determines that it is 

in the best interest of Indian Country as a whole. Beyond that, I 

want to reemphasize that the services in the Act, especially those 

related to health care delivery, are vital to the health and wellbeing of tribal families and communities. They need us to finish 

our work and get this bill signed into law this year. 

I look forward to continuing to work with Mr. McSwain and the 

Chair and Vice Chair and other colleagues to explore ways to address everyone’s interest and ensure that all Native Americans, not 

just some, receive the health care they need and deserve. 

The CHAIRMAN. Senator Smith, thank you very much. 

Mr. McSwain, thank you for being with us. We will at this point 

take your testimony and then ask some questions. You may proceed. 

STATEMENT OF ROBERT G. MCSWAIN, NOMINEE TO BE

DIRECTOR OF THE INDIAN HEALTH SERVICE, U.S.

DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Mr. MCSWAIN. Mr. Chairman, Madam Vice Chairman and other 

distinguished members of the Senate Committee on Indian Affairs, 

I am truly humbled and honored to have been nominated by President Bush, supported by tribal governments, endorsed by Secretary 

Leavitt, and for this Committee to consider my term as Director of 

Indian Health Service. I am quite surprised at the speed at which 

you have done this, and that speaks to your concern about the Indian Health Service’s continuity. 

I would like to thank and acknowledge my family, especially my 

wife, June McSwain, who has been my confidant and closest friend 

for over 35 years. 

The CHAIRMAN. Mr. McSwain, do you have family members here 

you wish to introduce? 

8

Mr. MCSWAIN. I have family members I will introduce in a moment, Mr. Chairman. My daughter, Kristin Ruud, who is a nurse 

in Houston, and my son, Major Eric Ruud, who is still in the forces 

and serving in places around the world. My daughter Elizabeth and 

my granddaughter Britney Ruud are here today to accompany and 

shore me up. 

On this special occasion, as Senator Murkowski noted, I have 

been doing a lot of reflecting as the nomination has occurred. I 

have reflected back many years, not only to my career, but to my 

roots, so to speak. In this case, I was calling upon my grandparents, Dan and Ella, who raised me, as the Senator noted, with 

the Indian values of listening, compassion, respect, mutual respect 

and caring for the environment. 

I am proud to pledge before this Committee to both Federal and 

tribal governments that if confirmed, I will do my best to uphold 

the Federal Government’s commitment to raising the health status 

of American Indians and Alaska Natives to the highest level. I remain committed to working with this Committee and the Administration and tribal governments toward our shared goals and objectives. 

I have had the privilege of having two distinct careers, obviously, 

as pointed out earlier, the first five years essentially in tribal 

health, health programming in California, and the second 30 years 

in actual engaging and working for the Indian Health Service. It 

is interesting, I want to make two points not quite on my statement, but when I decided to come to the Federal service, tribal 

folks told me they wanted me to be able to go to the Government 

and do something back for Indian people in California. Now, I find 

myself at the crossroads of another, what more can I do for Indian 

people. 

I have had the pleasure of working with and for five of the seven 

previous directors of the Indian Health Service. All my positions 

have occurred at stages of change and my nomination today reflects another stage of change. If confirmed, I will work diligently 

to support the decision of tribes to contract, compact or retain Indian Health Service as their provider of choice. The Indian Self-Determination Act allows tribes to manage their own health programs, and with some rare exceptions, they have done an absolutely outstanding job. Let there be no doubt that I support and advocate for the sovereign rights of tribes to self-govern. 

I am also committed to continuing the Director’s three initiatives, 

and work hopefully with Dr. Grim on these three initiatives, as 

they have a great potential for doing great things. These three initiatives are health promotion and disease prevention; behavioral 

health; and chronic care management. I firmly believe that the future of tribal communities depends on how effectively Indian 

Health Service and the health system addresses chronic diseases. 

The leadership of the IHS has concluded that we cannot address 

the health needs of American Indians and Alaska Natives alone. 

And if I am confirmed, I intend to continue to grow and expand the 

collaborations with other Federal agencies and private organizations who share our mission and vision. 

The key to our successes in the past and our future efforts is 

based upon two very, very important groups, both Senator MurVerDate 0ct 09 2002 09:08 Apr 03, 2008 Jkt 040848 PO 00000 Frm 00012 Fmt 6633 Sfmt 6601 S:\DOCS\40848.TXT JACK PsN: JACKF
9

kowski and Chairman Dorgan have noted, the committed, compassionate, competent work force that we have throughout the system. 

Indian health care is a labor-intensive process. I would say that 

our competence goes not only to our Federal but also our tribal employees as well. 

The second group is some amazing tribal leaders, we have one 

of them here today in Rachel, who have provided many selfless 

hours to the mission of the Indian Health Service. In looking to the 

future, we must pause and review where we are, namely, that over 

one-half of the Indian Health Service program over the last 30 

years now rests in the hands of tribes. Tribes operate over half of 

the Indian Health Service program. 

The Indian health care delivery system is comprised of many 

parts. Though outstanding in their individual performance, I believe we can be more efficient and effective if all the parts are 

working together. Such an example is our experience with IHS 

tribal and urban Indian communities piloting the chronic care 

management model in their communities. I have observed the excitement and commitment to a delivery of higher quality care that 

can only be a plus to American Indians and Alaska Natives in the 

future that we serve. 

I have been reflecting on the seven previous Directors of the Indian Health Service, particularly as we recently celebrated the past 

50 years. I come before you on the shoulders of a great legacy of 

Directors. As my predecessors, I have the same passion about this 

organization and our mission to raise the health status of our people to the highest possible level. My actions have and will always 

reflect the honor of being entrusted to provide health services to 

American Indian and Alaska Native people. 

If confirmed, I am ready to lead the Indian Health Service with 

honor and respect for our ancestors and to work with you and the 

Administration for the benefit of the American Indian and Alaska 

Native people. 

I would be pleased to respond to any questions you may have 

concerning my nomination, Mr. Chair. Thank you. 

[The prepared statement and biographical information of Mr. 

McSwain follows:]

PREPARED STATEMENT OF ROBERT G. MCSWAIN, NOMINEE TO BE DIRECTOR OF THE

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

Mr. Chairman, Madam Vice-Chair, and other distinguished members of the Senate Committee on Indian Affairs: 

I am humbled and honored to have been nominated by the President, supported 

by tribal governments across the nation, endorsed by Secretary Leavitt, and for this 

Committee to consider my nomination as director of the Indian Health Service. 

I’d like to thank and acknowledge my family, especially my wife June McSwain 

who has been my confidant and closest friend and daughter Kristin Ruud, son Major 

Eric Ruud, daughter Elizabeth McSwain and my granddaughter Britney Ruud. On 

this special occasion I wish to acknowledge my grandparents Dan and Ella 

McSwain, both passed on, who instilled in me the Indian values of mutual respect, 

compassion, listening, and caring for the environment. 

I am proud to pledge before this Committee, to both the Federal and tribal governments, to do my best to uphold the Federal Government’s commitment to raising 

the health status of American Indians and Alaska Natives to the highest level. 

Should I be confirmed, I will remain committed to working with this Committee, 

the Administration, and Tribal Governments toward our shared goals and objectives. 

10

For those on the Committee and those attending this hearing, I would like to provide some background about myself. I am a Tribal Citizen of the North Fork Mono 

Indian Rancheria that is located in the Sierra-Nevada mountain range, in North 

Fork, California. I began my health career in 1971 as the Director of Central Valley 

Indian Health, Inc., one of 16 original programs of the California Rural Indian 

Health Board. I then served as the Executive Director of CRIHB, providing leadership for a state-wide Tribal health program. 

In 1976 Dr. Emery Johnson, Director, Indian Health Service (IHS), selected me 

as Director of the IHS California Area Office (CAO). The CAO is one of 12 Area 

Offices of the IHS. My term as Director of the CAO was marked by significant 

changes brought about by the enactment of the Indian Self-Determination and Education Assistance Act (ISDEAA) Public Law (P.L.) 93–638; and, the Indian Health 

Care Improvement Act (IHCIA) P.L. 94–437. In 1986 I transferred to IHS Headquarters where I held several positions of increasing responsibility and authority, 

culminating in 2005 when Dr. Charles Grim, Director, IHS, selected me to be his 

Deputy Director. In September 2007, Secretary Leavitt designated me as the Acting 

Director, IHS. 

In the early history of the IHS program, the greatest achievements in reducing 

health disparities were through increased medical care and public health efforts 

that included massive vaccination programs and bringing safe water and sanitation 

facilities to reservation homes and communities. I believe future reductions in 

health disparities will be made through health promotion and disease prevention efforts and programs. 

If confirmed, I will work diligently to support the decision of Tribes to contract, 

compact, or retain the Indian Health Service as their provider of choice. The Indian 

Self-Determination Act allows Tribes to manage their own health programs. In addition, this Administration and the Secretary have put their words into action and increased tribal consultation with the Department. 

I am also committed to continuing the three Director’s Health Initiatives: Health 

Promotion and Disease Prevention; Behavioral Health; and, Chronic Care Management. I firmly believe the future of Tribal communities depends on how effectively 

the Indian health care system addresses chronic diseases. And, preventing and 

treating chronic disease is critical to addressing the most serious illnesses faced by 

the Indian community. 

Collaborative efforts are one way to bring the message of prevention to Indian 

people. As such, they IHS has collaborated with other organizations like the National Boys and Girls Clubs of America to increase clubs on reservations, NIKE Corporation to promote healthy lifestyles, per an Interagency Agreement CDC to fund 

IHS FTEs supporting epidemiology and disease prevention activities, Mayo Clinic 

to support efforts to reduce cancer and related health burdens, and Harvard University to improve American Indian and Alaska Native health and wellness. 

Organizational performance is also important to the agency’s effectiveness in administering its programs; and the IHS has made consistent progress in addressing 

management areas included in the President’s Management Agenda, a governmentwide management improvement initiative. In addition, the agency was rated ‘‘Exceptional’’ by the Department of Health and Human Services for the third year in 

a row for its overall organizational performance. 

The Indian Health Service has had a long history, some 50 plus years, of continually changing and reacting to meet the new challenges and I am excited to report 

that we have been looking closer at working smarter, more efficiently and effectively. Key to our successes in the past and our future efforts is the committed, compassionate, and competent workforce we have in our Indian healthcare system. 

In making the case for change and recognizing the forces driving the need to 

change we have concluded: The current healthcare delivery structure faces many 

challenges; such as, increasing needs to meet demographic and health condition 

trends. 

Healthcare is labor intensive and we must focus on filling vacancies in both 

health care professions and support positions to ensure timely and quality access 

to health care services for American Indian and Alaska Native people. 

The IHS and its Tribal partners through some amazing Tribal Leaders, have been 

advocates for Indian health: In the past we’ve simply adapted to the current health 

care environment without examination of how to improve the entire IHS system. 

This is a chance to change by design; we need to change in such a way as to maximize our capacity to deliver care; to continue to meet our responsibility to Indian 

people, we must develop a delivery system to increase access to care, and to achieve 

consistency in services across the system; and, design an integrated Indian health 

system to serve American Indian and Alaska Native people throughout the United 

States. 

11

We need a Indian Health Service delivery system that is flexible while considering 

the national needs of Indian country as well as regional differences. A system where 

an Indian from the Great Lakes region can walk into a clinic in the Southwest and 

be seen by a provider who, with access to the patient’s health information and 

records, is able to care for that patient with a level of service equal to that of any 

other facility or program in the system. 

As every previous Director of the Indian Health Service, I have the same great 

passion about this organization and our mission to raise the health of our people 

to the highest level possible. My actions will always reflect the honor of being entrusted to provide health services to American Indian and Alaska Native people. 

Should I be confirmed, I will lead the Indian Health Service, with honor and respect 

for our ancestors, and work with you and the Administration for the benefit of 

American Indian and Alaska Native people. 

I am pleased to respond to any questions you may have concerning my nomination. 

Thank you. 

A. BIOGRAPHICAL INFORMATION

1. Name: Robert Gerald McSwain. 

2. Position to which nominated: Director, Indian Health Service. 

3. Date of nomination: December 19, 2007. 

4. Date and place of birth: August 25, 1945—Clovis, California. 

5. Marital status: Married—June Clydene McSwain. 

6. Name and ages of children: Kristin Denise Ruud—40, Elizabeth Ann 

McSwain—26, Eric Phillip Ruud—38. 

7. Education:

Institution Dates attended Degrees received Dates of degrees 

Fresno City College 1963–1966 A.S. 6/1966

California State University—

Fresno 

1966–1969 B.S. 6/1969

University of Southern

California 

1984–1986 M.P.A./H.S.A. 6/1986

8. Employment record: List below all positions held since college, including the 

title and description of job, name of employer, location, and dates.

Office Manager—Kaweah Construction, Visalia, CA (1969–1970).

Director, Central Valley Indian Health Program, Clovis, CA (1971–1974).

Executive Director, California Rural Indian Health Board, Inc., Sacramento, CA 

(1974–1976).

Director, IHS California Area Office, IHS, Sacramento, CA (1976–1984).

Senior Advisor to Director, IHS, Sacramento, CA (1984–1986).

Director, Division of Health Manpower and Training, IHS, Rockville, MD (1986–

1988). 

Deputy Assoc. Director, Office of Admin. and Mgmt., IHS, Rockville, MD (1988–

1990).

Associate Director, Office of Human Resources, IHS, Rockville, MD (1992–1997).

Director, Office of Management Support, IHS, Rockville, MD (1997–2004).

Acting Dep. Director for Management Operations, Rockville, MD (2004–2005).

Dep. Director, IHS, Rockville, MD (2005–2007)/Acting Director, IHS (2007–

2008).

9. Military service: Enter all military service if not included above: service, dates, 

rank, type of discharge—None.

10. Honors and awards: List below all scholarships, fellowships, honorary degrees, 

military medals, honorary society memberships, and any other special recognitions 

for outstanding service or achievement.

President’s Rank Award for Meriterious Service (2004). 

President’s Rank Award for Distinguished Service (2006).

11. Memberships: List below all memberships and offices held in professional, fraternal, business, scholarly, civic, charitable and other organizations.

12

Senior Executive Association—1998–2008. 

Calif. State University—Fresno Alumni Assn.—1970–2008. 

Univ. of Southern California Alumni Assn.—1987–2008. 

Federal Executive Alumni Assn.—1984–2008. 

American Public Health Association—2007–2008. 

Sandy Springs Friends School PTA—2004–2008.

12. Published writings: List the titles, publishers and dates of any books, articles, 

or reports you have written.—None published. 

13. Qualifications: State fully your qualifications to serve in the position to which 

you have been named.

I have held a number of positions over my career that have brought me to this 

potential pinnacle of my career. My career, among other things, is marked by 

change. The highlights of which are the Agency-wide Tribal restructuring 

workgroups in the 1990’s, the Indian Health Design Team (I was one of 6 Federal representatives) and the Restructuring Initiatives Workgroup (I was one of 

4 federal representatives). I have always focused on balancing change with continuous improvement in both program (patient care) and administrative support 

systems. 

I began my health career in 1971 as the Director of Central Valley Indian 

Health, Inc., (CVIH). The CVIH Program was one of 16 original programs of the 

California Rural Indian Health Board (CRIHB) that marked the re-entry of Federal Indian Health Care into the State of California. At CVIH, I led the establishment of medical and dental centers supported by community health aides. 

Toward the end of my time at CVIH we added an alcohol and alcoholism residential treatment center. I then moved on to serve as the Executive Director 

of CRIHB, thereby providing leadership for a state-wide Tribal health program. 

My biggest accomplishment was to guide growth and the institution of direct 

medical and dental care supported by community health programs. 

In 1976 I was selected by Dr. Emery Johnson, Director, Indian Health Service 

(IHS), for the position of Director of the IHS California Area Office (CAO). The 

CAO is 1 of 12 Area Offices of the IHS. My principal role as Director of the 

IHS CAO was to provide support, advocacy and policy guidance to the California Indian health programs. My term as Director, CAO was marked by significant changes brought about by the enactment of the Indian Self-Determination and Education Assistance Act (ISDEAA) Public Law (P.L.) 93–638; and, the 

Indian Health Care Improvement Act (IHCIA) P.L. 94–437. ISDEAA enabled 

Tribes who previously were a part of CRIHB to contract directly with the IHS 

and IHCIA resulted in more resources coming into the CAO. 

In 1986 I transferred to IHS Headquarters where I held several positions of increasing responsibility and authority, culminating in 2005 when Dr. Charles 

Grim, Director, IHS, selected me to be his Deputy Director. Under the new 

structure, not only was I second in command, but I was responsible to supervise, guide and rate the performance of the twelve IHS Area Directors. As the 

principal Deputy Director I participated in setting overall Agency priorities, 

policies, and strategic direction. I provided significant input in managing the 

formulation, presentation, justification, and execution of the Agency budget. In 

September 2007, Secretary Leavitt designated me as the Acting Director, IHS. 

Finally, as it relates to recognition of my accomplishments, I have received 

many awards and recognition over the years, but the two that stand out as capstones are the President’s Rank Award for Meritorious Service in 2004 and the 

President’s Rank Award for Distinguished Service in 2006. 

It is my firm belief that given this experience, both in type and level of responsibility. I feel fully qualified to be considered for the position of Director, Indian 

Health Service.

B. FUTURE EMPLOYMENT RELATIONSHIPS

1. Indicate whether you will sever all connections with your present employer, 

business firm, association or organization if you are confirmed by the Senate: Not 

applicable. 

2. As far as can be foreseen, state whether you have any plans after completing 

government serve to resume employment, affiliation or practice with your current 

of any previous employer, business firm, association or organization: I fully intend 

to remain in government service. 

3. Has anybody made you a commitment to a job after you leave government? No. 

4. If you have been appointed for a fixed term, do you expect to serve the full 

term? Yes. 

13

4a. If you have been appointed for an indefinite term, do you have any known 

limitations on your willingness or ability to serve for the foreseeable future? Not applicable. 

C. POTENTIAL CONFLICTS OF INTEREST

1. Describe any financial arrangements or deferred compensation agreements or 

other continuing dealings with business associates, clients or customers who will be 

affected by policies which you will influence in the position to which you have been 

nominated: None. 

2. List any investments, obligations, liabilities, or other relationships which might 

involve potential conflicts of interest with the position to which you have been nominated.

My spouse has Stock interest in Westat, Inc., an employee owned research corporation, that has contracts with the U.S. Government including HHS. The 

company does not currently have any contracts with the Indian Health Service 

and it’s not expected to cause any conflict with my duties. However, as stated 

in my ethics agreement, I will not participate personally and substantially in 

any particular matter which will have a direct and predictable effect on the financial interest of Westat, Inc.

3. Describe any business relationship, dealing or financial transaction (other than 

taxpaying) which you have had during the last 10 years with the Federal Government, whether for yourself or relatives, on behalf of a client, or acting as an agent, 

that might in any way constitute or result in a possible conflict of interest with the 

position to which you have been nominated: None (except as a Federal employee). 

4. List and describe any lobbying activity during the past 10 years in which you 

have engaged for the purpose of directly or indirectly influencing the passage, defeat 

or modification of any legislation at the national level of government or for the purpose of affecting the administration and execution of national law or public policy: 

None. 

5. Explain how you will resolve any potential conflict of interest that may be disclosed by your responses to the above items.

Although I do not believe that I am involved in any issues that present a potential conflict of interest, as described in my ethics agreement, I have agreed to 

recuse myself from any matters that possibly could cause a conflict of interest. 

If questions arise, I will seek guidance from the Department’s ethics officials.

6. Explain how you will comply with conflict of interest laws and regulations applicable to the position for which you have been nominated. Attach a statement from 

the appropriate agency official indicating what those laws and regulations are and 

how you will comply with them.

As described in my ethics agreement, I have agreed to recuse myself from any 

matters that possibly could cause a conflict of interest. If questions arise, I will 

seek guidance from the Department’s ethics officials. 

14

The CHAIRMAN. Mr. McSwain, thank you very much. We appreciate your testimony. 

I personally will be supporting your nomination, and I will hope 

to move the nomination out of this Committee in an expeditious 

way and to the Floor of the Senate. 

Having said that, you and I talked yesterday, by telephone, and 

you know that I feel there are some very serious problems at the 

Indian Health Service. First and foremost, of course, is the problem 


207m6.eps
15

of funding. We have unbelievable funding problems, and you inherit a difficult situation. You inherit a system in which we are required to provide adequate health care to Native Americans, the 

First Americans, and yet about 40 percent of the money that is 

needed to do that is not available. So we have rationing going on. 

Give me your perspective about inheriting a system that is so 

dramatically under-funded. 

Mr. MCSWAIN. Senator, that is an excellent question. I was reflecting for a moment on the fact that you used the word inherited. 

I did in fact inherit a budget. But I was also very much involved 

in the preparation of that budget. As you well know, the current 

climate in which we operate is the fact that we have a budget deficit. We are in a reduction arena. There are a lot of problems that 

are being gauged about what is important to them. 

It is fair to say that we have begun to refocus our efforts toward 

that which is our primary core mission. The primary core mission 

of the Indian Health Service is to provide service to the Indian people living on or near reservations. And more importantly, to our 

clinical care that we need to provide, which is our primary care to 

American Indians and Alaska Natives. That may mean that other 

parts of our program will either be eliminated or downsized in 

order to make sure that we maintain those particular initiatives 

and program levels, particularly as it pertains to clinical services. 

In fact, as you have seen our budget, the increases we have are 

on the clinical side. And the decreases are on the non-clinical side. 

The CHAIRMAN. That is certainly true, overall, of course, there is 

a decrease in recommended funding with respect to the increased 

costs of living and so on. We are losing ground here with this budget. It is also the case that our facilities are in tough shape and we 

are cutting facility funding. 

I want to ask you about this, in July of 2007, Dr. Grim, at his 

confirmation hearing, told the Committee that the IHS Office of 

Environmental Health and Engineering had finalized revisions to 

the Health Care Facility’s Construction Priority System. That was 

July of last year, and the final report was being prepared to be submitted to the Department of the OMB for clearance. 

Any word about that? What is the status of that? 

Mr. MCSWAIN. Senator, what happened was unfortunately, Dr. 

Grim left, and his withdrawal resulted in him departing from the 

directorship rather quickly. He had wanted to really sign off on 

that. But I am pleased to report to you that I have in fact signed 

off on the basic system, the basic priority system that was recommended by the Tribal-Federal Appropriation Advisory Board 

that had been working on it for a number of years. And it is now 

moving through the Department and will be moving for clearance. 

They are vetting it at the Department level. It will be moving 

through to certainly OMB and then on down to the committee that 

requested the new system, which is the appropriations committee. 

The CHAIRMAN. Let me refer you to, without using names, a letter that I wrote to the Inspector General of the Indian Health Service, Inspector General of HHS, setting out a series of concerns 

about one of the regional offices of the IHS. And it dealt with a director of a tribal Indian Health Service facility and the complaints 

16

that had been made by the tribe, by employees, about employee 

harassment, financial impropriety, and other things. 

As I looked into it, it appeared to me, Mr. McSwain, that in a 

particular area office, there was staggering incompetence. I don’t 

know any of those people, but it seems to me that when you have 

circumstances of the kinds of complaints that existed, you would 

expect a regional office to move quickly to find out what is happening. Yet that was not the case here. 

As I looked into it, I am told that the very person that was running the Indian health facility at this particular tribe, a tribe, by 

the way, which passed two resolutions banishing that person from 

their reservation, I am told that the person had multiple complaints filed against them. There were five EEOC complaints, four 

of which were determined for the plaintiffs and against this employee, and yet this person has just been transferred along in the 

Indian Health Service to the next tribe. We here about all of these 

allegations, and nothing happens. 

It appears to me that in that region, and I am not using names, 

but you know what I am talking about, you have staggering incompetence with a bureaucracy that is just mired in the glue of indifference. I mention this because you know of this case. But I also 

sense it exists elsewhere in the system. I think this is a bureaucratic system that desperately needs reform. If you find some place 

where somebody has had four or five EEOC complaints filed 

against them, I hope you will determine that the person doesn’t get 

transferred, and that he or she gets fired. 

I am hoping that you are going to risk your job to do two things. 

Number one, to say to this Administration privately and publicly, 

if necessary, we need adequate money in this system to provide 

health care for Indians that we promised them. Number two, you 

are going to insist on reform in a system that is hard to reform, 

and you will take the risks to require that reform. That is what I 

am hoping from you. 

But I have asked you a big, long, formless question here. Give 

me your impression. 

Mr. MCSWAIN. Thank you, Senator. There are two parts to that 

question, obviously. The first one was about resources. 

I am of the belief that part of our challenge as the Indian Health 

Service is to make the case better and clearer to the people we 

must report to. And that is something I will work more diligently 

on. There has to be a better way to tell the story of why we need 

certain budgets each year. This year, the 2009 budget, we made a 

case for it, and now it is the President’s budget. We will defend it. 

We will go back and look and see whether or not there are parts 

of our proposals that we are missing on, recognizing that it is all 

about competing, if you will, across the board to ensure that the 

Government in total, I realize that poor OMB gets a rap every now 

and then about this whole thing. But they are trying to make a decision across Government, much like the Secretary must make decisions about cross all the octaves. And then for the Director of the 

Indian Health Service to make decisions about all of Indian health. 

So as it rolls up, it is how we make the case. But I can assure 

you, I will continue to make the case when the time comes during 

the rules process to do that. I will commit to that. 

17

On the second issue of the example of the EEO complaints and 

the like, let me just say that after your phone call, a lot of actions 

took place. I am only sorry that it had to require you to call me 

to make that occur. 

The CHAIRMAN. You are talking about the call four or five 

months ago? 

Mr. MCSWAIN. Yes. It should not have happened. And that I 

apologize for. But we are in fact looking across the Country, in fact, 

the concern about, was it systemic, we have looked into it. There 

are parts in the Country that we have found other, similar situations. It is not systemic, but there are some other examples. 

We are moving to, part of the whole of competency at the service 

unit director level, or the CEO of the service units, is that we have 

not paid a lot of attention to ensuring that we are getting the best 

qualified people to operate our service units, particularly in those 

service units where we actually are providing the care. And we 

have started a succession planning program that will in fact hopefully ensure that there is a level of professionalism and that they 

are adequately trained. 

As you can imagine, something I have observed over the years 

is that as you are very good at what you do, you are a good technician, and you do the job extremely well, the next thing someone 

does is say, well, you ought to run the whole thing, without any 

training on what it takes to manage people. That is a huge job, 

when you start to lead and manage people, as opposed to just doing 

your thing. You can’t be the best accountant and expect to be the 

director of finance without adequate training. 

So those are the things that I believe that we are working on and 

will continue to work and focus on them, particularly at our service 

units. 

The CHAIRMAN. Mr. McSwain, one of the things that I suggest 

that you consider is writing a letter to the tribes. We have 500 and 

some recognized tribes in America. Write a letter to those tribes 

and ask them, give me your perspective, from your level, what is 

happening in the health care system in your area. 

I walked through a clinic in North Dakota about three or four 

weeks ago with a wonderful IHS doctor—wonderful doctor. This is 

a clinic with poor structure, inefficiencies, and it needs to be 

rehabbed. The doctor said, we desperately need a new x-ray machine. I said, well, can you get it? He said, no, the requisition for 

it has been in for two years, but the request hasn’t gotten through. 

The regional office hasn’t assigned it yet, but the money is there. 

I said, how long has it been? Two years—can’t get it through the 

regional office. 

It is just a matter of processing paperwork. But when the paperwork doesn’t get processed, all those folks that were sitting in the 

waiting room, some of whom would want a good x-ray, aren’t going 

to get the x-ray they expected, because somebody sitting in a regional office hadn’t found ways to get through their papers. And 

this poor doctor just shook his head and said, you know, it is beyond my understanding of how people like that keep their jobs. 

So my hope is that you will be able to reform some of this. Let’s 

not protect incompetency. If we have incompetent people, let’s root 

them out, get good people in who are dedicated and passionate and 

18

want to do a good job. Because there are some incompetent people 

in this bureaucratic system of ours. That is true of the Indian 

Health Service. I believe I have documented some of that. I am not 

trying to be a policeman for the Indian Health Service. That is not 

my intention. But I want that service to work well, and I think it 

can work much, much better than it has. 

I have a couple of other questions, but I want to yield to the Vice 

Chair, Senator Murkowski. 

Senator MURKOWSKI. Thank you, Mr. Chairman. 

You point out one of the obvious problems. If you have incompetency in the system, that in and of itself brings great frustration 

to all involved. But to the practitioner who wants to be able to provide a level of care, they give up in frustration. So then you don’t 

have that experienced professional there. It builds on further and 

further problems. 

Mr. Chairman, I am notified that Senator Barrasso is going to 

be submitting a statement for the record and has asked that that 

be included as part of this as well. 

The CHAIRMAN. Without objection. 

Senator MURKOWSKI. Mr. McSwain, we had a chance a couple of 

days ago to talk at some length about the Indian Health Care reauthorization and some of the issues that are still outstanding and 

our hopes, our very strong hopes, that we will be able to move this 

legislation through the Senate in an expedient manner, allow the 

House to act quickly and get it to the President for his signature 

this year. Senator Smith raised an issue that is out there. As you 

know, we have been working on some of the few outstanding 

issues. 

What kind of commitment can you give to this Committee that 

you will actively participate in resolving any of the outstanding 

issues that are out there, or basically how you can help us get this 

bill signed into law? 

Mr. MCSWAIN. Thank you, Senator. As I mentioned the other 

day, this is an important bill for me personally and professionally. 

Certainly as I see the bill, I think I reflected with you the fact that 

the bill 30 years ago was not as complex as the bill is today, nor 

is our environment as simple as it was in 1976. It is much more 

complex. There are so many different pieces to it. In fact, I speak 

with Mr. Mahsetky almost daily about what is happening as the 

various issues are addressed in the bill. 

But the bottom line is, yes, we do need to have it reauthorized. 

It provides a framework. It provides a relationship between the 

tribes and the Federal Government about health services. That is 

the paramount. The goals that are set forth in the law are as real 

today as they were 30 years ago. It is about improving and it is 

about the responsibility the Government has to provide care to Indian people. 

Those being the underpinning fundamentals of the bill, there are 

all the pieces obviously that go into it. There are a lot of other interests that are expressed about the bill. I can assure you that I 

will work within the Department and within the Administration to 

the extent possible that I can help resolve those issues that are 

pending. I will use my office to do that. 

19

Senator MURKOWSKI. We appreciate that. We want to make sure 

that we have that continued support of the Administration. As you 

know, there was a set that was released a couple of weeks ago that 

raised some issues, that caused some concern. We want to be able 

to work through all of those and know that we have the support 

from the Administration and the President will sign this bill when 

we get it successfully moved through the Congress. 

You gave a little bit of a status on the health care facilities priority system. You mentioned briefly in our meeting the Barrow facility. Will both the Nome and the Barrow facility retain the priority status that they currently have under the newly-revised system? 

Mr. MCSWAIN. Yes, they will. In fact, all the facilities on the current system, some 20 facilities, are set there. As you were talking 

about facilities, I was also looking at the same five-year plan and 

realized that we have built a fair number of facilities since 1993. 

I was counting some rather large numbers. I can certainly submit 

those for the record. 

We have been moving out and building facilities, hospitals and 

health centers and YRTCs and the like for the last 18 years rather 

well. While the process is slow, we will continue to move forward 

with Barrow and Nome as well as the facilities in the lower 48. 

Senator MURKOWSKI. You responded a little bit about the budget 

issue. We recognize that these are times of budget restraints. We 

have been urging, certainly my constituents as they come to the office in frustration about the IHS budget, we have been urging Alaska Natives to get involved in the process early on, let the agency 

know what the concerns are. I do appreciate the IHS efforts to conduct these budget consultation meetings and trying to work with 

the tribes on their recommendations. 

But what we are hearing back from so many, from the tribes, is 

that their priorities are just clearly not reflected in the President’s 

budget. How can we make this consultation process more meaningful? It is one thing for me to say, go and make sure that your concerns are hear, they do, they participate, and then they don’t see 

anything on the other side. If it is not going to be meaningful consultation, it is tough for me to urge them to be a participant, it is 

tough for them to feel like they should continue to be a participant. 

How can we make this work better? 

Mr. MCSWAIN. That is an excellent question. It is one that we 

have wrestled with for some time. When the budget ultimately gets 

presented and the President rolls out the budget, tribes are wondering, raise questions about that. 

The process is fairly transparent until it gets up into the decision-making that goes on at the higher levels were the budget is 

embargoed. But up to that point, we have not done a very good job 

of relating back to the tribes that have participated in the process 

that, here are your priorities, this is what you priorities are by region, by area, and this is what they look like in a composite nationally. It is perhaps as simple as Chairman Dorgan says, write a letter back to the 562 tribes that says, for this year, these are the priorities by region, these are the priorities that we have collected for 

the national purposes, and we are going to rest on those priorities 

as we move forward. 

20

I can assure you that all the decisions that go on in the process, 

what goes on in the embargoed stage, we are mindful, ever mindful 

of the tribal priorities and what those priorities are. We will continue to do that. The unfortunate thing is the process does move 

into the embargoed state. We are not at liberty to share with them 

those kinds of decisions that are being made. But I can assure you 

that I and all the directors before me do in fact rely on those priorities. 

We just need to get the message back to them, and I think there 

is a better way of doing that. The national consultation meeting is 

going to occur next week out in California, where they will be talking about national priorities again. We will take another look as to 

how we best represent the priorities. 

Senator MURKOWSKI. Consultation is a two-way street. If the 

tribes don’t feel as if they are being heard or that it is a meaningful consultation, again, you are not getting much out of that process. So it seems to me that there has to be a way to ensure that 

that is meaningful. 

We all appreciate that there is that black hole at some point in 

the budget process, where it is not open and it s not transparent. 

We wonder what in the world happened to our priorities. But until 

that stage, I think every effort that can be made to make sure that 

there is clear understanding as to how we outline these priorities, 

I think it will be better for all. 

I mentioned in my opening statement the comment, don’t get sick 

after June. It just speaks to the need to support the contract health 

service program. How are we going to address the shortfalls in the 

contract health services? 

Mr. MCSWAIN. A couple of things have occurred. Certainly in the 

contract health service there is the $9 million increase for 2009. 

And there is also the increases that we have received for the catastrophic health benefit, which is the CHEF fund. That was the one 

that for cases over $25,000, they are referred to the headquarters 

office and they are paid out of CHEF. 

We were running out of money in the CHEF fund for those highcost cases as early as April, not June, but April. What was happening was that we didn’t have enough in the CHEF fund to be 

able to pay for those high-cost cases. Therefore, the areas were required to begin using their other CHS funds. So all you need is a 

few high-cost cases like that and your CHS budget is sorely affected. We are looking at possibly getting the CHEF fund all the 

way through August now, because of the increases in the CHEF 

fund. 

Senator MURKOWSKI. That is good, but that gets you through August. 

Mr. MCSWAIN. Yes, I know, but we are moving the ball. 

Senator MURKOWSKI. Yes, I know. It is just difficult to have to 

explain that to somebody who is ill and the expectation is that that 

care is going to be available. If the calendar doesn’t jive with when 

you happen to become ill, again, we wouldn’t accept this anywhere 

else. And yet we talk about it as though, well, it used to be April, 

now it is June, but soon it will be August and we should celebrate 

that success. I think we celebrate the success when we are able to 

provide for the level of health care services year-round, 365 days. 

21

Mr. Chairman, I have some more questions, but if you want to 

take a turn? 

The CHAIRMAN. Go ahead. 

Senator MURKOWSKI. All right, thank you. 

Third-party reimbursements. As you know, in the Indian Health 

Care reauthorization, this is a big effort here to make sure that we 

do allow for increasing Medicaid, Medicare enrollment in Indian 

Country. I understand that there may be some concern about how 

effective the enrolment efforts have been in some areas, and that 

patient care is delayed until they are enrolled. What is the plan of 

action for increasing Medicaid and Medicare enrollment, so that we 

don’t see these delays? 

Mr. MCSWAIN. Senator, I believe what you are talking about is 

the enrollment, obviously it is getting our patient registration system more robust than what it is. We do know that patients do arrive at our facilities, and in some cases, are immediately screened 

for alternate resources, namely Medicare-Medicaid, VA, private insurance. I know that some of our systems do just an outstanding 

job. The best practices, if you will, from those facilities, are being 

transported to other facilities. 

I know that for us, the collections mean a great deal. While they 

are intended to address deficiencies and accreditation issues in facilities, they are also a great source of additional resources for purposes of providing patient care. We are up close to $800 million in 

third-party collections now. That is a rather significant amount. 

The fact is that we are continually working with CMS on opportunities that CMS will provide, and also through the Tribal Technical Advisory Group, the TTAG, which is tribally, basically a 

group of advisors to CMS for all kinds of Medicaid-Medicare issues 

and reimbursements. We are working diligently. We know that 

some of the statements around the system are, make sure that we 

are capturing every possible Medicaid opportunity, Medicare opportunity, because it is such an important part of our system. 

I know that tribes have been doing an outstanding job, I know 

Alaska has done just a tremendous job, because they have literally 

tripled the collections since they have taken over the program. 

That tells us a lot. And clearly, this is an area that we feel we negotiate the rates each year to ensure that they are forward-moving. 

We will continue to do that. The business offices throughout the facilities are becoming, I think, better at what they do. The ability 

to bill and collect is another facet of our business infrastructure. 

Senator MURKOWSKI. What about contract support costs? Shortfalls are pretty significant. Under the contract support cost policy 

that was issued last April, how long is it, do you anticipate, before 

these shortfalls in contract support costs are addressed? 

Mr. MCSWAIN. That is a very difficult question. I would have to 

go back and look. I have some numbers in preparation, I know they 

are pulling some numbers together in preparation for the upcoming 

budget hearing. I don’t have the latest numbers. In fact, I know 

that I was trying to find out where the last shortfall report was. 

I am of the understanding that the last shortfall report that came 

to the Congress is probably about 2000, on 2000 data. We are looking for the latest report that should be coming to the Congress. I 

can report on that at that point. 

22

Senator MURKOWSKI. Is it still the IHS policy to deny the newer 

expanded contracts based on the lack of contract support costs? Is 

that still the policy that is in place, then? 

Mr. MCSWAIN. Excuse me, will you repeat the question? 

Senator MURKOWSKI. Whether or not it is the IHS policy still to 

deny new or expanded contracts if you don’t have sufficient contract support costs? 

Mr. MCSWAIN. No, Senator, the position of the Indian Health 

Service is to have a conversation with the tribe that wants to take 

over a program service, function or activity under the Indian SelfDetermination Act. We share with them the fact we do not have 

contract support cost money and allow them to say, do they still 

want to take it over. They can take it over, recognizing we don’t 

have the contract support costs. We have had a number of tribes 

in fact move forward, assume the program responsibility without 

the contract support costs. We have not denied any because we 

don’t have the money. I don’t know of anyone, anywhere we have 

denied them. 

Senator MURKOWSKI. Mr. Chairman, that is all I have at this 

point in time. I appreciate the responses from Mr. McSwain. 

The CHAIRMAN. Mr. McSwain, the President, either the President 

or his representatives, have suggested the potential of a Presidential veto on the Indian Health Care Improvement Act. Are you 

familiar with that and what the reasons for that might be? 

Mr. MCSWAIN. I am familiar with the statement of administrative policy. 

The CHAIRMAN. Right. 

Mr. MCSWAIN. I have only read about the veto. I am not involved 

in the actual messages from the White House. 

The CHAIRMAN. My sense is that we have worked through most 

of the concerns. Based on the Administration’s comments, at least 

one of them, I believe, they were confused about what the provision 

actually was. I think that we have worked through most of those. 

My hope would be that you, inside the Administration with OMB 

and the White House, would look at our work. Our hope would be 

to get that through the Senate next week. When we do, I hope you 

will look at that work and see that substantial changes have been 

made, changes that will resolve those issues. 

You have a responsibility to support the President’s actions, I understand that. You have a responsibility to support the President’s 

budget, I understand that. It is always a source of aggravation that 

those that come to the witness table steadfastly support the President’s budget. But then I understand that you work for the President, not for this Committee. 

I do think we have very serious funding problems, and it is very 

hard to run a system that is so dramatically under-funded. The 

contract health care issue is a very serious problem. I know that 

there is some effort to improve that. 

But in addition to what my colleague, Senator Murkowski, described, ‘‘don’t get sick after June,’’ any of us who go to reservations 

understand that this is happening in contract health, and as a result, people’s credit ratings are ruined. They have to postpone getting deathly ill in September or August, because there may not be 

23

any contract health money available. The nearest health care facility is not on the reservation, it is an hour and a half away. 

So they go, and the contract health money is not there to provide 

for their needed care. So the debt collectors come after them and 

destroy their credit. It is an awful thing to see. A lot of folks on 

Indian reservations have credit ratings that have been completely 

destroyed because of the inability to provide contract health care. 

You are familiar with that, I assume? 

Mr. MCSWAIN. Yes, I am, Senator. While you were speaking, I 

was thinking of a couple of parts of an answer. One part is that 

we need to fill the vacancies we have. Because if we don’t fill the 

vacancies, we don’t provide the care, we go buy the care. So we 

have some vacancies we need to fill. 

The interesting thing about that strange dynamic is that we 

wind up contracting out to fill those vacancies to even continue the 

care. So that reduces our ability to collect. 

The other thing that comes to mind also is the fat that we 

haven’t seen the full measure of the Medicare-like rights, where we 

are actually contracting with facilities for Medicare-like rights, and 

that is another facet of insuring that not as much contract health 

service is going out as billed charges. But we are still watching, it 

was only put in place last year. But clearly, this is another area 

that will at least moderate the out-go for contract health care. It 

is still a major issue. I agree with you, I think that the fact that 

we are moving some of our facilities, we are replacing them with 

health centers now. We are trying to, and I think the last couple 

of facilities we actually increased the contract health care for those 

facilities. One was Sisseton and the other was Clinton, they went 

from hospitals to health centers. We recognize that that is going to 

require them to go out and buy. 

So we put in our actual contract health care budget request some 

additional funds for those changes, for those two facilities. That is 

another means that we are doing to make sure that the care that 

we are providing when we are moving in that direction is actually 

available. 

Now, the overall set certainly is, in terms of the contract health 

services still operating at the highest level, we are only doing toplevel, priority one care. The only good thing about it is that we are 

not denying any priority one care across the Country. 

The CHAIRMAN. Yes, but what is priority one is sometimes a matter of judgment. You are talking about life or limb, right? 

Mr. MCSWAIN. That is correct. 

The CHAIRMAN. I was at a clinic where they have had a need to 

secure another pharmacist. They have been waiting for a year, because all the hires have to run through the regional office. The employees at the clinic and the tribe told me that that regional office 

has been unresponsive. So they have had to contract out pharmacy 

services, which runs up to $100,000 a month. It has resulted, in 

some cases, in over-spending to get contract pharmacy services, 

and four hour waits for getting prescriptions filled after somebody 

sees the doctor, in some cases doctors have to fill the prescription 

themselves instead of seeing patients, or some patients go without 

medicines they need. 

24

That is the thing I hear about with these regional offices that 

just makes me angry. We need the bureaucracy to work, and we 

need this thing to function. I think there is so much to do. I think 

what we will do as a Committee, in addition to trying to get this 

Indian Health Care Improvement Act passed, because I think that 

is a first step, is to look at much greater reform. But we have to 

take a first step in the right direction before you can get some momentum. 

I think we also as a Committee will write to all of the tribes and 

say to the tribes, tell us what is happening out there, give us your 

perspective. In some cases, their perspective may be just that, a 

perspective of their vision through a certain prism. But I think we 

will get a lot of good information. I would encourage you to do the 

same thing. Let’s find out what is really happening out there, 

where the top performers are and where there is dramatic need for 

change. 

I am going to conclude today with something my colleague has 

seen me do on the Floor. I want to do it because we are talking 

about individuals who are having trouble getting adequate health 

care. Adele Hill Baker, I will show you her photograph. This is not 

on your shoulders, it is the system you are inheriting now. This 

lady was having a heart attack on an Indian reservation. She was 

put in an ambulance, taken off the reservation, 80 miles or so, 90 

miles, to a hospital. She didn’t want to go in an ambulance, because she knew that she couldn’t possibly pay the charge, and she 

worried that the Indian Health Service wouldn’t pay for it. So she 

begged not to be put in an ambulance, despite the fact that she was 

diagnosed as having a heart attack. 

They put her in an ambulance anyway, and took her to the hospital. When they got to the hospital, she had a piece of paper taped 

to her leg that informed the hospital that there was no contract 

health care money available. If you admit this patient, understand 

it is at your own risk. So a woman comes in on a gurney with a 

piece of paper taped to her leg. It is just unbelievable. 

That is the story of Adele Hill Baker, a real person having a 

heart attack, who is put into this position of going into the hospital 

and having a piece of paper with her that says, by the way, admit 

me, you are in trouble. 

The other is a photograph of a young girl from Montana. Her 

grandmother saw me at the Crow Reservation in Montana. This 

young girl died, just a young girl, five years old. Her name was 

Teshon Rain Little Light. Her grandmother came to where Senator 

Tester and I were holding a meeting. She held up this big picture 

of this little girl in her Indian dress and she told us her story. This 

is a little girl. They took her to the clinic four or five times and 

they treated her for depression. Her grandparents pointed out that 

her fingers are bulbous and discolored, there is something wrong 

with the oxygen, something going wrong inside. 

And one day, of course, it all collapsed and they sent her to Billings, Montana on an emergency basis to the hospital from the 

Crow Reservation Clinic. They sent her immediately to the Children’s Hospital in Denver and discovered that she had terminal 

cancer. Her grandmother said she lived the last three months of 

25

her life in unmedicated pain, undiagnosed. Of course, she died 

shortly thereafter. 

It so happened I ran into this young girl’s aunt on an Indian reservation in North Dakota about two weeks ago. She again described the case. This is a five year old girl that probably shouldn’t 

have died, probably should have been diagnosed much, much earlier. These things are going on all across the system. Many of these 

reservations are remote, very remote areas where there is not a 

good hospital, not a hospital that is close. So the delivery of health 

service by the Indian Health Service in many cases is the only delivery that is available. I know in many cases it means life or death 

to have the right service at the right time. 

One of the clinics I told you about earlier has a lot of problems. 

But one of the significant problems is it is only open from 9:00 

until 4:00, five days a week. That reservation is very remote. You 

get sick there, have a serious problem there, you are in trouble. 

My point is, we need to do much, much better. I am going to 

move your confirmation, and I believe my colleagues will be supportive of it. But I do hope you are willing to risk your job and risk 

your career. By risk, I mean be aggressive, speak out, be loud. The 

only portion of your testimony today that caused me any problems 

at all was when you were complimenting the Office of Management 

and Budget. That almost lost me. But I am still with you, Mr. 

McSwain. The Office of Management and Budget knows the cost of 

everything and the value of nothing. That is why we get a recommendation that says, let’s cut some of these Indian Health programs and recommendations to spend money in other areas that 

are so absurd I shall not even describe them today. 

Having said all that, you inherit a pretty big load and a big responsibility. This Committee wants you to succeed. We don’t want 

you to fail, we want you to succeed. Chairperson Van Huss described your background with enormous pride, justifiable pride. 

You come from a background of, I am sure, circumstances where 

you had to overcome the odds, and you have carved out quite a significant career. 

So speaking for myself, I am pleased to support your nomination. 

But I really do expect a lot out of you. My guess is the Vice Chair 

does as well. 

So justify that faith, because together, we have to figure out a 

way to make something good out of this health care system and 

make it work. 

Mr. MCSWAIN. Thank you, Mr. Chairman. In fact, as I was looking at those pictures and hearing the stories, one of the things I 

want to do is stop the stories. We need to stop those stories. We 

can’t have people being moved about the system in most disrespectful manner. And clearly, patients not being seen in appropriate 

manners. When I say stop the stories, I hope these are the only stories we hear in a long time, that there won’t be any more. 

The CHAIRMAN. Well, this little girl named Teshon Rain Little 

Light, her aunt told me that when she got to Denver, finally, after 

going over and over and over again to the clinic and being treated 

for depression, they discovered she was going to die because of a 

terminal illness. The one thing she wanted to do was to go to see 

Cinderella’s Castle. So Make A Wish sent her to Orlando, Florida, 

26

to Disney World. And the night before she was to see Cinderella’s 

castle, she died in her motel room, in her mother’s arms. 

The point of it all is this. It is such a human tragedy that we 

can’t provide first-class medical help that we all are proud of. 

These are the first Americans, and it is our responsibility. We have 

made that commitment, a trust responsibility, and treaty commitments. Senator Murkowski and I and this Committee are just determined to do everything we can to try to effect change here. So 

when someone new begins to head an agency, you have an enormous opportunity to effect change. We hope that will be the case 

with your stewardship of the Indian Health Service. 

Senator Murkowski, did you have any final comments? 

Senator MURKOWSKI. Just to thank Mr. McSwain. You have to 

appreciate the courage of a man who, even knowing the obstacles 

that he will face, is willing to take on a challenge. I appreciate a 

great deal your willingness to face these obstacles, to stop the stories and to take the challenges and to really make a difference 

within a system that has experienced great difficulty. I appreciate 

your willingness to serve and do look forward to the opportunity to 

work with you and other members of the Committee, the Chairman, to really make a demonstrable difference in the lives of American Indians and Alaska Natives. Thank you. 

Mr. MCSWAIN. Thank you. 

The CHAIRMAN. The hearing is adjourned. 

[Whereupon, at 10:43 a.m., the Committee was adjourned.] 

(27)

APPENDIX

PREPARED STATEMENT OF HON. JOHN BARRASSO, U.S. SENATOR FROM WYOMING

Welcome, Mr. McSwain, and congratulations on your appointment. Your family 

has a right to be proud of your accomplishments. 

As we discussed yesterday during a meeting in my office, I believe all of us have 

a responsibility to plan for a healthy future. As a physician, I have worked for over 

two decades to help the people of Wyoming stay healthy and lower their medical 

costs. In my practice, I saw first hand the obstacles families face to obtain medical 

care. Rural and frontier areas have to overcome significant challenges in order to deliver high quality care in an environment with limited resources. Our unique circumstances require us to work together, share resources, and develop networks. I 

think we can all agree these same principles are critical to support and modernize 

the Indian health care delivery system. 

Everyone here knows the serious problems we face to deliver health care services 

in a cost-effective, efficient, and culturally sensitive way. Wyoming’s Wind River 

Reservation, located near Riverton, is home to 10,415 members of the Eastern Shoshone and Northern Arapaho tribes. It is the third largest reservation in the United 

States—covering more than 2.2 million acres. Tribal members in Wyoming have 

worse than average rates of infant mortality, suicide, substance abuse, alcohol 

abuse, unintentional injury, lung cancer, heart disease and diabetes. 

When I last visited the Wind River Reservation, tribal leaders told me how difficult it is for them to (1) recruit and retain staff, (2) stretch each dollar to deliver 

essential services, (3) respond to cultural barriers, and (4) give families necessary 

information to make better lifestyle choices. Additionally, the Wind River Reservation has one of the highest unemployment rates of the twelve IHS areas. The male 

unemployment rate is approximately 30 percent while the female unemployment 

rate is approximately 21 percent. I want to put that number into context. The national unemployment rate is hovering around 5 percent. 

These statistics arc important because they directly affect the health of Indian 

communities. Native American families living below the poverty level in areas with 

high unemployment rates most likely live in sub-standard housing, have poor nutrition, and suffer from chronic health problems. 

In order to make significant strides in reducing the health disparities among Native Americans and Alaska Natives, continued and sustained improvements in access to treatment and preventive services are needed. That is why I joined my colleague, Senator Smith, and other members of the Indian Affairs Committee, to send 

Office of Management and Budget (OMB) Director Jim Nussle a letter requesting 

increased IHS discretionary funds. I want to make sure that people on the Wind 

River Reservation, and all Native People across America, have equal access to quality, affordable medical care. 

That said, it is equally as important that the care we provide is cost effective and 

produces results. The IHS is not like other federal health care programs. Congress 

has only limited access to the research data that is needed to modernize and improve Indian health care. I know this Committee will continue to focus its efforts 

to improve health care services, but we need good data and research to evaluate the 

current delivery system—exposing barriers that prevent collaboration, networking, 

innovation, and sharing of resources. 

Today, neither the government nor private Native American/Alaska Native advocacy groups can explain exactly how funds are used to coordinate medical services. 

If we do not know where our resources are being spent, the number of programs 

dedicated to provide services, how these programs coordinate health services, or the 

outcomes achieved, then can we be certain we are maximizing our ability to help 

Native Americans and Alaska Natives? 

It is incumbent upon the IHS Director to provide timely, accurate answers to this 

Committee and Congress outlining (1) how much money the federal government is 

spending on discretionary and mandatory Indian health care programs and (2) how 

28

the IHS works with Medicare, Medicaid, SCHIP, states, and the tribes to coordinate 

programs and services. This way, we can target federal funds to programs making 

the greatest impact—then focus on additional areas where Native Americans and 

Alaska Natives need our support. 

Mr. McSwain, thank you for your willingness to serve in public office. I look forward to working with you to improve the health and welfare of the individuals living in Indian Country. 


207n1.eps
29


207n2.eps
30

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. GORDON H. SMITH TO

ROBERT G. MCSWAIN

Health Facilities Construction and the Area Distribution Fund 

Last July, during Dr. Grim, former IHS Director’s nomination hearing, Senator 

Smith asked him to confirm whether IHS had the authority to implement an ADF. 

Dr. Grim did not confirm the Agency’s authority. One week later Senator Smith sent 

a follow-up letter which also has not been answered. In 1999, Congress was concerned about the inequities associated with the allocation of health facilities construction resources. In turn, Congress directed the Indian Health Service, in conjunction with Tribes, to revise the Health Facilities Construction Priority System to 

make it more flexible and to respond and accommodate the wide variances in Tribal 

needs. Nine years later, the new list is finally complete, however it has not been 

approved by the Department of Health and Human Services, nor the Office of ManVerDate 0ct 09 2002 09:08 Apr 03, 2008 Jkt 040848 PO 00000 Frm 00034 Fmt 6601 Sfmt 6621 S:\DOCS\40848.TXT JACK PsN: JACKF

207n3.eps
31

agement and Budget. Many Tribes in Oregon and throughout the country are concerned that finalization of the list has been stalled. 

Question 1. Does the Indian Health Service have the authority to implement an 

Area Distribution Fund under the Indian Health Care Improvement Act? 

Answer. Section 301 of the Indian Health Care Improvement Act requires the IHS 

to submit an annual report to Congress setting forth the Service’s current Health 

Facilities Construction Priority System (HFCPS). The report must identify the highest priority inpatient and the highest priority outpatient healthcare facilities construction projects, but does not specify how IHS should fund these projects or 

whether their funding should have precedence over other high priority Indian 

Health Service needs. In practice IHS has based its funding requests on this listing 

of projects, and the Congress has appropriated funds based on these requests. IHS 

has the authority to adopt a health care priority system that allocates a portion of 

health facility construction funding to all Service Areas.

Question 1a. What is the Indian Health Service’s timeline to begin implementation of the revised priority list? 

Answer. The IHS Office of Environmental Health and Engineering has been working on the revision to Healthcare Facilities Construction Priority System (HFCPS) 

based on the Tribal comments and Facilities Appropriation Advisory Board (FAAB) 

recommendations. We do not have a timeline for implementation, as the revision requires Department, OMB and Congressional review prior to implementation.

Question 1b. How will the new list work with the current list of pending projects? 

Answer. We believe the current system has appropriately identified the priority 

order of construction projects IHS will undertake. Our goal is to avoid disruption 

of the current priority list when the new HFCPS is implemented. 

Special Diabetes Program for Indians Funds 

Question 2. Will you conduct Tribal consultation beyond the Tribal Leaders Diabetes Committee in allocating the Special Diabetes Program for Indians funds under 

the one year extension (FY 2009)? 

Answer. As you know, Tribal consultation is an integral part of the program planning process used by IHS. For the past 10 years, since the Special Diabetes Program 

for Indians (SDPI) was established, the IHS has conducted extensive and comprehensive Tribal consultation on the development and implementation of this program. Consultation has made SDPI a more innovative and successful program. On 

February 7–8, 2008, the Tribal Leaders Diabetes Committee met in San Diego, CA 

to review and discuss issues related to the reauthorization of the Special Diabetes 

Program for Indians (SDPI) funding for one year (FY09) at the same amount of $150 

million. I asked the TLDC to make recommendations to me regarding the new SDPI 

funding for FY09. Overwhelmingly, the TLDC recommended to me that Area Tribal 

consultation be held. Thus, I have prepared direction to the IHS Area Directors from 

my office to host tribal consultation activities in every IHS Area regarding this 

topic. The IHS Division of Diabetes Treatment and Prevention has developed a consultation discussion guide and background documents based on TLDC direction as 

well as from previous consultation activities. This was done quickly because Nashville Area was holding their tribal consultation on Tuesday, February 12th. 

There is a tight timeline for these Area Tribal consultations to occur. The deadline 

for providing results back to the Division of Diabetes is March 10th. On March 28th 

the TLDC is scheduled to review the Area Tribal consultation summaries and to develop recommendations to be provided to me in order for a final decision to be made. 

At this time, both Nashville and California Areas have completed consultation activities on this topic. IHS will distribute FY 2009 SDPI funds in a manner that provides the best diabetes care and prevention services possible to American Indians 

and Alaska Natives and in a manner that is consistent with Administration policy.

Question 3. Given the tremendous administrative challenges that the IHS grants 

management office has with getting awards out in a timely fashion, it has been recommend that the IHS not deviate from its grants process under the one-year extension. Are there plans to significantly alter the grants process for the SDPI? 

Answer. It is not clear at this time how the grant distribution process will change 

under the one-year extension. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. TOM A. COBURN, M.D. TO

ROBERT G. MCSWAIN

Question 1. Please describe how you have, or will have resolved the longstanding 

law enforcement void at the Claremore (OK) Indian Hospital? Provide details on 

32

how the solution will provide adequate protection for patients, employees and area 

residents? 

Answer. Since the Claremore Indian Hospital is Federal Property, the only law 

enforcement entity with jurisdiction is the Federal Bureau of Investigation, which 

responds in cases of serious breaches of law at the facility but does not provide onsite security or law enforcement services. As a result, security at the Claremore Indian Hospital currently consists of one individual whose authority and responsibility 

is limited because of the jurisdictional situation. The Claremore Hospital has contacted the Federal Protective Service, which is willing to provide on-site law enforcement services, but at a prohibitive cost. Consequently, the Claremore Indian Hospital is working to resolve jurisdictional issues so that local law enforcement entities 

can provide protection to patients and staff at the facility. The Hospital is also pursuing information on the option of contracting through the Department of Health 

and Human Services Program Support Center, which has delegated authority to 

contract for security services that will be available on a 24/7 basis to protect patients and staff on the grounds of and in the facility.

Question 2. Recent disclosures by the Indian Health Service indicate that the 

agency spent $2.8 million on conferences in FY 2006 and $33.7 million on travel for 

the same period. Please provide the Committee with updated data for FY 2007. 

Answer. The Indian Health Service spent $368,000 on conferences in FY 2007 and 

$38 million on travel for the same period.

Question 3. Do you support an agency-wide reduction in conference and travel 

spending, so that additional resources can be made available for patient care? If so, 

how do you plan to achieve this goal? 

Answer. Yes, the Indian Health Service significantly reduced conference spending 

by $2.4 million between FY 2006 and FY 2007. Departmental and agency policies 

increased oversight of conferences, limited attendance, and promoted the maximum 

use of technology in place of travel. Internal controls and increased interactive Web 

sessions, tele-conferencing, and video-conferencing, will continue to enable us to put 

more of our resources into patient transport and care, health professional coverage, 

recruitment, and facility compliance.

Question 4. Based on your impressive and extensive experience within the IHS 

system, please identify programs and/or offices that are in most need of your attention. In addition, please identify any programs that you believe are failing to meet 

their objective. 

Answer. My immediate priority is the recruitment and retention of health care 

professionals because it is fundamental to the ability of our hospitals and clinics to 

meet the health care needs of the American Indian and Alaska Native communities 

we serve. We are experiencing double-digit vacancy rates in physicians, nursing, 

pharmacy, and dental—all critical to the delivery of our core mission that is patient 

care to American Indians and Alaska Natives on or near reservations. These vacancies affect quantity and quality of care; continuity of care; and, increase our operating costs as a result of the higher costs of contracting for temporary replacements. 

It is my firm belief that all programs currently funded within annual appropriations are meeting their objectives.

Question 5. Do you believe the current Indian Health care system meets our legal 

commitments to tribes and their citizens? 

Answer. Yes, I believe that the current Indian health care system meets our legal 

commitments to serve eligible American Indian and Alaska Native people. The IHS 

has focused on those programs that positively impact the health status of Indian 

people. In 2006 we celebrated 50 years or accomplishments from the transfer from 

the Department of the Interior to the U.S. Public Health Service, Department of 

Health and Human Services. During these 50 years we have experienced the increased involvement of Tribes. The current system of care reflects not only our ongoing consultation with Tribes on the status and direction of the Indian health care 

system, but Tribes now operate more than 50 percent of the system.

Question 6. If your child was gravely ill and you had a choice between sending 

him/her to the very best physician/clinic (regardless of its status as private, tribal 

or IHS) with federal funds and sending them to a traditional IHS facility, what 

would you do? 

Answer. I would not hesitate to send my child to an IHS facility, knowing fully 

that my child will receive immediate care and will be referred out for more specialized care if necessary. All our IHS facilities (both IHS managed and Tribal managed) are fully accredited and staffed by competent, caring, and committed staff.

Question 7. Again, based on your experience, if you were asked to eliminate one 

program based on poor performance or its relevance to IHS priorities, and shift 

33

those funds to higher IHS priorities: what would you eliminate and where would 

you send the reallocated funds? 

Answer. IHS programs are not poor performers. Six major programs of the IHS 

have been subjected to the OMB’s Program Assessment Rating Tool (PART) evaluation and rated an average score of 80, with none below adequate. In addition, the 

IHS exceeded almost all the performance indicators for the Government Performance Results Act (GPRA). However, in times of deficit reduction budgets, the IHS 

chose to prioritize the mission critical health services for those American Indian and 

Alaska Native people who reside on or near reservations. This choice has resulted 

in decreasing or eliminating programs that have performed at the adequate or effective levels, such as the Urban Indian Health Program. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. MARIA CANTWELL TO

ROBERT G. MCSWAIN

Question 1. Mr. McSwain, please describe your view of the Indian Health Service’s 

obligation to provide urban Indians with appropriate health care services? 

Answer. Health care services for American Indian and Alaska Native people who 

reside in urban areas are part of our broad Federal mission stated in the Snyder 

Act, ‘‘for the benefit, care, and assistance of the Indians throughout the United 

States’’ including the purpose ‘‘For relief of distress and conservation of health.’’ 

However, Indians living in urban areas are able to access health care services from 

a variety of Federal, State, and local providers, including Health Centers operated 

by HRSA, which are located in every urban area currently being served by an 

Urban Indian Health Program.

Question 2. You are no doubt aware of the need to revise the current health facilities construction priority system and create a more equitable means of providing resources for every tribal area. 

I understand that the Facilities Appropriations Advisory Board has submitted its 

recommendations to the Office of the Director. This work is the product of years of 

collaboration with IHS and Tribal representatives. 

I am particularly interested in one of these recommendations—the establishment 

of an Area Distribution Fund. For sure, there are many elements that need to be 

considered in order to make this proposal work in a way that respects the needs 

of tribes awaiting facilities funds under the current priority system, as well as the 

tribes that receive no resources at all. 

As Director of the Indian Health Service would you plan to further examine the 

concept of an Area Distribution Fund? 

Would you be willing to implement an Area Distribution Fund? 

Answer. As Director of the Indian Health Service, I will continue to examine not 

only the concept of the Area Distribution Fund, but I would be willing to implement 

a funding distribution methodology that does not adversely affect the continued 

funding of ongoing construction projects. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. JOHN BARRASSO TO

ROBERT G. MCSWAIN

Question 1. Mr. McSwain, you have one of the most challenging jobs in Government. The last time I visited Wyoming’s Wind River Reservation, the issue I heard 

about most was health care. There is a very long list of needs. I know your department has made progress to improve the health and welfare of American Indians and 

Alaska Natives, but I think you would agree we still have much left to accomplish. 

Have you crafted an action plan that will help transform the Indian health care system and the way Indian communities receive health care over the next 4 years? If 

not, what are your goals? What do you hope to accomplish? 

Answer. I appreciate your comments regarding the challenges we face in the Indian health system. This is so important because, as you know, the work that we 

do in the Indian health system is not abstract or conceptual in any way. The care 

we provide affects the lives of individuals and the health of families and communities. The dedicated individuals in the IHS and Tribal Indian health programs that 

serve these communities know why they go to work every day. And yes, we have 

much left to accomplish. 

During his term as Director of the Indian Health Service, Dr. Grim visited a great 

many of these communities and spoke with and listened to Tribal members, Tribal 

leadership, and health professionals. Out of these discussions we developed the 

three Director’s Initiatives in Health Promotion and Disease Prevention, Behavioral 

34

Health, and Chronic Care. These three initiatives, together, provide the framework 

and strategy for improving the health status of American Indian and Alaska Native 

people. 

The Health Promotion and Disease Prevention Initiative is focused on creating 

the capacity in our communities to support healthy behaviors and wellness through 

evidence-based practices. Primary prevention is an investment that pays off in improved health for American Indians and Alaska Natives, in reduction in suffering 

in our communities, and in cost savings to our health system. 

The Behavioral Health Initiative addresses the total health of the individuals, 

families, and communities we serve. A novel and transformative strategy for the Behavioral Health Initiative involves bringing the whole person into focus in our 

health system through the integration of behavioral health services into primary 

care. The aim of the Chronic Care Initiative is to improve the health status of American Indians and Alaska Natives by reducing the impact and prevalence of conditions such as diabetes, depression, asthma, heart disease, and cancer. Through this 

initiative we have developed a partnership with the Institute for Healthcare Improvement (IHI) to use modern improvement methodologies to transform the system 

of care for prevention and management of chronic conditions. 

The Chronic Care Model (Care Model), developed and extensively validated by Dr. 

Ed Wagner of the McColl Institute for Healthcare Innovation and colleagues, captures and defines the essential features of a system of care that focuses on the relationship between an informed and activated patient, family, and community and 

their prepared and proactive health care team. The Indian health system has extensive experience with the Chronic Care Model in diabetes care. In fact, we attribute 

some of the success we have achieved in improved diabetes outcomes through the 

Special Diabetes Program for Indians to this model. Over the past year we have 

been working with the IHI to support 14 pilot sites representing a slice of the Indian health system in a learning community that is adapting the Chronic Care 

Model and developing strategies for implementation to improve care across conditions. These programs (including the Wind River Service Unit) are using rigorous 

and ongoing measurement to guide their improvement efforts. 

We have already begun to see remarkable improvement within the pilot sites in 

screening rates for cancer and alcohol misuse, and in diabetes care. Just as importantly we are seeing reductions in wait time, improved access and continuity of care, 

and the development of a truly functional, proactive and prepared care team. 

In the coming year we will take the lessons learned from these pioneering programs and expand the collaborative to approximately 40 Indian health facilities, further refining the process and the package of changes and preparing for the spread 

of improvement in the prevention and management of chronic conditions. Over the 

next two to three years, we will be spreading this improvement work across the entire Indian health system. 

This effort requires that we think differently about how we care for patients, families, and communities, and about how we support the spread of improvement and 

innovation in our health system. It focuses us on the patient and family at the center of care. It forces us to think about how to create an Indian health system characterized by pervasive and reliable quality; everywhere, every time, for every person. 

We are guided and supported in this work by the expertise of the Institute for 

Healthcare Improvement. 

I am pleased to report that we are beginning to see true integration of the work 

being done by some of our Special Diabetes Program for Indians grantees with that 

of the Chronic Care Initiative pilot sites. The Chronic Care Initiative provides the 

Indian health system with the opportunity to learn from our efforts in diabetes care 

and transform the prevention and management of other chronic conditions. Our 

partnership with the IHI offers the Indian health system new ways of working, new 

ways of thinking, and new hope in the prevention and management of chronic conditions. 

We have much left to accomplish. Over the next four years we will use the Director’s Initiatives in Health Promotion and Disease Prevention, Behavioral Health, 

and Chronic Care to build strength and wellness in our communities and quality 

in our system of care.

Question 2. I want to make sure Native Americans have equal access to quality 

medical care. But it is equally as important the care we provide is cost effective and 

produces results. Today, neither the government nor private advocacy groups can 

explain exactly how federal/state/tribal funds are used to coordinate medical services. It is incumbent upon the IHS Director to provide timely answers to the Committee and Congress explaining how much money we are spending on programs and 

how the IHS works with Medicare, Medicaid, SCHIP, and the tribes to coordinate 

35

that care. What efforts will it take to ensure we have the information and tools we 

need to make effective policy decisions? 

Answer. I share your concerns and we do make every effort to provide quality care 

and equal access to care in a cost effective way for all American Indians and Alaska 

Native patients who use our facilities. We are a comprehensive health care delivery 

system and provide a broad range of health care services with a focus on primary 

care. IHS and Tribally operated facilities (facilities compacted or contracted under 

P.L 93–638) all receive appropriated funds in specific health care categories. Also, 

both IHS Federal and Tribal facilities collect from Medicare, Medicaid, SCHIP and 

private insurance for health care provided to patients who are enrolled in those programs. Public and private insurance collected for services provided at each facility 

is returned to that specific facility and used to maintain accreditation and support 

the health care delivery system as required by law. IHS works closely with the Centers for Medicare and Medicaid Services (CMS) to enhance collections and ensure 

health care is delivered in an efficient way. CMS established a Tribal Technical Advisory Group to address Tribal concerns and policy issues and both CMS and IHS 

work closely with this group. Also, IHS facilities work closely with CMS regions 

across the country making the process more efficient and effective. Facilities work 

directly with States and State Medicaid Agencies and SCHIP programs and collaborate on a regular basis to improve health care delivery and health care funding. IHS 

facilities are accredited and work directly with local Tribes to coordinate the health 

care delivery system. The IHS collects information on health services and health 

status and uses this information in the decision making process for program planning and evaluation. The information is also used in budget preparation and allocation to assure funds for Indian health are used in the most effective manner. The 

IHS also consults with Tribes and Tribal programs to coordinate our efforts in improving the health status of American Indians. We want to be sure Congress has 

the necessary information and data to make sound decisions. We are committed to 

working with Congress and to providing you with the information that will assist 

you in your decision-making.

Question 3. Addiction to methamphetamine and alcohol are very serious problems 

on the Wind River Reservation. Mexican drug trafficking has substantially increased the supply of Meth in my state. The State of Wyoming is continuing to 

make strong efforts to address this issue. But, what are we doing—in collaboration 

with the states and tribes—in terms of treatment and prevention services? Have the 

IHS efforts been successful? 

Answer. IHS has been successful in collaborating with Tribes and States to increase clients’ access to substance abuse treatment services. Examples of this collaborative effort would be:

• Efforts by Tribes, IHS and States to increase awareness and knowledge of addictions and treatment to AI/AN communities;

• Certified and licensed counselors are employed;

• The tribal programs are gaining CARF (Commission on Accreditation of Rehabilitation Facilities) certification, a nationally recognized status, as well as State 

certification; many programs have both certifications;

• Increased use of evidenced-based models such as MATRIX motivational interviewing training are utilized in treatment services.

• Prevention and community education services are shared by mental health professionals, substance abuse counselors, health educators, public health nurses 

and diabetes professionals. All of these types of chronic diseases, including depression and substance abuse overlap.

Methamphetamine and alcohol dependence are very serious problems on the Wind 

River Reservation. The problems created by these two addictions impact a large 

number of individuals and families. The primary agencies and organizations involved in addressing these problems are the Indian Health Service, the Eastern 

Shoshone Tribe and the Northern Arapahoe Tribe and the State of Wyoming. Collaborative efforts are on the increase. Examples of this effort to work together for 

the common goal of meth reduction would be the Eastern Shoshone Tribe, which operates the Eastern Shoshone Recovery Program and the Sho-Rap Lodge, an 8 bed 

facility funded jointly by the State and Tribes, and also the Northern Arapahoe 

Tribe, which operates the White Buffalo Recovery Center, funded by IHS and the 

Tribes. Tribal programs are becoming increasingly aware of the value of State certification, such as with the Eastern Shoshone/Northern Arapaho substance abuse 

program’s certification through the State of Wyoming and stronger emphasis by 

Tribes to certify/license the counselors they employ. These efforts, among many, 

serve to illustrate the need and value of working collaboratively. 

36

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. TIM JOHNSON TO

ROBERT G. MCSWAIN

Question 1. When individual tribal members in the Aberdeen Area need help navigating the Federal agencies on their specific cases they often turn to their congressional delegation. In order to effectively serve these constitutions we need prompt 

and fluid communications with the agencies both at the area level and at the federal 

level, this has been a continuous problem with IHS. I can’t mention the names of 

the individuals involved in the cases without their permission, but some examples 

include:

• A first letter sent to Aberdeen Area office on July 23, 2004, congressional staff 

was informed the response was delayed at Rockville, after repeated inquiries a 

response was finally received on July 2, 2007.

• The first letter was sent to Rockville on Dec. 6, 2006, the third notice of ‘‘no 

response’’ was sent on June 4, 2007. As of today, there has still been no response. This is an urgent case on contract health appeal to Rockville that desperately needs a response.

These are just two examples. If you are confirmed, what will you do to ensure 

Congress will receive prompt responses to casework and other inquiries of your office? 

Answer. Congressional inquiries are considered to be of utmost importance to the 

Indian Health Service (IHS), and are treated as a high priority. Many of the responses, however, require extensive research and coordination with IHS staff located in various Area Offices and Service Units throughout Indian country. The IHS 

headquarters has a system in place to track and monitor Congressional inquiries, 

and will continue to make every effort to respond to these inquiries in a timely manner.

Question 2. The Aberdeen Area encompasses 6 of the 10 poorest counties in the 

Nation, all of which are reservation counties in South Dakota. The Healthcare needs 

are enormous and multifaceted, how do you plan to help these Tribes address some 

of the largest health disparities in the country? 

Answer. South Dakota is where the majority of Native Americans served by the 

Aberdeen Area IHS reside and where these six (6) poorest counties in the Nation 

are located. We are developing new methods of healthcare delivery and prevention 

by redesigning the IHS delivery system. As an example, Aberdeen Area has the only 

mobile digital mammography unit in IHS, which is beginning its third full year of 

operation reaching poor, rural communities with bone screening and breast cancer 

screening delivered in the community. Sioux San Hospital in Rapid City is a pilot 

site for colorectal cancer screening. 

Partnering with tribes, the injury prevention component of the chronic care initiative is being piloted at Sisseton and Santee. These pilot sites have developed screening tools to identify and to increase the use of seatbelts and car seats. They are also 

working to decrease substance abuse by early identification and referral for services 

to address alcohol-related injuries, which are a major contributor to years of potential life lost and millions of dollars in Contract Health costs. 

In addition, the IHS has implemented a 5 year strategic plan to develop a telemedicine hub that will provide telepharmacy, telepsychiatry, telepain management, 

teleradiology and other services to increase access to healthcare for these poorer isolated reservations. The telepharmacy Program is functioning on the Pine Ridge reservation and we are advertising for the telepharmacy program Director. We are already deploying ‘‘Good Health’’ videos into health facility waiting rooms bringing 

timely, community-specific health care and preventive services directly to the Indian 

communities we serve. Materials are being developed that are culturally relevant. 

The ‘‘Good Health’’ videos and culturally relevant health materials are already in 

at least four sites and being well received. 

Suicide continues to be a glaring marker of health disparity. The strategic plan 

employs the public health model to bring evidence-based best practices of community-oriented primary and secondary prevention such as Question, Persuade, and 

Refer (QPR), Critical Incident Stress Management (CISM), and Applied Suicide 

Intervention Skills Training (ASIST). The Area telemedicine strategic plan has telepsychiatry as a priority to increase access to care for patients and access to specialty 

consultation for providers starting with those sites with the highest suicide rates, 

such as Rosebud. We are developing partnerships with Avera Health, Sioux Falls, 

South Dakota, Sanford, Sioux Falls, SD, the Department of Veterans Affairs, and 

others to increase access and educational opportunities for reservation residents. 

The Behavioral Health Plan includes strategies to address primary, secondary and 

tertiary aspects of suicide prevention. The Chronic Care initiative focuses on DeVerDate 0ct 09 2002 09:08 Apr 03, 2008 Jkt 040848 PO 00000 Frm 00040 Fmt 6601 Sfmt 6621 S:\DOCS\40848.TXT JACK PsN: JACKF
37

pression and Meth specifically. The Area continues to develop and use many culturally specific CD, DVD, and written materials appropriate to the Northern Plains 

Tribes which are sought after by other IHS areas. 

The Area staff recruitment and retention plan includes efforts to work with various State, Veterans Health Administration, and private partners to address rural 

health needs and develop strategies to address the changing workforce needs. IHS 

intends to use telemedicine and telehealth to recruit, train, develop, and support the 

workforce.

Question 3. Do you have adequate funds to carry out your responsibility to provide 

healthcare for American Indian Tribes? What do you believe would be adequate 

funding level? 

Answer. The IHS maximizes health care services to Indian people with funds appropriated by Congress. IHS also supplements appropriated funds with collections 

from Medicare, Medicaid, and the State Children’s Health Insurance Programs and 

other third payers, including private insurance. With combined funding, the IHS 

system of tribal, and federal health programs annually provide millions of health 

care services to Indian people. The IHS is the major, often only, source of health 

care for hundreds of thousands of Indian people and has contributed to remarkable 

improvement in Indian health status in recent decades. In recent years the IHS has 

recognized the need to partner with other Federal agencies and private organizations to address the complex health conditions facing Indian people. For example, 

addressing suicides and methamphetamine abuse requires a concerted effort by the 

Indian community and Federal health and law enforcement agencies. Each year, 

when developing a budget request, IHS considers what level of funding is adequate 

for carrying out its responsibility to provide health care.

Question 4. Do you have adequate staff and personnel to carry out your responsibility to provide healthcare for American Indian Tribes? What do you believe would 

be an adequate staffing level? 

Answer. The health professionals and support staff of the IHS are extremely hard 

working and dedicated to serving the health care needs of Indian people. Our challenge to meeting the health care needs of American Indians and Alaska Natives (AI/

AN) is to assure adequate staffing at our hospitals and clinics. A recent personnel 

review showed that in FY 2008, the IHS anticipates the need to fill almost 1,500 

health care professional vacancies including 181 physicians, 131 dentists, 612 

nurses and 65 pharmacists. 

Recruitment of these health care professionals is challenging due to a number of 

factors including nationwide shortages of health professionals such as physicians, 

dentists, nurses and pharmacists, the pay differential between federal salaries and 

how much the private sector pays, and the rural settings for many of the IHS health 

care sites. 

To improve staffing at our facilities, the IHS must fill many, if not most of these 

vacancies. To reach this goal, IHS has initiated an extensive recruitment and retention effort. To raise awareness of IHS career opportunities among health professionals, the IHS launched the ‘‘IHS Public Health Professions—Recruitment Campaign’’ developing new advertisements, recruitment materials and new web sites. 

These new advertisements were placed in professional journals and on recruitment 

websites in late FY 2007 and will continue throughout FY 2008. 

The IHS Public Health Professions web site at http://www.careers.ihs.gov/ has 

several new updates planned for FY 2008, including an updated physician website 

which will allow physicians and medical residents to request materials and ask 

questions of recruiters.

Question 5. The Cheyenne River Sioux Tribe has indicated that the Design for the 

Eagle Butte service unit was done to cost–meaning IHS developed a total cost for 

the facility and the Tribe then asked the architects to maximize the center’s capabilities subject to the permitted cost allocation. As a result, any delay in seeking 

construction funds for this facility risks inflationary cost increases that will create 

a need to scale back and re-approve the project plans at additional cost. What steps 

is IHS taking to ensure that this will not happen? 

Answer. The design for the Eagle Butte Health Center has been completed and 

has been submitted by the architect. These plans and documents were designed not 

to exceed the IHS Facilities Budget Estimate which is based on the Program of Requirements (POR). The POR defined the required space necessary to provide health 

services at this new facility. The total cost of this project amounts to $111,100,000. 

Prior to FY 2008, Eagle Butte received $7,797,000 for design and initial construction of the new healthcare facility. The FY 2008 congressional appropriation to continue construction activities totaled $17,212,000. The IHS Facilities Budget EstiVerDate 0ct 09 2002 09:08 Apr 03, 2008 Jkt 040848 PO 00000 Frm 00041 Fmt 6601 Sfmt 6621 S:\DOCS\40848.TXT JACK PsN: JACKF
38

mate has nearly $7,600,000 in construction contingencies which can be used to assist in addressing acts of God and excessive inflation.

Question 6. IHS has release a document regarding the reduction of hours at the 

Wagner Service Unit claiming that it will allow IHS ‘‘to reprogram approximately 

$600,000 for other services and program support.’’ Will those cost savings go to benefit the Wagner Service Unit? 

Answer. The Yankton Sioux Tribal Chairman met with I.H.S. Headquarters staff 

on December 11, 2007 in Rockville, Maryland, regarding plans to transition 24 hour 

service at the Wagner I.H.S. Ambulatory Health Care Facility to an Urgent Care 

Clinic with hours of service from Monday–Saturday, 7:00 am to 11:00 pm. It was 

discussed at the meeting that I.H.S. can no longer justify 24-hour emergency room 

(ER) services, and will need to proceed with the transition to an Urgent Care Clinic 

at the Wagner I.H.S. facility. Last July, Wagner I.H.S. decided that the effective 

date for this transition would be January 1, 2008. The effective date was moved to 

March 1, 2008 in order to complete community education. Wagner I.H.S. staff continues to meet with the Yankton Sioux Tribe and Wagner Community Memorial 

Hospital to keep them informed of the transitional phase. Weekly notices were 

placed in the local newspaper beginning January 28, 2008. 

The Wagner Service Unit is hopeful that any cost savings will allow for more specialty services to be provided on-site which will enhance overall comprehensive care 

to better meet the needs of the patients.

Question 7. I have been contacted by several IHS employees from South Dakota 

who have been waiting for sometime to resolve long standing back pay claims. I 

hope that IHS and these employees through their Union, the Laborers’ International 

Union of North America, will engage in substantive dialogue to resolve these issues. 

What has IHS done recently to resolve this dispute? Is there currently an employee 

of the IHS charged with working on this issue? 

Answer. The Union and the Aberdeen Area Office have agreed to an arbitration 

schedule that will start on March 17, 2008. Out of a total of 145 claims listed on 

the Union’s (LUINA) list submitted by Mr. Robert Purcell, the Agency has reviewed 

and denied 84 claims because the employees were found to be in an on-call status 

and were paid appropriately and did not meet the requirements in regulations set 

forth for standby duty. Additionally 36 claims were found to be incomplete as only 

tolling letters were submitted with no claims or claims submitted without the tolling 

letter (a tolling letter is required to preserve the claim period). The remaining 17 

claims are in a review status.

Question 8. The Cheyenne River Eagle Butte Service Unit has faced some serious 

problems with its CMS certification. Are these problems being resolved? Why did 

these problems go unresolved for almost seven years? 

Answer. CMS determined in its most recent review that Cheyenne River Service 

Unit (CRSU) was fully in compliance with the Medicare Hospital Conditions of Participation. CRSU worked hard to achieve this result. However, on January 18, 2008 

CRSU was advised by CMS that it was out of compliance with several of the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements, which are 

separate from the Conditions of Participation and have to do with providing an appropriate medical screening examination and stabilizing treatment for individuals 

with emergency medical conditions. CRSU is making progress in this area, but further improvements are needed to achieve full compliance. 

CRSU is sending the CMS Regional Office weekly updates on its progress in 

achieving compliance. We understand CMS will make another unannounced inspection of CRSU sometime in the next couple of months, and we expect CRSU to be 

in full compliance at that time.

Question 9. We all know how chronically under-funded IHS is, yet I understand 

that the IHS’ efforts to collect reimbursement from private third-party payers have 

been minimal–even though such reimbursements could be as much as $50–100 million a year (based on IHS’ own past Budget Justifications). What has been done at 

the headquarters level to improve that effort and increase those collections? 

Answer. In FY 2007 the IHS collected approximately $90 million from private insurance payers. This is 12% of the estimated overall collections with the remaining 

88% of collections coming from Medicare and Medicaid, which totaled approximately 

$677 million. IHS has consistently increased collections in private insurance ever 

since it received the authority to bill. At Headquarters, the Office of Resource Access 

and Partnerships (ORAP) provides leadership and support to an IHS-wide National 

Business Office Committee comprised of 12 Area Office Business Office Coordinators. A major function of this National committee includes making recommendations 

to improve business operations, training requirements, software improvements and 

39

other major issues that can enhance or correct IHS wide problems that affect the 

collection of third party revenue at the hospital and clinic level. 

We are involved in a number of activities to enhance overall collections in the 

IHS. Third party training is provided on the Resource Patient Management System 

(RPMS) business office software applications. These classes are designed to improve 

skills in Patient Registration, Third Party billing, Pharmacy Point of Sale claims 

and Accounts Receivable. These skills include identifying alternate resources, provider documentation, procedural coding, billing and aging accounts receivable follow 

up. Another major training effort occurred when ORAP worked with CMS representatives to provide Outreach and Education Training sessions targeted to Benefit Coordinators and their role in assisting with processing Medicare and Medicaid application forms. When Medicare Part D became a billable service for IHS, training was 

provided to all of the Areas regarding the changes and issues that each Area needed 

to know. The Medicare Fiscal Intermediary (FI) and Medicare Administrative Contractor (MAC) also work closely with the National Business Office Committee to provide training both on-site or on-line to assist each of the IHS facilities on denials, 

new billing rules and system issues for Medicare. Private insurance activities are 

also addressed in the many training sessions conducted each year. 

The Office of Information Technology (OIT) maintains and improves the business 

office software applications that support electronic billing, payment posting and collections. One of the objectives for the IHS is to implement the electronic health 

record at all Federal IHS locations. With coding and data capture very important 

to the revenue process, separate Health Information Management/Business Office 

training classes are scheduled once a month through IHS. The ultimate objective 

is to transition IHS clinical providers to coding their encounters and not relying on 

manual data entry efforts. Moving away from manual data entry will make us more 

efficient and enhance our ability to bill and collect. 

In FY 2008, IHS is actively working with integrating the RPMS data with the 

Unified Financial Management Systems (UFMS). With this effort, ORAP has recognized the need to enhance and standardize the business process of posting in the 

RPMS systems the amounts identified on remittance advices issued from the payers. 

This will also assist Managers with current reports which identify unpaid revenue. 

These reports will not only assist the local facility managers but also Area and 

Headquarters staff if there is a major payer who is not reimbursing IHS at its appropriate level. 

In FY 2008, the IHS will continue its efforts to capture all private payer and third 

party payer information including Medicare and Medicaid and SCHIP for reimbursement purposes. The ORAP recognizes the need to work with private insurance 

payers and to maximize collections to the full extent of the law. Also, IHS collaborates with State agencies to enhance the systems necessary to enroll patients who 

may be eligible for Medicaid or the State Children’s Health Insurance Programs. 

Ongoing national broadcasts are scheduled in partnership with CMS to share this 

information and to further provide more leadership to the field staff.

Question 10. I have been informed that the Business Office Report of IHS has 

many provisions that are not consistent with the statutory authority given the agency to make these collections. Why would the agency voluntarily handcuff itself from 

collecting these reimbursements that are legally owed? 

Answer. The IHS is not sure what ‘‘Business Office Report’’ is referenced in the 

question and we do not believe that we have voluntarily ‘‘handcuffed’’ the organization from collecting reimbursements. The IHS pursues all alternate resources for 

payment for services provided at our hospitals and clinics and provides relevant 

training and support to Areas and Service Unit facilities. To support these efforts, 

the IHS has established Internal Controls and business operating manuals to guide, 

monitor and set standards for third party revenue collection. We do recognize that 

third party collections require management support at all levels of the IHS organization, and IHS management does realize the importance of maximizing collections. 

Since 1976, the IHS has had authority to collect Medicare Part A and Medicaid reimbursements. In the past 8 years this authority has been expanded to include billing for certain additional Medicare Part B services, SCHIP and Medicare Part D. 

Currently, third party revenue represents up to 50% of some hospitals’ and clinics’ 

operating budgets. Third party revenue is vital to maintaining the current levels of 

services accessible to AI/ANs at IHS hospitals and clinics. The IHS is making an 

effort to maximize collections to the full extent of the law.

Question 11. Has the Agency looked at how similar reimbursement issues are 

handled by other agencies, like the Veterans Administration? 

Answer. There continues to be increasing internal collaborative efforts on the utilization of automated systems between the Department of Veterans Affairs (VA) and 

40

IHS in which similar structure and functionality is shared. These include the Resource Patient Management System, Patient Information Management System and 

the Electronic Health Record. The VistA/Computerized Patient Record System systems are public domain and IHS is adopting these government developed systems. 

These systems contain core applications for storing codes and recording workload, 

however to facilitate appropriate coding and billing VA augments these systems 

with commercial software. Since IHS is modeling its software design based on the 

VA automated systems, business rules and processes are in progress which include 

coding systems, vista imaging and other solutions that will enhance the IHS third 

party revenue data capturing efforts to assure quality claims and accurate payments. Many of our facilities that are located near VA facilities do collaborate on 

systems development and support with the VA. The VA does not have authority to 

bill Medicare or Medicaid and concentrates its billing efforts on private insurance 

patients only. Private insurance is approximately 12% of IHS’ overall collections.

Question 12. One of the most alarming circumstances that Indian Country is currently facing is the issue of suicide and the lack of mental health services that provide prevention, intervention and aftercare services. While there are many contributing factors that lead to suicide, what steps should IHS take to alleviate the lack 

of mental health services? 

Answer. The IHS has been working with other Health and Human Service Federal agencies, in partnership with Indian Tribes and tribal organizations, to bring 

all resources to bear on improving behavioral health services for American Indian 

and Alaska Native (AI/AN) individuals and communities. Together, we are focusing 

on developing and expanding access to innovative and effective behavioral health 

interventions and resources that directly enhance our ability to address critical 

health issues such as suicide in Indian country. 

Increasingly, as more tribes contract to manage their own programs, the IHS is 

supporting them in the development and administration of suicide prevention and 

early intervention activities at the community level. Approximately, 87% of the IHS 

Alcohol and Substance Abuse and 47% of IHS Mental Health funding is distributed 

directly to tribal service programs. In FY 2008, the IHS Alcohol & Substance Abuse 

program received $14 million for a methamphetamine and suicide prevention and 

treatment initiative. Tribal consultation will take place before there is a final funding distribution plan put in place. We project that approximately $5 million of these 

funds will be used for suicide prevention. 

The IHS has historically had high vacancy rates and critical behavioral health 

personnel shortages in varying locations and professional categories. The IHS is taking the following steps to increase mental health services. 

Telebehavioral Health 

One technology being aggressively explored to improve access is use of telehealthbased services. Currently over 50 IHS and Tribal facilities in 8 IHS Areas are augmenting on-site behavioral health services with telehealth services. Areas, including 

Aberdeen Area in the Northern Plains, are building or have built telehealth infrastructure and programming to support this type of service where it has not existed 

before. 

Recruitment 

Through recruitment and retention activities, the Scholarship Program, and Loan 

Repayment Program, the IHS increases the number of Indians entering the behavioral health professions and works toward assuring an adequate supply of behavioral health professions to the Tribes, tribal organizations, and urban Indian organizations. The scholarship program supported a total of 461 students in 2006. 

The IHS InPsych Program addresses the need for American Indians in the Psychology field. There are 3 Indians into Psychology Programs. They are located at 

Oklahoma State University, Stillwater, OK; University of North Dakota, Grand 

Forks, ND; and the University of Montana, Missoula, MT. They are funded by Indian Health Service and have been in operation for approximately 10 years. 

Suicide Prevention Initiative 

The IHS Suicide Prevention Initiative is directly related to the Health and 

Human Services National Strategy for Suicide Prevention. IHS collaborates with 

consumers, and their families, Tribes and tribal organizations, Urban Indian programs, Federal (e.g. SAMHSA, NIH, BIA and others), State, and local agencies, as 

well as other public and private organizations to formulate long term strategic approaches, to develop a comprehensive system of care, and to share resources to address the issue of suicide in Indian Country more effectively. 

41

The IHS Division of Behavioral Health is actively promoting a suicide event database to record and track suicide events for IHS, Tribal and Urban Indian behavioral 

health programs across the nation. This application contains a suicide surveillance 

tool to capture data related to a specific incident of suicide, such as date and location of act, method, contributing factors and other useful epidemiological information. The Suicide Reporting Form (SRF) provides aggregate report options that can 

be analyzed and interpreted to inform program planning activities in support of 

Agency and Department suicide prevention and behavioral health initiatives. The 

reports are helpful in understanding and better addressing suicide in Indian country. 

Direct Care 

The overwhelming majority of direct services are provided in outpatient settings, 

but there are 12 IHS-funded Youth Regional Treatment Centers (YRTCs) that provide residential treatment, and many tribal and urban programs provide similar 

residential services across the country. IHS provides funding to these 12 Youth Regional Treatment Centers for prevention and early intervention of alcohol/substance 

abuse and co-occurring disorders, in youth ages 12–18, as mandated by P.L. 99–570 

and 100–690. Approximately $14.1 million is dedicated on an annual basis to IHS 

Area Offices for YRTCs. 

Partnerships 

IHS has developed formal partnerships in the formation of an IHS Director’s Behavioral Health Workgroup which includes representatives from the 12 IHS Areas 

and is comprised of Tribal behavioral health service providers. The workgroup is 

tasked with updating the original Alcohol/Substance Abuse 5-year strategic plan 

and integration of mental health services into the overall Behavioral Health initiative. In addition, the IHS Behavioral Health Program is creating a Tribal Advisory 

Committee to give guidance and direction to our Behavioral Health Initiative. 

IHS will continue to move the focus of behavioral health from a crisis orientation 

to ongoing behavioral health promotion by seeking new and sustainable resources, 

maximizing current program effectiveness through collaborations and data-driven 

models, and integrating technology and clinically sound behavioral approaches with 

the traditions and healing practices of the communities.

Question 13. What steps will I.H.S. take to ensure that requests for resources are 

considered when tribes and service units are experiencing suicide clusters? 

Answer. The Emergency Medical Services/Preparedness Division (EMS/P) is benefiting AI/AN Communities by responding with emergency personnel (to augment the 

mental health staff), programming, and logistical support to communities experiencing significant suicide crises. For example, in 2007, the IHS Emergency Medical 

Services/Preparedness Division provided oversight for an Office of Force Readiness 

Deployment (OFRD) to two (2) communities. In 2008, the IHS Emergency Services 

with the support of the IHS Division of Behavioral Health conducted a Suicide Response Assessment on one (1) community and is a part of an HHS Department-wide 

response to this tribal community. 

In 2003, the IHS established the Suicide Prevention Committee (SPC). It is the 

responsibility of the SPC to provide policy recommendations and guidance to the Indian Health Service Division of Behavioral Health (DBH) regarding suicide prevention, intervention and responding to suicide clusters in Indian country. The SPC is 

currently working on guidelines for responding to tribal requests for assistance. 

These guidelines will establish procedures for responding to emergent and nonemergent requests for assistance from tribal service organizations in the area of suicide and suicide prevention/intervention for the DBH within the Indian Health Service.

Æ