Good morning Mr. Chairman, I am the Deputy Director of the Indian Health Service (IHS).
Accompanying me today is Dr. Craig Vanderwagen, Director of the Division of Clinical and
Preventive Services, Office of Public Health in IHS. I am here today to present the views
of the U.S. Department of Health and Human Services (DHHS) on S.1507, a bill to authorize the
integration and consolidation of alcohol and substance programs and services provided by
Indian Tribal governments, and for other purposes. The Department strongly supports the
goals and intent of the legislation and would like to take this opportunity to provide a
few constructive comments on the proposal. The Administration is committed to preparing a
report addressing the most effective and efficient means to implement the concept outlined
by S. 1507 early in the next session of Congress. The report will be prepared in
consultation with Tribal governments, affected Federal agencies and other interested
parties. Further, the Administration believes that the bill should be amended to specify
the DHHS as the lead agency responsible for implementation of the bill=s provisions. I will discuss the rational for this
recommendation in my statement.
The issue of alcohol and other substance abuse is significant to American Indian/Alaska
Native (AI/AN) communities. The death rates associated with alcoholic cirrhosis and other
direct alcohol diseases for AI/AN are well above general U.S. population. In addition,
injuries are the leading cause of death for AI/AN=s
between the ages of 15 and 44 years. The majority of these deaths, whether intentional
(such as suicide and homicide) or unintentional (such as motor vehicle crashes) are
associated with alcohol and other chemical abuse.
The IHS and Tribes have initiated a significant program of injury prevention and in
fact the deaths related to injuries has declined. These programs have generally aimed at
making the environment safer through targeted intervention such as seatbelt use and
roadside safety enhancements. Notwithstanding, deaths due to injuries are still 2-3 times
more likely in the AI/AN population. Suicide deaths in our service population are 1.5
times more frequent than in the general U.S. population and certain age groups in some
communities may be 3 times more likely to die in this manner. Domestic violence associated
with chemical abuse is especially lethal for AI/AN women. A recent University of New
Mexico study revealed that American Indian women are the population most likely to die as
the result of domestic violence when compared to other ethnic populations. This is a
social and clinical issue of significant proportion.
The first official authorization for the IHS and Indian Tribes to provide alcoholism
treatment services was established in 1976 within the Indian Health Care Improvement Act,
Public Law (PL) 94-437. The Anti-Drug Abuse Act of 1986, PL 99-570, and the Omnibus Drug
Bill Amendments, PL 100-690, expanded this authority to include alcoholism and other
substance abuse treatment and prevention services for AI/AN youth, women, children, dual
diagnosed youth and family members. All of these authorities were later combined under
Title VII of the Indian Health Care Improvement Act Amendments of 1992, which is the
existing authority for the IHS/Tribal/Urban (I/T/U) programs.
The IHS receives close to $100 million in appropriations for its alcohol activities.
Greater than 90% of these funds are provided directly to the Tribes under Indian
Self-Determination agreements for programs which they design and implement. The Tribes and
IHS have addressed this problem persistently and have some demonstrated success. The IHS
has had significant and successful experience in developing and executing partnerships
with tribal governments. In the last 5 years Self-Governance agreements in IHS has
expanded from 14 tribes to well over 40% of the tribes we serve. This process of
transferring the Federal functions related to health programs has taught both Tribes and
the IHS many lessons in planning and implementing comprehensive health and social
programs. Indeed, the evidence suggests that tribes can address these issues in ways that
the Federal partners cannot.
The IHS and tribes have established outcome measures through the Government Performance
Results Act (GPRA) to evaluate the success of their health programs and have been lauded
for the appropriateness of the indicators associated with the anticipated outcomes. The
death rate due to alcoholism has in fact generally declined over the last 20 years.
Alcohol related illnesses that have been targeted (such as FAS and FAE in some high risk
communities) have been reduced. Inhalant abuse also appears to be on the decline. The
youth regional treatment activities are demonstrating clear success in treatment.
While the death rate due to alcoholism has declined 17% since 1980, current data shows
that this downward trend has stopped. Since 1990, the rate has been rising and is now 7
times greater than the U.S. All Races rate. These deaths are preventable, but only through
a comprehensive program of medical, behavioral, and preventive services. In fact, the
evidence suggests that comprehensive community wide efforts (including medical treatment
programs) are the most appropriate approach to prevention. This has been demonstrated in a
variety of IHS and DHHS funded programs to prevent alcohol and chemical abuse related
illness. The K=e project in Navajo is only the
most recent example of success. This effort, funded by SAMHSA, operated by the Navajo
Tribe, and in collaboration with IHS, utilized traditional tribal culture, more standard
alcohol prevention efforts, and clinical care activities to demonstrate a reduction in
chemical abuse among young people. The Tribes and the Federal agencies are seeking ways to
work collaboratively to develop the comprehensive and coherent programs to achieve the
dramatic changes in the health behaviors and social structures needed to redress these
Within DHHS there is a significant partnership among the agencies with health and
social programs targeting chemical abuse built around the highest quality professional
approaches to treatment and prevention. The IHS has working relations with the Substance
Abuse and Mental Health Services Administration (SAMHSA) for Mental Health Services
(CMHS), Substance Abuse Treatment (CSAT), and Substance Abuse Prevention (CSAP). These
programs provide will over $15 million in funding through the competitive grant processes
for service to AI/AN communities in a coordinated effort with IHS.
The Centers for Disease Control (CDC) also provides funding for prevention services in
partnership with IHS in the area of tobacco use. The CDC has also provided support to a
partnership between IHS and the Bureau of Indian Affairs to develop and disseminate an HIV
comprehensive prevention for school aged children and adolescents. The National Institute
for Alcoholism and Alcohol Abuse has provided support to research efforts examining the
characteristics of chemical abuse in AI/AN populations. Lastly, the IHS partnership with
the Headstart program has provided support and technical assistance to Indian Headstart
prevention program efforts.
There have also been significant efforts among the Department of Justice (DOJ), the
U.S. Department of Health and Human Services (DHHS), and the Department of the Interior (DOI),
and other Federal departments to plan and implement coherent programs of prevention and
treatment. A major vehicle for this effort has been the Domestic Policy Council Working
Group on Native Americans chaired by Secretary Babbitt. This forum has developed
innovative approaches to streamlining tribal access to government-wide programs through
inter-agency efforts and methods. The concept of integrated service access has been a
theme and focus for this group. Specific partnerships between DOJ, DOI, DHHS, and the
tribes are now being implemented to address chemical abuse and other behavioral problem
among Indian youth in detention. These principles should be formalized and validated more
effectively in the Federal relations with Tribes.
Accordingly, the IHS believes that the principles addressed by this bill reflect an
appropriate public health and intra- and inter- government approach to the issue. We are
concerned about how the distribution of funds authorized and appropriated under existing
competitive or formula grant authority will be affected. For example, SAMHSA is concerned
that given the broad scope of the bill, it might be construed (a) to make tribes eligible
for funding under a program for whose funding they are not currently eligible, or (b) to
guarantee tribes a share of funding from a discretionary grant program or other similar
program under which they are eligible for funding but have to compete for funding. There
are concerns that the technical assistance and other Ain-kind@ services and relationships between Tribes and
Federal agencies will decline significantly under this approach. The partnerships that are
functioning could be lost. There are also concerns that the funding levels keep pace with
identified need and that resource flexibility which works to the advantage of tribes not
Because of these and other potentially complex issues involved in applying the P.L.
102-477 model of program consolidation to Federally funded alcohol and substance abuse
programs serving the AI/AN population, we would recommend that a careful and comprehensive
report be prepared to ascertain the implications of applying this model to existing
programs. We need to ensure that the critical contributions of the multiple Federal,
Tribal and other health, social and community service agencies along with judicial and law
enforcement agencies are not compromised. A report to outline the issues at hand and
recommendations to address those issues prior to implementation would be sound investment
of time and resources. As I stated earlier in the testimony, the Administration will be
consulting with the appropriate Tribal governments in the preparation of this report.
The Administration believes that the DHHS, with its demonstrated record of health
improvements in public health, is a more logical choice to ensure that improved social and
health status changes are the outcomes. Based on these considerations, the Administration
recommends that DHHS be given the lead responsibility for the implementation of the
provisions of this proposed bill. The DHHS would work closely with the Department of the
Interior, other Federal agencies and Tribal governments to achieve the bill=s objectives.
Thank you for this opportunity to provide testimony on S. 1507. I will address any
questions you may have at this time.