Mr. Chairman and Members of the Committee:
Good morning. I am Dr. Michael H. Trujillo from Laguna Pueblo, New Mexico.
I am the Director of the Indian Health Service. Accompanying me today are Mr.
Michel E. Lincoln, Deputy Director; Kermit Smith, D.O., Chief Medical Officer;
and Mr. Gary J. Hartz, Director, Facilities and Environmental Engineering. We
are pleased to be here today to discuss the President's fiscal year (FY) 1999 budget
request for programs funded by the Indian Health Service.
Mr. Chairman, this April will mark four years since your Committee and I, as the
Director of the Indian Health Service, began working to improve the health status
of American Indian and Alaska Native people. The health of Indian people is the
result of many factors, the delivery of health care is one of those aspects, and I
want to acknowledge the Committee's positive influence over other programs that
affect Indian people. Your influence has greatly assisted our agency, and our tribal
and urban health partners to address many of the health care needs of Indian
I consider our success to be the result of the Committee's support of the Indian
Health Service, the considerable dedications of those who work for us to ensure we
are able to address the needs of Indian people through our decisions, and also
because we consult with and listen to the people we serve. Our decisions reflect
our commitment to the legacy that the treaties between the United States
Government and Tribal Nations began in 1784. I remain committed to working
with the Committee to address any questions you and other committee members
may have regarding the President's FY 1999 budget request for the Indian Health
The provision of Federal health services to American Indians and Alaska Natives is
based upon a special government-to-government relationship between Indian tribes
and the United States, which has been reaffirmed throughout the history of this
Nation. One example of this special recognition was made by President Lincoln in
1863. He presented to the then governors of the pueblo tribes of New Mexico, a
silver-headed cane in recognition of their political and legal right to land and
self-government. Today these canes are kept by the governors of each of those pueblos
as a symbol of their authority during their terms of office. The relationship has been
repeatedly reaffirmed by all three branches of this Nation's government. In 1997, the
President issued an Executive Memorandum directing all Federal Departments and
Agencies to implement policies and procedures for consulting with Indian Tribes on
matters that effect Indian people.
American Indians and Alaska Natives believe strongly in the treaties our forefathers
signed with the United States Government and in the status of their tribes as
sovereign nations. Many of our ancestors lost their lives forging this
government-to-government relationship. They gave up land, water rights, mineral rights, and
forests in exchange for, among other things, health care. I believe it is our solemn
responsibility to provide the best health care this Nation has to offer as we carry out
the commitment the United States is honor bound to keep.
The Indian Health Service provides a comprehensive health system in partnership
with Indian people to develop and manage programs to meet their health needs. In
addition, the Indian Health Service also acts as the principal federal health advocate
for Indian people. Our goal is to raise the health status of American Indians and
Alaska Natives to the highest level possible.
We have made much progress over the years. Infant mortality rates, maternal death
rates, morbidity and mortality from infectious diseases have all decreased
dramatically over the past 40 years. The resultant increase in the life expectancy
Indian people enjoy today is something in which we take pride. However, it is
important to note that American Indians and Alaska Natives still bear an increased
burden of illness and premature mortality compared to other U.S. populations.
Health conditions related to life style choices such as diabetes, heart disease,
substance abuse, and domestic violence are especially troublesome. Poverty, lack
of employment and educational opportunities, and communities whose social fabric
has been torn all contribute to these health problems. In addition, while the
Indian Health Service has made great strides in improving the water and sanitation
systems of many reservation communities, 12 percent of all American Indian and
Alaska Native homes lack safe water and adequate means of waste disposal.
Although we maintain accreditation for most of our health facilities, the aging
health facility infrastructure in Indian country requires costly upkeep and
maintenance which diverts precious resources away from health care. While the
average age of our health facilities is nearing forty years, some facilities are in
excess of eighty years old. Geographic isolation also contributes to lack of access
to health professionals and services, and lower per capita health care expenditures
add to this increased burden of illness and premature mortality.
The American Indian and Alaska Native population experienced a decrease in the
number of physicians per 100,000 population from 99.7 in FY 1982 to 89.8 in FY
1994. The physician ratio for non-Indian communities is 229 per 100,000
population. By comparison, in the four state region of the Indian Health Service
Aberdeen Area, the ratio for the Indian population is 87 physicians per 100,000.
In fiscal year 1997, the IHS per capita health care expenditure was $1,382,
compared to the U.S. civilian per capita expenditure of $3,261.
The President's fiscal year 1999 budget request for the Indian Health Service is
$2.118 billion which a net $19.7 million increase in budget authority, +0.94
percent, over FY 1998. The request assumes collections of $328 million from
third party health carriers for Indian patients which is a $25 million increase over
FY 1998 projected collections. Increased funding is provided for Presidential
initiatives on alcohol and substance abuse,+9.0 million; breast and cervical
cancer, +5.0 million; and first and second phase construction of two replacement
health facilities, +25 million. The President's request also includes reductions of
$10 million in the Hospital and Clinics, $5 million in the Sanitation Facilities, and
$3.8 million in Maintenance and Improvement.
Over 30 percent of the funds requested by the President for Indian Health Service
supported programs are administered by Indian Tribal governments for eligible
American Indians and Alaska Natives under the Indian Self Determination Act. In
the sixth year of implementing the Self-Governance demonstration program, there
are now 39 compacts and 55 Annual Funding Agreements in place. In addition, 34
urban Indian health programs administer $25.583 million for health services
utilized by tribal members living in metropolitan areas throughout the nation.
All tribes and urban Indian organizations are being included in the processes of the
Agency to ensure fairness and balance. No major decisions of the Agency are
made without consideration of the viewpoints and concerns of tribes: those that
contract, those that compact, and those that choose to stay within the federal
system of health care delivery. The Agency includes urban Indian organizations in
the decision making process of the Agency, particularly in policy decisions that
would impact on them.
Decisions on the allocation and administration of the $30 million appropriated by
the 1997 Balanced Budget Act and $3 million by fiscal year 1998 Interior
Appropriations Act for the Indian diabetes initiative were made based on tribal and
urban recommendations. Consultation on these new funds began at the 1997
National Indian Health Board Annual Consumer Conference in Spokane,
Washington, in October 1997, where tribes and urban representatives initiated the
development of area-wide recommendations.
In November 1997, a Diabetes Work Group comprised of tribal leaders
representing the National Indian Health Board, and the Tribal Self Governance
Advisory Committee; urban Indian health leaders; and, Indian Health Service and
outside Diabetes experts was convened to review and analyze the
recommendations. This work group used the tribal and urban recommendations to
develop proposed options for the distribution and use of the grant funds which the
Agency relied upon to make final decisions in January, 1998. The administration
of the diabetes grant funds is now proceeding on a timetable that will enable the
funds to reach the local service delivery points no later than June 1, 1998. Use of
the grant funds will include both preventive and treatment activities, and, in fiscal
year 1998 only, tribal/IHS data systems improvement activities.
I committed the Agency to increase the opportunity for tribal participation in
developing the annual budget request for Indian Health Service-funded programs.
The Indian Health Service Tribal consultation policy, the Indian Self Determination
Act, and Government Performance Results Act (GPRA) require significant tribal
and urban involvement from the beginning of the budget formulation process.
Therefore, the fiscal year 1999 budget process provided expanded opportunities for
tribal and urban participation in establishing the initial budget request funding
levels, identifying health priorities, and proposing program performance measures.
We conducted two day Government Performance Results Act (GPRA) and budget
formulation workshops in each of the 12 Areas of the Indian Health Service to
more fully explain the performance based federal budgeting process. The local
health priorities and associated program performance measures proposed by the
local Indian Health Service/Tribal/Urban (I/T/U) health programs were used in the
development of the Indian Health Service Annual Performance Plan. Twenty five
performance measures proposed by the plan include 14 treatment, 4 prevention, 3
capital programming/infrastructure, and 4 consultation/partnership/advocacy/core
functions indicators. The final Indian Health Service plan ranks as one of the two
top plans within the U.S. Department of Health and Human Services, according to
Each of the 12 Indian Health Service Area offices has established an Area-wide
budget formulation team comprised of local I/T/U health leadership to manage the
local input and ensure local I/T/U participation in the Indian Health Service
headquarters, Departmental and OMB executive review and decision making
processes. The intent of the new process is to foster improved government to
government discussions on national budget priorities between Indian tribes and
Federal government so that Indian health needs can be given equal consideration to
other national domestic needs. I remain committed to strengthening this new
collaborative approach to budget development.
Federal funding for Indian health programs must remain a priority for this Nation.
I look forward to working with the members of the Committee to honor and
strengthen this commitment and to work toward realizing the goal of elevating the
health status of American Indian and Alaska Native people to the highest possible
Mr. Chairman, this concludes my statement. We will be pleased to answer any
questions you may have. Thank you.