[Senate Hearing 110-191]
[From the U.S. Government Printing Office]


                                                        S. Hrg. 110-191
 
                             INDIAN HEALTH 

=======================================================================

                             FIELD HEARING

                               before the

                      COMMITTEE ON INDIAN AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                            AUGUST 15, 2007

                               __________

         Printed for the use of the Committee on Indian Affairs

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38-721 PDF                 WASHINGTON DC:  2007
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                      COMMITTEE ON INDIAN AFFAIRS

                BYRON L. DORGAN, North Dakota, Chairman
                 LISA MURKOWSKI, Alaska, Vice Chairman
DANIEL K. INOUYE, Hawaii             JOHN McCAIN, Arizona
KENT CONRAD, North Dakota            TOM COBURN, M.D., Oklahoma
DANIEL K. AKAKA, Hawaii              JOHN BARRASSO, Wyoming
TIM JOHNSON, South Dakota            PETE V. DOMENICI, New Mexico
MARIA CANTWELL, Washington           GORDON H. SMITH, Oregon
CLAIRE McCASKILL, Missouri           RICHARD BURR, North Carolina
JON TESTER, Montana
                Sara G. Garland, Majority Staff Director
              David A. Mullon Jr. Minority Staff Director


















                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on August 15, 2007..................................     1
Statement of Senator Dorgan......................................     1
Statement of Senator Tester......................................     3

                               Witnesses

Clark, H. Westley, M.D., J.D., M.P.H., Director, Center for 
  Substance Abuse Treatment, Substance Abuse and Mental Health 
  Service Administration, U.S. Department of Health and Human 
  Services.......................................................    14
    Prepared statement...........................................    17
Eaglefeathers, Melbert ``Moke'', President, National Council of 
  Urban Indian Health; Director, North American Indian Alliance; 
  accompanied by Marjorie Bear Don't Walk, Executive Director, 
  Indian Health Board, Billings, MT..............................    65
    Prepared statement...........................................    67
Joseph, Jr., Andy, Chair, Health and Human Service Committee, 
  Colville Confederated Tribes...................................   109
Killsback, Jace, Billings Area Representative, National Indian 
  Health Board, Council Member, Northern Cheyenne Tribe; 
  accompanied by Stacy Bohlen, Executive Director, National 
  Indian Health Board and Dr. Joseph Erpelding, Orthopedic 
  Surgeon, Billings, Montana.....................................    31
    Prepared statement...........................................    34
King, Tracy ``Ching'', Council Member, Fort Belknap Indian 
  Community, Assiniboine Tribe...................................    95
Lankford, Carole, Vice-Chair, Salish Kootenai Tribes; accompanied 
  by Kevin Howlett, Health Director, Salish Kootenai Tribes......    94
Little Coyote, Eugene, President Northern Cheyenne Tribe.........    96
    Prepared statement...........................................    97
Little Plume, Edwin, Chairman, Health Committee, Blackfeet Tribal 
  Business Council...............................................   101
    Prepared statement...........................................   102
McDonald, Dr. Joseph F., President, Salish Kootenai College......    49
    Prepared statement...........................................    51
North, Charles Q., M.D., M.S., Acting Chief Medical Officer, 
  Indian Health Service; accompanied by Pete Conway, Director, 
  Billings Area Office, Indian Health Service....................     5
    Prepared statement...........................................     8
Real Bird, Ken, Representative, Crow Tribe.......................   110
Red Eagle, Darryl, Tribal Executive Board Member, Fort Peck 
  Assiniboine Sioux Tribe........................................    82
    Prepared statement with attachments..........................    83
Stewart, Leo, Vice-Chairman, Confederated Tribes of Umatilla 
  Indian Reservation.............................................   100
Venne, Carl, Chairman, Crow Tribe................................   111
Walk Above, Ms., Member, Crow Tribe..............................   109
White, Ada M., Health Service Director, Crow Tribe...............    53
    Prepared statement...........................................    57
Wheeler, Julia Davis, Tribal Council Member, Nez Perce Tribe.....    95
Windy Boy, Hon. Jonathan, Council Member, Chippewa Cree Tribe 
  Business Committee; Montana Representative, House District 32..    60
    Prepared statement...........................................    62

                                Appendix

Adams, Barry, Browning MT, prepared statement....................   163
Belcourt, Gordon, Executive Director, Montana-Wyoming Tribal 
  Leaders Council, prepared statement with attachment............   129
Brown, Dick, President, MHA--an Association of Montana Health 
  Care Providers, prepared statement.............................   116
Confederated Salish and Kootenai Tribes of the Flathead Nation, 
  prepared statement.............................................   113
Clairmont, Gwen, Member of the Confederated Salish and Kootenai 
  Tribes, prepared statement.....................................   124
Fort Belknap Indian Community Council, prepared statement........   155
Gavin, Shawna M., Chair, CTUIR Health Commission, letter, dated 
  August 14, 2007, to Hon. Byron L. Dorgan.......................   172
Johnson, Laurene, Member of the Confederated Salish and Kootenai 
  Tribes, prepared statement.....................................   118
Juneau, Carol, State Senator, Senate District 8, Montana, 
  prepared statement.............................................   160
Myers, David B., M.D., Billings MT, prepared statement...........   159
Nez Perce Tribe, prepared statement..............................   168
Norgaard, Margaret, CEO, Northeast Montana Health Services 
  (NEMHS), prepared statement....................................   122
Sinclair, John, President, Little Shell Tribe of Chippewa Indians 
  of Montana, prepared statement with attachments................   126
Stone, Lou, Member of the Sngaytskstx Tribe, prepared statement..   119
Ward, Alex, Associate State Director, AARP Montana, prepared 
  statement......................................................   166


                             INDIAN HEALTH

                              ----------                              


                       WEDNESDAY, AUGUST 15, 2007

                                       U.S. Senate,
                               Committee on Indian Affairs,
                                                    Crow Agency, MT
    Pursuant to notice, the Senate Committee on Indian Affairs 
Field Hearing was held on August 15, 2007, at the Crow Tribal 
Multi-Purpose Building, 4 Cap Hill Road, Crow Agency, Montana.
    [Opening prayer offered by Mr. Earl Old Person.]
    [Crow Tribe Color Guard and Drum Presentation.]

          OPENING STATEMENT OF HON. BYRON L. DORGAN, 
                 U.S. SENATOR FROM NORTH DAKOTA

    Senator Dorgan. Ladies and gentlemen, we will call to order 
this U.S. Senate Committee Hearing. It's the Committee on 
Indian Affairs in the U.S. Senate.
    I'm Senator Byron Dorgan, the Chairman of the Committee. I 
am joined by Senator Jon Tester, a member of our Committee from 
the State of Montana.
    We are joined by Sara Garland, who is the Chief of Staff on 
the majority side of the Committee, and David Mullon, who is 
the Chief of Staff on the minority side of the Indian Affairs 
Committee.
    I want to thank, first of all, all of you for being in 
attendance. I know from just having visited with a number of 
you, we have Indian leaders and members of tribal governments 
and folks from all around this region, and I very much 
appreciate your taking the time to be with us today.
    I want to especially say to Chairman Venne, with whom I've 
had a chance to have a lengthy conversation today about these 
issues, thanks to your leadership, thank you for hosting us. 
I'm deeply honored to be here with the Crow Nation.
    To Earl Old Person, thank you very much for the blessing 
today. Earl and I were able to ride on a subway car underneath 
the United States Capitol about three, 4 weeks ago, and I asked 
him how long he has been in tribal leadership, and I think Earl 
told me that he's been the Tribal Chair since 1964. And if you 
want a definition of commitment and leadership, look at a 
commitment from 1964 to today. God bless you.
    Thank you very much for being here, Earl.
    I want to especially say, because I am in the State of 
Montana, how appreciative I am of being able to serve with 
Senator Max Baucus, with whom I've served for some long while. 
Max does a great job for Montana and for our country, and pays 
a lot of attention to and works hard on Indian issues.
    I want to also say that we have been joined in the U.S. 
Senate by someone new, someone who I think brings a real breath 
of fresh air to the U.S. Senate and to the Senate Indian 
Affairs Committee, and that is Senator Jon Tester.
    We are, as you know, pushing very, very hard to get the 
Indian Health Care Improvement Act done and to the President 
for signature. No one has been more important to that push and 
to our success in getting it out of the Indian Affairs 
Committee, our success in getting a commitment--Senator Baucus 
is going to mark it up on September 12th in the Finance 
Committee--our success in getting the majority leader, Senator 
Harry Reid, to say that he will give us opportunities on the 
floor of the Senate to get this passed.
    No one has been more instrumental in that than Senator Jon 
Tester. He is a tireless worker on behalf of American Indians; 
a tireless worker in search of good, thoughtful, sensible 
policies that address health care, housing, education and all 
the things that we know need addressing on Indian reservations 
in this country.
    So, I can't thank you enough for sending a real partner to 
Washington, D.C. to work on these issues.
    Now, I'm here because I was invited. I've taken over the 
reins of the chairmanship of the Committee of the Senate, the 
Committee on Indian Affairs. I've held some listening sessions 
around the country. We've held some hearings.
    I've decided this; I'm just a little tired of waiting for 
good things to happen. We have to make good things happen. We 
shouldn't have patience. When we have people dying because we 
don't have adequate health care on the reservations of the 
first Americans, the people who were here first, we ought not 
have patience to let that happen.
    When we have people living in inadequate housing, I'm out 
of patience. We shouldn't say that's okay. When we have 
children going to school through classroom doors that we know 
are not real class settings, we shouldn't accept that. And so, 
I'm just out of patience. I'm a little out of sorts.
    I believe that we ought to impose on everyone in the 
decision-making capacity in our government to say, keep your 
promise. You made the promises, you've broken too many. It's 
time that you ought to keep them. And that deals with health 
care, education, housing and more. And this Committee is going 
to work to see that happen.
    I was given the honor of an Indian name in a ceremony with 
the Standing Rock Sioux Tribe some long while ago, and the 
Indian name given me was Cante un Wiyukcan, which they said 
means ``thinks with his heart.''
    Well, my heart tells me that we don't have a lot of time. 
My heart tells me that there are people living among us who 
need us, and need answers. They need good schools; they need 
better health care, and they need decent shelter. And that's 
the mission of this Committee.
    So, I want to thank Senator Tester for inviting me here to 
Montana.
    Let me just say one additional point. I wish very much I 
could stay for about three or 4 days. Chairman Venne gave us a 
little ride around the area where there's a lot of camping 
going on, a lot of preparation for a very big event in the Crow 
Nation. I've not been to this event at the Crow Nation, but 
I've heard a lot about it.
    I sat next to a person on the airplane coming into Billings 
today, who was coming here from Iowa. He said well, I come to 
this celebration every year on the Crow Nation.
    So I've heard about it and I wish I could stay, but I 
can't. But I know that you all are going to have a great, great 
few days ahead of you.
    So, Senator Tester, we will hear testimony from a wide-
range of witnesses today, but before we do, again, I want to 
thank you, thank you for your leadership, thank you for 
focusing a laser on these issues.
    You and I and other members of the panel of the Indian 
Affairs Committee are going to get things done, and we're going 
to push until that happens.
    So, Senator Tester, let me call on you for some comments, 
and again, thank you, very much.

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Thank you, Mr. Chairman, for taking the 
time out of your busy schedule to come to Montana and visit 
with us. To the people of the State of Montana here in Indian 
Country, it's critically important. It's no small measure, I 
know how busy you are, and I appreciate you making the time to 
be here.
    I also want to welcome all my friends that are here that 
have come to listen and testify.
    You know, I think Montanans really appreciate, Mr. 
Chairman, you holding this hearing in Montana to address what 
we all know is a very critical issue.
    Health care in Montana's Indian Country is in serious 
trouble. American Indian citizens are suffering, and we really 
need to address the problem now.
    I am truly outraged by the statements, and I heard it again 
today by Chairman Venne, and that is you don't get sick in 
June, after June in Indian Country. That is absolutely 
unacceptable, and I'm sorry you have to wait until your illness 
gets to a point where you may lose a limb or your life.
    Those are examples of health care in Third World countries. 
We don't live in a Third World country. American Indians are 
Americans, American citizens who are entitled to deserve 
respect in this country. Our Federal Government signed binding 
legal treaties many years ago and those treaties are still in 
effect today. Those treaties promised that in exchange for 
millions of acres of land and vast amounts of natural 
resources, our government would use some of those dollars that 
emerged from those lands to provide American Indians with 
adequate health care, education and housing, economic 
development to distinct quality of lives.
    Everybody in this room knows over the past several hundred 
years the government has failed to tell the truth to the 
American Indian, cheated the Indians, and failed to fulfill 
promises made many, many years ago.
    The government got what it wanted out of the deal, but so 
far, Mr. Chairman, the government has failed to hold up its end 
of the deal. The result is that several generations later, our 
government still has legal obligations to live up to its end of 
the bargain.
    Since then, the price of health care has literally gone 
through the roof and will continue to go up. We need to address 
the situation now. We need to fund the system. This cannot wait 
to be funded any longer. We need to change the national 
priorities and introduce legislation to fix this broken system.
    All of us in the room know that merely to explain about the 
problem is not enough, we need to act and we need to act now.
    For my part, I'm seeking for some of the following actions; 
cosponsoring the Indian Health Care Improvement Act that 
Senator Dorgan talked about, that hopefully will be out of 
Finance by September 12. The last time it was passed was 1999. 
That's totally, totally ridiculous, and unacceptable.
    Also, I have introduced THE PATH Act that is a result of 
some hearings that I had in Browning 3 months ago. This 
important legislation will award grants and draft cooperative 
agreements with the Department of Health and Human Services and 
the tribal colleges and universities, to help Indian Country 
meet their staffing needs in health care.
    It will establish a coordinating officer to assure seamless 
transition and administration; establish community-based health 
and wellness affairs, and begin to address illness and injury 
before it gets to a life or limb situation.
    It will develop and expand public health professional 
educational opportunities, establish an endowment for rural 
tribal colleges to expand health education, and create health 
prevention and disease prevention research, particularly in the 
areas of diabetes.
    Tribal colleges and universities Faculty Loan Forgiveness 
Act, it does what it says, it will help forgive loans to 
individuals that want to teach in tribal colleges, to recruit 
and train more qualified professors at those tribal colleges or 
universities, particularly in the field of nursing or health-
related fields.
    Our goal, Mr. Chairman, should be to give equal access to 
health care for all Montanans. Make no mistake, Mr. Chairman, 
I'm not here today working to provide Indians with superior 
quality health and quality of life, I'm simply working to 
fulfill the promises our grandfathers made over a hundred years 
ago.
    Today, we focus on three vital issues in American Indian 
health care, immediate health care needs, recruiting and 
retaining of health care professionals, and improving the 
reimbursement process.
    In the end, Mr. Chairman, it is truly my goal on this 
committee, to re-prioritize issues affecting Indian Country. If 
the President can justify spending $3 billion a week to first 
destroy and then rebuild Iraq, the government certainly has the 
money to fund an Indian health care system.
    This issue is not about money, Mr. Chairman, it is about 
priorities, and American Indians deserve to be a higher 
priority in this country. For that reason, I want to thank you 
very, very much for coming to Montana and making Indian health 
care a national priority.
    I look forward to working with you, Mr. Chairman, in this 
session of Congress, to continue to shift our priorities to 
improving Indian health care.
    With that, I just want to thank you very, very much for the 
opportunity that you've given all the good people here to talk 
about an issue that's so critically important.
    Mr. Chairman.
    Senator Dorgan. Senator Tester, thank you very much.
    This is a formal hearing of the U.S. Senate, but I want to 
do something just a little bit unusual. As I saw the flags 
brought in, I saw some very beautiful people behind the flag-
bearers and one of them caught my eye. And if I could ask to 
have that young lady brought forward, I want to tell you 
something.
    [Kailyn Old Crow brought forward.]
    What I wanted to tell you is as I watched her come in 
following the flags, it occurred to me that we're talking about 
all these issues today, but what we're talking about is not 
about us, it's not about me, it's not about you, it's about 
Kailyn. That's what this is about. It's about our children. 
It's about our future, and I can't think of a more beautiful 
symbol of our future than this young lady. God bless you.
    Thank you very much.
    Dr. Charles North is the Acting Chief Medical Officer of 
the Indian Health Service, and Dr. Westley Clark, the Director 
of the Center for Substance Abuse Treatment. I'd like both of 
them to come forward and take their chairs at the witness 
table, please.
    Dr. Charles North, the Acting Chief Medical Officer of the 
Indian Health Service is accompanied by Mr. Pete Conway, the 
Director of the Billings Area Office of the Indian Health 
Service, and Dr. Westley Clark, Director of the Center for 
Substance Abuse Treatment, Substance Abuse and Mental Health 
Services Administration.
    We appreciate both of you taking time to be with us today 
at our invitation, and we will obviously include your entire 
statement as a part of the permanent Committee records.
    We would ask that both of you summarize, following which we 
would like to ask a series of questions. As you testify, I'd 
like to ask that you pull the microphone as close as possible 
so that everyone in the audience can hear clearly the testimony 
you are giving.
    Dr. Charles North, you may proceed.

STATEMENT OF CHARLES Q. NORTH, M.D., M.S., ACTING CHIEF MEDICAL 
                OFFICER, INDIAN HEALTH SERVICE; 
  ACCOMPANIED BY PETE CONWAY, DIRECTOR, BILLINGS AREA OFFICE, 
                     INDIAN HEALTH SERVICE

    Dr. North. Good morning, I am Dr. Charles Q. North, Acting 
Chief Medical Officer of the Indian Health Service.
    I am glad to be here this afternoon, and I would like to 
thank Chairman Venne also for having us at Crow Agency.
    Today I am accompanied by Mr. Pete Conway, the Area 
Director for the Billings Area of the Indian Health Service, 
and we're both pleased to have the opportunity to testify on 
behalf of the Indian Health Service Director, Dr. Charles Grim, 
on the status of the Indian Health Service and the health of 
Indian people.
    The Indian Health Service has the responsibility for the 
delivery of health services to more than 1.9 million federally-
recognized American Indians and Alaska Natives through a system 
of Indian Health Service, tribal and urban operated facilities 
and programs governed by statutes and judicial decision.
    The mission of the agency is to raise the physical, mental, 
social, and spiritual health of American Indians and Alaska 
Natives to the highest level, in partnership with the 
populations that we serve.
    The agency's goal is to insure that comprehensive, 
culturally acceptable personal and public health services are 
available and accessible to the service population.
    We are here today to discuss Indian health and the IHS 
focus on improving the health of Indian people, and eliminating 
health disparities through health promotion and disease 
prevention, behavioral health and chronic disease management.
    We will also address issues related to Indian health 
manpower, access to health care, consultation and contract 
health care.
    I would like to also note that the Health and Human 
Services Department summer of 2007 Indian Country bus tour to 
promote prevention and healthier living is here today and will 
follow the hearing.
    As part of the ``Healthier US Starts Here'' initiative, the 
U.S. Department of Health and Human Services is joining local 
officials and health care partners to raise awareness of the 
importance of preventing chronic disease and illness, promoting 
Medicare preventive benefits, and providing information about 
how individuals can take action to maintain and improve their 
health.
    This effort supports the Indian Health Service goal to 
create healthier American Indian and Alaska Native communities 
by developing and implementing effective health promotion and 
chronic disease prevention programs.
    We want to recognize the Crow Tribe for the outstanding 
work it does to promote healthy living in its community. 
Chairman Venne has been a great friend to the Department by 
hosting our former Deputy Secretary and our Assistant Secretary 
for Health, and we are here to thank his staff for all their 
efforts to make Indian Country healthier.
    While the mortality rates of Indian people have improved 
dramatically over the past 10 years, Indian people continue to 
experience health disparities and death rates that are 
significantly higher than the rest of the U.S. general 
population.
    Alcoholism rates are 550 percent higher; diabetes rates are 
almost 200 percent higher; unintentional injury rates, 154 
percent higher; suicide is 57 percent higher, and homicide is 
108 percent higher than the general population.
    Making significant reductions in health disparity rates can 
be achieved by implementing the best practices in medicine, 
using traditional community values, and building the local 
capacity to address these health issues and promote healthy 
choices. Since 1997, the Special Diabetes Program for Indians 
funding of $150 million has expanded our diabetes prevention 
and treatment efforts. These funds support over 300 IHS tribal 
and urban community-based diabetes prevention and treatment 
projects, along with a demonstration project focused on primary 
prevention of type 2 diabetes in 35 separate American Indian 
and Alaska Native communities.
    The competitive grant initiatives focus on American Indian 
and Alaska Native adults with pre-diabetes to determine if an 
intensive life-style intervention can be successfully 
implemented in our communities.
    One of the models we are using was developed by the 
National Institutes of Health that proved that diabetes could 
be prevented. This program will cover a four-year period. The 
outcomes of the demonstration project will enable us to learn 
what may be applicable to other communities throughout Indian 
Country.
    Indian health manpower is a critical issue, it's a critical 
issue here in Crow. IHS tribal and urban Indian health programs 
cannot function without adequate health care providers.
    Indian Health Manpower programs, which is also authorized 
in the Indian Health Care Improvement Act that you mentioned 
earlier, consists of the Indian Health Service Scholarship 
Program, the IHS Loan Repayment Program; and the IHS Health 
Professional Recruitment Program.
    The IHS Scholarship Program plays a major role in the 
production of health care and professionals of American Indian 
and Alaska Native descent. Since its inception in 1977, more 
than 7,000 American Indian and Alaska Native students have 
participated in the program.
    The IHS Scholarship Program has been the starting point for 
the careers of a number of health professionals now working in 
the Federal, tribal and urban Indian health programs.
    Many are also involved in academia continuing to help 
identify promising young American Indian and Alaska Native 
students and recruiting them to the health professions.
    The IHS Loan Repayment Program is very effective in both 
the recruitment and retention areas. There are currently 723 
health professionals in the Loan Repayment Program.
    Access to health care can be promoted by the Environmental 
Health and Engineering Program of the Indian Health Service, 
which is a comprehensive public health program administered by 
Indian Health and tribes.
    Indian self-determination and self-governance and 
consultation are extremely important to this administration. 
The IHS has been contracting with tribes and tribal 
organizations under the Indian Self-Determination and Education 
Assistance Act, Public Law 93-638, as amended, since its 
enactment in 1975.
    Indian Tribes now administer 54 percent of our budget with 
IHS funds transferred through self-determination contracts and 
compacts. IHS adheres strongly to its long-standing tribal 
consultation policy.
    The Indian Health Service purchases medical and dental 
services from providers in the private sector though its 
Contract Health Services program, which is a component of the 
Indian health care system.
    In Fiscal Year 2007, the CHS program is funded at $543 
million. Patients are referred to the private sector health 
facilities, programs and practitioners for treatment when 
needed services are unavailable as direct care through the 
Indian health care system.
    The CHS program makes payment for speciality services and 
inpatient care to private sector facilities and providers in 
accordance with established eligibility and medical priority 
guidelines.
    Mr. Chairman, this concludes my oral statement. Thank you 
for the opportunity to report on Indian Health Service programs 
serving American Indians and Alaska Natives and their impact on 
the health status of our populations.
    We will be happy to answer any questions that you may have.
    [The prepared statement of Dr. North follows:]

   Prepared Statement of Charles Q. North, M.D., M.S., Acting Chief 
                 Medical Officer, Indian Health Service
    Mr. Chairman and Members of the Committee:
    Good morning, I am Dr. Charles Q. North, Acting Chief Medical 
Officer for Indian Health Service (IHS). Today I am accompanied by Mr. 
Pete Conway, Area Director, Billings Area IHS. We are pleased to have 
this opportunity to testify on behalf of Dr. Charles W. Grim, Director, 
IHS on the status of Indian Health.
    The IHS has the responsibility for the delivery of health services 
to more than 1.9 million Federally-recognized American Indians and 
Alaska Natives (AI/ANs) through a system of IHS, tribal, and urban (I/
T/U) operated facilities and programs governed by statutes and judicial 
decisions. The mission of the agency is to raise the physical, mental, 
social, and spiritual health of AI/ANs to the highest level, in 
partnership with the population we serve. The agency goal is to assure 
that comprehensive, culturally acceptable personal and public health 
services are available and accessible to the service population. Our 
duty is to uphold the Federal Government's responsibility to promote 
healthy American Indian and Alaska Native people, communities, and 
cultures and to honor and protect the inherent sovereign rights of 
Tribes.
    Two major statutes are at the core of the Federal Government's 
responsibility for meeting the health needs of American Indians/Alaska 
Natives (AI/ANs): The Snyder Act of 1921, P.L. 67-85, and the Indian 
Health Care Improvement Act (IHCIA), P.L. 94-437, as amended. The 
Snyder Act authorized regular appropriations for ``the relief of 
distress and conservation of health'' of American Indians/Alaska 
Natives. The IHCIA was enacted ``to implement the Federal 
responsibility for the care and education of the Indian people by 
improving the services and facilities of Federal Indian health programs 
and encouraging maximum participation of Indians in such programs.'' 
Like the Snyder Act, the IHCIA provides the authority for the provision 
of Federal programs, services and activities to address the health 
needs of AI/ANs. The IHCIA also includes authorities for the 
recruitment and retention of health professionals serving Indian 
communities, health services for urban Indian people and the 
construction, replacement, and repair of health care facilities.
    We are here today to discuss Indian health and the IHS focus on 
improving the health of Indian people and eliminating health 
disparities through health promotion and disease prevention, behavioral 
health and chronic disease management. We will also address issues 
related to Indian health manpower, access to health care, consultation, 
contract health services and claims processing, eligibility, medical 
priorities and the Catastrophic Health Emergency Fund (CHEF).
HHS Summer 2007 Indian Country Bus Tour to Promote Prevention and 
        Healthier Living
    This summer, as part of the ``A Healthier US Starts Here'' 
initiative, the U.S. Department of Health and Human Services (HHS) is 
joining local officials and health care partners to raise awareness of 
the importance of preventing chronic disease and illness, promote 
Medicare preventive benefits, and provide information about how 
individuals can take action to maintain and improve their health.
    By the end of August, the bus tour will have visited each of the 48 
continental states to promote preventive services. While the bus tour 
is promoting healthier living with the country as a whole, the Indian 
Health Service has participated to promote and recognize the health 
promotion/disease prevention activities that Indian Country practices 
on a daily basis to promote healthier living.
    This effort supports the Indian Health Service's goal to create 
healthier American Indian and Alaska Native communities by developing 
and implementing effective health promotion and chronic disease 
prevention programs. This is accomplished in collaboration with our key 
stakeholders, the American Indian and Alaska Native people, and by 
building on individual, family, and community strengths and assets.
    On April 18, 2007, HHS hosted a kickoff event with Tribal Leaders 
and National Tribal Organizations in Washington, D.C. at the 
Smithsonian's National Museum of the American Indian. Since this event, 
HHS has visited over 20 Tribal Communities and we have over 6 tribal 
stops remaining and with one occurring right after this hearing here at 
the Crow Tribe.
    We are here this afternoon with our prevention tour to recognize 
the Crow Tribe for the outstanding work it does to promote healthy 
living in its community. Chairman Venne has been a great friend to the 
Department by hosting our former Deputy Secretary and our Assistant 
Secretary for Health and we are to thank his staff for all their 
efforts to making Indian Country healthier. We will recognize his 
tribal prevention programs; recognition of 50+ fitness challenge 
participants; and his Meth activities coordinator.
Health Disparities
    While the mortality rates of Indian people have improved 
dramatically over the past ten years, Indian people continue to 
experience health disparities and death rates (2001-2003) that are 
significantly higher than the rest of the U.S. general population 
(2002: National Vital Statistics Reports: Vol. 53 No. 5. National 
Center for Health Statistics):

   Alcoholism--551 percent higher
   Diabetes--196 percent higher
   Unintentional Injuries--154 percent higher
   Suicide--57 percent higher
   Homicide--108 percent higher

    These statistics are startling, yet they are so often repeated that 
some view them as insurmountable facts. But every one of them is 
influenced by behavior choices and lifestyle. Making significant 
reductions in health disparity rates can be achieved by implementing 
best practices, using traditional community values, and building the 
local capacity to address these health issues and promote healthy 
choices.
    Many issues that face the families nationally also affect families 
in Indian Country, and these problems are often magnified in the 
confines of Indian Country. If it is a problem nationally, it is 
magnified when it comes to Indian Country. Indian families are besieged 
by the numbing effects of poverty, lack of resources, and limited 
economic opportunity. Frustration, anger, and violence are among the 
prominent effects of this situation, and, while very understandable, 
they are equally unacceptable.
    Accordingly, the IHS is focusing on screening and primary 
prevention in mental health especially for depression, which manifests 
itself in suicide, domestic violence, and addictions. The agency is 
also working to more effectively utilize available treatment 
modalities; and, to improve documentation of mental health problems. We 
now have more effective tools for documentation through the behavioral 
health software package. We are also working with Tribal communities to 
focus on these mental health needs.
    Cardiovascular disease (CVD) is the leading cause of mortality 
among Indian people. This is a health disparity rate that the 
President, the Secretary of Health and Human Services, and the IHS are 
committed to eliminating. The Strong Heart Study, a longitudinal study 
of cardiovascular disease in 13 AI/AN communities, has clearly 
demonstrated that the vast majority of heart disease in AI/AN occurs in 
people with diabetes. In 2002, IHS was directed to address ``the most 
compelling complications of diabetes,'' including the most critical 
complication of heart disease. The IHS is working with other HHS 
programs, including the Centers for Disease Control and Prevention and 
the National Institutes of Health's National Heart Lung and Blood 
Institute, to develop a Native American Cardiovascular Disease 
Prevention Program. Also contributing to the effort are the IHS Disease 
Prevention Task Force and the American Heart Association.
    Our primary focus is on the development of more effective 
prevention programs for AI/AN communities. The IHS has begun several 
programs to encourage employees and our tribal and urban Indian health 
program partners to lose weight and exercise, such as ``Walk the Talk'' 
and ``Take Charge Challenge'' programs. Programs like these are cost 
effective in that prevention of both diabetes and heart disease, as 
well as a myriad of other chronic diseases, are all addressed through 
healthy eating and physical activity.
    Good oral health is essential to improving individuals' overall 
health and well being. The oral health of AI/AN people has improved in 
some age groups, but has gotten worse in others. While poor dental 
health is a significant problem for AI/ANs of all ages, the magnitude 
and long-term effects of the problem are greatest among very young 
children. The most recent oral health survey administered by the Indian 
Health Service showed that the AI/AN people experience some of the 
highest oral disease rates reported in the world. The 1999 IHS survey 
of Oral Health Status and Treatment Needs indicate the following:

   The majority of very young children experience tooth decay, 
        with 79 percent of children aged 2-4 years reporting with a 
        history of dental decay;

   Since 1991, there has been a significant increase in tooth 
        decay among young AI/AN children between 2-5 years of age;

   The majority of AI/AN children as a group have tooth decay 
        and the prevalence of decay increases with age: 87 percent of 
        the 6-14 year olds and 91 percent of the 15-19 year olds had a 
        history of decay;

   Most adults and elders have lost teeth because of dental 
        disease or oral trauma. 78 percent of adults 35-44 years and 98 
        percent of elders 55 years or older had lost at least one tooth 
        because of dental decay, periodontal (gum) disease or oral 
        trauma; and,

   Periodontal disease is a significant health problem for both 
        adults and elders. 59 percent of adults 35-44 years and 61 
        percent of elders have periodontal (gum) disease.

    In addition, the vacancy rate for dentists is at the highest level 
in our 52 year history, with 27.6 percent of authorized positions are 
vacant. In addition to the high vacancy rate, there is great concern 
over the oral health disparities experienced by the American Indian and 
Alaska Native people.
    We need to focus our efforts on these age groups that have shown 
declines in oral health status. Tribes have increasingly identified 
access to preventive and curative dental care as a major health 
priority; and the IHS and tribes will continue to advocate for 
additional resources for oral health.
    The incidence and prevalence of diabetes has been increasing 
dramatically since 1972. American Indians and Alaska Natives have the 
highest prevalence of type 2 diabetes in the United States (source: 
2003-2004 National Health Interview Survey and 2004 IHS Outpatient 
database). The prevalence of type 2 diabetes is rising faster among 
American Indian and Alaska Native children and young adults than in any 
other ethnic population, increasing 106 percent in just one decade from 
1990 to 2001 (source: IHS Division of Program Statistics). As diabetes 
develops at younger ages, so do related complications such as 
blindness, amputations, and end stage renal disease. Fortunately, the 
diabetes mortality rate for the entire AI/AN population did not 
increase between 1996-1998 and 1999-2001, so we are hopeful that we may 
be seeing a change in the pattern of diabetes mortality. In fact, the 
overall mortality rate for American Indians and Alaska Natives 
decreased approximately 3 percent between these same time periods 
(source: IHS Division of Diabetes Statistics and CDC Center for Health 
Statistics). And there is good news in that we have recently measured a 
slight, but statistically significant, decline in kidney failure in the 
AI/AN diabetic population as well.
    What is most distressing however about these statistics is that 
type 2 diabetes is largely preventable. Lifestyle changes, such as 
changes in diet, exercise patterns, and weight can significantly reduce 
the chances of developing type 2 diabetes. Focusing on prevention not 
only reduces the disease burden for a suffering population, but also 
lessens and sometimes eliminates the need for costly treatment options. 
The cost-effectiveness of a preventive approach to diabetes management 
is an important consideration, since the cost of caring for diabetes 
patients is staggering. The cost of managing care for treating diabetes 
ranges from $5,000-$9,000 per year with the annual cost per patient 
exceeding $13,000 (source: American Diabetes Association).
    In 1997, the Special Diabetes Program for Indians (SDPI) grant 
program was enacted and provided $30 million per year for a five year 
period to IHS for prevention and treatment services to address the 
growing problem of diabetes in AI/ANs. In 2001, Congress appropriated 
an additional $70 million for Fiscal Years 2001 and 2002. The program 
was funded at $100 million in Fiscal Year 2003. Then in 2002 Congress 
extended the SDPI through 2008, and increased the annual funding to 
$150 million for FY 2004-2008 with the directive to address ``primary 
prevention of type 2 diabetes and the most compelling complication of 
diabetes--cardiovascular disease.'' We are proud to announce that in FY 
2004 our Division of Diabetes Treatment and Prevention launched a 
competitive grant to implement two demonstration projects. One is 
focused on primary prevention of type 2 diabetes in people diagnosed 
with pre-diabetes to determine if an intensive life-style intervention 
can be successfully implemented in AI/AN communities. This effort is 
based on the NIH sponsored study called the Diabetes Prevention Program 
which provided evidence that type 2 diabetes could be prevention with 
lifestyle intervention. The other demonstration project is focused on 
cardiovascular risk reduction in people diagnosed with type 2 diabetes. 
Thirty-six AI/AN communities were awarded diabetes prevention 
demonstration projects and 30 AI/AN communities were awarded 
cardiovascular risk reduction demonstration projects in November 2004. 
These demonstration projects will cover a four year period. The 
outcomes of the demonstration projects will enable us to learn what may 
be applicable to other communities throughout Indian country. The last 
year of the demonstration projects will be aimed at dissemination of 
lessons learned to other tribal communities across the nation.
    With 65 percent of the IHS Mental Health budget and 85 percent of 
the alcohol and substance abuse budget going directly to tribally 
operated programs, tribes and communities are now taking responsibility 
for their own healing. They provide effective treatment and prevention 
services within their own communities.
    A primary area of focus is Dr. Grim's renewed emphasis on health 
promotion and disease prevention. This is our strongest front in the 
ongoing battle to eliminate health disparities which have plagued our 
people for far too long.
    Fortunately, the incidence and prevalence of many infectious 
diseases, once the leading cause of death and disability among American 
Indians and Alaska Natives, have dramatically decreased due to 
increased medical care and public health efforts including massive 
vaccination and sanitation facilities construction programs. As the 
population lives longer and adopts a more a western diet and sedentary 
lifestyle, chronic diseases emerge as the dominant factors in the 
health and longevity of the Indian population as evidenced by the 
increasing rates of cardiovascular disease, diabetes, and oral health 
problems. Most chronic diseases are affected by lifestyle choices and 
behaviors.
    In summary, preventing disease and injury, promoting healthy 
behaviors, and managing chronic diseases are a worthwhile financial and 
resource investment that will result in long-term savings by reducing 
the need for acute care and expensive treatment processes. It also 
yields the even more important humanitarian benefit of reducing pain 
and suffering, and prolonging life. This is the path we must follow if 
we are to reduce and eliminate the disparities in health that so 
clearly affect AI/AN people.
Indian Health Manpower
    IHS, Tribal and Urban Indian health programs could not function 
without adequate health care providers. The Indian Health Manpower 
program which is also authorized in the Indian Health Care Improvement 
Act (P.L. 94-437, as amended) consists of several components:

   The IHS Scholarship Program;
   The IHS Loan Repayment Program; and
   The IHS Health Professional Recruitment Program

    The IHS Scholarship Program plays a major role in the production of 
AI/AN health care professionals. Since its inception in 1977, more than 
7,000 AI/AN students have participated in the program, with the result 
that the number of AI/AN health professionals has been significantly 
increased. The program is unique in that it assists students who are 
interested in or preparing for entry into professional training. Most 
scholarships only provide assistance to those who have been accepted 
into a health professional training program.
    The IHS Scholarship Program has been the starting point for the 
careers of a number of AI/AN health professionals now working in IHS, 
tribal, and urban Indian health programs. Many are also involved in 
academia, continuing to help identify promising AI/AN students and 
recruit them to the health professions, thereby helping to produce a 
self-sustaining program. We have had several instances of parents going 
through the program, followed later by their children and not a few of 
the reverse, with children being followed by their parents. The average 
age of our students is 28 years, well above the norm for college 
students. It is not uncommon for students to have attended 5 or more 
colleges or universities during the course of their academic careers, 
not because they failed in the first four, but because they had to move 
in order to have the employment they needed to support their families.
    The IHS Loan Repayment Program (LRP) is very effective in both the 
recruitment and retention areas. There are currently 723 health 
professionals in the LRP. The scholarship and loan repayment programs 
complement one another. Scholarships help individuals rise above their 
economic background to become contributing members of the community and 
participate in improving the well-being of the community; while loan 
repayments are a way for participants to provide service in return for 
assistance in repaying loans that could otherwise be overwhelming.
    The recruitment program seeks to maximize the effectiveness of both 
programs, as well as to make the IHS more widely known within the 
health professional community and to assist interested professionals 
with job placement that best fits their professional and personal 
interests and needs.
Access to Health Care: The Environmental Health and Engineering Program
    The Environmental Health and Engineering program is a comprehensive 
public health program administered by IHS and Tribes. Two examples are 
the sanitation facilities construction program which provides safe 
drinking water, wastewater disposal, and solid waste disposal system; 
and the injury prevention program which focuses on unintentional 
injuries. As a result of these two successful programs, 88 percent of 
AI/AN homes now have safe water and mortality from unintentional 
injuries has been reduced by 58 percent between 1972-1974 and 2001-
2003. Unfortunately, 12 percent of Indian homes still lack adequate 
sanitation facilities compared to one percent of the rest of the United 
States population; and the leading cause of death for AI/ANs between 
the ages of 1 and 44 years of age is unintentional injuries. 
Improvement in these areas is integral to our mission.
    The Environmental Health and Engineering program, provides access 
to health care services through the health care facilities program, 
which funds federal and tribal construction, renovation, maintenance, 
and improvement of health care facilities. There are 48 hospitals, 272 
health centers, 11 school health centers, over 2,200 units of staff 
housing, 320 health stations, satellite clinics, and Alaska village 
clinics, and 11 youth regional treatment centers supporting the 
delivery of health care to AI/AN people. The IHS is responsible for 
managing and maintaining the largest inventory of real property in the 
DHHS, with over 9.6 million square feet (899,000 gross square meters) 
of space, and the Tribes own over 6 million square feet (571,000 gross 
square meters). This is in part the result of Tribally funded 
construction of millions of dollars worth of space to provide health 
care services by the Indian Health Service funded programs.
    Over the past decade, $600 million in funding has been invested in 
the construction of health care facilities which include, 1 Medical 
Center, 5 Hospitals, 9 Health Centers, 3 Youth Regional Treatment 
Centers, 500 units of Staff Quarters, 27 Dental Units, and 21 Small 
Ambulatory Program construction projects. Most of these facilities were 
replacements of inadequate health care facilities. We have 
substantially improved our health care delivery capability in the newer 
health care facilities and continue to improve access to services 
through health care facilities construction--health care facilities 
construction remains a priority.
    In response to a Congressional request to revise the Health Care 
Facilities Construction Priority System, we have been working to better 
identify the health care delivery needs. This will enable us to 
prioritize the need for health care facilities infrastructure. We are 
using a master planning process to address the complex nature of health 
care delivery for AI/AN communities. Both the Federal Government and 
Tribes will be able to use these plans to identify our greatest needs 
for services and health care facilities, and to plan carefully on how 
to best utilize any available resources. The IHS Health Care Facilities 
Construction program is fully prepared to address the needs identified 
through this process.
Indian Self Determination/Self-Governance
    The IHS has been contracting with Tribes and Tribal Organizations 
under the Indian Self Determination and Education Assistance Act, P.L. 
93-638, as amended, since its enactment in 1975. We believe the IHS has 
implemented the Act in a manner consistent with Congressional intent 
when it passed this cornerstone authority that re affirms and upholds 
the government to government relationship between Indian tribes and the 
United States. The share of the IHS budget allocated to tribally 
operated programs has grown steadily over the years to the point where 
today over 54 percent of our budget is transferred through self 
determination contracts/compacts.
Consultation
    A primary goal of the Agency has always been to involve Indian 
tribes and people in the activities of the IHS. Last year Dr. Grim 
adopted a revised IHS Tribal Consultation Policy that will enhance the 
partnership between the IHS and this country's 562 Federally recognized 
Tribes for the foreseeable future. The policy is the 3rd consultation 
policy adopted by the IHS since 1997. Its adoption fulfills a 
commitment Dr. Grim made to Tribal Leaders that the Agency's 
consultation policy and practices will continually be subject to review 
and improvement.
    The policy, which was developed by IHS and Tribal Leaders, contains 
an improved definition of consultation and the circumstances under 
which it needs to occur. The policy also commits the IHS to assisting 
Tribal governments in establishing meaningful dialogue and consultation 
with other HHS agencies and State governments. It revises the budget 
formulation process within IHS to allow for more meaningful Tribal 
participation and it contains requirements that IHS report to Tribes on 
IHS consultation, its outcomes and effectiveness.
Overview of CHS program
    The IHS purchases medical and dental services from providers in the 
private sector through its Contract Health Service program, which is a 
component of the Indian health care system. In Fiscal Year 2007 the CHS 
program is funded at $543 million. Patients are referred to the private 
sector health facilities, programs and practitioners for treatment when 
needed services are unavailable as direct care through the Indian 
health care system.
    The CHS program is administered through 12 IHS Area Offices and 
consists of 163 IHS and Tribal Service Units (SU). The CHS funds are 
provided to the Area Offices which in turn provide resource 
distribution, program monitoring and evaluation activities, and 
technical support to Federal and Tribal operating units (local level) 
and health care facilities providing care.
    The CHS funds are used in situations where:

   No IHS or Tribal direct care facility exists;
   The direct care element cannot provide the required 
        emergency or specialty services; and/or,
   The direct care facility has an overflow of medical care 
        workload.

    The CHS program makes payment for specialty services and inpatient 
care to private sector facilities and providers in accordance with 
established eligibility and medical priority guidelines.
    The CHS program contracts with Blue Cross/Blue Shield of New Mexico 
as its fiscal intermediary (FI) to ensure payments are made in 
accordance with the IHS payment policy and quality control 
requirements. An important and integral function of the FI is to 
provide highly effective management reports relative to the provision 
of services to our patient population and provision of services by 
health care providers from the private sector.
Eligibility
    To be eligible for CHS, an individual must be of Indian descent and 
belong to the Indian community served by the Tribal Contract Health 
Service Delivery Area (CHSDA). Generally, the Tribal CHSDA encompasses 
the Reservation, trust land, and the counties that border the 
Reservation. The individual must also either: (1) reside on a 
Reservation located within the CHSDA; or (2) if he/she resides within 
the CHSDA but not on a Reservation, he/she must also be a member of the 
Tribe(s) located on the Reservation or of the Tribe(s) for whom the 
Reservation was established, or maintain close economic and social 
contact with the Tribe(s). The following individuals remain eligible 
for CHS during periods of temporary absence from their CHSDA residence:

   Students who are temporarily absent from their CHSDA during 
        full-time attendance of vocational, technical, and other 
        academic education. The coverage ceases 180 days after 
        completing the course of study.

   A person who is temporarily absent from his/her CHSDA due to 
        travel or employment.

   Other persons who leave the CHSDA temporarily. Their 
        eligibility continues for a period not to exceed 180 days from 
        their departure.

   Children placed in foster care outside of the CHSDA by court 
        order and who were eligible for CHS at the time of the court 
        order.

Payor of Last Resort Rule
    The IHS is the payor of last resort and therefore the CHS program 
must ensure that all alternate resources that are available and 
accessible, such as Medicare Parts A and B, state Medicaid, state 
health program, private insurance, etc. are used before the CHS funds 
can be expended. An IHS or Tribal facility is also considered a 
resource, and therefore, the CHS funds may not be expended for services 
reasonably accessible and available at IHS or Tribal facilities. In 
FY06, IHS received $681 million in Medicaid, Medicare and Private 
Insurance collections And, the agency continues to strive toward 
maximizing these other sources of payment.
Medical Priorities
    To ensure funds are available throughout the year, medical 
priorities are used to authorize CHS funds. There are five levels of 
care within the medical priority system; they range from emergent/
acutely urgent care services to preventive and chronic tertiary care. 
Generally, IHS and Tribal funding programs currently reimburse only for 
Medical Priority I cases, which are for emergent/acutely urgent care.
Catastrophic Health Emergency Fund (CHEF)
    The CHS program also includes a Catastrophic Health Emergency Fund 
(CHEF) in the amount of $18 million. This fund pays for high cost cases 
and catastrophic costs. The CHEF is used to help offset high cost 
contract care cases meeting a threshold of $25,000. In FY 2006, the 
CHEF program provided funds for over 671 high cost cases in amounts 
ranging from $1,000 to $875,000 over the $25,000 threshold.
    Mr. Chairman, this concludes my statement. Thank you for this 
opportunity to report on IHS programs serving American Indians and 
Alaska Natives and their impact on the health status of AI/ANs. We will 
be happy to answer any questions that you may have.

    Senator Dorgan. Dr. North, thank you very much.
    Next we will hear from Dr. Westley Clark. Dr. Clark is the 
Director for Substance Abuse Treatment.
    Dr. Clark, you may proceed.

      STATEMENT OF H. WESTLEY CLARK, M.D., J.D., M.P.H., 
DIRECTOR, CENTER FOR SUBSTANCE ABUSE TREATMENT, SUBSTANCE ABUSE 
                   AND MENTAL HEALTH SERVICE 
  ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Dr. Clark. Thank you, Mr. Chairman, and I want to 
acknowledge Senator Tester and committee staff.
    I'm speaking on behalf of Dr. Terry Cline, who is the 
Administrator of the Substance Abuse and Mental Health Service 
Administration, commonly called SAMHSA.
    I am pleased to have this opportunity to join you and share 
with you how SAMHSA is working to create healthier tribal 
communities.
    I am Dr. H. Westley Clark, the Director of the Center for 
Substance Abuse Treatment. It is important for us to 
acknowledge the issues of substance abuse and mental health 
problems experienced among American Indians and Alaska Natives.
    We know that American Indians and Alaska Natives suffer 
disproportionately from substance use disorders, and they 
interfere with health, interfere with major obligations at 
work, school, or home.
    According to combined data from the National Survey on Drug 
Use and Health, American Indian and Alaska Natives over the age 
of 12 were more likely than members of other racial and ethnic 
groups to have a past year alcohol use disorders, to have past 
year illicit drug use disorders, and specifically, rates of 
past year marijuana, cocaine, and hallucinogen use, were higher 
among American Indians and Alaska Natives than other groups.
    With respect to mental health concerns among American 
Indian and Alaska Natives, between 1999 and 2004, suicide was 
the second leading cause of death among youths between the ages 
of 10 and 24. We also know that trauma and PTSD are significant 
critical issues for the American Indian community.
    Our work at SAMHSA requires partnership and the passion of 
others in order to make the largest impact possible. We work 
with the Indian Health Service, the Department of Justice, and 
the Bureau of Indian Affairs in ways that are instrumental in 
our success in assisting tribal communities in training and 
technical assistance.
    Our state partners are partnering with tribes and tribal 
communities to meet service needs. Tribal leaders across the 
country are expanding dialogue with SAMHSA every day. We 
acknowledge the importance of self-governance and self-
determination.
    One important tool to enhance collaboration are the tribal 
training and technical assistance sessions that SAMHSA, the 
Department of Justice, the Office of Justice Programs and the 
Department of the Interior, Bureau of Indian Affairs have 
conducted this year focusing on tribal priorities related to 
public safety and public health for families and communities.
    Four of these cross-agency sessions have been held this 
year, and they were designed so that Federal agency partners 
could share information on funding opportunities and agency 
initiatives with tribes and tribal organizations.
    Also included on the agenda for these sessions were 
opportunities for tribal leaders to consult with Federal 
officials on public safety, justice, and public health issues.
    We also rely on these tribal consultation sessions to gain 
insight on tribal priorities and gauge needs on pressing health 
and human services issues in tribal communities. Some of the 
most pronounced areas of concerns expressed at these sessions 
surround methamphetamine use, suicide and access to Federal 
grants.
    SAMHSA's proposed FY 2008 budget reflects these concerns. 
Our mission in Indian Country, and around the country, has been 
more focused and more clear with the release of our FY 2008 
proposed budget.
    SAMHSA Administrator, Dr. Terry Cline, has completed 
testimony on the FY 2008 SAMHSA budget and there are a few 
highlights I would like to share about the $3.2 billion 
proposal.
    We continue to invest available resources in priority areas 
like screening, brief intervention, referral and treatment, 
criminal and juvenile justice and drug courts, access to 
recovery, substance abuse prevention, children's mental health 
services, suicide and school violence prevention, HIV/AIDS, and 
mental health system transformation. This information is 
available on our website.
    I want you to recognize two priorities, and that is our 
screening, brief intervention program and our treatment drug 
courts. They have received increases for this budget year and 
tribes are eligible to apply for both.
    Currently, the Cook Inlet Tribal Council in Anchorage 
operates an SBIRT program. In FY 2008, approximately $25 
million is proposed for new SBIRT grants to increase screening. 
This objective is to wed primary care and substance abuse and 
mental health together so that we can identify problems early.
    Approximately $32 million is proposed to fund 75 treatment 
drug court grants. Again, tribes and tribal organizations are 
encouraged to apply for both of these important initiatives.
    With respect to suicide prevention, SAMHSA's FY 2008 budget 
includes $3 million for youth suicide prevention which will 
expand on a long-term commitment to tribal youth through the 
Native Aspirations project.
    The Native Aspirations initiative is a five-year project 
that is operated though a contract with Kauffman and 
Associates, a Native American business located in Spokane, 
Washington.
    SAMHSA consulted with tribes through the contractor, and to 
date, 24 tribal communities are participating in the Native 
Aspirations project, including the Crow Nation. With continued 
input from tribal leaders, we expect to expand this initiative 
in future years to include additional tribal sites.
    Our Access to Recovery program, or ATR program, permits 
states and tribal organizations to provide clinical substance 
abuse treatment as well as recovery support services through a 
voucher-based system.
    The ability to provide recovery support services is key to 
this grant, and it allows culturally appropriate and 
traditional healing practices to be reimbursed through the 
grant. Currently, the California Rural Indian Health Board was 
one of our first ATR grantees and it continues to serve as an 
example. For our second round of ATR grants, up to $98 million 
is available to fund approximately 18 new ATR grants in FY 
2007, and we expect that more than one tribe will be awarded a 
grant in this new addition.
    Since the recognition of a growing methamphetamine problem 
nationwide, SAMHSA has continued to put a strong emphasis on 
prevention.
    In FY 2006, SAMHSA awarded ten methamphetamine prevention 
grants of approximately $350,000 each for up to 3 years. The 
grant program is to support expansion of methamphetamine 
prevention, intervention and/or infrastructure development.
    Of the ten grants awarded, two were to tribes, the Cherokee 
Nation of Oklahoma and the Native American Rehabilitation 
Association of the Northwest. The grant program is designed to 
address the growing problem of methamphetamine abuse and 
addiction by assisting localities to expand prevention 
interventions that are effective and evidence-based, and to 
increase capacity through infrastructure development.
    In addition, SAMHSA is a part of the HHS Indian Country 
Methamphetamine Initiative along with the Office of Minority 
Health and the National Institutes of Health.
    Through this project, approximately $1.2 million was 
awarded to the American Association of Indian Physicians and 
its partners, to address the outreach and education of Native 
American communities on methamphetamine abuse.
    Five tribes are included in this project, the Winnebago 
Tribe, which has been funded as a preventionsite, the Navajo 
Nation and the Northern Arapaho Tribe, which are intervention 
and treatment sites, and the Crow Tribe and Choctaw Nation 
which are treatment and recovery sites.
    The Montana-Wyoming Tribal Leaders Council has a SAMHSA 
suicide prevention grant, and as a grantee, they are 
implementing the Planting of Seeds of Hope Project.
    In many ways, this Council has led the way in developing 
new collaborations between all of the tribes in Montana and 
Wyoming, along with the states, in order to share resources, 
ideas, and truly work together on suicide prevention 
activities.
    These new collaborations are building hope across the 
tribes and the states to overcome what once seemed an 
overwhelming and impossible problem to solve alone. These 
partnerships are leading the country in developing new 
strategies for saving the lives of our youth, and together they 
are spreading the word that suicide is a preventable tragedy.
    To continue to address the suicide clusters on Standing 
Rock, the tribe applied and was competitively awarded a youth 
suicide prevention and early intervention program grant in 
October, 2006.
    This grant is bringing together community leaders to 
implement a comprehensive tribal youth suicide prevention and 
early intervention plan at Standing Rock that is identifying 
and increasing youth referrals to mental health services and 
programs, increasing protective factors, reducing risk factors 
for youth suicide, and improving access to intervention 
services. Additionally, SAMHSA is establishing a new tribal 
advisory committee and is accepting nominations for community 
members. Similar to other SAMHSA advisory committees, the 
purpose of the Tribal Advisory Committee is to assist SAMHSA in 
carrying out its mission in Indian Country.
    Key to carrying out our agency mission in Indian Country is 
increasing awareness of and access to our grants. In response 
to comments at the 2006 HHS Tribal Consultation meetings and 
the HHS/ASPE published Barriers to American Indian/Alaska 
Native/Native American Access to DHHS Programs report, SAMHSA 
convened an internal workgroup to develop strategies to remove 
barriers in discretionary grant announcements.
    Senator Dorgan. Mr. Clark, I'm going to have to ask you 
that you summarize, please.
    Dr. Clark. One of the most important things is we want to 
make sure that tribes have access to our funding. I think one 
of the things that we view in these requests for proposals is 
making sure that tribes are not precluded from participating as 
states or other organizations have. So I'm pleased to note that 
we have done this.
    We're also having other strategies like the tribal policy 
academy on co-occurring disorders and that tribes are along in 
that effort so that we can deal with substance abuse and mental 
health problems of the tribes.
    So changes are underway, and we are working collectively 
with tribal communities and tribal governments so that we can 
address mental health and substance abuse problems.
    Thank you.
    [The prepared statement of Dr. Clark follows:]

 Prepared Statement of H. Westley Clark, M.D., J.D., M.P.H., Director, 
Center for Substance Abuse Treatment, Substance Abuse and Mental Health 
  Service Administration, U.S. Department of Health and Human Services
    Chairman Dorgan and Members of the Committee, I am Dr. H. Westley 
Clark, Director of the Center for Substance Abuse Treatment, Substance 
Abuse and Mental Health Services Administration or commonly called 
SAMHSA. I bring greetings from Dr. Terry Cline, SAMHSA Administrator. I 
am pleased to have this opportunity to join you and share with you how 
SAMHSA is working to create healthier tribal communities. However, 
before I detail a few of SAMHSA's initiatives, I think it is important 
to underscore the extent of substance use and mental health problems 
experienced among American Indians and Alaska Natives.
    American Indians and Alaska Natives suffer disproportionately from 
substance use disorders (defined by symptoms such as withdrawal, 
tolerance, use in dangerous situations, trouble with the law, and 
interference in major obligations at work, school, or home during the 
past year) compared with other racial/ethnic groups in the United 
States. According to combined data from the 2002-2005 National Survey 
on Drug Use and Health (NSDUH) conducted by SAMHSA, American Indian and 
Alaska Natives over the age of 12 were more likely than members of 
other racial/ethnic groups to have a past year alcohol use disorder 
(10.7 vs 7.6 percent). They were also more likely to have a past year 
illicit drug use disorder (5.0 vs 2.9 percent). Specifically, rates of 
past year marijuana, cocaine, and hallucinogen use disorders were 
higher among American Indians and Alaska Natives than among other 
racial/ethnic groups.
    One factor that may be driving the disparity in substance use 
between American Indian/Alaska Native youth and other youth is a higher 
rate of substance use risk factors among American Indian and Alaska 
Native youth. For example, data from the 2002 and 2003 National Survey 
on Drug Use and Health show that American Indian/Alaska Native youth 
are more likely than youth of other racial/ethnic groups to perceive 
moderate to no risk of substance use and less likely to perceive strong 
parental disapproval of substance use.
    With respect to mental health concerns among American Indian and 
Alaska Natives, between 1999 and 2004, suicide was the second leading 
cause of death among youth between the ages of 10 and 24, compared to 
the third leading cause of death among the youth population as a whole. 
Spirituality may play a protective role in reducing suicide attempts. 
Specifically, a study of American Indian tribal members living on or 
near their Northern Plains reservations between 1997 and 1999 showed 
that those with a high level of cultural spiritual orientation had a 
reduced prevalence of suicide compared with those with a low level of 
cultural spiritual orientation.
    Our work at SAMHSA does not stand alone--it requires partnership 
and the passion of others in order to make the largest positive impact. 
For example, our partners at the Indian Health Service, the Department 
of Justice (DOJ) and the Bureau of Indian Affairs are instrumental in 
our success in assisting tribal communities in training and technical 
assistance. Our State partners are partnering with Tribes and Tribal 
communities to meet service needs. In addition, our grantees are hard 
at work in the field providing services. And, Tribal leaders across the 
country are expanding the dialogue with SAMHSA everyday. All are 
examples of the type of collaborative efforts that create a wider reach 
than any single agency can provide alone.
    One important tool to enhance collaboration are the Tribal Training 
and Technical Assistance Sessions that SAMHSA, the Department of 
Justice, Office of Justice Programs (DOJ/OJP) and the Department of the 
Interior (DOI), Bureau of Indian Affairs (BIA) have conducted this past 
year focusing on tribal priorities related to public safety and public 
health for families and communities. Four sessions were held in FY 
2007. It should be noted that the fourth session included a 1-day 
Tribal Methamphetamine Summit hosted by the Office of National Drug 
Control Policy (ONDCP). These cross-agency sessions are designed so 
that Federal agency partners can share information on funding 
opportunities and agency initiatives with Tribes in one setting. 
Community challenges, best practices and lessons learned have been 
embedded into the session agendas to provide Tribes the opportunity to 
share their experiences and adapt strategies to their unique 
circumstances in their tribal communities. Also included on the agenda 
for these sessions are opportunities for Tribal leaders to consult with 
Federal officials on public safety, justice and public health issues. 
And, of course, we also rely on these Tribal Consultation Sessions to 
gain insight on Tribal priorities and gauge needs on pressing health 
and human services issues in tribal communities. Some of the most 
pronounced areas of concerns expressed at these sessions surround 
methamphetamine use, suicide and access to Federal grants.
    SAMHSA's proposed FY 2008 Budget reflects those concerns. Our 
mission in Indian Country and around the country has become much more 
focused and more clear with the release of the FY 2008 proposed budget. 
SAMHSA Administrator Dr. Terry Cline has completed testimony on the FY 
2008 SAMHSA budget and there are a few highlights I would like to share 
about the $3.2 billion proposed for SAMHSA.
    We are continuing to invest available resources in program priority 
areas such as: Screening, Brief Intervention, Referral and Treatment 
(SBIRT); Criminal/Juvenile Justice and Drug Courts; Access to Recovery; 
Substance Abuse Prevention; Children's Mental Health Services; Suicide 
and School Violence Prevention; HIV/AIDS; and Mental Health System 
Transformation.. A comprehensive list of our grants can be found on our 
website: www.samhsa.gov/grants/.
    I want to draw your attention to a few of these priorities briefly. 
Two of these priorities--the SBIRT program and the Treatment Drug 
Courts--have received increases this budget year and tribes are 
eligible to apply for both. Currently, the Cook Inlet Tribal Council in 
Anchorage, Alaska operates an SBIRT grant. For FY 2008, approximately 
$25 million is proposed for new SBIRT grants to increase screening, 
brief interventions, and referral to treatment in general medical and 
community health care settings. Approximately $32 million is proposed 
to fund about 75 Treatment Drug Court grants. Tribes and Tribal 
Organizations are encouraged to apply for both of these important 
initiatives.
    With respect to suicide prevention, SAMHSA's FY 2008 Budget 
includes $3 million for youth suicide prevention which will expand on a 
long-term commitment to tribal youth through the Native Aspirations 
project. The Native Aspirations initiative is a 5-year project that is 
operated through a contract with Kauffman and Associates, Inc. (KAI)--a 
Native American business located in Spokane, Washington. SAMHSA 
consulted with Tribes through the contractor and to date 24 tribal 
communities are participating in the Native Aspirations project. With 
continued input from Tribal leaders, we expect to expand this project 
in future years to include additional tribal sites.
    I don't want to just talk about proposed grant opportunities, but 
also current ones as well. One grant program I want to highlight is 
SAMHSA's Targeted Capacity Expansion Grants (TCE) program. In May 2007, 
SAMHSA announced $10.2 million in TCE Grants to expand or enhance a 
community's ability to provide a comprehensive, integrated, and 
community-based response to a targeted, well-documented substance abuse 
treatment capacity problem and/or improve the quality and intensity of 
services. Applications were accepted under four Categories: (1) Native 
American/Alaska Native/Asian American/Pacific Islander Populations; (2) 
E-Therapy; (3) Grassroots Partnerships; and (4) Other Populations or 
Emerging Substance Abuse Issues. Tribes were eligible to apply under 
all four categories and SAMHSA expects to award up to 16 grants in 
2007, with an average grant amount of $500,000 per year for up to 3 
years.
    Another program priority area is SAMHSA's Access to Recovery (ATR) 
program. The ATR program permits grantees (i.e., States and Tribal 
Organizations) to provide clinical substance abuse treatment as well as 
recovery support services through a voucher-based system. The ability 
to provide recovery support services is a key issue of this grant 
program because it allows clients to pursue and maintain their recovery 
through many different and personal pathways, including traditional 
healing practices. The California Rural Indian Health Board was one of 
the first ATR grantees and it continues to serve as an example of what 
can be accomplished through tribal collaborations. For our second round 
of ATR grants, up to $98 million is available to fund approximately 18 
new ATR grants in FY 2007 of which $25 million is expected to support 
treatment for clients using methamphetamine.
    Since the recognition of a growing methamphetamine problem 
nationwide, SAMHSA has continued to put a strong emphasis on 
prevention. In FY 2006 SAMHSA awarded 10 Methamphetamine Prevention 
grants of approximately $350,000 each for up to 3 years The grant 
program is to support expansion of methamphetamine prevention, 
interventions and/or infrastructure development. Of the 10 grant awards 
2 were to Tribes, the Cherokee Nation of Oklahoma and the Native 
American Rehabilitation Association of NW, Inc., of Portland, Oregon. 
The grant program is designed to address the growing problem of 
methamphetamine abuse and addiction by assisting localities to expand 
prevention interventions that are effective and evidence-based and/or 
to increase capacity through infrastructure development.
    SAMHSA is a member of the Office of National Drug Control Policy, 
Executive Native American Law Enforcement Workgroup along with members 
from DOJ, Indian Health Services, DOI, Tribal Police, and the Federal 
Bureau of Investigation. This workgroup is designed to coordinate and 
address the multidimensional aspect of methamphetamine use in Indian 
Country. In addition, SAMHSA is part of the HHS Indian Country 
Methamphetamine Initiative (ICMI) along with the Office of Minority 
Health and the National Institutes of Health. Through this project, 
nearly $1.2 million was awarded to the American Association of Indian 
Physicians (AAIP) and its partners to address the outreach and 
education needs of Native American communities on methamphetamine 
abuse. The partners are developing a culturally appropriate national 
information and outreach campaign on methamphetamine use in Indian 
Country. They are also developing a methamphetamine abuse education 
kit, documenting and evaluating promising practices in education on 
methamphetamine use, and creating methamphetamine awareness multi-
disciplinary education teams. Five Tribes are included in this 
project--the Winnebago Tribe, which has been funded as a 
preventionsite, the Navajo Nation and the Northern Arapaho Tribe, which 
are intervention and treatment sites, and the Crow Tribe and Choctaw 
Nation which are treatment and recovery sites.
    The Montana-Wyoming Tribal Leaders Council has received a SAMHSA 
suicide prevention grant and as a grantee they are implementing the 
``Planting of Seeds of Hope Project.'' In many ways, this Council has 
led the way in developing new collaborations between all of the Tribes 
in Montana and Wyoming, along with the States, in order to share 
resources, ideas, and truly work together on Suicide Prevention 
activities. These new collaborations are building hope across the 
Tribes and the States to overcome what once seemed an overwhelming and 
impossible problem to solve alone. These partnerships are leading the 
country in developing new strategies for saving the lives of our youth 
and together they are spreading the word that suicide is a preventable 
tragedy.
    In the Aberdeen Area, SAMHSA continues to work closely with the 
Standing Rock Sioux Tribe to respond to an outbreak of suicide clusters 
on their reservation. In 2005, through a SAMHSA Emergency Response 
Grant (SERG), SAMHSA staff and the One Sky Center staff began working 
with the Tribe to design and implement a suicide prevention program at 
Standing Rock. Based on SAMHSA's recommendation, tribal leadership 
mandated that the program must be Addiction and Dependency certified by 
the State of North Dakota. A Bismarck-based consultant from SAMHSA's 
Disaster Technical Assistance Center (DTAC) has assisted the Tribe with 
this process. The Tribe has funded two additional behavioral health 
staff positions to provide case management services and arrange for 
treatment and ancillary services for at-risk clients, which is making a 
difference. The strategic suicide prevention plan that was developed 
and implemented at Standing Rock is being considered as a model by 
other Indian reservations and the Indian Health Service. Although the 
SERG grant funding ended in December 2006, the Tribe was competitively 
awarded a Youth Suicide Prevention and Early Intervention Program grant 
in October 2006. This new grant is bringing together community leaders 
to implement a comprehensive tribal youth suicide prevention and early 
intervention plan at Standing Rock that is identifying and increasing 
youth referrals to mental health services and programs, increasing 
protective factors, reducing risk factors for youth suicide, and 
improving access to intervention services.
    SAMHSA is also working with the Office of National Drug Control 
Policy, the Office of Justice Programs/Bureau of Justice Assistance 
within the Department of Justice and with the National Alliance for 
Model State Drug Laws on regional planning events to identify common 
issues and concerns among States that may require interstate 
resolutions or a Federal focus to address methamphetamine use. Through 
this partnership, three regional planning events were conducted in FY 
2007. Attendance included representatives of substance abuse programs, 
law enforcement agencies, the criminal justice system, community 
coalitions and counties, cities and local municipalities. The goal was 
the identification of best practices that will be replicated in other 
States.
    In response to the inescapable link between addiction, mental 
illness, and crime, SAMHSA is coordinating across Federal agencies 
through our participation on the Native American Law Enforcement Task 
Force. When prevention and treatment services are targeted to adult and 
juvenile offenders the benefits are three-fold. First, if we prevent 
addiction, drug related crime will decrease. Second, if we intervene 
early and get the appropriate treatment services in place, recidivism 
rates drop. And third, as SAMHSA increases recovery support services, 
reentry success rates climb and public safety is increased. It just 
makes sense for SAMHSA to strengthen partnerships with the law 
enforcement communities both in Indian Country and around the country. 
We have reached out to police organizations, correctional 
organizations, as well as the National District Attorneys Association 
to open the paths to collaboration. And, we will continue working 
closely with DOJ as well.
    As you may know, the Department of Health and Human Services (HHS) 
revised its Tribal Consultation Policy in March 2005. Members of the 
Tribal-Federal Team contributed to developing the necessary 
recommendations. In early 2006, SAMHSA used the HHS document as a basis 
to create a starting point for revising the SAMHSA policy. We shared 
that document with tribes at each of the Regional sessions to solicit 
comments. During that process, we asked for volunteers interested in 
serving on a workgroup to assist with further review and revision of 
the Tribal Consultation Policy. In June of 2006, a Technical Team 
workgroup was formed. The first meeting of the workgroup produced a 
second draft of the SAMHSA Tribal Consultation Policy which was 
reviewed and comments as well as resulting edits were incorporated in 
the final Tribal Consultation Policy. SAMHSA's goal was to have a 
signed Tribal Consultation Policy by early 2007 and I'm very proud to 
say we have accomplished that. Additionally, SAMHSA is establishing a 
new Tribal Advisory Committee and is accepting nominations for 
committee members. Similar to other SAMHSA advisory committees, the 
purpose of the Tribal Advisory Committee is to assist SAMHSA in 
carrying out its mission in Indian Country.
    Key to carrying out our Agency mission in Indian Country is 
increasing awareness of and access to our grants. In response to 
comments at the 2006 HHS Tribal Consultation Meetings and the HHS/ASPE 
published ``Barriers to American Indian/Alaska Native/Native American 
Access to DHHS Programs'' report (April 2006) SAMHSA convened an 
internal workgroup to develop strategies to remove barriers in 
discretionary grant announcements. As a result, in August 2006 a Tribal 
Grants Review Team--with members from four Tribes/tribal 
organizations--reviewed nine previously published SAMHSA Requests for 
Proposals (RFAs). Their findings and recommendations were provided to 
SAMHSA grants and policy officials, some of which have already been 
incorporated into FY 2007 SAMHSA RFAs.
    In addition to increasing the voice of Tribes and Tribal 
Organizations through the various avenues mentioned, SAMHSA is also 
committed to increasing technical assistance to our tribal partners on 
improving services. For instance, through SAMHSA's Addiction Technology 
Transfer Centers (ATTCs), SAMHSA is planning one or more special 
projects to provide technical assistance on treatment-related issues 
through partnerships with Regional Indian Health Boards. We are very 
excited about this new partnership and expect to have it underway in 
early FY 2008. Also, SAMHSA's Center for Substance Abuse Prevention 
will be awarding a contract for a Native American Technical Assistance 
Resource Center that will provide targeted technical assistance to 
current Tribal Strategic Prevention Framework State Incentive Grants 
grantees and prospective grant applicants.
    I also want to mention that recently we participated in the IHS-
SAMHSA 5th Annual National Behavioral Health Conference held June 11-14 
in Albuquerque, New Mexico. This annual conference is an important 
training and networking opportunity for American Indians and Alaska 
Natives working in the behavioral health fields with the Indian Health 
Service.
    Similarly, I'm pleased to announce that plans are underway at 
SAMHSA for a Tribal Policy Academy on Co-Occurring Substance Abuse and 
Mental Health Disorders in September 2007. The purpose of this Academy 
is to improve and expand access to effective, culturally relevant, and 
appropriate prevention and treatment services and supports for 
individuals with and at-risk for co-occurring substance use and mental 
disorders. The Academy will bring together Tribal Teams of officials 
with policymaking influence in conjunction with nationally recognized 
faculty and facilitators who will assist the Teams to develop an Action 
Plan for expanding access and improving co-occurring treatment and 
prevention services in their communities. The Academy will also help to 
identify promising practices in Tribal communities that may assist 
other Tribes to address co-occurring disorders in new and innovative 
ways.
    Changes are underway--changes that will result in improved 
coordination of SAMHSA services to tribal communities. Ultimately the 
result will be healthier tribal communities--communities where lives 
are full and where native language, culture and traditions including 
native healing approaches can flourish. SAMHSA continues to look 
forward in assisting each of you in any way we can. Thank you.

    Senator Dorgan. Dr. Clark, thank you very much.
    Senator Tester.
    Senator Tester. Thank you, Mr. Chairman. I have a few 
questions here, first for Dr. North, who is the Chief Medical 
Officer of the Indian Health Service.
    Early this year, we asked your representative about the 
adequacy of the budget for this year for Indian Health. The 
response we got was, it's pretty good, we can meet most of the 
needs. Yet, when we talk with folks in Indian Country, we get a 
very different answer.
    Do you think the budget request was sufficient to meet the 
needs?
    Dr. North. The budget in direct care, in all the 
facilities, maintenance, is about $3.2 billion. In addition to 
that, we have increased our third-party revenue this year 
substantially. It's now about three-quarters of a billion 
dollars.
    We think with the tribal contract, the 638 health centers 
and hospitals, that we may be bringing in a billion dollars in 
third-party revenue this year in addition to the appropriated 
funds.
    Senator Tester. So do you think that it was sufficient to 
meet the needs?
    Dr. North. There are always needs that can be served in 
Indian Country.
    Senator Tester. Okay. Well, interestingly enough, I think 
this story could be repeated with any of the six other 
reservations in this state. As we were driving down from the 
airport with Chairman Venne today, I said, Carl, when did 
Indian Health services run out? He said I think it was about 
the first of June here in Crow. That indicates to me that the 
program is underfunded.
    What does that indicate to you?
    Dr. North. I would like to ask the Area Director to comment 
specifically on the contract health services funding in the 
local service unit and the area.
    Senator Tester. Do you want to defer to Mr. Conway at this 
time? Do you understand the question Mr. Conway?
    Mr. Conway. I believe so. Senator Tester, my thoughts on 
that is that we've heard stories, Carl Venne has told us 
stories about contract care. I think that whole issue centered 
around contract care is it probably not funded at the adequate 
level to provide all health care needs. What does that cost? 
Sometimes the cost share dollars may be another source to help 
cover those types of costs.
    Senator Tester. Are you allowed to make recommendations up 
the ladder for additional dollars, whether it's contract health 
care or some other item?
    Mr. Conway. I'm allowed to make recommendations to Dr. 
Grim, who is our boss.
    Senator Tester. Okay. How do you feel those recommendations 
have been accepted, received, I should say?
    Mr. Conway. I think generally the recommendations have been 
well received. I think that at meetings of the Area Directors 
there are problems in other areas also that are talked about 
need, where it goes from there.
    Senator Tester. How do you characterize the working 
relationship that you maintain with the tribal governments, how 
do you characterize that? Is it cooperative, productive, 
adversarial, how do you classify that?
    Mr. Conway. I think generally for the most part the working 
relationship that we maintain with the tribes is cooperative. I 
think there's some issues that are always going to come up 
which may be adversarial. I think working through the Montana-
Wyoming tribal leaders, and them being in Billings, being able 
to just walk up the street and discuss issues, I think it's 
been a real bonus.
    Senator Tester. So what issues are adversarial? What 
avenues do you use for reconciliation? Do you just say this is 
the way it is, too bad, or is there a process you go through?
    Mr. Conway. The process that I go through actually is to 
sit down across the table with tribal leaders and talk it over, 
just sit down and discuss the issue.
    Senator Tester. Okay. Other than dollars, is there anything 
we can do in Congress to make your job easier?
    Mr. Conway. I think some of the things you can do is look 
at some of the administrative requirements that we have, and 
perhaps, some HR things possibly, being able to offer somebody 
a job, those types of things.
    Senator Tester. The last question, do you take any 
administrative things off the top regarding what goes out?
    Mr. Conway. No, my understanding is funding for the Area 
Office, this has been funding before I got there, the cost of 
living and things like that.
    Senator Tester. Thank you, Mr. Conway.
    Mr. North, when I talk to folks in Indian County, they talk 
about the fact they can't get health care at certain times of 
the year unless they are life or limb, a loss of limb is 
involved.
    How do you suggest that we move away from a system that 
waits until the injury or the health problem disaster, and 
encourages more preventive maintenance or adaptive maintenance?
    Dr. North. We have a program in health promotion, disease 
prevention that's nationwide. We think it's better to prevent 
these conditions and ask for treatment later whether it's 
direct or through contract care.
    This area has a very high rate of contract health emergency 
funding, which is a reinsurance program in contract care, 
indicating to me that there are probably many opportunities to 
prevent illness in an early stage or altogether.
    Senator Tester. Do you work through Mr. Conway or through 
the tribe directly to encourage prevention programs in this 
case?
    Dr. North. Yes, we have a nationwide program. One of our 
Director's three initiatives is health promotion and disease 
prevention.
    We're working closely with CMS on that also, and we have 
some favorable rates now, Medicare like rates with hospitals 
all over the country which helps save our contract health care 
dollars.
    Senator Tester. Thank you.
    Before I go to Dr. Clark, I just want to make a comment, 
when we asked about the adequacy of the budget, Senator Dorgan 
was there and the Indian Affairs Committee, and they talked 
about that budget being adequate, when, in fact, we know when 
we go out in the field, it's not adequate.
    I think we're wasting a lot of time, I think the budget is 
just flat not adequate because it hasn't been a priority.
    Things would change a lot, from my perspective, if you guys 
would walk up to your bosses, or to the Secretary, and say, we 
need more dollars because we've got people dying out there 
unless we get more dollars for health care.
    There's a lot of things out there that are really 
important, and we can go down the list from housing to water to 
roads, but if you're sick, you're not going to care, and if you 
have the opportunity to get people to help you if you're that 
sick, it's just going to cost more and more money for health 
preventatives.
    With that, I do have a couple of questions for Dr. Clark.
    A couple things, Dr. Clark. In your testimony, when you 
talked about early intervention and drug use and suicide, in 
particular in Indian Country, are you seeing any impacts of 
that early intervention, are you seeing suicide rates becoming 
static or going down, and the same thing with drug use?
    Dr. Clark. One of the most important things from our point 
of view is working with tribes and tribal organizations to 
deliver the services. So, as a service delivery organization, 
we had opened our portfolio up to tribes and tribal 
organizations, and as result of economics, monitored the 
performance of the tribe and tribal organizations as we do for 
every other provider, and we're seeing that more people are 
being provided services to.
    So from the economic point of view, it's simply a matter of 
saying that I can cure the problem. We believe that working 
with tribes and tribal organizations with our resources, we are 
having a positive impact. Senator Tester: Okay. That's good. 
That's positive. We need to continue along that line.
    What can we in Congress do to really attack some of the 
root causes of moving toward drug addiction or suicide?
    Dr. Clark. Well, of course, making sure that we have an 
adequate work force, making sure that there's adequate 
collaboration between agencies so that this partnership between 
IHS, the Bureau of Indian Health Affairs, and the tribes, can 
work together so that we can target our interventions in such a 
way to produce satisfactory results.
    Senator Tester. Okay. One last question, Dr. North, I do 
have one more question for you, and thank you, Dr. Clark.
    You talked about a manpower program that 7,000 students 
have utilized, is that total or is that in the last year? The 
number really doesn't matter as much as the next question I'm 
going to ask, and that is, do you monitor the number of the 
folks that utilize this manpower program that actually come 
back into Indian Country and provide service?
    Dr. North. Yes, we do. That's 7,000 students since 1977, 
which is the year I joined the Indian Health Service 30 years 
ago.
    Senator Tester. And how many of them come back to Indian 
Country?
    Dr. North. We have more information on that, that's a 
complex answer. If you'd like, I could provide that for the 
record.
    Senator Tester. I would like more information on that, and 
also try to find out what's going to encourage them to come 
back to their homes.
    With that, thank you very much, Mr. Chairman.
    Senator Dorgan. Senator Tester, thank you very much.
    Let me ask a couple of questions of Dr. North and Mr. 
Conway.
    I want to ask about contract health care because Chairman 
Venne indicated this morning, that I believe at this point, on 
this reservation in the Crow Nation, they are out of contract 
health care dollars.
    Chairman Venne, you are out of contract health care dollars 
at this point in the fiscal year and probably ran out somewhere 
in June or July; is that correct?
    Chairman Venne. That's correct.
    Senator Dorgan. If that's the case, what that means is that 
if you are here in the Crow Nation and have a problem, a 
medical problem for which there is not treatment here, perhaps 
you need a specialist of some type, they're not going to pay 
for that specialist unless there is a life or limb at stake, 
you've got to lose a limb or lose your life; is that correct, 
Dr. North?
    Dr. North. And also special senses, hearing and eyesight 
would be included in priority one and child birth.
    Senator Dorgan. If that is the case, if we're out of 
contract health care here now, the Fiscal Year ends at the end 
of September, of course, I've had a tribal chairman say they 
were out of contract health care funds in January. Former 
Chairman Tex Hall used to say on that reservation everybody 
understood don't get sick after June because there's no 
contract health care money.
    If that's the case, isn't it a fact, then, that we are 
rationing health care to Native Americans?
    Dr. North. The Indian Health Service is the payer of last 
resort when it comes to referrals and notification of emergency 
care. All other alternate resources must be used first, like 
Medicare, Medicaid, private insurance, workmen's compensation, 
Veterans Administration benefits and county indigent programs 
and state indigent programs where they exist.
    So, we're not the only payor of health care for Native 
Americans. There are several other options.
    Senator Dorgan. Dr. North, you are absolutely correct about 
that, there are other payors in certain circumstances, but you, 
the Indian Health Service, represented by this government, is 
responsible. I mean, you do have a commitment. Others may or 
may not have a commitment, but we do know that the Indian 
Health Service does have a commitment.
    Senator Tester was asking the question the right way, I 
think. We have these hearings in Washington, D.C. or in Montana 
or elsewhere, and we ask questions, and what we always get is, 
you know what, things are pretty good, we're doing the best we 
can. We've made a couple percent improvement here or there, but 
it seems to me the following:
    Dr. Grim has admitted under my pretty intense questioning a 
couple of times, that the amount of health service that is 
required for American Indians is being covered to the tune of 
about 60 percent. That means 40 percent of the health service 
that is needed is not available. That means there's rationing 
of health care available.
    And I think it ought to be on the front page headlines of 
every newspaper, because I think it's scandalous, and what I 
don't understand is how we finally get people to speak up on 
this.
    I'm not trying to badger you, but Senator Tester made a 
point and I made a point to Dr. Grim when he was just re-
nominated. We said why don't you risk your job, if necessary, 
to speak out. Risk your job, if necessary, to speak out.
    The fact is, you've got some awfully good people working in 
Indian Health Service, in Public Health Service. I admire them, 
some terrific, committed, dedicated people. God bless them for 
doing it.
    But the fact is, they're doing it without the resources 
they need, and we have to find a way to deal with that. And the 
only way that we're going to do it is to get the Indian Health 
Service to stop saying things are pretty good and to start 
telling us exactly what's happening. Now, Dr. North, you or Mr. 
Conway can respond, but Mr. Conway, isn't it a fact that here 
on the Crow Nation if they're out of contract health care money 
at this point, that somebody can be pretty sick but it may not 
be life or limb and they're going to be told we're sorry, just 
wait, you're going to have to wait?, not we're sorry about the 
pain, but the pain is yours, not ours, we don't have the money, 
you wait.
    Isn't that what happens? Am I wrong about that, or isn't 
that what's happening?
    Dr. North. We have to live with the reality of medical care 
daily. I've done that for 30 years as a physician in the Indian 
Health Service with my patients, and I think----
    Senator Dorgan. I can't hear you, I'm sorry.
    Dr. North. I've been a family doctor for 30 years in the 
Indian Health Service, and I understand what you're saying, 
sir. We struggle to find the best resources for our patients, 
the best referral sources and the best methods to diagnose, 
treat and cure, and it takes creativity at times, sir.
    Senator Dorgan. Well, are you frustrated?
    Dr. North. I find this struggle to be a good struggle and 
one worth fighting.
    Senator Dorgan. All right. Well, let me ask this additional 
question.
    I assume that somewhere at the bottom of this structure, 
there are dedicated Indian Health Service employees who are 
saying we don't have enough resources, we need more. We're the 
ones that are seeing the patients that we can't take care of, 
so we need the additional resources. We need the additional 
equipment. We need the additional facilities, and that goes up 
the line someplace.
    My understanding is that the tribes are even asked to 
comment and to work and to make recommendations.
    Is there a circumstance where the tribes are involved in 
discussions up the line when, for example, the Indian Health 
Service goes to the Secretary and the Secretary goes to the 
Office of Management and Budget, or is it a circumstance where 
when it leaves at this level, the Indian Health Service, at 
that point there's no more consultation, it's just the Office 
of Management and Budget and perhaps the Secretary and somebody 
else makes the decision with no consultation with tribes at 
that level?
    Dr. North. We take pride in tribal consultation at every 
level of the Indian Health Service. About 70 percent of our 
employees are Native American and are community members in many 
cases, and are family members of the tribal leaders and often 
tribal leaders themselves, so we feel like we work very closely 
with the communities and we have good two-way communications 
with tribal leaders.
    Senator Dorgan. I should have mentioned, it's the Secretary 
of Health and Human Services, on other issues it's the 
Secretary of the Interior on Indian funding issues.
    But Mr. Conway, let me ask you that question about someone 
who is ill here on the Crow Nation Reservation, and is probably 
not going to die, but is in substantial pain, needs to go to a 
specialist somewhere else because the service isn't available 
here, tell me what happens in that case.
    Mr. Conway. Maybe what would happen in that case, they will 
be deferred until the next year when we have some money. I 
think our job is probably the issue of asking for us to 
appropriate more money.
    I think in my area, I think Chairman Venne receives 50 
percent of the Health Service funding. I think we know that, at 
least in this area, we have service units that are funded at 
58, 56 percent are being funded, all the way up to probably 76 
or 78 percent.
    And I think what we have to conclude from that, if they're 
funded at that level, there must be some needs out there that 
we need to continue to work on.
    Senator Dorgan. And isn't that another way of saying that 
health care is being rationed to American Indians, really?
    Mr. Conway. Yes, it's a way of saying that we do not have 
100 percent of the funding. If we're keeping track of every 
service unit in the country, what the level they're being 
funded at is, we have other areas probably in the Dakotas that 
are probably funded at 40 percent level of needed funds.
    Senator Dorgan. All I can tell you is I think most 
Americans, most Americans, if they've got a provider, health 
insurance, some other type of system, VA, they get sick, they 
want to go to a doctor, and if they're in pain they want to get 
it fixed, they want to get that pain resolved.
    It appears to me, and I say this from having visited many 
Indian reservations and talked to a lot of patients, it appears 
to me we're in a situation where we don't allocate enough 
funding so that, for example, here you're out of contract 
health care money, and the person that needs that help is going 
to be told you just live with the pain because your need is 
going to be deferred.
    I'm not saying you don't do all you can do, that's my 
point. My point isn't that the three of you don't do all that 
you can do. My point is we don't have anybody in the system 
that comes to us and pounds on the table and says publicly, in 
front of everybody, here's what's happening and we need to fix 
it.
    What happens is they come to these hearings and they say, 
we're doing the best we can. Well, you know what, if it's 40 
percent health care that's not available to people that need 
it, that's not good enough. The best we can is not good enough.
    And so, I really want to work with Chairman Venne and 
Senator Tester, with you, with some dedicated people in the 
Indian Health Service and regional officials, but we need, we 
really need to see some evidence of frustration and anger, 
saying this isn't working and it needs to be fixed. That's what 
we need from you.
    Dr. Clark, I've not asked you a question, but you know that 
I have held multiple hearings on the issue of teen suicide and, 
you know, where there are young people who feel that it is 
hopeless and they are helpless.
    I've been to the reservations where it's happened. And the 
fact is, mental health services were not available. They just 
were not available. And it's true that we're making some 
strides, but we're not anywhere near where we need to be. And I 
hope that you and others in the administration will begin 
speaking out as well.
    Methamphetamine addiction is a devastating addiction, and 
we can't treat that by putting somebody in a treatment program 
for 2 weeks, because that doesn't work. This is long-term and 
difficult and expensive, but it's the only way we can solve 
these problems.
    I'm not going to ask you any questions, except I thank you 
for your testimony. I want to get to the other witnesses, the 
tribal witnesses.
    Senator Tester has another question.
    Senator Tester. One point real quick. I would hope that 
this panel would stay around for the next panel group.
    One of the things I would like to inserted in the record, 
Chairman Venne passed along to me.
    In this region, it is not only underfunded, it's 48 million 
in the red on contract care here right now. That means when 
we're talking about Crow, Fort Belknap, Fort Peck, Rocky Boy, 
Salish and Northern Cheyenne, they're all in the same boat.
    Right now on this reservation 28 positions are not filled 
in this hospital, 28. That's just not good, so I just wanted 
that put in the record.
    Senator Dorgan. And before I let you go, one final point, I 
believe, and I believe, Dr. North, in your testimony you 
reiterate, I believe there is a trust responsibility that the 
Federal Government has for Indian health care. This isn't an 
option. This isn't a case where we say, well, on an optional 
basis we'll provide health care.
    I believe there is a trust responsibility. If that trust 
responsibility exists, and I think most all of us believe it 
exists by custom and by law, then we are far short of meeting 
the needs and keeping our promise, and that's the point of it 
all.
    Let me release you by saying, you are representatives of a 
lot of dedicated health professionals, I understand that. I 
don't ever want to diminish some Indian Health Service doctor, 
Public Health Service physician or others working in these 
kinds of circumstances. I don't ever want to diminish what they 
do. God bless them for doing it.
    But we as a country, and we as health care professionals, 
we in the Congress, starting with the President's budget, have 
to own up to our responsibility now, not later.
    So, thank you very much for testifying.
    Next I'd like to call to the witness table Dr. Joe 
McDonald, who is the President of the Salish Kootenai College, 
Ms. Ada White, the Health Service Director of the Crow Tribe, 
Mr. Jonathan Windy Boy, the Chairman of the Subcommittee on 
Health Care, Montana-Wyoming Tribal Leaders Council, if you 
will come forward when I call your name. Also, Mr. Moke 
Eaglefeathers, who is the President of the National Council of 
Urban Indian Health Board, and Director of North American 
Indian Alliance.
    Just let me mention briefly that Dr. Joe McDonald is 
accompanied by Ms. Marjorie Bear Don't Walk, the Director of 
the Indian Health Board of Billings.
    Others on the panel are accompanying Ms. Stacy Bohlen, 
Executive Director of the National Indian Health Board. We have 
Jace Killsback, Billings Area Representative of the National 
Indian Health Board, Council member of the Northern Cheyenne 
Tribe, and Dr. Joseph Erpelding, an orthopedic surgeon from 
Billings, Montana.
    We have many of you testifying on the second panel. I want 
to tell you that your entire testimony will be made a part of 
the record. And I wish that you would summarize for us, and at 
some point, if you're unable to summarize, you may hear me bang 
the gavel, gently for you, of course.
    I also want to tell you before we call on this panel, that 
we will ask any other testimony from any member of this 
audience or anyone listening, any testimony can be submitted by 
you or you can do it by fax or you can do it through the 
Internet or you can call the Indian Affairs Committee in the 
U.S. Senate, Washington, D.C.
    We will make your formal testimony a part of the record 
even though you have not been called as witnesses, but you will 
have the opportunity to make statements and provide statements 
to this Committee. And that opportunity will exist for 2 weeks 
following today, and it will be open to you to submit such 
testimony.
    Dr. Erpelding has surgery at 3 o'clock today, I understand, 
so because of your surgery schedule, we want to call on you 
first.
    So, Dr. Erpelding, why don't you proceed? And again, I 
would ask all the witnesses to speak directly into the 
microphone so that all in this gymnasium will be able to share 
in your comments.
    Dr. Erpelding. Chairman, Senator and distinguished guests, 
thank you for allowing me this opportunity.
    About a year ago, I was getting frustrated with the trend 
that I've seen practicing here for 11 years, that it's just 
gotten to the point where I searched out to try and look for 
some solutions outside of the current system, and I think Stacy 
is going to talk about that.
    But, in essence, the trend has been a gradual decline in 
access and an increase in severity and diversity of disease, 
and I can share some specific numbers that illustrate that.
    What I've been told is that IHS funding is currently at 54 
percent of need, and the reason I don't know, but the result is 
that I cannot take care of patients that come in and need care, 
and it's very frustrating.
    Access is limited by deferral of service. Patients wait 
anywhere from 2 weeks to a year to be seen in a clinic. I've 
had a patient wait 6 years to get a total joint replacement, 6 
years.
    Senator Dorgan. Six years for what?
    Dr. Erpelding. For a total joint replacement.
    Orthopedic care is the most common deferred service. There 
frequently is no wait list. The surgery list that we had here 
at Crow 3 years ago was lost. We had about 60 patients on that 
list. The list got lost; those patients have to come back in, 
be seen, be evaluated and get back on the list. So, we've got 
some areas that we need to work on.
    The deferral of service has consequences. I looked at the 
total joint and back patients that were waiting for surgery, 60 
percent of them were on opiates, 60 percent. That's their way 
of coping with pain. If they can't get the surgery, they need 
something.
    Last year we shut down the OR here for 2 months because we 
ran out of money, and I couldn't come down and do surgery here. 
I come down here and do surgery. There's also a decrease in 
employment and an increase in secondary disease due to lack of 
access.
    I can give you some numbers; total joint patients the last 
5 years, my non-Indian health service patients, the average age 
is 63\1/2\. The Indian Health Service patients, the average age 
was 54.2.
    Why? I would submit some of this reflects a lack of access. 
It reflects a lack of health opportunities earlier in the onset 
of arthritis, and it's seen many years later. But a nine-year 
difference in average age for total joint replacement, that is 
sad.
    When I looked at 20 patients that had ACL reconstructions, 
20 that were non-IHS and 20 that were Indian Country patients, 
95 percent of those that were Indian Country patients had a 
torn cartilage. That leads to an increase in arthritis. Only 10 
percent of those who were non-IHS, had torn cartilage.
    Why? The average wait for a non-IHS patient was 2 months. 
The average wait for an Indian County patient, 13 months. We 
can't keep doing this.
    I've brought some solutions to the state. I was the 
President of the Orthopedic Society in the state. I've asked us 
to focus on health disparity education, medical and nonmedical. 
People need to know about this. They need to know that there's 
a disparity and how can we help.
    We need to improve the cultural competency of those of us 
involved. I've got a surgery scheduled this Friday, it's during 
Crow Fair for heaven's sake. People wait a year to go to the 
Fair, and unfortunately, I tried to change it, could not, but 
that's cultural recognition, that I shouldn't be offering 
surgery on a week that is very important to this Nation.
    Additionally, there's prevention principles that we need to 
focus on. But most important, I listened to Michael Porter, who 
is a Harvard professor and strategist a couple days ago at a 
leadership conference, and he said American people respond and 
make things happen. He also said we need to provide value. When 
we look for increase in funding, we need to provide value when 
we do that.
    One of the areas that came up when I chatted with the 
Billings Area Office, is they need an infusion in business 
minds. It's difficult to do third-party collections if they 
don't understand how to do it. The private sector knows how to 
do it. This is an area where we can garner additional funds 
without a lot of increase in cost.
    The others areas that I'm concerned about is we measure 
things, but the measurements aren't accurate, so it's garbage 
in, garbage out. We need to measure access for diagnosis, not 
just well, they're going to see a specialist, but do they get a 
diagnosis. And then we need to measure access for treatment 
better.
    I plead with those of you that have the ability to improve 
the funding for health opportunity initiatives in Indian 
Country, and I thank you for the opportunity to talk.
    Senator Dorgan. Dr. Erpelding, thank you very much. Dr. 
Erpelding, as I indicated, has surgery scheduled today and so 
we took his testimony first.
    Thank you very much, and thank you for submitting testimony 
and giving us a different perspective, your perspective as an 
orthopedic surgeon on some very important issues. If you need 
to leave at this point, we will understand. Let me next call on 
Stacy Bohlen, and Stacy Bohlen is the Executive Director of the 
National Indian Health Board.
    Stacy, you may proceed.
    Ms. Bohlen. Thank you.
    On behalf of the National Indian Health Board, Mr. Chairman 
and Senator Tester, thank you for allowing the National Indian 
Health Board to be here today. Dr. Erpelding was here as a 
witness for the National Indian Health Board, and as you said, 
I am the Executive Director.
    I'm a member of the Sioux St. Marie Tribe of Chippewa 
Indians in Michigan, and I am actually accompanying Mr. Jace 
Killsback, who is a councilman for Northern Cheyenne, and he is 
also a Board member of the National Indian Health Board, so I'm 
going to turn this over to him, if you don't mind, sir.
    Senator Dorgan. All right.

          STATEMENT OF JACE KILLSBACK, BILLINGS AREA 
REPRESENTATIVE, NATIONAL INDIAN HEALTH BOARD, COUNCIL MEMBER OF 
   THE NORTHERN CHEYENNE TRIBE; ACCOMPANIED BY STACY BOHLEN, 
EXECUTIVE DIRECTOR, NATIONAL INDIAN HEALTH BOARD AND DR. JOSEPH 
        ERPELDING, ORTHOPEDIC SURGEON, BILLINGS, MONTANA

    Mr. Killsback. First of all, greetings Chairman Dorgan, 
Senator Tester and esteemed members of the Senate Indian 
Affairs Committee.
    As Stacy mentioned, my name is Jace Killsback, a member of 
the Northern Cheyenne Tribal Council, and also a Board member 
representing the Billings Area for the National Indian Health 
Board.
    Stacy will providing me with some technical assistance.
    On behalf of the National Indian Health Board, it is an 
honor and a pleasure to offer this testimony on health care 
issues in Montana and nationally.
    Our testimony today will focus on contract health service 
policy and practices and the consequences of poor funding and 
poor surveillance impacts on American Indians in Montana.
    During our discussion, we will focus on the lack of 
orthopedic care in Montana, and how contract health services or 
CHS funding implementation have created this crisis in Montana.
    We especially acknowledge the leadership of Senator Tester 
in organizing and holding this hearing on these critical 
issues.
    So please allow me to express again my gratitude of the 
tribes for the work the committee has done in advancement of 
the reauthorization of the Health Care Improvement Act.
    And we're especially thankful for the leadership that 
Senator Dorgan has provided and his tendency to bring this 
legislation to a successful conclusion to be enacted this year.
    This bill will not only advance without the vigilance of 
the tribes, but also Congressional leaders like Senator Dorgan, 
and we hope that you will continue to be a champion of this 
effort.
    We also would like to acknowledge the work of Senator 
Baucus and his assurance from the Senate Finance Committee that 
they will mark up the bill September 12. We look forward to 
seeing this bill progress of community consideration for the 
Senate floor.
    A snapshot of the health care status of American Indians 
and Alaska Natives, they have a lower life expectancy and 
higher disease burden than all other Americans. Roughly 13 
percent of American Indians and Alaska Native deaths occur for 
those under the age of 25. This is three times the rate of the 
U.S. population.
    Our youths are more likely to commit suicide at 70 percent 
in Indian Country. These are involved with alcohol. We haven't 
found the effects of methamphetamine abuse.
    American Indians have a life expectancy rate 6 years less 
than any other group in the United States, and rates for heart 
disease are twice the rate for Americans, and this continues to 
increase while the rate among the general public is decreasing.
    The Center for Disease Control reported earlier this year 
that for the first time in 75 years of cancer disease 
surveillance, the rates of cancer in the U.S. are decreasing. 
This is true for all groups except for American Indians, for 
whom cancer rates are continuing to increase.
    Disproportionate quality, poor education, cultural 
differences, and the absence of adequate health care and 
delivery are why these disparities continue to exist. The true 
tragedy is that most of these illnesses which American Indians 
suffer from are completely preventable.
    It's also because the funding for Indian health care on a 
per capita basis is half of what Federal prisoners receive.
    For the proud nations of people who fought for their 
freedom to protect their way of life and negotiated honestly 
for a few considerations like health care and education for 
their people in exchange for the land they had given up with 
their lives, surely Congress can do better.
    You guys are pretty familiar with the statutory provisions 
for health care for American Indians, which again, is under the 
Snyder Act of 1921 and Health Care Improvement Act.
    There are two types of services, direct services that are 
provided to IHS at our tribal hospitals and clinics, and our 
contract health services which are provided by the private 
sector facilities, and providers are based on referrals from 
IHS from the tribal CHS program.
    CHS services are utilized when a direct care facility is 
not available, the direct care facility is not capable of 
providing the required emergent or specialty care, or is not 
capable of providing the care due to medical care workload.
    CHS authorizes, subject to the availability of alternate 
resources, such as Medicaid, Medicare and private health 
insurance. Due to the limit of CHS funding, CHS regulations 
require that services must be preapproved at the local CHS 
program and determined to be medically indicated within medical 
priorities.
    If the services are provided in an emergency situation, 
notification must be made to the local CHS program within 72 
hours. The majority of CHS services are authorized for priority 
medical, emergent or acutely urgent care services.
    These services are defined in the CHS manual as services 
that are necessary to prevent the immediate death or serious 
impairment of the health of an individual.
    Other medical priorities include priority two for Indian 
health care, and priority three, secondary health care issues. 
Priority four, prompt tertiary and extended health care 
services such as rehabilitation.
    For those services that are within the medical priorities 
but are considered elective or not emergent or not authorized 
for pain due to lack of CHS funding, are considered deferred 
services.
    In Fiscal Year 2006, the IHS received over 150,000 requests 
for services that were deferred. If they had been approved and 
paid, they would represent $176 million from the CHS. The data 
on these numbers for deferred services is not consistent among 
the IHS areas and is probably under reported.
    Because the general deferred services are never authorized 
and never paid for, there is little incentive for an Indian 
patient to request IHS programs to pay for their services.
    As an example, the Northwest Portland Indian Area Health 
Board has estimated that due to lack of data on deferred 
services, that they have estimated there are probably 300 
million of unmet needs for CHS in their area alone.
    Senator Dorgan. I'm afraid I'm going to have to ask you to 
summarize the remainder of your statement in order that we 
might get all of the statements in from others.
    Mr. Killsback. Here in Montana, we represent the large 
land-based tribes, and we are the most desperate, the most 
needy of the neediest. Our communities are rural, and a lot of 
times we see economic development being pushed on our tribes, 
and the notion is here, we can't have economic development 
without healthy communities.
    The payor of last resort is something that, again, reflects 
a perception in Indian Country of the culture of IHS. We have 
patients that go in and are not being treated until there is 
appropriate funding, and so what you have is a creation of an 
addiction, painkillers.
    This has also allowed for some issues in the communities 
for black market drug trade of prescription drugs that isn't 
being addressed also.
    The culture of IHS in the continuing fighting for funding 
has the Indians playing the numbers game. Some numbers that are 
interesting, consider we have 30-year-olds walking around like 
50-year-olds on our reservation.
    Because of the deferments also, we are not keeping accurate 
records so we don't have the appropriate data even for 
diagnosis, and how can we get the proper amount of funding for 
treatment if we don't have the proper number for diagnosis or 
referrals.
    I just want to wrap it up by saying that the reimbursement 
issue that was brought up earlier, it's not IHS that's 
improving the third-party reimbursements, it's tribes improving 
third-party reimbursements, and yet, those reimbursements are 
still being utilized against us in the budget process when it 
comes to the IHS budget formulation.
    Thank you for allowing us to testify.
    [The prepared statement of Mr. Killsback and Dr. Erpelding 
follows:]

  Prepared Statement of Jace Killsback, Billings Area Representative, 
 National Indian Health Board, Council Member, Northern Cheyenne Tribe 
    and Dr. Joseph Erpelding, Orthopedic Surgeon, Billings, Montana





    Senator Dorgan. Mr. Killsback, thank you very much. I have 
read ahead of you in your testimony and you have provided, I 
think, some very important data and statistics on these issues. 
We appreciate that very much.
    I'm sorry to ask you to summarize at the end, but we have 
so many witnesses and I want to make sure all of them have an 
opportunity, but I want to thank you for putting together about 
12 pages of some very useful information about Wyoming, 
Montana, about some of the data that we are seeking, so thank 
you very much.
    And Ms. Bohlen, thank you very much for bringing Mr. 
Killsback and Dr. Erpelding with you as well.
    Dr. Joe McDonald is with us and we will hear next from Dr. 
Joe McDonald, President of the Salish Kootenai College.
    Dr. McDonald, thank you very much, and as I indicated to 
others, you may summarize and your entire statement will be 
made a part of the permanent record.

   DR. JOSEPH F. McDONALD, PRESIDENT, SALISH KOOTENAI COLLEGE

    Dr. McDonald. Honorable Jon Tester and Mr. Chairman, my 
name is Joe McDonald, I'm the President of the Salish Kootenai 
College. It's really an honor to appear before you today and 
provide this testimony. I thank you very much.
    And I extend a special thanks to Chairman Venne and the 
Crow Tribe for hosting this field hearing and nice lunch and 
the nice facility you have here and the excitement of the 
celebration that's about to begin.
    I can't say enough about the need for recruitment of 
American Indian people into the medical provider professions, 
ranging all the way from CNAs to medical doctors.
    It's difficult to recruit these people into our rural areas 
and get them to stay. And I think if we could recruit members 
of tribes and have the tribal colleges provide the training, 
that they would come and they would stay, and we would not have 
the shortage that we have on our reservations. I think they 
would provide consistent service.
    At Salish Kootenai College, we have been offering nursing 
for about 18 years now, and we've had 400 and some nurses 
graduate, 200 and some have been American Indian nurses. Our 
passing grade on the Implex has been over 90 percent.
    They told us when we started that, you know, Indians 
couldn't pass that test. They said, Joe, after all, they have 
to take this test. Well, we do take it and we do it well.
    The doctors say that our nurses are very good. You go to 
the hospitals in our western Montana, they say, Joe, you've 
really got some great nurses there. And so the Indian people 
can do this, and they can do it well.
    We have nurses working here at the Crow Hospital, as we 
have at all the IHS facilities, Indian Health Care facilities 
in Montana and much throughout Indian Country.
    When we started our program in 1989, our research showed 
that there was one American Indian in nurses training in 
Montana that year. This year, just this year, we'll have 46 
American Indian students in our classes in Salish Kootenai this 
fall.
    So given a chance, the American Indian students, they will 
enter the field, they will take on the challenge of becoming a 
nurse.
    We also have a dental assisting technology program. We 
hoped it could grow into a dental hygiene program, but it 
hasn't to this stage, but they do take the licensure to be 
certified dental assistants and they're working throughout the 
southwest. We have some even in Alaska and in dental clinics 
around our reservations.
    There's a need to have more of these programs, licensure 
programs in many medical fields, such as dental hygiene, 
occupational therapy, all the different x-ray programs, the 
medical records technology, all of them. There's a tremendous 
need for that.
    We in the tribal colleges could do that well if we just had 
the resources. We can do the training, and we can do the 
recruiting if we have the resources.
    Health care in Montana is one of the fastest growing areas 
of employment. It's one of the biggest employers in Ronan, and 
provides one other opportunity for Indians to get employment.
    In order to do the recruitment, our K-12 students need to 
be encouraged to think about these health care programs, and 
appropriate classroom instruction is needed and counseling is 
needed to build confidence and competence so that the Indian 
students at the sixth grade level, seventh grade level decide 
that I'm going to be a nurse or I'm going to be a doctor or I'm 
going to be a x-ray technician, or whatever it might be, 
because they can do that.
    We need to build a pipeline, a pipeline in Indian Country 
that will go from kindergarten all the way through the chosen 
profession.
    Once students are recruited in the program, they need help 
to overcome a lot of barriers and problems that they encounter.
    Finance is certainly a problem, individual finance is a 
problem. Many of the students come that need help in basic 
skills, college skills. They need to complete prerequisites 
before entering the nursing program. A lot of times they burn 
up a lot of their Pell grant eligibility getting ready to enter 
into the nursing program.
    Once they enter the nursing program, the study demands are 
enormous and they need confidence building, they need a pat on 
the back, they need a push and support.
    The graduating nurse must be very skilled and very 
confident, and we can't cut any slack with them because they 
have to be good and they have to be very good.
    The costs of the college for the health care provider 
training are much greater than the average other programs that 
we offer. At Salish Kootenai College we really struggle to find 
the fiscal resources and the instruction staff to maintain the 
nursing program.
    Every year as we get into the budgeting, part of the 
program is on the chopping block. We have not done it; we have 
been struggling with being able to meet those needs.
    Our salaries are not adequate. It's tough to recruit them 
with the salaries we pay. We have an opportunity right now to 
recruit an American Indian nurse that's been completing her 
doctorate degree. We'd like to have her come back, but I'm not 
sure that we could negotiate or get through that.
    So, I believe that Indian students can be recruited and 
retained if given the opportunity, that retention of the 
student depends on adequate funding for the college to provide 
the program.
    I think the solution is to continue to adequately fund the 
Tribal College Act, and I know that you've been a leader in 
that, and if we could just get our funding equal to the state 
allocation averages for 2 and 4-year mainstream colleges, we 
would be doing well.
    I'm pleased to hear that the legislation, THE PATH, has 
been introduced, because I think that's going to be a big help. 
I'm also pleased to hear that the Indian Health Care 
Improvement Act, Improvement Reauthorization Act is going to be 
marked up.
    We have suggested some amendments to it. I understand many 
of them have been included. I've included that in my testimony 
that we have suggested it, so I really do thank you for that.
    So, Mr. Chairman and Senator Tester, we thank you for 
inviting us and for considering any of our suggestions in the 
amendments.
    In closing, I want to extend my sincere thank you for your 
commitment and hard work in support of our nation's tribal 
colleges and Indian tribes.
    I think that both of you are true role models for 
lawmakers, and I really appreciate it.
    Thank you very much for taking this time.
    [The prepared statement of Dr. McDonald follows:]

 Prepared Statement of Joseph F. McDonald, President, Salish Kootenai 
                                College
    Honorable Senators John Tester and Byron Dorgan,
    It is an honor to appear before you and offer this testimony. Thank 
you very much. I also extend my thanks to the Crow Tribe for hosting 
this field hearing.
    There is a need to recruit American Indian students into the 
various medical provider professions ranging from LPN's to medical 
doctors. It is difficult to recruit skilled medical professionals to 
work in our rurally isolated Indian communities. The most efficient way 
is to recruit, and train American Indian medical staff. They are more 
willing to serve on their reservations and will provide consistent 
service to their communities.
    At Salish Kootenai College we started a nursing program in 1989. 
Thus far we have graduated 432 nurses, 202 are American Indian nurses. 
Our passage rate of NCLEX certification examination has averaged over 
90 percent. Our American Indian nurses that have graduated from Salish 
Kootenai College serve the hospital here at Crow Agency as well as the 
hospitals on the Blackfeet Indian Reservation, the Fort Belknap Indian 
Reservation, the health service agencies on each reservation, private 
hospitals, nursing homes, and home health agencies throughout Montana.
    When we started our nursing program in 1989 there was only one 
identified American Indian student in nursing programs in Montana. This 
fall we will have 46 American Indian students in our nursing education 
program. We will also have 41 non-Indian students.
    We also have a training program for dental assisting technology. 
Graduates of the program are eligible to take the Licensure Examination 
and become certified dental assistants. Our graduates work in Indian 
dental clinics throughout ``Indian Country'' and Alaska. Some go on to 
become dental hygienists.
    There is a need to have educational programs that lead to licensure 
in other medical fields such as dental hygiene, occupational therapy, 
x-ray technicians, laboratory technicians, medical records technology, 
and many others.
    Health care is one of the fastest growing areas for employment in 
Montana. It provides a great opportunity for employment for American 
Indian people.
    Our K-12 students on our Reservations need to be encouraged to 
think of working in the health care field. Appropriate classroom 
instruction and counseling is needed to build confidence, competence, 
and desire to pursue a career in the health care field.
    Once students are recruited into the program, they require help to 
overcome the many barriers and problems they encounter. Individual 
finance is a problem. In addition to family maintenance, students have 
the cost of going from Pablo to Missoula or Kalispell for their 
hospital practicum. Tutoring is needed, and counseling services are a 
necessity.
    Many of the Indian students that come need help in basic college 
skills and need to complete prerequisites before entering the nursing 
programs. Once they enter the nursing program, the study demands are 
enormous. The graduating nurse must be very skilled and competent.
    Costs to the college for health care provider training are much 
greater than for most training in fields of study.
    At Salish Kootenai College we really struggle to find the fiscal 
resources and the instructional staff to maintain our nursing education 
programs. We are competing poorly for faculty salaries and our turn 
over rate of nursing instructors is much higher than for the rest of 
our college.
    In summary, American Indian students can be recruited and retained 
in health care professions such as nursing. Retention depends on 
adequate funding for the student and adequate funding for the college 
providing the program. Continuing to increase the funding of the Tribal 
College Act would be a great help and would get tribal colleges funding 
equal to the state allocation averages for 2 and 4 year mainstream 
institutions.
    The passage of the legislation, S. 1779 entitled THE PATH will help 
greatly also. It is an Act that will help prepare an American Indian 
health workforce, improve health and wellness of students and their 
families, and combat substance abuse. It has been introduced by you two 
Senators and I thank you for it. And I speak for all of our colleges in 
extending thanks to you.
    Passage of the Indian Health Care Improvement Reauthorization Act 
of 2007 will provide valuable assistance to our tribal colleges. We 
have asked for some amendments in the legislation. The amendments 
address: (1) delivery of health training programs; (2) recruitment and 
retention of Native American nurses in our associate and bachelor 
degree programs; (3) scholarship payback options that would allow 
payback to include teaching in a tribal college nursing program; and 
(4) addition of a provision that would authorize TCU-based social work 
and psychology degree programs.
    The specific amendments are as follows:

    ``SEC. 104(b)(1) INDIAN HEALTH PROFESSIONS SCHOLARSHIPS, ACTIVE 
DUTY SERVICE OBLIGATION--OBLIGATION MET''

    Add a subsection (D) to read ``In a teaching capacity in a tribal 
college nursing (or related health profession) program.''

    ``SEC. 113. INDIAN RECRUITMENT AND RETENTION PROGRAM.''

    Add a subsection (c) to read: ``Tribal college health education 
programs shall be accorded priority for funding pursuant to this 
section.''

    ``SEC. 115(d) QUENTIN N. BURDICK AMERICAN INDIANS INTO NURSING 
PROGRAM, PREFERENCES FOR GRANT RECIPIENTS''--

    Add a subsection (5) to read: ``Programs conducted by tribal 
colleges.''

    ``SEC. 115(f) QUENTIN N. BURDICK AMERICAN INDIANS INTO NURSING 
PROGRAM, ACTIVE DUTY SERVICE OBLIGATION''--

    Add a subsection (5) to read: ``teaching in a tribal college 
nursing program.''

    ``SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY COLLEGES. (a) 
GRANTS TO ESTABLISH PROGRAMS--(1) IN GENERAL--

    It is essential to recognize that several tribal colleges, 
including Salish Kootenai College, are accredited as 4-year 
institutions of higher education by regional accrediting associations, 
rather than classified or accredited as ``community colleges.'' 
Construed to its logical extreme, Salish Kootenai College could 
arguably be considered ineligible for a training grant under this 
section, notwithstanding that it is a community college in the more 
global sense. We do not think this is Congress' intent. We therefore 
recommend modifying the first sentence of this subsection to read:

        ``The Secretary, acting through the Service, shall award grants 
        to accredited and accessible community colleges or tribal 
        colleges for the purpose of assisting such colleges in the 
        establishment of programs which provide education in a health 
        profession leading to a degree or diploma in a health 
        profession for individuals who desire to practice such 
        profession on or near a reservation or in an Indian Health 
        Program.''

    We further recommend that this language change be reflected in 
subsection ``118(a)(2) AMOUNT OF GRANTS,''--which should also increase 
the minimum annual grant award, as follows:

        ``The amount of any grant awarded to a community or tribal 
        college under paragraph (1) for the first year in which such a 
        grant is provided to the community or tribal college shall not 
        exceed $250,000.''

    The rationale for the increase of the first-year ceiling level from 
$100,000 to $250,000 rests with the fact that it is virtually 
impossible to adequately or credibly initiate a health career-training 
program with $100,000. This low amount is a set-up for failure from the 
beginning and accordingly needs to be increased.
    Also, the term ``or tribal college'' should be inserted after the 
phrase ``accredited and accessible community colleges'' or ``community 
college'' in Sections 118(b)(1), (2), and Section 118(c).
    Under Section 118(b)(2)(C)(i), strike the word ``advanced'' before 
the phrase ``baccalaureate or graduate'', as it is redundant, 
confusing, and unnecessary.
    As to Section 118(a) and (b), we urge that language be added to the 
effect ``Priority for the award of funds under this subsection shall be 
accorded to accredited tribal colleges with nursing programs.''
    Finally, for purposes of consistency, we recommend that the title 
of Section 118 be changed to read: ``HEALTH TRAINING PROGRAMS OF 
COMMUNITY OR TRIBAL COLLEGES.''

    ``SEC. 126. SUBSTANCE ABUSE COUNSELOR EDUCATIONAL CURRICULA 
DEMONSTRATION PROGRAMS''

    We recommend that tribal college social work and psychology 
programs be added to this section. In the case of Salish Kootenai 
College, our former substance abuse program has been incorporated in 
our new social work program. This appears to be the trend. The same 
holds true for psychology programs, which have essentially incorporated 
former stand-alone substance abuse curricula under the psychology 
rubric.

    ``SEC. 126 (c) TIME PERIOD OF ASSISTANCE; RENEWAL''

    A 1-year period is simply too short of a timeframe to administer or 
renew an academic program. Accrediting agencies require a minimum of a 
3-year timeframe for approval of any new program. These types of 
programs are two or 4-year programs, i.e., multi-year. Program and 
student learning outcomes (and academic planning and assessment, and 
budgeting) are accordingly based on multi-year timeframes, usually 3-5 
years. In short, a 1-year life period is wholly unrealistic from all 
relevant perspectives.

    Mr. Chairman, we thank you for considering our concerns regarding 
these much needed amendments to the Indian Health Care Improvement Act. 
We respectfully ask you to include this letter in the record of the 
Committee's mark-up of S. 1057.
    In closing, please accept my sincere thank you for your 
longstanding commitment, hard work, and support of our Nation's tribal 
colleges and Indian tribes. You are a true role model for lawmakers, 
and we will forever appreciate your service. My kindest regards.
    Thank you for taking the time to hear about health care for 
American Indians.

    Senator Dorgan. Dr. McDonald, thank you very much.
    Let me mention, as I prepare to recognize Ada White, that 
THE PATH legislation that you referred to is legislation that 
Senator Tester and I have jointly introduced in July.
    Senator Tester has added a great deal with this idea to the 
opportunities in education, and I am proud to be a partner with 
him and we intend to push it. And I think it's a testament to 
Senator Tester's concern and aggressiveness on these issues. So 
thank you very much for mentioning that.
    Next we will hear from Ms. Ada White, the Health Service 
Director of the Crow Tribe.
    Ms. White, if you will pull the microphone very, very 
close, and you may summarize and your statement will be part of 
the record.

 STATEMENT OF ADA M. WHITE, HEALTH SERVICE DIRECTOR, CROW TRIBE

    Ms. White. Good afternoon, distinguished members of the 
U.S. Senate. I am welcoming you to Crow Country, and I thank 
you for this great opportunity to provide testimony on behalf 
of the Crow Tribal health concerns.
    As stated earlier, my name is Ada White. Like many people 
in this room, I have devoted most of my life to working for the 
Crow Tribe. I can find a lot of value in the fact that we've 
had a lot of development, and I've been with the tribe for over 
36, 37 years.
    I share this information because I want to illustrate my 
passion and commitment to the health and welfare of the Crow 
people. Throughout my years of being involved, I have always 
worked to strengthen tribal sovereignty, to further tribal 
self-determination, and to remain vigilant in helping enforce 
other Federal trust responsibilities.
    Senator Dorgan and Senator Tester, and other members of the 
Indian Affairs Committee, I commend your commitment to Indian 
Country. I commend your vigilance in watching what's happening 
on Capitol Hill, protecting our interests.
    In particular, I am certainly indebted to your work in 
working for the reauthorization of the Indian Health Care 
Improvement Act, working on a special diabetes initiative, and 
also keeping in the forefront that it is the responsibility of 
the Federal Government to honor trust agreements, trust 
responsibilities as it relates to health care.
    Unfortunately, this is a challenge that we must continually 
work on, and that is to dispel the myth that scheduled 
ordinance provision of Indian health care is optional. And as 
we have heard from a speaker alluded to earlier, health care is 
a must; money is a must to develop health care.
    And as stated by my colleague from the Fort Peck 
Reservation, James Melbourne, he and I spoke, he says the issue 
of entitlement versus discretionary funding must be addressed 
by Congress.
    Health care provider for the Federal Government, as stated 
earlier, is based on the various acts and treaties, and for the 
Crow Tribe, it's the 1868 Treaty at Fort Laramie, the 1904 Crow 
Tribe Federal agreement and the 1920 Crow Allotment Act.
    Despite all this, today we are facing that fact that Indian 
Health Service is appropriating less than half of the necessary 
funding to provide basic medical services for the Crow people.
    I bring to your attention, and I've attached it to my 
testimony, a recent article entitled ``Cardiovascular Risk 
Factors in Montana--American Indians With or Without 
Diabetes.''
    The rationing of health care for American Indians described 
in the recent Institute of Medicine report on racial and ethnic 
disparities, emphasizes the lack of resources for preventive 
care in this population. And certainly we know that we get a 
lot of lip service on prevention, but when it comes to 
providing money for the actual provision of those activities, 
we have no funds.
    I am now going to direct my comments to the health care as 
it is, as we experience it here on the Crow Reservation. And I 
know that in the audience, Crow people are listening to how I 
cover this topic.
    You have been inundated with statistics. I can see them 
coming out of your ears. I know that's all you hear in 
Washington, D.C. Today, I am going to present some real 
information as to what it means for Crow people to receive 
health care.
    And before I do, I know that my comments and my 
observations may be perceived by some as bashing of Indian 
Health Service people, however, I want to take this time to 
commend the highly committed, the deeply compassionate and 
under appreciated health care professionals who serve our 
community.
    However, I must be honest about dire conditions that exist 
here on Crow Reservation so that we may work together to 
address the problems. And as alluded to earlier, these problems 
are apparent in all of the reservations within the Billings 
Area.
    I direct your attention to a meeting held in Billings, 
Montana August 2, 2006, wherein Dr. Charles Grim, the Director 
of the Indian Health Service, was asked for improved health 
services. Dr. Grim responded, quote, ``Indian Health Service, 
people are the services.'' So what does that do when you look 
at Indian health care, that means we look at people providing 
those services within the IHS system.
    As has been shared, in June of 2006, the Crow service unit 
fiscal deficit was approximately 4.3 million. At a meeting 
yesterday, I was told that the deficit is 12.3 for this year. I 
asked at that time, have you resolved that 4.3 deficit, and no, 
it has not.
    That just illustrates the accumulation of the deficits that 
have gone on here at the Crow service unit historically.
    I remember several years ago, I asked a question to the 
acting Service Unit Director about personnel and project costs. 
Again, I quote, ``67 percent of the local budget was applied to 
personnel salaries.''
    I remember a comment that our esteemed chairman asked Dr. 
Charles Grim in Billings. He said, ``If there are no funds for 
pay raises, why give it?'' Dr. Charles Grim at the time 
responded that he got that money from third-party 
reimbursements. And we know that third-party reimbursements is 
a collection activity that sometimes is realized, most often 
not.
    Again, at the same meeting in Billings, Montana on August 
7, 2006, Billings Area IHS Director Pete Conway stated, quote, 
``As the dollar get's tighter, there is a need to find ways to 
cut in other areas.'' The implications of this statement are 
evidenced in many areas.
    For example, one, according to Indian Health Service, there 
has been a 46 percent increase in denials from Indian Health 
Service for services through the contract health service 
program from 2001 to 2006. In an article in the Great Falls 
Tribune, IHS stated that it's an effort to budget the funds 
available efficiently.
    Two, the deferred contract health service list increases 
daily. For those waiting in excess of several years and living 
in constant pain, there is often prolonged use of pain 
medication that cause a host of other medical problems, which 
may too go unaddressed due to the lack of funding.
    As people like to say, ``if it ain't broke, don't fix it.'' 
In this case, CHS is beyond repair. We pose a challenge for the 
decisionmakers in IHS to explore other options. If the CHS 
system is not working, come forth with something else that 
will.
    Third point, prescriptions originating from contract health 
care referrals are not filled locally. Over the counter 
medications are not provided locally. Certain drugs have been 
eliminated. The result is that financially strapped individuals 
are unable to purchase needed medications that have been 
prescribed for them.
    Many of us in here are working, but there are many Crow 
people living out there that have very little money to purchase 
over the counter medications. A member of the Crow legislative 
body brought to my attention the fact that his wife cannot get 
the arthritis medication that she had been receiving for 
treatment prior years.
    I go on to point four, access to proper health care is 
inadequate, and in many cases, is denied. I know every Crow 
person in this room listening to this testimony can provide 
examples of the deficiency and lack of health care, and I 
encourage those persons to share their stories with members of 
the Senate Committee.
    I will personally at this point share with you two cases 
involving members of my family. Additionally, I will be 
providing several more copies of letters that have been 
provided for me.
    Senator Dorgan. Ms. White, I want you to share both of 
those cases, and then following that, I need to have you 
summarize because we have to have the other testimony.
    Ms. White. Thank you. Thank you.
    Senator Dorgan. But why don't you share both of those 
cases.
    Ms. White. First, you have here a very cute little girl in 
her native outfit, that was very hard work, good to see, but 
difficult. People say there is a thousand words in pictures. I 
show this picture of my 5-year-old granddaughter. This was 
taken at the Lodge Grass Pow-Wow last July. My granddaughter 
left us, she died short of a year ago.
    From May, 2006 to August of 2006, numerous visits were made 
to the clinic at Crow. During this time, Ta'shon (phonetic) was 
treated for depression. During one of her clinic visits, 
Ta'shon's grandfather pointed out the bulbous condition on her 
fingertips and toes, which is indicative of a lack of oxygen.
    In June, 2006, I spoke with Ta'shon's doctor and asked the 
doctor to eliminate cancer and leukemia. On August 7, 2006, my 
granddaughter was rushed from the Crow clinic to St. Vincent 
Hospital in Billings due to a collapsed lung.
    She was airlifted to Denver. After being there 5 days, we 
were told that she had a tumor that was untreatable and 
incurable. She died on September 1st.
    The point is, if she had been diagnosed earlier, could some 
of that have been prevented? I believe she spent the last 2 
years of her life in unmedicated pain. One premature death of a 
child who suffered excruciating pain is too much for the 
conscience.
    Case two, Ta'shon's great-grandmother, Ada Rides the Horse 
was brought to the Crow Emergency Room, waited 3 hours, taken 
by her daughter to the Hardin Clinic, transferred from the 
Hardin Clinic to St. V's, she died in the Emergency Room from a 
ruptured aneurism.
    The RN who was working at the Crow Emergency Room says 
later to Ada's daughter, I'm sorry, if I would have known, I 
would have taken your mother right in.
    Those are the two stories I'd like to share. There are 
other points here. We have received a lot of information. We 
compliment you, the support that you have given us.
    Pryor people, Lodge Grass people are concerned about the 
continual discussions about the possibility of closing those 
clinics, and again, the same financial considerations exist. 
People do not have the money to come to Crow.
    Again, you will get all the information, and I present this 
to the Committee.
    Thank you very much.
    [The prepared statement of Ms. White follows:]

Prepared Statement of Ada M. White, Health Service Director, Crow Tribe
    To the august Members of the U.S. Senate, serving on the Senate 
Select Committee of Indian Affairs, welcome to Crow Country. On behalf 
of the Crow Tribal Members, I thank you for this opportunity to provide 
Crow Tribal Health concerns to this esteemed Body.
    My name is Ada White, I am a member of the Crow Tribe, and 
currently employed by the Crow Tribe as the Director of the Crow tribal 
Health Department. Previously, some 17 years ago, I worked in Tribal 
Health, as the Director of the Community Health representatives Program 
for nineteen years. I briefly worked for Indian Health Service for 18 
months, and returned to Crow Tribal Employment in the Administrative 
Department (Finance, Social Services and Administrative Officer) for 10 
years. I then became employed by the Little Big Horn College as the 
Grants and Contracts Officer for 3 years, and have been back with the 
Crow Tribe, at the Health Department for an additional 4 years. I share 
my employment history for the sole purpose in validating the commitment 
and involvement I've had in the various aspects of Tribal Health 
development. Throughout these years, the maintenance and protection of 
the Federal Trust Responsibility; the strengthening of Tribal 
Sovereignty, and the enhancement of Tribal self-determination have been 
dominant in my endeavors.
    Senator Dorgan, Senator Tester and other members of the Senate 
Committee on Indian Affairs, I commend your vigilance, in assuring the 
Indian Tribes of this Country that Indian Health Care is a Federal 
Trust Responsibility.
    However, as Tribal Groups continue to work with the Federal 
Government, this Trust Responsibility must be promulgated and enforced. 
According to my Colleague (James Melborne) from the Ft. Peck 
Reservation, ``the issue of entitlement versus discretionary funding 
must be addressed by Congress.''
    On July 3, 2007, an article in the Great Falls Tribune stated, 
``access to and the availability of health care for the First Americans 
of this Nation was a trust contract in the Constitution in 1787.'' 
Certainly, Members of the Crow Tribe firmly believe health care is 
assured in the Ft. Laramie Treaty of 1855.
    We are also cognizant of this Great Nation's growing pains in 
affording basic human rights to its citizenry: the need for the Civil 
Rights Act; the need for the Voting Rights Act (there is a pending case 
here in Big Horn County, filed by the Citizens Equal Rights Alliance a 
right winged group alleging ``denying non-tribal members an opportunity 
to participate effectively in the political process on an equal basis 
with other members of the electorate. .''); the list can go on and on. 
To those associated with the current Administration in Washington, D.C. 
alleging ``race based'' considerations, I strongly urge their perusal 
of printed materials and studies which document racism in the delivery 
of health care; race based discrepancies in health care and funding 
restrictions prohibiting resource parity.
    I quote from an article, CARDIOVASCULAR RISK FACTORS IN MONTANA 
AMERICAN INDIANS WITH AND WITHOUT DIABETES, ``Yet the rationing of 
health care for American Indians described in the recent Institute Of 
Medicine Report on Racial and Ethnic Disparities emphasizes the lack of 
resources for preventive care in this population.'' A dichotomy is 
self-evident wherein a major study indicates a lack of funding for 
preventive care, and Indian Health is emphasizing Health Promotion and 
Disease Prevention. Or, most likely it's the ``catch up'' syndrome.
    Honorable Senators Dorgan and Tester, we know you are monitoring 
this race based phenomena very closely, and you have voiced your 
displeasure, and for this we are most grateful.
    I will now proceed in localizing my observations to the Crow Tribal 
Health Care concerns. Let me emphasize, that my observations and 
comments are not to be interrupted as ``Indian Health Service 
Bashings.'' I know we have many Health Professionals highly committed, 
deeply compassionate and under recognized for their services.
    HEALTH CARE MEANS ACCESSING HEALTH RESOURCES. HEALTH CARE MEANS THE 
PROVISION OF HEALTH SERVICES. BEING HEALTHY MEANS A CONDITION OF 
WELLNESS, OR FEELING WELL.
    At a meeting in Billings, Montana, August 2, 2006, Dr. Charles 
Grimm, the Director of Indian Health Service was asked about the 
prospect for improved health services, and his response was, ``Indian 
Health Service people are the services.'' So this leads one to focus 
attention on ``the people.''
    THE CURRENT STATE, RELATIVE TO HEALTH CARE, OF THE CROW INDIAN 
HEALTH SERVICE HOSPITAL AND CLINICS HAS EXCEEDED THE CRISIS MODE. What 
is being provided by Indian Health Service is woefully inadequate and 
can be classified as scandalous, unconscionable.
    Approximately 3 years ago, the Acting CEO of the Crow Service Unit 
stated that ``67 percent'' of the local budget was applied to personnel 
salaries.
    June 2006, Indian Health Service indicated the Crow Service Unit 
fiscal deficit was approximately 4.3 million.
    August 2, 2006 at a meeting in Billings, Montana, Mr. Pete Conway, 
the Director of the Billings Area Indian Health Service stated: ``As 
the dollar gets tighter, there is a need to finds ways to cut in other 
areas.'' What implications does this comment bear locally, Consider:

        1. According to Indian Health Service, there has been a 46 
        percent increase in denials from Indian Health Service for 
        services through the Contract Health Service Program from 2001 
        to 2006. It's an effort to budget the funds available, $520.5 
        million in Fiscal Year 2006 efficiently'' (Great Falls Tribune 
        Article, July 3, 2007).

        2. The deferred Contract Health Service surgical list increases 
        daily. For those waiting in excess of several years, and 
        experiencing continual pain, prolonged usage of pain medication 
        leaves other undesirable results.

        3.Prescriptions originating from Contract Health Care referrals 
        are not filled locally. Over the Counter Medications are not 
        provided locally.

    Financially strapped individuals are unable to purchase needed 
medications. Is this a National policy for all Indian Health Service 
Facilities?

        4. Access to proper health care is inadequate or in some cases 
        denied. Each Crow Person in this room, listening to this 
        testimony, can provide examples of unanticipated results of 
        this concern. I personally share with you the following two 
        cases.

           Case One: My 5 year old granddaughter, Ta'Shon Rain Little 
        light, died September 1, 2206. From May of 2006 to August 7, 
        2006, numerous visits were made to the Crow Clinic for 
        services. During this time, Ta'Shon was being treated for 
        depression. During one of the Clinic Visits, Ta'Shons 
        Grandfather pointed out the bulbous condition of her finger 
        tips and toes. This condition is indicative of a lack of 
        oxygen. June 2006, I spoke with Ta'shons Doctor and I asked the 
        Doctor to eliminate cancer and leukemia. August 7, 2006, My 
        Granddaughter was rushed from the Crow Clinic to St. Vincent 
        Hospital in Billings, Montana for a collapsed lung. The next 
        day Ta'Shon was air lifted to the Denver Children's Hospital, 
        where she was diagnosed with an untreatable, incurable form of 
        cancer. The question remains, what if this tumor was detected 
        earlier, would it have made a difference? Our baby lived with 
        unmedicated pain, the last 3 months of her life. Even one 
        premature death is too much.

           Case Two: June 2003, Ta'Shons Great Grandmother, Ada Rides 
        Horse visited the Crow Emergency Room for stomach pain. After a 
        wait of 3 hours, her daughter transported her to the Hardin 
        Hospital (12 miles NW of Crow) for care. Ada Rides Horse was 
        admitted, and then transferred to the St. Vincent Hospital in 
        Billings, where she died in the Emergency Room from a ruptured 
        aneurysm. The ordeal did not end here. The RN who was working 
        in the Crow Emergency Room later approached Ada Rides Horse' 
        daughter and said: ``I'm sorry, if I were clairvoyant, I would 
        have taken your mother right in.''

        5. The excessive waiting time for services (Out Patient Clinic, 
        ER, Pharmacy) needs to be addressed. Throughout the years, the 
        local facility has tried to modify some of the national trends 
        and adapt them for local operations, but rather that producing 
        a positive result, the bureaucratic stratum increases. Case at 
        hand is having a walk in clinic; add walk in clinic plus a 
        speciality clinic; add walk in clinic, speciality clinic, plus 
        prescheduled appointments with specified providers. Tuesday, 
        August 8, 2007, I waited 3 hours at the Out Patient Clinic, 
        then I was called to the ER for care. The waiting continues, 
        patients become angry, and providers become defensive.

    The problem in waiting, and not having enough providers on a given 
day could be addressed by having some of the professional health 
administrators, including the Commissioned Officers Corp provide some 
``hands on'' care. Again, I am reminded of Dr. Grimm's Statement that 
Our health care is the ``Indian Health Service People.''
    I inquired about the list of Medical Professionals posted on the 
wall in the Crow Waiting Room, and the ER Nurse stated that ``\1/2\ of 
them have left.'' This may be so, however, three of the current 
Physician's are employed part-time (Wilson, L. Byron, Upchurch). This 
certainly affects the level of care, and may also affect the 
recruitment process, because it ties up 1.5 positions.
    Our distinquished Crow Tribal Chairman, Mr. Carl Venne asked Dr. 
Charles Grimm, the Director of Indian Health Service, ``if no 
additional funding is provided for pay raises, why give it? '' Dr. 
Grimm responded, ``We make up for this with third party 
reimbursements.'' What impact does the fluctuations in third party 
collections have on this reasoning? Futhermore, a pay and time audit 
may be necessary to fully understand the issues surrounding employee 
pay. What we do know is that the salary and benefits for Commissioned 
Officer Corp Members runs much higher than it does for a Civil Service 
Employee.
    There are several other concerns that impact the level of 
resources, which impacts the level of care.

        1. It has been reported to the Crow tribal Health Board that 
        non-beneficiaries receive treatment at the Crow facility. The 
        concern becomes one in determining whether reimbursements are 
        received for these services?

        2. Vacant positions need to be advertised and filled according 
        to established procedures and Federal requirements; in lieu of 
        filling these positions, contracts are awarded for services. Is 
        there a sizable cost savings in this procedure? Recently there 
        was controversy in the way the Director of Nursing position was 
        filled, and then ``unfilled.'' Actions of this sort impact the 
        morale of the service Unit, which in turn impacts the kind of 
        service Crow People receive.

    Certainly, we applaud the efforts of this Senate Committee on 
Indian Affairs and their passionate support in pursing the: 
reauthorization of the Indian Health Care Improvement Act; recognizing 
the effects of Diabetes and addressing the Special Diabetes initiative. 
Yet the need for quality health care, which resonated in the past, and 
continues today, is an ever present challenge. How does the 
equalization in health care occur? As long as we have a dual health 
care system (the haves and the have not's); as long as socioeconomic 
disparities are apparent, there is going to be a continual need for 
this Committee Senators.
    The provision of Dialysis is a health concern, and Indian Health 
Service can no longer bury its head in the sand, hoping this issue will 
dissipate. We need one funding source for this, available for all 
Tribes. Diabetes is the fifth (out of ten) ranked health problem for 
the Crow Reservation.
    We need to continually fund the Epidemiology Center serving the 
Billings Area Tribes. The data collected will be made available to and 
will be utilized by the specific Tribes.
    Funds need to be identified and made available for HPV 
immunizations. A recent article in the Billings Gazette identified the 
Crow reservation as having the highest reported cases of HPV 
infections. Approximately 50 percent of the Crow Tribal enrollment is 
under the age of 30. This is the age group with pronounced sexual 
activity.
    Long term planning and resource identification needs to be 
addressed for the problems associated with aging, especially for the 
``baby boomers.'' It is anticipated that Cancer and Diabetes will have 
an increased prevalence in this group. Expanded care for this age group 
includes: nursing home care; assisted living; independent living 
services (including home monitoring and health tracking measures); 
ophthalmology; prosthetics; mental health.
    Senators, the Crow People have a rich heritage. There is a bit of 
ethnocentrism, for Crow Speakers still abound, traditional and cultural 
practices are adhered to. It is this identity has been the cohesiveness 
quality that has kept the Crow Tribe distinct among other groups.
    Again, thank you for this opportunity to share the Health Concerns 
of the Crow People.

    Senator Dorgan. Ms. White, thank you very much, and thank 
you for your powerful statement, and we grieve for your loss of 
that beautiful young girl.
    Let me also thank you for 17 years of work in Indian health 
care. That's great dedication. We appreciate your being here 
and we will read very carefully the testimony you have 
presented as well.
    State Representative Jonathan Windy Boy. Representative 
Windy Boy, thank you very much for coming. Let me ask if you 
would summarize.
    I think following your testimony, we will hear from Mr. 
Moke Eaglefeathers as well. So if you would summarize, we would 
appreciate it very much.
    We thank you for your service and thank you for being here, 
Representative.

         STATEMENT OF HON. JONATHAN WINDY BOY, COUNCIL 
    MEMBER, CHIPPEWA CREE TRIBE BUSINESS COMMITTEE; MONTANA 
               REPRESENTATIVE, HOUSE DISTRICT 32

    Mr. Windy Boy. Thank you Chairman Dorgan and Senator Tester 
for having this hearing.
    For the record, my name is Jonathan Windy Boy. I'm a member 
of the Chippewa Cree Tribal Council, and also State Legislator 
representing House District 32, Chairman of the Rocky Boy 
Health Board, and also been appointed Chairman of the National 
Caucus of Native American State Legislators Committee on 
Health.
    I'm going to kind of zip through my testimony here because 
you can probably get a copy of it and highlight it.
    The situation today is the under-funding of Indian health 
care and American Indian health disparities. Under-funding of 
Indian health care for some time now in the United States is 
not under the true meaning of health services for American 
Indian people.
    The medical inflationary rate over the past 10 years sat at 
11 percent. The average increase for IHS accounts over the same 
period has been only 4 percent so that those numbers are kind 
of off a little bit from each other on the true need.
    In FY 1984, IHS services account received 777 million; in 
FY 1993, the budget totaled 1.5 million. Still 13 years later 
in 2006, the budget for health services was 2.7 billion, when 
to keep pace with inflation and population growth, this figure 
should be more like 7.2 billion.
    American Indians die at higher rates than other Americans 
from tuberculosis at 600 percent higher; alcoholism, 510 
percent higher; motor vehicle crashes, 229 percent higher; 
diabetes, 18 percent higher; unintentional injuries, 152 
percent higher; homicides, 61 percent higher.
    There are many challenges in the existing health care 
budget, and one of the things that you have heard earlier from 
some of the Federal Government is that Medicaid third-party 
reimbursements has been accounted for.
    And I think the misnomer with that, I feel is that should 
not be included in IHS funding, because that is pretty much a 
given for the tribes and the states at 100 percent last year. 
So I think that should be excluded from the IHS budget.
    You know, Mr. Chairman, Senator, aside from all of these 
facts and figures and all of that, I want to go back to a real 
life happening at home. I have an aunt that's 77 years old. For 
several years now she's been diagnosed as a diabetic. She 
travels to Great Falls Monday, Wednesday and Friday for 
dialysis. That's 120 miles from Rocky Boy to Great Falls.
    I have some of my constituents at home that go to dialysis 
three times a week to Billings, and that's 250 miles one way.
    So if you take those figures, you're looking at 1500 miles 
a week to Billings, approximately 720 miles to Great Falls and 
back.
    If you can imagine the same situation with Fort Peck having 
to come to Billings, which is approximately 300 miles one way, 
and if a diabetic has to go through the dialysis that's needed 
just to stay alive, the remoteness that we have is one of the 
factors that tribes in Montana are up against.
    Fort Belknap is in a similar situation. They're about 200 
miles from Billings, round-trip 400, multiply that times three, 
1200 miles. Great Falls is about 160 miles one way. So the 
remoteness is really a factor that hasn't really been placed 
into call here.
    One of the things when you're talking about contract health 
services, right now in the middle of July, we have over 360-
some thousand dollars short in my contract health services 
budget, and I still have 3 months to go. And if I'm going to be 
only having to provide life or limb for those members, I'm 
going to be in a real stickler here very shortly.
    One of the things too, you know, about recently with the 
contract health dollars, there's something that isn't talked 
about. You know, when a person who has an emergency to them 
which does not fall under the regulations of IHS regulations, 
then that individual will go to the Emergency Room. In my case, 
we go to Havre or Great Falls.
    If they don't fit under those standards, qualifications to 
receive contract health service dollars, then those bills are 
going to accrue and accrue and accrue, and finally those 
hospitals are going to send them to the credit bureau and 
that's a reality. And I'm even on that credit bureau for health 
services.
    One of the things too, you know, it was kind of ironic to 
hear that a dentist from Helena that testified in Senator 
Baucus' hearing on CHIP a couple months ago, provided 
testimony, and why it was ironic to me is because he said that 
there was a child who needed surgery, orthodontic surgery, a 
child from Box Elder, and that's, come to find out that's one 
of my grandkids. And if they had waited a couple more days, 
that child would have died from that.
    So, you know, the levels of what the Feds and everybody 
else tells you, that everything's fine and dandy, you know, 
that's a bunch of hogwash.
    Every time as a tribal leader, we go to D.C., we go to HHS, 
we go to different departments. The one thing that they tell 
us, is okay, you go back to the states, we've funneled more 
money into the states that you're eligible for. We have grants 
that the tribes are eligible for.
    If you know the granting process, there's 560-some tribes 
across the country, and if we have to complete, the ones with 
the best grant writers are going to get the money. So that's 
another thing that we're up against as tribal leaders as well.
    And also, too, on Medicaid, we talk about Medicaid and the 
barriers that we see. One of the things that we see on my local 
level is, I'll give you an example of an elderly couple. Right 
away that elderly couple, on any reservation, when they see a 
brand-new, spanking new car come driving up the driveway, a 
non-native guy looking like Jon Tester--in jest, Jon--but 
anyway, right away they're going to be cautious.
    They're going to take a couple of steps back because 
they're not going to trust. Trust is a real thing that we're up 
against as far as one of the barriers. And I think in order to 
make the Medicaid eligibility process, we need to train our 
home to be in that process.
    So again, I want to thank you for having this hearing, and 
thank you for letting me be a part of your panel, and I'll be 
open for questions.
    Thank you.
    [The prepared statement of Representative Windy Boy 
follows:]

    Prepared Statement of Hon. Jonathan Windy Boy, Council Member, 
 Chippewa Cree Tribe Business Committee; Montana Representative, House 
                              District 32
    Good afternoon, Chairman Dorgan and Senator Tester. My name is 
Jonathan Windy Boy. I am an enrolled member of the Chippewa Cree Tribe 
of Rocky Boy's Reservation and a citizen of the beautiful State of 
Montana. I have the honor to serve as a council member for the Chippewa 
Cree Tribe Business Committee. I also serve as a Representative in the 
Montana State Legislature, House District 32. I serve as the Chairman 
of the Rocky Boy Health Board, the governing body for the Chippewa Cree 
Health Center. I also serve as the chair of the Montana Wyoming Tribal 
Leaders Council--Subcommittee on Health and I was recently appointed 
the interim Chairman of the National Caucus of Native American State 
Legislators'--Subcommittee on Health. I appreciate this opportunity to 
address the healthcare issues of the Montana Tribes. I would like to 
thank the Committee for the opportunity to testify at this ``Field 
Hearing on Indian Healthcare.''
    Before I begin this testimony, I would like to reaffirm the 
foundation of the provision of health services in relationship to the 
sovereign status of Tribes.

    ``No right is more sacred to a nation, to a people, than the right 
to freely determine its social, economic, political and cultural future 
without external interference. The fullest expression of this right 
occurs when a nation freely governs itself.''

        The Late Joseph B. DeLaCruz, Former President, Quinault Nation, 
        1972-1993.

The Foundation: Tribal Sovereignty and the Provision of Health Services
    The overarching principle of Tribal sovereignty is that Tribes are 
and have always been sovereign nations, Tribes pre-existed the Federal 
Union and draw our right from our original status as sovereigns before 
European arrival.
    The provision of health services to Tribes is a direct result of 
treaties and executive orders entered into between the United States 
and Tribes. This Federal trust responsibility forms the basis of 
providing health care to Tribal people. This relationship has been 
reaffirmed by numerous court decisions, Presidential proclamations, and 
Congressional laws.
The Situation Today: Underfunding of Indian Healthcare and American 
        Indian/Alaska Native Health Disparities
Underfunding of Indian Healthcare
    For some time now, the United States has not funded the true need 
of health services for AI/AN people. The medical inflationary rate over 
the past 10 years has averaged 11 percent. The average increase for the 
Indian Health Service (IHS) health services accounts over this same 
period has been only 4 percent. This means that IHS/Tribal/Urban Indian 
(I/T/U) health programs are forced to absorb the mandatory costs of 
inflation, population growth, and pay cost increases by cutting health 
care services. There simply is no other way for the I/T/U to absorb 
these costs. The basis for calculating inflation used by government 
agencies is not consistent with that used by the private sector. OMB 
uses an increase ranging from 2-4 percent each year to compensate for 
inflation, when the medical inflationary rates range between 7-13 
percent. This discrepancy has seriously diminished the purchasing power 
of Tribal health programs because medical salaries, pharmaceuticals, 
medical equipment, and facilities maintenance cost Tribes the same as 
they do the private sector.
    In FY 1984, the IHS health services account received $777 million. 
In FY 1993, the budget totaled $1.5 billion. Still, thirteen years 
later, in FY 2006 the budget for health services was $2.7 billion, 
when, to keep pace with inflation and population growth, this figure 
should be more than $7.2 billion. This short fall has compounded year 
after year resulting in a chronically under-funded health system that 
cannot meet the needs of its people.
    As the Federal Government develops models that aim to reduce or 
eliminate racial and ethnic disparities (i.e., ``Closing the Gap'') a 
balance needs to be made between the Federal deficit model (comparison 
to All U.S. Races) and a positive development model. Otherwise health 
policy (and the subsequent allocation of funding toward Indian 
healthcare) will be determined on the basis of Tribes being a 
marginalized minority and not as sovereign nations with distinct treaty 
rights, which have been negotiated with the ``full faith and honor of 
the United States of America.''
American Indian/Alaska Native Health Disparities
    American Indians have long experienced lower health status when 
compared with other Americans. Disproportionate poverty, discrimination 
in the delivery of health services and cultural differences has 
contributed to the lower life expectancy and disproportionate disease 
burden suffered by American Indians. American Indians born today have a 
life expectancy that s 2.4 years less than the US All Races.
    American Indians die at higher rates than other Americans from:

   Tuberculosis--600 percent higher
   Alcoholism--510 percent higher
   Motor Vehicle Crashes--229 percent higher
   Diabetes--18 percent higher
   Unintentional injuries--152 percent higher
   Homicide--61 percent higher

    Some of these health disparities are historic. Alcoholism continues 
to be a serious challenge to American Indian health. Since its 
introduction to Tribal people early in this Nation's history, alcohol 
has done more to destroy Indian individuals, families and Tribal 
communities than any disease. Today in 2007, Tribal people are dying at 
a rate 510 percent HIGHER than other Americans from alcoholism. The 
overall impact of these health disparities has made us ``at-risk'' 
communities, weakened and vulnerable. In fact, as reported in a Denver, 
Colorado newspaper, the Wind River Reservation in Wyoming was targeted 
by Mexican drug cartels because of their history with alcoholism. The 
drug dealers figured that the Tribal community (already inundated in 
alcohol addiction) would be easy to infiltrate for drug distribution. 
Their business plan included marrying into the Tribe, giving free 
samples to get people addicted and then get them to distribute to 
support their addiction. This is an approach that is being implemented 
throughout Indian Country.
    Given the significant health disparities that Tribal people suffer, 
funding for Indian healthcare should be given the highest priority 
within the Federal Government. Many of the diseases that Tribal people 
suffer from are completely preventable and/or treatable with adequate 
resources and funding.
The Challenges: Access to Medicaid Services, Medicaid and Medicare 
        Reimbursements, Recruitment and Retention of Health Providers
Access to Medicaid Services
    The IHS budget cannot provide the health services needed thus 
Tribes must depend upon alternate health resources, such as, Medicaid 
for critically needed healthcare for our people. The Indian health 
system is funded at less than 60 percent of need and is heavily 
dependent upon Medicaid. Understanding this, accessing Medicaid is an 
important health issue.
    The barriers to accessing Medicaid have been identified by Tribes 
through out the years. Though there has been some positive movement, 
many of those identified barriers still remain. The most critical of 
those identified is the application and eligibility determination 
process. This is the first gate and if a Tribal member cannot get 
through the first gate--access to needed healthcare is denied. The 
application and eligibility determination barriers are often protocols 
developed to ``cost contain'' or manage the National Medicaid budget. 
Unfortunately, Tribal people often cannot afford to jump through the 
``hoops'' of a budget management protocol and the denial of access to 
care can be disastrous for the individual Tribal member and their 
family.
    In FY 2004, the Chippewa Cree Tribe and the Confederated Salish & 
Kootenai Tribes partnered with the State of Montana and CMS/Region VIII 
to begin discussion on how to alleviate the barriers to accessing 
Medicaid for the Montana Tribes. In May 2007, the Chippewa Cree Tribe 
signed an agreement with the Governor of Montana and the State of 
Montana to contract Medicaid Eligibility Determination. Having the 
ability and authorization to determine Medicaid eligibility onsite at 
our Tribal healthcare center will facilitate access to care for 
eligible Indian users that are eligible Medicaid users. Getting access 
to healthcare through Medicaid to those eligible Montana citizens 
(whether Indian or non-Indian) as soon as possible benefits the 
recipient and the State of Montana. A healthy state community is one 
where its citizens can fully participate in education, employment and 
economic development.
Medicaid and Medicare Reimbursement
    Thirty-one years ago, in 1976, in response to the health conditions 
in Indian Country, Congress provided the IHS and Tribes with the 
authority to bill for and receive Medicaid and Medicare reimbursements 
for services provided to American Indian beneficiaries. Today, Medicaid 
and Medicare reimbursements provide a critical source of supplemental 
funding for the underfunded IHS and Tribal healthcare delivery service 
programs.
    Originally Congress did not intend for Medicaid revenue to 
``offset'' the strained Indian Healthcare budget but to supplement it. 
Today, the IHS and Tribes are expected to bill and collect for Medicaid 
to replace IHS appropriations. In the FY 2008 budget Request 
Congressional Justification includes specific amounts of Medicaid and 
Medicare collections (total of $625,193,000) as part of its total FY 
2008 President's request of $4.1 billion. Members of the Committee, we 
need this situation remedied in order to realize an appropriate level 
of funding for Indian healthcare.
    The Indian health system is funded at less than 60 percent of need 
and is heavily dependent upon Medicaid payments. States receive 100 
percent FMAP for Medicaid services provided in an IHS or Tribal 
facility. These facilities have a limited capability to provide all 
needed direct care. Any health care not provided by the facility is 
referred to a private or public provider. The state must then provide 
the regular state Medicaid match for that eligible Indian user/eligible 
Medicaid user. Thus states are given an incentive to limit the benefits 
that American Indians referred to outside providers would receive under 
the state Medicaid plan.
    A current issue relating to both Medicaid and Medicare is the 
imposition of increased cost sharing or premiums. States may charge a 
co-payment for medical services or drugs. The rationale for charging 
co-payments is to achieve a more appropriate utilization of Medicaid 
covered services. First of all American Indian participation is very 
low and the imposition of a co-pay has a negative effect as many 
American Indians cannot afford even a modest co-pay (and why would they 
if they can receive services from IHS without a co-pay). This could 
prevent them from enrolling in Medicaid or Medicare, which could 
deprive the chronically underfunded IHS or Tribal facility critical 
Medicaid revenue.
    Imposing a co-payment has not changed the utilization of American 
Indian Medicaid or Medicare beneficiaries because IHS and Tribes do not 
charge co-pays to their beneficiaries. Instead co-pay amounts are cost 
shifted to the Indian health programs, causing a further reduction to 
services they can provide.
Recruitment and Retention of Health Providers
    The recruitment and retention of health providers has been a 
barrier to effective healthcare delivery for Montana Tribes. As in most 
rural areas of this Nation, Montana Tribes are challenged with 
providing a continuity of care, because of a high turnover of 
healthcare providers. Montana Tribes are located in geographically 
isolated areas (only Alaska has a remoteness designation more severe 
than Montana). Montana is considered a ``frontier'' area with a 
population of less than 6 people per square mile.
    It is a challenge to recruit health providers that will commit to a 
long term, interact and invest in the Tribal Community and work to 
understand and respect the Tribal culture and traditions. These 
attributes for health providers are imperative to the effective 
provision of healthcare for our Tribal communities. Ideally, most 
Tribes want a Tribal member as their healthcare provider, knowing that 
a Tribal member would have the maximum investment for their community.
    Chairman Dorgan and Senator Tester, it will take the commitment of 
the Administration, the U.S. Congress, the State of Montana, and the 
Montana Tribes to insure that the issues I have presented are addressed 
and accomplished by reauthorizing the Indian Healthcare Improvement 
Act. The provisions of the IHCIA will insure that Montana Tribes will 
have access to building the healthy Montana Tribal communities where 
healthcare is more than a promise but a reality for every man, women 
and child. I thank you for this opportunity to provide testimony.

    Senator Dorgan. Representative Windy Boy, thank you very 
much. Thanks for your service in the state legislature, and 
thank you for coming today to testify.
    Our final witness is Mr. Moke Eaglefeathers, President of 
the National Council of Urban Indian Health and Director of 
North American Indian Alliance.
    He is accompanied by Ms. Marjorie Bear Don't Walk, Director 
of the Indian Health Board of Billings.
    I might mention that we had a meeting in Washington D.C. a 
while back and Mr. Eaglefeathers was there as well.
    So, let me ask you to proceed for the final bit of 
testimony, and let me see if we can get a microphone over to 
you.
    Mr. Eaglefeathers, why don't you proceed. Once again, if 
you would please summarize, your entire statement will be made 
a part of the permanent record.

MELBERT ``MOKE'' EAGLEFEATHERS, PRESIDENT, NATIONAL COUNCIL OF 
URBAN INDIAN HEALTH; DIRECTOR, NORTH AMERICAN INDIAN ALLIANCE; 
   ACCOMPANIED BY MARJORIE BEAR DON'T WALK, DIRECTOR, INDIAN 
                         HEALTH BOARD, 
                          BILLINGS, MT

    Mr. Eaglefeathers. It is an honor for me to be here on 
behalf of the National Council of Urban Indian Health, which is 
a 36-member organization, and 120,000 urban Indian patients 
that are served annually.
    I would like to take this opportunity to thank you, and the 
opportunity to provide the testimony and address an assessment 
of the Indian Health Care Improvement Act.
    My name is Melbert Eaglefeathers. You know me as ``Moke''. 
I am the Executive Director of the North American Indian 
Alliance here in Montana. I also serve as the President of the 
National Council of Urban Indian Health. I am a Northern 
Cheyenne enrolled member here in Montana.
    I am honored to serve as a representative of the urban 
Indian population. Thank you for providing me the opportunity 
to testify in support of the reauthorized Indian Health 
Improvement Act.
    Urban Indian Health program has spent the last year 
regrouping and solidifying relationships with local and 
national tribal leaders. One thing Salish Kootenai was to work 
on tribal relationships, I've spent many hours in tribal 
leaders' offices and meetings discussing health concerns. To 
understand this issue is to look at our next generation for our 
health care issue.
    At this time, I would like to turn to my colleague, 
Marjorie Bear Don't Walk, to talk about the Montana program.
    Thank you.
    Senator Dorgan. Thank you very much.
    Ms. Bear Don't Walk, why don't you proceed?
    Ms. Bear Don't Walk. Good afternoon, Chairman Dorgan, 
Senator Tester.
    I would like to say that the Urban Indian Health program, 
we need more money. At the present time 67 percent of Indian 
people live off the reservation and they receive 1 percent of 
the Indian Health Service budget. By saying that, I would also 
like to say, that we do not receive any funds for contract 
care.
    So, for all of the people who are having problems getting 
contract care money, we have none. So our problem with contract 
care is that if you are ill and you need contract care, you can 
forget it.
    The other problem that we have is we need more dollars, 
period. One percent of the budget provides the minimal health 
care, which is very insulting to any Indian person, let alone a 
hurting Indian person who is not eligible for contract care 
anywhere.
    In Billings, there are about 10,000 Indians, about half of 
them are Crows and they are eligible for contract care. About a 
fourth of them are Northern Cheyenne, and they are ineligible 
for contract care, even though it is the Crow/Northern Cheyenne 
hospital. All of the others, and the largest number are Sioux 
and Chippewas, are not eligible for contract care.
    I am a member of the Confederated Salish and Kootenai 
Tribe. Forty-one years ago, when I was young and foolish, I 
married a Crow Indian.
    [General laughter.]
    Senator Dorgan. All right, you're done testifying.
    [General laughter.]
    Proceed, I'm sorry.
    Ms. Bear Don't Walk. His name is Urban Bear Don't Walk, and 
I have worked in urban health in excess of 20 years. So, it is 
kind of interesting for the definitions of Indian people, of 
reservation and urban Indians, when urban Indian, the name 
Urban came from a fifth century pope who urbanized Europe.
    So we have been branded with the term ``Urban Indians''. 
And I hear very often that urban Indians have more opportunity 
for health care. That truly is bull. The Indians who have 
opportunities in urban areas are the Indian Health Service 
workers who have insurance.
    Almost all of the other Indians that I know of, unless they 
work for the Federal Government, do not have insurance. So if 
you're working two jobs or three jobs and you have children and 
you need health care, you've got to make a choice, you can use 
Indian Health or someplace else.
    I have felt that we need to advocate for all Indian people, 
that we are all considered as the people who were here when 
Columbus landed.
    The Federal Government has done a lot to divide us all, and 
I would like to see that stop. And we have continued, as Indian 
people, to divide ourselves also, and I think that we need to 
stop that also.
    We, as Indian people, are here in the area of a large 
number and my children, while they are Salish and Crow, are 
enrolled as Crow Natives.
    So I would like to ask the Senate to give more money to 
urban Indians for health care, and I would like to see the 
health care of urban Indians to be as valuable as anybody 
else's health care.
    I would like to see Indians, the money appropriated per 
capita for people in the United States, I would like to see 
where Indian people are no longer at the bottom of that list.
    I thank you very much.
    [The prepared statements of Mr. Eaglefeathers and Ms. Bear 
Don't Walk follow:]

   Prepared Statement of Melbert ``Moke'' Eaglefeathers, President, 
   National Council of Urban Indian Health; Director, North American 
                            Indian Alliance



                                 ______
                                 
  Prepared Statement of Marjorie Bear Don't Walk, Executive Director, 
                   Indian Health Board, Billings, MT




    Senator Dorgan. Thank you very much for your testimony. 
Thanks to all of you for your testimony.
    I know that you have told on occasion a North Dakota joke. 
We've told a Montana joke from time to time over on the North 
Dakota side of things, but I must tell you that coming to 
Montana today has been really impressive for me.
    The number of people who have attended this hearing, your 
passion, the statements by the witnesses, that is impressive 
and a very powerful, strong statement.
    You come here at a time when there is a Crow Fair, which 
I'm told, I've not attended it, but I'm told is widely attended 
and much anticipated. I hope all of you have a wonderful 
opportunity to participate in that.
    Chairman Venne has been wonderful today to me and to 
Senator Tester, as well.
    I'm going to have to leave in a little while, and I hope 
you will excuse me. I think you will when I tell you why.
    I have to be on an airplane at the Billings airport, and 
the reason I have to be off an airplane about midnight tonight, 
is tomorrow morning I am taking my daughter to college as a 
freshman, and we're driving her to college for her first year 
of college. And so you understand, I hope, how important that 
is to me to be there and catch that airplane.
    So I will take my leave in a few minutes and ask Senator 
Tester to continue chairing the remainder of this hearing.
    I also want to say this, David Mullon, who I introduced 
earlier, is a member of our staff, has been a member of the 
staff as a Chief of Staff and now Chief of Staff to the 
minority, David is from the Cherokee Tribe in Oklahoma. David 
is right here.
    Heidi Frechette, sitting over there, Heidi, would you stand 
up? Heidi is a counsel, an attorney on our staff in the Indian 
Affairs Committee, and she is from the Menominee Tribe in 
Wisconsin.
    At the end of this hearing, both David and Heidi will also 
be here and available to spend time with those who have some 
issues you want to discuss personally with our staff. And I'd 
like you to feel free to seek them out if you would.
    My understanding also is that Senator Tester will, 
following questioning of this panel, be taking some brief 
statements by other tribal officials who have come today and 
who have not been able to testify.
    But if you will allow me to take my leave for the purpose I 
have described, I want to tomorrow morning be driving my young 
daughter to her first year in college, and so I want to catch 
that airplane out of Billings.
    But again, let me say a heartfelt thanks, and to tell you 
this, with Senator Tester, myself, Senator Baucus, and so many 
others, we will work very, very hard.
    This is not just some other time. This is the time for us 
to demand that these things get fixed, and I pledge to you 
that's what's going to happen. We're going to work and work and 
work, and we're going to get things fixed and make some 
progress.
    So, let me with that turn it over to Senator Tester to 
chair the remainder of the hearing, and I thank you for your 
hospitality and your passion, and I say God bless to all of 
you.
    Senator Tester. Senator Dorgan, I just want to express my 
thanks to you, Senator Dorgan, as Chairman of the Indian 
Affairs Committee and a true leader in the U.S. Senate for the 
work that you have done, really working for, not only the folks 
in Indian Country, but everybody in the United States that 
needs help.
    Thank you very much for your commitment and your public 
service to this country.
    I do have a few questions, and we'll kind of jump around a 
little bit.
    I'll start with Joe, if you've got a mike that works, Joe, 
in front of you.
    First of all, Joe, my compliments to you on really a top 
rate organization. You've done a great job educating folks in 
Indian Country, and I hope you continue in that venue for many, 
many more years.
    You talked a little bit about having tribal colleges do the 
training for everybody, not everybody, but as many people as 
possible that could deal with health care in Indian Country. 
And you had talked about in 1989 you had one nurse in the 
program and now you've got as many as 46.
    Over the last few years, I'll ask you the same question I 
asked Dr. Moore, have you been able to track where any of these 
students have ended up at? Have you been able to determine 
whether these they stayed in Salish Kootenai Country. or have 
they gone to some other reservation somewhere else?
    Dr. McDonald. Yes, pretty well. I could go to the nurse 
director. We have their pictures on the wall, and that way I 
could point at the nurse and she would tell me pretty much 
where they're at because it's very close, and we did keep track 
of them.
    Senator Tester. Did most of them stay in Indian Country?
    Dr. McDonald. The American Indian nurses stayed, they most 
generally stayed. We just lost one to Portland. The Sisters of 
Providence made an offer to her she couldn't turn down.
    Senator Tester. Okay, good.
    You talked about adequate funding for tribal colleges in 
order for you to be successful, in order for students being 
able to afford to go to your institution.
    Just where are you at funding-wise as far funding for trial 
colleges if we're going to push this along, are you 
underfunded, are you adequately funded, where are you at?
    Dr. McDonald. We're really underfunded for nursing. Nursing 
costs the college about $10,000 per student.
    Senator Tester. Okay.
    Dr. McDonald. And our money we get on the Student Tribal 
College Act is about $5,000. We try to keep the tuition down 
for them, so we get about $7,500 of that $10,000.
    Senator Tester. Well, thank you. It's good to know that 
nursing is something that's going to require some additional 
resources.
    Would you pass the mike down to Ada, if you're available 
for a few questions. I do have a few for you.
    I asked, I think I asked Pete Conway about the working 
relationship between Indian Health and the tribes, so I'm going 
to ask you the same question.
    I want to start with your perspective, and I hope it's the 
same, but I'm asking the question to find out. Is your working 
relationship that you maintain within your health service, 
would you classify it as productive, cooperative, adversarial 
overall?
    Ms. White. I think it's a work relationship that is 
fairly--there's a lot of mutual respect, a mutual coming 
together sharing ideas.
    There are points that I raise and I make them very aware 
that my presence there is most often in an advocacy position. I 
may articulate, I may question in a manner that may be a little 
confrontational, or whatever, but it's a give and take, I 
believe a productive relationship.
    Senator Tester. Good, outstanding.
    You are put in a very difficult position because you have 
to make health care decisions when they have more sick people 
than they have money. How do you do that? How do you deal with 
that?
    Ms. White. You're asking me how I make health care 
decisions in view of restrictive funds?
    Senator Tester. Correct.
    Ms. White. I try to put myself in the shoes of the medical 
providers, and I look at the doctors, some of them being 
extremely capable and competent, not being able to take care of 
what's presented to them.
    Now, having explored that, sometimes I marvel, I wonder 
what goes through their heads, because on my side of the point, 
certainly we have very limited funds to operate on. Certainly 
we're not the direct service provider that IHS is, but I am 
sensitive to that issue, that there is a profound need for more 
funds.
    Senator Tester. Okay.
    You talked about, and I just want to make sure that I heard 
what you said, you said that there is no money for prevention; 
did I hear that correctly?
    Ms. White. My comments had to be tailored somewhat from my 
original draft that I sent you. That's why I resubmitted those 
copies of the information I received.
    I am a person that believes in the buck stops here. If I'm 
in a position to make a decision, I certainly do, and if I have 
to defer to higher-ups, I certainly do that.
    However, in response to your question, what do we mean by 
prevention and promotion? It becomes a semantical game. I 
believe that the money is not there for people to do an 
adequate job in promoting health information, health concepts 
and in providing the opportunities for promotion to exist.
    We're at a point where that is a novel idea. I do not see 
how we can emphasize promotion and prevention when basic care 
is not being provided. You have to be well to listen.
    You have to have the information at an early age. You have 
to be educated to understand what some of the ideas are, and I 
think sometimes we get bogged down with lofty ideals.
    Senator Tester. That's a good point.
    I'll just tell you that for both promotion and prevention, 
to my perspective, is one and the same because it's about 
education. But I hear what you're saying. Thank you very much, 
Ada.
    Jonathan Windy Boy, I've got a question or two for you. 
Jonathan, good to see you again. I want to tell you that you 
being in the legislature, you understand that oftentimes we're 
put in positions where you've got X number of dollars and you 
need to spread it around between health care and infrastructure 
projects and education.
    Sometimes I see this as being in the same boat, where 
you're pitting one tribe against another tribe for financial 
resources.
    My question is, and they may already be doing it, so you'll 
have to enlighten me on this, how can Montana Indian Nations 
work together to promote and improve health care in Indian 
Country and not be in competition with one another?
    Mr. Windy Boy. Well, first of all, thank you, Mr. Tester. I 
think there is a number of ways that the tribes and the 
government can work together.
    First of all, one of the things, to use an example of what 
we did most recently, in 2003, if you recall, there was the 
Medicaid redesign--or 2005, I'm sorry, the Medicaid redesign 
that came in effect. And what that allowed us to do is to 
demonstrate how to stretch the dollar for health care.
    And what that basically did, it allowed the tribes and the 
state to do, is to think outside the box, basically. The result 
of that was to try to access existing resources that are 
available, and in this case, Medicaid, Medicare, was that 
vehicle.
    Realizing that Federal dollars have been limited to the IHS 
accounts, there are other resources outside that, and CMS has 
definitely been a part of that.
    Demonstrating part of that, Senator Tester, is that we have 
partnered with the state of Montana. Governor Schweitzer has 
come to the table and we have signed agreements. And I think 
that while the atmosphere is friendly, I think it's best that 
we take advantage of that to try to think outside the box.
    And realizing that, like you mentioned, that the dollars 
are limited to make it stretch, but I think by doing that, 
we're going to make things better hopefully for everybody.
    Senator Tester. Okay, thank you.
    I'll just say that the point that you made, and you made 
many good points, but one of the points that you made that I 
thought was particularly appropriate, especially for Montana, 
is the remoteness.
    And, you know, people back in Washington, D.C. talk about 
rural areas. We're beyond rural, we're frontier. It's a huge 
issue when you talk about distance in this state to get quality 
health care. And it's something that when we talk to our folks 
back east that are administering the programs, the only way you 
can ever appreciate it is if you drive between Rocky Boy and 
Billings and back in the same day. That's one hell of a drive. 
So, you know, that's important.
    I want to pass it down to Stacy and Jace, and I'll just ask 
a question, either one of you can answer it. Do you have a 
working mike?
    Just curious how the needs of Montana tribes compare with 
other tribes in the Nation.
    Mr. Killsback. Well, like I mentioned before, the tribes in 
Montana are large land-based tribes with large populations, and 
our needs reflect those of the direct service tribes.
    Another example is during the budget formulation process 
this year, the tribes got together and said the number one 
priority, instead of piecemealing prevention, different types 
of health care needs, we all came together at the table and 
said contract health service is the number one priority. And 
that's the message we need to take to D.C. when you do describe 
the needs.
    Senator Tester. So the major disparity between Montana 
tribes and other tribes in the U.S. is in contract health care?
    Mr. Killsback. I think it could be seen as a possibility 
because we are direct service tribes and we don't have the 
access to--well, the money is a big factor and that's why 
contract health is the number priority here as well.
    So I believe our area and Aberdeen Area, those areas with a 
large population of urban areas, these populations are served, 
have similar issues concerning funding, have similar relations 
concerning health care, access to health care.
    Ms. Bohlen. Can I say something about that?
    Senator Tester. Yes, Stacy.
    Ms. Bohlen. Thank you, Senator Tester.
    I think that one of the real challenges that Indian Country 
faces is the lack of reliable data on where the disparities 
specifically are, who's being treated, who's being turned away, 
what the outcome of a person being turned away is, where do 
they go from here, do they ever get care.
    At the National Indian Health Board, we're trying to come 
up with programs, like we're trying to work with the American 
Academy of Orthopedic Surgeons to get a volunteer orthopedic 
program for the Indians in this state. And it's very difficult 
to start because we don't have the data about where everyone 
is, what the problems are.
    I think that's something that Congress could really help 
with.
    Senator Tester. And as the good doctor, Joe Erpelding said, 
the data is probably not necessarily good data, and so we need 
to work on that.
    I'm going to take just a few minutes here to have some 
other comment by elected officials, and I've got to get out of 
here by shortly after 3, so I'm in the same kind of boat.
    What I'm going to do is this, if we could get a 
representative, if you want, if you can add to it, to talk 
about health care. I know there's a lot of other issues, but 
health care is it.
    Go ahead, state your name for the record and what tribe you 
represent. You're going to have 2 minutes, and I've got to hold 
you strictly to it, otherwise I can't give everybody a chance 
to speak.
    Go ahead.

 STATEMENT OF DARRYL RED EAGLE, TRIBAL EXECUTIVE BOARD MEMBER, 
               FORT PECK ASSINIBOINE SIOUX TRIBE

    Mr. Darryl Red Eagle. Thank you, Senator Tester. My name is 
Darryl Red Eagle. I'm tribal executive Board member for the 
Fort Peck Assiniboine Sioux Tribe.
    Senator Tester. Sir, what I'll ask you to do is talk into 
that mike, summarize your statement, your written testimony. 
You will turn it in and it will be a part of the record. So 
summarize it very quickly. I'm sorry, but this is not something 
we normally do anyway.
    Speak into that other mike, please.
    Mr. Red Eagle. The Fort Peck Tribes appreciate the 
committee having this hearing in Montana, and urge swift 
passage of this Act. If you have any questions, we will be glad 
to respond.
    Thank you.
    [The prepared statement of Mr. Red Eagle follows:]

Prepared Statement of Darryl Red Eagle, Tribal Executive Board Member, 
                   Fort Peck Assiniboine Sioux Tribe



                                 ______
                                 
Testimony of John Morales, Jr., Chairman, Assiniboine and Sioux Tribes, 
                         Fort Peck Reservation



                                 ______
                                 

                                 

    Senator Tester. Thank you very much. Next up?

   STATEMENT OF CAROLE LANKFORD, VICE-CHAIR, SALISH KOOTENAI 
 TRIBES; ACCOMPANIED BY KEVIN HOWLETT, HEALTH DIRECTOR, SALISH 
                        KOOTENAI TRIBES

    Ms. Lankford. I am Carole Lankford, Vice-Chair of Salish 
Kootenai Tribes. I want to thank you for coming out and giving 
us this opportunity.
    We are submitting written testimony and I would also like 
to give my tribal health director a chance to say a few words.
    Senator Tester. Thank you.
    Mr. Howlett. Senator Tester, my name is Kevin Howlett, I'm 
the Health Director for the Salish Kootenai Tribes. I would 
just like to thank you for holding this hearing.
    I think the issues that have been addressed have been 
certainly sincere, and I think that as you look across Indian 
Country, it isn't just Crow, it's every reservation that has 
these kinds of issues.
    Things have got to change. People have got to think about 
this differently and we really have to move health care into 
the twenty-first century.
    We will be submitting testimony, and thank you and Senator 
Dorgan for having us at this hearing.
    Senator Tester. Thank you, I appreciate it, and the 
problems are not exclusive to here, but all Indian Country.
    Go ahead.

STATEMENT OF TRACY ``CHING'' KING, COUNCIL MEMBER, FORT BELKNAP 
              INDIAN COMMUNITY, ASSINIBOINE TRIBE

    Mr. King. Good afternoon, Senator Tester, my name is Tracy 
``Ching'' King, I'm the Assiniboine representative at large of 
Fort Belknap.
    I want to personally thank you for looking into the matter 
of my daughter who is a combat vet of the Iraq war and the 
mistreatment she had with the Veterans Administration in 
Helena. I appreciate that.
    But I'd also like to say that the Tribal Council believes 
they don't have a good relationship with Indian Health Service. 
If you look at the disparities of the funding, it's somewhere 
in the 60 percent range.
    In the corporate world, Wall Street, there's like 
incentives built into some of the people in corporate America. 
Corporate America executives received $154.9 billion, billion. 
for incentives for the past 10 years.
    And the top 20 executives in Wall Street, their salary is 
260 million and up to $1.5 billion totaling $13 billion that 
corporate America gets.
    170 years ago, my grandfather fought with Sitting Bull, my 
three grandfathers, and I come from a family of leaders and 
veterans. My daughter is a combat vet. My nephew is a combat 
vet, my brother, and I think we need to listen to our needs.
    Thank you.
    Senator Tester. Appreciate your comments, appreciate your 
service and your family's service.
    Next up?

 STATEMENT OF JULIA DAVIS WHEELER, TRIBAL COUNCIL MEMBER, NEZ 
                          PERCE TRIBE

    Ms. Julia Davis Wheeler. Yes, good afternoon. Good 
afternoon everyone, my brothers and sisters that are here. My 
name is Julia Davis Wheeler, and I'm a Nez Perce Tribal Council 
woman from the Nez Perce Tribe in Idaho.
    The Nez Perce Tribe is one of the 42 tribes in the 
northwest that count on contract support costs to take care of 
the majority of our major health needs. We do not have 
hospitals, even though in our treaties it's stated that we 
would have hospitals.
    Nonetheless, having no hospitals, we need to have inpatient 
facilities. Regional centers of excellence would be a great 
help in helping those of our people that are suffering.
    The Nez Perce Tribe is a self-governance tribe by choice of 
the General Council, not the Tribal Council, the General 
Council. This has been a good move, but this also comes with 
inadequate funding. I just returned from a self-governance 
meeting in Bellingham, Washington, and we talked about that 
issue.
    The tribe has been working tirelessly with the issue of 
trying to recoup contract support costs that were formerly 
withheld for certain Fiscal Years. We're trying to get that 
money from the Indian Health Service.
    Claims have been dated back to 2005. Two years later we 
received letter after letter stating that the $600,000 claim 
that we have put in has not been processed. This is a shame. 
This is a shame and an atrocity to the people that are counting 
on contract health service.
    I wanted to bring this to your attention, but I also wanted 
to echo what everyone has stated here.
    But I want to end my comments with something that is very 
near and dear to me, as well as the descendants of chiefs here 
in this room.
    Chief Joseph stated 120 years ago; I have heard talk and 
talk, but nothing is done. Good words do not last long until 
they amount to something. Good words do not give my people good 
health and stop them from dying. Good words will not give my 
people a home where they can live in peace and take care of 
themselves. I'm tired of talk that comes to nothing, it makes 
my heart sick. But I remember all the good words and all the 
broken promises. Too many misrepresentations have been made. 
Too many misunderstandings have come up between the white man 
about the Indians. There need be no trouble, treat all men 
alike, give them all an even chance to live and grow. All men 
were made by the same Great Spirit Chief. They are all brothers 
and the Earth is the mother of all people.
    I end my speech with this from Chief Joseph. Thank you.
    Senator Tester. Thank you.

STATEMENT OF EUGENE LITTLE COYOTE, PRESIDENT NORTHERN CHEYENNE 
                             TRIBE

    Mr. Little Coyote. Good afternoon. I'm Eugene Little 
Coyote, President, Northern Cheyenne Tribe.
    I'll be very brief. Of course, the Northern Cheyenne Tribe 
strongly encourages and supports the reauthorization of the 
Indian Health Care Improvement Act.
    We have three priorities we were going to mention today, 
diabetes and dialysis, methamphetamine prevention. We have a 
war on meth on the Northern Cheyenne, and I'd like to mention 
that Chairman Venne and the Northern Cheyenne Tribe have a 
interdepartmental coalition, Safe Trails Task Force. We're 
doing very well on that.
    Third is contract health care. We need increased funding in 
all areas of Indian health care, and the Northern Cheyenne will 
submit a detailed written testimony on these.
    Thank you.
    [The prepared statement of Mr. Eugene Little Coyote 
follows:]

Prepared Statement of Eugene Little Coyote, President Northern Cheyenne 
                                 Tribe




    Senator Tester. Thank you very much, Eugene, appreciate it.

STATEMENT OF LEO STEWART, VICE-CHAIRMAN, CONFEDERATED TRIBES OF 
                  UMATILLA INDIAN RESERVATION

    Mr. Stewart. Good afternoon, my name is Leo Stewart. I'm 
the Vice-Chairman of the Confederated Tribes of Umatilla Indian 
Reservation, which consists of Walla Walla--I almost said Nez 
Perce because the Cayuse is part of the Nez Perce and the 
Umatillas.
    One of the things, we would like to thank you a lot for 
reintroducing the Indian health care plan.
    Another thing, too, is that we have strong care need, like 
Julia Davis said about the Indian health care for hospitals in 
our areas. It's really a need.
    It shouldn't specifically be put into designated areas, but 
into the remote areas that would help our people a lot, and the 
reaching out for these kinds of funds to make these things 
work.
    Another thing, too, is to the support of all our funds that 
is important to let the unfairness of facility construction 
fund is when it takes over 50 percent of IH budget increases to 
phase in staff and to new facilities, and only three to four of 
the areas get the participant end of facility construction 
plan, so that's what we need.
    So I'd just like to thank you and thank you for letting me 
have this time.
    Senator Tester. Thank you for your comments.
    And this applies to everybody, we take written comments, so 
please, if there's more that you wanted to say that you 
couldn't, write them and send them in.
    Go ahead.

 STATEMENT OF EDWIN LITTLE PLUME, CHAIRMAN, HEALTH COMMITTEE, 
               BLACKFEET TRIBAL BUSINESS COUNCIL

    Mr. Little Plume. Good afternoon, Mr. Tester, appreciate 
you coming back to Montana, as well as Mr. Dorgan, Senator 
Dorgan. We appreciate your good words for funding for us back 
in D.C.
    As a new member of our Tribal Council, I sit on the health 
committee and chair that committee. As you know, being a new 
guy like yourself in Washington, I experience pretty much the 
same on our home reservation, funding for health care.
    Our hospital, in the 30 years since the original facility 
expansion, many variables have changed. Most noticeably, the 
hospital visits have continued to increase steadily over the 
time from 60,000 outpatient visits in 1984 to 124,000.
    Our hospital has become a regional hospital, which 
originally was designed for the Blackfeet people which our 
treaty stated.
    At this time, our hospital visits takes in patients from 
all the urban centers in the state of Montana. We have patients 
coming from Illinois, Idaho, Minnesota, Oregon, Washington 
State, North and South Dakota, are traveling to the Blackfeet 
Community Hospital in Browning for their health care needs.
    The Browning hospital, which was designed for the health of 
the Blackfeet people has become a regional health facility for 
many other tribes. The impact of this has become very 
noticeable to our own people as their needs for health care are 
not being met.
    So, with that, I thank you for listening to today's 
testimony.
    [The prepared statement of Mr. Little Plume and Ms. Tatsey 
follow:]

 Prepared Statement of Edwin Little Plume, Chairman, Health Committee, 
       Blackfeet Tribal Business Council and Jane Tatsey, Health 
            Administrator, Blackfeet Tribe Health Department




    Senator Tester. Thank you.

STATEMENT OF ANDY JOSEPH, JR., CHAIR, HEALTH AND HUMAN SERVICE 
            COMMITTEE, COLVILLE CONFEDERATED TRIBES

    Mr. Joseph. Good afternoon to my friends here in the Crow 
Nation and Senator Tester. My name is Andy Joseph, Jr. I'm the 
chair of the Health and Human Service Committee for the 
Colville Confederated Tribes.
    I'm also the Vice-Chair for the Northwest Portland Indian 
Health Board of 43 tribes in Washington, Idaho and Oregon.
    The testimony that I'd like to give is on the IHS budget. 
The Office of Management and Budget requires the staff to work 
on rules-based budget.For the last 4 years we've had to work on 
a rules-based budget of 2 percent or 4 percent.
    This last meeting we requested a 23 percent increase in 
current spending. That pays for the pay act, Federal employees 
get a raise every year. It covers the inflation and it also 
covers the population growth for all of the nations.
    By being stuck with a rules-based budget every year, we 
have to go back there. Dr. Grim negotiates for us the funding 
that has been given and he's not a tribal leader. I want to see 
tribal leaders at the table.
    I pushed a resolution to have a leader from NCAI, a leader 
from the National Health Board, a direct service type 
representative to be at that table. Government staff according 
to Executive Order should not be talking for us.
    As you know, he's a commissioned officer and he doesn't 
have the high rank to tell his superiors what we really need, 
and he's paid to save money for the government, but it's 
costing a lot of our people's lives.
    I imagine if you took the numbers down of all the people 
we've lost over the years, we'd be right up there with our 
soldiers that we're losing in Iraq.
    Senator Tester. Please, please put it in written testimony. 
I'm literally going to have to walk out of here in 1 minute. So 
thank you very much.
    Mr. Joseph. We'll send in our written testimony from the 
Northwest Portland Area Indian Health Board on our health care 
status.
    Senator Tester. I appreciate that very much.
    The next two very quick comment, I mean very quick comment 
because I've got to boogie.

        STATEMENT OF MS. WALK ABOVE, MEMBER, CROW TRIBE

    Ms. Walk Above. Good afternoon, Jon Tester, I'm (inaudible) 
Walk Above. I'm a parent, I'm a member of the Crow Tribe.
    My baby has been having health problems, which he's okay 
now, but I have these bills and I've written to the hospital 
here for them to pay for my bill and have them pay for it, and 
they didn't approve it.
    So I wrote a letter to the Indian Health Service in 
Billings and they denied my letter. So I wrote a letter to 
Washington, D.C. I haven't heard from them yet, but I would 
really appreciate it if they would help me.
    And I'm glad that you're here to hear our testimonies 
because we cannot go to Washington, D.C. and to go and see you.
    Thank you.
    Senator Tester. That's one of the reasons we're here. Thank 
you very much.

     STATEMENT OF KEN REAL BIRD, REPRESENTATIVE, CROW TRIBE

    Mr. Real Bird. Thank you, I'm Ken Real Bird. I'm a victim 
of this flawed health----
    Senator Tester. Are you an elected official?
    Mr. Real Bird. Yes, I represent the legislative branch of 
the Crow Tribe. I'm a victim of this outfit right here. And I 
think that there needs to be some law so the issue of 
malpractice is addressed by IHS doctors.
    See, when they do something wrong, it's acceptable because 
they're covered by IHS, but the individual who causes the 
problems, the doctor needs to be liable for some of the things 
that they have done.
    Now, there's so many problems with the IHS, especially in 
management. And one of the things that I'd like to bring out is 
that us Indian people have to wait 5 hours or more to get 
health care.
    Senator Tester. Could you do me a favor? Could you write it 
down and send it in because----
    Mr. Real Bird. Yes, I could send it out. I've written two 
letters before you were elected. I wrote one to Burns and 
Baucus on this issues of my problems that I've dealt with.
    Thank you.
    Senator Tester. That would be great. If you could do that, 
that would be marvelous. Thank you.
    At this point in time, I have to hurry and I'd like to 
thank you because we're out of time. I want to first of all 
thank some staff people here, Mark Jette and Amanda Arnold from 
my staff; Anna Sorrell from Governor Schweitzer's staff; 
Richard Litsey and Jim Corson from Senator Baucus' staff; and 
David Mullon who is from Senator Murkowski's staff, the ranking 
minority.
    I will tell you this, there was one lady that got up and 
spoke from the Nez Pearce that talked about Chief Joseph, 
talked and talked and nothing was done.
    I can tell you this, and I can speak for Senator Dorgan 
when I say that, it takes 60 votes to get things done in the 
U.S. Senate so we can't do it alone, we need 58 other people to 
help us out.
    But we will work and we will work and we will continue to 
work to make sure that health care is adequate in Indian 
County. We will be diligent on that, make no mistake about it.
    And finally I want to thank the folks who provided us with 
the facility and the great dinner.
    I want to thank Chairman Carl Venne. Carl, I want to thank 
you very, very much, not only for your friendship but for your 
hospitality and courtesy in doing all the work necessary to 
help pull this thing off.
    Thank you very much.
    Before we go, I want Carl to get the last word in.

         STATEMENT OF CARL VENNE, CHAIRMAN, CROW TRIBE

    Chairman Venne. Senator, I want to thank you for coming and 
the committee. If you look at that map of the United States 
over there, it says Council of large land-based tribes. That's 
where most of the Indian people live. That's where most of the 
land is that Indians own, and we are the poorest of the poorest 
in the United States of all ethnic groups.
    It's sad to see when you look at the Federal budget, when 
you see wild horses out in the Pryors, when we in this region 
are in the red for $48 million and they give them horses, which 
we don't ride or don't eat, $40 million a year.
    Something is wrong in this country. We, as Indian leaders, 
need to speak up. We don't beg no more. It's rightfully yours 
because of the treaties that we have done with these United 
States.
    During the time of war, 70 percent of all young men and 
women from all of the tribes enlist to go to war. Did you know 
that? You're the largest population or ethnic group in these 
United States who serve this country, but yet to be treated 
like we are today, is not good.
    We, as leaders, have to speak up. You should be mad at what 
this administration has done to Indian tribes throughout the 
country.
    They wanted to do something way a long time ago when they 
infested army blankets and gave it to us and everybody got 
smallpox and died. Is that what is still going on today with 
this administration?
    No, don't take a backseat to nobody. You're entitled as 
Indian people.
    The Indian people working for Indian Health Service, don't 
be afraid to speak up. You know what is wrong. You know what we 
need. How can Dr. Grim sit in his office and say no, we don't 
need no more money when he has a committee that says we need a 
lot more money.
    What is going on in this country? We're not begging the 
U.S. Government. They made promises.
    I can only speak for my tribe, if you look at the Powder 
River Basin, the billions and billions of dollars that this 
government has made off of it, and yet we're treated like this 
today. It's time for Indian leaders to get up and speak.
    And I want to thank Senator Tester and his Committee for 
coming to Crow Country, and I appreciate what they're trying to 
do for us, but we need to speak up and back them up. We need to 
get out the vote also.
    Thank you.
    [Whereupon, at 3:15 p.m. the hearing was adjourned.]




















                            A P P E N D I X

 Prepared Statement of The Confederated Salish and Kootenai Tribes of 
                          the Flathead Nation



                                 ______
                                 
  Prepared Statement of Dick Brown, President, MHA--an Association of 
                     Montana Health Care Providers



                                 ______
                                 
   Prepared Statement of Laurene Johnson, Member of the Confederated 
                       Salish and Kootenai Tribes



                                 ______
                                 
    Prepared Statement of Lou Stone, Member of the Sngaytskstx Tribe



                                 ______
                                 
Prepared Statement of Margaret Norgaard, CEO, Northeast Montana Health 
                            Services (NEMHS)



                                 ______
                                 
Prepared Statement of Gwen Clairmont, Member of the Confederated Salish 
                          and Kootenai Tribes



                                 ______
                                 
 Prepared Statement of John Sinclair, President, Little Shell Tribe of 
                      Chippewa Indians of Montana



Attachments



                                 ______
                                 
  Prepared Statement of Gordon Belcourt, Executive Director, Montana-
                     Wyoming Tribal Leaders Council



Attachment




                                 ______
                                 
    Prepared Statement of the Fort Belknap Indian Community Council



                                 ______
                                 
        Prepared Statement of David B. Myers, M.D., Billings MT



                                 ______
                                 
 Prepared Statement of Carol Juneau, State Senator, Senate District 8, 
                                Montana



                                 ______
                                 
             Prepared Statement of Barry Adams, Browning MT




                                 ______
                                 
Prepared Statement of Alex Ward, Associate State Director, AARP Montana 



                                 ______
                                 
               Prepared Statement of the Nez Perce Tribe



                                 ______