[Senate Hearing 109-162] [From the U.S. Government Publishing Office] S. Hrg. 109-162 INDIAN HEALTH CARE IMPROVEMENT ACT ======================================================================= JOINT HEARING BEFORE THE COMMITTEE ON INDIAN AFFAIRS UNITED STATES SENATE AND THE COMMITTEE ON HEALTH, EDUCATION, LABOR AND PENSIONS UNITED STATES SENATE ONE HUNDRED NINTH CONGRESS FIRST SESSION ON S. 1057 INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2005 __________ JULY 14, 2005 WASHINGTON, DC U.S. GOVERNMENT PRINTING OFFICE 22-554 WASHINGTON : 2005 _________________________________________________________________ For sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC area (202) 512-1800 Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001 COMMITTEE ON INDIAN AFFAIRS JOHN McCAIN, Arizona, Chairman BYRON L. DORGAN, North Dakota, Vice Chairman PETE V. DOMENICI, New Mexico DANIEL K. INOUYE, Hawaii CRAIG THOMAS, Wyoming KENT CONRAD, North Dakota GORDON SMITH, Oregon DANIEL K. AKAKA, Hawaii LISA MURKOWSKI, Alaska TIM JOHNSON, South Dakota MICHAEL D. CRAPO, Idaho MARIA CANTWELL, Washington RICHARD BURR, North Carolina TOM COBURN, M.D., Oklahoma Jeanne Bumpus, Majority Staff Director Sara G. Garland, Minority Staff Director COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS MICHAEL B. ENZI, Wyoming, Chairman JUDD GREGG, New Hampshire EDWARD M. KENNEDY, Massachusetts BILL FRIST, Tennessee CHRISTOPHER J. DODD, Connecticut LAMAR ALEXANDER, Tennessee TOM HARKIN, Iowa RICHARD BURR, North Carolina BARBARA A. MIKULSKI, Maryland JOHNNY ISAKSON, Georgia JAMES M. JEFFORDS (I), Vermont MIKE DeWINE, Ohio JEFF BINGAMAN, New Mexico JOHN ENSIGN, Nevada PATTY MURRAY, Washington ORRIN G. HATCH, Utah JACK REED, Rhode Island JEFF SESSIONS, Alabama HILLARY RODHAM CLINTON, New York PAT ROBERTS, Kansas Katherine Brunett McGuire, Staff Director J. Michael Myers, Minority Staff Director and Chief Counsel (ii) C O N T E N T S ---------- Page S. 1057, text of................................................. 4 Statements: Brandjord, DDS, Robert, president-elect, American Dental Association................................................ 363 Brannan, Richard, chairman, Northern Arapaho Business Council 352 Dorgan, Hon. Byron L., U.S. Senator from North Dakota, vice chairman, Committee on Indian Affairs...................... 334 Enzi, Hon. Michael B., U.S. Senator from Wyoming, chairman, Committee on Health, Education, Labor and Pensions......... 1 Forquera, Ralph, executive director, Seattle Indian health Board...................................................... 353 Grim, Dr. Charles, director, Indian Health Service, Department of Health and Human Services.................... 335 Hartz, Gary, director, Office of Environment Health and Engineering, Indian Health Service, Department of Health and Human Services......................................... 335 Joseph, Rachel A., chairperson, Lone Pine Paiute Shoshone Reservation................................................ 348 Kashevaroff, Don, president, Seldovia Village Tribe and president Alaska Native Tribal Health Consortium........... 350 Kennedy, Hon. Edward M., U.S. Senator from Massachusetts..... 334 McCain, Hon. John, U.S. Senator from Arizona, chairman, Committee on Indian Affairs................................ 334 McSwain, Robert G., deputy director, Indian Health Service, Department of Health and Human Services.................... 335 Murray, Hon. Patty, U.S. Senator from Washington............. 347 Vanderwagen, M.D., Craig, acting chief medical officer, Indian Health Service, Department of Health and Human Services................................................... 335 Williard, Dr. Mary, Yukon Kuskowim Health Corporation Dental Clinic..................................................... 361 Appendix Prepared statements: Anderson, Trudy, President/CEO, Alaska Native Health Board... 452 Brandjord, DDS, Robert (with attachment)..................... 385 Brannan, Richard............................................. 440 Cantwell, Hon. Maria, U.S. Senator from Washington........... 375 Dorgan, Hon. Byron L., U.S. Senator from North Dakota, vice chairman, Committee on Indian Affairs...................... 376 Enzi, Hon. Michael B., U.S. Senator from Wyoming, chairman, Committee on Health, Education, Labor and Pensions......... 377 Forquera, Ralph (with attachment)............................ 456 Friedman, DDS, MPH, Jay W. (with attachment)................. 570 Gottlieb, Katherine, president/CEO, Southern Foundation...... 581 Grim, Dr. Charles............................................ 584 Ignace, Georgiana, president, National Council of Urban Indian Health.............................................. 598 Inouye, Hon. Daniel K., U.S. Senator from Hawaii............. 379 Joseph, Rachel A. (with attachment).......................... 623 Kardos, B.D.S., M.D.S., Ph.D., FFOP (RCPA), Thomas B., professor of Oral Biology and Oral Pathology, University of Otago, Dunedin, New Zealand (with attachment).............. 643 Kashevaroff, Don............................................. 716 Kelso, DDS, Mark, Norton Sound dental director, Nome, AK..... 381 Kennedy, Hon. Edward M., U.S. Senator from Massachusetts..... 379 Kovaleski, DDS, Tom, director, Southcentral Foundation Dental Program.................................................... 382 McCain, Hon. John, U.S. Senator from Arizona, chairman, Committee on Indian Affairs................................ 380 Milgrom, DDS, Peter, center director, Professor of Dental Public Sciences and Health Services, University of Washington, Seattle, WA.................................... 750 Murray, Hon. Patty, U.S. Senator from Washington............. 381 Nash, D.M.D., M.S., Ed.D., David A., professor of pediatric dentistry in the College of Dentistry at the University of Kentucky in Lexington, KY (with attachment)................ 757 Willard, William R., professor of dental education; professor of pediatric dentistry, University of Kentucky Medical Center (with attachment)................................... 757 Williard, Dr. Mary........................................... 784 Additional material submitted for the record: Letters: Clark, Robert J., Bristol Bay Area Health Corporation........ 788 Dawson, RDH, BS, Katie L., president, American Dental Hygienists' Association.................................... 793 Evans, Robert D.............................................. 798 Juan-Saunders, Vivian, president, Inter Tribal Council of Arizona, chairwoman, Tohono O'odham Nation (position paper) 800 Kaufmann, ND, Andrew J., San Carlos Apache Tribe............. 804 Sekiguchi, et al, letter to the Editor, American Journal of Public Health, November 2005............................... 806 Questions: From Hon. Orin G. Hatch, U.S. Senator from Utah (no responses at time of printing)....................................... 383 Reports: Intergrated Dental Health Program for Alaska Native Populations, by Howard Bailit, D.M.D; Tryfon Beazoglou, Ph.D; Amid Ismail, D.D.S.; and Thomas Kovaleski, D.D.S..... 808 INDIAN HEALTH CARE IMPROVEMENT ACT ---------- THURSDAY, JULY 14, 2005 U.S. Senate, Committee on Indian Affairs, Meeting Jointly With the Committee on Health, Education, Labor and Pensions Washington, DC. The committee met, pursuant to notice, at 10:16 a.m. in room 106 Dirksen Senate Building, Hon. John McCain (chairman of the Committee on Indian Affairs) and Hon. Michael B. Enzi (chairman of the Committee on Health, Education, Labor and Pensions), presiding. Present: Senators McCain, Enzi, Cantwell, Coburn, Dorgan, Inouye, Isakson, Kennedy, Murkowski, Murray and Reed. STATEMENT OF HON. MICHAEL B. ENZI, U.S. SENATOR FROM WYOMING, CHAIRMAN, COMMITTEE ON HEALTH, EDUCATION, LABOR AND PENSIONS Senator Enzi. I am going to call to order this historic joint meeting of the Committee on Indian Affairs and the Committee on Health, Education, Labor and Pensions. Today's hearing will focus on the state of Indian health care and specifically the Indian Health Care Improvement Act. We will be welcoming Senator McCain here shortly, and the rest of the members of the Indian Affairs Committee to our HELP Committee meeting room. Senator Kennedy and I started a policy of punctuality and we are continuing that. We will go ahead and make our comments and then they can make theirs when they arrive. Earlier this year, Senator McCain did approach me about holding a joint committee hearing on the state of Indian health care. I immediately accepted, as health care is important, perhaps the most important issue facing tribes today, in fact, facing all people today. Today's hearing will enable us to chart our current progress and discuss what we can do to increase the services that are available to address the physical and emotional problems that continue to plague American Indians and Alaska Natives. When the Indian Health Care Improvement Act was first signed into law in 1976, it was written to address the findings of surveys and studies that indicated that the health status of American Indians and Alaska Natives was far below that of the general population. It continues to be a matter of serious concern that, as the health status of most Americans continues to rise, the status of American Indians and Alaska Natives has not kept pace with the general population. Studies show that American Indians and Alaska Natives die at a higher rate than other Americans from alcoholism, tuberculosis, auto accidents, diabetes, homicide and suicide. In addition, a safe and adequate water supply and waste disposal facilities, something we all take for granted, is not available in 12 percent of American Indian and Alaska Native homes, as opposed to 1 percent in the rest of the Nation. Several years ago, residents of the Wind River Reservation in Central Wyoming faced a drinking water shortage that threatened the health and safety of everybody in the area, so drinking water was donated to tribal members and local residents. The lack of these basic services makes life even harsher for these people and contributes to those already-high death rates. Coming from Wyoming, I know full well the problems we encounter in the effort to provide quality health care to all people of my home State. As I noted during my visits to the Wind River Reservation, their problems are not unique. They have an impact on all those who live on reservations from coast to coast. We need to take a varied approach to address each of those problems separately. Clearly, people of different ages have different problems. A multifaceted approach to solving each of the problems will require a systematic, as well as financial approach. Local, State and national governments and agencies must work together with tribal leaders to focus our resources where they will do the most good. That kind of approach has the greatest chance of being successful. I appreciate all the witnesses taking time out of their busy schedules to be with us today. In addition, of course, I would like to welcome Richard Brannan, the chairman of the Northern Arapaho Business Council of Fort Washakie, WY. No one knows better than he does the problems faced by those living on reservations and by those who rely on the Indian Health Service for their health care needs. I am very pleased he was able to make the journey and to share his experiences with us today. I look forward to his comments and those of the entire list of witnesses. Each of you has a perspective and a point of view to share that only you can provide. I look forward to hearing a summary of your prepared remarks so that we can address the underlying issues during our question and answer session. To the members of the joint committees, we have a longstanding tradition on the HELP Committee that opening statements are made by the Chairman and Ranking Member, and due to the combined number of members of both committees and the fact that we have three panels and the fact that we begin voting again at 3 p.m., I would respectfully submit or ask that the tradition apply for today's hearing, but all members' full statements will be made a part of the record, as will all witnesses full statements be made a part of the record. In addition, members may use the question and answer period to make remarks. I did mention that this is an historic situation of having the two committees that have an intense interest in Indian health working together to come up with some solutions. I really appreciate Chairman McCain suggesting that, and following through on it. I think this will be the first time that this has actually been done outside of Energy and Water. This is probably an appropriate place to do it. [Text of S. 1057 follows:]Senator Enzi. Chairman McCain, welcome to our home. STATEMENT OF HON. JOHN McCAIN, U.S. SENATOR FROM ARIZONA, CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS Senator McCain. Thank you very much, Mr. Chairman. I will make my statement part of the record and ask unanimous consent to do so. I would just like to comment that this act is long overdue. It is important. I think you, in your opening statement, articulated the importance of this legislation very well. I am very pleased for Senator Dorgan and I to have the opportunity to work with you and Senator Kennedy and get this bill done. It is long overdue. Thank you, Mr. Chairman. Senator Enzi. Thank you. [Prepared statement of Senator McCain appears in appendix.] Senator Dorgan. STATEMENT OF HON. BYRON L. DORGAN, U.S. SENATOR FROM NORTH DAKOTA, VICE CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS Senator Dorgan. Mr. Chairman, let me just add my thank you, and ask that my statement be made a part of the record. I have said often I think we have a bona fide emergency in health care on Indian reservations, the first Americans. I hope very much that this hearing is one more stimulus towards finally passing this legislation. We should have done it in the last session of Congress, but we were unable to get there. So my hope is, and I believe Senator McCain and I have worked very hard and appreciate your cooperation to do this. My hope is that we will get a bill to the President for signature that advances health care on Indian reservations and with Native Americans. Thank you very much. Senator Enzi. Thank you. Senator Kennedy. STATEMENT OF HON. EDWARD M. KENNEDY, U.S. SENATOR FROM MASSACHUSETTS Senator Kennedy. Mr. Chairman, I want to first of all join you in thanking Senator McCain and Senator Dorgan for inviting us to participate in this program. As we know, they have the primary jurisdiction in terms of where Native Americans are living, and the enormous health disparities that exist for Native Americans in Indian country. We know that also there are a number of Native Americans who are in urban areas. We want to try and make sure, to the extent that we can, is harmonize whatever we are doing here and in your committee so it ties on into the excellent legislation which they have introduced. I just want to commend them. It has been far too long since the Senate addressed this issue. We have many health challenges in this Nation, but the disparity issue is such a compelling one. We will hear time after time of what is happening out there in Indian country this afternoon. And that is absolutely intolerable in our country and in our society. Once in a while we get disparities in urban areas among different kinds of groups, but if we look at the total range of health disparities, it does not exist in any place in our Nation as it exists with Native Americans. This cries out for action. It cries out for response. I just want to thank Senator McCain and Senator Dorgan for their leadership. This legislation is way, way overdue. I thank you for having the hearing and giving the spotlight on this. I pledge to work with you and our colleagues to do what we can so we have a seamless web in trying to make sure that those whose tradition comes from Indian land are going to have the kind of health care needs that they are entitled to in our Nation. I thank you, and I would like to ask that my full statement be put in the record. [Prepared statement of Senator Kennedy appears in appendix.] Senator Enzi. Without objection, all statements will be in the record. I think you can tell from the opening statements that there is a lot of passion behind this, so let's get on to the witnesses. Our first witness is Dr. Charles Grim. Dr. Grim is the director of Indian Health Service. He is the Assistant Surgeon General and holds the rank of Rear Admiral in the Commissioned Corps of the Public Health Service. We thank you for being here, Dr. Grim. STATEMENT OF Dr. CHARLES GRIM, DIRECTOR, INDIAN HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES, ACCOMPANIED BY ROBERT G. McSWAIN, DEPUTY DIRECTOR; GARY HARTZ, DIRECTOR, OFFICE OF ENVIRONMENT HEALTH AND ENGINEERING; AND CRAIG VANDERWAGEN, M.D., ACTING CHIEF MEDICAL OFFICER Mr. Grim. Thank you, Chairman Enzi. Mr. Chairman and members of the committee, we are very appreciative of this joint hearing that you agreed to hold and we are very honored to be able to testify before you here today on the important issue of the reauthorization of the Indian Health Care Improvement Act. My name is Dr. Charles Grim. I am accompanied today by Robert McSwain, my deputy director; Craig Vanderwagen, our acting chief medical officer; and Gary Hartz, our director for the Office of Environmental Health and Engineering. I will be giving the opening comments for the Department, but my colleagues are with me today so that we can respond to your questions. This month, July 2005, marks the 50th anniversary of the Transfer Act, Public Law 83-568, which officially transferred the Indian health programs from the Bureau of Indian Affairs [BIA] to the U.S. Public Health Service, effectively establishing the Indian Health Service. The Transfer Act provided that all functions, responsibilities, authorities and duties relating to the maintenance and operation of hospitals and health facilities for Indians and the conservation of Indian health shall be administered by the Surgeon General of the United States Public Health Service. This transfer was significant in that our program was moved to an executive branch department, then the Department of Health, Education and Welfare, and now the Department of Health and Human Service. This transfer was more appropriate to the role of the Federal Government in addressing the health care needs of American Indians and Alaska Natives. Since the Transfer Act, the health status of Indians have improved significantly. Today, we are here to discuss another significant milestone in the evolution of our Federal Government's responsibility for the provision of health services to American Indians and Alaska Natives, the Indian Health Care Improvement Act which was first authorized in 1976. It forms the backbone of the system through which the Federal health programs serve American Indians and Alaska Natives and encourage their participation in these and other programs. IHS has the responsibility for the delivery of health services to more than 1.8 million federally recognized American Indians and Alaska Natives through a system of IHS, tribal and urban Indian-operated facilities in programs based on treaties and judicial decisions and statutes. The mission of the agency is to raise the physical, mental, social, and spiritual health of the American Indian and Alaska Natives to the highest level in partnership with the population we serve. Our goal is to assure that comprehensive, culturally appropriate, acceptable personal and public health services are available and accessible. Our foundation 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. The Indian Health Care Improvement Act builds upon the Snyder Act of 1921, which authorized regular appropriations for the relief and distress and conservation of health of American Indians and Alaska Natives. Like the Snyder Act, the Indian Health Care Improvement Act authorizes programs that deliver health services to Indian people, as well as providing additional directives and guidance. For example, the Indian Health Care Improvement Act contains specific authorities addressing recruitment and retention of health professionals serving Indian communities, the provision of health services, the construction, replacement and repair of health care facilities, access to health services, and the provision of health services to urban Indian people. We are here today to discuss the reauthorization of the Indian Health Care Improvement Act and its impact on programs and services provided for in current law. S. 1057 proposes to amend current program authority to assure the highest possible health status for Indians. Improving access for health care for all eligible American Indians and Alaska Natives is critical to achieving this goal and a priority for all those involved in the administration of this important program. S. 1057, however, also provides expansions which may negatively impact access by requiring the secretary to consult, negotiate, develop reports and establish programs and activities beyond the reasonable scope necessary to effectively implement the Indian Health Care Improvement Act. In S. 1057, between desire to improve access and provisions that potentially compromise access, we hope to find a means for achieving our common goal. Since enactment of the Indian Health Care Act in 1976, statutory authority has substantially expanded programs and activities to keep pace with advances in health care delivery and administration. Federal funding for the Indian Health Care Improvement Act has contributed billions of dollars to improve the health status of American Indians and Alaska Natives. Much progress has been made, particularly in the areas of infant and maternal mortality. The Department has also reactivated the Intra-departmental Council on Native American Affairs to provide a consistent HHS policy when working with more than 560 federally recognized tribes. This council, which was authorized in the Native American Programs Act of 1974, gives the IHS Director a highly visible role within the Department on Indian policy. I serve as the vice chair of that council. The Department has also revised our consultation policy recently through a process which involved tribal leaders. The policy emphasizes the unique government-to-government relationship between Indian tribes and the Federal Government and assists in improving services through better communications. Consultation is conducted at different levels and includes annual budget consultations with tribes to ensure their participation in this important process. The annual budget meetings provide tribes with an opportunity to meet directly with all department agencies and identify their priorities for upcoming years. In addition, the Centers for Medicare and Medicaid Services has established a technical tribal advisory group which was established to provide tribes a vehicle to communicate concerns and comments to CMS on Medicare, Medicaid and SCHIP policies impacting their members. IHS has been vigilant about improving outcomes for Indian children and families with diabetes by increasing education and physical activity programs aimed at preventing and addressing the needs of those susceptible or struggling with this potentially disabling disease. The Department has not been a passive observer of the health needs of eligible American Indians and Alaska Natives, yet we recognize the health disparities among this population do exist and are among some of the highest in the Nation for certain diseases, as you pointed out. We know that improvements in access to IHS and other Federal programs and private sector programs will result in improved health status for Indian people. We support the provisions that increase the flexibility of the Department to work with tribes and urban Indian programs to increase the availability of health care, including new approaches to delivering care and to expand the scope of health services available to American Indians and Alaska Natives. I commend Congress for including in S. 1057 various changes that respond to the concerns raised in previous proposals. Some of the changes improve the ability of the Secretary to effectively manage the program. In the area of behavioral health, title VII of S. 1057, it provides for the needs of Indian women and youth and expands behavioral health service to include a much-needed child sexual abuse and prevention treatment program. The Department supports this effort, but opposes specific requirements in certain sections of this title, specifically 704, 706 and 711. Essentially, it is a ``shall'' versus ``may'' issue that diminishes the flexibility of the secretary in providing for these important programs in a manner that supports the local control and priorities of tribes and be able to address their specific needs. The Department also opposes a new section 104(a)(2) which proposes to allocate the Indian Health Profession Scholarship Program funding by formula to the 12 IHS areas. If allocation by formula is authorized, students will not be given an opportunity to apply for a scholarships if their area does not receive an adequate allocation and if their desired profession is not considered a priority in their area, even though there may be great needs nationally for such professions. We would recommend that this program remain a national program. My written testimony includes other specific areas of concern. In addition, the Department continues to carefully analyze all provisions contained in S. 1057. The department would like to continue to work with your committees to discuss our concerns with the bill as drafted. Based on the work that has occurred between the Department and congressional committees in the 108th Congress on the predecessor proposal, S. 556, to this current bill S. 1057, I am confident that we can reach a mutual agreement on a bill that can be acceptable to our parties, including tribes and urban Indians, and raise their health status in the years to come. I would be pleased to answer any questions that you may have, and thank your for having us today. [Prepared statement of Dr. Grim appears in appendix.] Senator Enzi. Thank you very much for being here. I will mention that we are going to have some confusion with votes that are starting at 3 p.m. today, but one of the things that we do by having people serve on panels, we are hoping that they are also open to written questions. A lot of times we have written questions anyway that go into much more detail than would be possible for us to be able to do in a forum like this. So we hope that all witnesses will be open to answering written questions, from all committee members. Our purpose is to build a record so that we have the capability to write the best bill. I appreciate the testimony you have given. As you might be aware, I am very interested in expanding health information technology to all health care providers. We have done some legislation on that. Could you briefly tell me what kinds of information technology activities are occurring in the Indian Health Service? More importantly, are there any barriers to broader implementation of those programs? Mr. Grim. The Indian Health Service has had electronic health records for many, many years. Just this year, we started the implementation of a fully electronic graphical user interface health record. It has now been rolled out in 24 of our sites. We are in hopes that by the year fiscal year 2008 or 2009, we will have a fully electronic health record in all of our programs. We are making use of the latest technology that there is. We have tele-health programs that are excellent that are in the State of Alaska that tie all of the community health clinics into some of the regional hub hospitals. We are looking at the expansion of tele-medicine across our agency in the years ahead. We have it in various sites, but not others. So I would say, Senator, that we are I think right on the cutting edge. We are working with the President's Health Information Technology Program. We have representatives that are sitting on that. I would be happy to answer anything further or more details that you might about that for the record. Senator Enzi. I will do some followup questions in writing. Senator McCain. Senator McCain. Thank you very much, Dr. Grim. For the record, you might mention who is accompanying you at the table. Mr. Grim. Okay. I have my deputy director, Robert McSwain; Gary Hartz, our director for the Office of Environmental Health and Engineering; and Craig Vanderwagen, our chief medical officer. Senator McCain. Welcome. Doctor, we have been around this track a few times before, as you know. Mr. Grim. Yes, sir. Senator McCain. Last year, you raised several objections. We tried to accommodate them. A lot of those objections have to do with flexibility. You want maximum flexibility for the Department to work on meeting the health care needs of Indian people. I understand that. Most bureaucracies do. But some of the objections you raised last year and this year seem to reflect an unwillingness to accord the same flexibility to Indian tribes. We find that not proportional. What is your response? Mr. Grim. I would just say that we would continue to work with the committee if there are specific provisions in the bill where you think that we are giving up the tribes' flexibility I would be more than happy to discuss it. As I mentioned earlier, we have a very robust consultation policy within both the Department and the Indian Health Service, and do not make any major policy or budgeting decisions without consulting tribes. So we would be more than happy to work with the committees on those specific issues. Senator McCain. One specific issue, you raise objection to the GAO preparing a comprehensive baseline report on Indian health facilities that is presently in the bill. Mr. Grim. Yes, sir. Senator McCain. Yet your department has never been able to provide the tribes or Congress any total information on the number, size or status of the Indian health facilities. If the GAO does not prepare a comprehensive baseline report, then who does? Mr. Grim. The reason that we made those comments, Senator McCain, is that the agency has been in the process over the course of the last 1\1/2\ years in consulting with tribes on a new priority system for the agency. It will be a more expansive type of priority system than our current one. We are in the final process of that. We had a tribally driven work group called the Facilities Appropriation Advisory Board, made up of tribal members across the Nation that developed a priority system recommendation with waiting and criteria. We sent that out to tribal leaders all across the Nation. We received over 800 comments on that. The group incorporated those and they are very close to making a recommendation to me. That will be a much more comprehensive listing than we currently have. That was the reason we asked that reference to GAO doing that report be removed. We feel that we are very, very close to implementing that. It has been through tribal consultation. Senator McCain. How does a GAO baseline report interfere with any of the things you just said? Are you concerned about needless expenditure of taxpayer dollars? I do not see how a GAO report would interfere with any of the good things that you just described. Mr. Grim. Our concern, I think, is that it would take additional time of agency staff. We are almost there. We almost have the data. We would have to work with GAO I think rather extensively to get the data transferred over to them into a report, but if that is the committee's wish. Senator McCain. Mr. Chairman, I have several questions I would like to submit for the record. I thank you, Mr. Chairman. I thank the witnesses. Mr. Grim. Certainly, Senator. Senator Enzi. Senator Dorgan. Senator Dorgan. Mr. Chairman, thank you very much. Dr. Grim, you and I have had plenty of opportunity across the dais to talk about these issues. I will not ask you again the question, what was your recommendation to the Office of Management and Budget for funding for the Indian Health Service. Was it substantially different than that which was expressed in the President's budget to the Congress? I have asked you that a couple of times and I think you have felt like you have been unable to answer it or unwilling to answer it and would probably get in trouble if you answered it. Do you still feel that way? Mr. Grim. Yes, sir. [Laughter.] Senator Dorgan. Why don't we get you in trouble today? [Laughter.] Let me ask you, at a recent hearing one of the witnesses who testified after you and Dr. Carmona spoke mentioned that the Indian Health Service is funded at about 40 percent or 45 percent of the level of need. What is your assessment of that? Almost all of us would agree that there are in many cases a bona fide emergency with respect to health care on reservations, so it is funded at something below the level of need. What is your assessment of the statement that it is only at 40 percent or 45 percent? Mr. Grim. We have some data on that and we can provide that for the record, Senator Dorgan. Senator Dorgan. But do you think it is 50 percent of the level of need or 75 percent of the level of need? Any notion? Mr. Grim. We have data that we update annually on that and I cannot recall what the exact numbers are right now, but we will provide that. Senator Dorgan. Do any of your staff know the answer to that? It just seems to me like that is a pretty fundamental question. What is the need out there and how close are we to meeting the need? I have said before in other venues that we have a trust responsibility for health care for American Indians. We also have responsibility for health care of Federal prisoners, and we spend about twice as much per capita for Federal prisoners' health care as we do for Native Americans'. So it seems to me just by observation we are something substantially below the level of need. I am trying to determine whether we have any notion of what that is. Mr. Grim. We do have a notion of what that is. I do not know if it has been updated for the current fiscal year, Senator Dorgan, but it is somewhere in the nature of 60 percent. Senator Dorgan. At 60 percent? All right. That would suggest we are about 40 percent short of fulfilling the need, which is really a serious, serious omission. My colleague, Senator McCain, asked the question about the health care facilities. I believe this year the recommendation is a cut in health care facilities. I think it is around $70 million, $75 million. I would share his question about why would anybody object to a GAO baseline report. I understand that you are working on a priorities list. I also understand from an inquiry I made yesterday that that is about 6 months or 9 months away. Mr. Grim. We have done the master health services planning for that whole process across our regions, but you are probably accurate in an about 6-month timeframe before a final report would be done. What we still have yet to do is we have told the tribes that if the recommendations that all came in resulted in a significant change to either the criteria that we were suggested or the weighting of the criteria, that we would come back to tribal leadership one more time, show them the formula, talk to them about the changes that had been made and why those had been made based on the recommendations from around the Nation. And then if there was not significant disagreement, we would implement that new priority system, run all of our health services master plans through that, and then come up with a comprehensive list. Senator Dorgan. Yes; there is an urgency to do that and get that done as quickly as possible. I hope you would not object to the requirement in the bill with respect to the GAO. If it is duplicative, so be it. Although perhaps by the time that would be implemented, you would have finished your report. I think certainly on behalf of those of us who serve on the Committee on Indian Affairs, there is an urgency here to find a way for us to move this legislation forward. We are very frustrated. We could not do it last year. We should do it now. I hope that you and others will play a constructive role in letting us, not letting us, in cooperating with us to move this legislation sooner rather than later. Mr. Grim. Yes, sir; Senator Dorgan. Senator Dorgan. Thank you, Mr. Chairman. Senator Enzi. Thank you. Senator Murkowski. Senator Murkowski. Thank you, Mr. Chairman. Welcome, Dr. Grim. I always appreciate your being here and hearing from you. Your statement this afternoon does not make any reference to the Dental Health Aide Therapist Program. We are going to be hearing a little bit more on the third panel this afternoon. As a dentist and as a public health professional, can you give your opinion regarding this program? Mr. Grim. I have traveled to Alaska numerous times, as you know. Senator Murkowski. And we like that. Mr. Grim. I am looking forward to coming again sometime soon. I have traveled with our former secretary to that region. We did have an opportunity to talk with the tribes about that particular program the last time we were up there last summer. We felt that the program had merit, and since then additional views have been coming forward and additional concerns. We are continuing to meet with all the parties that are concerned. We have met with the Alaska tribes. We have met with the American Dental Association. We continue to try to look for a solution to the problems of the high levels of unmet dental care that occur in the bush in the very rural parts of Alaska. We are committed to working with you and with the tribes there to try to resolve that issue. Senator Murkowski. Some of us feel that one way to resolve it is through this Dental Health Aide Therapist Program. Can you kind of speak to some of the challenges that IHS has in recruiting dentists for rural Alaska and to these villages? Mr. Grim. Yes; I can, Senator. We currently have about a 24 percent vacancy rate for dentists nationally, IHS-wide. The last statistics that I had seen from the tribes in Alaska showed that in the outer-lying parts of Alaska that number is getting close to about 50 percent. We are having trouble nationally recruiting dentists into many of our programs. So we continue to work with organizations like the American Dental Association. We work with the U.S. Association of Colleges of Dentistry to try to do what we can to recruit at locations like that, but currently we are simply lacking the ability to fill those. Senator Murkowski. Are you having any success with that recruitment then? Mr. Grim. We are able to fill our positions to this level, but we seem to be at about this level and cannot seem to quite get over to filling greater than about 75 percent of our dental positions right now. It has been hovering around that for a couple of years. Senator Murkowski. So as we look into the future, then, with meeting the dental health care needs of our Alaska Natives in our villages, do you see a way that we are going to be able to get enough dentists out there in rural Alaska to meet the need? Mr. Grim. I think it is going to require a long-term concerted effort, but I am always hopeful that we are going to be able to do that. We continue to have moneys in our scholarship and loan repayment programs that we use to try to train new native students, and I think we need to continue to try to be very aggressive at recruiting current Alaska Natives who want to get into dental school and try to encourage them to do that; get them into our scholarship program and hopefully have them go back home and serve their obligations in their communities, and then continue to stay with their tribal programs and serve out their professional career. I do think it is going to be a long-term effort. We are working with all sorts of individuals, as I said, universities and the American Dental Association, among others, to try to jointly work on that issue for the Indian Health Service. Senator Murkowski. You have kind of ducked the specific question of how you feel about the Dental Health Aide Therapist Program. What I am hearing you say is you recognize the need. We have to do something. We must do something and that you are going to be working with us on that. Mr. Grim. Yes; Senator Murkowski. Senator Murkowski. Thank you, Mr. Chairman. Senator Enzi. Thank you. Senator Reed. Senator Reed. Thank you, Mr. Chairman. Thank you, Dr. Grim. Let me follow on with Senator Murkowski's question and broaden it to recruiting other health care professionals. It is not just dentists you have a problem recruiting. Could you lay out the shortcomings for recruiting as you see them today? Mr. Grim. I can give you some specifics on percentages of where we are right now in many of the professions. I can supply that for the record. Really, a lot of what we deal with tracks with what the Nation as a whole is. There is a nursing shortage, and so we are facing difficulty recruiting nurses as well. Pharmacy and dentistry continue to be areas where we have high vacancy rates, too, and it seems to track with some of the needs in the Nation as a whole. So not only are we facing the private sector economy trying to recruit the same types of people. Many times our locations are rural and isolated and so we have the difficulty of that as well on top of it. But we do have, as I said, scholarships and loan repayment programs. We have very active recruitment programs for nursing, medicine, dental, pharmacy, and we are doing the best we can. I know the professions themselves are looking at those issues, too, as they see the numbers of certain types of professions, you know, more people retiring than are graduating and what it is going to mean for the country. Senator Reed. Is there more that we can do to assist you in terms of legislation or appropriations? Is this simply a social problem that is beyond any additional help from us? Mr. Grim. I guess if I knew the answer, we might already be here. Yet we would welcome any help that the committee might be able to provide us. We are still studying the issues, too, and working with the various professional organizations. We have a large group of professional organizations we work with on a regular basis. They are all very, very supportive of our program and try to help us within their own ranks of their professions, but we still face those difficulties. Thank you for your support. Senator Reed. Doctor, Senator Dorgan alluded to the budget shortfalls which your rough estimate is about 40 percent gap between the need and the resources. In high-cost parts of the country like Rhode Island, where we have the Narragansett Tribe, not only is this funding insufficient, but the costs are significantly higher. Is there any attention to these areas? Where there are high costs, housing costs in the area where the tribe has their tribal lands growing at 100 percent, I am not exaggerating, in the last five years. It is incredible. Mr. Grim. I believe you. Senator Reed. It is hard to just maintain the staff. They have not had a raise in 5 years. Is there any attention to these specifically high-cost areas? Mr. Grim. Well, there are some pay adjustments that staff can get for living in higher cost areas, but one of the things that we are trying to do is to recognize it on a formula allocation basis. As I said, whenever we get any new additional program increases, we consult with tribes on how that is distributed across the Nation. As they have joined us in the process and the agency not making those decisions alone, our formulas for distributing money have become more and more complex, but more sensitive to issues like that. We have certain formulas now for types of funds that we give out that a portion of the funds are given out based on the nearest metropolitan area and the costs in that area. So we are trying to take some of that into account now as we allocate funds. We will divide a formula into three parts and maybe one-third is devoted to the costs in an area. So if you live in a higher- cost area, you get more funds in that component of the formula. So we are trying to do that to try to address it within the funds that we have. Senator Reed. Thank you very much, Doctor. Thank you, Mr. Chairman. Senator Enzi. Thank you. I would mention that Senator Inouye could just be here briefly between committee meetings and the vote. He does have a statement to submit and questions that he will want to have submitted, too. And that is open to members of both committees, as well. Senator Coburn. Senator Coburn. Thank you, Senator. Welcome from one Oklahoman to another. Glad to see you again, Dr. Grim. Mr. Grim. Thank you, Senator. Good to see you. Senator Coburn. Would you like to have an irreversible dental procedure done on you by a dental health aide? Would you want your family to have an irreversible dental procedure done by a dental health aide that has a high school graduation and some foreign training? Mr. Grim. I think if I was in a situation where I was in pain with a lack of adequately trained dentists, I would be able to do that. Senator Coburn. That is my whole point. We are going to give less quality because we are not meeting our need. I just came through a campaign and one of the things I was critical of, and I am critical of, is health care to Native Americans, with six times the rate for dialysis for Native Americans, six times the rate, which says we are not doing diabetes right. The question is, the ADA opposes this, but why can't you work out a deal where they have locum tenens up there? If they really do not want this to happen, why won't they volunteer for service up there? Let's work a deal. Let's have them do the right thing. You create an environment where we can have dentists who will volunteer their services for Native Alaskans and solve this problem while we are in a shortfall. I think you will find that they will be agreeable to that. I think that would solve the problem. But this idea of not meeting our obligation, meeting it by name, but not in quality, I think is one of the most critical things we have to do at the Indian Health Service. That is by no means a reflection on the people who work there. You have a burden and you do not have the resources with which to carry out the completion and attack that burden. With your electronic medical record, have you instituted best practices, especially for diabetes? Mr. Grim. Yes, sir; we have. Senator Coburn. And that is being followed? Are you tracking that to see the better outcomes and lower hemoglobin and A(1)(c)s and better compliance? Mr. Grim. Yes, sir; we have. We have seen a downward trend in the hemoglobin A(1)(c)s. We are seeing better blood pressure control; better us of the ACE inhibitors. We have an extensive database of almost our entire diabetic patient population, tracking both clinical indicators. We also with the special diabetes program funds for Indians that Congress made available for us, we have just recently released the report to Congress that shows a huge increase in the number of both primary and secondary prevention programs in Indian Country that were present now, prior to the funds were not available to the population. So we are seeing a very positive trend in the care of diabetes. We have been in the diabetes care business for many years. In fact, the diabetes grant funds, one of the things we did was put together with professional experts in the agency and the American Diabetes Association a series of 11 or 12 best practices that tribes could use in their grants, depending on what were the particular problems in their communities, and suggested ways they might assess which of those they wanted to do. So I think we have done an outstanding job with the use of the funds that Congress given. Tribes deserve a lot of credit for that because the vast majority of those funds went directly to tribes. They have implemented a lot of great programs. Senator Coburn. I would just note that the Congress refused to support recently with an amendment that I offered for additional funding for diabetes prevention. We are going to buy more land, rather than take care of the Native American obligation that we have. It was pretty disappointing to me. I think we got 17 votes in the Senate to fund prevention activities for diabetes, so it might reflect on the Senate where our priorities are. Do you ongoing tracking on prevention across the board within Indian Health Service? Mr. Grim. Yes, sir; we do. We have long been an agency and a health care system that focuses on prevention, not just in the clinic, but also in environmental health arenas as well, and safe water and sanitation facilities, to make huge improvements. Senator Coburn. So can you give me a time at which we are going to see the same type of diabetic control in the Indian population, Native American population, that we see in the rest of the population in this country? Mr. Vanderwagen. Dr. Coburn, I would say right now we are probably leading the Nation in diabetic treatment, not necessarily primary prevention, but in secondary prevention through effective treatment with evidence-based best practices. I would say we have evidence to support the assertion that we are probably leading the country right now. Senator Coburn. So we are going to see a decline in complications, amputations, dialysis? Mr. Vanderwagen. In fact, we have had a 50-percent decline over the last 5 years in amputations. We are the only sub- population where deaths due to ESRD have declined between 2000 and 2002. I think the Senate, the Congress invested well in putting that money into that diabetes effort. Now, can we extend it to heart disease, cancer and other chronic diseases is the real challenge that I think we are facing in Indian country. Senator Coburn. Well, best practices is going to help you do that. This is a great example to help us know how we solve the rest of the health care problem in this country. It is called prevention. It is not treatment after the fact. It is prevention. And you all are to be complimented on the institution of best practices because it is what it is going to take for us to get out of the health care crisis that we are in in this country. My hat is off to you. I just want to see the results coming forward, and then work on the prevention in terms of diet because that is just as important for not only the Native American community, but the entire American community. Mr. Grim. Our three primary focus areas that we have been working with tribes around the country on are health promotion, disease prevention, behavioral health issues, both alcohol, substance abuse and mental health, as well as those behavioral issues with the lifestyle diseases like diabetes and chronic disease management. We are looking at better models with now that we might put in place in many of our programs because we do have a huge burden right now of patients that already have these diseases, but we are focusing on all three of those areas. Again, we are looking at some best practice models in chronic disease management that we will start using in some other disease areas. Senator Coburn. I can ask this later and ask it formally as part of the record, do you have tracking on malpractice claims within the Indian Health Service as relative to outside of the Indian Health Service? Can you give that data to the Committee so that we can look at it? Mr. Grim. Yes, sir; I believe we can. Mr. Vanderwagen. In brief, it is about 100 cases per year that come to torts. That rate really is about 50 percent compared to the private sector. Senator Coburn. Come to trial or that are filed? Mr. Vanderwagen. That are filed and deemed worthy and are carried forward. That has been a pretty steady state for about the last 10 or 15 years, some slight trending up. Most of that is associated with our larger, more complex hospitals, but we would be happy to give you the full picture. Senator Coburn. Thank you very much. Let me just thank you again for your service, and I am proud you are an Oklahoman. Mr. Grim. Thank you. Senator Enzi. Senator Murray. STATEMENT OF HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON Senator Murray. Mr. Chairman, I know that we have a series of votes on and another panel to come before us. I will be very brief. I just want to really thank you and Senator Enzi for having this joint hearing. I hope that this allows the members of our Health Committee to really begin to understand this legislation so we can move it forward. I think we all understand the severe crisis facing our tribal communities today and the responsibility that we have to make sure that we address some of the tremendous disparities that are out there. I am very pleased that my friend Ralph Forquera, who is from the Seattle Indian Health Board, is part of the second panel. I think he is going to provide us with some really excellent information concerning Native Americans who live in urban areas. I am pleased that he is here. I am sorry that we are going to be having votes and I will be missing much of his testimony, but it is very important for our committee to hear that. I think when we hear the statistics about the fact that Native Americans are much more likely to die from specific diseases, 420 percent more likely to die from diabetes, 52 percent more for pneumonia and influenza. It goes on and on. I think we have a responsibility, really, to address that. So Mr. Chairman, I will not ask a question at this time. I will submit them for the record. Dr. Grim, if you could respond because I do know we have a series of votes. I am really pleased that we are having this hearing and allowing our Committee to begin to understand this problem and help move it forward. Thank you very much. Mr. Grim. Thank you for your interest. Senator McCain. Thank you very much, Dr. Grim. You got off easy today. We had a series of vote. [Laughter.] Mr. Grim. Thank you for that, Senator McCain. Senator McCain. Thank you. We would really like to get down to some serious negotiations so we can get this thing done as quickly as possible. That is going to require, and I know some of this is not totally up to you, but some of it going to require some concessions on both sides. We do have another body that has to consider it as well, who we have been in constant communication with, but this is almost an abrogation of our responsibilities when we do not address this much-needed legislation. So thank you, and thank your colleagues for all you do. Our next panel is Rachel Joseph. She is the chairperson of the Lone Pine Paiute Shoshone Reservation in Lone Pine, CA. She is also the cochair of the National Steering Committee for the Reauthorization of the Indian Health Care Improvement Act. Mr. Don Kashevaroff is the president of the Seldovia Village Tribe in Alaska. He is also the president and chairman of the Alaska Native Health Tribal Consortium. We are glad you could travel this long distance to be with us today. I would also like to send a special welcome to Richard Brannan, the chairman of the Northern Arapaho Business Council from Fort Washakie, WY. Thank you very much from Fort Washakie, WY. I thank you for being here today. I have appreciated all the expertise on tribal issues that you have provided to us over the years. I know the committee will appreciate your testimony. I would also like to introduce Ralph Forquera, the executive director of the Seattle Indian Health Board in Seattle, WA. Ms. Joseph, it is nice to see you. Please begin. Ms. Joseph. Thank you, Mr. Chairman. Senator McCain. By the way, my colleagues are voting and they will be coming back and forth. I want to extend my apologies for the interference of our parliamentary procedures. Welcome, Ms. Joseph. STATEMENT OF RACHEL A. JOSEPH, CHAIRPERSON, LONE PINE PAIUTE SHOSHONE RESERVATION Ms. Joseph. Thank you, Mr. Chairman. I am here today to present testimony on behalf of the National Steering Committee for the Reauthorization of the Indian Health Care Improvement Act, the National Indian Health Board and the National Congress of American Indians. Thank you for this joint hearing and providing me the opportunity to testify in support of S. 1057. The message of Indian nations across the country is please reauthorize the Indian Health Care Improvement Act this year. This act enacted in 1976 declared this Nation's policy to elevate the health status of our population to the highest possible level. We believe this should be at parity with the general U.S. population. Nearly 30 years later, we are no where near achieving this goal. However, S. 1057 would facilitate forward movement. Health care reality in Indian country compared to the general population is our people still die due to accidents 204 percent greater than rest of the population; 650 percent more likely to die from tuberculosis, a preventable disease; 318 percent more likely to die from diabetes. The epidemiology center in the Northern Plains has recently reported that the Northern Plains Indians have the highest SIDS rate in the world. The Surgeon General reports that Indian youth are dying at 3.1 times greater than the general population. Our challenges are escalating, and like so many other programs in the country we are seeing employee take-backs, reduced hours of operation, staff reduction and burnout. Resources are limited and our estimates indicate that the Indian health budget has lost over $2.46 billion in purchasing power over the last 14 years. I have testified to this before. Medical inflation has increased over 200 percent since 1984. Unfortunately for the IHS, the OMB inflation rate ranges from 1.9 percent to 4 percent a year, when medical costs inflation is between 6.2 and 18 percent. Like the private sector, we face ever-increasing costs for pharmaceuticals, equipment and other costs. As raised earlier by the Senator, the per capita expenditures for our patients is approximately one-half of the per capita expenditures for Medicaid beneficiaries, and the expenditures for a prisoner's health care is almost double what is spent on a patient in the IHS system. In 1999, a national steering committee for the reauthorization was formed. Consultation was held extensively across the country to develop consensus recommendations to address our current needs. Included among those recommendations was the authorization for a comprehensive behavioral health program which reflects tribal values and emphasizes collaboration among alcohol and substance abuse social services and mental health programs, which was reflected in title VII of S. 1057. I was quite taken aback when I heard Dr. Grim express objection to section 11(2)(b). In fact, that has been a challenge for us in dealing with reauthorization. We have never seen a finite list of what the objections are. But if I might briefly talk about what our intent was when we developed language with 711(2)(b). This is a section dealing with fetal alcohol disorders. We feel strongly that we need to do everything we can to change the behavior of pregnant women, high-risk pregnant women, and women that are pregnant with Indian babies, to encourage them not to indulge in alcohol and substance abuse. That was our intent. We think this is a priority and we think that the program should do this. We are surprised that there is an objection to that provision. Another recommendation is authorizing the elevation of the Assistant Secretary, elevation of the Indian Health Service Director to an Assistant Secretary appointed by the President with the advice and consent of the Senate. The deplorable disparities in our health indicators compared to the general population require us to assert that we need to approach our responsibilities differently. Status quo is not acceptable. We believe that elevation would be comparable to the administration of the BIA programs by an Assistant Secretary in the Department of the Interior and the Assistant Secretary for Public and Indian Housing in the Department of Housing and Urban Development. We also recommend authorizing the Entitlement Commission to study the optimal way that health care should be provided to our people. Indian tribes strongly believe that through the cession of 400 million acres of land to the United States in exchange for promises for health care and other services often reflected in treaties, that we secured a de facto contract which entitles us to health care in perpetuity, based on the moral, legal and historic obligations of the United States. We also believe that we need to be able to address the long-term health care for the elderly as an option, rather than more expensive, costly or clinical care. We believe that these recommendations, many of which are included in S. 1057, are essential to help us modernize our health care delivery. In closing, I want you to know that in spite of our deplorable health conditions, we remain optimistic because our tribal governments and programs are having successes and do so much with so little. We hope for reauthorization this year. We hope that one day our young people no longer commit suicide because they will have hope. We hope that one day we will no longer have to deal with meth problems and other substance abuse in our communities. We hope that our grandchildren will be healthy. We hope that we can provide long-term quality health care to elders in the waning years of their lives. We hope for all these things because we know that the Creator has put us here for a purpose and we need your help. Thank you for this time. [Prepared statement of Ms. Joseph appears in appendix.] Senator Enzi. Thank you. Mr. Kashevaroff? STATEMENT OF DON KASHEVAROFF, PRESIDENT, SELDOVIA VILLAGE TRIBE, AND PRESIDENT, ALASKA NATIVE TRIBAL HEALTH CONSORTIUM Mr. Kashevaroff. Thank you, Mr. Chairman. My name is Don Kashevaroff. I am appearing here as the chair of the Tribal Self-Governance Advisory Committee, which has appointed me to the National Steering Committee for the Indian Health Care Improvement Act. I am from Alaska. I am the president of my very small tribe of 400. I am also the president and chair of the Alaska Native Tribal Health Consortium, which through Anchorage and the Alaska Native Medical Center, we co-manage that and we serve 130,000 Alaska Natives through the hospital and water and sewer projects in various other programs that we have. Both my small tribe and my very large company practice self-determination and self-governance by assessing the health needs of our people and redesigning and expanding our programs to improve the available care. I have a couple of issues that I want to address with you today. The first one is home health care. I also have submitted written testimony. Hopefully, that can be in the record, sir. What we found at ANMC, we have 150 beds. About one-quarter of the beds we have are taken up by folks that might or should not be there. If we were a private sector hospital, they would discharge the people. We continue to serve them because we have no place to send them. Many of them need step-down units and various other care that we do not have in existence. Home health care is in S. 1057, and we are very supportive of that staying in there. What we found out, as I have stated already, Indian Health Service does not have the money we need to provide the services to Indians. What we have been doing over the past few years is relying more and more on third party payers. We bill insurance companies, if the Indian happens to have insurance, we bill the insurance company. Those insurance companies actually say, well, you only can have a stay in the hospital for a couple of days and then we will not pay anymore, because they know that there are cheaper ways of providing health care to people than staying in a hospital bed. So we are kind of stuck with the hospitals and we do not have all the home health care provisions that we are looking for. So we are very supportive of that in the bill that we can expand those services. We have also found out that our elders, the best care we can give our elders are close to home. When we make our elders travel, they come in and they actually encounter a foreign language, they encounter English, and they have to be with us. They have unknown areas that they have to live in. They lose track of their families. They are removed from their family. Many of them just refuse to come in for care. So by having a home health care-based system where we are able to get out there and provide the services to them like the rest of the country has realized, will modernize IHS and bring us up into where we should be, and be able to provide better health care at a lower price. So we are very supportive of the home health care provisions in there, Senator. I would also like to touch on the Federal Tort Claims Act coverage. I noticed in Dr. Grim's written testimony that they thought that there might have been an expansion of FTCA coverage. To the best of my knowledge looking at the Act, there is no change in FTCA services to ineligible non-beneficiaries. The language does not increase any change in it. What we are faced with with Federal tort claims coverage is that we provide a service, and if we do not have Federal tort claims coverage, we have to take money out of our contracts support costs or a direct-service budget to pay for insurance that the government or IHS did not have to pay for before. So when our tribes take over programs, we have to have coverage. If we do not have coverage, we have to pay an insurance provider. The amount is staggering that we have to take out of our direct services budget. In ANTHC alone, if we had to provide insurance for everybody, we would lose about four or five specialty providers. We have very many specialty docs, and we would have to basically let them go and take the money and buy insurance. We do not want to be in a situation where we end up doing that. So I am actually puzzled a bit by Dr. Grim's written testimony that the Administration has these concerns that we are expanding coverage because we just do not see it, and maybe they can tell us later on where they see those concerns at. Real quick, also negotiated rulemaking is in the S. 1057. The Tribal Self-Government Advisory Committee is very supportive of negotiated rulemaking. We have found in the past that when we implemented title V of the ISDEAA that it worked extremely well. They even gave us awards for how well it worked, that we were able to get IHS in the room, and the tribes in the room. The tribes are delivering the health care out there and we are encountering a lot of things that IHS does not have to encounter. We have the understanding of how to provide health care out in the country. By working together, we are both able to understand the rules and put the rules down on paper so we can work better in the future. It has helped tremendously, us both having the same common understanding. I also wanted to mention about the dental health aide therapists. I know we are going to have a panel on that pretty quick. Alaska Native Medical Center, which is managed by the Alaska Native Tribal Health Consortium and by South Central Foundation, we strongly support dental health aide therapists. Without question, that is our answer to our crisis that we are having in Alaska. I grew up in a village that luckily had a dentist come every 6 months from Anchorage. And it was the same dentist, so he knew me, and I got decent care. People are concerned that there will not be good care. Well, these dental health aide therapists are sent out to school on it, and for 2 years they are down getting trained to do what they are going to do. I personally have had times when dentists maybe did not do as good a job on me as I wished they would have, and I had to go in for follow-up care. So I think it really comes down to the individual person whether you are going to get a quality dentist or quality care or not. We have a huge crisis in bush Alaska. If you go to a village of 100 or 200 people, you are not going to have a dentist wanting to live there. Even if you have a volunteer come in once a year, it is not going to provide the services the folks need. I personally would love to have a DHAT work on my teeth, just as I go to a nurse practitioner and a physicians assistant for care. I have no problem doing that. Finally, I wanted to mention that the tribes want to have, fundamentally we want to look at S. 1057 and make sure that it does not regress from anything in current law. There was one instance that we found in section 403, which is the current law section 206, where Indian health programs may only bill third- party payers for reasonable charges as determined by the Secretary. This is a change. Our concern is by making the Secretary figure out what the reasonable charges are is going to increase the bureaucracy extensively, as opposed to current practice where we bill under current practice methods. So I do want to thank you for holding this hearing, Mr. Chairman, and hopefully trying to move this legislation forward. I am here to answer any questions. Thank you. [Prepared statement of Mr. Kashevaroff appears in appendix.] Senator Enzi. Thank you. Chairman Brannan. STATEMENT OF RICHARD BRANNAN, CHAIRMAN, NORTHERN ARAPAHO BUSINESS COUNCIL Mr. Brannan. Good afternoon, Senator Enzi. Thank you for asking me to come and testify. I come from the Wind River Reservation, carrying a very heavy heart because of the suffering, the pain, that children and older people are going through on our reservation. I want to thank you personally for asking me to come here, and giving us a voice. There are many statistics that justify the need for improving health care on the Wind River Reservation and Indian country in general. I have listed a number of them in my written statement and I know you hear them from many others. But what I would like to do is spend my time here today to try to put a face on the problem that we are faced with every day on the reservation. My testimony here today is in honor of Francis Brown, a respected elder and ceremonial leader of the Northern Arapaho Tribe, and Marcella Hope Yellow Bear, a baby, both of whom died needlessly because of lack of funding. Both of them suffered terribly before their untimely deaths. Francis had four brain tumors. He went to IHS for assistance. He was told there was no funding to help him to get the care he needed. He went home, suffered and died. Marcella Hope Yellow Bear was 18 months old when she died. Her entire short life was one of torture and pain. According to the newspaper accounts, she had an open hole through her chin, numerous broken bones, and burns on her body and the bottoms of her feet. She was found hanging from a coat hook in a closet. The police found her that way. Physically abused and tortured, her whole life was nothing but pain. When I did hear, it was like somebody shooting my heart with an arrow, and part of my soul died when I heard that. Both of these could have been prevented. The system and all of us failed them because of lack of adequate funding. For his entire life, Francis Brown was one of the cultural and ceremonial leaders and elders of our tribe. Among his many contributions, he helped preserve the medicine wheel up in the Big Horn National Forest and other sacred sites. His early loss robbed not only his family, but our tribe of his culture and ceremonial knowledge. Marcella was a beautiful and innocent little baby, just so beautiful I cannot describe how pretty she was. She was also the hope of our future. That is our future, our children. In our tribe, we believe children are sacred and we hold onto them because they are not tainted by the world and they are a blessing from God. Yet she was killed by her own parents, both members of our tribe, because of their addiction to methamphetamine. Those drugs and others, including alcohol, are the scourge of our reservation in Indian country. As you can see from these two painful examples, we need funding for both prevention and treatment. I am here today to give my support to S. 1057, but also to remind you of the need to fully fund it and to remind you of the trust responsibilities of the United States to American Indian tribes. Also, the Almighty gave me a vision where I saw this beautiful, wonderful white house with a bright picket fence, immaculately maintained yard, with a swing, a play area full of children. I am sure people have experienced children full of joy, full of happiness, smiling, seen them dressed in their Sunday best on Easter Sunday with their little beautiful socks and dresses and healthy and smiling, and just shrilling with happiness. That is the vision the Almighty gave me of the Northern Arapaho children and our people. I do know that this committee has the ability to make that vision come true for the Arapaho people, and I ask for your help. I thank you for allowing me to testify here today. [Prepared statement of Mr. Brannan appears in appendix.] Senator Enzi. Thank you. Mr. Forquera. STATEMENT OF RALPH FORQUERA, EXECUTIVE DIRECTOR, SEATTLE INDIAN HEALTH BOARD Mr. Forquera. Thank you, Mr. Chairman. My name is Ralph Forquera. I am the executive director for the Seattle Indian Health Board. I am also the director for the Urban Indian Health Institute, which is a division of the Seattle Indian Health Board we created in 2000 to conduct research and perform epidemiologic studies on the health of urban American Indians. I am an enrolled member of the Juaneno Band of California Indians, which is a State-recognized tribe from the San Juan Capistrano region of Southern California. The Seattle Indian Health Board is a private nonprofit community health center established in 1970 as a free clinic in what was then an old U.S. Public Health Service hospital, so we are celebrating our 35th anniversary this year. We are currently under a contract and hold several grants from the Indian Health Service under title V of the Indian Health Care Improvement Act. We are one of 34 such nonprofit Indian- controlled corporations located in 41 cities and 19 States around the country that contract with the Indian Health Service under title V. About 20 of the 34 existing programs provide some level of direct care. The remaining 14 programs provide health education, information, referral assistance and other services designed to improve access to health care. In addition, urban Indian health organizations play an important cultural role in many cities by offering programs and services that are culturally appropriate and socially acceptable to the wide array of Indian people living in cities. For example in Seattle we serve Indian people from over 150 American Indian tribes and Alaska Native villages each year. The role of providing an identifiable and culturally acceptable place in American cities for Indian people is an often overlooked effect of these programs that in many ways has become an essential part of the healing process for Indian people who often feel abandoned and isolated in American cities. According to the 2000 census, the majority of Indian people are now living in American cities. Over 70 percent of Americans who self-identify as American Indian alone or mixed race on the census are living in American cities. The trend toward urbanization has been steady since the 1950's when the policy of this Nation was to relocate Indian into cities in an ill-fated attempt at assimilation. Over 160,000 people were directly affected by the relocation and termination policies. There remains a sizeable number of urban Indians who carry an emotional scar of this experience with them. As a result, that experience greatly influences their behaviors and their ability to trust government institutions, including oftentimes our own. Little is known about the overall health status of urban Indians across the Nation. While the Urban Indian Health Program has been a part of the Indian Health Service for nearly 30 years, only recently have formal efforts to document the health of urban Indians been attempted. The lack of available data has made it difficult for us to defend the need for help in addressing the growing health crisis among urban Indians. However, in March of 2004, the Urban Indian Health Institute released a first report documenting for the public the severe health disparities among urban Indians. Using data from the National Centers for Health Statistics and the 1990 and 2000 U.S. census data, that we know is woefully inadequate for urban areas, the report still found significantly higher rates of illness and identified multiple known risk factors that likely contributed to these findings. The report brought greater attention to the plight of urban Indians and helped us to begin to build interest in looking at the health of this population. The report documented for the first time our anecdotal assertion that urban Indians were experiencing ill-health in disproportionate numbers. Our principal partner in this work to date is the Indian Health Service, which has now included us as one of the 10 Indian Health Service-funded regional tribal epidemiology centers, ours being the only one that focuses specifically on urban Indians and is on a nationwide basis. Title V, the urban Indian health section of the Indian Health Care Improvement Act, provides the critical link in recognizing that Indian country encompasses both reservation and urban communities. The 34 urban Indian health organizations reflect the nature of their local communities. They offer not only services, but a place of Indian identity that is frequently lacking for Indian people in American cities. In the broadest sense of healing, finding a place of belonging and acceptance can have a powerful and positive effect on the health of Indian people. Our ability to focus on Indian people and not be encumbered by the restrictive nature of limiting services to federally recognized tribal members adds to our capacity to heal wounds also. Title V is the only authority that specifically defines the health care role for the Indian Health Service in addressing the needs of urban Indians. For this reason, title V is an essential tool in assuring that urban Indians are not forgotten as a group of Americans in need of health improvement. In the request for my participation in the hearing today, two specific questions were posed to me. The first deals with the extension of Federal tort claims protection for urban Indian programs. The second concerns an issue that periodically has been brought to our attention by the Department of Justice regarding equal protections provisions of the Constitution and the fact that urban Indians are not subject to tribal governments with self-governance authority. With regard to the Federal Tort Claims Act issue, similar protections have been extended to community health centers through the Public Health Services Act. Those of us who receive funding through the Bureau of Primary Health Care are already eligible for FTCA protection. It would seem to me that extending this protection to urban Indian health programs would add minimal risk to the government. Inclusion could save considerable expense for those programs who are now purchasing private liability insurance for support for their work. The resulting savings could be used to provide needed services. It should also be noted that the title V program is truly crafted using the community health centers as a model. So therefore the extension of the privilege of FTCA for another group of federally sponsored safety net providers seems a fair and equitable action. With regard to the Department of Justice's concern about equal protection matters, I first need to state that I am not an attorney nor am I professionally trained in this area. However, it seems to me that the enactment of title V defined a special class of health care provider similar to various arrangements made through other Federal programs like the Federally Qualified Health Center Program under the Bureau of Primary Health Care and disproportionate share hospital payment structure under CMS and others. Clearly, the Federal Government has a rational basis for providing funding, tax breaks and other benefits it deems to be in the interest of the Government or society in general. That rational basis should not allow such distinctions to withstand an equal protections challenge. In the case of urban Indian health programs, the Congress has a clear and rational basis for its decision to provide programs, services and funding to urban Indians. After all, it was the ill-conceived policies of relocation and termination that led to the removal of large numbers of Indian people from reservations to cities. Congress dealt with Indians as a special class of citizens then, and it clearly can and should so do as it tries to rationally address the consequences of those policies. The structure of the title V program, that of using a nonprofit Indian-controlled corporate structure, offers the full benefits of the self-determination principles called for in President Nixon's special message to Congress in July 1970 that forms the foundation for today's Federal Indian policy. Successful urban Indian health organizations in some respects embody the spirit of self-determination. Our use of IHS funds to leverage our other public-private resources to extend our capacity to serve urban Indians is exactly what I believe the authors of title V intended. It is clear that the Congress has the authority and the will to direct programs to address identified and documented health disparities affecting American Indians and Alaska Natives. In these times of rapid change in the health care system in America, and the sharp escalation in the cost of health care, the importance of having organizations devoted to assuring access and quality health care for Indian people makes good public policy. It is fitting, then, that the Congress continue this policy by reauthorizing Title V. Thank you for offering me this opportunity to testify. I would be happy to answer questions. [Prepared statement of Mr. Forquera appears in appendix.] Senator McCain. Thank you very much. Ms. Joseph, what is your response to the Department's view that the Intra-departmental Council consultation and Tribal Technical Advisory Groups are sufficient for Indian policy so that the elevation of the director to an assistant secretary is not necessary? Ms. Joseph. Thank you for the question, Mr. Chairman. The request or the advocacy for the elevation is not a new issue for tribes, for one thing. It has been around long before this effort to reauthorize. We feel the deplorable health conditions of our people warrant us to carry out our responsibilities in a different way, and maybe elevating the issues to a higher level would be a better approach. We know that status quo is not acceptable. We think that it is also consistent with the government-to- government relationship in that it is comparable to the assistant secretary that has oversight of the BIA programs in the Department of the Interior. There is an assistant secretary for Public and Indian Housing in the Department of Housing and Urban Development. We think an agency that has such large responsibilities for Indian people should be at a level where they can collaborate at a higher level in the Department; be a member at the table when priorities and policies are addressed; be a player in the decisions that are made when the Department's priorities are established; and be at a level that ensures that other agencies in the Department are also considering the needs of American Indians and Alaska Natives. Senator McCain. What is your response to the Department's view that we should mandate positions such as the diabetes coordinators within IHS? Ms. Joseph. Mr. Chairman, I thought that was real interesting a request, to require a mandate when earlier in the testimony there was an objection to mandates. In particular, that is related to mandating diabetes coordinators. For the record, I believe all areas have diabetes coordinators. The one we have in California, she is wonderful and we like her and she is doing a lot to inspire us, to prevent and to educate. But the tribal leaders during this discussion weighed this and did discuss it. They said, say for instance in five years we have a major epidemic in our area, and we might want a cardiovascular disease prevention coordinator or a tuberculosis prevention coordinator. With limited resources, the tribes locally may need to move resources and have another priority in five years. That was the wish to have some flexibility for local decisions. Senator McCain. Thank you. Mr. Kashevaroff, how would you respond to the views of the American Dental Association that there is a ``false concern'' that in Alaska that is only a choice between no dental care and some dental care, so that dental health aides are necessary? Mr. Kashevaroff. I believe that anybody that wants to come up to Alaska and go out to the bush, which we call it, will see that there is basically no access to dental care out there. Village folks that live there, if they have a toothache, they have a choice of either waiting six months to a year for a dentist from a regional hub to arrive, or to get on an expensive plane and fly in. That is what we are faced with. We do have some dental care. Dr. Grim mentioned that we have a 50 percent vacancy rate out in the bush in Alaska. That means we only have one-half the dentists. If Washington, DC only had one-half the dentists, you would have a lot of lines around here of people wanting dental care. So it is compounded in the fact that you live in a village and there is no way to access dental care than hop on a plane, which you cannot always do because we get snowed in for weeks at a time sometimes. And you only have one-half the dentists out there in the first place. So we have a very big problem, Mr. Chairman. Senator McCain. You mention in your statement that negotiated rulemaking was used in the self-governance regulations. What benefits have you seen in the implementation of the regulations? What is your response to the Department's concerns that negotiated rulemaking is costly and time- consuming? Were your negotiations costly and time-consuming? Mr. Kashevaroff. Mr. Chairman, I was not privy to the budget of the negotiations. I do not think they are that time- consuming because we actually had a deadline imposed. I know S. 1057 has a longer deadline imposed. But the little bit of time put up front saves a lot of time in the end. By us coming together and working out the issues with the IHS, the tribes and IHS working out the issues, getting on the same foothold, understanding the same things, has saved us immensely right now years later from having tons of lawsuits back and forth because we cannot agree on what we said. When we are both in the same room, we negotiated it out and you had negotiations go where there is give and take, and everybody is satisfied somewhat, and we were able to achieve that. As I said earlier, they gave us some kind of awards because we were so efficient at doing it. I cannot imagine why the Administration is against having negotiated rulemaking after we have been so successful in the past. Senator McCain. As has self-governance. Mr. Kashevaroff. Yes. Senator McCain. Chairman Brannan, in your testimony you state that addiction to methamphetamine and alcohol are epidemic on your reservation. What is currently being done to combat the problem and, in your opinion, will the new comprehensive care behavioral health programs provided in the Act be helpful in any way? Mr. Brannan. Yes, Chairman; they would be. Senator McCain. It is epidemic on your reservation? Mr. Brannan. Yes; it is. Senator McCain. Would you give me a few statistics to describe that situation? Mr. Brannan. I guess throughout Wyoming it is considered epidemic, even in the State of Wyoming. I do not have the specifics. Senator McCain. For example, most of your teenagers? Mr. Brannan. What you see is an underlying culture of people, and we have a number of tribal members coming up and saying, can you please do something for my family member; they are going to die, because all they are doing is ingesting poison into their system. There is no place for us to send them. There is no treatment dollars available for methamphetamine whatsoever. Alcohol is a significant problem, but methamphetamine is 50 times worse. Probably their life expectancy is less than 5 years once they take it for the first time. Typically, they are addicted for life once they do it, just the first time. There is a significant backlog of patients that need alcohol treatment alone. In some instances, it takes them 6 months to 9 months just to go to treatment. With an alcoholic, if they finally identify or I guess understand that they do have a problem, they confess it, you need to get them to treatment as soon as possible. It is a constant theme. People are dying from cirrhosis. Senator McCain. You have a lot of dental problems, I would think. Mr. Brannan. Oh, yes. Senator McCain. Because of methamphetamines. Mr. Brannan. Yes, yes. Even without the methamphetamines, we can only serve 25 percent of our actual need. Our service unit is funded at 51 percent of the level of need funding. Our denial rate is about three times more than what they approve under a contract health service budget. We are sending people home that have cancer, saying there is no money for chemotherapy, therefore you have to die. That is the reality of it. Senator McCain. Then you must have a problem with teen suicide as well. Mr. Brannan. Yes; we did in the 1980's, there were over 20- some young people that killed themselves, one right after another. It is consistent. Senator McCain. Is that associated quite often with the use of meth? Mr. Brannan. No; it is mainly associated with the lack of hope on the reservation, lack of opportunity. What we are doing right now is we are trying to develop a boys and girls club to give them some type of outlet. But the main thing is prevention on the reservation. Right now, the lack of funding within IHS is so significant we cannot even do prevention. We have to wait until somebody is sick or almost dying because the funding is so inadequate. What we need is preventive health dollars. We can work with our children. We can get them to exercise. We can get them to have a vision for their future, hope. But right now, we do not have that resource available. Senator McCain. Mr. Forquera, is your clinic the only urban clinic doing epidemiologic studies on urban Indians? Mr. Forquera. It is currently, Senator. We actually established the Urban Indian Health Institute out of frustration on my part. Nobody was doing work to directly address the issue of urban Indians. Shortly after we established the organization, Dr. Trujillo, who was then the director of the Indian Health Service, who had had some experience working in the urban Indian community, helped to find some resources to help us set up the epidemiology side of the research element of the program. We have been struggling since we have had no directed resource in order to be able to track the health of urban Indians, and the fact that a lot of our data has to come from local municipalities or from other institutions that sometimes do and sometimes do not collect information that is Indian- specific. We have been having to go and develop those databases in order to be able to do the work that we are doing. We are in the process of doing that now, and I think are making progress, but we are also finding tremendous obstacles because of resource and other problems. Senator McCain. Many of your patients are in Seattle due to the policies of relocation and termination. Do you maintain contacts with the tribes in which these individuals may be members? Mr. Forquera. A large number of our clients are in fact enrolled members of their tribes. We also see a number of Indian people who are members of terminated tribes. We see a few Canadian Indians who come down. And then we are also identifying an awful lot of Indians who were adoptees or children of adoptees or people that had been displaced from their nativeness not only in the 1950's, but prior to that. One of the great advantages of the work that we do and one of the fun things that we do is helping people re-link themselves up to their nativeness. It is amazing the power of that experience for the individual and how good that makes us as an institution feel that we can help people reconnect with their roots and help them. They then become great supporters of the organization. They get services from us. They help the community by using their skills as part of the community. It is a wonderful thing. Senator McCain. Chairman Brannan, where is the nearest city or metropolitan area to your tribal lands? Mr. Brannan. Mr. Chairman, we have two cities. One is Lander, WY. That is approximately 24 miles from Fort Washakie. The other town is called Riverton, WY. Senator McCain. Are there problems with drugs and teen suicide in those non-Indian areas? Mr. Brannan. It is not as prevalent, but the meth problem is throughout the State, especially within Fremont County where the reservation is located. Senator McCain. Are there meth labs on your reservation? Mr. Brannan. Well, a lot of it I believe is foreigners from old Mexico. They did have a drug bust, and I think they had 250 pounds of methamphetamine. Senator McCain. That is a lot of doses. Mr. Brannan. Yes; it is. Senator McCain. Well, it is a national problem, as you know, but it also seems to be most concentrated in lower-income areas, and naturally that means Indian country. At least we would see some benefits from passage of this act, wouldn't you think? Mr. Brannan. Yes; it would help us significantly. Senator McCain. I thank the witnesses. I thank you for your patience today. I apologize for this back and forth shuttle as we try to finish up our voting on the Department of Homeland Security. I can tell you at least we passed on amendment yesterday that directs funding directly to the Indian tribes, so it does not have to go through the State and local authorities. So a small benefit. Thank you for all you do. Thank you for your good work. We look forward to seeing you again. This panel is adjourned. Now, our last panel is Mary Williard, DDS, deputy director of the Yukon Kuskokwim Health Corporation in Bethel, AK; and Robert M. Brandjord, DDS, who is the president-elect of the American Dental Association in Washington, DC. Dr. Williard, welcome. Maybe out of pure curiosity, where is Bethel, AK located, in relation to, say, Anchorage? Ms. Williard. We are about 450 air miles west of Anchorage. Senator McCain. And the population is? Ms. Williard. In Bethel itself, about 6,000 to 7,000, depending on the time of year. Senator McCain. What is it in January? [Laughter.] Ms. Williard. Probably around 6,000. Senator McCain. And in August? Ms. Williard. More like 7,000. Senator McCain. Some come to the great State of Arizona in the wintertime, and we are always glad to have them. I thank the Chairman. Dr. Williard, who is that with you? Ms. Williard. This is my daughter. Her name is Suskwok or Shauna Williard. Senator McCain. You are welcome to be here. Do you have written testimony? [Laughter.] Thank you. She is welcome here, Dr. Williard. Ms. Williard. Thank you. STATEMENT OF MARY WILLIARD, DDS, YUKON KUSKOKWIM HEALTH CORPORATION DENTAL CLINIC Ms. Williard. Mr. Chairman and members of the committee, as you know, my name is Dr. Mary Williard. I have been practicing public health dentistry for my entire career. About 9 years of that has been in the Public Health Service through the IHS. I completed a 2-year dental residency in general practice at a hospital in North Carolina. I have practiced both in the Navajo area as well as in the Bethel, AK area. I have been in Alaska for 7 years working for the Yukon Kuskokwim Health Corporation [YKHC]. I have also chaired the Academic Review Committee for the Dental Health Aide Program since its inception. On behalf of the Alaska Native Health Board and YKHC, I would like to say it is an honor to be here and have the opportunity to testify, and to bring my daughter to see how this great country runs. I really think this is a very important hearing for the future of the people in my area and especially for the children. I learned this morning that the ADA has started a campaign in our village newspapers that states that we are providing substandard care, second-tier of care to our village people through the Dental Health Air Program, specifically dental therapists; that we are experimenting on the people of the villages. I am here to say very strongly and clearly that that is not true. I personally have a vested interest to make sure that that is not happening. I believe that what we are doing is a good thing and it has been well thought out. I know that the tribes and the people in the area are supportive of us. I am a little nervous so I might stutter a little. Anyway, one of the things that I have done as part of my role in the Dental Health Aide Program is help to develop the dental standards that dictate how we work with the dental health aides and specifically the dental therapists, and how they become certified to provide the care that they are allowed to do. The quality assessments that are being one on our dental therapists are taken directly from the Indian Health Service for dentists. We are not allowing them to provide a second-tier or a substandard quality of care. They are expected to provide the services that they provide at the same level of quality. These candidates have been hand-selected from large numbers of applicants. They are very responsible, respectable members of the community. I feel like we have gotten some really wonderful people into our programs. Part of my job at YKHC is to supervise the dental therapists that we have there. We do have two dental therapists who have completed the 2-year training in New Zealand to receive their diploma of dental therapy. These two young people are Alaska Natives and have been in our clinic for about 6 years now providing services. I have looked at every aspect of their service and their skills. I have found them to be quite skilled at what they are doing. They learned well during their schooling. They have taught our dentist, actually, some new materials and information that they learned in school. One of the other things that I do during my time in YKHC is I have observed the new dentists coming in from dental school. I have to work with them and bring them up to par with the other dentist on our staff. What I can say is comparing dental school graduates with our dental therapists is that I have seen that the skills are equal. Hearing Dr. Grim say, sort of hesitate whether he would let a dental therapist work on his own teeth or his own children, I am not surprised. Most dentists are very picky about where they go. I do not know that I would Dr. Grim work on my teeth. I have never seen what he can do. [Laughter.] But I can tell you that my children and I have been treated by the therapists, and I have no problem with that because I have seen what they can do and I believe that they are very well trained. They provide a good service. I look forward to allowing them to go out to the villages once they are certified and working in a general supervision capacity with the dentist in Bethel. One of the things that I really think is important about this is that we will have very competent dental providers in the villages with the people on a daily basis, so that not only will the people out there be able to see a dentist maybe once a year, but they will actually be able to see one when they need one, a dental provider. They will be able to see the therapist at the school, at the basketball games, mostly, in the villages, and be able to talk to them in the grocery store and say, you know, gee, I know you told me I need to brush my teeth all the time, but what can I do when I cannot afford a toothbrush? And maybe when they are deciding what to purchase at the store, they can, you know, what were you saying about the diet soda compared to the regular soda? Those kind of things are really important when you are talking about trying to change a community's habits about oral health. Daily presence is a much more effective way of changing habits in a population than the itinerant-type approach that has been utilized in the past. So I think that is a very strong aspect of our program. I do not think volunteer programs will work. I am not saying that I do not want to see volunteers come. Please come. Please do as much volunteer work as you can. I think that would be great. I do think that they do not provide the continuity of care that will address the issues that we need and to help build a strong prevention program. The drill-and-fill model is still the old volunteer model as well. When you come in and you see patients, you drill and fill and you just get back out, and you have not made that connection with the patient. It just has not worked. One of the things that I have seen as well is that village residents have long, 30 years there have been community health aides in the villages. And when a doctor comes out to the village and talks to the patients and tells them what they know, the patients will listen, but when the doctor leaves the room, the patient turns around and asks the community health aide, you know, is that right? What can you tell me? So the trust is there when the people are there in the communities. One of the things about the Dental Health Aide Program is that the main focus is that we are looking at prevention. However, the dental health aide therapists are going to be there to help us deal with the problems that are already existing. You have already heard there is a very large problem with dental decay in our areas, unmet needs. Even if Dr. Grim was able to recruit dentists to our area to fill all the available positions, that is not going to meet our dental needs. A study in 1991 was done in Alaska that showed that even if the number of dentists in Alaska was doubled at that time, it would still take 10 years to meet the needs. So recruiting dentists to fill positions is not the only answer. We need all the help we can get. That does not mean we are looking for substandard care. That means we are looking for good quality care and we have come up with a method to do that. The dental health aides or dental therapists have been working in a number of countries for years and have a very good track record. In Canada, over 30 years of practicing; in Saskatchewan, being regulated by the dental profession, there has never been any merited claim against a dental therapist, and they provide the same level of services and more than we will allow under our Dental Health Aide Program. So in closing, well, one other thing I would like to say is that we do thank Dr. Grim for his letter of support of our program, and we will have that in our written testimony. We also have e-mails of written support from the South Central Foundation in Anchorage that states that they strongly endorse the Alaska Dental Health Aide Therapy Program. What I would like to ask you all, Mr. Chairman and the members of these committees is to please listen to the people that live and work in these communities and refuse to take away our federally recognized right to manage our own health care. Please support S. 1057 of the Indian Health Care Improvement Act, and do not limit the scope of practice of the dental health aides. Thank you. I am open to questions. [Prepared statement of Dr. Williard appears in appendix.] Senator Enzi. Thank you. Dr. Brandjord. STATEMENT OF ROBERT BRANDJORD, DDS, PRESIDENT-ELECT, AMERICAN DENTAL ASSOCIATION Mr. Brandjord. Thank you, Mr. Chairman and members of the committee. I am Bob Brandjord. I am president-elect of the American Dental Association and a practicing oral surgeon in Minnesota. I am here to express the American Dental Association's strong support for using dental health aides and other innovations in dental care delivery to help reduce the disproportionate burden of dental disease that many Alaska Natives suffer from today. Equally important, I must state the American Dental Association's unequivocal opposition to experimenting on Alaska Natives by allowing non-dentists to perform irreversible dental surgical procedures. This is second-class care. It is unsafe. It is unfair. And most of all, it is unneeded. It is an admission that those who have been entrusted with the care of these people have essentially given up on them. Instead of really focusing on preventing disease, the solution is to extract it. Alaska Natives deserve better. They deserve high- quality, fully trained, licensed dentists to provide the care. They can receive that care if we can break down the bureaucratic obstacles that are preventing it. Decades ago, Alaska Natives were almost entirely free of dental decay, but the trend has reversed. Many Alaska Natives now suffer from often severe untreated dental disease. Deterioration is due partially to the transition from the traditional subsistence diet to processed sugary foods and beverages; partly to the lack of oral health education and proper self-care; and partly to inadequate access to appropriate dental care. Alarmed at the declining oral health of its constituents, the Alaska Native Tribal Health Consortium has resorted to the desperate measure of deploying dental therapists to extract teeth, drill out cavities, and do pulpotomies, which are like a root canal. With only 18 to 24 months of post-high school training, these well-intended, hard-working people do not know what they do not know. They are not prepared to routinely perform these procedures safely. Dentists perform thousands of procedures every day with such expertise that the public views them as routine or simple. But there is no simple surgical procedure. I know this. I spend a great deal of every working day removing teeth. For example, extracting a tooth can lead to serious and in some cases life-threatening complications. It can lead to chronic and acute infection, injury to adjacent teeth, gums, and bone, including fractured or broken jaws, displacement of teeth, parts of teeth, or foreign objects into the airway, gastrointestinal tract, and sinuses; even severe life- threatening breathing or airway problems. Proponents of the dental therapist plan argue that there are only two choices: Second-class care or no care. This is not true. Our written testimony includes an alternative model that builds on the current dental delivery system by making it more efficient. The authors include the dental director of the Alaska Native Medical Center in Anchorage. Central to this plan is the creation of the new mid-level aide called a community oral health provider. They can be trained in Alaska and not in New Zealand. These community-based dental aides could provide the patient education and preventive services that ultimately are the best and perhaps the only way to end the epidemic of dental disease that plagues Alaska Natives. Despite our attempts to help, we have continually run into a bureaucratic brick wall of opposition by those who, by their own admission, are so vested in the therapist position that they will not consider any alternative. Mr. Chairman, the public health agencies who took responsibility for providing care for Alaska Natives have been unable to meet their own goals. Dentistry did not create this situation, but we are willing to help remedy it. But therapists are a big step in the wrong direction. Rather, we need a dental health aide to provide education, prevention and appropriate services in every village. We need a more efficient system to provide the needed care safely and effectively. We need less redtape. We urge the Senate to adopt the language offered on the House side by Chairman Young which supports dental aides, but precludes the use of therapists to perform irreversible dental surgical procedures. I want to thank you for your time and attention, and I would be happy to answer any questions. [Prepared statement of Dr. Brandjord appears in appendix.] Senator Enzi. Thank you. I thank both of the people who testified. The one who is probably the leading expert among Senators among this would be Senator Murkowski from Alaska. I will defer to her for questions. Senator Murkowski. Thank you, Mr. Chairman. I appreciate the opportunity to lead off with the questions. I unfortunately will have to be excusing myself after this because I have to get over to the energy conference, so I am splitting my time. I do not know. I am not the resident Senate expert because I spend a lot of time in the dental chair, but I do spend a lot of time traveling around my State and do know that in terms of health care issues and the area where we are so lacking is in dental health care. Dr. Williard, I appreciate your bringing your daughter here. As a mom with kids that are spending a lot of time in the dental chair nowadays, it is at this age where we are able to make a difference with our kids. Unfortunately, our Native children out in the villages are the ones that are suffering most. They are suffering because of the change in diet, as you have indicated Dr. Brandjord, and because of other changes as we are evolving as a new State, as a society that is moving from a subsistence lifestyle to a cash economy. It is hurting out kids' teeth. As a consequence, it is hurting us as adult. It is putting a stress and a strain on the whole health care system. What is the answer? The answers are very, very difficult. I, for one, I have a real hardship when people say that we are experimenting on Alaska Natives by providing them with something. We are not experimenting. We are trying to do something to take that first step to give the care that is so necessary and is so needed. I appreciate your testimony, Dr. Williard. I could tell that it was coming from the heart and very unscripted. You are living there. You are talking with the people and you know that when you have a doctor come to town who just blasts in and blasts out, the information that was left with you while you were sitting in that dentist chair goes out the window with that dentist. I know because I was raised in a tiny community where the doctor came to town every other week. It was good news for my family that my mother was not pregnant that year because she did not have to worry about whether or not she was going to deliver the baby by herself or whether the doctor was going to be in town. So we know what happens when we do not have that continuity of care. There are lapse. There are gaps. So we have to do something. We have to do something. The program that we are talking about here today is novel. It is new and as a consequence it is raising concerns. I guess I would like to primarily direct my questions to you, Dr. Brandjord. When the first class of dental health aide therapists graduated from the University of Otago in New Zealand, the Associate Dean Tom Kardos, who himself is a dentist, said the following. He said: The dental therapist will be able to provide oral health care, including undertaking procedures such as fillings and extractions, along with educating their communities in good oral health care and habits in accordance with the course they have taken. He has been obviously an advocate for the program. He believes that the dental health aide therapists can safely do the work for which they have trained. So I guess my question to you is, what kind of reach-out or conversation or dialogue has the American Dental Association had? Have you sent any kind of a delegation to New Zealand to meet with Dr. Kardos, with his colleagues, to observe the level of training that goes on; to attempt to work out some of the differences that you have indicated that we have with this program? Mr. Brandjord. Thank you, Senator. No, we have not sent anybody to New Zealand, but last year we sent six volunteers from our government affairs committee up to Alaska to work in the villages. They went through their normal credentialing process which was somehow expedited thanks to Indian Health Service. They worked side by side with Indian Health Service dentists. They were extremely productive and they worked with Alaska Native dental assistants and dental health aides that were there. Those dental health aides and dental assistants helped them with the cultural sensitivity and with continuity of care issues that are brought up. Even in the Indian Health Service, there is a problem with continuity of care with the low number of dentists and the rapid turnover. So the dependence on continuity of care comes exactly from the dental health aides and dental assistants in the area. Dental health aide therapists doing the procedures are not the answer. When we looked at the different things, the level of care that had to be provided, it was very extensive care. If we could look at the screen up there, you can see one of the patients that was treated by one of our volunteers. That is not simple work. That is something that is more complex. If we are going to take care of these individuals, we need fully trained, licensed dentists to provide that level of care. So that is what we are talking about. We agree almost completely with everything Dr. Williard was talking about in regards to prevention. Absolutely, prevention is the foundation of all health care. We know that. Dentistry has done a good job with prevention. We have to do a good job in Alaska, and that is why we believe that there should be dental health aides in every Alaskan village to help provide dental preventive services, doing services such as providing fluorides, sealants, cleanings, and also placing temporary restorations. So we really think that is a very valuable resource and we agree on all of those things. In fact, when you look at our proposal, that is exactly what it is about. Then we add the community oral health care provider who coordinates all these efforts among a number of villages and a population base so that when the dentist comes to that community, villagers will have continuity of care through the dental health aide that is there, and dentists can be more efficient by providing care that is a broad spectrum of care at that time. In fact our program, when you look at it, uses the Anchorage Hospital model, and with this efficient system to provide the care, their productivity increased many-fold. In fact, in the last year of implementation, their production increased over 100 percent, and over a 3-year period of time, over 300 percent. So we believe that there are four things that we have to do. First of all, we have to fill up our quotas of Indian Health Care dentists. The American Dental Association has been to Congress and we have supported increasing the loan forgiveness payments, which seems to be a big advantage for getting students out of dental school going into the Indian Health Service. In fact, when we met Dr. Grim and one of his assistants, Chris Halliday from Indian Health Service, he said he believed if he had loan forgiveness for every slot in the Indian Health Service for dental positions, he could fill them. So he would need the funding for that. That is one thing that we want to do. Second is prevention. I talked about that. Prevention is the foundation for dental care. Third, are the volunteers. We want to get the volunteers back up into Alaska. Senator Murkowski. How do we get them there? We have the greatest State on Earth and we cannot get professionals to come out to our villages. We might get them to come out and give us 1 week or 2 weeks on either side of a fishing trip, but we need care and the care is not just when the fish are running. We have to figure out a way. Mr. Brandjord. It is interesting you say that because our volunteers went up there in the dead of winter. They were not there during fishing season. They understand they are not going up there on a vacation. They are going to work. We are putting together, and are now in the process right now of hiring a full-time individual at the American Dental Association to work with finding volunteers and setting up the coordination of getting these volunteers into Indian villages and into Alaskan villages. We are trying to get the care where it is needed. In fact, when we were putting this together, it is interesting that we talked to other different health care providers who have volunteer programs. The great State of Alaska is a little different than some other States because when we talked to the American College of Obstetricians and Gynecologists, they have a volunteer program and their members sign up to participate in these programs to go out specifically through the Indian Health Service. They have given up on going to Alaska because of the credentialing problems. They are different than anyplace else. So one thing that this Committee could do is to bring about a central certification process that could be used for volunteers to go into these areas to help. Our volunteers that went, it has been a year and a half now, those that went then have to reapply and get recredentialed now. If they went to one village for one week and another village for another week, they would have to be recredentialed. That is inappropriate. Senator Murkowski. It is. Mr. Brandjord. When we talked to the Joint Commission on Accreditation, of Healthcare Organizations those people say we could work with a much simpler form where there would be temporary privileges less paperwork. Senator Murkowski. We want to work with you on that credentialing. Mr. Brandjord. We would love to work with you. Senator Murkowski. From what I understand, we have extended that offer to kind of work through some of these issues on the credentialing. To the best of my knowledge, you have not taken us up on the offer, so we would hope that we would be able to. That seems like one that we ought to be able to figure through. Mr. Brandjord. I would totally agree with you. It is interesting that I have a letter here from a dentist in Alaska. If I may read it, it is very short. It is dated May 25: On or about February 11 of this year, I submitted an application to participate in dental project backlog. During the first week of April of this year, I was fingerprinted as part of the application process. It is now almost June. I understand there are building transition issues on your part, but what is the status and fate of my efforts to help alleviate the access issues in the villages? So yes, we have made that effort, but we are not getting a response on the other side. I do not know how we do that. But if there is some way to aid us, and when we went out there, we did not just go out on our own. We went with the Indian Health Service dentists and we worked with them. We believe that that is not a solution that is going to last forever, but if we can get them over this backlog of dental disease, we believe we can make a difference. Senator Murkowski. How many dentists do you think you are going to be able to or would have to recruit to be able to assist in this effort, full-time dentists? Mr. Brandjord. For full-time dentists, I do not know. That would have to be through the Indian Health Service. I am not sure. But last year at our House of Delegates, which has 360 members, on 1 day, we handed out a paper, just asking how many would volunteer for a minimum of 2 weeks to go to Alaska. We had 140 volunteers. Senator Murkowski. Well, I am not meaning to be the negative nabob here, but one of our big problems is that most of these villages, there is no hotel. There is no bed and breakfast. You are there and you might sleep at the home of the community health practitioner or maybe in the gym. It makes it tough on people. So we have some issues that just make this tough. We need to know that we have a realistic timeframe that we are dealing with, and that we are dealing with enough numbers that we can actually make a difference. We need to get through this backlog, but we recognize that kids are born every day, and they are going to have the next generation of dental problems. So this is not just something that we can get on top of the wave now and be clear with. Mr. Chairman, I am going to have to submit the rest of my questions for the record. I really apologize because this is extremely important. I think you can tell that I want to do something. I hear that you want to do something. We certainly know that from the Alaska perspective, those professionals who are giving so much every day want to make something work. I do not want to get in a situation where I feel it is the Dental Association saying this is our turf and nobody else can come onto it. This is not about turf. This should be about the health and well-being of Alaska Native people. If we can put together a program that provides for continuity of care, that is good and safe and works, we have the benefits of telemedicine where you can be talking to your real-live doctor in Boston and working on a procedure. We have made incredible advancements in the State with telemedicine. I would like to think that we can work through some of these issues so that we do not have dentists saying there is no other way except for us to come up, and as Alaskans knowing that Shauna here is going to be able to see a dentist two weeks out of every year, and hope that her toothache is during that 2-week time period. So work with us. Mr. Brandjord. We will work with you. We realize the epidemic of dental disease that is there. We want to do nothing more than help to resolve that issue. But to resolve that issue, to keep doing fillings and extractions will not resolve it. What will resolve it is to have good preventive care. We can accomplish that with the dental health aides. In regards to your statement about the facilities and the bed and breakfasts up there, yes, the bed and breakfast for every one of our volunteers up there was bringing their own sleeping bag and sleeping on the floor of the clinic. So yes, we are familiar with that, but they are still willing to go back. They are that dedicated. I think that is something that is hard for people to perceive. I thank you for your concern. Senator Murkowski. It is also hard for them to give more than 2 weeks, and that is one of our biggest problems. That dedication, that passion is there and they will come up and they will give, and it is extremely generous. We do not want to denigrate that generosity, but there is a recognition that there are 50 other weeks of the year that are without any kind of care. So we will work on filling those gaps. Mr. Chairman, thank you very much. Senator Enzi. Thank you. Senator Isakson. Senator Isakson. Thank you, Mr. Chairman. Yesterday, I had one of those irreversible dental procedures known as a root canal, so I am having a tough time talking about this subject. [Laughter.] Senator Isakson. I am honored to be here and appreciate both your testimonies. I am sorry I was late for the other panels. Dr. Williard, you are a dentist and I take it you oversee a regional plan. Do you manage the dental health aides? Ms. Williard. Yes; I do. Senator Isakson. I do not want to cut you off, but I want to get to the end question. Ms. Williard. Okay. Senator Isakson. And that is a full-time program for the Native Alaskans. Ms. Williard. Yes. Senator Isakson. How many dentists and how many dental health aides are in that program? Ms. Williard. We have nine dentists in the Bethel area. We have two dental therapists, and we have nine primary dental health aides. Senator Isakson. Okay. Here is my question, and I did not get a chance to read. I take it this S. 1057 has a scope of practice component to it. What new scope of practice are these therapists or aides going to be allowed to do under this bill that they cannot do now? Dr. Williard. There is no new scope of practice that they would be able to do under S. 1057. What the American Dental Association would like to see done is to have this bill modified so that it takes away the rights that we have to practice as we are doing right now. Senator Isakson. Okay. Now, Dr. Brandjord just referred to the program they had recommended. They have suggested a program which I take it drew the line on scope of practice for the therapist and the aides. Is that correct? Dr. Williard. Yes. Senator Isakson. You said you have nine dentists there in your program now? Ms. Williard. Yes. Senator Isakson. Then that is not enough dentists to do the irreversible dental procedures? Ms. Williard. We have 15 dental positions in our area, so we have 6 that are vacant right now. As I have said before, filling those vacancies does not actually provide enough treatment ability to meet the needs. So even if we were to get 100 percent filling of those positions, it still would not meet the needs that are out there. That would just meet the criteria that have been set by what is able to be funded by the IHS and by our corporation. Senator Isakson. One of the issues that comes up in many health professions in scope of practice is a shortage of trained people being the justification to allow a scope of practice possibly beyond the training of others. Are we in that position in Alaska now where we in effect have people who are trying to do the best they can, but are not sufficiently trained to do, say, root canals, which I think take a lot of training after yesterday's experience? I hope so. Dr. Williard. You are talking about the dental therapists not having the training to do that? Senator Isakson. Yes. I am saying, in Alaska are we having to resort to asking people, with the best of intention, to do procedures they are not trained for? Ms. Williard. No; we are not asking them to do procedures they are not trained for. The dental therapists that we have sent to training and are training further in our own facilities have a specific scope of practice which limits what they can do in a patient care setting. That limit will keep them in a practice setting that utilizes only what their skills are. If a patient's care needs get beyond the limits that a dental therapist has been trained to provide, then they are trained to recognize those limits and refer to a dentist. The picture that you saw earlier from the ADA, definitely I agree with them. That is beyond the scope of practice of a dental therapist. That patient would be referred to the hub clinics for treatment. But fortunately, that is not the only kind of patient we see. We do have a lot of patients that need a little less than that severe care, and can be seen by the therapists and the procedures that they are capable and competent of performing. Senator Isakson. Okay. Dr. Williard, in the proposal that the ADA made, what is it that you do not like about their proposal? Ms. Williard. They have excluded the use of the therapists. Senator Isakson. Totally? Or just for these irreversible procedures? Ms. Williard. The therapists are distinguished by the fact that they can do irreversible procedures. What their suggestion would do for a therapist is strip them of their ability to provide those services. They would become basically a primary dental health aide, which is a health aide that we already have and who we can train for about a month in Bethel to provide the preventive services and the fluoride treatments that they are providing already. So basically, it would be the equivalent of tying a dentist's hand or arm behind their back and asking them to treat a patient. That is what their proposal would do. We do not say that their proposal is not okay, for lack of a better word. I think it is a good proposal in some settings. I think it would be fine to do that Community Oral Health Practitioner Program in parallel with the Dental Health Aide Program. Anything that people are willing to do to try and help provide more services to our area is a good thing as long as it is well thought out and supported with data. What I do not agree with is that the American Dental Association is not willing to allow that to happen at the same time as our Dental Health Aide Program is running. They want us to drop the program and then pick up this other program. That will not work. We have seen and looked at all of the studies that show that the dental therapist is a safe, quality provider. You can look at Gordon Trueblood from Canada who has done extensive studies on the quality of care provided by a dental therapist. In those studies, he has shown that the quality is equal, if not better, than a dentist in the procedures that a therapist is allowed to perform. A therapist does not do a whole scope of dental procedures that a dentist would do. Their training is very heavily geared towards teaching them what their limits are. This is very different from what you might learn in dental school, where you are taught all eight different specialties in the dental field. Nobody tells you that you cannot do something. Senator Isakson. Mr. Chairman, could I have the liberty of asking two more questions? Senator Enzi. Certainly. Senator Isakson. I know I have gone beyond my time. I have said this before, and am not taking sides here even though it is going to sound like I am. The dental profession, of all the health professions, seems to me to have done a remarkable job of lessening the volume of work because of what they did in preventive health care, fluoridation of the water, and good health practices. You, Doctor, and the association are to be credited for that. It sounds to me like the exacerbation of the problem in Alaska over the last 10 years is a whole absence of that, or at least a significant one. Otherwise, it may be the change in eating habits, you referred to people fluoridating and things like that. If it has been done once in the continental United States, understanding there is a world of difference in Atlanta, Georgia and Alaska, and where Native villages might be. I know accessibility is a problem and everything else. I guess I ought to ask the Doctor a question for a minute, because I have been directing everything to you. Is your proposal designed with that goal in mind? If it is, can the number of trained professionals be available to meet the demand that exists today, and even would exist if there were some lessening of those problems? Mr. Brandjord. Thank you for your question. First of all, with the proposal that has been made, using the community oral health provider, that particular program, and it has been looked at by these three people in education and then one who is the director up at the Anchorage dental facility, they estimate that using that particular program, 85 percent of the individuals within that village could be seen and taken care of in any year. Now, that is in the paper that has been submitted along with our written testimony. One other thing in regard to your comments about the scope of practice of individuals, part of the issue is that the expanded function dental assistants can help do some of the reversible procedures and that is why they become more efficient. They will have one dentist per three or four auxiliaries in the Anchorage facility working in up to three chairs at one time so that they can be more efficient and produce more care, and then deliver also more preventive services. So yes, there is an expanded scope that is there that can be done, and yes they can reach more people. If I can just add one thing. You mentioned fluoridation. There are fluoridation units in the villages, but they are not activated right now. Some of it is the CDC's requirements for maintenance. From our understanding now, we have some new technology that CDC has and that has been implemented in the tribal villages in South Dakota where they have remote control of the fluoridation of the water system that can work. Senator Isakson. Well, I have abused my time. CDC is in my home State and if you all have any problem with them, you let me know because you need all the help you can get out there. Your daughter is beautiful, Dr. Williard. Ms. Williard. Thank you. Senator Isakson. Thank you for the time, Mr. Chairman. Senator Enzi. Thank you. Ms. Williard. Could I make one comment about the program, the community oral health aide program? Senator Enzi. Certainly. Ms. Williard. Thank you, sir. The program, it was written by a panel of people who did include one of the chiefs from the Anchorage area, Tom Kovalesky. In teleconferences and meetings with the authors of that proposal, and the dental chiefs of Alaska throughout the State, Dr. Kovalesky and the other officers did concede that this proposal was probably not as effective in the rural areas and that it would be more effective in an urban setting. The situation that we find in our individual villages, having to fly in by airplane and being spread out with such small populations in some of these communities, the models that are used in that program do not apply. That is something that the dental directors outside of Anchorage unanimously agree with. Senator Enzi. Thank you. I want to thank both of you and all of the other people that have testified. I apologize for the interruptions. We are still doing votes. Senator McCain and I have been shifting off and on here so that we would have somebody chairing and could continue to gather the information. All of this, of course, builds some testimony that will be used in furthering the legislation, correcting the legislation, drafting additional legislation. There will be more statements submitted by other members of both committees, and questions that I hope all panelists will take time to answer. You will not all receive questions because we will be searching for things that are in your area of expertise or clarifications on what you said in your statement or things that you may have said today. Also, members of the panel, if you have some comments in regard to other questions that were not asked, or if you want to expand on the comments that were made, you are perfectly able to do that, too. The record will remain open for another 10 days to complete that process. So I appreciate everyone who has helped out here today and the hearing is adjourned. [Whereupon, at 4:55 p.m., the committee was adjourned, to reconvene at the call of the Chair.] ======================================================================= A P P E N D I X ---------- Additional Material Submitted for the Record ======================================================================= Prepared Statement of Hon. Maria Cantwell, U.S. Senator from Washington Thank you, Mr. Chairman. I appreciate your continued leadership on these issues which we have been working on for a number of years. I'd also like to thank you for opening this hearing up to our HELP Committee colleagues. Their expertise in healthcare delivery, will be extremely valuable as we work together to improve the health and well- being of Native Americans. I believe reauthorizing the Indian Health Care Improvement Act will help us begin to close the disturbing health disparity in Indian country and allow us to fulfill the United States' obligation for Indian health. According to the U.S. Commission on Civil Rights, between 1998 and 2003, industry experts estimate that medical costs grew approximately 10-12 percent, while the IHS funding increases are less than 5 percent annually. When compared to other Federal health expenditures, it's clear that IHS is grossly under funded. We have a responsibility to take a close look at the healthcare services we're providing to this population and make sure that they're equitable and adequate. This issue is particularly important to Washington State. Between 1990-2000, the Indian population grew almost by almost 28 percent--7.5 percent faster than the rest of our population. The life expectancy for Indians living in Washington is approximately 4 years shorter than that of the rest of the population, due to factors that we can impact-- chronic under funding of the Indian Health Service, the lack of geographically available health services and the lack of trained providers that are available to serve the Indian population. We can address these issues for Washington and the rest of Indian country by moving forward with the reauthorization of this critical legislation. To give you an idea of how badly this legislation needs to be updated, I'll use the example of behavioral health services. The current law limits behavioral health services to those dealing with substance abuse. While substance abuse is a critical health issue, mental health disorders are not addressed. This is particularly alarming when one looks at the suicide rate of the Indian population-- 91 percent higher than the rest of the United States. Clearly there is a need for increased attention to the behavioral health needs of the Indian population. I'm pleased to see the increased focus on preventative health in this bill. While Indian country is still experiencing a shorter life expectancy than other American populations, the causes of death have shifted. Today the leading causes of death among Indian populations are chronic disease rather than infectious disease, communicable diseases. The health disparities that exist among the Indian population are numerous and unacceptable. They have higher rates of almost every disease and adverse health condition:
Alcoholism--777 percent higher. TB--650 percent higher. Diabetes--450 percent higher. Accidents--208 percent higher. Pneumonia/influenza--52 percent higher. Suicide rate--91 percent higher. Although the health disparities still exist in Washington and across the country, we have made progress. I am aware, for example, of our success in the Northwest in reducing the rate of Sudden Infant Death Syndrome, diabetes, HIV/AIDS, cancer and tobacco use through the use of health promotion and disease prevention programs. Reauthorization would allow for the expansion of facilities construction options, enhance tribal decisionmaking and enhance the ability to recruit, train and retain health professionals. The last time this bill was reauthorized was in 1992 and it expired in 2000. Since then, bills have been proposed every year to no avail. This is a very complicated issue, it's a huge bill but the time has come to fully address the health needs of the Indian population. We have a legal and ethical responsibility to provide healthcare to Indians and this is the perfect opportunity to begin to address ways in which we can improve the way we do so. One area of great concern to me is the impact of the Medicare Prescription Drug Benefit implementation on Indian country. The Tribal Technical Advisory Group was formed to consult with the Center for Medicare & Medicaid Studies (CMS) on reimbursement rates and policies. Under the roll-out of the transitional assistance or, the drug discount card, under the Medicare Modernization Act earlier this year, we saw many problems in the implementation of this program. Beneficiaries were often confused about their choices and many didn't know they even had a choice to make. Like other low-income elders across the country, low- income Indian elders will experience a gap in prescription drug coverage when their costs exceed the initial $1,500 coverage limit. Most Indians will expect their HIS and Tribal Clinics to pay for their pharmaceuticals after they fully utilize their prescription drug coverage. However, IHS expenditures will not be counted toward the threshold to qualify for the catastrophic coverage under the drug plan. IHS will have to absorb all pharmacy costs for Indian elders up to the $3,600 annual limit. I am hopeful that in consultation with my colleagues on the Senate Finance Committee, we will resolve this inequity. Another area of grave concern to me is the lack of attention that behavioral health services in our healthcare delivery system. According to the Indian Health Service, 13 percent of Indian deaths occur in those younger than 25 years of age--three times that of other populations and the U.S. Commission on Civil Rights points out that American Indian youth are twice as likely to commit suicide. Reauthorization is especially important as it provides an opportunity to address the need for mental health coverage within the IHS. Title VII proposes a comprehensive approach for behavioral health assessment, treatment and prevention. Under current law, behavioral health provisions are largely limited to substance abuse treatment and prevention and the issue of mental health is largely unaddressed. The current Indian health bill is a product of much collaboration between tribal leaders, IHS officials and program personnel and it's imperative that we look to these experts during this process. I'd also like to thank Ralph Forquera, the executive director of the Seattle Indian Health Board, for joining us here today. Each year, the Seattle Indian Health Board serves over 6,000 individual patients and provides approximately 30,000 patient encounters. While the Seattle Indian Health Board has become quite skilled at providing high quality services with limited funding, they're currently facing a budget shortfall of $200,000 for clinic services. We must work to make sure that our providers have the resources they need to provide high quality health care to the Indian populations all over the country and especially here in Washington. I'm looking forward to hearing of the Seattle Indian Health Board's many accomplishments, especially as they relate to the health needs of urban Indians. Once again, thank you Mr. Chairman for beginning the reauthorization of the Indian Health Care Improvement Act and for holding this hearing. The time has come for this bill to finally be reauthorized and I look forward to working with my colleagues in the Senate to make this a reality year. ______ Prepared Statement of Hon. Byron L. Dorgan, U.S. Senator from North Dakota, Vice Chairman, Committee on Indian Affairs I thank Chairman McCain for his leadership. I thank my colleagues on the HELP Committee for joining with us in considering today the Indian Health Care Improvement Act Amendments of 2005. I am particularly pleased to note that two of our colleagues from the HELP Committee Senator Kennedy and Senator Bingaman--have asked to be added as cosponsors of S. 1057. It is my earnest hope that, by working together--together as authorizing committees, and together with the Administration and representatives of Indian country--the Indian Health Care Improvement Act will be reauthorized this year. I know our witnesses today will provide additional statistics regarding health needs in Indian country. We cannot, in good conscience, be satisfied with the status quo like this: \\\\\\Native American youth are more than twice as likely to commit suicide; in the Great Plains area the likelihood is as high as 10times. \\\\\\American Indians and Alaska Natives are 517 percent more likely to die from alcoholism. \\\\\650 percent more likely to die from tuberculosis. \\\\\\318 percent more likely to die from diabetes. \\\\\\204 percent more likely to suffer accidental death. Over the past few months, my colleagues have heard me speak on the Senate floor about Indian health care in connection with amendments I have offered to the fiscal year 2006 budget resolution and the fiscal year 2006 Interior appropriations bill. My amendments proposed to provide an additional $1 billion for programs not only in the IHS, but also BIA, tribal colleges, water infrastructure. I have talked on the Senate floor about people in tribal communities who are hurting and in desperate need of services. Many of these people I know or have known, or, in the tragic case of Indian youth suicide, whose surviving family members I have met with. I know this is true, too, for Dr. Grim and the other witnesses who will testify today--you all see and hear and experience, every day, the very real need for the kinds of services and programs and facilities, the kinds of best practices, collaborations and innovations that S. 1057 would authorize for American Indian and Alaska Native communities. I want to thank each of you who has stuck with this reauthorization process since 1999 and earlier for your persistence and continuing vision. I want to say that I am particularly pleased with and supportive of the provisions of title VII of the Indian Health Care Improvement Act Amendments of 2005. This section of the bill would authorize the Secretary of Health and Human Services--through the Indian Health Service, the tribal health programs and the urban Indian organizations--to develop a comprehensive behavioral health prevention and treatment program. Such a program would emphasize collaboration among alcohol and substance abuse, social services and mental health programs and would benefit all age groups. Since the Committee on Indian Affairs' hearing on June 15 on teen suicide prevention, several more youth suicides have occurred on the Standing Rock Reservation in North and South Dakota. The services and programs for Indian youth, in particular, the training of paraprofessionals, the education of community leaders, the construction and staffing of new facilities and research that would be authorized by title VII will make a very real difference in the lives of men and women who live at Standing Rock, and all Native Americans. I look forward to the comments today of the Indian Health Service, the tribes and urban Indian organizations, and others and appreciate your help in improving this legislation that will provide creative and effective solutions to address the health needs of Indian people. ______ Prepared Statement of Hon. Michael B. Enzi, U.S. Senator from Wyoming, Chairman, Committee on Health, Education, Labor, and Pensions Good afternoon. Thank you for coming to today's joint hearing on the Indian Health Care Improvement Act. There is no greater challenge before us in the Congress than the work we must do to continue to improve the quality of the health care that is available to those living on reservations. Unfortunately, it seems that no matter how much progress we make, there is always more to do. Today's hearing will enable us to chart our current progress and discuss what we can do to increase the services that are available to address the physical and emotional problems that continue to plague American Indians and Alaska Natives. When the Indian Health Care Improvement Act was first signed into law in 1976, it was written to address the findings of surveys and studies that indicated that the health status of American Indians and Alaska Natives was far below that of the general population. It continues to be a matter of serious concern that, as the health status of most Americans continues to rise, the status of American Indians and Alaska Natives has not kept pace with the general population. Studies show that American Indians and Alaska Natives die at a higher rate than other Americans from alcoholism, tuberculosis, auto accidents, diabetes, homicide, and suicide. In addition, a safe and adequate water supply and waste disposal facilities, something we all take for granted, isn't available in 12 percent of American Indian and Alaska Native homes--as opposed to 1 percent of the general population. Several years ago, residents on the Wind River Reservation in Central Wyoming faced a drinking water shortage that threatened the health and safety of everybody in the area. Canned drinking water had to be donated to tribal members and local residents. The lack of these basic services makes life even more harsh for these people and contributes to those already high rates of death. Coming from Wyoming, I know full well the problems we encounter in the effort to provide quality health care to all the people of my home State. That is why I have always made it one of my goals to help bring that perspective to the hearings and floor debates we have on the issues that affect the people of my State. When I was first elected to the Senate in 1996 I knew that quality of life issues on the reservations in Wyoming and throughout the country would continue to be a top priority of mine. I also knew that, in order to make life better for those living on the Wind River Indian Reservation specifically, and other reservations nationwide, my staff and I would need to be intensely committed to taking the issues head-on and looking for creative ways to solve complicated problems. That is why I put someone on my staff who already had a great deal of experience with these issues and shared my commitment to act on them. His name is Scotty Ratliff and he served with me in the Wyoming legislature. I tasked him with the challenge of helping me to find solutions to the problems on our reservations that would be both progressive and culturally sensitive. Tribal leaders are already committed to making things better on their reservations and I congratulate them on their vision and the hard work they have put into making it a reality. My only question continues to be, ``How can I help?'' In the years since I have been in the Senate I have made numerous trips to the Wind River Reservation in Wyoming and met and spoke with the residents and tribal leaders. We all want the same goal--a better life for those who live there. I am confident that working together we will continue to make the kind of progress we must make if we are going to find effective and efficient ways to address the problems that continue to plague those living on our reservations across the country. As I noted during my visits to the Wind River Reservation, their problems are not unique to them. To have an impact on all those who live on reservations from coast to coast, we will need to take a varied approach to address each of these problems separately. Clearly, people of different ages have different problems. A multi-faceted approach to solving each of their problems will require a systemic, as well as a financial approach. Local, State, and national governments and agencies must work together with tribal leaders to focus our resources where they will do the most good. That kind of approach has the greatest chance of being successful. Earlier this year the HELP Committee held hearings on the nomination of Michael Leavitt to serve as Secretary of Health and Human Services. I believe we are fortunate to have Michael Leavitt at the helm of an agency that oversees the health care needs of the people of reservations all across the country. I am also pleased Dr. Charles Grim is here with us today. Dr. Grim has an important job to do as the Director of Indian Health Services and he knows firsthand the level of dedication it will take to steadily improve health care for all American Indians. Dr. Grim has an unmatched understanding of the needs of Native Americans that you can't get from reading reports and memos from people out in the field. I have every confidence in his willingness and his ability to be an important part of the solution to the health care needs of those on our reservations and beyond. Again--the good news is--we're making progress. As we do, we continue to find so much more that needs to be done. How do we best provide the assistance that is needed effectively and efficiently? That is the challenge that lies before us. As we begin to hear from our witnesses, I would like to acknowledge and thank them all for their willingness to share their experiences with us so that we might craft a more effective bill to address the health care needs of our American Indian and Alaskan Native population. I would also like to welcome Richard Brannan, the chairman of the Northern Arapaho Business Council of Fort Washakie, WY. No one knows better than he does the problems faced by those living on reservations and by those who rely on the Indian Health Service for their healthcare needs. No one understands better than he does the necessity of making progress in addressing the health disparities experienced by American Indians. Most important of all, no one is more committed than he is to making a difference in the lives of all those who live on the reservation. I know he has an important message to share with us based on his experience and background with all those who live on the Wind River Reservation. I look forward to his comments and those of our entire list of witnesses. Each of you has a perspective and a point of view to share that only you can provide. I look forward to hearing a summary of your prepared remarks so we can address the underlying issues during our question and answer session. ______ Prepared Statement of Hon. Daniel K. Inouye, U.S. Senator from Hawaii Thank you Mr. Chairman. I commend the committees for holding this hearing today. The status of Indian Health Care has significantly improved over the years and Indian mortality rates have declined. However when compared to the United States general population Indians have a higher likelihood of dying from diseases such as alcoholism [770 percent], tuberculosis [650 percent], AND DIABETES [420 percent]. Life expectancy is also 5 years less than the general population. Preventive health services are needed more than ever as is increased funding for those programs and services. In 1976 the Indian Health Care Improvement Act was enacted into law for the specific purpose of increasing the health status of native peoples. Since then bills were introduced in the 106th, 107th, 108th, and 109th congresses. Although these efforts were disappointing, I commend Congress for continuing to work on these crucial issues. This bill is critical to Indian country. It authorizes behavioral programs, provides alternatives for rural dental care, and authorizes the Indian Health Service to provide long-term care, are among the many positive changes that I have seen in this bill. I believe it is congress' obligation to ensure that Native Americans have full and timely access to health care. There is some language in the bill that I am concerned about because it may be detrimental to tribal sovereignty. However I will continue to work closely with my colleagues. I commend my colleagues Senators Dorgan and McCain for drafting this legislation. Once again, thank you for holding this hearing. ______ Prepared Statement of Hon. Edward M. Kennedy, U.S. Senator from Massachusetts I commend Senator McCain, and Senator Enzi for convening this joint hearing on the Indian Health Care Improvement Reauthorization Act. The Nation has a legal and moral commitment to provide Native Americans-- the Nation's first Americans--with the best possible health care, and I'm pleased to be a cosponsor of this important bill. From the earliest days of colonization that brought infectious diseases to Native Americans, to the 18th century military conflicts that sought to destroy Native peoples, to the 19th century treaties that sought to confiscate Native lands, to the 20th century boarding schools that sought to undermine, tribal culture and language, the history of Native America has often been a shameful part of the history of America. The Federal Government has long promised better health care to Native Americans in exchange for land. Since at least 1926, the Government has been looking into the adequacy of such health care, but sadly, many of the inadequacies identified in the 1920's still exist today. Decade after decade, Congress refused to give tribes the resources to develop and operate their own communities. Too often, it was said that Indian peoples did not have the expertise to invest such resources wisely to conduct their own governments, operate their own businesses, educate their children, or provide health care to their people. For generations, this reactionary national mentality poisoned the relationships between tribes and the Federal, State, and local governments. Native Americans are eager to improve the health status of their people. They deserve control of their own destiny, but they require Congressional action to make their vision a reality, and it is time for us to honor the commitments we made long ago. Chronic underfunding of American Indian and Alaska Native health care by the Federal Government has weakened the capacity of the Indian Health Service, tribal governments, and the urban Indian health delivery system to meet the health care needs of the American Indian and Alaskan Native population. The Indian Health Service per capita expenditures for American Indians and Alaskan Natives are one-half of what is spent for Medicaid beneficiaries, one- third of that spent by the Veterans Administration, and one-half of what the Federal Government spends on Federal prisoners' health care. As a result of inadequate funding, American Indians endure health conditions most Americans would not tolerate. Native Americans are 8 times more likely to die from alcoholism, 7 times more likely to die from tuberculosis, 5 times more likely to die from diabetes, and 50 percent more likely to die from pneumonia or influenza than the rest of the United States, including white and minority populations. Native American infants die at a rate 2\1/2\ times greater than the rate for white infants. Native Americans are at a higher risk for mental health disorders than other racial and ethnic groups in the United States. Their cardiovascular disease rate is twice that of the general population. Their life expectancy is 71 years--nearly 5 years less than the rest of the population. These statistics represent real people who deserve more from the U.S. Government. The Indian Health Care Improvement Act has been amended many times, but it was only extended through 2001. It is long past time to reauthorize this act. Congress has been working to do so for the past 5 years. The current legislation reflects years of consultation with the Tribal National Steering Committee and holds great promise for improving the lives of Native Americans through comprehensive public health efforts. Despite widespread support, the bill has not been brought to the Senate floor for a vote. A better future is well within our grasp. We have a unique opportunity to make much more rapid progress on the long journey toward respect for our First Americans. We must bring the Indian Health Care Improvement Reauthorization Act to the floor. We must pass this legislation. Until every American Indian and Alaskan Native receives first class health care, we will never give up the fight. I look forward to this hearing and to the testimony of each of the witnesses. ______ Prepared Statement of Hon. John McCain, U.S. Senator from Arizona, Chairman, Committee on Indian Affairs Good afternoon. The bill before us today, S. 1057, is the latest iteration of the reauthorization of Indian Health Care Improvement Act that has lingered in the Senate for many years. And while there was much debate about the measure at the end of the last Congress, the need to improve the provision of health care services for Native Americans is undebatable. I am very heartened that our colleagues from the HELP Committee under the leadership of Chairman Enzi and Ranking Member Kennedy have so actively engaged in advancing the legislative process. I appreciate not only their support, but the expertise and insight that the HELP Committee brings to the effort. Nearly 30 years ago, Congress enacted the Indian Health Care Improvement Act to meet the fundamental trust obligation of the United States in providing comprehensive health care to American Indians and Alaska Natives. It was last reauthorized in 1992--13 years ago. This act is the statutory framework for the Indian health system and covers just about every aspect of Indian healthcare. S. 1057 builds on that framework by providing significant advancements in health care delivery and by promoting local decisionmaking, tribal self- determination and cooperation with the Indian Health Service. Those critical improvements include increased access to care, especially for Indian children and low-income Indians, programs designed to recruit and retain healthcare professionals on Indian reservations, and alternative financing for healthcare facilities and other services. Reauthorization of this Act is a high legislative priority. It has been 6 years in the making--far too long for the much needed improvements. Substantial work was completed last year and we have but a few remaining issues that I hope we can resolve quickly so that the bill can be enacted soon. I welcome the witnesses and look forward to the testimony. ______ Prepared Statement of Hon. Patty Murray, U.S. Senator from Washington Thank you Mr. Chairman. I want to thank Chairman Enzi for holding this joint hearing. I'm happy that my colleagues on the HELP committee have this opportunity to learn more about the crisis facing tribal communities today and why this bill is so critically important. Mr. Chairman, I believe improving the quality and access of health care in tribal communities is one of the Federal Government's greatest treaty obligations. But when it comes to providing that care---- \\\\\\the Federal Government has fallen short of its moral and legal obligation. Chairman Enzi, I'd ask for your commitment to continue to work together on this important issue so that we can help the Committee Indian Affairs move this bill forward. I know you have some concerns about the bill and I'd like to work with you to address them. As you may know, this legislation has been through an exhaustive review by tribal leaders and health professionals, the Committee on Indian Affairs and the Administration. And in light of two reports by the U.S. Commission on Civil Rights documenting the health care disparities facing Native Americans living on reservations and in urban areas it is time for the Congress to reauthorize this law. Finally, I'd like to join with my colleagues in welcoming Ralph Forquera to the committee. Ralph is a national leader on issues affecting Native Americans living in urban areas and I'm pleased to see he's here today representing the Seattle Indian Health Board. Thank you. ______ Prepared Statement of Mark Kelso, DDS, Norton Sound Dental Director Nome, AK As a dentist with 19 years of direct patient care experience in Western Alaska, I believe that I can speak with great credibility regarding the dental needs of the indigenous people of the region. I have observed the cycle of destructive dental disease repeated from one generation to the next. The current method of itinerating dentists to rural communities for several weeks annually does little to elevate the public's aptitude toward the importance of good oral health. The dentists' role is viewed as one of simply alleviating pain and infection or repairing decayed teeth. While this service is important, it ultimately shifts the burden of one's own responsibility in the maintenance of their oral health to that of the provider. The dentists being of different ethnicity and cultural upbringing are not easily viewed as a role model for children and young adults to emulate. The dentists' short duration in the village also hampers their ability to bring about long-term patient motivation. Patients respect the dentists' advice while they are there, but their enthusiasm to better clean their teeth and limit the intake of sugary foods soon fades upon the dentists' departure. Established poor dental habits re- emerge. A dental chart review demonstrates that patients receive the care that is warranted. An ongoing trend of preschool children being afflicted with rampant dental decay in the baby teeth and subsequent restoration of these teeth either by multiple sedation appointments locally or by operating room procedures in Anchorage is a frequent occurrence. The erupting adult teeth are cleaned, sealed, and fluoridated but ultimately succumb to the rigors of poor diet and hygiene. The teeth usually receive several fillings of increasing complexity. In too many cases, the teeth reach a diseased state in which extraction of all of the teeth is the only viable treatment. Full dentures are fabricated. An analysis of the cost and effort to provide all of these services with the end result of being an edentulous teenager or young adult is sobering. Thousands of dollars per patient in both dental and hospital services along with associated travel were expended. A change in public perception regarding the importance of good oral health is needed. Native American dental providers are key in this process. Dental Therapists, residing and working in villages of a high oral disease rate, will be a constant dental presence in those communities. They will have the luxury to examine and treat patients more than once a year. More time can be spent on improving patients' oral hygiene index. Weekly fluoride rinse programs in the school will be an important job duty. But to gain the respect of the communities, the Dental Therapists must be known as the primary dental health care providers. They will obtain this status by alleviating existing need. The Dental Therapists must be able to perform routine fillings, treat infected nerves in children's teeth, and extract painful, hopeless teeth. The dentists will still itinerate through the villages to perform more complex treatment, eventually providing higher level services such as root canal completions, permanent crowns and bridges, denture fabrications, and orthodontic assessments not currently available in these remote locations. As the level of dental care increased in the hub-clinic in Nome, the dental expectation of the community did too. A decrease in basic dental disease followed. Such a model could be extended to the villages through the use of Dental Therapists. Another important aspect is the influence that the Dental Therapists will have on the school-age children and young adults. A criterion for the selection of all of the Dental Therapists in the Norton Sound region was that they all possess nice teeth, value a healthy smile, and practice good oral habits in their daily lives. Many junior and senior high school girls in the villages, the future mothers of the next generation, desire to look their best like most American girls. They may wear trendy clothes, style their hair, and apply cosmetics, but the deteriorated condition of their teeth negates these other measures. The Dental Therapists will frequently reinforce the need to alter dietary choices and practice daily oral hygiene to improve this segment of the population's oral health. Through the Dental Therapists own actions, they can inspire the youth that it is important and ``cool'' to have good teeth. It will not be socially acceptable any longer to brandish a smile of decay -riddled teeth or missing teeth altogether. Usually the children's teeth mirror those of the mother, either good or bad. This will be an excellent opportunity to stop the generational cycle of rampant tooth decay and premature tooth, loss. The Dental Therapists will be an ever-present, walking advertisement to the importance of good oral health. I urge the Senate Committees on Indian Affairs and Health, Education, Labor, and Pensions to support S. 1057 as it is written. The ability of the Dental Therapists to perform the procedures of fillings, dental pulp treatments, and basic extractions is crucial to their success. The Dental Therapists' potential to bring about positive long- term change is greater than that of any number of itinerant dentists, either compensated or volunteer. ______ Prepared Statement of Tom Kovaleski, DDS, Director, Southcentral Foundation, [SCF] Dental Program Thank you for the opportunity to submit testimony to the SCIA and HELP Committee regarding the practice of DHATs and section 121 of S. 1057, the Indian Health Care Improvement Act Amendments of 2005. Please include my testimony in the record of the July 14, 2005 hearing regarding S. 1057. I was honored to be one of the four authors of the paper, ``Integrated Dental Health Program for Alaska Native Populations.'' Since the first draft was released, I have been in regular discussion with tribal dental health program directors in Alaska. I have stated to them repeatedly that in my view the COHP model should be viewed by them, by the ADA, and by Congress, not as a substitute for DHATs, but rather as a tool for achieving additional efficiencies and improvements. In my view, there is a place for implementation of COHP and DHATs as part of an integrated dental health program. I do not endorse the conclusion of the ADA that COHP can substitute for DHATs in resolving the crisis regarding access to dental services among Alaska Natives. I would recommend both programs be implemented as pilot programs with the results evaluated closely. While I think both SCF's efficiency expertise and the full implementation of a COHP model may help the crisis, there is still a pressing need for additional practitioners that expanded function dental hygienists and DHATs could help fill. Throughout the development of the DHAT standards ultimately adopted by the Community Health Aide Program Certification Board, I actively participated with other dental providers in reviewing the Standards and the research base for mid-level dental practice and shared my concerns around the training and quality assurance components. I believe that DHATs have the potential to be high quality providers with proper training and quality assurance. As a practicing, licensed dentist responsible for a large program serving both an underserved urban and rural populations, I do not believe the dental community can afford to reject any responsible approach to expanding access to dental services. I believe dental assistant training, increased capacity, expanded function hygienists, COHP, and DHATs, provide such a responsible options for reducing the backlog of dental disease in Alaska. I urge Congress to not make changes in the authority of the community health aide program pursuant to section 121 of the Indian Health Care Improvement Act under which DHATs are certified so that we can evaluate their impact along with other strategies. If I can offer additional information that will help you in your deliberations, please let me know. ______ Indian Health Care Improvement Act: Questions for the Record (Senator Hatch) July 15, 2005 Panel I Questions for Ms. Rachel Joseph National Steering Committee Chairperson, Lone-Pine Paiute Shoshone Reservation No. 1. Title VII would authorize a comprehensive behavioral health program, reflecting tribal values and collaboration among various substance abuse, social service, and mental health programs. You spoke of the need to have a ``systems of care'' approach to mental health in addition to this comprehensive package. Can you tell me specifically what this ``systems of care'' approach would add to the comprehensive program already outlined in title VII? No. 2. The National Steering Committee has a long history with this legislation. Can you tell us what the major stumbling blocks have been to passing this bill in the past, and how this bill has addressed these issues? Panel II Questions for Mr. Don Kashevaroff Alaska Native Health Tribal Consortium and Tribal Self- Governance Advisory Committee No. 1. What, specifically, are the concerns on the part of the Administration with negotiated rulemaking and how does this bill address those concerns? Why is negotiated rulemaking of particular importance to tribes? Questions for Mr. Richard Brannan, Chairman, Northern Arapaho Tribe No. 1. In your testimony, you stated that the Arapaho Tribe has a high disproportionate number of diabetics--would you please describe the current state of the dialysis program available to the Arapaho Tribe? No. 2. Regarding the issue of care for the elderly, you mentioned that most Arapho elderly, choose to remain in their own homes--do you believe that they would still remain in their own homes if better facilities were available to them? No. 3. I understand that family and domestic violence remains a large problem facing the American Indian population, and that expansion of related services is vital to combating that problem. What services are currently provided on the Wind River Reservation with regard to family and domestic violence; and what services do you suggest be added to enhance the current program? Questions for Mr. Ralph Forquera, Executive Director, Seattle Indian Health Board; and Director, Urban Indian Health Institute No. 1. I am concerned by your statement about the lack of available data needed to address the growing health crisis among urban Indians-- it appears that this crisis may be much larger than we are even capable of gauging. What are the main reasons it is so difficult to collect data of urban Indians; and, do you have suggestions of what Congress can do to improve the data collection process? No. 2. Do you consider the trend toward urbanization to be increasing? No. 3. With regard to the Federal Tort Claim Act, you stated that inclusion could save considerable expense for programs that are now purchasing private liability insurance to support their work ? can you provide a hypothetical estimate of those savings? Panel III Questions for Dr. Mary Williard, D.D.S. Yukon-Kuskokwim Health Corporation, AK No. 1. You support the current program which permits Dental Health Aide Therapists (DHAT) to perform various procedures on patients in remote areas. The American Dental Association has concerns with three of these procedures (extracting teeth, drilling cavities, and pulpotomies). What programs are currently in operation that are similar to the DHAT program? Do participants in these programs perform these controversial procedures? Can you provide us information on these programs: where they are, how long they have been in operation, what studies have been done assessing their safety and effectiveness, particularly with regard to these three procedures? No. 2. You mention that the dental therapists will work under the supervision of a dentist. Who are these dentists and how can they supervise dental therapists who are in remote villages? What ``back- up'' exists if a procedure runs into unexpected complications?