Good morning, Chairman Campbell, Chairman Young, and Members of the Committees
on Indian Affairs and Resources. I am pleased to appear at today's joint hearing to convey the
views of the Department on S. 1770, the Assistant Secretary for Indian Health Act of 1998, and
to discuss our shared concern for the health and well-being of the nation's American Indian and
Alaska Native people.
The Administration strongly supports the elevation of the Director of the Indian Health
Service to the Assistant Secretary level, and we look forward to continuing to work with you on
statutory language to achieve our shared goal.
Mr. Chairman, provision of federal health services to American Indian and Alaska Native
communities is based upon the special government-to-government relationship between Indian
Tribes and the United States. This relationship has deep historical, legal, and moral roots. These
deep roots reach back not only to the signing of the first treaties between the United States
government and the Tribal Nations in 1784, but to the earliest encounters between European
settlers and the original inhabitants of the Americas over five centuries ago. It is a relationship
born of solemn promises. It was forged at great cost and sacrifice. The sovereign Tribal Nations
gave up land, water rights, mineral rights, and forests in exchange for guarantees of peace,
security, and among other things, health care. Over the years, the special relationship between
Indian Tribes and the United States has been reaffirmed by all three branches of the federal
Through several important initiatives, the Administration and the Department of Health
and Human Services are working to fulfill the promises made between the United States and
Indian Tribes. For example, President Clinton has directed all federal agencies to implement
policies and procedures for consulting with Indian Tribes on matters that affect Indian people. In
response to the President's directive, an HHS Tribal Consultation Working Group developed the
Department's plan to engage in meaningful consultation with Tribes. The plan was approved by
Secretary Shalala and announced in October, 1997. As an initial step in implementing our plan, I
traveled last November to Santa Fe, New Mexico, where I attended the annual conference of the
National Congress of American Indians and had opportunities to meet with elected Tribal leaders
and delegates from throughout the United States. I will again be traveling this fall, and will be
inviting Tribal representatives to listening sessions in regional locations.
Also at the President's direction, special efforts are being made to support Tribal colleges
and universities. These institutions, chartered by Tribal governments, play a vital role in
providing higher education opportunities to American Indian and Alaska Native students and
preparing them for future leadership and service to their communities. On February 2, 1998, the
presidents of the Nation's Tribal colleges and universities were in Washington and met with
HHS officials. I chaired the meeting, which was attended by Department principals, senior
advisors, and staff. We heard the delegation of Tribal college presidents share their concerns
and expectations for this relationship with HHS. Several of our Operating Divisions are
participating in this year's Washington Internship for Native Students (WINS) program in
conjunction with American University, and the entire Department has been enriched by the
presence of a group of American Indian students interns.
Also within the Department, the Racial and Ethnic Health Disparities Initiative is now
underway. The President has committed the nation to an ambitious goal by the year 2010: the
elimination of disparities in six areas of health status experienced by racial and ethnic minority
populations while continuing the progress we have made in improving the overall health of the
American people. These six areas of health status -- infant mortality, child and adult
immunizations, diabetes, cardiovascular diseases, cancer screening and management, and
HIV/AIDS -- include some of the most important health issues for American Indian and Alaska
In these and other efforts, the Indian Health Service fulfills a critical mission. Under the
continued leadership of Dr. Michael Trujillo, and in partnership with American Indian and
Alaska Native communities and Tribal governments, the IHS provides a comprehensive system
of primary health care, prevention, and public health services. The IHS also acts as the principal
federal health advocate for Indian people.
As both Dr. Trujillo and Assistant Secretary for Health and Surgeon General, Dr. David
Satcher reported to the Committee on Indian Affairs in June, there have been some important
gains in the health status of Indian people during recent years. Infant mortality rates, maternal
death rates, deaths due to unintentional injuries, and morbidity and mortality from infectious
diseases have decreased dramatically. The work of the Indian Health Service has been a
cornerstone in achieving these successes.
But as American Indian and Alaska Native families and communities know only too well,
there continue to be major challenges. Diabetes, heart disease, substance abuse, and domestic
violence continue at especially troubling rates. Poverty, unemployment, and lack of educational
opportunities complicate intervention efforts.
In his remarks upon introducing the "Assistant Secretary for Indian Heath Act" on March
17, 1998, Senator McCain characterized the health problems facing Indian people as an
"epidemic crisis." The real challenge before us is how best to mobilize and allocate resources in
response to this situation.
S. 1770 proposes to establish within the U.S. Department of Health and Human Services an
Office of the Assistant Secretary for Indian Health. We support the elevation of the IHS Director
to the Assistant Secretary level, and look forward to continuing ongoing discussions with you
and your staff on the design of this legislation. We share your goals, Mr. Chairman, and those of
Senators McCain, Inouye, and Conrad, to address the health challenges in American Indian and
Alaska Native communities and to effectively position the Indian Health Service for this effort
within the changing environment of Tribal self-governance. We commend all of you for the
depth of concern and sincerity of purpose that your legislation demonstrates.
We recognize that the Indian Health Service is not just a program serving the interests of
one among a number of minority constituencies. Rather, the IHS is the organizational
embodiment of the government-to-government relationship between the United States and the
Indian Tribes. It exists because of the solemn promises this government has made to Indian
people. On matters of health care, the head of the Indian Health Service acts principally as the
administrator of the vast Indian Health Service system, as well as an advocate on behalf of the
needs of the nation's more than 550 federally-recognized Indian Tribes. The elevation of the
IHS Director to the position of Assistant Secretary is consistent with the government-to-government relationship and unique political status of American Indian and Alaska Native
In conveying our support for the proposal to establish an Office of the Assistant Secretary
for Indian Health, we should note, at the same time, that issues of Indian health are the concern
of the entire U.S. Department of Health and Human Services. Elevating the IHS Director to the
position of Assistant Secretary will strengthen the government-to-government relationship and
facilitate communication and consultation with the Tribes on matters of Indian health. But in
making this change, I think we all want to be sure that we continue to utilize the resources and
expertise that exist within every Operating Division of HHS to address Indian health needs,
either directly or indirectly. Whether it is the National Institutes of Health or the Centers for
Disease Control and Prevention, each component of the Department has dedicated staff who have
made Indian health the focus of their professional work.
In this same connection, the Assistant Secretary for Health is empowered by the President
and the Congress to attend to the health needs of all of our citizens, regardless of their racial or
ethnic background. The people of the United States are privileged to be served in this role by Dr.
David Satcher, who has reaffirmed a commitment to continue the work of his predecessor, Dr.
Philip Lee, to work closely with Tribal leaders on Indian health concerns.
As we move to elevate the head of the Indian Health Service to the Assistant Secretary
level, we look forward to working with you and your staff to recognize in statute the important
ongoing responsibilities of the Office of the Assistant Secretary for Health. The work of the
ASH is vital to ensuring that research, resources, and policies are integrated in ways that benefit
all the people of the United States.
Our support for the proposal to elevate the IHS Director to the position of Assistant
Secretary reflects our commitment to consultation with the nation's Indian Tribes. While in
Santa Fe last fall, I listened closely as Tribal leaders discussed their views on the proposal and
described their hopes for what the change might accomplish. We have reviewed resolutions and
correspondence from the National Congress of American Indians, Tribal governments, and other
bodies representing Tribal interests. While elevating the IHS Director to the level of Assistant
Secretary will not have an immediate impact on how decisions are made about IHS
administration and budget, it will raise awareness of Indian health concerns throughout HHS and
the entire federal government. We do not underestimate the importance of increased awareness,
because heightened awareness is the first step toward meaningful action.
We have closely reviewed the proposal in S. 1770 to separate the IHS from the Public
Health Service. As we have conveyed to your staff, we believe that the present organizational
structure of the Public Health Service -- especially its ability to flexibly utilize the resources of the Commissioned Corps -- benefits the Indian Health Service and the individuals, families, and
Tribal governments that receive services through its programs.
Through the combined and complementary resources of its component agencies, the PHS
offers the nation - and under-served or remote communities in particular - unsurpassed medical
treatment, health promotion and disease prevention services, public health and biomedical
research, and health professions education programs.
The close ties and collaboration between PHS components directly benefit American
Indian and Alaska Native people. For example, during last year's bipartisan discussions about
the need to allocate more resources to diabetes prevention and treatment, scientists of the Centers
for Disease Control and Prevention worked closely with medical personnel from the Indian
Health Service to provide information and technical assistance. The support of the CDC helped
assure that funds authorized for diabetes interventions would not only provide immediate, short-term assistance to Indian Tribes and communities, but also be a long-term investment in
identifying effective prevention strategies that respect American Indian culture. CDC support
would assure that future generations of American Indian children, not yet born, will benefit from
this important effort.
Another example of how existing relationships and collaboration between PHS
components benefits American Indian people is the integrated research on non-surgical
intervention for refractory periodontal disease being conducted by the IHS and the National
Institute on Dental Research (NIDR), part of the NIH. The IHS and NIDR recently entered into
an agreement to repeat an important clinical trial on the effectiveness of this method for treating
a troublesome form of gum disease, in order to validate the results of an earlier trial on the same
protocol. The State University of New York (SUNY) at Buffalo is also a partner in this project.
The original protocol was developed and tested by IHS, NIDR, and SUNY in the Phoenix Area
between 1995 and 1997. The new testing will be done in the Albuquerque Area. Data indicate
that this treatment may offer clinicians an exciting new non-surgical tool to combat tooth loss,
especially among those with diabetes. Inter-agency collaboration of this kind means that lower-cost, less-invasive medical treatments will continue to become more widely available.
While Sen. McCain's bill makes provisions for the IHS to use officers or employees of
the Public Health Service, the assignment of PHS personnel and Commissioned Corps officers to
the IHS will be complicated by additional administrative procedures that must be used when
details of these personnel are made outside of a PHS agency. Currently, for example,
Commissioned Corps personnel -- personnel that comprise the backbone of the health
professional cadre in IHS -- can be assigned to the IHS directly, utilizing administrative
processes that are common to all PHS agencies using common authorities contained in the PHS
Act. The IHS can then, in turn, assure that Tribes receive health professional personnel
appropriate to the need. IHS currently uses these shared PHS-wide processes which help to
minimize personnel overhead costs and assure optimal efficiency.
If the IHS is separated from the PHS, Commissioned Corps personnel will need to be
detailed to the IHS and Tribal facilities under multiple, Tribe- or location-specific detail
agreements, utilizing unique administrative processes which will undoubtedly be more expensive
and complex to administer. Operating through this type of administrative process would also
complicate personnel supervision, thus impeding the ability to respond promptly to personnel
concerns and performance issues.
It is also important to note that we can maintain IHS as part of the Public Health Service
without impeding the direct reporting relationship to the Secretary, that we all support. All heads
of PHS Operating Divisions, including the Director of the IHS, currently report directly to
Secretary Shalala without having to go through any intermediate level of management authority.
There is no filtering of information between operating division heads and the Secretary. Budget
requests for the IHS are handled in the same way as budget requests for every other component
of the Department.
In short, we believe strongly that the IHS should remain part of the Public Health Service.
In our view, there is nothing to gain in administrative relationships or patient care by separating
the IHS from the PHS, but there is potentially much to lose.
We share the concerns of Members of these Committees that the IHS be positioned and
structured in the best possible way to respond to a future of growing needs, changing
expectations, and developing operational and management methods. As the system of delivering
Indian health services evolves, organizational independence for the IHS must be balanced against
the recognized need to collaborate with federal and Tribal partners, leveraging maximum benefit
from limited resources, and being able to bring all appropriate aspects of the Department's
talents to bear.
Mr. Chairman, the U.S. Department of Health and Human Services looks forward to
continuing our effort to develop consensus legislation to elevate the IHS to the Assistant
Secretary level. We stand ready to work with Congress and Tribal governments as, together, we
seek to fulfill the solemn promises to which we are committed. We look forward to a vital
partnership and pledge continued -- and thoughtful -- responsiveness to changing health care and
public health needs in Indian country.
Thank you, Chairman Campbell, Chairman Young, and Members of the joint Committees. I appreciate the opportunity to share the Department's views on these matters, and look forward to answering any questions you may have.