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

53–636 PDF 2009

S. HRG. 111–181 

REFORMING THE INDIAN HEALTH CARE SYSTEM 

HEARING 

BEFORE THE

COMMITTEE ON INDIAN AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

JUNE 11, 2009 

Printed for the use of the Committee on Indian Affairs 

( 

(II) 

COMMITTEE ON INDIAN AFFAIRS 

BYRON L. DORGAN, North Dakota, Chairman 

JOHN BARRASSO, Wyoming, Vice Chairman 

DANIEL K. INOUYE, Hawaii 

KENT CONRAD, North Dakota 

DANIEL K. AKAKA, Hawaii 

TIM JOHNSON, South Dakota 

MARIA CANTWELL, Washington 

JON TESTER, Montana 

TOM UDALL, New Mexico 

lllll, lllll 

JOHN MCCAIN, Arizona 

LISA MURKOWSKI, Alaska 

TOM COBURN, M.D., Oklahoma 

MIKE CRAPO, Idaho 

MIKE JOHANNS, Nebraska 

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 June 11, 2009 ............................................................................... 1 

Statement of Senator Barrasso ............................................................................... 58 

Statement of Senator Johanns ............................................................................... 59 

Statement of Senator Tester ................................................................................... 1 

Statement of Senator Udall .................................................................................... 55 

WITNESSES

Carlton, Jr., Paul K., M.D., Director, Office of Homeland Security, Health 

Science Center, Texas A&M University ............................................................. 47 

Prepared statement with attachment ............................................................. 49 

Davidson, Valerie, Senior Director, Legal and Inter–Governmental Affairs, 

Alaska Native Tribal Health Consortium .......................................................... 35 

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

Keel, Jefferson, First Vice President, National Congress of American Indians . 2 

Prepared statement .......................................................................................... 6 

Rolin, Buford, Chairman, Poarch Band of Creek Indians; Vice Chairman, 

National Indian Health Board ............................................................................ 11 

Prepared statement .......................................................................................... 13 

Roth, Geoffrey, Executive Director, National Council of Urban Indian Health . 19 

Prepared statement with attachment ............................................................. 22 

APPENDIX

Chickasaw Nation, health care reform—Indian Country recommendations ...... 101 

Cook, Michael, Executive Director, United South and Eastern Tribes, Inc., 

prepared statement .............................................................................................. 125 

Direct Service Tribes Advisory Committee, resolution ......................................... 115 

Engelken, Joseph, CEO, Tuba City Regional Health Care Corporation, prepared statement ................................................................................................... 117 

NCAI, health care reform—Indian Country recommendations ........................... 69 

NPAIHB and ATNI, letter with health care reform recommendations .............. 81 

Oklahoma City Area Inter-Tribal Health Board, health care reform recommendations ...................................................................................................... 97 

Response to written questions submitted to Paul K. Carlton, Jr., M.D. by: 

Hon. John Barrasso .......................................................................................... 157 

Hon. Byron L. Dorgan ...................................................................................... 143 

Hon. Tom Udall ................................................................................................ 157 

Response to written questions submitted to Valerie Davidson by: 

Hon. John Barrasso .......................................................................................... 160 

Hon. Byron L. Dorgan ...................................................................................... 157 

Hon. Tom Udall ................................................................................................ 162 

Response to written questions submitted to Geoffrey Roth by: 

Hon. John Barrasso .......................................................................................... 136 

Hon. Byron L. Dorgan ...................................................................................... 133 

Hon. Tom Udall ................................................................................................ 138 

Response to written questions submitted to Buford Rolin by: 

Hon. John Barrasso .......................................................................................... 130 

Hon. Byron L. Dorgan ...................................................................................... 128 

Hon. Tom Udall ................................................................................................ 132 

Skeeter, Carmelita, CEO, Indian Health Care Resource Center of Tulsa, 

Inc., prepared statement ..................................................................................... 107 

Smith, Chad, Principal Chief, Cherokee Nation, prepared statement ................ 112 

Sunday-Allen, Robyn, CEO, Central Oklahoma American Indian Health 

Council, Inc., prepared statement ....................................................................... 120 

(1) 

REFORMING THE INDIAN HEALTH CARE 

SYSTEM 

THURSDAY, JUNE 11, 2009 

U.S. SENATE, COMMITTEE ON INDIAN AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 2:20 p.m. in room 

628, Dirksen Senate Office Building, Hon. Jon Tester presiding. 

OPENING STATEMENT OF HON. JON TESTER, 

U.S. SENATOR FROM MONTANA 

Senator TESTER. I call the Committee to order. 

I appreciate the panelists giving testimony today. Unfortunately, 

Chairman Dorgan is unable to be with us here for this hearing, 

and I can tell you I know that he would love to be here because 

this is a big issue in Indian Country, and he knows it. It is something he talks about all the time. 

Today’s Committee is to discuss ideas for how to reform the Indian health care system. Everybody in this room knows that the 

Indian health system is broken. Estimates are that the Indian 

Health Service is funded at about 52 percent of need. 

However, the issues in the Indian health system extend far beyond lack of funding. Myself, as well as Chairman Dorgan and 

other Members of this Committee, have expressed serious concerns 

about the IHS. It has been over 10 years since Indian Country first 

asked Congress to reauthorize the Indian Health Care Improvement Act. 

Last Congress, this Committee brought the Indian health care 

bill to the floor and it was debated for the first time in 16 years. 

The Senate passed the bill overwhelmingly. Regrettably, the House 

did not. 

Health care continues to be a top priority for this Committee. We 

must do something to address the appalling health statistics among 

Native Americans. In my home State of Montana, Native American 

women have a median life expectancy of 64 years as compared to 

81 for the general population. That is a difference of 17 years. 

Native Americans have the highest rate of Type II diabetes of 

any population in the world. Native Americans have tuberculosis at 

a rate of 650 percent higher than the general population. Infant 

mortality rates for Native Americans are 12 per 1,000 compared to 

7 per 1,000 for the general population. Suicide rates are nearly 

double than the general population. Among Native Americans, my 

State of Montana has one of the highest rates of suicide for Indian 

2 

Country. American Indians die of alcoholism at the rates of 670 

percent higher than the general population. 

You get the idea. It is clear that the Federal Government is not 

fulfilling its trust responsibility to provide health care for Native 

Americans in this Country. 

On May 6, the Senate confirmed Indian Health Service Director 

Yvette Roubideaux. Having an IHS Director committed to addressing the deficiencies at the agency is an important step toward improving Indian health. Dr. Roubideaux has also expressed a commitment to reforming the Indian health care system, and I look forward to working with her and achieving that goal. 

President Obama has tasked Congress with passing national 

health care reform this year. With health care gaining such attention, there is a unique opportunity to improve the Indian health 

care system. 

The Committee is working on a draft bipartisan legislation that 

does more than reauthorize the Indian Health Care Improvement 

Act. We want to look for ideas in the Indian health care system 

that are needed and significant reform, which is why we are here 

today. We hope to hear ideas from our witnesses today on how Indian Country can move forward with reform. We want to address 

and find solutions to such areas as serious health disparities, 

health provider shortages, rationing of health care services. 

Myself, like Chairman Dorgan and the Committee, look forward 

to working with the new Administration, the Indian Health Service 

tribes, and all of you to bring meaningful change to truly reform 

the Indian health care system. 

I want to thank our witnesses for being here, and I would remind 

the witnesses to limit their remarks to five minutes. Your entire 

testimonies will be in the official hearing record. 

The expert witnesses that we have here today are Jefferson Keel, 

Vice President of the National Congress of American Indians. Good 

to have you here, Jefferson. 

Buford Rolin, Vice President and Nashville Area Representative 

of the National Indian Health Board. Good to have you here. 

Geoffrey Roth, Executive Director of the National Council of 

Urban Indian Health. Geoffrey. 

Valerie Davidson, Senior Director of Legal and Government Affairs for the Alaska Native Tribal Consortium. 

And Dr. Paul Carlton, Jr., Director of Homeland Security of 

Texas A&M Health Science Center. 

A powerful group of witnesses, and we look forward to tour testimony. I believe that we will just go from Jefferson and go down the 

line. Is that okay? All right. Yes. 

So how about it, Jefferson? Thank you. 

STATEMENT OF JEFFERSON KEEL, FIRST VICE PRESIDENT, 

NATIONAL CONGRESS OF AMERICAN INDIANS 

Mr. KEEL. Good afternoon. Thank you, Mr. Chairman, Members 

of the Committee who could not be here, we look forward and want 

to thank you for being here. 

My name is Jefferson Keel. I am Lieutenant Governor of the 

Chickasaw Nation and First Vice President of the National Congress of American Indians. 

3 

I want to thank you for the opportunity for testifying today. I am 

honored to be here. 

First and foremost, the provision of health care to American Indian and Alaska Native tribes is founded on a sovereign government to government relationship between the United States and 

tribes. As such, the provision of health care to American Indian 

and Alaska Native people is based on a unique political relationship and is not based on race. 

This provision of health care is formalized as a Federal trust responsibility to American Indian and Alaska Native people that has 

been guaranteed as a Federal trust responsibility, and been guaranteed through numerous treaties and Federal law. 

Health care for American Indian and Alaska Native people was 

permanently authorized in the Snyder Act of 1921. The Indian 

Health Care Improvement Act, as you mentioned, Senator, needs 

to be reauthorized immediately. Perhaps no where in the Country 

is debate on health care more important or will have more of an 

impact than in tribal communities. 

Tribal leaders and tribal health advocates have been working 

diligently to ensure that Indian Country and current Indian health 

delivery systems are being included in a meaningful way in the national plan for health care reform. We are poised to consider 

achievable reform opportunities for the delivery of health care 

throughout the Indian health care delivery system. 

We have provided for the record a copy of health care reform Indian Country recommendations put forth by the National Indian 

Health Board, the National Council on Urban Indian Health, and 

the National Congress of American Indians. 

I might also add that the Chickasaw Nation has provided testimony for the record, and those are included in the testimony. 

These recommendations have been shared with all committees of 

jurisdiction in the House and Senate working on health care reform. 

The National Congress of American Indians respectfully offers 

the following recommendations. I want to quickly address eligibility 

before we get into the recommendations. 

To be clear, there is no problem with eligibility. The issue that 

should be addressed, however, is resource allocation. If the Committee wishes to examine the issue of resource allocation more 

closely, tribes and the National Congress are happy to assist, and 

you will also hear later about self-governance tribes and how they 

are innovative in this approach. 

It has been proven that self-governing tribes are the most efficient and deliver the highest quality of health care to our people. 

Self-governing tribes have developed sophisticated collection systems to enable them to enter partnerships with other agencies to 

utilize every dollar effectively. Current law authorizes tribes to set 

priorities for health care delivery, therefore avoiding bureaucratic 

delays and life-threatening situations. We urge that those current 

laws be preserved. 

Tribal consultation. Given the expeditious nature of moving 

health care reform forward, we would like to thank the Committee 

for engaging and including Indian Country. We need to continue 

the consultation process. Realizing the short time frame involved, 

4 

we would suggest partnering with the Department of Health and 

Human Services, who will be conducting a consultation session in 

Denver later in July. 

Contract health services. Reducing the spiraling cost of health 

care is a priority for Indian Country, as you well know. Astronomical medical inflation rates, the expense of providing services in extremely rural communities, along with an increasing Indian population and limited competitive pricing have all tremendously hindered tribes’ and IHS’s ability to provide health care to Indian people. 

One of the most impacted areas of the Indian health system is 

the Contract Health Service Program. This program provides funding for primary and specialty health services that are not available 

at IHS or tribal health facilities to be purchased from the private 

sector health care providers. This includes hospital care, physician 

services, outpatient care, laboratory, dental, radiology, pharmacy 

and transportation services. It is estimated that CHS is currently 

funded at about 50 percent of the need. 

While the Committee has previously heard from Indian Country 

on this issue, we must continue to stress that anything less than 

full funding and recurring funding of CHS compromises the health 

and lives of those in our communities. By supporting us in these 

efforts, you will be ensuring that tribes have the ability to deliver 

the highest quality services to the tribal members. 

One way to immediately and dramatically address the shortfall 

in CHS funding is by ensuring that all American Indians and Alaska Natives are auto-enrolled in Medicaid. Creating an Indian-specific subsection or category of Medicaid would facilitate access to 

the comprehensive health care benefits of this program, while easing the already overburdened CHS system. This joint proposal submitted by the national Indian organizations provides recommendations of fast-tracking Indian patients into the Medicaid system. We 

suggest that proper consideration be made to establishing a new 

category of eligibility under Medicaid for Indian patients. 

Tribal health facilities are oftentimes located in remote rural geographic locations, making them in some instances the only viable 

option of health care delivery. With the anticipated increase in demand for health services, tribes recognize that they are likely to be 

asked to open their doors to serve non-Indians. This is a challenging decision that requires consideration of capacity and resources, and whether adding users will improve the services that 

can be offered or would diminish an already limited capacity. 

Senator TESTER. Jefferson? 

Mr. KEEL. Yes? 

Senator TESTER. Your entire statement will be in the record. I 

would ask you to try to wrap it up. It is a critically important issue 

that literally we all could talk on for a long time, but if you could 

hit your high points so we can do it, then we will move on. 

Mr. KEEL. Okay. I certainly will. 

Senator TESTER. Okay. 

Mr. KEEL. Indian health care workforce. Indian Country is not 

alone in its concern on how to address this ever-increasing workforce shortage. Mid-level practitioners is one answer. 

5 

Exclusion of health benefits as income. This is an important part, 

and I want to touch this and I will wrap up. 

Tribal governments have been trying to meet the challenge of addressing the health care needs in our communities. Some tribal 

governments have met this challenge by providing supplemental 

services above and beyond the limited IHS services, while others 

are providing more comprehensive care through self-insured funds 

or third party plans. This type of universal health coverage for tribal citizens is similar to Medicare. 

However, some IHS field offices are asserting that this type of 

coverage when provided by a tribal government should be treated 

as a taxable benefit. In order to continue to encourage tribal governments to provide such benefits to their members on a nondiscretionary basis, NCAI seeks a statutory exclusion to clarify that 

the health care benefits and coverage provided by tribal governments to their members are not subject to income taxation and excluded from gross income in the same manner as Medicare. 

Senator, I thank you for the opportunity to speak here. One final 

note. As a tribal leader, I would simply ask that the gains that we 

have made since 1975 in the Indian Self-Determination and Education Assistance Act not be compromised, and the Indian Health 

Service has been characterized as broken. We believe it is starved 

because we can’t determine how much is broken until we fully fund 

it. 

Thank you. 

[The prepared statement of Mr. Keel follows:] 

6 

PREPARED STATEMENT OF JEFFERSON KEEL, FIRST VICE PRESIDENT, NATIONAL

CONGRESS OF AMERICAN INDIANS


611a1.eps
7 


611a2.eps
8 


611a3.eps
9 


611a4.eps
10 

Senator TESTER. Thank you very much. 

You are exactly right, and have great hopes for Yvette when she 

gets fully going that we can get some good recommendations out 

of Indian Health Service. 

We have a vote that has just started, but I think Senator Dorgan 

is on his way. Correct? And so, Buford, if you want to start. If in 


611a5.eps
11 

fact he doesn’t get here, I don’t want to miss this vote, so I may 

have to call you down. 

Better yet, we are going to adjourn for a minute, because evidently Senator Dorgan may not. And I will run down and catch the 

vote and I will be right back, or potentially Senator Dorgan may 

be here. 

So we sit in adjournment until one of us returns. 

[Laughter.] 

[Recess.] 

Senator TESTER. I call the Indian Affairs Committee hearing 

back to order. 

Welcome, Senator Johanns. 

And Buford Rolin, if you want to continue with your statement, 

we would much appreciate it. 

Mr. ROLIN. I will begin. 

Senator TESTER. All right. 

STATEMENT OF BUFORD ROLIN, CHAIRMAN, POARCH BAND 

OF CREEK INDIANS; VICE CHAIRMAN, NATIONAL INDIAN 

HEALTH BOARD 

Mr. ROLIN. Thank you, Mr. Chairman and Members of the Committee, I am Buford Rolin, Chairman of the Poarch Band of Creek 

Indians and Vice Chairman of the National Indian Health Board, 

and I co-chair the Tribal Leaders Diabetes Committee, in addition 

to serving on the National Steering Committee for the Reauthorization of the Indian Health Care Improvement Act. 

The National Indian Health Board worked together with the National Congress of American Indians and the National Council of 

Urban Indians to examine reform proposals from the perspective of 

the Indian health care system. These organizations have taken the 

first step to make recommendations on national health care reform 

and NIHB has submitted a joint paper for the record. 

The Indian health care system is not health insurance, but it is 

Indian Country’s health care home. Our system was designed by 

the Federal Government to carry out its trust responsibility for 

providing and making health care accessible to all Indian people. 

The Indian health care system is a community-based delivery 

system that provides culturally appropriate health care services to 

our people. Thus, we must be assured that reform measures do not 

inadvertently cause harm to our system. We ask you and your colleagues to evaluate all components of health care reform proposals 

to guarantee that the proposals do not harm the Indian health care 

system. 

Assure that the legislation supports and protects the Indian 

health care system through Indian health-specific provisions where 

needed. Ensure that the Indian people in the Indian health programs have full opportunities to participate in and benefit from national health care programs, and respect the status of Indian tribes 

as sovereign nations. 

On behalf of the NSC and NIHB I would like to express our appreciation to the Chairman and this Committee for their leadership 

in the Senate’s passage of S. 1200. We shared your disappointment 

that the House did not complete their job. Reauthorization of the 

12 

Indian Health Care Improvement Act remains a top priority for Indian Country. 

Today, I request Congress to fulfill the Nation’s responsibility to 

Indian people by reauthorizing the Indian Health Care Improvement Act this year. I also urge Congress to make this law permanent, as Congress has done with other major Indian laws such as 

the Snyder Act and the Indian Health and Self-Determination Act. 

The joint paper includes a list of the Indian Health Care Improvement Act provisions which would bring long-sought authority 

and advancement to the Indian health care system. We ask this 

Committee to advocate for their inclusion in national health care 

reform legislation. 

This joint paper also sets forth recommendations for protecting 

the Indian health care system in the area of national health care 

reform. 

Today, I would like to discuss three of these recommendations. 

First, the joint paper notes that in one sense, the IHS system does 

not constitute credible coverage because it is not health insurance, 

and not all locations are able to provide a comprehensive health 

benefits package. However, American Indians and Alaska Natives 

need the protections offered by the concept of credible coverage in 

order to shield individual Indians from any penalty imposed for 

failing to obtain health insurance and for many late enrollment 

penalties. 

It would be a gross violation of the trust responsibility for the 

Federal Government, which is responsible for providing health care 

to Indian people, to then penalize these beneficiaries for failing to 

obtain insurance coverage. 

Second, American Indians and Alaska Natives should be expressly exempt from all such cost sharings. This policy is consistent 

with the recent amendments to the Title 19 Medicaid of the Social 

Security Act, which prohibits the assessment of any cost-sharing 

against any American Indian, Alaska Native enrolled in Medicaid 

who is served by the IHS or by a health program operated by a 

tribe, tribal organization or urban Indian organization. 

Third, health care reform legislation must assure that programs 

operated by IHS, tribes and urban Indian organizations are admitted to provide a network established by insurance plans. This is essential to ensure that these providers are not excluded from network and denied payment for services to insured patients. 

Lastly, I would like to make some observations about the Indian 

health system. We can all agree that the Indian health care system 

is grossly underfunded, with a funding level of only 50 percent. I 

am very hopeful that this unacceptable situation will end in a reform environment. 

Some have suggested that the Indian health care system is broken, but I would disagree. Even though it is burdened with having 

to do more with less, our system has made many strides towards 

fulfilling its mission of improving the health status of our Indian 

people. 

I am particularly proud of the many innovations and improvements made by many of our tribes and tribal organizations. For example, the Special Diabetes Program, for instance, has led to a draVerDate Nov 24 2008 11:19 Dec 10, 2009 Jkt 053636 PO 00000 Frm 00016 Fmt 6633 Sfmt 6601 S:\DOCS\53636.TXT JACK PsN: JACKF
13 

matic decline in blood sugar levels. Just imagine the success we 

could achieve if our system were fully funded. 

Finally, this is not to say, however, that our system is perfect or 

that the only thing needed to make it perfect is more funding. 

There are inequities and inefficiencies in the system that require 

attention. I am aware that the Committee would like to make some 

changes in IHS operations, such as facilities construction and contract health service. Indian Country looks forward to hearing these 

ideas and to working in partnership with the Committee to advance those ideas that truly promise for our Indian health care system. 

Thank you very much. 

[The prepared statement of Mr. Rolin follows:] 

PREPARED STATEMENT OF BUFORD ROLIN, CHAIRMAN, POARCH BAND OF CREEK

INDIANS; VICE CHAIRMAN, NATIONAL INDIAN HEALTH BOARD


611b1.eps
14 


611b2.eps
15 


611b3.eps
16 


611b4.eps
17 


611b5.eps
18 


611b6.eps
19 

Senator TESTER. Thank you, Mr. Rolin. I appreciate your comments. 

Geoffrey Roth? 

STATEMENT OF GEOFFREY ROTH, EXECUTIVE DIRECTOR, 

NATIONAL COUNCIL OF URBAN INDIAN HEALTH 

Mr. ROTH. Thank you, Mr. Chairman. 

My name is Geoffrey Roth. I am the Executive Director of the 

National Council of Urban Indian Health and the President of the 


611b7.eps
20 

National Native American AIDS Prevention Center in Denver, Colorado. 

I am a descendant of the Hunkpapa Band of Lakota Sioux Nation, part of the Standing Rock Sioux Tribe. 

On behalf of NCUIH, our 36 member organizations, and the 

150,000 Indians that we serve annually, I would like to thank the 

Senate Committee on Indian Affairs for allowing us to testify on 

Indian Country’s recommendations for health care reform. 

I would also like to thank the tribal leaders for allowing us to 

be here today and testify. 

NCUIH strongly supports the joint recommendations drafted together with the National Indian Health Board and the National 

Congress of American Indians. All of our organizations believe that 

these recommendations are the minimum of what must be included 

in health care reform. 

NCUIH also strongly encourages the Committee to pursue a 

standalone bill to reauthorize the Indian Health Care Improvement 

Act. 

While NCUIH fully endorses all the recommendations in the 

joint document, I would like to highlight a few of the recommendations. 

Health care reform must take into account the trust responsibilities to Native American people. As the Members of this Committee 

understand, the trust responsibility to provide health care follows 

Indian people regardless of where they reside. Congress has clearly 

and unequivocally stated this since 1921 in the Snyder Act. 

While we do not object to an individual mandate for health care 

coverage, we firmly believe that any penalty enforced on Indian 

people for failing to acquire health insurance would violate the 

Federal trust responsibility. 

There are three other areas of recommendations I would like to 

highlight: health information technology, a needs assessment for 

urban Indian health programs, and fast-tracking provisions for 

Medicaid and SCHIP enrollment. 

Health information technology is the future of health delivery. 

Any provider that does not develop HIT infrastructure and systems 

now will be behind in the advance of medicine, to the detriment of 

their patients. Given that Indian health providers are already at 

such a disadvantage and our communities suffer high health disparities and disease burden, all possible support should be given to 

Indian health providers that are trying to develop HIT infrastructure and technology. 

The Indian Health Service should be encouraged to work with Indian providers to develop interoperable HIT systems that link together the ITU system. 

A comprehensive needs assessment must be conducted for off-reservation Native Americans. Such a needs assessment must be undertaken in order to determine health status, health outcomes, 

health access and utilization, and the availability of health services. The study must be conducted not only in areas where current 

urban Indian health program exist, but also in all major urban cities. 

The last comprehensive needs assessment undertaken by the Indian Health Service was done in 1981. We have seen indications 

21 

of increased migration and need in the cities that do not currently 

have urban Indian health programs. 

We need to allow urban Indian organizations to expand needed 

health services by alleviating financial and bureaucratic strain. A 

fully developed and actualized urban Indian health program could 

be the center for health services, social services, enrollment in all 

public programs, and the cultural center for the urban Indian community. 

Many urban Indian health providers would be able to expand 

their current range of health services if they were able to better access third party billing opportunities either through inclusion in 

the all-inclusive rate, better IHS support of third party billing software, directly billing Medicaid and Medicare, or if they were able 

to alleviate some of their overhead costs with medical liability insurance coverage. 

The Indian Country recommendations also include fast-tracking 

provisions for Medicaid and SCHIP enrollment. The ability of all 

urban Indian health providers to undertake fast-track enrollment 

and be provided funding for staff to do this would help urban Indian health program providers identify Indians eligible for enrollment in Medicaid, get them enrolled, and then start providing services at the very moment the patient presents at the clinic. 

Urban Indian health program providers excel at preventive 

health care and fast-track enrollment would help these programs 

reach patients at earlier stages of illness and even maybe prevent 

illness. 

On behalf of NCUIH and the urban Indian organizations that we 

represent, I want to take this opportunity to thank the Committee 

for allowing us to testify today. We thank the Committee also for 

the dedication on Indian health care reform and Indian health. We 

have a rare moment with this Administration and this Congress to 

seriously reform the health delivery system for this Nation and for 

Indian Country. 

NCUIH strongly urges the Committee to seize this moment and 

undertake comprehensive health care reform with Indian health in 

mind. Pass the Indian Health Care Improvement Act and initiate 

a comprehensive review of the Indian health care delivery system. 

Thank you. 

[The prepared statement of Mr. Roth follows:] 

22 

PREPARED STATEMENT OF GEOFFREY ROTH, EXECUTIVE DIRECTOR, NATIONAL

COUNCIL OF URBAN INDIAN HEALTH


611c1.eps
23 


611c2.eps
24 


611c3.eps
25 


611c4.eps
26 


611c5.eps
27 


611c6.eps
28 


611c7.eps
29 


611c8.eps
30 


611c9.eps
31 


611c11.eps
32 


611c12.eps
33 


611c13.eps
34 


611c14.eps
35 

Senator TESTER. I want to thank you for your comments. Our 

work is laid out ahead of us. Thank you. 

Valerie Davidson? 

STATEMENT OF VALERIE DAVIDSON, SENIOR DIRECTOR, 

LEGAL AND INTER–GOVERNMENTAL AFFAIRS, ALASKA 

NATIVE TRIBAL HEALTH CONSORTIUM 

Ms. DAVIDSON. I thank you for the opportunity to testify today. 

[Greeting in native tongue.] 

My name is Valerie Davidson, and in the interest of time, I will 

skip through some of my qualifications. And I want to thank the 

Committee for the opportunity to testify today on behalf of self-governance tribes. 

I think as we are thinking about health reform as it applies to 

Indians, I think we should be mindful that Indian families want 

what every family wants. We want our families to be healthy. We 

want them to be happy, and we want them to live in safe communities. 

But because of our history, because of our circumstances and 

some of our unique political status, in order to be able to accomplish that, we have to do things a little bit differently in our communities. And what works for one tribe may not necessarily work 

for another. 

Some tribes have chosen to have their health care services provided directly by the Indian Health Service. Other tribes choose to 

contract or compact services through self-governance compacts or 

contracts. 

The other that is equally important is that opportunities for individual tribal members who live in urban centers need to continue 

to have access to urban Indian programs for their health care. 

And those three things really work together to make sure that 

the Indian health system really is a public health system that 

works as well as the funding allows. And any diminishment of 

those choices really further limits the already limited resources 

that are available to the collective Indian health system. 

Some of my written testimony outlines the fact that self-governance tribes, we provide more services and more facilities than the 


611c15.eps
36 

Indian Health Service does. Because of self-governance, we are able 

to actually leverage our IHS funds and seek additional grant funds 

to be able to extend our reach and extend our programs in ways 

that a direct Federal agency is unable to, for example, because they 

are barred from applying for other agency grants. 

One of the reasons that many tribes choose self-governance isn’t 

because it is an indictment of the Indian health system. We actually choose to be able to provide that because we have greater control. We have greater flexibility, and we can provide services as 

close to home as possible. One of the things that is important to 

know is that kind of flexibility is not necessarily as possible before 

self-governance. 

Through self-governance, we have been able to do very innovative things in our communities. Examples include the Community 

Health Aid Program, the Behavioral Health Aid Program, and the 

Dental Health Aid Program, which allow us to be able to extend 

our provider types in very, very small communities. 

The Cherokee Nation also has an incredible PACE Program that 

provides services for elderly patients in their communities, and 

those services are really amazing. 

In the interest of time, I am not going to spend any more time. 

I am just going to go highlighting some of the accomplishments. I 

am just going to go straight to the recommendations. 

First, we have incredible opportunities to be able to eliminate 

barriers where they exist, for example, with veterans’ services. It 

really makes more sense where veterans’ services are not available 

in small rural Indian communities for the Veterans Administration 

to be able to partner with tribes and Indian health facilities to be 

able to extend that reach. And there is no reason why the Veterans 

Administration can’t provide reimbursement to the already underfunded Indian health system to make sure that health services can 

continue. 

We recommend specifically the creation of a VA clinical encounter rate to reimburse IHS facilities for that care, and precedent is 

already there. 

Anytime we talk about health reform, we need to be really mindful of the opportunities for the existing funding, as well as the opportunities to expand third-party reimbursement. We already know 

that the Indian health system is severely underfunded. That point 

has been made by many folks who have spoken here today. 

Specifically, if health reform legislation is really inclusive of Indian health providers and creates opportunities for expanded coverage for individual American Indians without breaking the trust 

responsibility, it will help to provide additional resources to be able 

to cover that gap in funding. 

Health reform also has to include individual American Indians 

and Alaska Natives without imposing penalties on those who 

choose to use the Indian health system. It also has to assure so on 

the one hand we need to be mindful of the opportunities that are 

available to individuals, but we also have to be mindful of the implications that health reform has on providers, that providers have 

to be able to have the full opportunity to be participants in the 

same way that other private providers are. 

37 

And finally, we have to extend to Indian health care programs 

all of the resources that are available to any other safety net providers. And in health reform, if there are any other special considerations that are made to, for example, Federally qualified health 

centers, the 330 clinics, I would ask that the Committee take a moment and pause and ask yourselves: Is there an opportunity? Does 

it make sense to include Indian health facilities? 

And I would guess that 99 times out of 100, that is probably 

true. 

We endorse the recommendations that were provided by the National Indian Health Board, NCAI, NCUIH, as well as the Northwest Portland Area Indian Health Board, tribes. 

I do want to clarify one inconsistency with regard to the whole 

issue of creditable coverage. I don’t want to get caught up in the 

details, but one thing we all actually agree on is that Indian health 

people shouldn’t be barred from qualifying for subsidies due to 

their eligibility for health care from the Indian Health Service 

health care delivery system, whether it is the I, whether it is the 

T or whether it is the U. 

Similarly, though, I think there is universal support among the 

panel for objection to imposing any penalties on an Indian individual who fails to obtain mandatory health insurance. 

We strongly support expanding Medicaid coverage or any other 

kind of coverage options as indicated earlier. Funding alone is not 

enough. There is a tremendous opportunity to look beyond the Indian Health Service and look at Title VI as an opportunity to expand health care delivery. This Committee actually made great 

progress. Unfortunately, we weren’t able to actually realize that in 

the prior Administration. 

There is incredible opportunity here, and we believe that it is the 

greatest opportunity to be able to extend health care. 

Some folks thought it was kind of odd that we recommended 

Title VI, but the reason is pretty simple, that you can’t undo the 

economic status of people with their health status, and therefore it 

really makes sense to the extent that we can, to utilize TANF programs, where often it is the first time people hear about Medicaid 

and health programs that might be available. 

Finally, we urge passage of the Indian Health Care Improvement 

Act. We have been waiting too long. It is time. I served as one of 

the founding members of the National Steering Committee on the 

Indian Health Care Improvement Act I think 10 years ago. Many 

of us are hoping that this year will really be the year. My kids ask 

me every year, is this the year that it is passed? And every year, 

I keep having to say, not quite, but maybe next year. 

Finally, I just wanted to emphasize that full funding really is 

critical. It is a critical piece of being able to accomplish what we 

need to. We really need full funding for contract support costs. In 

the event that you are considering insurance participation, tribes 

are employers. We are providers of health care as well. Contract 

support cost is what pays for buying health insurance for employees, so we urge that as well. 

Thank you so much for the opportunity, and I appreciate it and 

will be available to answer any questions. 

[The prepared statement of Ms. Davidson follows:] 

38 

PREPARED STATEMENT OF VALERIE DAVIDSON, SENIOR DIRECTOR, LEGAL AND INTERGOVERNMENTAL AFFAIRS, ALASKA NATIVE TRIBAL HEALTH CONSORTIUM


611d1.eps
39 


611d2.eps
40 


611d3.eps
41 


611d4.eps
42 


611d5.eps
43 


611d6.eps
44 


611d7.eps
45 


611d8.eps
46 


611d9.eps
47 

Senator TESTER. Thank you very much. 

Paul Carlton? 

STATEMENT OF PAUL K. CARLTON, JR., M.D., DIRECTOR, 

OFFICE OF HOMELAND SECURITY, HEALTH SCIENCE 

CENTER, TEXAS A&M UNIVERSITY 

Dr. CARLTON. Mr. Chairman, Members of the Committee, it is 

nice to be here from Texas A&M. 

Senator TESTER. Good to have you here. 

Dr. CARLTON. Texas A&M focuses on solutions. As you know, we 

regard complaints without solutions as whining, and we live in a 

no-whine zone. 

I am a Professor of Surgery at Texas A&M and a retired Air 

Force Surgeon General. We have the only college of medicine dedicated to rural health in the Country, and we have been addressing 

the rural health issues aggressively for the last several years. 

As universities are wont to do, we had a semester-long project in 

the fall of 2007 with our College of Architecture and the Health 

Science Center saying: How can we bring this new revolution in 

construction into the health care industry? 

We invited many of the players to come. We got actually several 

of our Iraqi senior officers to come. And out of that spun the testimony that I will give you today. 

Specifically, what we learned is the building industry in our 

Country has truly undergone a revolution in efficiency, with new 

methods and new thinking in the last decade. This is prefabrication 

of larger portions of buildings, done in climate-controlled facilities. 

Literally led by the modular building industry, they have progressively improved their quality, their efficiency and their timeliness. 

There are currently over 100 manufacturers scattered throughout 

the Country. 

As you look at the value equation of cost, quality and time, timeliness is what always wins on the modular side. We have a perfect 

example of that in Balad in Iraq. We contracted for two major 

headquarters to be built, same square footage, same signing time. 


611d10.eps
48 

One was completed in 18 weeks component. The other is four 

years, site-built, still under construction. Same cost. And so in the 

value equation, time counts. 

Now, literally in the component building industry, what you do 

is you don’t build 25 hospitals. You build one hospital 25 times, 

each unique on the outside, but common on its inside. So you don’t 

pay the engineering, the architectural firm, et cetera, 25 different 

times. 

Now, in that revolution that has been going on, the in-patient facilities started in Bensalem, Bucks County, Pennsylvania in 2007, 

a combination of factory-built and site-built. This is a consistently 

superior quality, literally 24 hospital beds were laid in two days. 

The timeliness of this is remarkable. It is understandable. It is 

done in a factory by a staff that does things repetitively, increasing 

their individual productivity, as well as avoiding weather delays. It 

is exactly what Henry Ford taught us. 

On the outpatient side, we had a facility languishing at Creech 

Air Force Base north of Las Vegas, where money had been allocated and no contractor could come within four times of the price. 

Out of this group that we pulled together in fall 2007 at Texas 

A&M, we said we can do this. We brought it in on time, on price. 

After languishing for four years, it was completed in four and a 

half months, a remarkable meets all standards steel and concrete 

building, a beautiful building. 

As we look at our critical access hospitals, I am learning an 

awful lot as those come due to be replaced, and it is much the same 

story as our IHS facilities. We have a perfect example in 

Tehachapi, California which has recently been estimated at $67 

million. It was turned down in a component proposal at $25 million. And it is all about change, as the standards, they are the 

same way either way. 

An innovative physician from Nashville has come back and said, I can do better than that. Instead of $25 million, I can do $14.5 

million and put in an electronic medical record. 

So the question is: Can we afford to resist change at that difference in price? We are doing exactly the same thing for Iraq 

today, recommending to them that we use the workforce in America to rapidly solve many of the pressing issues they face in medicine, in housing and in other areas. 

Now, how does this apply to the Indian Health Service? Well, 

using factory-built options literally replacing critical access hospitals at half the price, for that $2.4 billion construction backlog 

that I have now see, I believe we could more timely and cost-effectively bring that backlog down considerably using these two techniques. 

On the outpatient facility, if Creech really is a model for the Nation, we could put in new clinics in the Indian Health Service at 

a fraction of the current cost, delivery time measured in months, 

not in years. 

Now, the piece that pulls all of these together I call the mobile 

health care. Obviously, there is no difference in quality. These are 

State-certified, joint commission-certified, meet all standards. But 

what it would do is allow you to turn any clinic into a full-up hospital. As a practicing physician, that took care of a referral popuVerDate Nov 24 2008 11:19 Dec 10, 2009 Jkt 053636 PO 00000 Frm 00052 Fmt 6633 Sfmt 6601 S:\DOCS\53636.TXT JACK PsN: JACKF
49 

lation throughout my 37 years in the military. Every time I stuck 

my hand out and said, I’m Dr. Carlton and I am here to help you, 

if the patient was local, it was fine. If they were from far away and 

had traveled, the other side of that was, you rascal. You are telling 

me you are more important than I am because you have made me 

travel instead of you. 

We then started an outreach program that we call Medical Center Without Walls. We did it for 25 years. The same thing could 

be done in the Indian Health Service through a concept that we 

call the Thursday Hospital. This literally pays for itself by training 

the Public Health Service, if this equipment using mobile facilities 

was available and it was designated as going to the FEMA. Then 

whatever medical national emergency there was, you would have 

already trained the Public Health people there on its use, by using 

it every day in Indian Country. 

Now, linking all of those together, then, with an electronic medical record or telemedicine, literally I think we could build an integrated delivery system that was first class in the world. There 

would be no isolated nurse practitioners, no isolated physicians. 

They would all be part of a bigger piece so that you could have 

morning rounds. You could have weekly rounds. You could have 

grand rounds, literally university-based, but tying all of them together. I believe that would solve a tremendous recruitment problem as well, and again tell people they are important members of 

the team. 

So I encourage you to go look at these facilities. They are very 

first-class facilities. Bucks County is just outside Philadelphia. Our 

clinic at Creech, you may see when you have other business in Las 

Vegas. The mobile units are out of St. Johnsbury, Vermont. All of 

these are available to see. 

What we lack right now is the vision to say, I am sorry, quite 

whining. Let’s solve the problem at the current dollars. We are not 

asking for money. 

Thank you for this opportunity to share some thoughts. 

[The prepared statement of Dr. Carlton follows:] 

PREPARED STATEMENT OF PAUL K. CARLTON, JR., M.D., DIRECTOR, OFFICE OF

HOMELAND SECURITY, HEALTH SCIENCE CENTER, TEXAS A&M UNIVERSITY

I am Dr. Paul K. Carlton, Jr., currently a professor of surgery at The Texas A&M 

Health Science Center, TAMHSC, and the retired Air Force Surgeon General. As 

part of the Texas A&M land grant mission, the TAMHSC seeks to provide solutions 

to the many challenges we face in healthcare delivery, particularly in rural, frontier, 

and emerging regions. This includes training providers willing to serve these areas, 

promoting the use of innovative technologies to increase access to healthcare, and 

application of the breadth of science across the Texas A&M University System to 

improve the public health. This focus on solutions led to a joint conference hosted 

by the Texas A&M Health Science Center and the Texas A&M College of Architecture in the fall of 2007. This conference presented a pioneer effort on how to use 

the component building method in medical applications. Out of this conference came 

many new and innovated ideas for the reconstruction of Iraq, applications for Air 

Force facilities and applications for the Indian Health Services. These medical construction innovations comprise the rest of this testimony. 

The building industry in our country has been undergoing a revolution in efficiency using new methods and new thinking with pre-fabrication of larger portions 

of buildings, done in climate controlled factories. The Modular Building Industry has 

been leading this charge by progressively improving their quality, their efficiency, 

and their timeliness. They currently have over 100 manufacturing facilities scattered across our country. 

50 

They recently started moving into the healthcare field with both in-patient and 

out-patient facilities. The largest user of out-patient, pre-fabricated facilities has 

been in the dialysis field. By moving these facilities closer to their population 

served, they are able to give better service, closer to home. The in-patient pre-fabrication world opened with a full up hospital in Bensalem, Bucks County, PA., in 

2007. This was a combination of factory built and site built. The factory portion of 

this building is what allows the efficiencies and quality improvement that have been 

noted. A consistently superior quality has been delivered by these factories because 

of the excellent working conditions that are not influenced by weather or availability 

of professional workers. These are done in a factory by a staff that does tasks repetitively, increasing their individual productivity as well as avoiding the weather 

delays. The facilities were even certified as meeting all standards before leaving the 

factory by the State of Pennsylvania. The transportation issues are worked through 

by designing exactly what the transportation system will allow in terms of moving 

these larger portions of buildings. 

A provider of these types of facilities, U3 Innovations of San Antonio, along with 

Modern Renovators and Aspen Street Architects built the Air Force their first truly 

component, pre-fabricated section clinic in the last six months at Creech AFB, Nevada. All of these businesses participated in the fall semester project with the College of Architecture and Health Science Center at Texas A&M in 2007. This clinic 

was to fulfill a need that had languished for over two years, with no bids coming 

close to the allocated amount of money. Using pre-fabricated sections, this clinic was 

built in four and a half months and on budget for $1.5M. Our group from the fall 

project held a grand opening for all of our colleagues to see what high quality this 

building represented. It has an all-steel frame, concrete floors, and an exterior that 

blends with its surroundings nicely. It was built in six components in Loretto, TN., 

and transported by truck to the site. The beauty of this approach is that it was built 

to cost and we will add a nicer parking lot and nicer roof as money becomes available. Pending those, we have a fully functional facility to meet the needs of this isolated Air Force Base so vital to the current wartime mission. 

Our critical access hospitals (and many urban hospitals) have now reached their 

life expectancy, having been built about 50 years ago under the enlightened funding 

initiatives of the Hill-Burton act. These under 25 bed facilities, vital to the nation’s 

healthcare system in rural American, need to be replaced and we cannot afford to 

do so. A critical access hospital construction project in Tehachapi, California, was 

recently estimated at $67M, to be completed in three to four years. The similar sized 

pre-fabricated hospital, using all components, had been contractor proposed at 

$25M. It was cancelled because pre-fabricated construction was considered unacceptable. Standards are standards and both would have met all standards. Unfortunately, the change was more than Tehachapi was ready to accept. Change is hard 

for all of us but fiscal reality has to be considered at some point. 

One innovative physician executive from Nashville, Dr. Jerry Tannenbaum, has 

designed such a critical access hospital and is ready to write contracts on such facilities for $14.5M. That design includes 12 beds, two large operating rooms, a post anesthesia recovery unit, a complete imaging suite, a full laboratory, a 12 bed patient 

wing, Emergency Department, and administrative section. This would be 33,000 sq. 

ft., all pre-fabricated, and up in nine months from contract signing with a fixed 

guaranteed price. Comparing that to the $67M that Tehachapi estimated for their 

hospital and you have to say ‘‘what is the difference? ’’ Can we afford to resist 

change at that difference in price? 

I am currently involved in the rebuilding process of medical activities in Iraq. We 

are proposing all pre-fabricated section type construction for them, using the work 

force in America, to rapidly solve many of the pressing issues they face in medicine 

and in housing. We have also proposed using mobile surgical vans, that meet all 

standards of care, to turn any clinic into a full up hospital whenever and wherever 

it is needed. The Iraqis currently have one of these units in country and love its 

flexibility and ease of use. 

How does all of this then apply to the Indian Health Service? I believe that what 

we have learned could easily be applied by providing better service to the Indian 

Nation at a more affordable cost: 

1. In-patient facilities: If we used the critical access model proposed by Dr. Tannenbaum, the physician from Nashville, at $14.5M each, you could provide 

twice the number of hospitals for the same cost. A similar component model by 

the Rural Health Consortium in California, comprised of 13 critical access hospitals, has similar numbers. If you used either of these models, tailored it to 

the exact size needed in any location, using pre-fabricated sections, you could 

51 

cut down on the $2.4B construction backlog that currently exists for the Indian 

Health Service. Better service at a lower cost is hard combination to beat. 

2. Out-patient facilities: If we use the Creech AFB model for clinics for the Indian Health Service, we could be building modern state of the art out-patient 

facilities for fractions of the cost of what we are paying now. The issue of timeliness is also a critical portion here—these are done in a factory, with fixed pricing, and they meet delivery dates because weather is not a factor. 

3. Mobile Medical Care—You could also use the mobile surgical vans, as the 

Iraqis do. These vans are used in our country for operating room renovations 

routinely and meet all standards of care including Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), Medicare certification and 

state licensure. They would allow us to turn any clinic into a full up hospital 

for the number of days per month that it would be effectively used at our more 

remote Indian Health Service locations. This would allow each reservation to 

have surgical or other specialty services offered to them as the need dictated. 

The real payback for using such a concept is that by providing better service 

for the Indian Nation, we would be fulfilling a training requirement for the Public Health Service. We call this the ‘‘Thursday Hospital’’ concept, moving the 

surgical vans from place to place as demand exists. These vans, which are totally self-contained, could then be the foundation of a national response system 

for any medical large scale disaster. Since they meet all standards of care, they 

can be used daily for non-emergency healthcare. The Indian Health Service, 

comprised of Public Health Service people, would have been using them daily, 

so no equipment training would be required to respond to national emergencies. 

You would use them like you use a portable CT scanner or MRI machine, simply have a docking station built onto the clinic or hospital so the patient never 

has to move outside. To have the potential of superb mobile facilities, no training tail involved for the professional staff, and used every day is exciting to contemplate! There would then be little fixed cost for preparedness for equipment 

for our nation in times of a medical emergency. From a national preparedness 

perspective, this is a very cost effective alternative to consider. 

The Indian Health Service has a great mission, to take care of the health needs 

of our Native Americans. You have a great group of people to do this with, the Indian Health Service medical professionals. Perhaps these new methods for providing 

high quality facilities could enhance the delivery of healthcare to this deserving 

group of people—at an affordable cost. I encourage you to look closely at all I have 

discussed. Go see the facilities I have described in Bucks County, PA; at Creech 

AFB, NV; and in St. Johnsbury, VT. Look closely at how to allocate the tax payer 

dollars involved. I believe that you will find this revolution in the building industry 

applicable to the Indian Health Service and other federal building projects. 

Thank you for this opportunity to share these thoughts. 

52 

Attachment 

Description: The nearly 66,000 square-foot project could be done by January 2013. 

A new Tehachapi hospital came several steps closer to reality with the presentation March 18 of a proposed $67 million, 65,909-square-foot master space plan. 

Hospital Project Executive Manager Norm Clendenin told the Tehachapi Valley 

Healthcare District Board of Directors that the $67 million preliminary project 

budget amounts to about $720 a square foot and includes contingencies. 

‘‘I’m suggesting that’s about as tight as we can get,’’ Clendenin said. 

He said the target date for license approval and to welcome the hospital’s first 

patients is January 2013. 

Stephen Wen, AlA, senior principal in SWA Architects of Pasadena and Phoenix, 

presented the space plan, which is an outline of the overall traffic flow and placement of the elements of the hospital. 

‘‘There is no fat in this program,’’ Wen said. ‘‘It is pure muscle, pure functional.’’ 

The healthcare district directors, who junked a previous state-approved but unsatisfactory hospital design at a loss of $1 million, were pleased with SWA’s conceptual 

plan. 

‘‘It looks great,’’ district director Dr. Susan Hall said. ‘‘I love how it’s expandable. 

The flow really looks good. It seems to make sense.’’ The board is accepting bids 

from architects to refine and develop the final design. 

Sought staff input 

Wen said that to develop the made-to-order master plan, his team spent the last 

four months working closely with Tehachapi Hospital’s senior staff. Detailed interviews with all the staff, he said, ‘‘allowed us to trim this and fine tune that.’’ 

The hospital components will be comprised of more expensive medical sections 

that must be approved by the Office of Statewide Health Planning and Development 

(OSHPD, pronounced ‘‘OSH pod’’) and less expensive non-medical sections that include administration, storage and reception (‘‘Non–OSHPD’’). 

The OSHPD components amount to 54,296 square feet. 

The non–OSHPD components amount to 5,413 square feet in Phase I and an additional 6,200 square feet in Phase II. The hospital complex, to be built on a 22.36- 

acre hospital property at Capital Hills north of Highway 58 near the Post Office, 

will fit snugly into a gently sloping hillside that will require minimal grading, Wen 

said. 

‘‘We would like it to be readily visible but not on the steep slope,’’ he said, ‘‘So 

we placed it on the lower end.’’ 


611f1.eps
53 

Wen studied the morning and afternoon sun angles as well as view sightlines before selecting the optimum location to build on the property. 

The public entrance will be on Magellan Road, with a side entry for emergency 

vehicles, a service road that loops around the structure and a heliport on the north 

side. 

Core elements of the emergency room, lab, radiology, operating suite, medical surgical units, imaging, surgery supply and intensive care unit were placed ‘‘in close 

functional relationship’’ with each other, he said. 

The plan includes ‘‘growth directions’’ for core elements that are expected to expand, notably the operating room and the emergency room. 

Wen’s plan provides for 141 parking spaces, more than double the required number. 

Healthcare District CEO Alan Burgess said the new hospital will be as green as 

possible, ‘‘No grass—that saves water for other purposes—and we will use indigenous plants like Joshua Trees and yucca.’’ 

Squeezed ’em down 

Clendenin said Wen and his team had quite a job on their hands when they got 

the Tehachapi assignment last October. 

‘‘I made it very difficult for SWA to get this done,’’ Clendenin said. ‘‘They had to 

get it down from 88,000 square feet to 54,000 [OSHPD] square feet. I squeezed ’em 

down as far as they could go.’’ 

The new 25-bed hospital is designed to replace the 1954-vintage existing hospital 

on F Street, which will be remodeled as a rehabilitation center and outpatient clinic 

featuring global consultation via telemedicine, according to Burgess. The original 

plan to retain the old hospital as a skilled nursing facility is unworkable because 

of state seismic requirements related to overnight bed stays. 

The old structure must abandon its role as an acute care, overnight hospital by 

the last day of December, 2012, Burgess said. The state granted the Healthcare District a five-year extension past Jan. 1, 2008, to meet new seismic requirements, 

which will be met by the new hospital complex at Capital Hills. 

Clendenin said that he has received 40 responses to requests for architectural 

bids on the new hospital and it is a good time to build. 

At the beginning of the board meeting, held at the Golden Hills Community Services District boardroom, Clendenin introduced Division Chief Gordon Oakley and 

Regional Compliance Officer Brian Coppock from OSHPD. They promised their support to Tehachapi. 

Oakley said the state is happy to approve incremental or phased construction ‘‘instead of waiting for the big package.’’ He called the phased process ‘‘bite-sized, like 

eating one scoop of ice cream at a time.’’ 

Now for the money 

Bringing the space concept and the total cost into focus is the first step in formulating an aggressive fundraising plan, according to Healthcare District Chief Financial Officer Joe Demont. 

Demont said the financial picture for the Healthcare District is positive. 

Cash collections are up and adjustments are down, he said, and the district operating budget is on its way to being ‘‘significantly in the black.’’ 

In 2004, voters authorized $15 million in bonds to seed development of a new hospital. The district raised $12.7 million under Series A and B, he said, and the C 

series was never raised. 

That $12.7 million has increased in value to $14 million, which is sitting safely 

in the bank. 

Further fundraising could take the form of a new bond issue, donations, government grants and other sources. 

Burgess said he will approach local religious congregations and other organizations to help fund the ‘‘quiet room,’’ which in former times was called a chapel. The 

room will be available for meditation and will offer a place for families to meet with 

spiritual advisors and counselors. 

At least $50 million has to be raised or borrowed to build the hospital. 

‘‘We have been holding back until we got the numbers accurate and the conceptual site plan,’’ Burgess said. ‘‘There’s error in to going out too early. We have to 

do a sales job. The whole community has to get behind it.’’ 

Tehachapi cannot afford to lose its hospital and its emergency room, Burgess said, 

and building a new one is the only option. 

Burgess said that $5 million will put the name of the angel donor on one of the 

core elements. 

54 

Senator TESTER. I thank you all for your testimony. I appreciate 

it very, very much. 

As long as you are warmed up, Dr. Carlton, we will start with 

you, and I will just go in reverse order. 

What is the disadvantage of the component construction? 

Dr. CARLTON. I am sorry? 

Senator TESTER. What is the disadvantage? You talked about a 

lot of advantages. Are there disadvantages? 

Dr. CARLTON. Oh, yes, sir. Tremendous disadvantages, it is different. 

Senator TESTER. That is it? 

Dr. CARLTON. That is it. It is the same concrete. It is the same 

steel. You do it in a climate-controlled environment. The quality is 

consistently better. It is just different. 

Senator TESTER. You have dealt with Federal agencies, mainly 

the military. Is there problems with this kind of construction with 

guidelines that you know of through other government agencies? 

Dr. CARLTON. Well, sir, I have learned a lot about construction, 

a nice physician has had to learn an awful lot about construction. 

The reality is there are national guidelines. There are State guidelines. There are international guidelines. Every one of these meets 

those guidelines, and literally the facility in Bucks County was certified by the State of Pennsylvania before it left the factory. 

Senator TESTER. Okay. I just got a note that said Jefferson, you 

have to leave. So I will jump over to you. And then I will turn it 

over to Senator Udall in case he has any questions for you, and 

then we will kind of hop around here a little bit. 

The National Congress of American Indians, the National Indian 

Health Board, the National Council on Urban Indian Health all 

produced a position paper with proposals for health reform in Indian Country. Was this vetted with individual tribes that you know 

of? 

Mr. KEEL. Yes, sir. The individual tribes around the Country, or 

the National Indian Health Board represents tribes around the 

Country. And all of those tribal leaders from all of the different 

areas and different regions have had an opportunity to provide 

input to that, to review it, to take a look at it, provide comments. 

And then they brought it back and put together a comprehensive 

set of recommendations. 

There are some specific areas around the Country that have 

some innovative ideas. Portland area has some specific ideas. The 

Oklahoma City area Indian health boards, all of those have some 

very innovative folks who look at these plans and provide various 

ideas and input to this comprehensive set. Thank you. 

Senator TESTER. Okay. And in your testimony, you spoke about 

mid-level practitioners, actually, and how they are underutilized in 

health care delivery in Indian Country. Do you have any barriers 

that come to mind as to why this is the case? 

Mr. KEEL. Well, primarily there are some issues. One, I would 

specifically talk about would be the dental health practitioner, the 

dental health aides that are utilized in Alaska. Those are not well 

utilized around the Country primarily because of funding. However, there is an opportunity for the self-governing tribes to partner 

with the local universities. For instance, in the Chickasaw Nation, 

55 

we have an opportunity to contract with the University of Oklahoma Health Science Center to contract and provide internships 

with PAs and nurse practitioners. The problem is funding for those. 

I could talk a lot about it. 

Senator TESTER. I come from frontier America where nurse practitioners and physician assistants are the standard. That is who is 

providing the front line care. And if they are not being utilized in 

Indian Country, I would love to know why. If it money, that is one 

thing. If it is something else, then we want to go the direction to 

fix it, is what I am saying. 

Mr. KEEL. I think, Senator, that the self-governing tribes, you 

are absolutely right. The nurse practitioners and PAs are pretty 

much the norm for the self-governing tribes. I think the problem 

exists in the direct service tribes and it is a lack of funding. 

Senator TESTER. Okay. All right. 

Senator Johanns, did you have any questions? The reason I do 

is Jefferson Keel has to leave quicker than the rest. So if you have 

any questions for him in particular? Okay. 

Senator Udall? 

STATEMENT OF HON. TOM UDALL, 

U.S. SENATOR FROM NEW MEXICO 

Senator UDALL. So you are suggesting we get our questions out 

of the way? 

Senator TESTER. I don’t want to see him leave unscathed. 

Senator UDALL. Good, good. Oh, okay, okay. 

[Laughter.] 

Senator UDALL. Let’s see here. 

Mr. Vice President Keel, you mentioned Medicaid auto-enrollment and the establishment of an American Indian/Alaska Native 

category of eligibility as an easement on the Contract Health Service program. As you know, there are very strict criteria for Medicaid eligibility. Do tribal data collection systems currently have 

the capability for supporting auto-enrollment practices? 

Mr. KEEL. Yes, sir, they do. The self-governing tribes are perfectly capable of collecting all the data that is required. They have 

sophisticated business systems, business models to allow for data 

collection, auto-enrollment, providing partnerships with all of those 

agencies to enhance the overall level and quality of care for those 

patients. 

So, yes, sir, they do have the capability. 

Senator UDALL. And you state there should be a limit on the 

amount of funds that the Indian Health Service can use for administrative costs. That way, more money can be used for direct health 

care services. Would you also support a limit being placed on the 

amount of funds a tribe can use for administrative costs when it 

is the tribe that is operating the facility? 

Mr. KEEL. I really can’t answer that directly because there is 

such a wide variance across the board with different tribes. Some 

tribes, for instance, have sophisticated third party collection systems that are required in order to meet the shortfall in funding 

that is provided by the Indian Health Service. Those collection systems enable us to hire practitioners, provide other services that are 

56 

not normally provided by the Indian Health Service in terms of 

funding. 

So providing a limit on those administrative costs is normally offset by those third party collections that the tribes enjoy right now. 

Senator UDALL. And you also state that Indian tribes must retain the authority to make decisions regarding whether to provide 

services to non-IHS eligible beneficiaries. One reason that the 

tribes may choose to provide services to non-IHS beneficiaries is so 

they may become a preferred provider organization in a State network. 

If a tribe decides to serve non-IHS beneficiaries at its health facility, what protections would need to be in place to ensure that the 

IHS-eligible patients continue to receive the care they need? 

Mr. KEEL. Thank you, Senator. That is a very good question. The 

only protection that would be needed, the only legislative fix would 

be that the Federal tort claims would be extended to cover the liability of the tribe providing those non-beneficiaries. The tribal 

leaders will guarantee that their citizens are provided the highest 

quality of care that is available. 

Senator UDALL. Thank you. 

Thank you, Chairman Tester. 

Senator TESTER. Absolutely. 

Senator UDALL. Doesn’t that sound great? 

Senator TESTER. I don’t know. We will have to talk to Chairman 

Dorgan about that. 

[Laughter.] 

Senator TESTER. Mr. Rolin, you stated that the Indian Health 

Care Improvement Act should be made permanent. This is a 

change. And you mentioned some of the ones that were permanent, 

the Indian Self-Determination Act, Snyder and some others. Can 

you give me some insight into why the change and is this a new 

position of the tribes, too? 

Mr. ROLIN. Well, as I said in the testimony, for years now we 

have been trying to get the Indian Health Care Improvement Act 

reauthorized, some 10 years. 

Senator TESTER. Yes. 

Mr. ROLIN. As you have heard. We just feel like it is time now 

to make this reauthorization a permanent part of health care for 

our Indian people. I gave you some examples that we have already. 

We just believe with tribes that are now going into self-governance 

or contracting or compacting, we have found that working with the 

local health providers in our communities and adjoining cities that 

we can provide and make better use of that dollar that is available 

to us, and as Mr. Keel said, provide some additional services here, 

and that is what we are all looking for, is better use of that dollar. 

Senator TESTER. Okay. 

Mr. Roth, you demonstrate a need for funding authorities for 

urban Indian data collection. The Committee has demonstrated 

strong support for strong information technology. What kind of information technology systems do urban programs currently operate, 

if any? 

Mr. ROTH. Good question. Well, it is kind of a patchwork system 

right now. The programs have been highly encouraged by IHS as 

of the last couple of years to move to the RPMS system which is 

57 

difficult for our programs because it doesn’t have a real strong 

third party billing application to it. It takes a lot of maneuvering 

and then programming support in order to get the system working. 

But other than that, our organizations tend to buy off-the-shelf 

software packages, and many times end up having to hire individuals to do data input in two different systems in order to keep reporting with the RPMS system and the other system that actually 

works for their program. 

So there needs to be some reform and a uniform system across 

the board. 

Senator TESTER. Okay. Are there specific areas where data collection is particularly difficult? 

Mr. ROTH. Are you talking about geographic areas? 

Senator TESTER. I mean, it wasn’t geographic. I was thinking 

more of just areas where you try to get information from the folks 

and you can’t get it, or from the medical professionals, too, as far 

as it goes. 

Mr. ROTH. Yes. I would say that data is a really difficult issue, 

especially for us as a system, an urban Indian health system, and 

I believe the entire ITU system. The Indian Health Services seems 

to be a bit fragmented in the way that it is administered right now 

through the areas. And I don’t know how good the accountability 

is back to headquarters and the ability to bring data together. So 

that is one area that we have had difficulty in getting data from. 

Senator TESTER. Okay. 

Ms. Davidson, you stated that the Alaska Native Medical Center 

is a level two trauma center in Alaska. It is tribally operated. Does 

it serve any non-IHS beneficiaries? 

Ms. DAVIDSON. We primarily serve IHS beneficiaries, but we do 

have authorization to serve some non-IHS beneficiaries who are 

Public Health Service employees. 

Senator TESTER. Are there protections against malpractice 

claims? 

Ms. DAVIDSON. Yes, there are. Those services are covered under 

Federal Tort Claims Act. One of the things that it is really important for the Committee to understand is that over the last Administration, sometimes there are protections in the law that have 

been construed very, very narrowly by the previous Administration, 

and that sometimes those terms were constrained a little bit too 

narrowly. For example, with FTCA coverage, so long as a service 

and activity is adequately described in your resolution, your tribe’s 

resolution, with applicability to non-IHS beneficiaries, FTCA coverage applies. 

The challenge we have is sometimes we have to go to incredible 

steps to get the Department of Justice to overcome that determination. 

I do want to revisit one of the questions you asked earlier about 

data. 

Senator TESTER. Yes? 

Ms. DAVIDSON. Quite honestly, our capabilities to be able to access that data really vary depending on where you go. And the simple reason for that is because there are not sufficient funds for 

health information technology enhancements. 

58 

For example, some folks are able to use RPMS, but right now 

with RPMS the only way to be able to get it to work effectively is 

it has to be so customized to each service unit that any upgrades 

that happen, tribes and tribal organizations really have to spend 

a lot of money to be able to make it work, to be able to fix those 

patches. 

The other piece is that, for example, the recent funds that came 

through ARRA for health information technology, zero of those 

funds went through self-governance tribes or urban Indian programs. And so to the extent that tribes should have the opportunity to get their health information technology funds met, we 

should be clear that that opportunity should be available through 

ONC. 

The other piece is that normally what pays for health information technology systems is contract support costs. So the simple answer is we have that capability to the extent that we are able to 

use contract support cost dollars to fund that. 

Senator TESTER. Okay. 

Mr. Carlton, I especially appreciate your perspective that talked 

about meeting people on their home turf instead of making them 

come to you. Can tribes purchase the mobile units at this point in 

time? Are they available? 

Dr. CARLTON. Yes, sir, they are available. The mobile units are 

literally used in the VA system right now for operating room renovation. University of Virginia just finished a four year contact. So 

the key is not the equipment. The key is the staffing. And the Indian Health Service’s chief problem is they end up needing a .1 or 

a .2 full-time equivalent staff. This solves that problem by serving 

multiple areas. 

Senator TESTER. Got you. 

I am going to turn it over to Senator Barrasso, the Ranking 

Member, to take the hearing from here. 

STATEMENT OF HON. JOHN BARRASSO, 

U.S. SENATOR FROM WYOMING 

Senator BARRASSO. [Presiding.] Thank you very much, Mr. Chairman. 

And I want to thank all of you for being here today. This is a 

very important hearing, as the health care debate continues nationwide. It is timely, Mr. Chairman, that we hear from Indian Country today. 

Recently, I had a meeting in Riverton, Wyoming on this very 

issue. I also met on the Wind River Reservation with the Joint 

Business Council of the Eastern Shoshone and the Northern Arapaho Tribes. The Wind River community was generous to meet with 

me and my staff to share their concerns and their priorities for 

health care reform, prevention, accountability, increasing access to 

care. They really were among the most important issues that we 

raised. 

And Mr. Chairman, I also want to, while you are still here, 

thank Senator Dorgan, as well as the capable staff from the majority, Allison and John, who attended the meeting in Wyoming. They 

fully participated in the meeting and their input was significant 

and very much welcome. 

59 

There is significant support, of course, for reauthorizing the Indian Health Care Improvement Act. There is also recognition that 

we must do more than simply reauthorize a troubled, inefficient 

system. That is why I was so pleased that Senator Dorgan and I 

have been able to work together and that Senator Dorgan has 

agreed that we begin a path to reform. I expect a significant 

amount of work is going to be done this summer. The Committee 

operates in a very bipartisan manner. We roll up our sleeves. We 

work together. Our work is going to require outreach to our tribal 

friends to help with refining health policy. 

We need to act in a quick way, as well as a cooperative way so 

that Indian Country does not get left behind in the nationwide 

health care reform effort. 

And I would like to say that Senator Murkowski has not been 

able to be here today. She has asked me to express her regret for 

not being able to join us. She is wrapping up amendments in both 

the Energy Committee, as well as the Appropriations Committee. 

But Ms. Davidson, she specifically wanted me to welcome you with 

the Alaska Native Tribal Health Consortium, to welcome you to the 

Committee. And I know that she is going to be very interested in 

reading all of your testimony and the answers to your questions. 

So thank you so much for traveling such a great distance. 

And with that, I would like to turn it over to Senator Johanns, 

who has some questions. Thank you. 

STATEMENT OF HON. MIKE JOHANNS, 

U.S. SENATOR FROM NEBRASKA 

Senator JOHANNS. Well, let me thank each of you for being here 

today. It is a very important topic. 

Let me, if I could, start with Mr. Roth, a couple of questions on 

IHS-funded urban Indian clinics. I think you mentioned in your 

testimony, or mentioned that 36 member urban Indian clinics serve 

about 150,000 American Indian/Alaska Natives. Congress has gone 

on record, as you know, in support of the trust responsibility to Indian people no matter where they reside. Of the 36 member clinics, 

do you know how many utilize IHS eligibility regulations to determine who receives services? 

Mr. ROTH. They all do. It is part of their contract with their 

areas and IHS. So all of the programs adhere to their contracts. 

Now, some of our programs are dual-funded, so they are also funded by other sources of funding, so they provide services to other 

non-Indian individuals as well, but all the programs adhere to 

those. 

Senator JOHANNS. Okay. What other eligibility standards, then, 

would they use in addition or in place of IHS? Are there any that 

you are aware of? 

Mr. ROTH. Well, I believe it is seven of the programs are dualfunded urban Indian programs and community health center programs. So they are funded, 330-funded programs. They would use 

the 330 funding formula for eligibility of non-native individuals to 

provide services to them. 

Senator JOHANNS. Okay. Something you said in your testimony, 

I must admit, kind of lit up the light bulb, if you will. I think you 

were talking about health care reform and the potential that a FedVerDate Nov 24 2008 11:19 Dec 10, 2009 Jkt 053636 PO 00000 Frm 00063 Fmt 6633 Sfmt 6601 S:\DOCS\53636.TXT JACK PsN: JACKF
60 

eral mandate might have on already existing Federal obligations in 

Indian Country. Can you talk me through that a little more extensively, your concerns there? 

Mr. ROTH. Was that in relations to the trust responsibility? 

Senator JOHANNS. Yes. 

Mr. ROTH. At the beginning? Yes. The trust responsibility, we believe and I believe, that it extends to all Native Americans in this 

Country no matter where they live. And there is a Federal obligation at that point to provide health care services to all Indian people. 

The Federal Government isn’t doing that right now. There are 

cities where Indian people live where they cannot access services 

that are provided by Indian Health Services or services that are 

free of charge. 

So that is what I was intending to get across there, and I hope 

that that did. 

Senator JOHANNS. Okay. Great. That clarifies it. 

Chairman Rolin, if I could ask you a question, and actually this 

was not in your testimony. This was in Jefferson Keel’s testimony, 

but I am hoping you will have some thoughts on this. 

He had a section in his testimony relative to service to non-Indians out of Indian health care facilities. And he basically, at the risk 

of paraphrasing his position, he said, look, we need to continue to 

reserve the power to decide whether we will provide those services 

or not. Again, the light bulb kind of came on. In our State, we have 

reservations that are in parts of the State that aren’t very populated. And I can think on one reservation that I visited, they had 

a dialysis facility there, very much utilized, providing a very necessary service there in Indian Country. 

And then it occurred to me as I was reading that testimony, 

gosh, I wonder where the next dialysis equipment is at. It could be 

150 miles away. 

Talk me through this whole issue about making that available to 

non-Indians and what concerns you might have about that, if you 

would. 

Mr. ROLIN. Well, the issue before us, sir, is in most cases, our 

Indian tribes, there is just not enough resources to provide the 

services that we had hoped to provide to our own people. However, 

in different areas, the situations are quite different. And as far as 

Indian tribes are scattered throughout the Nation, in my area, I 

live in South Alabama, I have access to the city of Mobile, Alabama; the city of Pensacola, Florida. We are in a general area right 

on the Alabama line there. Working within the community that I 

live, we utilize, you mentioned dialysis, we utilize the system that 

is within our county because that one particular area that you 

mentioned there in Dallas is so expensive. And we have been able 

to provide services for our people by referring them to that facility, 

which is utilized by all of the people that live within the area. 

As far as tribes, again, that is a new aspect of whether tribes 

want to move in to providing services to the community. It is certainly an opportunity for them to have some additional resources 

and income. But most of the time, the problems that we have on 

our reservations is that we just, the facilities that we have we can 

barely provide care, something like maybe 50 percent at the most, 

61 

to our people. And when you start providing these services beyond 

that, it really takes a way from the needs of your community. 

Senator JOHANNS. So it is more of a resource issue and a what 

you have got. 

Mr. ROLIN. It is indeed, sir, resources. 

Senator JOHANNS. Okay. That helps me understand that because, 

again, if we could somehow solve these problems, that may be a resource for that area and provides, I am sure, necessary revenue for 

the facility. 

Let me, if I might, turn to Valerie Davidson. I had a couple of 

questions for you, and I hope I am asking the right person. 

I come from a State, the State of Nebraska, where we have everything from very urban areas, Omaha, Lincoln, Kearney, Grand 

Island, I could name other communities, to very, very rural areas. 

One of the things that we have been working to put in place quite 

successfully is telemedicine. And we have found real advantages 

not only in delivering mental health services like counseling, but 

diagnostic services and that sort of thing. 

How much telemedicine is available in Indian Country, or maybe 

even more specifically, in your State? Has that been something we 

have been able to move down the field a little bit? 

Ms. DAVIDSON. I think the availability of telemedicine in Indian 

Country is really varied. It is like many of the things we have 

talked about. In Alaska, we are fortunate that we do have telemedicine in many of our communities. 

One of the things that telemedicine has been able to allow us to 

do is to be able to extend the reach of the provider. In many of our 

villages, in Alaska we have a four-tier health care delivery system, 

where about half of the patient encounters occur in a small village 

community, average population of about 350 people. And they get 

their care from a community health aide. That is where I got most 

of the health care during my entire childhood. 

And one of the great things about having a person who is from 

that community, who speaks the language, who knows who you 

are, and quite frankly knows all of the things you are or your 

should or should not be doing as a child, it is amazing how much 

those folks know about you, and can set you in the right direction. 

Having that relationship with that person at the community 

level is what we have found, along with interactions with small 

children, really helps to be able to shape health care decisions, and 

also be able to focus on wellness and prevention. 

Now, what telemedicine brings to the equation, though, is if it is 

service that is beyond that person’s training or capability, then for 

them to be able to be hooked up to a telemedicine machine to be 

able to have that conversation with a doctor or a psychiatrist or a 

dentist or another person in another community, that also extends 

their ability to provide care. 

In other parts of the Country, however, telemedicine really isn’t 

utilized at all, and there is a tremendous opportunity to make 

those services available. 

The other piece besides just having the equipment available, and 

we have Alaska Federal Health Care Access Network has a great 

telemedicine cart that is available that we have developed over 

time. But in addition to the hardware, the other piece that is a 

62 

really critical piece is having the available band width to be able 

to provide that service. 

And the USAC, the Universal Services Administrative Companies, subsidies to be able to provide decent band width to rural 

communities, including tribal communities, is critical because tribe 

simply can’t afford a $13,000 a month T1 line, whereas USAC 

comes in, pays the difference, and it will cost about $1,000 a 

month. 

Senator JOHANNS. Has the stimulus package helped any in that 

area? I know there was some money identified in the stimulus 

package to try to get broadband into more rural areas. Is that impacting this at all? 

Ms. DAVIDSON. I believe it has the opportunity to provide impact, 

but I am not sure that the rules are actually out for how tribes can 

actually access that. And I appreciate the question today so much 

because things are moving so quickly that sometimes tribes aren’t 

necessarily aware of some of the issues and opportunities that are 

available. So to the extent that this Committee can do its part to 

make sure that as services or opportunities are available for any 

other health care provider, for individual, if you can help to make 

sure that tribes are included in that mix, that will help tremendously. 

I did mention earlier that we were concerned that the Health Information Technology Funds that were made available to the Indian Health Service, we were hoping that some of those resources 

would be available to self-governance tribes, as well as to urban Indian programs, to be able to meet that unmet need. And unfortunately, that did not happen. 

So any opportunity, we should be careful that sometimes when 

we are making funds available to the Indian Health Service, it is 

important to keep in mind not only direct service programs, but all 

three, not only direct service, but also self-governance, tribally operated programs, as well as the Urban Indian Centers, because it 

takes all three working together to be able to meet the need of individual American Indians and Alaska Natives. 

Senator JOHANNS. Those are really excellent points. Sometimes 

I think that part of our challenge is just getting everybody on the 

same page, and making sure that the funding that we are providing really gets to helping people, if you know what I am saying. 

Not to indict anybody, that is not what I am suggesting. It is just, 

gosh, this seems terribly complicated to me sometimes. 

Ms. DAVIDSON. On that point, if I may? There has been a lot of 

talk about how the Indian health system is broken, et cetera. And 

there was a point that was made earlier, I think by Jefferson, that 

we are not broken. We are starved. And I don’t know any other 

health care delivery system who could continue to operate year 

after year after year with the level of funding at about 54 percent. 

And if you are looking at making investments in health care reform, and making investments in the right place, I would challenge 

this Committee to look for any other health care delivery system 

in this Country that has shown that it can do more with less. Quite 

frankly, we have been innovative because we have been forced to. 

We live in these communities. We don’t have that option. 

63 

And this Committee could do so much in health care reform by 

remembering the impact that it has on individual American Indians and Alaska Natives. So if there is a health benefit that is available, make sure that Indians are expressly eligible. If there is an 

opportunity for health providers to be able to get additional reimbursement or additional considerations, make sure that the Indian 

health system, whether it is an IHS facility, direct operated; 

whether it is tribally operated; or whether it is an Urban Indian 

Center, also has that express authority. 

And then finally, because tribes are, like many areas, we are employers. If there are any opportunities that are available for employer health plans, for us to be able to get some tax benefits just 

like any other employer, please also remember to expressly include 

tribes. 

Unfortunately, our experience has shown that unless that express authority is there, we encounter resistance after resistance 

after resistance. And often what we hear is, well, if Congress intended that to happen, Congress would have provided express authority. And so therefore, we are asking the Committee that if 

there is any opportunity to provide that express authority, please 

do so, because otherwise we may just be left out of the mix. 

Senator JOHANNS. Okay. 

Dr. Carlton, I will wrap up my questions with you. 

I was reading your testimony and I have to admit I was just 

amazed by what you were laying out there in terms of the capacity 

to put something up quickly, that gets the job done. Let me zero 

in, if I might, a little more on cost. Give me just a rough idea of 

how what you are suggesting with this kind of facility, compares 

with ground-up sort of construction, that sort of thing. What are 

the cost differentials here? Is there a rule of thumb? 

Dr. CARLTON. Well, when we talk cost differentials, you break it 

down into housing, commercial buildings, and then the highest end 

is medical, and the most expensive. So standard housing construction generally $100 to $150 per square foot; commercial buildings, 

$150 to $250; and unfortunately medical has gone skyrocketing. 

The Air Force planned to reconstruct their medical facilities in San 

Antonio at $400 a square foot. By the time the bill was passed, it 

was $600 a square foot, and in many areas of our Country, it is 

$1,000 a square foot today. 

So what we are talking about is we are talking about critical access hospital for $14 million is you have minimized the space so 

that the staff is more effective. And so what used to take 50,000 

feet and the staff having to walk twice as far, now can be done in 

33,000 feet, and the staff is more effective. 

So it is an efficiency model, but when you come down and say, 

well, how big a hospital do you need? The critical access is defined 

as it can’t be bigger than 25 beds, but the reality is that most of 

them are running five and six-bed censuses, because their world 

has changed. We have changed to an outpatient environment for 

surgery. 

So when we have an example, and I included the Tehachapi example specifically for you, that was bid in a component fashion for 

$25 million and construction ready to start. An outside consultant 

64 

came in and said, oh, we don’t do component in the medical world. 

You need to go to site-built, stick-built, $67 million. 

Now, at some point, fiscal reality has to come to our Nation. And 

I am not sure it has in the medical world. Now, that $14.5 million 

isn’t $14.5 million. It is $14.5 million with a full lab, with a full 

x-ray, fully equipped nurses station, beds and an electronic medical 

record. 

So it is not exactly an apple to an apple. And so we have to be 

careful as we talk about even Tehachapi. Tehachapi at $25 million 

was 50,000 square feet, $500 a square foot. And at $67 million, it 

is 60,000 square feet because they wanted more administrative 

area. 

Well, if you keep it under the same roof under California directives, you have to then built to the highest standard. Where if you 

separate by seven feet, you can build an administrative area at a 

lower standard, which is what the component builders had done. 

So it is a complicated issue, but for rural States like yours, to be 

able to replace a rural hospital that then has an electronic medical 

record, and the other piece of this, we are talking facilities and I 

am talking equipment and facilities with you, but you have to have 

people, equipment, facilities, training and organization all at the 

same time. 

What we are trying to do in Texas is tie this on the people side 

into the university. The biggest problem we have in rural Texas is 

getting people to go. So the nurse, the physician won’t go because 

they are all by themselves. 

Well, if we tie them to a central location so that if they train in 

our training program, they never leave the boss. They can always 

call back. They can present the cases. It is part of the deal. 

And the Congress has made that available. That is a passthrough under this critical access, but we are not doing it because 

that is not the way we do things. So the potential is remarkable. 

Senator JOHANNS. I agree with you based on what I know. Like 

I said, as I was reading through your testimony, I just was amazed 

by what you were laying out there. The challenge, I think, for us 

today with this hearing is how to interface the knowledge you have 

and the experience, with what we are trying to do out there. Because you are absolutely right, with budget issues and everything 

else going on, we have to bring reality to this. 

So I would encourage you to continue somehow to interface with 

Committee Members, but then also with your Senate delegation 

back home because oftentimes they will come to a meeting where 

we are all together, and say, hey, I have a good idea, and that is 

another way of keeping you in the loop, because I do think there 

are some things here that we can use. 

I will wrap up there, and I just and I just want to say to all the 

panelists again thank you so very much for being here today. 

Senator BARRASSO. Thank you, Senator Johanns. 

Just following up on what you were asking Mr. Carlton, I am 

also very interested in what you are doing with these mobile clinics 

and then the way you can do this, because in limited health resources and big distances, I think it would be really the answer for 

the future. 

65 

I was going to ask, have you engaged other Federal agencies on 

the use of this kind of activity with mobile units and the component construction? What have you found? Has there been any difficulty moving forward in a big government bureaucracy? 

Dr. CARLTON. Senator, as a physician, we understand change is 

difficult for all of us. In a governmental setting, change is difficult 

for all of us. 

I am the architect of the Iraq War plan, laid it out in 1983 on 

the medical side. It took 20 years to implement because it wasn’t 

the way we do business. 

Far forward, surgery critical care, the air, and integrated delivery system, right now, our centers in San Antonio, we have two 

level one trauma centers are two standard deviations above the 

mean for survival on identically injured patients. And you say, 

why? It is because we have a standardized protocol. We do things 

the same way. 

We may deviate from that and explain it just like a pilot in command, but our charter now I believe as military members or former 

military members is to share that with our community and bring 

the standard deviation up on the civilian side. If we are running 

two standard deviations above, it means that we are in a 97 percentile. We are doing something right. 

And we need to come talk to the Senate, and we need to say, 

well, here is what we have done in Iraq. We are doing better for 

the severely injured in Iraq across a system of 8,000 miles than we 

are in rural Nebraska. Well, there is something wrong with that. 

And so, with the Mayo Clinic and Texas A&M, we have now 

started a program to say, okay, let’s integrate the lessons learned. 

Maybe we even need different types of surgeons. Maybe a general 

surgeon, maybe a general orthopedic surgeon shouldn’t do everything, but we should all teach them salvage surgery, how to get a 

survivor in the first 12 hours, knowing that your partner will be 

behind you six hours later, connected by a transportation system. 

For the Indian Health Service, the same thing. 

So the challenge before us now is how do we standardize construction in a cost-effective manner, delivery of health care in a 

cost-effective manner, and the lessons learned in wartime how can 

we quickly bring them to the United States of America. And I think 

rural America, you two gentlemen, are the perfect examples of how 

we might be able to show that, and then integrate that. 

I mean, I am very excited about it. But it is a 20-year program, 

and so we could be a two-year program into the civilian world. We 

just have to figure out how to properly reward it. 

Senator BARRASSO. So then specifically with regard to the Indian 

Health Service, obviously there is huge value there. Are there bureaucratic barriers? Or how do we get this accomplished in a timely 

manner? 

Dr. CARLTON. Our Government has bureaucratic barriers. I presented this in 2003. The Surgeon General was a very good friend, 

Rich Carmona. And he said, you have to bring this to our architects, this component construction. It was a solid turn-down, no, we 

are not going to do that. No, thank you. 

And that is okay. We had to prove it. Now, we have proven on 

the inpatient side, on the outpatient side, and oh, by the way, we 

66 

can then connect them all with a mobile system and a telemedicine 

system, and an electronic medical system, and do a much better job 

than we are doing today. 

That is not to say we haven’t done a good job in the past. We 

can just do better. 

Senator BARRASSO. Okay. 

For the other panelists, usually you come to these hearings, you 

testify, and then you say, I just wish I had said this one other 

thing. And I would just go down, Ms. Davidson and Mr. Roth and 

Mr. Rolin, if there are any last things that you would like to share 

with the panel, the Committee, as part of the formal record, I 

would love to hear what you have to say now. 

Ms. DAVIDSON. I just want to go back to a statement that we 

made earlier that may have gotten lost in the comments, which is 

that I think time and time again, we have shown that we are a 

good investment, that we do every year more with less. But you 

also need to know that we are at a point right now where our resources, we have no more margin. I mean, we don’t have it. 

And a lot of times when we talk to people about contract support 

cost, people immediately think contracts, lawyers, litigation, and 

they completely turn off. But to us, contract support cost is really 

providing necessary infrastructure. It is about jobs and it is about 

people. 

If we know that we have to use resources to be able to pay rent, 

to buy insurance, to do all of the things that are required, but 

those resources aren’t available, then what happens is that instead 

of being able to provide as many direct services as we could, what 

happens is that we necessarily, because we have to do all those 

other things, all the infrastructure that it takes to be able to operate, those come from the service that we would be able to provide. 

So contract support cost is more than just about infrastructure 

because when we don’t fund infrastructure, we have to take that 

money from direct services and from services that we otherwise 

would be able to provide, things like dental services, things like 

long-term care services, things like behavioral health services, residential treatment services. Those are things that we just don’t have 

the resources to provide. And contract support costs lack of funding 

means that there are even fewer resources that are available. 

So thank you. 

Senator BARRASSO. Thank you. 

Mr. Roth? 

Mr. ROTH. Yes, I realized about 10 minutes after Senator Tester 

asked me my question that I answered it incorrectly. 

Senator BARRASSO. Go right ahead. 

Mr. ROTH. So I would like to highlight a little bit more about 

data and the need for really doing a comprehensive review in this 

Country on where urban Indian people live and how or if they are 

accessing services. We know that there is a lot of migration between reservation and urban communities, and we know there is 

a great deal of need in communities that don’t have urban Indian 

health programs now. 

I was recently in Riverton as well, and was able to tour the 330 

clinic that the tribe has started up in Wyoming. And that is a great 

example of a tribe that has come in and has decided that they are 

67 

going to deal with the urban Indian population there by providing 

services because the access or the funding didn’t exist within Title 

5 of the Indian Health Care Improvement Act to do that and to expand services to that. So I applaud the tribe there and I applaud 

Riverton for being able to do that. 

What we really need is a needs assessment to get an accurate 

picture of what the population looks like and examine systemic 

issues related to delivery of health care to urban Indians, facilities, 

buildings, issues and workforce development issues. 

Thank you. 

Senator BARRASSO. Thank you for the clarification. Thank you. 

Mr. Rolin? 

Mr. ROLIN. Thank you. 

Well, as you have heard from all of us here in our comments, 

there is a need in Indian Country. I want to first make that known 

for the record. We have all done well at some point, and we have 

this and utilize the services and have the services that we do. We 

really utilize those resources to the very end. And it is important 

for us as Indian people to provide health care to our tribal members. In certain areas we have talked about, certainly providing 

that service has not been the hardship as it has other areas. And 

that is our concern, is to be able to bring health care up to the 

level. 

Earlier years when Dr. Everett Rhoades was Chair, I mean Director of the Indian Health Service, he used an example of getting 

us to a level. At that time, he said if we could get to 70 percent. 

Well, we haven’t been able to get there, Senator, and that is a goal 

that we are all working on. 

And if we could get to that level and go beyond that level, certainly by meeting the needs of our people, certainly that would benefit us all, and we would be a much happier community. 

Senator BARRASSO. Well, I want to thank all of you for coming 

to testify. We will keep the record open for two weeks if there is 

some additional information you would like to supply us. We may 

supply you with some additional written questions. 

But I want to thank everyone who has come here to participate 

and to listen. 

And with that, this hearing is adjourned. 

[Whereupon, at 3:57 p.m., the Committee was adjourned.] 

(69) 

A P P E N D I X 


611a6.eps
70 


611a7.eps
71 


611a8.eps
72 


611a10.eps
73 


611a11.eps
74 


611a12.eps
75 


611a13.eps
76 


611a14.eps
77 


611a15.eps
78 


611a16.eps
79 


611a17.eps
80 


611a18.eps
81 


611e1.eps
82 


611e2.eps
83 


611e3.eps
84 


611e4.eps
85 


611e5.eps
86 


611e6.eps
87 


611e7.eps
88 


611e8.eps
89 


611e9.eps
90 


611e11.eps
91 


611e12.eps
92 


611e13.eps
93 


611e14.eps
94 


611e15.eps
95 


611e16.eps
96 


611e17.eps
97 


611e18.eps
98 


611e19.eps
99 


611e20.eps
100 


611e21.eps
101 


611g1.eps
102 


611g2.eps
103 


611g3.eps
104 


611g4.eps
105 


611g5.eps
106 


611g6.eps
107 

PREPARED STATEMENT OF CARMELITA SKEETER, CEO, INDIAN HEALTH CARE

RESOURCE CENTER OF TULSA, INC. 


611f2.eps
108 


611f3.eps
109 


611f4.eps
110 


611f5.eps
111 


611f6.eps
112 

PREPARED STATEMENT OF CHAD SMITH, PRINCIPAL CHIEF, CHEROKEE NATION

On behalf of the Cherokee Nation, please accept this correspondence as testimony 

regarding reform in the Indian Health Care System. The Cherokee Nation believes 

it is vital that the Indian health care system join in the broader discussion of national health care reform and have the ability to fully participate in any implemented advancements in health care policy. Through our engagement in state-level 

health care reform, the Cherokee Nation has identified three key areas where the 

Indian health system can play an active role in national reform: Addressing the Uninsured, Increasing Access, and Improving Information Technology Capacity. 


611f7.eps
113 

Addressing the Uninsured 

Although increasing health coverage alone does not necessarily equal reform, the 

lack of health coverage does serve as one of the largest barriers to seeking health 

care. Because the Indian health system is able to access 3rd party payment sources, 

the Indian Health Service (IHS) and Tribal Nations have a vested interest in increasing the number of American Indians/Alaska Natives (AI/AN) with health insurance. 

Community outreach and education efforts must be undertaken to ensure existing 

programs are serving all that are eligible to participate. Outreach and education is 

especially important for the AI/AN population as many do not participate in Medicare, Medicaid, State Children’s Health Insurance Program, or private insurance because of the misperception that participation is not necessary due to IHS eligibility. 

It is important to note that according to the U.S. Census Bureau’s Current Population Survey, individuals who report IHS eligibility and no other coverage are classified as uninsured. Due to inadequate funding and limited access, IHS eligibility 

does not equal health coverage. Therefore, national health reform legislation should 

include language that will allow IHS/Tribally-operated Programs/Urban Indian 

Health Organizations (I/T/U) expenditures to apply toward Medicare Part D True 

Out-of-Pocket-Expenses. Another legislative effort that would greatly improve the 

ability of the Indian health system to access private insurance resources is automatically classifying services provided within the Indian health system as ‘‘in-network’’ for purposes of payment. 

The Cherokee Nation is aware of recent proposals to explore ‘‘privatizing’’ Indian 

Health Services by providing AI/ANs with a voucher or credit to seek health care 

in the private sector. Based on the per capita funding level for IHS users in Oklahoma ($976 annually) and nationally ($1,914 in 2003), funding is woefully inadequate to purchase comparable health services in the private sector. In recent reviews of similar efforts at the state and federal level, the Cherokee Nation has 

found that the State of Oklahoma in a 2006 privatization pilot project determined 

that it spent an average of $3,453 per capita annually on Medicaid beneficiaries. In 

FY 2003, the Federal Government spent $5,200 per capita annually for patients 

within the Veterans’ Health Administration (VHA) system. These findings lead the 

Cherokee Nation to conclude that the level of funding provided by the Federal Government for IHS beneficiaries is not adequate to seek coverage through the private 

sector. 

Additionally, the Cherokee Nation urges the Committee to take into consideration 

that in FY 2001 IHS provided health services to only 1.3 million American Indians 

and Alaska Natives. Using 2000 Census figures, even if every one of the 4.1 million 

eligible AI/AN accessed the IHS system, the federal fiscal impact would still be negligible compared to the 37.7 million Medicare enrollees, 29.2 million Medicaid enrollees, and the 8.4 million accessing services through the VHA and Department of Defense. 

Given the significant disparity in per capita spending for Indian health system 

users relative to other populations, the fact that the AI/AN population represents 

only a small segment of the overall population, and the Indian health system’s consistently demonstrated ability to provide quality care with minuscule resources, the 

Committee should champion an effort to fully implement the framework of the Indian health system in order to increase the services for current patients and improve access for those unable to utilize the system. 

Increasing Access to Healthcare Services (workforce and rural needs) 

In order to address the impending healthcare workforce crisis, efforts must be 

made to both increase the workforce and make the current workforce more accessible to the rural population. The Cherokee Nation supports appropriate expansions 

of the quantity and quality of health care professionals and workers, and supports 

practices that allow this workforce to operate at ‘‘the top of their licenses.’’ 

While it may not be practical to construct full-time, dedicated clinics in remote 

areas, efforts can be undertaken to utilize existing infrastructure such as schools, 

places of business and retail establishments, to host health provider sites. The flexibility to allow the IHS and Tribally-operated health systems to carry out such efforts is critical. 

In FY 2008, the Indian Health Service Scholarship program accepted only 101 (or 

5.3 percent) of the over 1,900 new applications were able to be funded. It is apparent that the IHS Scholarship Program is an attractive program designed to both 

meet the needs of the Indian health system and enable qualified individuals to pursue health careers. Adequate funding will allow this existing program to accomplish 

its designed purpose. 

114 

National health reform should also include specific language to ensure Tribal facilities operated by a Tribe or Tribal organization authorized by Title I or III of the 

Indian Self-Determination and Education Assistance Act, aka ISDEA (P.L. 93–638, 

as amended) are eligible to participate in the National Health Service Corp (NHSC). 

Further, facilities in Indian Country continue to be desperately needed. The IHS 

Joint Venture (JV) program demonstrates the shared commitment of Tribal Nations 

and the Federal Government in providing additional health facilities within the Indian health system and the staff necessary to support the facilities. The JV program 

is a proven success in leveraging resources to construct and build critically needed 

health facilities, making federal funds go farther. The JV program would greatly 

benefit from funding on an annual basis, including contract-support-costs funds and 

adequate operational funds. 

Finally, it is a well settled principle that the government-to-government relationship between the United States and federally recognized Tribal Nations provides the 

foundation for the federal trust responsibility to carry out various programs and 

services for Tribal citizens. Eligibility for such programs and services should be 

based on the political status of the individual. By virtue of citizenship in the Cherokee Nation, an individual should have equal access to all programs and services 

carried out by the Federal Government as part of the federal trust responsibility. 

For uniformity and objectivity, the Cherokee Nation recommends eligibility criteria 

be based on citizenship in a federally recognized Tribal Nation. 

Improving Information Technology Capacity 

Tribal Nations still need further assistance in developing Universal Enterprise 

Network Systems to build inter-network connectivity and operability. An investment 

in the technological capacity of Indian Country will enable the expedited implementation of electronic health records, telemedicine, health information exchange and 

related initiatives in an efficient, secure and user-friendly manner. 

The Cherokee Nation fully embraces the principle that, in order for health care 

reform to be effective, preventive health must be considered on the same level as 

health coverage, access, and information technology. To create and implement effective preventive health programs however, better data collection and dissemination 

procedures are needed. To address the health disparities facing AI/AN, improved 

data collection is particularly needed on topics such as the quantification of chronic 

disease prevalence, chronic disease risk factor reduction, hypertension, and stroke 

prevalence and prevention. One of the most beneficial improvements in this area 

would be the establishment of a single, integrated website with data available to 

calculate simple statistics, such as incidence and prevalence rates, as well as access 

to relevant published data. 

115 


611h1.eps
116 


611h2.eps 611h3.eps
117 

PREPARED STATEMENT OF JOSEPH ENGELKEN, CEO, TUBA CITY REGIONAL HEALTH

CARE CORPORATION


611i1.eps
118 


611i2.eps
119 


611i3.eps
120 

PREPARED STATEMENT OF ROBYN SUNDAY-ALLEN, CEO, CENTRAL OKLAHOMA

AMERICAN INDIAN HEALTH COUNCIL, INC. 


611j1.eps
121 


611j2.eps
122 


611j3.eps
123 


611j4.eps
124 


611j5.eps
125 

PREPARED STATEMENT OF MICHAEL COOK, EXECUTIVE DIRECTOR, UNITED SOUTH AND

EASTERN TRIBES, INC. 


611k1.eps
126 


611k2.eps
127 


611k3.eps
128 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. BYRON L. DORGAN TO

BUFORD ROLIN

Behavioral Health 

Question 1. In the absence of expressed authority, what types of behavioral health 

services are being provided by tribes? 

Answer. Behavioral health programs in Indian Country address key health priorities such as suicide prevention, violence/injury prevention, and alcohol/drug use 

prevention. Services may include mental health and alcohol and drug assessments, 

counseling, consultation, and training services. In the delivery of behavioral health 

services, many Tribes emphasize a culturally sensitive method that respectfully integrates tribal spirituality and cultural awareness into the full range of behavioral 

health assessment and treatment. 

Examples of these programs include: 

• From Legacy to Choice—A suicide prevention program run by the Colville Confederated Tribes. 

• Youth Prevention Programs—The Penobscot Nation Health Department supports various youth programs that provide skills in the areas of substance abuse 

prevention, chronic disease prevention and suicide prevention. 

• The Home Grown Project—A healthy eating program developed by the Little 

Traverse Bay Bands of Odawa Indians to encourage nutritious eating by utilizing a more traditional approach/relationship with growing, gathering and 

cooking food. 

• Healthy Lifestyle Programs—The Houlton Band of Maliseet Indians implemented seven behavior health programs to address tobacco prevention, increased physical activity, diabetes self-management and nutrition. 

Additionally, the Indian Health Service Health Promotion and Disease Prevention 

Program has compiled a database of the best and promising practices and local efforts in Indian Country regarding behavioral health. Topic areas include cardiovascular disease, oral health, injury/violence, mental health, overweight/obesity, sexual behavior, substance abuse, physical activity, and tobacco use. To access the comprehensive database of best and promising practices and local efforts, please visit: 

http://www.ihs.gov/hpdp/ or http://www.ihs.gov/NonMedicalPrograms/HPDP/ 

BPTR/index.cfm?module=BestPractices&option=BPPPLE. 

However, not all tribes are able to provide such integrated services or have limited availability of such services due to chronic under-funding. The proposed Title 

VII in the Indian Health Care Improvement Act would provide the authority for all 

tribes to have authority to access comprehensive behavioral health programs to address the behavioral needs of their tribal members. In addition, additional funding 

would enable IHS and Tribal governments to provide culturally appropriate behavioral health services in a more timely and efficient manner. 

Question 2. How are behavioral health services being funded? 

Answer. Tribal behavioral health services may be funded through a number of 

sources such as: 

• Office of Minority Health (example: Cooperative Agreement with the Association of American Indian Physicians) 

• Office of Juvenile Justice and Delinquency Prevention Tribal Youth Program 

• Indian Health Service 

• Substance Abuse & Mental Health Services Administration 

• Center for Disease Control and Prevention 


611k4.eps
129 

1The Congressional Budget Office, in its paper titled Key Issues in Analyzing Major Health 

Insurance Proposals (Dec. 2008), observed (at page 127): ‘‘Because of staff shortages, limited facilities, and a capped budget, the IHS rarely provides benefits comparable with complete insurance coverage for the eligible population; as a result, estimates of the uninsured population in 

the United States do not treat the IHS as a source of insurance.’’ 

• Department of Health & Human Services (via various grant opportunities 

through the agencies and divisions of the DHHS) 

• State and local agencies/health departments 

• Tribes (through the Public Law 93–638 contract with the Bureau of Indian Affairs and a Self Governance Compact with the Indian Health Service) 

• Health organizations (e.g. American Heart Association, American Diabetes Association) 

• Private entities/donors 

Question 3. Do you know of any successful tele-mental health programs being operated in Indian Country? 

Answer. The Indian Health Service has compiled a database of current Telemedicine programs existing in Indian Country broken down by the twelve Tribal areas. 

The IHS reports that there are about forty telemedicine programs and partnerships 

within the IHS that are delivering care to smaller, more isolated communities. 

These programs (including mental health programs) are listed on the IHS Telemedicine website at http://www.oehe.ihs.gov/telemed/. 

Creditable Coverage 

You stated in your testimony that IHS does not qualify as creditable coverage in 

all instances, but that sometimes it does or should for ‘‘protections’’. This concept 

is new to the Committee. 

Question 1. In what instances would IHS be considered ‘‘creditable coverage’’ ? 

Question 2. In what instances would IHS not be considered ‘‘creditable coverage’’ ? 

Question 3. Has Indian Country considered other terminology to alleviate the confusion? 

Answer. The implications of the term ‘‘creditable coverage’’ can only be understood 

in the context of the program or policy in which the term is used. In the Medicare 

Part D context, for example, a Medicare beneficiary who already has prescription 

drug coverage which meets the minimum requirements of Part D would not suffer 

any adverse consequences if he/she retained the existing coverage instead of enrolling in a Part D prescription drug program immediately upon becoming eligible to 

do so. By contrast, a Medicare beneficiary without ‘‘creditable coverage’’ who delayed 

enrolling in a Part D plan as soon as he/she became eligible would be subject to 

a late enrollment penalty when he/she did decide to enroll. The amount of the penalty is calculated according to the number of months delay in enrollment. 

The prescription drug programs operated by IHS, tribes and urban Indian organization (I/T/U) pharmacies were declared to be ‘‘creditable coverage’’ for purposes of 

Medicare Part D. Thus, an Indian Medicare beneficiary served by an I/T/U pharmacy would not be subject to a late enrollment penalty if he/she later decided to 

enroll in a Part D plan—which might occur if the Indian moved to a location where 

an I/T/U pharmacy was not available to him/her. 

The term ‘‘creditable coverage’’ is not used in any of the draft health care reform 

bills released so far. The Senate HELP draft uses the term ‘‘qualifying coverage’’, 

and the House draft employs ‘‘acceptable coverage’’. In essence, both terms are intended to describe existing health insurance coverage, which includes certain minimum benefits set out in the drafts. If the coverage does not meet these minimums, 

the individual is considered uninsured. Such an uninsured individual is required to 

comply with the individual mandate—meaning he/she must acquire ‘‘qualifying’’ or 

‘‘acceptable’’ health insurance coverage. Failure to do so would result in assessment 

of a penalty in the form of a tax. 

In most cases, the health services offered by I/T/Us do not meet the minimum 

benefits packages because IHS programs are so badly funded they cannot afford to 

supply the minimum required services. 1 In that case, IHS would not be ‘‘qualifying 

coverage’’ or ‘‘acceptable coverage’’, and the Indian beneficiary would be subject to 

the individual mandate, and to the tax penalty if the individual does not purchase 

or otherwise obtain such coverage. Assessing a penalty on an Indian who was promised adequate health care by the United States but does not receive the appropriate 

level of care, would, in our view, constitute a gross violation of the trust responsibility for Indian health. That is why Indian Country has asked that individual IndiVerDate Nov 24 2008 11:19 Dec 10, 2009 Jkt 053636 PO 00000 Frm 00133 Fmt 6601 Sfmt 6621 S:\DOCS\53636.TXT JACK PsN: JACKF
130 

ans be exempted from the penalty for failing to comply with the individual mandate 

called for in the health care reform proposals. 

Furthermore, it must be noted that IHS offers direct care services to Indian beneficiaries; IHS is not an insurance program. In that sense, then, eligibility for IHS 

services is very different from having insurance coverage. 

Health care reform proposals are expected to offer subsidized insurance to low/ 

moderate income individuals and families who do not have qualifying/acceptable 

coverage. Indian Country wants to assure that eligible Indian individuals can qualify for these subsidies to the same extent as all other Americans, and that Indians 

enrolled in such insurance plans can use their benefits at I/T/U providers. 

At the same time, Indian Country wants to assure that Indian people who currently receive care from an I/T/U can, at some future date, elect to enroll in a subsidized (or even an un-subsidized) health insurance plan without suffering any penalty for a delay in enrollment—such as a late enrollment penalty or a waiting period 

for eligibility—consequences that might otherwise attach to a delay in enrollment. 

You ask whether Indian Country has considered using terminology other than 

‘‘creditable coverage’’ to avoid confusion. Selecting other terms is not within Indian 

Country’s authority. We must work with the terms used in each legislative proposal 

and make sure that we know what they mean in any given bill. When Indian Country developed its first policy paper for the health care reform debate, no draft bills 

had yet been released. Thus, we used the terminology of ‘‘creditable coverage’’ as 

that term was already in use in Medicare Part D and other health insurance contexts. 

Cost Sharing 

Question 1. Has the National Indian Health Board discussed tribally imposed cost 

sharing provisions? 

Answer. The issue of whether a tribally-operated health program charges a co-pay 

to an Indian beneficiary is and should remain a decision made by the tribe in the 

exercise of its self-determination rights. 

Question 2. Do you have a sense of what Indian Country’s view of this issue is? 

Answer. Like other issues affecting Indian Country, there are tribes who support 

and tribes who are against cost sharing levied by tribes for tribally delivered health 

care. Although there is not a uniform perspective across Indian Country, this decision, like other areas affecting a tribe’s administration of its government and services, should be left for Tribes to decide. 

Working in Partnership 

You stated, with emphasis, the interest of working in partnership with the Committee on reforming the IHS facilities construction and Contract Health Services 

programs. This Committee agrees that the best solutions will be developed in partnership with the tribes, tribal organizations, urban organizations and IHS. 

Question 1. Is there the perception that the Committee has not worked in partnership with key stakeholders like the National Indian Health Board? 

Answer. Our emphasis on ‘‘working in partnership’’ with this Committee was by 

no means intended to convey the notion that such a cooperative relationship does 

not already exist. We believe that it does—and are very grateful for it. 

The emphasis was merely intended to recognize that any legislation which would 

make changes in the operation of critical programs such as facilities construction 

and CHS must be supported by both the lawmakers who order them and the tribes 

who will be impacted by them. We sincerely doubt that this Committee would ever 

want to force on the Indian health system alterations whose consequences have not 

been fully considered and found to be desirable. We seek the opportunity to examine 

in detail any proposed changes; in fact, we have a responsibility—both to the Committee and to our beneficiaries—to do just that. If we believe a new idea will 

strengthen the system’s ability to provide better/greater care to Indian people, we 

will support it; but if we believe a change would harm the system, we know you 

want us to tell you that, too. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. JOHN BARRASSO TO

BUFORD ROLIN

Personnel Shortages 

Your written testimony urges some new approaches to address the personnel 

shortages in the Indian health system. 

Among other things, you suggest revising mechanisms for assignment of National 

Health Service Corps personnel. 

131 

Question 1. How would you revise those National Health Service Corps mechanisms to be more user-friendly for the Indian health system? 

Answer. The placement of National Health Service Corps personal would help address the significant shortage in personal within the Indian health care system. 

However, the competition with other Health Professional Shortage Areas (HPSAs) 

for National Health Service Corps personnel decreases the probability for placement. 

HPSAs are designated by Health Resources and Services Administration (HRSA) as 

having shortages of primary medical care, dental or mental health providers and 

may be geographic (a county or service area), demographic (low income population) 

or institutional (comprehensive health center, federally qualified health center or 

other public facility). Although an Indian health service site is likely to located in 

a designated HPSA, Tribes and IHS must compete with other designated HPSA 

areas for the limited Corps personal available. The other qualified sites typically 

have a larger population and the ratio for need is likely higher. 

Another limitation of placement of National Health Service Corps personnel in 

IHS or Tribal facilities is the requirement that qualified sites must accept all patients who can receive care covered by Medicare, Medicaid, and The Children’s 

Health Insurance Program. Currently, I/T/U may not have the physical capacity or 

resources to provide services to non-Indians who may qualify to receive care under 

these entitlement programs. An example of a solution to this issue is in the House 

bill H.R. 2708. Sec.124 (b) provides that for the service of National Health Service 

Corps member assigned to an I/T/U may be limited to the persons eligible for services from the I/T/U. 

Question 2. How could telehealth programs assist in addressing personnel shortages in the Indian Health System? 

Answer. Through telehealth programs, patients located in geographic isolated 

areas of Indian Country, may received initial diagnosis and services from medical 

staff located miles away. Application of such programs could reduce the need for 

health care personnel, reduce travel for health care professionals and patients and 

improve diagnosis. Various I/T/U sites could all rely on the same specialists for care. 

The health care professional would also gain an experience in delivering care to the 

AI/AN population. Also, telehealth programs would reduce the need for such health 

professionals and patients to travel long distances during unsafe weather periods. 

Only patients who require necessary care in person would be required to travel. 

Likewise, only health professionals who had to provide care in person would be required to travel to isolated and remote tribal communities. Lastly, telehealth programs provide the opportunity for the initial diagnosis or review of such diagnosis 

to be conducted by experience specialists located in other parts of the country. 

As noted in a response to Senator Dorgan, there are forty telemedicine programs 

and partnerships within the IHS that are delivering care to smaller, more isolated 

communities. These programs are listed on the IHS Telemedicine website at http:// 

www.oehe.ihs.gov/telemed/. 

Your written testimony also recommends expanding funding to train and support 

alternative provider types who have proven records of providing quality care, such 

as community health representatives, community health aides, behavioral health 

aides, and dental health aid therapists. Several of these alternative providers are 

already authorized under the Indian Health Care Improvement Act for the Indian 

health system. 

Question 3. How would those alternative providers which are not authorized 

across the Indian health system such as the dental health aide therapists be regulated? 

Question 4. What standards of practice or care would apply to the services performed by these alternative providers? 

Answer. Dental health aide therapists are regulated under the Indian Health 

Care Improvement Act now, as they are part of the Community Health Aide Program (CHAP) for Alaska authorized by Sec. 119 of the current law (25 USC § 1616l). 

That provision requires CHAP aides and practitioners to undergo rigorous training 

programs with established curricula, and to quality for certification from the Community Health Aide Certification Board. Their work is subject to ongoing review and 

evaluation ‘‘to assure the provision of quality health care, health promotion, and disease prevention services.’’ 25 USC § 1616l(b)(6). 

Current law authorizes the CHAP program to operate in Alaska, only. Tribal leaders have supported expansion of CHAP authority to tribes in the Lower 48 states, 

and S. 1200, the 110th Congress bill from this Committee, contained such a provision. If enacted, new money and development of appropriate curricula and certification standards would be needed to implement the Lower 48 authorization. Because of issues previously raised by the American Dental Association, the 110th 

132 

Congress legislation did not permit expansion of the dental health aide therapist 

component of the CHAP program to Lower 48 tribes. Instead, the legislation ordered 

an evaluation of Alaska’s DHAT component. Presumably, if that evaluation demonstrates the value and soundness of DHAT services, as we expect it will, the Committee would recommend new legislation to permit Lower 48 tribes to also offer a 

DHAT component in the CHAP program. 

With regard to standards of practice, the CHAP aides and practitioners in Alaska 

must comply with the standards set by the Certification Board for each discipline. 

This same procedure would be followed for regulation of CHAP programs for Lower 

48 tribes if program authority is extended to them. 

Facilities 

The committee received testimony that pre-fabricated health care facilities have 

been constructed in this country and in Iraq which have cut construction costs and 

time delays. 

Question. How would these types of in-patient and out-patient facilities fit within 

the Indian health care system? 

Answer. Such facilities may be tailored to address the unique health needs of each 

tribal community. For example, a tribal community with a high rate of diabetes but 

without local access to a dialysis treatment facility may consider having a pre-fabricated facility serve as its own dialysis center. Indeed, there are many possibilities 

to incorporate such facilities into the Indian health care system. Still, due to the 

prevalent presence and historic experience with prefabricated and mobile homes in 

tribal communities, Indian people may be initially hesitant to using pre-fabricated 

buildings as their tribal health care facilities. Indian Country must be reassured 

that such facilities are safe and cost efficient. In addition, there must be a guarantee that such structures satisfy all building safety codes. Serious discussions must 

occur in each tribal community to determine that if this tribe would like this type 

of structure and the structure can addressed the health needs of the community. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. TOM UDALL TO

BUFORD ROLIN

Question 1. How does the tribal experience with stimulus funds provide any insights for Indian Health Care Improvement reauthorization, or is it too soon to tell? 

Answer. It is probably too soon to fully evaluate the extent of stimulus funding 

provided for construction and maintenance of Indian health facilities, although the 

promise of funding for the two projects identified for new construction has brought 

the hope for better and expanded health care to the tribal communities in which 

they are being built—Barrow, AK and Eagle Butte, SD. Both communities have 

waited a long time to qualify for facility construction. While we are grateful that 

these projects can now move forward, there are many projects on the IHS facilities 

construction priority which still await funding, and many more tribal communities 

in need of facilities who have not yet had the chance to be added to the priority 

list. 

It was a big disappointment to Indian Country to learn that none of the $85 million appropriated for health information technology will be made available to tribes 

who operate health programs. Rather, the IHS Director decided that all funds will 

be retained and expended at the headquarters level. This decision denies tribally 

operated programs the resources needed to upgrade their health IT systems and to 

realize the efficiencies upgrades would provide. The IHS Director’s decision also 

means that tribes will not be able to take advantage of the incentives/rewards federal law offers to health programs, which meet IT goals. 

Question 2. What is available for the tribes to help Indian people develop health 

behavior—such as smoke free and having a healthy weight, in order to prevent diabetes and heart disease? 

Answer. Focusing on wellness is good public health practice and reflects Tribes’ 

traditional cultural values. Tribes cite a variety of effective strategies, including: 

community-based health education, patient case management, screening and early 

detection campaigns, training for healthcare professionals, and incorporating traditional healing approaches to improve wellness. As noted in a previous response to 

Senator Dorgan, the IHS’s Indian Health Service Health Promotion and Disease 

Prevention Program has compiled a database of the best/promising practices and 

local efforts in Indian Country regarding behavioral health. Topic areas include cardiovascular disease, oral health, injury/violence, mental health, overweight/obesity, 

sexual behavior, substance abuse, physical activity, and tobacco use. To access the 

comprehensive database of best & promising practices and local efforts, please visit: 

133 

http://www.ihs.gov/hpdp/ or http://www.ihs.gov/NonMedicalPrograms/HPDP/ 

BPTR/index.cfm?module=BestPractices&option=BPPPLE 

Question 3. With health care reform about to be debated in Congress, what 

changes would tribes recommend to enhance the health outcomes of Native Americans? 

Question 3a. What are the major stumbling blocks to improving these outcomes? 

What assets/strengths helped tribes achieve the successes that have been reached 

so far? 

Answer. Since our system suffers from chronic underfunding (we are funded at 

only 54% of need), the most meaningful and beneficial ‘‘change’’ we can recommend 

is to greatly improve the level of resources supplied to the Indian health system. 

The budget process for Indian health must build in automatic increases for medical 

inflation and population growth merely to avoid losing ground, and it should routinely request actual program funding increases to enhance the quality and quantity 

of care these programs should be providing. In addition, the unmet backlog of facilities needs remains staggering—in the billions of dollars. 

Health care reform could pump additional revenue into the Indian health system 

by assuring that Indian providers have full opportunity to participate in provider 

networks serving individuals enrolled in insurance products listed on the proposed 

insurance Exchange/Gateway. We heartily support reform proposals which would 

encourage prevention/screening services by exempting such services from patient copays. Also, incentives to enlarge the health workforce must apply to the Indian 

health system which constantly experiences difficulty in recruiting and retaining 

health care professionals in all specialties. 

In terms of identifying assets/strengths which have helped tribes achieve successes that have been reached so far, tribal contracting/compacting of health care 

programs gets my vote. The Indian Self-Determination and Education Assistance 

Act has empowered tribes in all areas of Indian Country to become knowledgeable 

about health care delivery; to design programs which respond to local community 

needs; to hire and train community members to operate programs and deliver culturally appropriate care; and to be accountable to their beneficiaries for program 

outcomes. Because of chronic resource shortages, we are constantly challenged to do 

more with less and to develop more efficient methods of operation. Knowing how 

much tribally-operated programs have achieved with inadequate funding makes me 

dream of how we could improve the health status of Indian people if we were funded 

at our real level of need. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. BYRON L. DORGAN TO

GEOFFREY ROTH

National Needs Assessment 

Question 1. What federal agency would the urban programs propose to conduct 

a needs assessment study? 

Answer. In 1981 the Indian Health Service conducted a comprehensive needs assessment not bound to the current locations of the urban Indian health programs. 

This was not only the last study conducted on the needs of the urban Indian community, but the most comprehensive needs assessment conducted for the urban Indian community by any federal agency. This study is the basis upon which NCUIH 

has developed its own recommendations for a new needs assessment. 

Given the good work that the Indian Health Service did with that assessment, 

NCUIH would suggest that IHS be the ideal federal agency to oversee the study. 

We feel strongly that the study should be undertaken with the maximum amount 

of urban Indian participation as possible to ensure that such a study is truly reflective and understanding of the unique position of urban Indians. 

If the Indian Health Service, for reasons not currently considered, is unable or 

not the ideal federal agency for conducting—or overseeing the contract/grant process 

for this study—then NCUIH would suggest either the National Institutes of Health 

or the Agency for Healthcare Research and Quality. Both of these institutions are 

well equipped to conduct such a study in theory. However, in practice neither NIH 

nor AHRQ have undertaken an extensive study involving Native Americans involving social determinants of health. The 2008 AHRQ study on health disparities indicates that AHRQ would find doing such a study for urban Indians to be difficult 

as they cited difficulties obtaining data on American Indians and Alaska Natives as 

the primary reason for the very short section on AI/AN health disparities in their 

report. 

134 

1See generally, Unnatural Causes: Is Inequality Making Us Sick? PBS Documentary, 2008; see 

further, ‘‘Health Inequality, Not Health Disparities’’ lecture by Dennis Raphael at the Center 

for Health Disparities 12/14/2006. 

NCUIH believes that Indian health organizations and epidemiology centers are 

best equipped to do such a study through collaboration with either the Indian 

Health Service or NIH. Any contractor chosen to conduct the needs assessment 

must be thoroughly grounded in and accountable to the urban Indian community. 

Question 2. Has your organization considered what methodology and criteria 

would be required of such a study? 

Answer. While NCUIH has not developed a detailed proposal for the needs assessment, recommended methodology is included in Appendix A. NCUIH does rely heavily upon the 1981 needs assessment conducted by the Indian Health Service as a 

guide for which criteria and methodology should be used, with the caveat that new 

criteria explained below must be included. That study was a complete analysis of 

the health status of urban Indians including the social determinants of health. Comprehensive demographic data was pulled from various sources to understand the 

various communities across the country. Comprehensive demographic data is necessary to determine not only where UIHP providers are needed, but also what kinds 

of services are needful. The social determinants of health extend beyond traditional 

health indicators such as health care access to economic and social status. 1 Such 

details are necessary to better understand the urban Indian community and its 

needs. 

Service access was thoroughly examined in the 1981 report; however, service access, utilization, and availability should be more clearly delineated. These three concepts are imperative for helping identify the health status of American Indians and 

Alaska Natives and are not interchangeable. For example, a patient may have a 

particular service available in their community; however they may not be able to 

access the service. Likewise, a patient may be able to access a service but may not 

utilize the service for a variety of reasons that include environmental barriers and 

cultural barriers. Perhaps most importantly, the 1981 report had no focus on health 

outcomes for American Indians and Alaska Natives. Available, accessible, and utilized health care is ineffectual if people do not receive positive outcomes. Today, we 

must demand that the available health care people access and use is appropriate, 

needed, and results in improvements in health. Therefore, examining availability, 

access, utilization, and outcomes of health care is a necessity in determining the 

current state of health for urban Indian people. These are the criteria that NCUIH 

would suggest. 

For a full discussion of proposed methodology please see Appendix A. 

All-Inclusive Rate, Federal Tort Claims Act Coverage and Federal Supply 

Schedule 

Question 1. Has your organization conducted a review of requirement and/or 

guidelines for all-inclusive rates, Federal Tort Claims Act coverage and the federal 

supply schedule to make certain they can be met by the urban Indian programs? 

Answer. Unfortunately NCUIH has not had sufficient resources to undertake a 

comprehensive review of the requirements or guidelines for the all inclusive rate, 

the Federal Tort Claims Act, or the federal supply schedule. NCUIH could conduct 

such a review if it would be helpful to the Committee, but has not currently been 

able to direct resources to doing so. However, NCUIH has developed an initial legal 

analysis of the FTCA coverage insofar as it could be extended to urban Indian 

health providers with minimal amendments to current law. 

In developing our ask for FTCA coverage for urban Indian health programs, we 

envisioned the protections largely applying to urban Indian health programs in a 

manner analogous to the Federally Qualified Health Clinic (FQHC) FTCA protections, which would mean that only those programs providing comprehensive primary care would be eligible for FTCA protections. NCUIH does have a great deal 

of experience with the FQHC requirements for FTCA coverage as 8 urban Indian 

health providers are FQHCs. Another 13 are FQHC look-a-likes and 2 are Rural 

Health Clinics (RHC). Under current law neither FQHC look-a-likes nor RHCs receive FTCA coverage, meaning the majority of urban Indian health programs providing comprehensive primary care services are currently ineligible for FTCA coverage despite meeting all other requirements for FQHC status except receiving a 

section 330 grant. Some urban Indian health providers have made a principled decision not to pursue 330 status as it would require serving non-Indians. Some urban 

Indian health providers have decided not to pursue 330 status as they do not have 

the support staff necessary to maintain the necessary accounting firewall between 

their Title V grant funds and funds received through a potential 330 grant. These 

135 

2 California Rural Health Board (CRIHB), American Indian and Alaska Native Medicaid Program and Policy Data, 2009. 3 Agency for Healthcare Research and Quality (AHRQ). National Healthcare Disparities Report 

2008 

programs have FQHC look-a-like status which confers upon them higher Medicaid/ 

Medicare reimbursement, but does not include FTCA coverage. 

Full FQHC programs receive FTCA coverage under the theory that as 330 grant 

or contract recipients they are contracting with the federal government to provide 

a service and thus deserve protection from liability for those services. NCUIH believes that those programs who meet the requirements for FQHC look-a-like status 

and receive a grant/contract under Title V of the Indian Health Care Improvement 

Act should be treated in an analogous manner as they, like a Community Health 

Clinic (CHC), are providing clinical health services as part of a grant/contract with 

the federal government. The 13 FQHC look-a-likes and 2 RHCs already met all necessary requirements for FQHC status except for a 330 grant. 

With regard to the all inclusive rate, it is NCUIH’s understanding that the all 

inclusive rate is not the result of any statute, regulation, or other law—but rather 

the result of an agreement or understanding between the Centers for Medicare and 

Medicaid and Tribes and Tribal organizations, and thus the requirements are a 

matter of agency policy and thus do not require legislative activity. As NCUIH currently understands the all inclusive rate, the main requirement is being deemed an 

eligible Indian health provider by CMS. Currently the agency employees the definition of Indian health program found in the current law text of the Indian Health 

Care Improvement Act which does not include urban Indian organizations. While 

changes to existing law—such as 100% FMAP or FTCA coverage—would make negotiations with CMS for the inclusion of urban Indian health providers in the all inclusive rate easier, there exists no law for Congress to directly amend for the inclusion of urban Indians in the all inclusive rate as the all inclusive rate exists nowhere in statute. However, urban Indians could potentially be included within this 

agreement between CMS and Tribes/Tribal organizations if urban Indian organizations were included in the definition of Indian health program. NCUIH does strongly encourage the Committee to consider writing a letter suggesting that CMS consider including urban Indians in the all inclusive rate. 

Question 2. Will the requirements/guidelines require amendments or modifications? Please describe. 

Answer. To NCUIH’s current understand of FTCA law, and how NCUIH envisions 

it being applied to urban Indian health providers, requirements/guidelines for that 

law would not need any major amendments, although not all urban Indian health 

programs would be able to access FTCA coverage. 

NCUIH cannot definitively state at this time whether or not inclusion in the federal supply schedule would require amendments or modifications any applicable federal law as we have been unable to complete a comprehensive legal review of all 

impacted law. It is, however, NCUIH’s initial impression that no amendments or 

modifications to existing law should be necessary beyond the proposed amendment 

that urban Indian health programs be given similar status as Tribal health organizations, though of course deferment should be granted to Tribes and Tribal organizations. 

Adequate Data 

Question 1. Lack of adequate data is often cited as problematic when addressing 

and improving Indian health care. Does this problem exist strictly within the Center’s for Medicare and Medicaid Services or does it extend beyond that particular 

agency? 

Answer. Unfortunately the lack of data on American Indians and Alaska Natives 

is not unique to the Center for Medicare and Medicare Services. CMS has particular 

constraints upon their data collection as their methods for collection of current enrollment are woefully inadequate and antiquated; 2 however, federal agencies such 

as the Agency for Healthcare Research and Quality also have reported difficulties 

in obtaining necessary data to conduct a complete health disparities analysis for 

American Indians and Alaska Natives. The 2008 AHRQ health disparities report 

only spends a scant 3 pages out of over 289 on American Indians and Alaska Natives because of the difficulty obtaining needed data. 3

The difficulty with obtaining health data for American Indians and Alaska Natives stems from several interconnected causes that are difficult for any one agency 

to overcome. American Indians and Alaska Natives are a small portion of the population, generally live in isolated communities, have cultural and linguistic difficulties communicating with researchers, and are often an afterthought to many public 

136 

4Kaiser Family Foundation, American Indian and Alaska Natives: Health Coverage Access to 

Care, 2004. 5 Recent documentation on H1N1 have be unable to quantify impact on Indian communities. 

6Sallie Sharp, Symposium Addresses Disparities in Native American health care, Harvard 

Science online. November 10, 2007 @ http://www.harvardscience.harvard.edu/medicine-health/ 

articles/symposium-addresses-disparities-native-american-health-care; 7See fn 2. 8http://www.ehealthinitiative.org/stimulus/education.mspx 

9http://www.ihs.gov/CIO/EHR/ 

10To be ‘‘locked-in’’ in a technology that is hard to update, upgrade or obsolete is a common 

problem faced by early technological adapters as explained by various technology theorists. For 

a quick and easy explanation about this issue see: Miozzo, Marcela and Grimshaw, Damian. 

Knowledge Intensive Business Services: Organizational Forms and National Institutions Edward Elgar Publishing (2006). p. 142 

and private studies. Other institutions that have reported difficulty obtaining data 

on American Indians and Alaska Natives include the Kaiser Family Foundation, 4

Centers for Disease Control, 5 and Harvard School of Public Health. 6 In fact Indian 

and urban Indian epidemiology centers have also reported difficulties obtaining necessary information. 7

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. JOHN BARRASSO TO

GEOFFREY ROTH

Health Information Technology 

Question 1. Please describe the current capabilities urban Indian clinics have for 

health information technology? 

Answer. It is important to recognize that the urban Indian health program within 

the Indian Health Service consists of a wide array of programs and services, not all 

of which constitute clinical care. The vast majority of those offering clinical care 

have some technology as the demands for patient documentation and billing demand 

technological support. Only 2 have an electronic health record. One operates on the 

Indian Health Services, RPMS system. The other uses a private source. 

The capabilities for carrying out operations with Health Information Technologies 

(HITs) in Urban Indian Health Programs (UIHPs) as a group are—in general—varied. However, it is critical to note that UIHPs present a variety of developmental 

stages; therefore readiness to implement operations through HITs will depend very 

much on the stage of development that each UIHP operates within. The introduction and use of Information and Communication Technologies (ICTs) for health matters is precisely one of the quickest and most efficient manners for clinics and public 

health programs to leapfrog developmental stages and expand services in an optimal 

fashion. The latter explains the recent Obama Administration’s extensive focus on 

the use of technologies for all American health facilities . The main issues in the 

introduction of these technologies have been; 

1. They require an initial moderately expensive investment in hardware and 

personnel training. 

2. The right technology must be used in order for these systems to render the 

maximum benefits. If the technology used is not the correct one, the implementing agency may find itself thwarting its own path for ongoing development. 

A comprehensive assessment on the HIT capabilities for UIHPs must be conducted in order to find the best approach to introduce or improve the HIT capacity 

of our programs. There is, however, 8 one issue that is ongoing and common to many 

Urban Indian Health Programs: the compatibility of the current Indian Health Service strongly preferred Resource and Patient Management System (RPMS) 9 with current technologies. There is also a lack of flexibility with RPMS when it needs to be 

improved in a comprehensive fashion. RPMS was a pioneer HIT when it was first 

launched (30 years ago), but its current version does not seem to work in a seamless 

fashion with other systems. 10

For instance, the information entered and electronically stored into RPMS cannot 

be migrated or used by other software systems for Third Party Billing, which, in 

many cases, forces the UIHPs to duplicate efforts in both entering information and 

in training personnel for the use of various systems. As mentioned, a comprehensive 

and in depth assessment for solving this common issue must be conducted in order 

to find the best solution for all UIHPs. 

Aside from the afore-mentioned specific issue, the National Council of Urban Indian Health believes that in order to make HITs effective for UIHPs the following 

137 

factors must be addressed: (a) Basic Infrastructure—PC’s, Server, other hardware; 

(b) Appropriate Software, (c) Correct Training; (d) Updates for the previous three. 

Information in these four factors is very scarce and indeed necessary. Having that 

in mind, NCUIH recently carried out a survey to preliminary assess UIHPs in a variety of fields, including the basics of e-readiness (the ability of an organization to 

use electronic systems for their operations). The survey was responded to by 20 out 

of 37 UIHP members (around 61% of all members). The following results shown 

below must be taken into context as most of the programs responding the survey 

were those on the middle and higher ends of the average UIHP development stage. 

It must be taken into account that some of the non-respondents are far from being 

considered technologically ready, infrastructure and personnel-wise. 

NCUIH UIHP 2008 Survey results for—basic e-Readiness Components 

Of UIHP’s reporting, 72.2% of UIHP’s reporting have T1 Internet Service 

(broadband), 16.7% Dial up connection. Approximately 95% of all staff has e-mail 

access. UIHPs use the following methods for Internal Operations: 

• 41.88% using Email/PDF • 2.64% Fax • 11.50%Written • 33.00% Face-to-face • 2.67% intercom • 2.86% memos • 16.40% phone/cell 

UIHPs use the following methods for External operations: 

• 48.75% Email/PDF • 6.07% Fax • 25.31% Telephone/Cell • 10.93% Written letters • 14.47% face to face • .46% text 

All UIHPs reporting have their own server, with a specific email for work used 

by staff, and most with an organizational website (94.1%). UIHP websites offer General UIHP Information (100%), Programmatic Information (100%), Contact Information (87.5%), News/Events (81.3%), Job Opportunities (31.3%), Community Resources (43.8%), Online Services (25%), Community Stats (25%), and Forums 

(12.5%). 

According to this same survey the top three UIHP priorities for an information 

technology grant are (1) Online RPMS Infrastructure, (2) Online RPMS Training 

and Upgrading computer equipment (tied), and (3) Training on Special Software. 

Again, comprehensive assessment on both Information and Communication Technologies and on HIT capabilities for UIHPs must be conducted in order to find the 

best approach to introduce or improve the capacity and capabilities for our programs. NCUIH would be glad to participate in the conducting and coordination of 

such assessment if necessary. 

Please see Appendix B for further information on HIT and urban Indian health 

programs. 

Question 2. Please explain why urban Indian programs are not able to currently 

access this source of supply. 

Answer. Current law does not permit urban Indian health programs as urban Indian health programs to access the federal source of supply. Some urban Indian organizations may be able to access certain aspects of federal sources of supply 

through their status as Community Health Centers. However, that access is extremely limited, temporary, and any resources received under the 330 grant must 

be kept separate from resources received through the Indian Health Service in 

terms of accounting. However, only 8 of the 36 urban Indian health providers are 

also CHCs. 13 are FQHC look-a-likes and 2 are Rural Health Clinics, but neither 

FQHC look-a-likes nor the 2 RHCs have access to the federal supply schedule under 

current statute. The type of access given to Tribes and Tribal organizations through 

the Indian Health Care Improvement Act’s current law provisions are not currently 

available to urban Indian health programs, even those that are full FQHCs. 

In terms of federal Indian law currently only Tribes and Tribal organizations have 

the legal authority to access to the federal supply schedule. Urban Indian health 

programs are not included in those provisions and FQHC look-a-likes—13 urban Indian health providers are FQHC look-a-likes—are not permitted to access federal 

sources of supply for property. Urban Indian health providers may, in certain situaVerDate Nov 24 2008 11:19 Dec 10, 2009 Jkt 053636 PO 00000 Frm 00141 Fmt 6601 Sfmt 6621 S:\DOCS\53636.TXT JACK PsN: JACKF
138 

11See National Indian Health Board. Testimony to the Subcommittee on Interior Appropriations. 2008. 

tions, have access and use of federal facilities, but not of other property such as 

medical equipment. 

Question 3. Please describe how urban Indian programs will ensure accountability 

if such access is authorized, particularly regarding the pharmaceutical programs. 

Answer. As Indian Health Service contractors, and since the Indian Health Service would be the primary point of contact for accessing the federal supply schedule, 

urban Indian health programs would be bound by the new requirements and accountability procedures recently enacted by the Indian Health Service to combat 

waste and misuse of federal supply. 

Moreover, those urban Indian health programs with pharmacy capacity would be 

already bound by federal law and regulation regarding the safe and accountable access of those pharmaceuticals. The 23 urban Indian health programs with pharmacy 

capacity (8 full FQHCs, 13 FQHC look-a-likes, and 2 Rural Health Clinics) already 

have implemented policies and procedures compliant with federal law to ensure the 

safety and accountability of pharmaceuticals and pharmaceutical scripts handled by 

the urban Indian health provider. It is difficult to describe a single set of policies 

or procedures for accountability as the difference between FQHC, FQHC look-a-like, 

and RHC status among the urban Indian health programs means that each program, depending upon status, may have different sets of standards and requirements to follow. 

Access to federal sources of supply will not elevate those programs currently unable to meet the requirements of federal law for class D pharmacies, or the regulations surrounding FQHC/RHC pharmacies, to the position of maintaining pharmacies. Those programs will still be required to meet such requirements as set in 

place by agency regulation or federal law. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. TOM UDALL TO

GEOFFREY ROTH

Question 1. What are the two most important changes you would recommend to 

improve the health care system delivery for Native Americans? 

Answer. Full funding of the Indian Health Service, including full funding of the 

Urban Indian Health Program—it’s well documented that the Indian health delivery 

system is underfunded and that lack of funding has a deep, damaging impact upon 

the ability of Indian health providers to provide comprehensive health services. The 

Indian Health Service is funded at roughly 50% of actual need 11 and the Urban Indian Health Service is funded at 22% of estimated need. While Indian health providers are among the most innovative and dedicated, there are limitations on a providers ability to make up for lack of funds through sheer determination and creativity. Funding for Indian health providers must be the very first priority in order 

to deliver serious change to the health status of Indian people. Changes to the law 

and additional programs are necessary and helpful, but without the underlying sustainable funds to support them those programs can only go so far. 

With full funding Indian health providers—including urban Indian health providers—would no longer be force to essentially ration health care services. Complete 

funding would allow Indian health providers to develop comprehensive, community 

based intervention strategies, and workforce development programs focused on cultural competence. Indian health providers are required to spend an inordinate 

amount of time simply struggling to stay financially stable and maintain the base 

level of services required by their communities. If Indian health providers were financially stable these resources—both financial and human—could be freed to focus 

upon developing new best practices. 

Complete funding for the Indian health system—and for the urban Indian health 

programs within IHS—would allow Indian health providers to build upon their innovations that have been born from necessity. Programs such as the special diabetes 

program for Indians could be expanded beyond diabetes into the co-morbid, chronic 

diseases suffered by many American Indians and Alaska Natives such as hypertension, heart disease, and depression. 

Fully integrate the I/T/U system so that each element of the Indian health delivery system is fully supported and fully integrated with the other providers. We 

know our patients move between provider types within the Indian health delivery 

system. They may see a direct service provider (I) one year and then be living in 

Los Angeles being seen by an urban Indian health provider the next. However, 

there is very little continuity of care or continuity of service level. Indeed many proVerDate Nov 24 2008 11:19 Dec 10, 2009 Jkt 053636 PO 00000 Frm 00142 Fmt 6601 Sfmt 6621 S:\DOCS\53636.TXT JACK PsN: JACKF
139 

12One of the things noted by the DC health department in a lecture given to the Tri-Caucus 

health brain trust was that in most major cities health care providers—particularly primary 

health care providers—have migrated to the suburbs leaving inner city dwellers without reliable 

access to health care. 13See fn 2 and fn 4. Neither the Kaiser Family Foundation nor the California Indian Health 

Board are able to determine the exact reason for the low rates of eligibility given the lack of 

necessary data on enrollment from CMS; however, both note a low rate of enrollment given the 

statistical calculation of probability of eligibility for the population. 14See Urban Indian Health Commission. Invisible Tribes: Urban Indians and Their Health in 

a Changing World. 2007 15 ibid. 

viders across the Indian health service exist at wildly different capacities. While certain communities may require different services, the entire community still requires 

the highest level of services and to be assured that as they move from one provider 

to another that they will receive the services that they require. 

Full integration would mean assured portability of health care regardless of where 

and Indian patient went. Under the proposed changes to the health care system 

under the American Affordable Health Choices Act Indian patients need to be able 

to access Indian health providers without fear of penalty. Furthermore, Indian 

health providers need to be included in any and all preferred provider organizations/ 

networks for public health programs. 

Protections need to be secured for Indian health providers that preserves the 

choice of Indian people to use Indian health providers, protections such as section 

50006 and 50007 of the American Recovery and Reinvestment Act. Moreover, urban 

Indian health providers must be included in any such protections—such as section 

201 of Title II of HR 2708 the Indian Health Care Improvement Act—because when 

urban Indian health providers are not included in these provisions they are unable 

to maintain financial stability which in term threatens the health of Indian patients. 

Question 2. What would you say are the current priorities areas for urban Indian 

health services? 

Answer. Financial stability is the first and foremost priority for urban Indian 

health providers. Unless a program is fully financially secure that provider will always be fighting for survival rather than building upon existing services. 

Fully developing the urban Indian health providers—this priority is less easy to 

concretely describe or even really give definitive dates for conclusion. Ultimately the 

development of the urban Indian health providers will only be completed when all 

urban Indian health providers are able to fully serve all of the needs of the urban 

Indian communities in which it exists—and that all urban Indian communities have 

culturally appropriated health providers. 

Question 3. How would you characterize the options urban Indians have for health 

services if they don’t have access to the Indian Health Service? 

Answer. NCUIH would have to characterize the health services available to urban 

Indians outside the Indian Health Service in one word: poor. Urban Indians are 

often poor, underemployed, and lack health care benefits. Accessing non-Indian 

health providers is difficult for most urban Indians as non-Indian health providers 

are not culturally accessible, often not financially accessible, and in the case of some 

areas are not locationally accessible. 12

Financial and cultural accessibility are the largest barriers to health care outside 

the Indian health provider network. Despite the high rate of poverty and underemployment in Indian communities, the enrollment rates for American Indians and 

Alaska Natives in public health programs such as Medicaid, Medicare, and CHIP 

remain very low. 13 Enrollment rates in private insurance for the urban Indian community are even lower than enrollment in Medicaid, Medicare or CHIP. 14 Without 

the financial means to pay for health care, many urban Indians are forced to delay 

care until they can return to their tribal homes or are forced to seek emergency care 

when they reach medical emergency. 

Cultural inaccessibility is the companion problem to financial inaccessibility as 

urban Indians, even if they are able to afford non-Indian health provider care, are 

often unable to effectively communicate with a non-Indian health care provider leading to higher rates of misdiagnosis and poor care. 15 Moreover, most urban Indians 

will simply refuse to seek care at non-Indian health providers as they feel shut out 

and shut down by those providers. 

Question 4. What solutions are there for improving this situation? 

Answer. Expand the urban Indian health program to serve all cities with significant urban Indian communities and assure the portability of health care. Currently 

the urban Indian health program has 32 programs across the country and accounts 

140 

16 ‘‘Stepwise’’ refers to the process of building knowledge and systems from each step of a proposed methodology so that information builds upon previous developments. 

for only 25 of the major US cities. Urban centers such as Atlanta, New Orleans, 

and Nashville where the Census bureau has reported large Indian communities remain without urban Indian health programs because the urban Indian health program has been struggling to simply survive and has not been able to make the necessary steps to expand the program. The best first step to fully developing the urban 

Indian health program would be a comprehensive needs assessment to determine 

not only where urban Indians are currently without necessary Indian health providers, but to also determine what needs exist in areas with current Indian health 

providers. Plans to build upon the urban Indian health program in a comprehensive, 

sensible manner can begin after this necessary first step is taken. 

American Indians and Alaska Natives need the ability to not only move between 

Indian health providers, but also to move between the Indian health system and the 

general health system. American Indians and Alaska Natives need the ability to 

participate in any public health program as well as be assured that private insurance plans will accept their decision to see Indian health providers. NCUIH strongly 

encourages the Senate Committee on Indian Affairs to endorse and enact Indian 

health care provider protections that assure that American Indian and Alaska Native patients can seek care at Indian health providers without penalty. 

APPENDIX A: METHODOLOGY

NCUIH suggests that a National Needs Assessment on Urban Indian Health 

should begin with the development of an Urban Indian Health Advisory Board to 

guide the project. The Advisory Board would include 13 members representing the 

following: tribal leader, urban Indian leader, urban EPI Center representative, a 

representative from a national, membership based urban Indian health organization, a representative from a national tribal health organization, federal representatives (HHS, IHS, CMS, Census), urban Indian Community member, urban Indian 

elder, community cultural/spiritual leader, and a university partner. 

Data collection will include archival data collection and both qualitative and 

quantitative data collection. 

1.) The Archival Data Review would involve a stepwise process. 16

The first step will be a review of Census data to determine the population of 

American Indians and Alaska Natives in cities across the United States. This review 

will be reported in both real numbers, as well as, percentage of population. Census 

data will also report demographics by city, such as income, educational levels, and 

other household information. 

In collaboration with the advisory board, the entity conducting the study will develop criteria for selecting 70 communities based on Census data for further assessment of archival data. Once selected, archival data will be reviewed for each of the 

selected cities from: 

CMS 

HHS 

Justice 

Education 

This data should provide insight into the current state of health, primarily service 

access and use, for urban Indians living in the respective cities. 

In collaboration with the advisory board, the entity conducting the study will develop criteria for selecting 50 communities for original data collection. These 50 communities will be selected from the 70 that were selected for more in-depth data collection. 

2.) Original Data Collection will involve both qualitative and quantitative data 

from a variety of stakeholders, including: 

Urban Indian Leaders (ED’s Board Members) 

Urban Indian Staff (Direct Care Providers, Ancillary and Support Staff) 

Consumers (Elders, Adults, Youth) 

Urban Indian Community Leaders (Spiritual, Cultural) 

3.) Methodology will include random selection of both consumers of services, as 

well as, those who choose not to use area services (or have limited and/or emergency 

use). 

4.) Specific assessment tools will be developed in consultation with the advisory 

board and include the major constructs identified in the assessment. The constructs 

141 

17The official language states HIT as an IT system that ‘‘allows for comprehensive management of medical information and its secure exchange between health care consumers and providers.’’ To learn more about these systems visit: http://www.hhs.gov/healthit/ 18Svennsson, Pre-Gunnar. eHealth Applications in Health Care management. E-health International journal.2002. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=135526 

will include service availability, access, use and patient outcomes. The broader service system will be examined given that many of the cities identified for assessment 

will be those without current Urban Indian Health Programs. 

5.) The entity conducting the study will work with the selected communities to 

identify and train local evaluators to complete the assessment at the local level. 

These evaluators will either comprise or work with an independent review board. 

Training will be provided by teleconferences, webinars, and teleconferencing. The 

entity conducting the study will use a community-based participatory research 

model with university partnerships at both national and local levels. Community 

evaluators will be compensated for their work. 

Data Protection 

A national Institutional Review Board will provide oversight of the project 

through a university partner. All data will be de-identified at the local level and reported to the entity conducting the study for data analyses and reporting. 

Data Analyses 

All data will be reported in aggregate. Site specific reports will be generated for 

each of the 50 communities selected for original data collection. National aggregated 

reports will be generated for: 

The US Census Archival Data Review 

The 70 sites selected for further archival data review from various federal agency data. 

The 50 sties selected for original data collection 

Data Dissemination 

Site specific reports will be shared with local communities (i.e., Indian organizations, local FQHCs, community advocacy organizations), area tribal communities, 

other stakeholders (such as Indian Health Services Area office), US representative(s) and state legislators. 

National reports will be shared with legislators, Indian Health Services, and Indian organizations. 

APPENDIX B: INFORMATION ON HIT FOR UIHPS

What exactly is Health Information Technology? 

In plain English, it is the use of electronic means to carry out an operation related 

to a health care or to a medical management task. 17 HITs therefore, range from 

purely administrative operations, to task-specific tools for management systems; to 

highly specialized, patient-customized solutions. 

How does it affect me and my Clinic? 

The most common notion about the use of information technologies for health is 

the use of Electronic Health Record (EHR) systems. These systems bring about a 

great deal of benefits to any implementing clinic by making information: quickly 

available, customizable, shareable and searchable in a quick fashion (in addition to 

greatly lowering the costs and making management more efficient). However, there 

are many other e-health-based systems and applications that once implemented can 

help our health programs expand services, improve existing ones and/or leapfrog 

stages of development and catch up with national trends. According to international 

expert, Dr. Per-Gunnar Svennsson, e-Health Care Management can be divided according to their type of user: (a) Consumers informatics, Clinical Informatics and 

Biomedics. 18

A recent report of the Health Information Management Systems Society (HIMSS) 

stresses the potential for HITs to help clinics provide better, more customized and 

efficient care for their patients: ‘‘Today much of the driving clinical need centers 

around efforts at enhancing patient safety, patient satisfaction throughout and the 

demand for quick and accurate access to clinical information in order to provide not 

only quality patient care, but also access real time information for crucial leadership 

142 

19To Learn more about the use and impact of HITs go to: http://www.himss.org/content/ 

files/ClinicalPerspectiveslwhitepaperl052907.pdf 20 Idem. 21For a list of HITs applications please visit http://www.medpac.gov/publications/congressionallreports/June04lch7.pdf 22For more information on the stimulus package: http://www.ehealthinitiative.org/stimulus/ 

education.mspx 

23http://esciencenews.com/articles/2009/01/27/ 

health.information.technologies.associated.with.better.outcomes.lower.costs 

decision making.’’ 19 In general terms, there are three crosscutting themes where 

HITs can improve health care facilities and practitioners’ performance: (a) Administrative tasks, (b) Clinical Support; and (c) infrastructure efficiency. Some examples 

of specific areas where HITs can positively impact performance are: 

• Clinical Decision Making— generating case-specific advice 

• Chronic Care 

• Managing clinical competency 

• Maintaining cost control 

• Monitoring medication orders 

• Avoiding duplicate or unnecessary tests 

• Support of patient safety 

• Clinical research 

• Education of future caregivers 20

As technologies evolve, it is expected that HITs will be embedded in many more 

specific tasks and supportive areas of health care. The more practitioners get used 

to working with e-health systems, the more customized solutions will arise. 21

Why are Urban Indian programs better suited for HITs; and why is this a 

great opportunity for us? 

Traditionally, the government has fostered the use of information technologies as 

great alternatives for getting rural and isolated areas connected to regional and national systems. Under this general notion, urban communities were greatly overlooked, regardless of the fact that cities offered the advantage of services agglomeration—that is, the series of services that can be found in urban settings— such as 

technology providers, cheaper broadband access, skilled personnel, transportation 

options, etc. 

The American Recovery and Reinvestment Act takes a two-pronged approach to 

advanced education relating to the use of health information technology, providing 

support both for health informatics programs and for clinical education programs 

that integrate HITs. 22

How HITs are tools for Sustainable development in my organization 

HITs can foster sustainable development in three main ways: 

a.) Freeing up resources: although the initial investment can be expensive funding and training wise, Information technologies have proven to lower fixed costs 

significantly through significantly faster operations and increased efficiency. 23

These resources can be used for improving or expanding services. 

b.) Knowledge Transfer and Foundation: once the technology has been 

engrained in the health facility, it creates a technological foundation that can 

be used by managers to find customized solutions according to the challenges 

they are facing—which can expand capabilities without much investment. 

c.) Standardized systems: the technology to be provided through this government initiative would be standard for all facilities, which reduces costs as well 

as it eases both management and IT personnel recruitment, etc. 

What if we do not join these efforts? 

The technological and medical gap will increase considerably. As health care providers, UIHPs would not only be missing the opportunity to take advantage of the 

funds and efforts this administration is putting into creating the basis for a sustainable health care system for all (including minorities and the Indian Health Service); 

but we would also be thwarting our own way to get further government funding in 

the future—as federal and local initiatives and grants will most likely require the 

utilization of these systems. Lastly, our population would suffer from not getting the 

improved and expanded health care services that could potentially be provided with 

HIT systems. 

143 

Where can I find more information on HITs? 

There is plenty of literature available depending on the specific topic you would 

like to research on. You may also contact your regional I.H.S Office for information 

on the initiatives to be implemented. Alternatively you may visit the following informational websites: 

Indian Health Services: http://www.ihs.gov/cio/ihimc/ 

e-Health Initiative: http://www.ehealthinitiative.org/ 

U.S. Dept. of Health and Human Services: http://www.hhs.gov/healthit/ 

National Alliance for Health Information Technology: http://www.nahit.org/ 

Human Resources Services Administration: http://www.hrsa.gov/healthit/ 

Center for Information Technology Leadership: http://www.citl.org/ 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. BYRON L. DORGAN TO

PAUL K. CARLTON, JR., M.D. 

Mobile Health Units 

Question 1. How much do the mobile medical units cost? What are the financial 

benefits to using mobile units? 

Answer. The units that are certified by Medicare, licensed in nine states, and recognized as meeting all standards by the Joint Commission are the only ones that 

I would recommend, to do otherwise would be very controversial. They are made in 

St Johnsbury, Vt., by a company called Mobile Medical International. Their basic 

surgical unit cost about $2.5M, dialysis unit cost about $2.1M for four chairs fully 

equipped, dental unit about $2.5M, ICU unit a little more at $2.7M, so the round 

number to use is $2.5M each. 

The financial benefits to using the mobile units are that you can make any clinic 

fully hospital capable simply by pulling one up to the door and hooking it up. This 

would meet the ambulatory surgical needs of most reservations very nicely. I will 

attach a proposal that I gave to the Public Health Service about five years ago, outlining exactly how these could be used to greatest effectiveness. This was for the 

Aberdeen Area Indian Health Service in the Dakotas. Instead of building an Ambulatory Surgical Unit that cost over $10M each and is not used on a regular basis, 

you could pull up one of these mobile surgical units, use it for one day or longer, 

then move on to the next reservation and provide the surgical services to that area. 

This would solve the biggest challenge to the Indian Nation on medical care, the 

requirement for care that is only 0.1 or 0.2 Full Time Equivalents medical practitioner. The demand is not on the reservation to keep full time people assigned, so 

today they must travel for their medical care. Unfortunately, this tells the Indian 

customer that his time is not as important as the medical practitioners—a bad customer relations position. This would allow you to deliver the care on site to the reservation in any specialty that is ambulatory in nature and then move to the next 

reservation. 

The most complex and harder to measure financial benefit is the use of these mobile units in disaster situations. If we have complex medical equipment sitting and 

not being used, it will last as long as it would if it were being used every day. Medical technology progresses so fast that any medical piece of equipment has a half 

life of about 3–4 years max. By using your response equipment everyday for elective 

surgical or conscious sedation care, you are telling the Indian customer that they 

are important and using the medical equipment that you might need in a true national medical disaster. You can then, in such a national disaster, delay that on reservation convenience care and move this same surgical unit down to the site of the 

disaster, set it up in hours, and use it in austere environments while meeting all 

standards of care. The best part is that the Public Health Service would be the 

group that uses this equipment every day, and they are also designated to be the 

disaster response group. So you could avoid the expense of training the Public 

Health service on different equipment, just let them use the equipment that they 

have been using every day. 

That is a double return on investment–no training cost and you are using disaster 

equipment everyday while waiting for that disaster to occur, instead of letting it sit 

and outdate. 

Unless you put both of these two functions together, regular care on site on the 

reservation and disaster response, you have not optimized your investment! Together, they give you the double return! 

Question 2. Are you aware of any mobile units used in Indian Country now? 

144 

Answer. Yes, the Tuba City Reservation has a mobile breast care unit that has 

been in use for several years and been very well received. It provides comprehensive 

screening tests for woman’s health issues. That mobile breast care unit was also 

manufactured by the group in St Johnsbury, Vt, Mobile Medical International. 

Question 3. Is it possible for the units to rotate between Reservations? Do you 

have recommended schedules? Do you see this being a problem during winter 

months in cold, snowy climates like North Dakota? 

Answer. The units should rotate between reservations to optimize their usage. It 

is not a necessity, but to maximize their utility, I would certainly plan to rotate 

them. 

I will attach a schedule that I proposed in 2005 for how such units could be used 

on different Indian Reservations in the Dakotas. You could rotate daily if distances 

are short, or on a weekly basis if distances are long. If the weather is really bad, 

as sometimes occurs in our northern areas, then the mother hospital could just keep 

the units and use them themselves. I have included an architect’s drawing of what 

such a mother facility would look like. These would allow the units to be actually 

indoors for each location, yet the facility could utilize the space for waiting rooms 

or whatever when the mobile units are on the road. 

Question 4. As you know there is very high rate of diabetes in Indian Country, 

could mobile health units be used for dialysis services and other specialty care? Do 

you see a benefit to using these units in Indian Country? 

Answer. The dialysis question is a more difficult one because the typical dialysis 

patient requires every other day treatment (Monday, Wednesday, Friday or Tuesday, Thursday, Saturday). This limits your mobility distances greatly if you use only 

one mobile unit to take care of two different locations. For distances of less than 

one hundred miles, it would be easy to run a morning clinic in one location, fold 

up, drive the next location, set up for an afternoon and next morning dialysis run, 

then come back to the original facility and pick up the afternoon dialysis run. This 

would give you the capability to run two locations easily. You could do four if the 

numbers were small at each location, and the distances were short 

My recommendation for this dialysis concern, because of the frequency of treatment, would be to go component instead of mobile for these. Several hundred of 

these component dialysis clinics have been built around the country at prices less 

expensive than mobile and removes the challenges of moving the dialysis units. 

These are then steel framed structures that the Army Corps of Engineers calls 100 

year construction. The mobile units are great, but will not last 100 years. Such component construction could be on site and fully functional in 3–4 months easily. Two 

such component dialysis facilities would cost the same as one mobile system. 

Other specialty care is certainly something that could be planned for using these 

types of sophisticated mobile medical units. The Mobile Medical group just built a 

mobile endoscopy unit for a VA hospital in West Virginia. Every medical group has 

different requirements for support. Any reasonable outpatient surgery or conscious 

sedation could be accomplished in the mobile unit. Any outpatient oriented medical 

specialty could be set up for full function in such vehicles. The Breast Care unit in 

Tuba City is a perfect example. 

145 


611l1.eps
146 


611l2.eps
147 


611l3.eps
148 


611l4.eps
149 


611l5.eps
150 


611l6.eps
151 

Component Model Construction 

Question 1. Could you explain briefly how component construction was selected for 

the federally funded facility at Creech Air Force Base? 

Answer. The project was funded in FY 2005 at $1.5M. No one gave a bid that 

came close until the pressure really got high from the SECDEF to make our training base at Creech AFB fully mission capable (the people assigned to Creech AFB 

were driving over 60 miles one way for routine medical and dental appointments, 


611l7.eps
152 

which hurt mission capability a lot). That opened the Corps to entertain other potential construction methods. A group called U3I out of San Antonio teamed with 

an 8A company to do this in a component fashion and built it to cost. That meant 

that it was built and fully functional 4.5 months after contract signing but other 

things can be added as needed in the future. A planned better parking lot, nicer 

looking roof, expanded Dental Clinic, etc., are all planned for the future. But the 

fully functional component Clinic and Dental facility were delivered on time and on 

cost in 4.5 months. 

Question 2. Have you engaged other federal agencies on the use of component construction or mobile units? Has there been difficulty moving forward with this type 

of construction at federal agencies? 

Answer. 

A. Other federal agencies have used the mobile units: 

1. The White River Junction VA Medical Center in White River Junction, Vt., 

used two Mobile Surgery Units for an operating room renovation in Jan-Feb 

2008. This saved them money and preserved the function of the medical center 

for surgical workload. 

2. The Miami VA is building the docking stations to bring in six surgical units 

for a two year operating room renovation to begin fall 2009. 

3. The Muskokee VA has started initial procurement to use two Mobile Surgery 

Units for an operating room renovation in late 2009 or early 2010. 

4. The Naval Hospital Pensacola is in process of leasing two surgical vans for 

an operating room renovation in FY 2010. 

5. The New Orleans VA is beginning the process for a major renovation project 

for the operating rooms in 2010 and begun negotiations for use of the surgical 

units. 

6. FEMA used the surgical units to respond to the Hurricane Ike problems in 

Galveston in Sept 2008. The vans were on site and fully functional three days 

after being requested to provide surgical support for the damaged University 

Medical Center. 

7. The countries of Oman, Saudi Arabia, and Iraq have bought these surgical 

units and use them on a regular basis. Oman modified their Police Hospital in 

Muskat to house these surgical units, use them on a regular basis, and make 

them available for disaster response. 

B. Other federal agencies have begun to use the component construction method 

cautiously, mostly in non-medical activities: 

1. Non-Medical Facilities 

a. Fort Bliss has built entire complexes using these component methods. A 

local Texas group from DeSoto, Warrior Group, has gotten several of these large 

contracts that include headquarters buildings, training buildings, and dormitories. 

b. Fort Carson, in Colorado, has used this component method of construction 

and they are very happy with its results. Again, the Warrior Group has gotten 

several of these contracts, building a 3 story Headquarters building and multiple 2 story barracks. 

c. Fort Hood has also used this method of construction and been very happy 

with the results. 

d. The Immigration and Customs Enforcement Agency has purchased a number of these component facilities for their outposts in the unpopulated areas of 

New Mexico and Arizona. A Texas firm from Burleson, Modular Designs have 

done these outposts. 

e. I just toured the Medical Education and Training Complex, METC, in San 

Antonio that was begun under BRAC 2005 to consolidate all enlisted medical 

education and training on one campus on Fort Sam Houston, Tx. It is a hybrid 

facility, about 1⁄3 site built, and 2⁄3 factory built. It is a huge project at 1.9M 

sq. ft. and $500M in total cost, and is on time and on cost right now. It was 

a very short timeline from contract award to completion, which was greatly facilitated by the use of component construction. I have just built a brief on this 

method, which I would be happy to share with the group. The Air Force Civil 

Engineers and the Army Corps of Engineers are monitoring all of these projects 

very closely and are very impressed with their quality and timeliness. Again, 

the Warrior Group has been awarded the component portion of this project. 

153 


611l8.eps
154 

2. Medical Facilities 

a. Clinic at Creech AFB, delivered February 2009. 

b. MRI unit, refurbished at 60% of new cost, to Tuba City Reservation 2009. 

c. MRI unit, refurbished at 60% of new cost, to Brook Army Medical Center, 

August 2008. The above represents one of the greatest savings–you can pull a 

component out totally, refurbish it to new standards in the factory, and save 

the customer about 40% off new cost by this recycling. A group out of Loretto, 


611l9.eps
155 

TN, Modern Renovators, has done the MRI units and showed us the utility of 

recycling these components. 

d. The VA Medical System has built several clinics using component methods 

and they have been very impressed with their quality, cost effectiveness, and 

timeliness. The VA considers this permanent construction and has done both offices and clinics. 


611l10.eps
156 

Question 3. What are the disadvantages to component construction? 

Answer. Overcoming the stereo-type of poor quality! This is not the mobile home 

industry, it is factory building in the same manner and using the same methods 

used on site, only doing it in the comfort and convenience of a factory. The economies of scale, comfort of a factory environment, and repetitive tasks all lead to a 

higher quality of product at a lower cost and in a more timely manner. 

I see no other disadvantage to this method. I have made multiple visits to factories around the country, gone to medical component building construction sites, 

non-medical component construction sites, and seen how this works in detail. I was 

a skeptic about this method until I did my very thorough investigations and am now 

its biggest supporter! 

Question 4. How long do these types of facilities last? 

Answer. The Army Corps of Engineers calls the wood based frame a 40 year structure. That is what the ICE group has bought for their outposts. They call the steel 

frame construction a 100 year structure. That is what the Air Force bought for our 

Clinic at Creech AFB, Nv. These can be specified to any wind strength, any snow 

load, or any seismic activity load—just as any site built building can be. 

Component Construction in Indian Country 

In our Committee’s research of component construction, one of the concerns we 

have developed is the fixed structure of units. Health facilities in Native American 

communities tend to be very culturally appropriate–with Native art, ample light and 

circle-shaped rooms. 

Question 1. How flexible are the component units for these types of features? 

Answer. As flexible as you would like them to be. This is a method of construction, not any different than conventional in its innovations or culturally appropriate 

features. The METC construction site in San Antonio is a perfect example of the 

flexibility of this method. It was designed as a hybrid, part site built and part factory built. It has innovative traditional features and maximizes the efficiency of factory building. Any exterior or interior design can be created using these methods. 

Question 2. Are you aware of any Indian Tribes or groups approaching people like 

yourself about using component construction? 

Answer. No Indian Tribe or group has approached me personally regarding component construction. 

However, the Past President of the Modular Building Industry, Mike Mount, was 

invited with other representatives of the industry out to Albuquerque, NM June 17– 

18, 2009, to discuss this method with the Bureau of Indian Affairs. Since our hearVerDate Nov 24 2008 11:19 Dec 10, 2009 Jkt 053636 PO 00000 Frm 00160 Fmt 6601 Sfmt 6621 S:\DOCS\53636.TXT JACK PsN: JACKF

611l11.eps
157 

ing as on June 11, 2009, that makes me believe that the BIA is listening and doing 

their homework now to move into a new and very exciting future! 

U3 Innovations, the group that did our medical facility at Creech AFB, met with 

the Indian Health Services’ Facility Planning Consultant in Denver this week, July 

6–8, 2009. They discussed the applicability and advantages of modular construction 

for IHS clinics and small hospitals. 

So, the process seems to have started for the application of component construction into Indian new construction of all types. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. JOHN BARRASSO TO

PAUL K. CARLTON, JR., M.D. 

The prefabricated facilities discussed in your testimony have been used for both 

in-patient and out-patient facilities in this country and in Iraq. 

Question. Can you elaborate on the potential life-span and maintenance costs of 

these facilities, particularly in harsh climates such as in Wyoming or the Dakotas? 

Answer. The Army Corps of Engineers refers to these facilities in year expected 

life span. For the wooden framed component construction buildings, they call them 

40 year life structures. For the steel framed component construction buildings, they 

call them 100 year life structures. 

When the state of California directed that 10% of their classrooms be built with 

high end modular construction 20 years ago they never expected these buildings to 

last so long. When they went in to do renovation/modernization to the schools they 

found that the modular buildings were in better shape and required less upgrades 

than the traditional site built structures. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. TOM UDALL TO

PAUL K. CARLTON, JR., M.D. 

Question. Ideally we will construct facilities that meet the needs of Indian people 

at a cost that meets the needs of the government. You discussed modularity being 

the most efficient way to lower construction costs of Indian health facilities. How 

do you see IHS implementing this proposal? 

Answer. In a perfect world, I would recommend that several pilot programs be 

started to prove the concept in many different areas of the Indian Health Service 

and see if we have missed anything in our thinking. 

However, your needs are great and the facilities are old, so I would ask your IHS/ 

BIA architectural and engineering staff to go to several of the facilities that I have 

described, see the quality, see the innovation, see the timeliness, and recognize that 

there is nothing experimental about any of this. That could be done in a matter of 

weeks and may have even already started with the meetings in Albuquerque and 

Denver. Then I would plan a significant percentage of your building program for the 

next several years to be component in its method of construction. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. BYRON L. DORGAN TO

VALERIE DAVIDSON

Veterans Affairs 

Question 1. What recommendations do you have regarding the Memorandum of 

Agreement (MOA) between the Indian Health Service (IHS) and Veteran’s Administration (VA) to address the issue raised in your testimony? 

Answer. American Indian and Alaska Native (AI/AN) veterans frequently come 

from very rural and remote locations within the United States. There are few, if 

any, Veterans’ Administration facilities in these locations. As a result AI/AN veterans must travel long distances to use their veteran’s health benefits. Because this 

is impossible for many, instead they use the IHS or tribal health program that is 

nearer to them. Under current VA practice, no reimbursement is provided to the Indian health program. As I stated in my oral testimony, a VA clinical encounter rate 

needs to be established so that Indian health facilities can bill the VA for care provided to VA-eligible individuals. The VA should be directed to work with IHS to develop the VA clinical encounter rate. We believe there is no legal obstacle to implementing the VA–IHS MOA. The primary holdup in implementing the MOA seems 

to be resistance from an entrenched bureaucracy within the VA that is resistant to 

change. 

Question 2. Describe any legislative fixes that may be required to serve this 

unique population? 

158 

Answer. Related to the answer to question one, there would appear to flexibility 

under current law to currently serve this population, however unfortunately there 

has been little action to take advantage of that authority. Sections 406, which 

amends section 816 of current law, and 407 of the recently introduced Indian Health 

Care Improvement Act Amendments of 2009 (IHCIA), H.R. 2708, would address this 

issue by granting explicit authority for reimbursement from VA to IHS, and viceversa, for services rendered to dual eligible American Indian and Alaska Native (AI/ 

AN) veterans. This would allow these individuals to be served by Indian health providers when VA providers are not available and for the Indian health providers to 

be reimbursed for providing services for which VA is obligated to provide. This 

would lessen the unfair burden on the significantly underfunded Indian health system, provide better care to these individuals and allow more care to be provided to 

other AI/AN beneficiaries with additional resources provided by VA reimbursement. 

Title VI of the Indian Self-Determination and Education Assistance Act 

Question 1. You reference a 2003 HHS report supporting Title VI which proposed 

11 programs that could be accessed to begin expansion of Self-Governance. Is this 

report still applicable 6 years later? 

Answer. The report is even more applicable today. Self-Governance began in 2000, 

so the data for the 2003 report was collected in the early years of Self-Governance. 

Even then, the data and report showed that tribes were overwhelmingly good stewards of federal funds and programs and recommended expansion of Self-Governance. 

Now six years later these findings have been proven valid. Self-Governance is one 

of the few federal programs for Indian country that has been an unequivocal success. Tribes have countless stories of how Self-Governance has allowed them to succeed in meeting the unique needs of their communities and provide better and more 

care to their members. Expanding Self-Governance to the 11 other HHS agencies 

and beyond would greatly enhance the success of Self-Governance. It would eliminate administrative burdens and costs by lessening the number of different reporting requirements on tribes and decrease the confusion and complexity of tribes having to follow many different rules, policies and regulations when utilizing funds 

from these many separate agencies. 

As I briefly mentioned in my oral testimony, the health of AI/ANs is affected by 

many factors, economics and education being among the most significant. Expanding Self-Governance to Temporary Assistance for Needy Families and Head Start 

programs would allow tribes to address employment and education issues that affect 

the health of AI/ANs. 

Question 2. The ISDEAA is already law, in your opinion what can Congress do 

to make sure Title VI is implemented? 

Answer. The genius and challenge of self-determination and self-governance are 

that they require the ‘‘bureaucratically unthinkable’’; they require federal agencies 

to transfer funding and authority upon demand to the Tribes they serve. The tendency toward bureaucratic entrenchment is as predictable as it is unfortunate. The 

legislative history of the Indian Self-Determination and Education Assistance Act is 

riddled with legislative ‘‘fixes’’ of various administrative interpretations that were 

unworkable and clearly at odds with congressional intent and, often, contrary to the 

plain language of the statute. A number of the proposed provisions in the IHCIA 

and the implementation of Title VI follow suit. 

In order for Title VI to be successfully implemented at this point, Congress would 

need to pass legislation granted authority to go forward with a demonstration 

project. We believe that there is ample data to support that Congress should indeed 

authorize the Title VI demonstration project. The 2003 HHS report was supportive 

of the ability of tribes to run HHS programs. The Senate Committee on Indian Affairs has already drafted the legislation and held hearings on this issue and favorably reported out the draft bill to the full Senate in 2004. That bill, or a similar 

one, should be revived and reintroduced in Congress. 

Question 3. Has Title IV of the ISDEAA been successfully implemented within the 

Department of Interior (DOI)? Please provide some examples of why or why not? 

Answer. Although we do not have a contract with DOI for any programs under 

Title IV, I can speak to the issues that other tribes have voiced regarding Title IV. 

At past Congressional hearings tribes have voiced concerns that Title IV is outdated 

and that Title V has been vastly superior in allowing tribes greater flexibility in operating HHS programs. Many tribes have voiced their desire that DOI programs be 

given analogous authority to Title V. 

Level II Trauma Center in Alaska 

Question 1. Does this medical center serve non-IHS beneficiaries? 

159 

Answer. The Alaska Native Medical Center (ANMC) provides services to a small 

proportion of non-IHS beneficiaries under specific circumstances. Many of these 

cases involve individuals who need immediate emergency medical services because 

they have been seriously injured. ANMC, as the only level II trauma center in Alaska, is sometimes the only facility in Alaska with the capacity to provide the care 

they need. As a Medicare provider, ANMC must comply with the Emergency Medical Treatment and Labor Act by providing emergency medical screening and stabilization services within its capability and capacity to all individuals who come to 

the emergency room. 

ANMC also provides services to non-IHS beneficiaries in other limited circumstances under the auspices of the Alaska Federal Health Care Partnership 

agreement and the authority of several statutes and regulations, such as the Public 

Health Services Act and the Indian Health Care Improvement Act. For example, 

ANMC provides pre-natal care and labor and delivery services for non-Indian 

women who are pregnant with the child of an AI/AN. Similarly, ANMC may treat 

an infectious disease of a member of a Native household or community to help safeguard the health of beneficiaries. 

Question 2. What protections does the facility have against malpractice claims? 

Answer. Several provisions of federal law combine to protect ANMC from the financial liability for most malpractice claims (primarily 25 USC § 450f(d), 25 USC 

§ 1680c, 25 USC § 1638c). Because these laws provide a remedy to individuals 

through the Federal Tort Claims Act, these provisions are sometimes referred to as 

‘‘FTCA protection’’ or ‘‘FTCA coverage.’’ 

These laws protect ANMC from malpractice claims brought against ANMC when 

the activity the led to the claim is related to fulfilling ANTHC’s and Southcentral 

Foundation’s (SCF) compact and funding agreements with HHS/IHS, are described 

in the resolutions ANTHC and SCF have adopted pursuant to section 813 of the Indian Health Care Improvement Act (25 USC § 1680c), or when the claim is otherwise covered by law. As a practical matter, these claims are ‘‘deemed’’ to be claims 

against the federal government. The Department of Justice defends the claims. Settlements and judgments are paid by the Treasury. Claims are subject to the limitations and protections of the Federal Tort Claims Act. Employees of ANTHC and 

SCF are similarly protected when they act within the scope of their employment. 

(The Federally Funded Health Care Assistance Act provides somewhat similar protection to ‘‘330 Community Health Clinics,’’ which tribes and tribal organizations 

sometimes combine with ISDEAA clinics, resulting in potentially overlapping protection and considerable confusion due to the differences in protection. Section 314 of 

P.L. 101–512 provides similar protection for other types of claims.) 

Although we think that virtually all ANMC services should be within the ambit 

of the so-called FTCA protection, both ANTHC and SCF purchase supplemental 

malpractice insurance due to concerns about some ambiguities in existing law and, 

more importantly, due to our lack of confidence in how the HHS Office of General 

Counsel and the DOJ will interpret the laws in specific cases. 

These laws also create an inadvertent gap in protection for peer review activities 

that almost all other providers have, including providers for the Veteran’s Administration and the Department of Defense. Section 814 of the proposed IHCIA amendments would fill this inadvertent gap. However, neither these laws nor section 814 

in H.R. 2708, shield physicians and other providers from being reported to licensing 

authorities or from the National Practitioner Data Bank. 

Fee for Service Model 

You state that using a fee-for-service model would undermine the IHS/tribal system because it ignores preventive, community, and environmental health, etc. 

Question 1. What kinds of billing mechanisms would you recommend that support 

the IHS/tribal system? 

Answer. IHS (and the tribal programs) rely on both appropriated funds and revenue from third-party payors, which include Medicaid, Medicare, private insurance 

and other payors. The latter are generated only for direct health care services. As 

I noted in my written testimony before the Committee, even with both sources of 

funding, Indian health programs receive less than 60 percent of the funding necessary to provide services equivalent to those provided under the Federal Employee 

Health Benefit Program. 

For direct medical services, the current reimbursement model used by Medicaid 

and Medicare that provides for an encounter rate is a very efficient reimbursement 

method. Most Indian health programs still lack the health information technology 

infrastructure and financial capability that is necessary to assure that Indian health 

programs have the same financial and billing infrastructure of private facilities. 

Thus, encounter rates are preferred. 

160 

Other critical components of Indian health programs, such as preventive, community, and environmental health, are funded only with direct appropriations, supplemented somewhat by grants when they are available. These program components 

are essential to improvement in health status, but are not addressed in any billing 

mechanism. My testimony regarding the limitations of fee-for-service was intended 

to highlight the fact that the Indian health system is far more expansive in its scope 

than of a typical health provider and that fee-for-service reimbursement does not 

address the wrap-around elements of our programs, which are critical to our mission 

and to achieving the goals in the Indian Health Care Improvement Act and the 

goals trying to be achieved under health care reform. No fee-for-service payment of 

which we are aware addresses these critical services. Nor, is fee-for-service a viable 

model for funding such services since they are generally community-based services 

in which frequently the population as a whole is benefiting. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. JOHN BARRASSO TO

VALERIE DAVIDSON

Federal Tort Claims Act Coverage 

Under limited circumstances, non-Indian patients may receive health care at tribal health facilities. The Committee has received testimony suggesting that the current Federal Tort Claims Act coverage for tribal programs should be expanded to 

include tribal services to these non-Indian patients. 

Question 1. Please elaborate on what tribes currently have to do to provide services to non-Indians that would be covered by the Federal Tort Claims Act? 

Answer. In general, tribes and tribal organizations could provide services to nonIndians that would be theoretically covered by the ISDEAA/FTCA protection in one 

of three ways: (1) negotiate with the IHS for the inclusion of those services for that 

population in their funding agreements; (2) provide the services in accordance with 

other legal authority; or (3) adopt a tribal resolution in accordance with section 813 

of the Indian Health Care Improvement Act (25 USC 1680c(b)(1)(B)). 

Section 813 includes several significant requirements for the governing body’s resolution. The governing body must consider the extent to which other services are 

available to the non-IHS beneficiaries and whether extending services to them 

would result in the denial or diminution of services to IHS beneficiaries. Although 

it appears to be contrary to the statute, the IHS and one administrative tribunal 

have taken the position that the resolution is not effective for the purposes of 

ISDEAA/FTCA protection unless IHS concurs with these findings and agrees to incorporate the resolution into the individual funding agreements of each tribe/tribal 

organization. 

The IHS typically rejects tribal resolutions regarding services to non-beneficiaries 

unless it concludes there are no other providers of the particular service anywhere 

in the area. Some of the circumstances in which tribes concluded services to nonbeneficiaries should be offered and IHS rejected the resolution, include: 

• locations in which elders who rely on Medicare or children with Medicaid coverage cannot find a non-Indian provider who will accept new Medicare or Medicaid patients; 

• communities in which there are only part-time practitioners who have limited 

their practices leaving many (particularly those with only Medicare or Medicaid 

coverage) without access to a primary care or dental provider; 

• communities in which some services are available only through the emergency 

room (for instance, IHS rejected a resolution authorizing services to non-beneficiaries in a community-based health program for homeless individuals that 

would have served both AI/AN and non-Indian homeless people even though the 

program was not viable unless both were served and the only access to health 

care for the non-AI/ANs was in the hospital emergency room and the AI/ANs 

were much less likely to seek care if it were not offered in this kind of alternative setting.) 

Also, the IHS/HHS and DOJ have taken the position that ISDEAA/FTCA protection cannot be determined in advance, but must be decided on a case-by-case basis. 

Their case-by-case determinations (together with discussions in other contexts) demonstrate a marked tendency to apply the protection as narrowly as possible (and 

often more narrowly than could be justified by any plain language interpretation of 

the law). In a recent (non-malpractice case), we were very disturbed to see what appeared to be a form letter automatically denying protection, despite language in our 

funding agreement clearly describing the activity that led to the lawsuit and despite 

161 

signed agreements with the IHS approving those very projects. Although the correct 

determination was eventually made, the practice is similar to that of insurance companies that automatically deny everything in hopes of discouraging people from benefiting from assistance to which they are entitled. 

At the same time, the DOJ tries to take advantage of any insurance policy that 

a tribe/tribal organization may have purchased, even if the policy was intended just 

to fill the gaps and provide a backup plan. 

As a practical matter, there is some ambiguity and vagueness in existing law providing ISDEAA/FTCA protection, partially because it results from a series of piecemeal enactments. Unfortunately, the DOJ, HHS and IHS have expanded considerably the uncertainty associated with ISDEAA/FTCA protection through their unreasonably stingy interpretations and various practices that undermine the value of 

that protection. 

Question 2. Do tribes obtain medical malpractice coverage and, if so, what is the 

cost of that coverage? 

Answer. There are a wide range of practices with respect to purchasing malpractice insurance due to the practical uncertainties described above together with 

the great variety of circumstances among self-determination contractors and selfgovernance compactors. Some tribes and tribal organizations rely entirely on the 

protections provided through ISDEAA and the FTCA, while others purchase a full 

spectrum of insurance. Some, like ANTHC, try to purchase policies specifically designed to fill the ‘‘gaps’’ in ISDEAA/FTCA protection rather than paying the full 

price for policies that provide duplicative coverage. 

The price of ‘‘gap’’ policies can vary considerably, depending on what the limits 

and deductibles are, how well the insurance brokers and carriers understand the 

ISDEAA/FTCA protection, the negotiating skill of the tribe/tribal organization, and 

whether the insurance is intended to cover other things that are clearly not within 

the ambit of the ISDEAA/FTCA protection. For ANTHC, which co-manages the 

Alaska Native Medical Center with the SouthCentral Foundation (SCF), a supplemental ‘‘gap’’ policy for malpractice related to inpatient hospital care, outpatient 

specialty services, emergency care, specialty field visits to small Alaskan communities, etc. is about 25–30% of the cost of a full policy. (Gap insurance for primary 

care, behavior health and other programs administered by SCF is purchased separately.) While this price is much improved over prior years, it is still too much from 

our vantage point. As noted below, this is a cost that is allocated to the Secretary 

by law. Also, ANTHC is paying 25–30% of the cost of a full malpractice policy (even 

though there is little, if any, activity that we think should not be covered by the 

ISDEAA/FTCA protection) rather than 100% of a policy for those few things that 

might genuinely be unprotected. Without more decisive answers about what exactly 

is or is not covered, however, actuarial determinations are elusive. 

We understand that some insurers provide little, if any credit for the ISDEAA/ 

FTCA protection to other tribes/tribal organizations, which pay considerably more 

for malpractice insurance. 

This is both the cause and effect of a practice of the DOJ that has injected another element of uncertainty that artificially elevates the price of supplemental coverage as well. It often demands to be treated as an implied insured so that the supplemental gap policy essentially becomes the primary policy for a wide range of 

risks that the tribe and insurer specifically intended to exclude. Since it is difficult 

to predict when this might happen, the price is adjusted upward to compensate the 

insurer for this risk. 

While we agree with the DOJ and courts that the insurance companies should not 

be permitted to enjoy windfall profits under these circumstances, the better policy 

would be to disgorge the profits in favor of the tribes and tribal organizations that 

have been taken advantage or to simply enforce existing law which requires the Secretary of Health and Human Services to purchase liability insurance for tribes and 

tribal organizations, taking into account the extent of ISDEAA/FTCA protection— 

that is to fill the gaps. (25 USC 450f(c).) To the best of our knowledge, the Secretary 

has neither purchased such insurance nor issued any determination no such insurance is needed since there are no real gaps in the protection. The latter would be 

especially helpful, assuming courts would be required to adhere to the determination. In any case, the cost of procuring insurance for each individual tribal program 

is likely to be significantly more expensive than pooling the cost at a national level. 

Title VI Expansion 

Your written testimony recommends expanding the self-governance program to 

other programs within the Department of Health and Human Services such as Head 

Start. 

162 

Question 1. Please explain how expanding self-governance principles to these 

other programs will ensure accountability, particularly that the funds will be used 

in accordance with governing statutes and purposes. 

Answer. The 2003 HHS report found that self-governance programs are good 

stewards of federal funds and exhibited high degrees of accountability for federal 

fund and complied with the use of the funds for which they were intended. Title 

VI would merely be an expansion of Title V authorities to other HHS programs outside of IHS. The auditing standards and reporting requirements would still be the 

same as Title V for any programs compacted for under Title VI and should have 

the same high degree of accountability and effectiveness that tribes have shown 

under Title V IHS programs. Title VI is not about eliminating accountability for federal funds provided to tribes, it is about eliminating bureaucratic red-tape and administrative burdens that tribes are encumbered with by having to deal with a multitude of reporting requirements from the different HHS agencies. It is also about 

respecting the tribe’s priorities within its own tribal community. Title VI would 

eliminate this problem by only requiring tribes to meet one reporting and accountability requirement for all the programs—one that has shown to be effective in providing accountability through Title V. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. TOM UDALL TO

VALERIE DAVIDSON

Question 1. All of us have habits that promote our health and habits that compromise our health. I imagine that you have encountered obstacles in your efforts 

to motivate tribal members to take charge of their health and to motivate tribal 

leaders to provide adequate health services. What can we learn from your experience that would help us improve Indian health? 

Answer. Indian health programs are unique among providers in their focus on 

prevention and community health. Unfortunately, funding for health promotion and 

disease prevention is inadequate, particularly as the health challenges have 

changed from those that can be addressed with immunizations to those that require 

behavioral changes. Passage of H.R. 2708, the Indian Health Care Improvement Act 

Amendments of 2009, is important as it broadens the definitions of health promotion and disease prevention to bring them up-to-date. The integration of behavioral health in Title VII is also important. Many tribal health programs have begun 

this process, and some have even begun to fully integrate behavioral health assessment and treatment into their primary health programs. This is important to earlier 

identification of mental health and substance use disorders that trigger or confound 

other health problems. 

As I alluded to in my oral testimony, improving Indian health is a complex issue 

and to successfully address the issue a multitude of approaches must be taken. This 

is why the authorization of the demonstration project of Title VI of the Indian 

Health Care Improvement Act is so important. The 2003 HHS report, Tribal SelfGovernance Demonstration Feasibility Study, concluded that it was feasible and desirable to extend tribal self-governance to the Department of Health and Human 

Services (HHS) programs outside of the Indian Health Service. The report recommended 11 HHS programs that could be included to begin with. The eleven included programs such as Temporary Assistance for Needy Families and Head Start 

that would allow tribes to better address economic and education issues in their 

communities that have been shown to have a significant impact on the health of 

AI/AN communities. 

Question 2. I am aware that one element of improving Indian health services is 

to increase the number of skilled Indian health care providers. What specific suggestions could you offer this Committee to inspire more American Indians and Alaska 

Natives (AI/ANs) to succeed in school and become doctors, dentists, nurses, and 

other health care providers on reservations or in the urban areas where other Indians live? 

Answer. First, more mid-level health providers, such as a community and behavioral health aides, are needed to provide services in Indian country. Obtaining education and training to be certified as a community or behavioral health aide lowers 

the burden for many Native American members of these communities who may 

want to provide health services to their community but do not want to be away from 

their communities for years and years to obtain the training necessary to become 

a physician or psychologist. 

Second, for those AI/ANs that do wish to pursue higher education and training 

outside of their communities, there needs to be proper and adequate support. This 

can be accomplished by expanding the Indian health professions program by allowVerDate Nov 24 2008 11:19 Dec 10, 2009 Jkt 053636 PO 00000 Frm 00166 Fmt 6601 Sfmt 6621 S:\DOCS\53636.TXT JACK PsN: JACKF
163 

ing more scholarships for AI/AN students pursuing health professions. Additionally, 

the waiver of taxation on scholarship and loan repayments can be waived as it is 

for the Veteran’s Administration. Providing health services to AI/AN people is not 

a lucrative career, health professionals work for the Indian health system because 

they believe in what they are doing and want to make a positive contribution to the 

health of AI/AN and their communities. Whatever opportunity there is to allow AI/ 

AN students and providers to accomplish this should be pursued. 

Question 3. Providing care for Indian children with disabilities is a major need. 

I know that the IHS has a contract with three universities (Utah State, Northern 

Arizona University and New Mexico State University) to serve Indian children with 

special needs in the Southwest region of the country. These universities are looking 

for funding to expand tele-behavioral health to serve rural, geographically isolated 

communities in New Mexico and Arizona. Can you comment on successful strategies 

that provide health promotion and health services to rural areas such as in my sate 

of New Mexico? 

Answer. As I stated at the hearing, Alaska has a long history and advanced model 

for providing health services to rural areas. The model that has worked for us in 

Alaska for providing care in rural communities is a combination of having mid-level 

health providers in the rural communities who are able to consult with higher-level 

health providers through a telehealth network. 

By necessity the Community Health Aide (CHA) program was born in the 1950s 

to address the TB outbreak in remote Alaska villages, where CHAs were needed to 

provide vaccinations. Through ingenuity this program has been improved and expanded. First by establishing a uniform and accepted certification standard for 

CHAs, and later by expanding the program to include Dental Health Aides and Behavioral Health Aides. 

The small rural villages in Alaska do not have the population base to support 

higher level providers, such as physicians or psychiatrists, to be in the communities 

full-time. However, they can support health professionals that are mid-level providers. These mid-level providers still have training and expertise and are more 

willing to work in rural communities at salaries that smaller communities can support. Additionally, while people from these small communities may neither have the 

desire or opportunity to obtain a medical or dental degree and study for 10 years 

outside of their communities, they can obtain training and certifications as CHA, 

DHAT and BHAs without having to leave home for too long and with much less financial burden. This allows them to return to their communities to provide services 

and allows for a steady and trusted presence in those communities. 

Telehealth is an important support for the modern CHA program because it allows higher-level providers located in more populated areas to actually see how various symptoms present rather than relying exclusively on verbal descriptions from 

CHAs in difficult cases. This helps to extend their expertise out into the rural areas 

in cases that would otherwise require patients to travel to a regional hub or Anchorage for care. ANTHC has developed special AFHCAN telehealth carts and software 

that provide CHAs with the tools they need to capture photos, images and other 

data that often allows the higher-level providers to evaluate and direct the treatment of patients at great distances without the high cost or time involved in travel. 

Æ