Title I—Indian Health, Human Resources and Development, has been substantially rewritten primarily to shift priority setting and decisionmaking to the local Area levels, where appropriate. The importance of education is highlighted by changes proposed to the act. Title II-Health Services represents a collection of diverse sections addressing issues related to the delivery of health services to American Indian and Alaska Native populations. Diabetes programs and epidemiology centers are just two of the many health programs authorized by this title. Title III-Facilities, proposes that tribal consultation be required for any and all facility issues, not just facility closures. It shelters projects on the current priority list while moving toward a new method for selecting facilities projects. This title gives permanent authority to small ambulatory facilities construction. Title IV-Access to Health Services, seeks to maximize recovery from all thirdparty coverage, including Medicaid, Medicare, and the State Children's Health Insurance Program (S-CHIP) and any new federally funded health care programs. It also will contain new authority for long-term care and protection against estate recovery. This was a title that resulted in the largest dollar total in the CBO score, but the NSC has agreed to some modifications to the provisions in the first tribal bill and this has resulted in billions less in costs to the Federal Government. The main change is that States will not receive huge increases in reimbursements. Title V-Health Services for Urban Indians, adds facility construction authority and coverage by the Federal Tort Claims Act for the 35 urban programs. Urban representatives were very active members of the leadership group on the NSC and they feel that the changes in title V will result in million of dollars in new funding for urban programs. Title VI-Organizational Improvements, includes changes including the elevation of the Indian Health Service Director to Assistant Secretary in the Department of Health and Human Services. Although tribes are generally very satisfied with the relationship Interim Director Dr. Charles Grim has with top policymakers in the Department of Health and Human Services, we want to institutionalize this access with this role change. Title VII-Contains the newly named Behavioral Health title with major revisions, specifically to integrate Alcohol and Substance Abuse provisions with Mental Health and Social Service authorities. I know the committee is having a hearing next week on consolidation of alcohol and substance abuse programs and I think this title can be complementary to the goals of that legislation. Title VIII-Miscellaneous was largely rewritten. It now includes a proposal to establish an entitlement commission to study and make recommendations on making Indian Health an "Entitlement," in the same manner as Medicaid and Medicare. Ten sections were moved out of title VIII to more appropriate sections in the IHCIA. All CHS provisions were moved to title II. A majority of the "free-standing and severability" provisions from other titles were incorporated into title VIII. Conclusion On behalf of the National Indian Health Board, I would like to thank the committee for its consideration of our testimony and for your interest in the improvement of the health of American Indian and Alaska Native people. I know that this act will not pass this year unless Congress hears from tribes that it is indeed a priority in 2003. The National Indian Health Board and tribes nationwide are renewing their efforts to make this happen. The National Steering Committee, working with the National Congress of American Indians, the Tribal Leaders Self-Governance Advisory Committee and the National Council of Urban Indian Health stand ready to work with this committee to make necessary changes and improvements to craft a bill that will assist us in our goal of raising the health status of American Indian and Alaska Natives. STATEMENT OF THE INDIAN HEALTH SERVICE HEARING ON THE REAUTHORIZATION OF THE INDIAN HEALTH CARE IMPROVEMENT ACT APRIL 2, 2003 Mr. Chairman and Members of the Committee: Good morning, I am Dr. Charles Grim, Interim Director of the Indian Health Service (IHS). Today, I am accompanied by Mr. Michel Lincoln, Deputy Director, Mr. Gary Hartz, Acting Director of the Office of Public Health, and Dr. Craig Vanderwagen, Director, Division of Clinical and Preventive Services, Office of Public Health. We are pleased to have this opportunity to testify on behalf of Secretary Thompson on S. 556, the Indian Health Care Improvement Act Reauthorization of 2003". And, at the Committee's request, I will report on the Secretary's One-Department Initiative as it impacts the IHS and the President's FY 04 budget proposal to consolidate automated information systems in the Department. The IHS has the responsibility for the delivery of health services to more than 1.6 million Federally-recognized American Indians and Alaska Natives (AI/ANs) through a system of IHS, tribal, and urban (I/T/U) operated facilities and programs based on treaties, judicial determinations, and Acts of Congress. The mission of the agency is to raise the physical, mental, social, and spiritual health of AI/ANs to the highest level, in partnership with the population we serve. The agency goal is to assure that comprehensive, culturally 2 acceptable personal and public health services are available and accessible to the service population. Our foundation is to uphold the Federal government's obligation to promote healthy American Indian and Alaska Native people, communities, and cultures and to honor and protect the inherent sovereign rights of tribes. Two major pieces of legislation are at the core of the Federal government's responsibility for meeting the health needs of American Indians/Alaska Natives (AI/ANs): The Snyder Act of 1921, P.L.67-85, and the Indian Health Care Improvement Act (IHCIA), Public Law 94-437. The Snyder Act authorized regular appropriations for "the relief of distress and conservation of health" of American Indians/Alaska Natives. The IHCIA was enacted "to implement the Federal responsibility for the care and education of the Indian people by improving the services and facilities of Federal Indian health programs and encouraging maximum participation of Indians in such programs." Like the Snyder Act, the IHCIA provided the authority for the programs of the Federal government that deliver health services to Indian people, but the IHCIA also provided additional guidance in several areas. The IHCIA contained specific language that addressed the recruitment and retention of a number of health professionals serving Indian communities focused on health services for urban Indian people and addressed the construction, replacement, and repair of health care facilities. We are here today to discuss reauthorization of the IHCIA and tribal recommendations for change to the existing IHCIA in the context of the many changes that have occurred in our country's health care environment since the law was first enacted in 1976. S. 556 3 reflects the product of an extensive tribal consultation process that took two full years and resulted in a tribally drafted reauthorization bill. IHS staff provided technical assistance and support to the Indian tribes and urban Indian health programs through this lengthy consultation. The Department supports the purposes of S. 556 to improve the health status of AVAN people and to raise health status the highest possible level. We do, however, continue to have concerns, as expressed previously to the Committee in the Secretary's September 27, 2001 report on S.212, regarding a number of provisions in that bill. As introduced, S. 556 is identical to S. 212. There are several provisions in S. 556 that are inconsistent with current Medicare and Medicaid provider payment practices and could inappropriately increase costs. For example: Title II, Section 202, which describe a new provider type called a Qualified In addition, Section 419 proposes to exempt patients eligible for Medicare or The Department also reported in the staff analysis of its September 27, 2001 bill report some concerns with the managed care provisions in Section 423 which limits appropriate cost and utilization incentives in Medicare and Medicaid by potentially undermining capitated payments in managed care settings. The Administration is seriously concerned about these provisions, which undermine standard practices in Medicare and Medicaid. The most pressing concerns were outlined in the Secretary's September report which I will present to you today: 1) the Qualified Indian Health Program (QIHP); 2) negotiated rule making; and, 3) extension of 100% Federal matching rate for Medicaid and SCHIP. While the Administration continues to have serious concerns about S. 556 in its current form, we are committed to working with the Committee on legislation to reauthorize this important cornerstone authority for the provision of health care to American Indians and Alaska Natives. Qualified Indian Health Program (QIHP) The bill would amend the Medicare statute to add various detailed provisions for a new provider type called a Qualified Indian Health Provider (QIHP) for IHS, Tribal, and urban Indian (I/T/U) providers participating in the Medicare and Medicaid programs. The most problematic aspects of QIHP are the structure and operation of the payment provisions, which are not only burdensome but, more importantly, would not be feasible to administer. QIHP would require the Federal government to complete a series of 5 |