Senator MURKOWSKI. That is great. It is nice to hear that Alaska can be used as a model throughout the rest of the country. I am pleased to hear that.

Mr. KASHEVAROFF. Thank you.

The CHAIRMAN. Julia?

Ms. DAVIS-WHEELER. Yes, Chairman Campbell, I would like to respond to Senator Murkowski's question on self-governance. The Nez Perce Tribe in Idaho, we just recently in 1999, 2000 went to compact. One of the things that we have done with the compacting process that we went through is we were able to build two clinicsone a small satellite clinic for our up-river people that live 70 or 80 miles away from the main headquarters, because they were in a community building. So we have one building for them. It is not a big one, but a small building where all the health programs are together. We did that with some of our compact money reserves that we had, and then other grants.

Now, recently, we are working on the main tribal health clinic for the Nez Perce Tribe where the headquarters sits. So if we did not do the self-governance compact, we would not have been able to do that. So that shows that if tribes have the initiative or know how to do this, that they can get some things done. Whereas if we would have gone through the facilities priority selection process, we would have never gotten a new facility. So I just wanted to comment on that.

Mr. Chairman, I would just like to take the opportunity to thank you. With your assistance last week, we were able to bump up the number for the funding for IHS. I know it is not as much as some would have liked, but I think we agreed it was an attempt to address the need and we will work toward additional funding. I thank you for your initiative.

The CHAIRMAN. It was a 10-percent increase, was it not?

Senator MURKOWSKI. 10 percent over the President's number. So every little bit, I think we all would agree, helps.

Thank you for your assistance when we worked on that.
The CHAIRMAN. Thank you.

I appreciate your testimony and your support of S. 556. I have to tell you, I am really concerned about this One-HHS proposal. I understand that we need to streamline and consolidate and not duplicate efforts and make better, more efficient use of tax money and so on, but I have seen too many times in the past when Indian programs get folded into bigger programs, money that had formerly been designated for Indian programs somehow gets transferred or moved or something. The Indian people have never had a real strong voice in the Administrations, any Administration or here either, unfortunately. I am really concerned about that.

When one out of every two Pimas on this earth, for instance, suffer from diabetes, and there are people who three out of their whole 7-day week and sometimes four is spent on a road somewhere just so they get dialysis, I sometimes worry that folding things into making things look more efficient sometimes is going to leave Indian people out.

I would appreciate your looking at this One-HHS proposal in depth and giving the committee back some written guidance. We will look forward to that, too, and hopefully you can do that in the next few weeks if you could, Julia. I think Senator Inouye would be equally concerned about it.

With that, I have no further questions, but we may have some that will be submitted in writing. Thank you for appearing.

The committee is adjourned.

[Whereupon, at 10:54 a.m., the committee was adjourned, to reconvene at the call of the Chair.]

APPENDIX

ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD

PREPARED STATEMENT OF MELANIE BENJAMIN, CHIEF EXECUTIVE, MILLE LACS BAND

OF OJIBWE

Mr. Chairman and members of the committee, this testimony is offered in support of Reauthorization of the Indian Health Care Improvement Act. The Mille Lacs Band of Qjibwe is a federally-recognized tribe with 3,570 enrolled members. Located in east central Minnesota, we operate three separate clinics offering services to more than 2,000 Mille Lacs Band members, as well as other non-members, through 20 different programs.

When Congress first enacted the Indian Health Care Improvement Act (IHCIA) in 1976, one of the major policy reasons for doing so was to address the health disparities in Indian Country by raising the health status of the Indian population to a level consistent with that of the general population of the United States. Unfortunately, the overall health status of Indian people has improved very little, and those same disparities continue to exist in alarming numbers. Reauthorization of the IHCIA would greatly assist efforts to rectify the continuing health disparities in Indian country.

One of the primary purposes of the IHCIA is to authorize appropriations for tribal health programs so that they may better satisfy their health care goals. Even so, federal funding levels have not kept pace with inflation or with the increasing needs that directly impact the costs of health care delivery. In fact, today's medical dollar is worth less than the funding received, making it very difficult to provide comprehensive health care.

As is true for most tribal communities, the Mille Lacs Band is confronting an increased health care burden due to growing incidents of conditions such as diabetes, heart disease, and cardiovascular disease. These health conditions, which are approaching epidemic proportions, are impacting not only our adult population, but also our youth. This weighs heavy on our hearts as our children are our future.

Factors such as poor diet and lack of exercise contribute greatly to the increase of these chronic health conditions. The Mille Lacs Band would like to develop preventative programs addressing these significant health deficiencies. Soaring treatment costs for chronic health conditions quickly drain program dollars, and the reality is that preventative programs are, in the long run, far more cost-effective.

Our health care burden is impacted further by our ever-growing user population, which has increased by more than 30 percent in recent years. As a result, we have outgrown our current facilities. Inadequate space does not permit us to effectively address the existing needs of our members, much less those that continue to emerge each year.

Presently, we are limited as to the services we are able to provide. While we currently employ one full-time dentist, two full-time physicians, and a handful of certified nurse practitioners, we are not capable of providing the comprehensive health care that our people rely upon, and frankly, deserve. Examples are programs targeted at substance abuse, mental health, and other behavioral health programs that contribute toward wellness beyond basic medical and dental care. We greatly need

to expand our facilities and construct additional space to meet those growing demands for health services.

Present funding levels are not sufficient to keep up with increasing health care needs and the associated costs. Level of need funding is designed to bring tribal health care programs to the equivalent of mainstream funding agencies throughout the United States. Our level of need funding is currently at 30 percent, an amount far below comparable non-tribal agencies. As a consequence, the Mille Lacs Band consistently faces a challenge in meeting the health care needs of our members and other tribal members who utilize our clinic services.

The Mille Lacs Band makes every effort to access outside funding services to complement Federal funding. Third party billings are submitted to insurance providers and payments are sought from Medicare and Medicaid reimbursements. Regardless, these efforts are not sufficient to keep up with increased costs of health care delivery and frequently, the Mille Lacs Band must provide the difference. The problem with this is that it means other tribal programs and services are affected when dollars must be shifted.

The impacts of non-reauthorization to the Mille Lacs Band of Ojibwe and other Tribes are numerous. Educational programs and campaigns may be eliminated, which will reduce health awareness. There will be an inability to provide comprehensive health care services to our clinic users, especially if clinic staff numbers are not increased. There will also be reduced access to the latest technology, a problem we already face with outdated technology that does not keep up with the latest medical advances. These are just some of the problems tribes will face without reauthorization of the IHCIA.

Reauthorization of the Indian Health Care Improvement Act is beneficial to the Mille Lacs Band of Ojibwe and to all tribes who depend upon federal funding to provide comprehensive health care for our communities. Reauthorization will allow the Mille Lacs Band of Ojibwe to pursue our health care objectives and goals intended to rectify the significant health disparities that the United States acknowledges exist on our reservation and reservations across the United States.

Underlying the Indian Health Care Improvement Act Reauthorization is the Federal trust responsibility of the United States. The Federal trust responsibility extends to all the federally-recognized tribes of the United States who have a government-to-government relationship with the United States. This trust obligation arises out of the government-to-government relationship that is articulated in article 1, section 8, clause 3, of the U.S. Constitution, the governing instrument of the United States. The trust responsibility also arises out of the numerous treaties, executive orders, court decisions and Federal laws of the United States, and frequently is acknowledged in the same. Reauthorization of the IHCIA is the means by which the United States can continue to fulfill its trust obligation to tribal nations.

Encompassed within the government-to-government relationship is the United States' recognition of tribes' right to self-governance. The Mille Lacs Band of Ojibwe is a self-governance tribe under the Tribal Self-Governance Act of 1994. We were one of the first tribes to enter into a self-governance compact, and not long after, entered into an Annual Funding Agreement, an arrangement which allows the Mille Lacs Band to design its health care programs and services in a manner that best addresses goals and objectives we have identified in our community. The Mille Lacs Band has been able to prioritize its health care needs and attempts to meet those needs as best we can through sound policy decisions. However, our self-governance status does not interfere with the federal trust responsibility of the United States. Indian health care must be improved. Reauthorization of the Indian Health Care Improvement Act is essential to improving the lives of Indian people and the health care that they receive. Mii Gwetch.

PREPARED STATEMENT OF JULIA DAVIS-WHEELER, CHAIRPERSON, NATIONAL INDIAN HEALTH BOARD

Chairman Campbell, Vice Chairman Inouye, and distinguished members of the Senate Indian Affairs Committee, I am Julia Davis-Wheeler, chairperson of the National Indian Health Board (NIHB). I am an elected official of the Nez Perce Tribe, serving as Secretary, and also Chair the Northwest Portland Area Indian Health Board. On behalf of the National Indian Health Board, it is an honor and pleasure to offer my testimony this morning on S. 556 to reauthorize the Indian Health Care Improvement Act, which is the most important authorizing legislation for American Indian and Alaska Native health delivery. As you recall, I stated in my recent testimony on the FY 2004 Budget that I looked forward to coming back and testifying on the Indian Health Care Improvement Act. I am pleased that this day has come

and it demonstrates your commitment to American Indian and Alaska Natives as we work toward eliminating the unique health problems facing Indian Country.

As you are well aware, the NIHB serves nearly all Federally Recognized American Indian and Alaska Native (AI/AN) Tribal governments in advocating for the improvement of health care delivery to American Indians and Alaska Natives. It is our mission to advance the level of health care in Indian Country and the adequacy of funding for health services that are operated by the Indian Health Service, programs operated directly by Tribal Governments, and other programs. Our Board Members represent each of the twelve Areas of IHS and are elected at-large by the respective Tribal Governmental Officials within their regional area.

I have been associated with the reauthorization effort since May 1999 when I first met with other tribal leaders and the Indian Health Service to explore how we, along with Congress and the Administration, could work together to pass this vital legislation.

In June 1999, the director of the IHS, Dr. Michael Trujillo convened a National Steering Committee (NSC) composed of representatives from tribal governments and national Indian organizations to provide assistance and advice regarding the reauthorization of the IHCIA. Over the course of 5 months, the National Steering Committee drafted proposed legislation, which was based upon the consensus recommendations developed at four (4) regional consultation meetings held earlier in that year. The consensus recommendations formed the foundation upon which the National Steering Committee began to draft proposed legislation to reauthorize the IHCIA. In October 1999, the National Steering Committee forwarded their final proposed bill to the IHS Director and to each authorizing committee in the House and Senate and the President. Previously, the House and Senate introduced legislation based on the tribal bill, but neither passed.

Last year the Northwest Portland Area Indian Health Board and other Area Health Boards hosted a May 28-30, 2003 Indian Health Care Improvement Act meeting. The purpose of the meeting was to consider changes and provide recommendations on the proposed legislation in response to concerns raised in a September 27, 2001 letter and memorandum from Health and Human Services Secretary Tommy G. Thompson to Senator Daniel Inouye. The primary issues raised in Secretary Thompson's correspondence focused on the high costs associated with some of the bill provisions, questions about what outcomes were sought in regards to certain sections of the bill, and it also included opposition to certain elements in the bill. The participants at the Portland meeting took a hard look at the high Congressional Budget Office (CBO) score on S. 212 and the other concerns and forwarded recommendations to the House and Senate in July 2002.

I am very pleased you have introduced S. 556 early this year and have held prompt hearings. The Bill appears to be identical to S. 212 introduced during the 107th Congress, so we look forward to bringing you up-to-date on some changes recommended by the National Steering Committee. The National Steering Committee is currently working with House members and committee staff on a House bill that is expected to be introduced very soon that incorporates the recommendations developed at the 2002 NSC meeting in Portland, further changes discussed in subsequent meetings with House Legislative Counsel, other legislative staff meetings, and at the March 20 and 21, 2003 NSC meeting hosted by the Northwest Portland Area Indian Health Board just a couple of weeks ago.

I should tell you that in December 2002 the NSC met in Rockville, MD and selected Lone Pine Paiute Shoshone Tribal Chairperson Rachel Joseph and me to cochair this year's effort. In addition, Don Kashevaroff representing the Tribal SelfGovernance Advisory Committee, former Navajo Nation Vice President Taylor McKenzie, and Kay Culbertson of the National Council of Urban Indian Health make up this years NSC leadership group. The balance of members represent each of the 12 areas of the Indian Health Service and several national Indian organizations that I mention below. A lot of good things are possible if we pass the bill with our recommended changes. The titles have exciting new authorities.

I want to briefly review the titles contained in the Indian Health Care Improvement Act. Time only permits mentioning highlights in each title, but I am ready to answer your questions on any of the titles to the best of my ability. Although I have worked extensively on the bill over the past 4 years, I may have to call upon one of the technical advisers who possess a detailed knowledge of the legislation to assist with my answers to your questions.

The Preamble section of the act has been revised, including sections on Findings, Declaration of Nation Policy and Definitions. Emphasis has been placed on the trust responsibility of the Federal Government to provide health services and the entitlement of Indian tribes to these services