July 14, 2005
I am honored to testify before you today on the important issue of reauthorization of the Indian Health Care Improvement Act (IHCIA). Accompanying me today are Robert McSwain, Deputy Director, Craig Vanderwagen, M.D., Acting Chief Medical Officer, and Gary Hartz, Director, Office of Environmental Health and Engineering.
This landmark legislation forms the backbone of the system through which Federal health programs serve American Indians/Alaska Natives and encourages participation of eligible American Indian/Alaska Natives in these and other programs.
The IHS has the responsibility for the delivery of health services to more than 1.8 million Federally recognized American Indians/Alaska Natives through a system of IHS, tribal, and urban (I/T/U) health programs based on judicial decisions and statutes. The mission of the agency is to raise the physical, mental, social, and spiritual health of American Indian/Alaska Natives to the highest level, in partnership with the population we serve. The agency goal is to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to the service population. Our foundation is to uphold the Federal government's responsibility to promote healthy American Indian and Alaska Native people, communities, and cultures and to honor and protect the inherent sovereign rights of Tribes.
Two major statutes are at the core of the Federal government's responsibility for meeting the health needs of American Indians/Alaska Natives: The Snyder Act of 1921, P.L.67 85, and the Indian Health Care Improvement Act (IHCIA), P.L. 94 437, as amended. The Snyder Act authorized regular appropriations for "the relief of distress and conservation of health" of American Indians/Alaska Natives. The IHCIA was enacted "to implement the Federal responsibility for the care and education of the Indian people by improving the services and facilities of Federal Indian health programs and encouraging maximum participation of Indians in such programs." Like the Snyder Act, the IHCIA provides the authority for the Federal government programs that deliver health services to Indian people, but it also provides additional guidance in several areas. The IHCIA contains specific language addressing the recruitment and retention of health professionals serving Indian communities; the provision of health services; the construction, replacement, and repair of health care facilities; access to health services; and, the provision of health services for urban Indian people.
The Department under this Administration’s leadership reactivated the Intradepartmental Council on Native American Affairs (ICNAA) to provide for a consistent HHS policy when working with the more than 560 Federally recognized Tribes. This Council gives the IHS Director a highly visible role within the Department on Indian policy where he serves as vice chairperson of the Council.
The Department has also recently completed work ushering through a revised HHS Tribal consultation policy and involving Tribal leaders in the process. This new policy further emphasizes the unique government-to-government relationship between Indian Tribes and the Federal government and assists in improving services to the Indian community through better communications. Consultation may take place at many different levels. To ensure the active participation of Tribes in the development of its budget request, an HHS-wide budget consultation session is held annually. This meeting provides Tribes with an opportunity to meet directly with leadership from all Department agencies and identify their priorities for upcoming program requests. Last year, Tribes identified inflation and population growth as their top budget priorities and IHS’s FY 2006 budget request included an increase of $80 million for these items. Both the House and the Senate have included these increases in FY 2006 appropriations action, and we appreciate their efforts in this regard.
Through the Centers for Medicare & Medicaid Services (CMS), a Technical Tribal Advisory Group was established which provides Tribes with a vehicle for communicating concerns and comments to CMS on Medicare, Medicaid and SCHIP policies impacting their members. And, the IHS has been vigilant about improving outcomes of Indian children and families with diabetes by increasing education and physical activity programs aimed at preventing and addressing the needs of those susceptible to, or struggling with, this potentially disabling disease.
It is clear the Department has not been a passive observer of the health needs of eligible American Indians/Alaska Natives. Yet, we recognize that health disparities among this population do exist and are among some of the highest in the Nation for certain diseases (e.g., alcoholism, tuberculosis, diabetes, and injuries), and that improvements in access to IHS and other Federal and private sector programs will result in improved health status for Indian people.
The IHCIA was enacted to provide basic primary and preventive services in recognition of the Federal government’s unique relationship with members of Federally recognized Tribes. Members of Federally recognized Tribes are also eligible for other Federal health programs (such as Medicare, Medicaid and SCHIP), on the same basis as other Americans, and many also receive health care through employer-sponsored or other healthcare coverage.
It is within the context of current law and programs, that we turn out attention to S.1057.
The Department brings a keen awareness of the health care needs of Indian country and is supportive of reauthorization of the IHCIA. We support provisions that increase the flexibility of the Department to work with Tribes, to increase the availability of health care, including new approaches to delivering care, and to expand the range of options of health services available to eligible American Indians and Alaska Natives. Accordingly, I commend Congress for including in S. 1057 various changes that respond to concerns raised in previous proposals. Some of these changes go a long way toward improving the ability of the Secretary to effectively manage the program within current budgetary resources.
Moreover, I would like to note our particular interest in other provisions of S. 1057.
In the area of behavioral health, title VII of S. 1057 provides for the needs of Indian women and youth and expands behavioral health services to include a much needed child sexual abuse and prevention treatment program. The Department supports this effort, but opposes language in Sections 704, 706, 711(b) and 712 that requires the establishment or expansion of specific additional services. The Department should be given the flexibility to provide for all Behavioral Health Programs in a manner that supports the local control and priorities of Tribes, and to address their specific needs within IHS overall budgetary levels.
Provisions Related to Medicare and Medicaid
Indian Health Professions Scholarships
New section 104(a) (2) proposes to allocate the program funding by formula to the twelve IHS areas. If allocation by formula is authorized Indian, students will not be given an opportunity to apply for a scholarship if their area does not receive adequate allocation and if their profession is not considered a priority in their area e.g., dental hygienist, physical therapist, medical technology. This would even impact a medical student who has identified general surgery or general psychiatry as a specialty. They will not receive the scholarship, because it is not a priority or there are no positions available for these disciplines/specialties.
We are concerned that the large areas will receive the greatest amount of appropriated funds, leaving the smaller areas with amounts sufficient to fund only a small portion of their health professional needs. If an area chooses to allocate the funds among the tribes within the area, funds available to many will be insufficient to support even one student.
We recommend retaining the provision in current law which would maintain the national focus of the scholarship program to more appropriately meet the health professions needs of Indian country.
Diabetes Evaluation and Coordination
We recommend that the requirement to employ at least one diabetes control officer in each of the 12 areas, as well as the requirement to evaluate the effectiveness of services provided through model diabetes projects established under this section, be retained.
Health Care Facilities
Health Care Facilities Needs Assessment & Report
We recommend the deletion of the reference to the Government Accountability Office undertaking the report because it would be redundant of and a setback for IHS’s current efforts to develop an improved facilities construction methodology. This would allow the IHS to complete its new priority construction methodology which will address the future federal and tribal health facility needs.
Retroactive funding of Joint Venture Construction Projects
Sanitation Facilities Deficiency Definitions
In addition, the definition for deficiency level V and deficiency level IV, though phrased differently, have essentially the same meaning. Level IV should refer to an individual home or community lacking either water or wastewater facilities, whereas, level V should refer to an individual home or community lacking both water and wastewater facilities.
We recommend retaining current law as more appropriate for distinguishing the various levels of deficiencies which determine the allocation of existing resources.
Threshold Criteria for Small Ambulatory Program
New Negotiated Rulemaking and Consultation Requirements
We have other objections to S.1057, including, for example: new requirements using “shall” instead of “may” in provisions that will create budget pressures on current program activity; expansion of the scope of Federal Torts Claim Coverage for services provided to otherwise ineligible non-Indians; expansion of authorities for Urban Indian Organizations; elimination of the term “grant” and replacement with the term “funding”; and new provisions that contemplate the Secretary exercising authority through the Service, Tribes and Tribal Organizations which is not tied to agreements entered into under the Indian Self-Determination and Education Assistance Act (ISDEAA). The Administration may also have additional views on this legislation.
I reiterate our commitment to working with you to reauthorize of the Indian Health Care Improvement Act, and the strengthening of Indian health care programs. I hope to work with this Committee and other Committees of the Congress, the National Tribal Steering Committee, and other representatives of Indian country to develop a bill that all stakeholders in these important programs can support. Again, I appreciate the opportunity to appear before you today to discuss this important legislative proposal. I will be pleased to try to answer any questions that you may have. Thank you.
Last Revised: August 8, 2005