Third Annual Tribal Budget Consultation Meeting

Hubert H. Humphrey Building
200 Independence, Southwest
Washington, D.C.

Friday, June 15, 2001

Appearances | Morning Session | Afternoon Session

The hearing in the above-entitled matter was convened, pursuant to Notice, at 8:30 a.m.

MORNING SESSION PROCEEDINGS

"This transcript has not been edited or corrected, but rather appears as received from the commercial transcribing service. Accordingly, the Office of Intergovernmental Affairs makes no representation as to its accuracy."

(8:30 a.m.)

MR. MASON: To our distinguished guests and colleagues, welcome to the U.S. Department of Health and Human Services, and our third annual department-wide Tribal Budget Consultation.

I am Jim Mason, Acting Director of the Office of Intergovernmental Affairs. And I am very pleased and honored to welcome you on behalf of the Department. We look forward to a very informative and productive day.

Just one ground rule before we get started. We are recording the session today. And Wallace, from Heritage Reporting, is here, and has asked as each of you make a comment or presentation, if you would use one of the microphones around the table, and introduce yourself each time that you speak. It will help him as he transcribes the day's proceedings.

To start our morning session, I would like at this time to invite Alvin Windy Boy, Senior, Chairman of the Chippewa Cree Tribe, and Vice Chair of the Tribal Self-Governance Advisory Committee, to come forward to provide the blessing.

Alvin? And if you all would stand, please.

FEMALE VOICE: Wallace, if you would turn off the recorder for this part of our session, I would appreciate it.

(Whereupon, a brief recess was taken.)

FEMALE VOICE: You may continue recording.

MR. MASON: Thank you, Alvin. At this point it would be helpful to all of us to know who you are, and who you represent. So I would like to go around the table, and then the guests in our audience, just to tell us your name and who you represent.

I am going to start with President Masten.

MS. MASTEN: Susan Masten, President for the National Congress, American Indians, and Chairperson for the Yurok Tribe located in Northern California. Good morning.

MR. ALLEN: Good morning. Claude Allen, Deputy Secretary, Health and Human Services.

MR. WILLIAMS: Dennis Williams. I am the Acting Assistant Secretary for Management and Budget.

MR. TRUJILLO: Mike Trujillo, Director, Indian Health Service.

MR. A. WINDY BOY: Alvin Windy Boy, Tribal Chairman, Chippewa Cree Tribe, and most important, Chairman of the Montana/Wyoming Stump Growers Association.

MR. CAGEY: Henry Cagey with the -- and the Tribal Self-Governance Advisory Committee.

MR. KOPANTA: Rich Kopanta, Executive Officer of -- and Mental Health Services of --

MR. SAWMILL: I am Steve Sawmill. I am the Intergovernmental Coordinator for --

MR. CARUFEL: My name is Robin Carufel, Lac du Flambeau Band of Lake Superior, Chippewa Indians.

MS. JOSEPH: I am Rachel Joseph, Chairwoman of the Lone Pine Payute Shoshone Reservation in California.

MR. VIGIL: My name is Gil Vigil. I am the Secretary/Treasurer of the -- Council in Mexico, also former Governor of the -- and today I am representing the National Indian Child Welfare Association.

MS. DUPREE: Good morning. I am Dorothy Dupree, the Senior Policy Advisor on many of the programs at the Center for Medicare and Medicaid Services, formerly known as HCFA.

MR. HERREL: Morning. I am Mike Herrel, Office of Planning and Evaluation in the Department. Our office is doing the Title VI Self-Governance Study.

MS. THOMPSON: I am Penny Thompson. I am the Deputy Director of the Center for Medicaid and State Operations, one of the centers for Medicare and Medicaid services.

MS. GRAVES: I am Meg Graves. I am the Deputy Director for the Office of American Indian Alaskan Native and Native-Wide Programs at the Administration on Aging.

MS. McCAULY: Good morning. My name is Sharon McCauly. I am the Executive Director for the Interdepartmental Council on Native American Affairs, and also the Acting Director of Program Operations in the Administration for Native Americans.

MR. BOTT: Good morning. I am Robert Bott. I am the Acting Director, Office of Community Services.

MS. KIRSCHSTEIN: I am Ruth Kirschstein, the Acting Director of the National Institutes of Health.

MS. DAVIS: Good morning. My name is Julia Davis, and I am a member of the Nez Perce Tribe. I serve on the Tribal Council. Today I am here representing the National Indian Health Board.

MS. TYNER-DAWSON: Good morning, everyone. My name is Gena Tyner-Dawson. I am the Senior Advisor for Tribal Affairs in the Office of Intergovernmental Affairs.

FEMALE VOICE: I am -- and I am a staff specialist with the Office of Intergovernmental Affairs -- Virginia.

MR. WILLIAMS: Carl Williams, Jr. -- Council.

MS. BROWN: Carol Brown, Special Assistant to the Director of the Office of Civil Rights.

MR. WESTIN: Good morning. Richard Westin. I am the Acting Associate Administrator of the Agency for Toxic Substances and Disease Registry, an agency of this department.

FEMALE VOICE: I am -- I am an intern --

MR. WILLETTO: Good morning. My name is Frank Chee Willetto. I am representing the National Indian Council on Aging from the Navajo area. Thank you.

MR. BALDRIDGE: Hello. I am Dave Baldridge, Executive Director of the National Indian Council on Aging.

MS. KLEIN: Good morning. I am Sue Klein with the Centers for Medicare and Medicaid Services. Let's see if I can get that out right. I am in the Office of Legislation, where I work on --

FEMALE VOICE: Good morning. Betty -- Secretary -- Office of the Secretary.

MR. MORRIS: I am Willis Morris, Office of the Deputy Secretary.

FEMALE VOICE: Good morning. I am --

MALE VOICE: I am -- the new Assistant Secretary of --

MR. BURBANK: And I am -- Burbank, also with -- Secretary --

MALE VOICE: -- Office of the Director of Indian Health Services.

FEMALE VOICE: -- Center for Disease Control and Prevention --

MS. WALLACE: Mary Wallace with the -- Administration.

FEMALE VOICE: -- Office of Facility Services.

FEMALE VOICE: Good morning. Maria -- Food and Drug Administration Headquarters, Office of Financial Management.

MS. GARTHRIGHT: Good morning. I am Karen Garthright with the Office of Minority Health --

FEMALE VOICE: Good morning. I am -- Office of General Counsel, Public Health pision.

MS. WILLIAMS: Good morning, everyone. I am Paula Williams, Office of Tribal Self-Governance, Indian Health Services.

MR. LINCOLN: Good morning. I am Mike Lincoln. I am with the Indian Health Service.

MS. HUDSON: Hi. I am Maddy Hudson, Office of Community Services, pision of Tribal Services.

MS. IRON CLOUD: Good morning. Patty Iron Cloud, Office of -- of the Secretary.

MALE VOICE: Good morning, all. My name is Don -- I am with the Northwest -- Area, Indian Health Board.

MS. FOX: Good morning, everyone. My name is Yvette Joseph Fox. I work as the Executive Director of the National Indian Health Board. It is good to be here.

MR. MASON: Thank you. And welcome, everyone.

It is now my pleasure to introduce the new Deputy Secretary of Health and Human Services, Claude Allen. Deputy Secretary Allen was confirmed by the Senate on May 26, and sworn into his new position on June 4. So he is actually finishing up his second official week here in our department.

(Laughter.)

MR. MASON: And given all the new initiatives that he is chairing on behalf of the Secretary, I think he is going to have a pretty busy time at HHS.

Deputy Secretary Allen came to us from the Commonwealth of Virginia, where he served as the Secretary of Health and Human Resources. Among his many responsibilities, he led Governor Gilmore's initiative for the Virginia Patients' Bill of Rights, as well as the State's Welfare Reform Initiative.

Deputy Secretary Allen also implemented the Virginia's private health insurance program for children and families.

We are very pleased to have Deputy Secretary Allen with us this morning, and please join me in welcoming him.

(Applause.)

MR. ALLEN: Good morning.

MULTIPLE VOICES: Good morning.

MR. ALLEN: Good morning.

MULTIPLE VOICES: Good morning.

MR. ALLEN: Much better. Welcome. Indeed, it is a real privilege and honor to be here with you this morning.

As we were just talking, I was confirmed on the 26th. I had to leave the country to be confirmed. I was in South Africa, I believe it was, when I got a phone call in the middle of the night that said that the Senate decided to confirm me.

When I started here on Monday, June 4, at 10 a.m., I was signing some papers. At 10:30 they had me on my way to the airport, on a plane to Boise, Idaho. I stopped and paused, and asked, and said, "When do I get confirmed?" They said, "Do you remember those papers you signed?" I said, "Oh, okay."

(Laughter.)

MR. ALLEN: So it has been a whirlwind of a trip for these first two weeks. But it has been a distinct honor and privilege to serve both the Secretary, Thompson, and President Bush's Administration.

One of the things I lament is, in Virginia I had the privilege of serving as Secretary of Health and Human Resources. And as Secretary, one of the duties I had, and real honors I had, was to work with eight tribes in Virginia who are not Federally recognized. But we worked very closely. In fact, as we were going around the room introducing ourselves, the one person that was missing from here would be my son, my eight-year-old son Alexander.

Alexander, he would travel with me every year to the Governor's Conference for the Council on Indians in Virginia. And he became their honored guest every year. And so we hope that as we continue to consult and to work together, you will have an opportunity to enjoy my eight-year-old son, as well.

Again, on behalf of Secretary Thompson, I want to say welcome to the tribal leaders, to our national tribal organization leadership, and tribal guests, to the Third Annual Department of Health and Human Services Department-Wide Tribal Budget Consultation Meeting.

We all are pleased to continue the strong consultation policies and processes of this department by hosting you, once again this year at HHS, to listen to your budget priorities and issues. We have invited each of HHS staff pisions and operating pisions to today's meeting to listen to your presentations, as well. In fact, last evening, as we were talking in my office to confirm who were in attendance, we sent out another call to ensure that we had full representation from this department, so that they, and all of us, could hear, and to work with you on these very important issues.

Each of these staff ps and op ps will be preparing their inpidual budgets for submittal next week. Therefore, it is important that they hear how your issues may impact their budget submissions.

I want to take this time to tell you a little bit more about myself. I did serve on the United States Senate Foreign Relations Committee staff from 1985 to 1987, and then actually had an opportunity to clerk in the D.C. Circuit Court of Appeals just down the street, for the Honorable David Sentel. Judge Sentel was one of the premiere lawyers, judges in the country, studying Indian law. And so I had the privilege of working with him on some very important issues that came through that Court that affected Indian peoples and Indian country.

I also served as the Secretary of Health and Human Resources for the Commonwealth of Virginia. In Virginia we enjoy great success by forming partnerships in communities to provide benefits, services, and most significantly, support, a concept that is not new to Indian country or the African-American community.

I also worked with the Council on Indians, as I stated earlier, during my tenure in Virginia. And I am committed to working with you to ensure the success of efforts to reduce health disparities.

I came to State Government with the belief that strengthening families and encouraging local independence and self-sufficiency are fundamental goals that we share. I want to continue this philosophy here at HHS. I want to ensure we uphold our trust, responsibility to tribal governments, and I want to continue to expand opportunities to American Indians and Alaskan natives, because these citizens, these nations, are vulnerable, and are hard to serve populations for a variety of reasons.

As the new Deputy Secretary, I am interested in looking at innovative ways to expand access to, and quality of, health care coverage to American Indian and the Alaskan native children. I believe the Federal Government should give the states and tribes greater flexibility to develop efficient, cost-effective health care.

On May 16, 2001, I went before the Senate Committee on Finance for my confirmation hearing. I testified that evidence in recent years suggests that race and ethnicity correlate with the continued and increasing health disparities in minority communities. I cited the prevalence of diabetes among Native Americans as an example of this fact.

On Wednesday afternoon, key HHS leadership also heard from the Indian Health Services and tribal representatives of the Indian Health Services National Tribal Urban Budget Formulation Team regarding their budget priorities for fiscal year 2003.

As you can see from today's meeting on the HHS budget, the meeting with IHS held on Wednesday, and the Tribal Self-Governance Feasibility Study National Tribal Consultation Meeting, held yesterday, as well as recent meetings and appearances with tribal leaders, tribal consultation at all levels is an important matter to this Secretary and this Administration.

Let me be clear. Secretary Thompson and I are fully committed to tribal consultation. HHS has a strong record on consultation, but we can always improve.

Many of you have read the consultation policies that our department and inpidual agencies have put in place. As the new team here at HHS reviews these policies, I invite you to send us your thoughts and your suggestions on how we can strengthen those policies, as well as our consultation process.

In his testimony before the House Budget Committee, the Secretary stated that we must no longer be content to do things a certain way because that is how we have always done them. But instead, we must be willing to reform our business practices, and seek innovative ways to manage our programs.

We will continue to seek ways to improve our partnerships with tribal governments, and the respective tribal organizations that represent many of your concerns. We want to hear from you on how we may improve the process, as well.

I am also pleased to make an announcement this morning. HHS is conducting an awards ceremony today in which the Indian Health Service Tribal Urban Budget Formulation Team will be given an award for their outstanding performance.

The ITU Budget Formulation Team strengthens government-to-government relationship by collaborating Government Executive, and Congressional branches, and Indian Tribal Governments, which produces investments, reducing health disparities for American Indians and Alaskan natives.

I want to congratulate the tribal leaders and their tribal representatives that serve on this work group, as well as to commend the IHS for their efforts. This is a wonderful example of collaboration between our Federal and Tribal partners.

Tribal Chairperson Rachel Joseph and Ms. June Tracy of IHS are here representing the ITU Budget Formulation Team at today's awards ceremony. I understand that other tribal and federal representatives of the team are also here, as well, and I want to acknowledge all of you, too.

Will the members of the ITU Budget Formulation Team please stand? Congratulations on a job well done.

(Applause.)

MR. ALLEN: Again, I want to welcome all of you to HHS. It is an honor to be here with you today, and we look forward to your presentations and future collaborations and consultations. Thank you.

(Applause.)

MR. MASON: Thank you, Deputy Secretary Allen. This consultation is our third annual department-wide consultation. And even though it is our third year, these are still programs that are very difficult in some ways to put together, because we want to make sure that we get the information that you, that you have to help us develop our budgets.

And we cannot do this alone. In fact, we do not do it. The tribal leaders and tribal organizations do it. You put together the agenda for these consultations.

And we have had several conference calls over the last few weeks with tribal representatives, including representatives from several national organizations. And I wanted to take just a minute to acknowledge and thank you for all your help in making today's session possible.

The National Congress of American Indians. The National Indian Health Board. The IHS Tribal Self-Governance Advisory Committee. Land-Based Tribes Coalition. National Indian Child Welfare Association. National Indian Council on Aging. The National Indian Council on Urban Health. And many, many more folks who helped to put this together.

Additionally, I would also like to thank the staff from the various staff pisions and program offices in our department who helped put this together, including staff from the Office of the Assistant Secretary for Management and Budget, the Administration for Native Americans, the Indian Health Service, the Office of Minority Health, and certainly the Office of Intergovernmental Affairs.

It has been a real pleasure to work with Acting Assistant Secretary Dennis Williams and Dr. Trujillo in putting these consultations together. Their leadership and support for these consultations is tremendous.

Before I introduce our moderator for this morning's session, I just wanted to give you kind of an overview of the day. We will -- this morning's session is scheduled to end a little before 11 o'clock. As Deputy Secretary Allen mentioned, we have the Departmental Awards Ceremony downstairs in the great hall that begins at 11, so we will need to break in order to let folks get down there in time. You are certainly welcome to attend that.

We will have a two-hour break between 11 and 1 to accommodate that ceremony. And for folks who want to grab a bite to eat, we have a cafeteria on the eighth floor here in the Humphrey Building. There are also restaurants nearby. Stacey Eckaffee, our Kaiser Fellow, will guide you to those opportunities.

We will assemble back here at 1 o'clock. And I believe Buford Rolin will be our moderator for this afternoon's sessions.

To moderate this morning's presentations, though, we are very honored to welcome Sue Masten, Turok Tribal Chairperson and President of the National Congress of American Indians.

Sue was elected President of NCAI in October, 1999, only the second woman to serve in that capacity, and the first President from the state of California.

Prior to her presidency, she was very, has been very active in NCAI, serving as the NCAI First Vice President from 1994 to 1996, and as the NCAI Sacramento Area Vice President from 1992 to 1994. And Sue has been Yurok Tribal Chairperson since 1997.

Her goals in these positions are to advocate for the betterment of native communities, which, from my observation in several meetings with her, she does quite well.

Sue, thank you for your leadership, and for your support to our department's consultation processes over the past few years. And we look forward to working with you in the future. Thank you.

(Applause.)

MS. MASTEN: My warmest greetings to my very close friends and relatives, to the honorable tribal leaders, to Deputy Secretary Claude Allen, to Acting Assistant Secretary -- I thought I talked pretty loud, it is not loud enough? Okay. This is so awkward. To Acting Assistant Secretary of Management and Budget, Dennis Williams. And of course, to the Acting Intergovernmental Affairs Director, Jim Mason, and Dr. Trujillo. And the health professionals that are here, my warm greetings.

I want to, at this time, because we do not often get a chance to do that, and I certainly appreciate -- I, as the President -- to acknowledge my esteemed colleagues for their hard work and dedication on behalf of our people, and the numerous hours that they spend looking at and providing for input to the agencies on our health care needs. And it is quite appropriate that we do that, because I depend on my colleagues for, you know, the expertise that they have in this field. So I wanted to just take a little time out to say, you know, thank you so much.

And so the Department knows, these truly are our experts in the field of health. And when they call or contact you, they do know the needs of Indian country, and they should be paid the respect and have your ear at any time.

And so, with that, I want to acknowledge the Co-Chairs for the Indian Health Service Budget Formulation Team Chairwoman, Rachel Joseph, and Vice President Taylor MacKenzie, and Chairman Guyashkobosh, who served in that capacity, and the Vice Chair of the Tribal Self-Governance Advisory Committee, and Chairman Alvin Windy Boy, and Acting Chair of the National Indian Health Board and Councilwoman Julia Davis, and Henry Cagey for his role in the Policy Advisory for Indian Health Service, Self-Governance Advisory Committee.

Rachel Joseph, the Executive Director for the National Indian Health Board, and Frank Chee Willetto, Sr., for the National Indian Council on Aging, the Chairman and the Executive Director David Baldridge. And of course, Gil Vigil for his role in the National Indian Child Welfare Association, in his role as the Secretary/Treasurer for the All Indian Pueblo Council.

Barbara Namais for her role with the National Council on Urban Health Care. And Buford Rolin for his role with the National Indian Health Board, as well as the Advisory, Self-Governance Advisory Council.

You know, these are the people who we look forward to, and we appreciate. And of course, you know, staff. Gena Tyner-Dawson, and Paula Williams, you know, we thank you.

And I want to say, too, up front, you know, without Dr. Trujillo's leadership and his efforts to ensure that consultation occurred, that, you know, we would not have this model process that we, we use whenever we are talking to other agencies. And we want to thank him. And I look forward to working close with him, and coming to the Department and working with the issues that we face at the Indian Health Service. And I want to thank and acknowledge him for being our champion in health care issues. He has done a wonderful job on our behalf, and should be commended for so. And I think we should acknowledge him at this time.

(Applause.)

MS. MASTEN: You know, they spend a lot of time away from their families and homes. And our people have benefitted from that, by the increases in funding in these last couple of years. And so we thank you. And I appreciate all that you do on our behalf. And I thank you for providing me the expertise that I need to do the job that I do on behalf of all Indian country. Because without you, I would not be as successful as I have been.

The relationship between Indian country and the Department of Health and Human Services is an important one. The well-being of our people is often contingent upon the programs that HHS administers.

This gathering, the Third Annual Meeting of HHS and Tribal Governments, to discuss the priorities and concerns that affects Indian country, shows me that the Department is committed to meaningful and timely consultation, as well as the need for native people to be healthy and prosperous.

Thank you for your invitation to be here, for inviting the tribal leadership and the national organizations to today's consultation. I look forward to a productive day of dialogue between the Agency and the leaders in the organizations.

The first issue I would like to address is the relationship between federally-recognized tribes and governments. But before I do that, I want to reiterate, you know, that it is exciting for me to see that the Department is fulfilling the Government's trust responsibilities, and the commitment to tribal governments that President Bush made during his campaign trail this past year, where he recognized the Government's unique legal and moral obligations to tribal nations.

As stated in the U.S. Constitution and over 800 treaties that has been upheld in numerous Supreme Court decisions, it is nice to see the Department continue to express this commitment to government-to-government relationships.

I think that, you know, we cannot overstate it enough. It is not okay in these times, where the Government is experiencing such prosperity, and that we have enough money that we are giving tax refunds back to its citizens, that you know, the first people of this nation are still dying from preventable diseases. And that our numbers are at the highest in increasing, when everyone else's issues in health care are, are decreasing.

And with that unique relationship that the Government has with tribal governments, it is a time when we should be paying attention to our reports, and looking at the numbers and seeing what we can do to overcome the barriers that keep us from addressing the health care needs of the people, first people of this nation.

So in looking at, by addressing the need to improve health care for American Indians and Alaskan natives communities, we can eliminate racial health care disparities and reach the goals of healthy people for 2010, as well as other campaigns, such as the Department of Health and Human Services and the American Public Health Association's national campaigns to eliminate racial and ethnic disparities. We look forward to working with you to see how we can make this possible.

In looking at tribes and state relations, given the unique number and persity of tribal governments, and the variance in the way that states operate, there is not a definite scenario for a tribal-state relationship.

However, it is generally acknowledged that the special governmental status of tribes and the authorities of states often come into conflict. Many states do have positive working relationships with tribes in their area, but others do not hold the interests and concerns of their native populations in high regard. As a result, the needs of native people are sometimes ignored. This is particularly problematic when the Federal Government depends on the state's good-faith efforts to distribute funds that are intended to go in part to tribes.

Many of the problems that the leaders that, throughout Indian country have found are a direct result of the Federal Government's not conferring grants directly to tribal governments, in the same way that it distributes them to states. The inability of tribes to provide adequate human and health services to our people because of underfunding, due in part to channeling of funds to state coffers, that often do not reach our people, many who need the assistance the most.

The problem of indirect funding is one that occurs again and again in the HHS program structure. As such, NCAI would like the Department of Health and Human Services to make direct funding of HHS programs to tribes a priority in coming years.

Now I would like to turn specifically to some of the Department of Health and Human Services, with NCAI's recommendations for the upcoming budget. Under the administration of Native Americans, NAA is responsible for grant programs in various areas, including social and economic development strategies, environmental regulatory enhancement, and native language preservation and revitalization.

NCAI is pleased that last year's increase in funding for ANA, which was $10.5 million, this marked the first increase for the Agency in 20 years. We urge continued support for ANA in order to build tribal government infrastructure and increase tribal government capacity to administer programs.

For the year 2003, social -- we would like to see an increase in the budget of ANA in order to maintain the Agency's ability to support the programs that are vital to our people.

Under Title XX of the Social Service Block Grants, the grant is intended to provide social services for children and families throughout the United States. Unfortunately, tribal governments, whose communities often have the greatest social service needs of any other in our nation, received virtually none of the funds available in the 20 years of this program. Because of an oversight in the development phase of the program, it provided no provisions for tribal government funding, which left tribes out of the funding formulas or put tribes on the fringe during the funding process.

Tribes have not received a fair share of the $2 billion available under this entitlement. Since Title XX block grants are available only to states and territorial governments, not directly to tribes, the distribution of funds from grants do not reach tribal governments.

There is no explicit authority in the legislation that would either require or persuade states to distribute funds to the tribes, which has created a funding disparity that will continue unless action is taken to remedy the situation.

Our recommendation is that tribes be eligible for the receipts of Title XX block grants in the future.

Under Tribal Temporary Aid to Needy Families, TTANF, one of the many successes that some tribes have realized in the contracting and compacting for the temporary aid of needy families program, authorized under the Welfare Reform Act of 1996, to date 32 tribal TTANF plans serving 160 tribes have been approved. There is expanding interest in the tribal TTANF programs throughout Indian country, which is reflected in the increasing number of tribes applying for contracts.

However, with the growing number of people served by tribal TTANF programs, there must be an accompanying increase in funds available, so that tribes can adequately serve our people's needs.

NCAI has five recommendations to make to the Department in regards to TTANF. Tribal TTANF number one, tribal TTANF funding formulas should ensure that resources are sufficient to meet tribal needs, and are available at no less than former funding levels under state AFDC programs. Tribes should be able to select, and, the funding formula that most benefits their programs, and should have access to incentive bonuses and contingencies funds the same way that states do.

Number two, tribal TTANF guarantees should continue to have the flexibility to define their service area and service population.

Number three, tribal TTANF should be, have the option of administering eligibility determinations for related support programs. And the Medicaid and Children Health Service Insurance Programs, excuse me, matching funds for these programs should be waived, and tribes should be authorized to administer them. TTANF reporting requirements need to be streamlined so that they are not so burdensome to the tribes, and the Secretary of HHS should be authorized to develop, through consultation with tribes, alternative reporting requirements appropriate for tribal circumstances.

Under Section 419.4(b) and 412(h), they restrict self-determination of tribes in Alaska to make tribal-specific program decisions. These Alaska-specific provisions should be removed in the reauthorization process, thus allowing Alaska's natives to be treated as tribes, are in other states.

Under child care, our children's welfare is a priority for all of us, as they are, carry on our traditions, our languages, and our cultures. And their welfare is paramount. Nearly 40 percent of Indian children between the ages of six and 11 live below the poverty level. And a way to remedy this is to increase funding for tribal child welfare programs. We suggest a minimum of $25,000 a year be provided for each tribe in order to create a base level of child welfare services in Indian communities.

Under Headstart, tribal communities have benefitted greatly from the Headstart program, not only through the education and care provided our children, but from employment opportunities that the program has provided.

However, there are problems in the system. One of these problems is that the infrastructure in the Headstart program does not adequately address the needs of tribal programs. We suggest that a separate budget and department be created for the administration of tribal Headstart programs, to minimize or eliminate tribal-state conflicts which prevent our children from receiving adequate education and care.

Another major problem is that our teachers are overworked and underpaid. NCAI suggests that HHS increase funding for tribal Headstart programs to allow for the hiring of more teachers, which will both help our children and communities.

Also, many of tribal Headstart administers have complained that there is very little consultation occurring between tribes and the larger Headstart program. The culture and community's specific needs of Indian people are significant. And through our ongoing consultation, we can begin to address them.

The NCAI stresses that -- the practices with regard to Headstart program, and to provide funding for needed consultation.

Again, in conclusion, thank you for inviting us to address the needs of our people. Our needs are many. But through consultation and collaboration, Indian country and the Department of Health and Human Services can work together to remedy the problems.

We are looking forward to working with you on the recommendations that the tribal governments have made in the past, the ones it will make today, and the ones it will make tomorrow, and looking at ways that how we can access all of HHS's programs and services to create healthier Indian communities for a healthier America.

I thank you again.

(Applause.)

MS. MASTEN: At this time, it gives me great pleasure to introduce the Honorable Alvin Windy Boy, who is Chairman of the Chippewa Cree Tribe of Rocky Boy, and who is the Vice Chairman of the Tribal Self-Governance Advisory Committee, to please come forward. Along with -- I am not sure if you are going first and Henry is following you, or you are doing joint? Henry, you are going to follow?

Thank you, Alvin.

MR. A. WINDY BOY: We will go with you first. Again, good morning. My name is Alvin Windy Boy, Sr., recently elected Tribal Chairman of my tribe as of last November. Been in politics for 12 years, the past 12 years, as a councilperson. And as I mentioned before, I was the last person that ever thought I would ever get involved in health. Health, to me, prior to 12 years ago, I knew nothing about, but to know how to get toothaches, and even an ingrown toenail here and there.

(Laughter.)

MR. A. WINDY BOY: And I did not know an ingrown toenail, in medical terminology, is -- it all stuck in my mind.

But anyway, it is always a pleasure to be back here in D.C., hopefully trying to better the life of, of Indian people.

I was born, raised, lived all my life on Rocky Boy Reservation. I am going to probably die there. That is, that is my home. And we, as Indian people, all have homes somewheres.

The homeland concept of, of knowing who we are, where we are, what we are will always be intact, particularly in this ever-changing life that that we have to endure every day.

Rules, regulations, and policies have all been developed most recently. Rules, regulations, and policies can be changed. But the lifestyle of the Native American Indian person in this great country cannot be changed, should not be changed, will not be changed.

It was just most recently, in the last, last hundred years, that we have, we have gone to a different level of learning. Many of our elders who have gone on to that happy hunting grounds have ventured back here, and trekked many a mile. And that time it was on bus and train.

Just most recently I had the opportunity to look at old documents of my elders that had, that had come back here. And there were 12 of them, on a train that took that seven days, to speak of a plight that no one was listening back there in Montana.

You analyze that, what they had mentioned then, and now it is probably no different. The thing that they sought back there was the same thing that we are seeking today. Better health care, better quality of life in Indian country.

Many tribal governments, the 560-some-odd tribes in this country, all operate different in some fashion. My tribe is one of the new tribes in the self-governance, self-governance initiative. We undertook that initiative, and are very proud of what we succeeded and what we have done thus far.

I chair the local Rocky Boy Health Board, and also chair the Montana-Wyoming Area Indian Health Board for the Montana-Wyoming Tribal Leaders. I also co-chair the National Tribal Self-Governance Advisory Board. And I have been asked to represent, with this session, Mr. Merle Boyd, the second Chief of the -- Fox Nation, who is also a co-chairman of the Federal Tribal Negotiated Rule-Making Committee for Title V, the Tribal Self-Governance Amendments of 2000, which is public law 106260.

Currently we are in the process of developing regulations for the permanent authorization of self-governance in the Indian Health Service. We expect that the regulations will be in place in calendar year 2002, and anticipate that both the tribes and the Department will need to make appropriations requests to address a number of items in this new statute and the regulations.

Title VI of the Tribal Self-Governance Amendments of 2000 mandates a study to determine the feasibility of a tribal self-governance demonstration project for programs, services, functions, and activities for portions thereof within the Department of Health and Human Services, other than the Indian Health Service. The study requires consultation with tribes, states, municipalities, program beneficiaries, and interested public interest groups.

We have just concluded the national wrap-up consultation yesterday and the drafting of a study that is expected to get underway within the next 30 days.

The window of time will, will provide an additional opportunity for comments. And that would be submitted, going to be submitted to the Department. The study is to be completed by February 18, 2002, and delivered to both the Extended Committee of Indian Affairs and the House Resources Committee.

Again, we anticipate that, that for fiscal year 2003, appropriations will need to address a number of issues associated with this DHHS tribal self-governance demonstration project. And when that time comes, that I would anticipate, as Chairman of a tribe, that I would only see that it would be appropriate that the elevation of the self-governance office be within the Department.

If there is anyone that is going to practice true government-to-government tribal consultations, that is going to be me. And I would encourage other tribal leaders to do the same.

Hopefully, it is unnecessary to state once again the, fundamentally, the Department should request full funding for all program functions, services, and activities that are included in the provisions of health services to Indian tribes and people.

With respect to Title V, the Indian Health Service should request additional funding for planning grants, as well as negotiations grants. And we expect that when the new regulations are in place, there will be some expansion of a number of new applications from tribes, tribal organizations, and tribal consortias, to enter into self-governance compacts and funding agreements.

These grant programs explicitly and implicitly authorized in Title V can be effective, can be an effective mechanism for assuring a smooth transition into the permanency of self-governance.

The Department should also request adequate self-governance shortfall funding. It seems the best and least complex way of assuring that all beneficiaries who are entitled to services under the existing programs would be most effectively protected in this manner.

To the extent that tribes request to shift to a calendar year as their funding period for funding agreements, it will also be necessary to request funds for the transition quarter.

A new provision authorized by Section 507(a)(1) is health status reports. Compacts and funding agreements are to include provisions that require tribes to report to the Secretary on health status and service deliveries.'

However, the statutes specifically requires funding to tribes before any new, additional reporting requirements are effective.

The Department should request adequate funds to support the preparation of these reports, which both the tribes and the Department consider an important element of the health care delivery system.

Finally, with respect to Title V, there are clusters of departmental responsibilities that cannot be withdrawn from the funding transferred to tribes under Section 505 that need to be separately requested. These include, for example, the Secretary's obligation to provide technical assistance with respect to both reassumption and rejection of final offer.

Other reporting requirements and responsibilities of the Office of Tribal Self-Governance, which, at a minimum, includes funding distribution responsibilities, under Section 513.

With respect to Title VI, the study that should determine the feasibility of a demonstration project will be completed and the programs and agencies available for the demonstration project will be known. Past experience, as well as the consultation process just completed with tribes and others, indicated that capacity funding for tribes, as well as start-up funding, will be necessary for the demonstration project, and should be requested by the Department.

Partnership. Partnership is a word that, that, that I, that I have seen over the last two, three, four years as a tribal leader of a sovereign nation with a treaty. We, as a tribal government, do not ask for much but to be at the table. We hear of fair share. What is that fair share? Are we, as tribes, going to ever receive that fair share?

We have seen statistics over the course of time that tell us on an average, most recent that I have seen, health delivery in Indian country is anywheres between 30 to 40 percent. And depending on what geographical location we come from.

You know, there was this long time ago, there was these people that came back to, back out west. They were all riding horses as they journeyed west. They come upon a Cree guy laying on the ground there. There were four of them. One, two of them had cowboy hats, one had one of those fur, fur coon hats like, and the other one had a beaver cap.

And as they rode up, they seen this horse standing, and this Indian on the ground with his head to the, to the ground. This non-Indian person looked down, and, "My gosh," he said, "Look at that Cree guy. He is listening to see where the buffalo are going."

"Or maybe," the other guy said, "maybe he is looking for his enemy." Yeah, could be. So they ride up to him, and they said, "Hey, sir, what you listening for?" And this Cree guy on the side, listening. He looked up, he said, "One wagon, bunch of blankets, clothes, husband, wife, two kids."

"My gosh," that one guy said in that beaver hat, "this guy is good. Do you suppose we could recruit him?" "I don't know," he said. "Hey, sir," he said, "how do you know those?"

"They ran over me one hour ago."

(Laughter.)

MR. A. WINDY BOY: I guess the moral of what I am saying, the moral of what I'm saying is just because we, as tribes, approach you with braids, a ponytail, short hair, we approach you in the, in such a manner that we are sincere. And I hope that, in the proceedings that happen today, that you lend a mindful ear, and a caring ear, from a caring heart. I hope.

(Applause.)

MR. A. WINDY BOY: Incidentally, I did leave some, some documents outside.

MS. MASTEN: Do you want to take questions now? Because I have, Henry is next. Do you want to wait until his presentation, and then -- yes? Ms. Davis.

MS. DAVIS: I don't know, is this on? Okay. My name, again, is Julia Davis, and I'm here as a tribal leader today to participate in this consultation.

If you look on the agenda, one of the things on the agenda is open question period time, which I think is very, very important. I don't think a one-way communication is going to do it.

This is the third year that we are doing this, and we need some interaction, as tribal government officials, from the Department heads. And I would really like to see some questions being asked from the Department heads to us, as tribal leaders. So I am challenging all of the departments here to, don't be hesitant to not ask any questions. Because any small question you may ask, someone else probably wanted to ask the same thing.

But my point is, in the remarks that -- that is just my comment. I just wanted to make that.

But I made a note here. When President Masten was talking about the needs of our Indian children and our young Headstart children, one of the concerns that I have as a tribal leader, with the -- and I know that will probably come up on that later, with some remarks later on. But the Administration on Families and Children Department head, is that person here? Acting? Okay.

FEMALE VOICE: I am just representing ANA, but there will be the Deputy Assistant Secretary for Policy and External Affairs for Administration for Children and Families for this afternoon's session.

MS. DAVIS: Okay. I will just save my, I had some questions that I wanted to ask, so I will wait.

MS. MASTEN: Any other questions or comments at this time, so far? Mr. Windy Boy.

MR. A. WINDY BOY: (Inaudible.) I see some faces here that were here several years ago. And we (inaudible). It's not a Republican, it's not a Democrat issue, it's not even -- it's not even a Rainbow Coalition issue. It's an issue of what is best for Indian country.

We have been doing this for, as I mentioned, I don't know if they followed me, the third annual, but the third time -- but what I want to know is, all the reports that we have been given as tribal leaders, what are you going to do for us? That had not been done. Or you have heard a lot of, a lot of direction given. But what actually (inaudible).

What's that one show, that one guy that says "show me the money, show me the money." That's basically what we're about.

MS. TYNER-DAWSON: Mr. Chairman Windy Boy, I have a question for you regarding your presentation.

You indicated it would be necessary to identify additional funding that may be required under the 507(a) provision of the new statute.

I have the pleasure of serving as a Federal Co-Chair to the Subwork Group working on the regulatory language. And my question also goes to Paula Williams as the Federal Co-Chair of the Rule-Making Committee.

And I would simply ask a process that our subwork group might move forward. Appropriation issues. I grant you, we have not discussed that, and I thank you for bringing this to our attention. And then I will seek Paula's guidance on how we might move those type of issues forward within the rule-making process on over to the Director of the Indian Health Service.

MS. MASTEN: I would like to add one more, too, because we have not had an opportunity, and I do not know if I will get to.

But in part of when I was talking about past recommendations, we made some extensive recommendations, and looked at the barriers to accessing the other program areas. And one of the things that we also recommended was institutionalizing the process, and for us to develop the same kind of team that would address issues with all of the departments.

And I would really like to have you check on taking a closer look at those recommendations from those listening conferences, and then the final look at what are the real barriers. Because we did a pretty in-depth review. And then for us to talk about, and I would offer my assistance to you, to reach out to Indian country to identify inpiduals who would be willing to serve on, on, you know, a consultation committee for the Department.

But also, at the time we had talked about the existing committee. And just through IHS, expanding their role, and then maybe adding whoever is missing to that committee. Because you will notice that whenever you deal with health issues, you will see the same faces. Because we are all, you know, overtaxed by the issues that we face as tribal leaders. And the people who care and are entrenched in the health care issues are the same inpiduals that you will see at any meeting that you call. And that is true.

And so, in order to not overtax them with consultation, to streamline the process would I think be helpful. So in taking a look at that, to consider that. I look forward to working with you on that, because I would like for us to institutionalize this process, and not wait until, you know, once a year to get together to have discussions. Because we are not going to create access to those other program areas, or address those barriers that need to be addressed to accessing those funds. So if you could take a look at that, I would greatly appreciate it.

Any other comments or questions at this time? Yes, ma'am.

MS. DUPREE: Yes, I am Dorothy Dupree with (inaudible). I am Dorothy Dupree with CMS, the Centers for Medicare and Medicaid Services.

I am interested in the Tribal Consultation process. And within the Indian Health Care Improvement Act, its language requesting that the, at that time, HCFA establish a National Tribal Technical Advisory Group. And we are in the process, as most of you know, of laying out a draft charter in working with tribal leadership. We have comments back and so forth.

And based upon what you just said, Sue, does that change how CMS would consult relative to moving away from the National Tribal Technical Advisory Group?

MS. MASTEN: I do not want to propose that at this time. I think that we would need to, because there are some ongoing efforts that are working real well, and I do not propose to, you know, interfere with those processes.

I am just, on the broader scheme of things and looking, if each of the pisions were to institutionalize constitution, you would run our leadership ragged, and would not get the valuable input that we need to be providing to you, and the serious consideration that you need to be giving to our recommendations, by overtaxing us. Because they are going to be the same inpiduals who respond to each of those inpidual pisions.

So I am looking at, you know, globally trying to figure out how to best utilize this expertise that we have in Indian country, to serve Indian country the best that we can.

So you know, we can talk through those. And those of leadership that are involved in those would be the best ones to make those recommendations, whether they want to continue with those, or whether they want to elevate to something different. I would defer to them, because they are in the trenches, and they are involved in those processes now.

Mr. Windy Boy.

MR. A. WINDY BOY: (Inaudible.)

(Laughter.)

MR. A. WINDY BOY: (Inaudible.)

(Laughter.)

MR. A. WINDY BOY: But anyway, one would have to take a look at existing direction that some of the work groups are doing. Excuse me.

As an example, the Self-Governance Advisory Board is made up of tribal elected officials. And likewise, the formulation of the Tribal Leaders Diabetes Council, which is made up of 13 elected officials from the lower 48 and Alaska.

And every organization or consortia has, has some mechanism of consultation in how they, how they interpret consultation.

MS. MASTEN: Okay. I am just offering my services to help facilitate getting the word out and coordinating that effort in Indian country, you know, with our member tribes and non-member tribes. It is just a vehicle I am offering to assist the Department with.

With that, then, I think I would like to have Henry. And then we will open it up again after Henry's presentation. I would like to ask Henry Cagey to please come forward. He currently serves as the Policy Advisor to Indian Health Service Self-Governance Advisory Committee, but he also has been active in the trenches for a very long time. And he was the past Chairman for the Lumet Tribe in Washington, and he was the past Chairman for the Tribal Self-Governance Advisory Committee.

So with that, I give you Henry Cagey, who has been in the trenches for a very long time and served us well.

MR. CAGEY: Well, good morning, everyone.

MULTIPLE VOICES: Good morning.

MR. CAGEY: I just want to say, you know, it has been a pleasure to sit here and listen and give the opportunity to observe, you know, what is going, what is happening right now is the Administration picking up the ball and really carrying it on to what we started three years ago, with the HHS.

And I am hopeful that, that the people that are here today, shaping our 2003 budget, are going to be able to, to, as Julia said, you know, clarify some things that, that we would like to see increased over these next two or three years. So this is what I think we are here for.

Mr. Allen, I appreciate your opening remarks, and to what you have committed to do. And just a little comment on your consultation policy, is the policy I think is fine. But it is the process that needs to be clarified. You know.

And we have pushed for consultation for the last several years, but it is the process that I think is, is where we kind of tend to stumble a little bit on what, what we need to do as tribes, organizations, and agencies to better serve the people at home.

Just a little things before I get into my presentation, is, adding on to Title V and Title VI, is that as a reminder to some of the Agency heads and Department heads, is that this legislation that was created was tribally-driven. What I mean by tribally-driven is that, is that we wrote the legislation. We walked it through and got a lot of support from IHS, HHS, in getting this bill passed. And as you heard, the study is upon us. And I hope that the Department heads and the agencies will consider what the tribes are looking at furthering self-government.

The other thing that self-government would like to see is the elevation of our Director. I think it was, I do not know if it was going to be mentioned later on, but we do support the Elevation Bill that we started a few years ago, by Senator McCain. And I would like to see this happen this year.

We have come over the obstacle with a couple committee chairs that did not understand Indian issues, or Indians at all. But we think that this bill that we will see passed this year, will go through. And we need your support, Mr. Allen, to get this bill underway.

Dental, or oral health, I guess, is what I am here to talk about. As the former Chairman of our tribe, and Chairman of the Advisory Committee, is oral health, or dental, as I like to call it, has been really overlooked by a lot of our people. Not overlooked, but I guess really not well-supported.

Dental, within our communities, is a very serious issue. I have just experienced it these last couple days with my nephew, trying to get an appointment for his teeth. His teeth became infected, and our clinic could not serve his needs. So he got sent home with antibiotics, and hopefully that they will see him in July. Because it is that far back that they cannot, they cannot see him.

So my wife and I went through a tedious process in trying to figure out what to do with his needs. So he has got an infected tooth of the root canal, that they could not do anything with. They were just booked solid. And there was nothing we can do except ease his pain with medication.

So dental is a serious problem. I just got a taste of it the other day. So, I am not much of a dentist supporter, but I know it is important.

(Laughter.)

MR. CAGEY: But dental I think is a serious problem that we lack the administration to look at these next two, three years in supporting our initiative. You will see our paper, that I will hand out later, what we are asking for. So I will try to go through this carefully, but I tend to kind of get off track a little bit. And so I will leave the paper with you.

Indian people have significantly poorer oral health than any other American. The situation is not likely to improve without the investment of additional resources to increase awareness, educate the public in targeted populations, and improve access to care.

A little background is that in 1999, IHS Oral Health Survey indicated that 78 percent of our children ages two through five had a history of dental decay. Sixty-eight percent of the adults and 56 percent of the elders have untreated dental decay. Fifty-four percent of adults 35 through 44, and 84 percent of the elders have periodontal gum disease. When I look in this room, you know some of these people have that problem.

This data confirmed that the long-standing oral health disparities that confronts Indian people and reflects disease rates that range from two to 10 times the rate experienced by overall population. A factor which contributes to this disparity is a difficulty experienced by IHS and the dental programs in recruiting and retaining dentists.

Recruiting dentists has reached crisis proportions for many tribal programs. Currently 90 positions for dentists are vacant across Indian country. This represents 20 to 25 percent of the dentist positions.

This shortage of providers has resulted in significant declines in access to dental care nationwide. In fiscal year 2000 only 25 percent of IHS and travel clinic users were able to get dental appointments. This compares with about 60 percent of the overall US population that sees a dentist each year.

Objectives. The ultimate goal of this initiative is to make dental care more available to Indian people, and to ultimately improve their overall oral health status. To improve this goal, the following objectives of this initiative are: Work towards establishing oral health as a funding priority within IHS, HHS, OMB, and Congress. Achieve parity in access to dental care between Indian people and the rest of the nation. Improve the recruitment and retention of dental staff. Develop partnerships with HHS to improve the oral health of Indian people.

Enhancements and partnerships. Tribal leaders believe that in addition to IHS and other agencies within HHS have the responsibility to improve the health of Indian people. With regards to oral health initiative, tribal leaders strongly encourage you to include the following initiatives in your 2003 budget request.

Under the direction of the Secretary, Deputy Secretary and Surgeon General, NHA staff and operating pisions are in the position to implement this initiative, which I will describe further.

HHS. As the Secretary moves forward with his health plan initiatives, emphasizing the cross-cutting issues between oral health and the 10 leading health indicators within the Health Plan 2010. The Surgeon General's report on oral health, eliminating health/oral health disparities. Continuing to emphasize the significant disparities which exist between Indian people and the overall population, and advocate for the resources to eliminate these disparities.

The Indian Health Commission authorized by public law 106-310, implementing and funding this Commission, and include the oral health as a major agenda item for the Commission.

Implement the oral section public law 106-310, consistent with the tribal leaders' oral health initiative, which is designated to be community-based partnerships.

The National Institute of Dental and, I have a problem with this word, Cranial Official Research.

MS. MASTEN: Cranial Facial Research.

MR. CAGEY: Cranial Facial Research. Okay. NIH budget --

(Laughter.)

MR. CAGEY: That would be a lot easier, NIH budget is scheduled to double in five years. And we have seen that statistic in a booklet that we have seen what is happening with NIH. And we would like to see some similar sort of support from NIH for this initiative.

Okay. NITCER and IHF have partnered over the last 10 years to develop an innovative procedure to treat periodontal disease in persons with diabetes. The same thing needs to occur for the treatment of dental carriers.

Include $1.5 million in NITCER budget request to establish a dental NACRC charged with studying why oral disease rates are so high, as well -- disease rates are so high, as well as develop public health initiatives for improved prevention and treatment of dental carriers.

CDC -- is CDC here? Increased support for water fluoridation process for the community, water fluoridation for traveling-operated systems. CDC currently partnerships with IHS to improve technical assistance for community water fluoridation. This effort funds two demonstration projects.

We recommend expanding to 20 additional sites, and including one million CDC pisions of oral health budget to support this effort. We recommend that CDC use the authority to include public law 106-310 to provide support to tribes for expanding application of sealants in Indian communities.

Toward this end, we recommend that CDC pision of Oral Health request $1 million for this proposal.

HRSA -- I think it is called something else now, isn't it? Health Revision Shortage Area designation for IHS and travel sites.

National Health Service Corps Scholars at IHS and travel sites. Not just those you take, you cannot replace. You need to request funding to increase the number of specifically to serve Indian people.

I guess clarifying a little bit of this is that we would like to see NHC Service Corps take a little more stance in helping us recruit our dental assistants and dental people. And you can start at -- we need one up here right now.

I would recommend that HRSA request $1 million to provide grants directly to tribes to improve access to dental care for children.

To recap our recommendations for 2003, is $1.1 million for NIDCR to support dental NRC, $2 million for CDC to support travel community water fluoridation and sealant programs, $1 million for HRSA for grants to tribes and to increase access to care for children. In addition, we also recommend that IHS include $5 million in its budget request to support this initiative.

In closing, this amount of funding, in comparison to the overall HHS budget, is a drop in the bucket. We would like you to do the right thing for us, and hopefully things go good.

I thank each and every one of you for coming here today and allowing us to present our oral health initiative. And if you have any questions, I will be here most of the day. Thank you.

(Applause.)

MS. MASTEN: Thank you, Mr. Cagey. Any questions or comments at this time?

We have a couple minutes, and so a couple people have come in that I want to take time to allow for introduction, since we did introductions this morning. And first of all, I would like to introduce and welcome and, and talk about her unique talents, because she is our new Executive Director for NCAI, Ms. Jackie Johnson. And she is with us this morning.

(Applause.)

MS. MASTEN: Jackie comes with a wealth of experience, and we are real excited about her being a part of the team at NCAI. She came to us from HUD. She formerly was the Vice President of her own tribe, Quincut Heida in Alaska, and served as their Executive Director for their Housing Authority, as well as was the President for the National Indian Housing Council. So she comes with a wealth of knowledge and expertise, and we are excited to have her with us.

Also, Charles Blackwell, you came in, and someone came in with you. If you want to introduce yourself to the --

MR. BLACKWELL: (Inaudible.)

MS. MASTEN: A brief introduction.

MR. BLACKWELL: A brief introduction. I am the Chickasaw Nation, Ambassador to Washington. I am the Director of -- here on Capitol Hill.

This is my Aide, Darrin Callero, who is also Chickasaw, and in his last year at Dartmouth.

As long as you have given me the floor, I want to take just a minute, and ask on a policy-making level, of Dr. Trujillo, and as a fellow advisor at a policy-making level, to distinguish at this period in time the historical or the significance between self-government and self-determination. And how, and the -- not that there is an answer to that.

(Laughter.)

MR. BLACKWELL: In the process of your administration, Dr. Trujillo, as you all go on with your discussion, the thought occurred to me here, and being one of the oldest and biggest Indians left standing in Washington. I have seen it go from self-determination to self-governance. And there has been a lot of talk about self-governance, and certainly the Chickasaws are a self-governance tribe, as are many of the tribes who are represented here.

We are now in a new Administration Secretary, who is moving the new Administration, who as you well know is moving back to the basic tenets and premises of self-determination, as established in the Nixon years. And for those of us who, some of us who have been around that long, and in service, travel service that long, I just feel a little inspired to ask, as you proceed in your discussions, for my edification and maybe some of those of us who are old, and some of us who are new, to come and talk about that a little bit.

Thank you, Sue.

MS. MASTEN: You are welcome, sir. And of course, serving as NCAI's Subcommittee Chair for the Elders Committee, Mr. James Delacruz, who also serves with the National Indian Council on Aging, and is a member of the Quinault Nation in Washington State.

(Applause.)

MS. MASTEN: Anyone else that I did not see come in, please stand and introduce -- oh, Buford, I did recognize you, though, and thank you for your work on our behalf earlier. But, please.

MR. ROLIN: Thank you, Sue. I apologize for being a little late. I had a phone call from home, I had to take care of a situation there.

And I just wanted to thank everyone for the opportunity for convening this session again. It is always good to see -- I know we started two years ago the work -- continued to work with the tribes. I know Mr. Windy Boy and I have been there for several forums, and we really -- and I look forward to continuing work with us and Dr. Kersten is committed to that, as well as --

It is good to see now Deputy Secretary Allen again. We saw him in April when he just got his nomination. And of course, the Assistant Secretary, Mr. Williams. We met with him on Tuesday.

Again, it is good to be here -- dialogue that we have. And moving forward with an agenda that will hopefully include more resources for tribes. And you have just heard already some needs that we definitely have. And I just thank you for -- here.

FEMALE VOICE: May I say something? I am just delighted to tell you all that Buford is now a member of the Advisory Group to the Director of NIH.

(Applause.)

MS. MASTEN: And I believe someone on this side of the room came in. I do not know if it is from -- yes, ma'am.

MS. CLARK: I came in. I am Gwen Clark, the Deputy Director of the Office of Minority Health at Herson.

MS. MASTEN: Welcome. Anyone else that I missed? Yes, ma'am.

FEMALE VOICE: (Inaudible.)

MS. MASTEN: Good. Welcome.

FEMALE VOICE: (Inaudible.)

MS. MASTEN: Welcome. Anyone else here? Yes.

MR. GREEN: My name is Joe Green. I am with the HHS office of Inspector General.

MR. TERRY: I am Sean Terry. I am a senior director in Health Services, the Cherokee Nation in Oklahoma.

MS. MASTEN: Over here, is there --

MR. ROBERTS: Jim Roberts with the National Indian Health Board.

MS. MASTEN: Anyone else? Did we get everyone? Okay, thank you. Any further questions or comments so far this morning? If not, then I would ask for the last presentation to -- yes, Ms. Davis.

MS. DAVIS: Did somebody respond to the self-governance, self-determination? Oh, my name. Julia Davis.

I would like, after the comments of Dr. Trujillo, I would like to comment on that.

DR. TRUJILLO: Yes, it was an interesting question. This is Dr. Trujillo, Director of Indian Health Service.

In regards to hopefully the practice of the Agency, and certainly within my own mind, is the issue of self-determination, which is really a relationship between the Federal Government and sovereign nations, tribal nations throughout the United States.

And really, the ability for tribes to choose and make their own choices in regards to not only the Government, but also the infrastructure and the programs that they wish to institute. And within that realm, in relationships at least within the Federal Government, and especially with the Indian Health Service, to choose how they wish to have their programs of indian health care and social services managed.

Either, number one, through a self-governance process through compacting, through a Title I 638 process, or if they choose to do so, also continue to have a direct relationship where the Federal Government, through the Indian Health Service, deliver their health care through that special relationship and obligation.

So within the self-determination as the overall umbrella, you have various mechanisms by which a tribe may be able to choose how they wish to do business with the Federal Government, through the Indian Health Service. One, through the direct services. Two, Title I 638, or compact through the self-governance process.

MS. MASTEN: Ms. Davis?

MR. TRUJILLO: I believe he wanted Alvin to also talk about this.

MR. A. WINDY BOY: In reference to self-governance, I will give you, I will give you Chippewa Cree tribe's perspective of the undertaking of such an initiative.

The bottom line, the bottom line to the tribal government at that time was, was, health care. How do we get the best quality and quantity of health care with the existing dollars that was available.

We did an analysis through a tribal management grant process with the Indian Health Service. Halfway through the fiscal year we found the, the positive ramifications that we, that, that we, what we were able to do, if we were compacting. Halfway into the fiscal year the tribe then decided to undertake such an initiative.

Like everything else, you know, you get these little kids, you know. You, they start walking. And it's, we praise the little kids, and they take their first step, and sometimes they fall down and we help them back up. That's, that's how we encourage them. And that's the way self-governance officially was for Rocky Boy.

Being mindful of there also, to every good thing there is always the negative. The good and the bad, I guess. And true, we, we, we were on, on alert by our own people ourselves. But in the last, in the last several years, I do not think my tribe would ever, would ever look at doing business any other way. It was a matter of, it was a matter of getting quality care or not. Bottom line.

MS. MASTEN: Ms. Davis.

MS. DAVIS: Yes. Thank you, President Masten. I just, I just wanted to expand on the very well-thought-out question that the gentleman had asked.

For those of you that do not really understand the compacting and contracting concept, I think back in the mid-80s there was a group of tribal leaders that decided that there must be a better way that we could do these things. And we had some very powerful leaders at that time that pushed the concept of contracting from the Indian Health Service. Monies that we could, like doing a contract with anybody in, you know, any other agency, and then the tribe would do that.

But there was a limit on the money that we could receive as tribes. So the self-governance concept came into play. And I can't remember the exact year of that.

MALE VOICE: Nineteen-eighty-eight.

MS. DAVIS: Eighty-eight. And that was when I was elected on council. And that is when I saw, as a personal tribal representative to my tribe, I saw the changes in the, the whole overall of taking care of our people at home, either through the direct service tribes or the compact tribes, or the contracting tribes.

We are now the Nez Perce tribe. And I forgot to say my name again, Julia Davis. That we are now a newly self-governance tribe with the Indian Health Service. We just completed our negotiation last May. So what we have done with that self-governance concept is take it to another level.

We just opened a clinic at one of our satellite offices up at Camya, Idaho. You need to come and see it, Dr. Trujillo. And it has just been wonderful. And now we are in the planning stages of our other new clinic that we are looking at for the main headquarters.

But to get to the finance part of it, and what Alvin has stated, Chairman Windy Boy has stated is that we, at home, still receive complaints because sometimes the services that we wanted to really do, we cannot do because we do not have the finances to do it. And that is why we are here.

I think that through the finance mechanism, there must be a way that we could do, through, through our physical intermediaries with our finance offices, be able to get a contract from one of your departments right to our tribe, where we could work back and forth, where we could increase our base budget that we do receive from Indian Health Service. For the reason that we do not receive an adequate amount of funding because of the overall budget, which we are talking about today, that trickles down and affects our people.

Even though we have made some big strides in doing the compacting and contracting, it is still not quite enough. And you will hear more about that later during our other presentations.

But if there is a way, as a department head with your department, that we could work through a contract process, whether it is through, I do not know, I am not an expert on that, but through the Indian Health Service or through the tribal government themselves, that would be excellent. That would be something that we could take home and share with our tribes that surround us, and you know, expand upon that.

And I just need to make one last comment. You know, many times different agencies -- and I am not saying yours, but different Federal agencies -- say well, Indian Health Service has taken care of them, or BIA has taken care of them. Why do they need this?

They do not realize that it is not enough. And I know that the great American Congress helps other countries. And right now, President Bush is over meeting with Russia. And Russia has their hand out, and they are saying the great American United States is going to help us, they are going to give us some money to help our country.

Well, we are the same. In another context, the American Indian, the Alaskan Native tribes, we are another government. We are also, all we are asking for is a way that we could better get our services to our people, through our mechanisms that we have developed here.

So that is all that we are asking, is some creative way of working this out to take care of our people. Thank you.

MS. MASTEN: And I would just like to capture a little bit on it. Because I think Mr. Blackwell, in the broader scheme of things, was saying the Nixon Administration started something exciting, some exciting principles of self-determination.

And this Administration, under President Bush and Secretary Thompson, what do we see the ideals under this Administration in elevating and ensuring those principles are expanded upon and implemented under the current Administration? And do you feel that so far in your term as the Deputy, do you feel that there is a firm commitment there? And do you anticipate that that is going to help us to better access these other programs and services under HHS, as well as increasing funding opportunities for Indian Health Care.

So if you could talk a couple of moments, I think that is what I was kind of hearing in the bigger scheme of things.

MR. ALLEN: I will be glad to address that briefly. I think the question was right on point. I think that you can have, self-determination to me says that -- and as I said in my opening statement, we are dealing government-to-government. It is dealing with you as a coequal in terms of you determining, as Indian nations, what services you are requiring.

I believe the comment about how you choose to do that, when I look at self-governance, self-governance is a subset of self-determination. It is one form of relating to a sovereign. Thereby, you can choose a compact, you can choose contracting as you are suggesting, or you can choose any combination thereof. But that does not change the fundamental relationship of the sovereign to the sovereign.

And so I think what you are seeing, we are firm believers in self-determination. What needs to be worked out is how, through this process and other processes, and I think there was a question about needing to clarify the process -- and I would agree that that is part of what we are trying to do here, is to clarify the process, get to the place where self-determination is elevated to the level that it should be. And self-governance being a vehicle to accomplish that, or a tool of accomplishing that.

And I think Dr. Trujillo articulated that probably the very best, in what we believe will be the outcome of this process.

So with that, let me suffice to say that the Administration, as I believe the Secretary has articulated, is looking to an opportunity to work with, in the area of self-determination. And how we do that, whether it is through compacts, through self-governance, or through a combination thereof. I think we can get there, but that is something that will be worked out over time.

MS. DAVIS: President Masten, as a tribal leader I just need to say this. In all honesty. What is the difference between a tribal government and a state government? The states receive monies from federal agencies all the time. And now we, as tribes, have been asked to go to the states to ask them for money.

I do not agree with that concept. We have asked before that we be able to receive monies directly from the Agency without going through the state. And we did get into a big debate about that yesterday. Some states are back in the ages of 1800, and they do not want to work with tribes.

So I just, all I am asking is that you look at the tribes the same as you look at the states. And if there is a way that the states receive money, there must be a way that the tribes could receive money. Thank you.

MS. MASTEN: And I guess to help you in that endeavor, I just ask that you refer to the U.S. Constitution, where it identifies states and tribal governments as entities that the Government will deal with to assist you in helping to get states and tribes funded directly. And I would ask you to pull that language out and use it as your key.

MR. ALLEN: And I think, going back, because I think you, you have hit on a very key point. And it is one that I do not have an answer for you here, but it is one that I think that we need to answer. And that deals with this question of whether we go through the states to fund, or whether it is direct funding. And that is a question that I cannot answer at this point for you. But it is a fundamental question that I think that we will have to grapple with, and it is one that goes to the heart of self-determination versus self-governance.

MS. MASTEN: It does make the President and the Secretary's job easier to uphold the Constitution.

I want us to move on at this point, because we do have one last presentation for this morning. So I would ask that the Honorable Chairman Alvin Windy Boy please come back to the podium at this time. And then it looks like we may have a little opportunity for a couple of more comments or questions before the Deputy Secretary has to leave us to go to the honoring ceremony.

MR. A. WINDY BOY: Good morning again. Again, I do have some position papers that I will leave out, outside. Health -- epidemiology needs, American Indian and Alaska Natives. Specific goals, healthy people, 2010. Twenty-ten, the year 2010. Remember that year. Because that is when I will finally reach 40.

(Laughter.)

MR. A. WINDY BOY: As the Chairman of the Chippewa Cree tribe, I am encouraged by the invitation of the Department of Health and Human Services to tribal leaders to provide recommendations on the American Indian and Alaska Natives' health needs and priorities for the fiscal year 2003 budget.

Addressing the health disparities of American Indians is enormous, a task that will necessitate the input and commitment of tribal communities and their partner agencies for success.

Through public health needs, we know that the health status of a population is influenced by many factors drawn from biology, behavior, the environment, and use of health services.

Social and cultural factors also play a role in the disease patterns experienced by different populations, as well as in the responses of these populations to diseases and illnesses.

It is critical for tribes that we look at definitive factors such as poverty, poor housing, unemployment, and other socioeconomic problems that may challenge and cause changes to health status.

We know that one of the most destructive effects of poverty is that it debilitates some individual tribal members physically and psychologically to such a degree that they are effectively shut out from participating in life. Poor health is a result of poverty, and not the cause.

Health, nutrition, and social service programs are essential components to the lifeblood of tribal communities.

In Montana, which is probably no different than Alaska, the isolation, I think the Department needs to take a look at the ruralness, the isolation. The cost of doing business in Indian country.

I have some people that are on dialysis that we have got to transport 310 miles one way. That is three times a week. Not because of, because of, because of accessibility. It is because dialysis units are filled in Great Falls, 120 miles away, and have the closest town 40 miles away.

Health, nutrition, and social service programs are essential components to the lifeblood of tribal communities. Most importantly these programs seek to advance the well-being of individual tribal members. By improving the health standards of tribal members, these programs increase the individual tribal member's ability to participate in personal tribal community and global community progress and growth.

The Indian Health Service, in partnership with tribes, have made some significant achievements in improving the health status of American Indians and Alaska Natives. Yet mortality rates for American Indians continue to surpass those of the general population.

American Indians have a 249-percent chance of dying from diabetes. And a 200-percent chance of dying from accidents. And you know, from the Indian Health Service statistics, that STDs are on the incline in Indian country, in comparison to the general population, for the first time.

Though we do not have an analysis that would substantiate that rise of the STDs could signal a potential rise in other communicable diseases, such as Hepatitis C and HIV. And tribes are afraid it could happen.

Infectious disease, often what we associate with public health, but now we are seeing health status affected by behavioral mediated risks, such as tobacco use, diet, alcohol and injuries.

As a co-chair of the Tribal Leaders Diabetes Committee, I believe to effectively adjust diabetes, we as tribal communities must deal with the associated behaviors of diet, exercise, and ability to comply with taking medications which affect whether we can successfully combat diabetes.

Diabetes is on the rise not only in tribal communities, but also in the nation as a whole. Type II diabetes is on the incline. Type II diabetes is preventable.

What can a tribal community do to prevent diabetes? Educate our community on diabetes, and monitor our diabetic tribal members to ensure we are providing responsible and quality health care.

We are seeing not only an increase in diabetes within the age groups most commonly affected, but in the younger populations, as well. American Indian and Alaska Natives are known to be young, fast-growing populations. We have seen that in statistics.

We are developing diabetes at a younger age. What strain will this add to our underfunded health care system, knowing we may be supporting, at great cost, an individual at a younger age for a potentially longer time?

Tribal leaders and tribal communities have expressed that we need to do more than focus on clinical issues in diabetes treatment. We have stated that we must focus as tribal communities on all areas of diabetes prevention, especially in our young people. It will take the cooperative effort of a family, tribal community, and our agency partners to address diabetes in our tribal communities.

According to the Association of Schools of Public Health, health promotion and disease prevention technologies have three core functions. These functions are, number one, assessment and monitoring of health, monitoring of the health communities in populations at risk to identify health problems.

What we know as, in some American Indian and Alaska Native communities, 60 percent of the adults have diagnosed diabetes. American Indian and Alaska Natives with diabetes have over four times greater mortality deaths from diabetes compared with, with the general population.

Research from the Indian Health Service shows that tight blood sugar control prevents complications of Type II diabetes. The issue, in collaboration with the Indian Health Service, tribes are in the beginning stages of, of data collection, management, and analysis.

Assessment means data. Monitoring is dependent upon the analysis of data. Research is dependent upon data to ask, to ask the questions needed. Tribes are at different levels of expertise in this process. The new Indian Health Service epicenters are in the lead in this effort, but not all IHSAs have an epicenter.

Data needed at the operating unit is local data, and may be specific to a tribe. Tribes need a boost. Tribes need a boost in institutional capacity to collect, house, and interpret their own data, as well as to have access to a national databank.

Tribes want the control of their data, and the interpretation of it, as well. This lack of, lack of data prevents any alert to a potential health risk until a problem becomes a crisis. Any preventative measures which could save lives and costs are limited, limited because this, by this lack of data.

Formulation of public policies, in collaboration with community and governmental leaders designed to solve, identify the national health problems and priorities. What we know, the Indian Health Service National Diabetes Program and the Tribal Leaders Diabetes Committee, of which I serve as Chairman -- I would like to acknowledge Buford Rolin as a Board member -- and the elected leadership group representing each of the 12 IHS areas in the nation, with one at-large tribal leader member, continuously collaborate on diabetes policy issues affecting American Indian and Alaska Natives.

The issue, though tribes are the most effective at developing their programs to best serve their communities, the lack of adequate data about the communities limits the tribe's ability to identify local problems and prioritize accordingly.

As I mentioned earlier, partnerships. Partnerships could be interpreted in many ways. I want to expound a little on the partnership that we have created with the Indian Health Service in reference to, to diabetes. Because we know that diabetes is, is a disease that is running rampant in Indian country.

The magical word of "cure" always seems to be close, but out of reach. In collaboration and in partnership, not only with the Indian Health Service, we have developed an initiative through the Tribal Leaders Diabetes Committee of working with existing agencies within the Department. And I could never get this one right, but I am working on it. NIDDK, National Institute for Digestive Disorder of Kidneys. Yes, there you go.

(Laughter.)

MR. A. WINDY BOY: It took me two years. But finally, we have collaborated with both the Tribal Leaders Diabetes Committee, the Indian Health Service, NIDDK, and the American Indian Higher Education Consortium, to look at demonstration projects that would allow our, our grade school and high school students to become more in tune with health and science subjects in their area. To get them more in tune, and to help delivery fields. And we are just in the beginning stages of that.

We also are, will be entering into partnership with the HIV program, under Dr. Bertoli.

Assuming that all populations have access to appropriate cost-effective care, including promotion, disease prevention services, and evaluation of that care. What we know to achieve tight blood sugar control and prevention of complication, the average person with diabetes takes 10 prescription medications.

Within the last 10 years, new and more effective diabetes medications and glucose monitoring equipment are available for people with Type II diabetes. Many Indian Health Care units, sites are unable to afford these medications and supplies. Operating unit pharmacy budgets remain flat, while drug costs increased 25 percent last year alone.

Using a conservative managed care clinical figure of $5,000 per patient with diabetes within a diabetes year, we can say that, number one, clinical diabetes treatment and management of the 80,000 American Indian and Alaska Native people known with diabetes will cost $400 million per year. This $400 million would cover clinical costs only.

In 1996 the Indian Health Service received $1,578 per capita to care for American Indians and Alaska Natives, compared to the $3,920 per capita expended for the US general population.

Those two figures, if there is anything that I can, that I can say and leave with you, $1,578 versus $3,920. Compare the two figures.

Then a question was raised about the self-governance issue a little bit ago. All the self-governance tribes have done was taken the $1,578 figure to provide care that, that, with a budget that is not up to par. And in comparison with NIHB statistics, was determined that, in comparison with other federal agencies within the system, that even the prisoners in the prison system get better health care than Indian country. Their health care delivery is quoted at about a $5,000 level. Where is the disparity? Where is the parity?

On the issue, the tribes are utilizing the public health ideals to combat diabetes. But funding is an issue, again. Even with the increase in Indian diabetes funding, the majority of the monies will go to emerging needs of direct care.

Prevention is the key. And there are still insufficient levels of funding for diabetes prevention.

The fiscal year 2001 budget includes an increase of $35 million to provide additional services, services in several key areas, which were determined through tribal consultation between the Indian Health Service and tribal leader representation.

These key areas are diabetes, cancer, heart, and infectious diseases. Domestic community violence program prevention, emergency medical services, and injury prevention, mental health, alcohol/substance abuse, prevention, treatment, and as mentioned earlier, dental health.

The health disparities within each of these areas are significant and challenge tribal people in gaining healthy lives. Given the alarming shortages of resources, financial and otherwise, tribes are challenged to find a balance between our tribal communities towards, needs toward a healthy life, and what resources are available to assist us to that healthy life.

What can DHHS do? Tribes have an existing public health infrastructure that needs increased funding. Technical assistance and collaborative partners that respect the needs and wishes of tribal communities. We are looking to the essential collaboration of DHHS with tribes and the Indian Health Service, adjusting the health disparities crisis, which includes diabetes in Indian country.

I thank you for this opportunity to speak this morning. And I have got 15 minutes.

(Laughter.)

MR. A. WINDY BOY: And with that, I want to thank you. I enjoy, I enjoy doing presentations to the Department. And I hope this is one of many. And I hope, with the ear that you are providing, that we can see results. I hope.

(Applause.)

MS. MASTEN: And just closing, while it seems daunting to address our, the health disparities in Indian country, we are extremely excited and encouraged by the Secretary's commitment to government-to-government relations, and look forward to this afternoon's session.

I want to ask that those of you that are sitting around the table, to please, when you come back, take the same seats, so it can help the recorder in the proceedings. And we need to adjourn so that we can all participate in the honoring ceremony that the Department is going to conduct at 11. So we will adjourn at this time, and reconvene this afternoon.

(Whereupon, at 10:50 a.m., the hearing was recessed, to reconvene at 1:05 p.m. this same day, Friday, June 15, 2001.)

Last revised: November 10, 2003

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