[Senate Hearing 108-127]
[From the U.S. Government Publishing Office]
S. Hrg. 108-127
NOMINATION OF CHARLES GRIM
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
ON
NOMINATION OF CHARLES W. GRIM, TO BE DIRECTOR OF THE INDIAN HEALTH
SERVICE AT THE DEPARTMENT OF HEALTH AND HUMAN SERVICES
__________
JUNE 11, 2003
WASHINGTON, DC
87-906 U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON : 2003
____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpr.gov Phone: toll free (866) 512-1800; (202) 512�091800
Fax: (202) 512�092250 Mail: Stop SSOP, Washington, DC 20402�090001
COMMITTEE ON INDIAN AFFAIRS
BEN NIGHTHORSE CAMPBELL, Colorado, Chairman
DANIEL K. INOUYE, Hawaii, Vice Chairman
JOHN McCAIN, Arizona, KENT CONRAD, North Dakota
PETE V. DOMENICI, New Mexico HARRY REID, Nevada
CRAIG THOMAS, Wyoming DANIEL K. AKAKA, Hawaii
ORRIN G. HATCH, Utah BYRON L. DORGAN, North Dakota
JAMES M. INHOFE, Oklahoma TIM JOHNSON, South Dakota
GORDON SMITH, Oregon MARIA CANTWELL, Washington
LISA MURKOWSKI, Alaska
Paul Moorehead, Majority Staff Director/Chief Counsel
Patricia M. Zell, Minority Staff Director/Chief Counsel
(ii)
C O N T E N T S
----------
Page
Statements:
Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado,
chairman, Committee on Indian Affairs...................... 1
Conrad, Hon. Kent, U.S. Senator from South Dakota............ 11
Dorgan, Hon. Byron, U.S. Senator from North Dakota........... 15
Grim, Charles, DDS, nominee for Director of Indian Health
Service, Department of Health and Human Services,
Washington, DC............................................. 3
Inhofe, Hon. James M., U.S. Senator from Oklahoma............ 2
Murkowski, Hon. Lisa, U.S. Senator from Alaska............... 14
Nickles, Hon. Don, U.S. Senator from Oklahoma................ 2
Appendix
Prepared statements:
Grim, Charles................................................ 17
NOMINATION OF CHARLES W. GRIM
----------
WEDNESDAY, JUNE 11, 2003
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The committee met, pursuant to notice, at 10:01 a.m. in
room 485, Senate Russell Building, Hon. Ben Nighthorse Campbell
(chairman of the committee) presiding.
Present: Senators Campbell, Murkowski, Conrad, and Dorgan.
STATEMENT OF HON. BEN NIGHTHORSE CAMPBELL, U.S. SENATOR FROM
COLORADO, CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS
The Chairman. Good morning, and welcome to the committee's
hearing on the nomination of Dr. Charles Grim to be the
Director of the Indian Health Service.
Since August 2002 Dr. Grim has been serving as the Interim
Director of the Indian Health Service. In March 2003, President
Bush submitted his nomination to the U.S. Senate.
Dr. Grim is an enrolled member of the Cherokee Nation of
Oklahoma, and, despite his relative youth, has already had
quite a distinguished career with the Indian Health Service. In
fact, I was reading about some of your latest accolades and
awards, Dr. Grim. A dentist, Dr. Grim has been twice awarded
the U.S. Public Health Service Commendation Medal and the
Achievement Medal. He is the recipient of the Jack D. Robertson
Award, which is given to senior dental officers in the U.S.
Public Health Service who demonstrate outstanding leadership
and commitment. He also currently holds the rank of Rear
Admiral as part of the Commissioned Corps of the U.S. Public
Health Service.
We have, by the way, received numerous letters regarding
this nominee, and every single one of them is very positive. I
was very pleased to see that Dr. Grim. These and other letters
will be included in the record, and during the next 2 weeks, I
imagine we will be getting a few more.
I will also tell the Members that it is not my intention to
vote on this nomination at the conclusion of this hearing
because we will be doing another hearing right afterwards. But
we will schedule a vote on it before the end of the month.
Senator Inouye may not be attending this morning, so we
will go ahead. Senator Inhofe, if you would like to introduce
Dr. Grim.
STATEMENT OF HON. JAMES M. INHOFE, U.S. SENATOR FROM OKLAHOMA
Senator Inhofe. Thank you, Mr. Chairman. It is my honor to
be here. I know that Senator Nickles is planning to be here
because I talked to him, so I will stall a little bit while he
comes. I would like to say that it is kind of unique that our
honoree this morning is from Oklahoma. You can say he is from
two cities, Tulsa and Ponca City. As it happens, Tulsa is my
home town and Ponca City is Don Nickles' home town. So that is
a little bit of a coincidence.
It is very meaningful to me, with the background that
Charles has, that he has taken the position. I do not think
that you could have a more qualified person to confirm for any
position than our nominee today. I think probably the best way
for me to introduce him is to read to you a proclamation that
makes today a very special day in the State of Oklahoma, and it
is actually proclaimed by our Governor who is a Democrat, not a
Republican. So, if you would allow me to read this proclamation
into the record, I would appreciate it.
The Chairman. Please do.
Senator Inhofe. Here is Don. I will tell you what I will
do. I will go ahead and read this proclamation, and then I will
turn it over to Don.
The Chairman. All right.
Senator Inhofe.
Whereas, Charles W. Grim, DDS, is a native Oklahoman and a
member of the Cherokee Nation of Oklahoma; and
Whereas, Dr. Grim, a 1983 graduate of the University of
Oklahoma College of Dentistry, has served in the IHS for nearly
20 years and has held several positions, most recently serving
as Director of the Oklahoma City Area Office; and
Whereas, in August 2002, President George W. Bush appointed
Dr. Grim as the Interim Director of the Indian Health Service,
an agency of the Department of Health and Human Services; and
Whereas, on June 11, 2003, the Senate Committee on Indian
Affairs will officially confirm President George W. Bush's
appointment of Dr. Grim to serve as the Director of the Indian
Health Service; and
Whereas, as Director, Dr. Grim will administer a nationwide
multi-billion dollar health care delivery program providing
preventive, curative, and community health care for
approximately 1.6 million of the Nation's 2.6 million American
Indians and Alaska Natives.
And as the IHS is the principal Federal health care
provider and health advocate for Indian people, I will be
working very closely with you, Doctor, as we discussed in my
office yesterday, on a pet project I have had for quite some
time, and that is Indian diabetes and some of the unique
problems that we are facing there.
So it is a great deal of honor for me to second the
nomination for Dr. Grim. And I turn it over to my senior
Senator, Don Nickles.
The Chairman. Thank you. Senator Nickles.
STATEMENT OF HON. DON NICKLES, U.S. SENATOR FROM OKLAHOMA
Senator Nickles. Mr. Chairman, thank you very much. I want
to join my colleague, Jim Inhofe, in urging the committee
toward a rapid confirmation of Dr. Grim to be the Director of
Indian Health Service.
We are very honored, to have an Oklahoman and a member of
the Cherokee Nation who has 20 years of experience in Indian
Health Service, a lot of that experience in Oklahoma as well as
New Mexico. He graduated from the University of Oklahoma School
of Dentistry. He also has a Masters degree in Health Services
Administration from the University of Michigan. He now holds
the rank of Rear Admiral in the Commissioned Corps of the U.S.
Public Health Service. Dr. Grim has 20 years of experience in a
lot of different capacities. He has served as Area Director of
the Oklahoma City Area Indian Health Service--with a
jurisdiction that includes Oklahoma, Kansas, and portions of
Texas. He oversaw health services for the largest IHS
population in the Nation. He has done an outstanding job.
Everyone has told us that, both within the Indian Health
Service and others that have had the pleasure of working with
him.
I am excited about his nomination. I am excited about his
eventual confirmation. And I look forward to working with Dr.
Grim and others in this committee to see if we can make
positive improvements in Indian health throughout the country.
I appreciate the Chairman's commitment for doing that as well.
I think we have an outstanding nominee who will do a great job
in service to our country and to our Nation's Indian
population.
Mr. Chairman, thank you very much.
The Chairman. I thank you, Senator Nickles and Senator
Inhofe, for making that very fine introduction. If you have a
busy schedule and need to leave, that is fine. But you are
certainly invited to stay as long as you can.
Senator Nickles. We will leave it in your very capable
hands, Mr. Chairman. Thank you.
The Chairman. Dr. Grim, we will now take your statement. I
need to tell you that every letter that we have gotten, as I
mentioned before, is in support of your candidacy. You have a
very outstanding background. There does not seem to be any
opposition at all. We will take your complete statement. But I
should tell you that around this place sometimes the longer you
talk the more questions arise. [Laughter.]
The Chairman. So you are welcome to submit your complete
written statement that will be included in the record, and if
you would like to abbreviate or depart from it, that is fine.
Please proceed.
STATEMENT OF CHARLES GRIM, DDS, NOMINEE FOR DIRECTOR OF INDIAN
HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES,
WASHINGTON, DC.
Mr. Grim. Thank you, Mr. Chairman, Mr. Vice Chairman, other
distinguished members of the Committee on Indian Affairs. It is
a pleasure and an honor for me to be sitting here before you
today as the nominee by President George W. Bush, and supported
by tribal governments across the Nation, also endorsed by
Secretary Tommy Thompson, and for this committee to consider me
as the seventh Director of the Indian Health Service.
For those on the committee and those attending this
hearing, I would like to introduce myself. My name is Charles
W. Grim. I am a member of the Cherokee Nation of Oklahoma, and
I am descended from those who walked the Trail of Tears. I come
from the town of Cushing, OK. I am the father of two children,
Kristen and Steven, who are sitting behind me and are here
today. My sister, Denise Grim, is also here with me to
celebrate this honor. My mother, Ruth Kannady Grim, has also
travelled to be with me today and understands how important an
occasion this is for me.
The Chairman. Where is your family, Dr. Grim?
Mr. Grim. They are right here behind me.
The Chairman. Very good. Thank you.
Mr. Grim. We got here early so they could have a front row
seat.
The Chairman. Good. Do not worry, in this committee your
mom will always have a front row seat.
Mr. Grim. I also wanted to mention my father, Charles Grim,
who has passed away but whose confidence in me gave me the
strength to face moments in life such as this.
As a child, both my parents and also my aunt and uncle,
Larry and Dorothy Snake, instilled in me a sense of heritage
and culture. With their encouragement and guidance, I grew up
knowing my Indian heritage while living in a non-Indian world.
As an adolescent, I wanted to work for the Indian Health
Service as a way to help Indian people. And after I decided on
dentistry as my career field and graduated from dental school,
my aunt also encouraged me to work for the IHS as part of my
National Health Service Corps educational scholarship pay back
requirement.
My first assignment was with IHS at the Indian health
center in Okmulgee, OK. Working there was like coming home and
fulfilling the dream I had as a teenager to help Indian people.
I knew then, and I know now just as strongly, that working for
the IHS is part of my life. I cannot imagine being as satisfied
or having a sense of reward working anywhere else. To be
nominated to lead the Indian Health Service, and to be in a
position to do so much for so many Indian people is an
unexpected and humbling opportunity, as well as a great honor.
The opportunity to set before you today is the culmination
of events put into motion in 1784 with the signing of the first
treaty between the Federal Government and an Indian Nation. My
ancestors and yours helped build this great Nation and have
brought us to this moment and the opportunities before us. I
pledge both to the Federal and tribal governments that I will
do my best to take full advantage of this opportunity and to
work with this committee who has done so much for Indian
affairs, the Administration, Secretary Thompson, and tribal
governments toward our shared goals and objectives.
I am pleased to serve as the Director of the IHS during
this time in our Nation's history and also to be a part of the
Department's management team under the leadership of Secretary
Thompson as this Department undergoes change to respond to the
health needs of all Americans. Through Secretary Thompson's
leadership as a key policymaker, I am confident that tribal
governments and the position of the Director of the IHS will
enjoy new opportunities to be involved in the evolution of
their health programs. I will also benefit from the Secretary's
policy guidance as I lead the IHS to a position of greater
influence within the Department that has been envisioned by the
Secretary.
I believe one of the overriding questions of my tenure with
IHS would be: How will I meet the challenges of eliminating the
disparity between the health status of American Indians and
Alaska Natives and the rest of the Nation? I intend to focus
heavily on health promotion and disease prevention. The rates
of some health disparities within our population are
decreasing, but the rates of most leading causes of death for
Indian people remain more than double the rates for the rest of
America.
In the early history of the Indian Health Service, the
greatest achievements in reducing health disparities were
through increased medical care and public health efforts that
included massive vaccination programs and bringing safe water
and sanitation facilities to reservation homes and communities.
I believe future reductions in disparities of any significance
will be made through health promotion and disease prevention
efforts and programs rather than through treatment. I believe
the more we invest in promoting good health the less will be
needed for treating the consequences of poor health.
The Indian Health Service has a proud history of
dramatically improving the health of Indian people. Indian life
expectancy has increased by 7.1 years since 1973, although
still 6 years below the general U.S. population. And while
significant disparities still exist, mortality rates have
decreased for many health indicators, and the greater
involvement since the passage of the Indian Self-Determination
and Education Assistance Act of 1975 of Indian tribes and
Indian people in the decisions affecting their health has also
produced significant health improvements for Indian people. I
will continue to support the decision of tribes to contract,
compact, or retain the Indian Health Service as their provider
of choice.
The Indian Self-Determination Act gives tribes the right to
manage their own health programs. And the continual increase in
the number of tribes electing to contract and compact for IHS
programs, and the increased political influence of Indian
tribes and organizations at the State and national level are
also having positive impacts on health indicators. In addition,
this Administration and the Secretary have put their words into
action and have increased the involvement of tribal and urban
Indian representation in advising and participating in the
decisionmaking process of the Department.
Increased tribal involvement has also resulted in the
development of an American Indian and Alaska Native workforce.
The significance of this is twofold: It is a demonstration of
self-determination, but it also improves the health status of
Indian people, because it is well known that there is a
positive co-relation between employment and health status. For
example, 69 percent of the 15,000 employees within the Indian
Health Service workforce are American Indian or Alaska Native.
And because of the location of many of the IHS and tribal
facilities, many are the major employers in the area. So, in
addition to salaries, most of the operating funds are spent or
invested back into the local and surrounding economies, and in
many cases through tribal and Indian community businesses and
operations.
I feel we should invest wisely in our communities and in
promoting good health. We cannot increase our health promotion
and disease prevention programs at the expense of our treatment
programs. And without improvements in other areas that affect
health, improvement in health status cannot be sustained.
Health status is a result of an interwoven tapestry of factors
such as socioeconomic status, educational status, community and
spiritual wellness, cultural and family support systems, and
employment opportunities, just to name a few. The connection
between poverty and poor health cannot be broken just by access
to health services or treatment alone.
Based on identified trends in Indian health care, I believe
that we must begin to lay the groundwork now for the health
environment that we want to have 5, 10, or 20 years down the
road. I believe we must focus on identifying the emerging
infectious and chronic disease patterns, and the related
dramatically increasing cost of pharmaceuticals to treat these
illnesses and disease. These issues can best be addressed I
believe through health promotion and disease prevention
activities so that our people improve their health, which will
decrease the demand for both health services and
pharmaceuticals.
I have mentioned that my health emphasis will be on health
promotion and disease prevention. My business emphasis will be
to focus on strengthening the infrastructure of the Indian
health system, which consists of the Indian Health Service
programs, the tribal, and the urban health programs. Just as
the health challenge has changed since 1955 when the IHS was
transferred to the Department of Health, Education, and
Welfare, so too has the infrastructure needed to meet those new
demands. In 1955, our 2,500 employees and annual appropriation
of approximately $18 million provided health services for a
population of 350,000 people with a life expectancy of 58
years. We have since increased to a staff of approximately
15,000 and an appropriation of $3 billion, supplemented by
almost half a billion dollars from our third party collections,
which provide limited comprehensive health services for now 1.6
million American Indians and Alaska Natives with an average
life expectancy of 71 years.
Our collections have become critical to the solvency of our
programs because these funds return to the service unit to pay
for additional staff, equipment, or other infrastructure
elements to address the health needs of the community. It is
among my priorities to implement a market-based business plan
that actively promotes innovation. The plan is expected to
enhance the level of patient care through increased revenue,
reduced costs, and improved business processes. The plan will
be implemented as part of the reorganization of the
headquarters function that I have also initiated.
Our workforce is another infrastructure element that is in
crisis. Our annual average vacancy rate for critical health
professions such as doctors, dentists, nurses, pharmacists,
sanitarians, and engineers is approximately 12 percent, ranging
from 5 percent for sanitarians to a high of 23 percent for
dentists. I have initiated a review of the various recruitment
and retention tools available to the agency in order to
establish a more rigorous recruitment and retention effort.
Scholarships, recruitment and retention grants, and health
career specific collegiate programs are some of the funded
tools that will create a greater pool of potential IHS and
tribal employees. Currently, the agency is spending
approximately $33 million of our budget on those efforts.
However, nationwide the demand for health care
professionals and support staff outpaces the supply available.
So to augment our health workforce, particularly for remote and
isolated locations that are difficult to staff or do not have
sufficient workload to justify an on-site or local facility,
the agency will need to continue its efforts to maximize the
use of telemedicine and export the use of an electronic health
record from the few test sites today to across the IHS network
as early as next year.
Another infrastructure issue is the age of the IHS
buildings. Excluding housing, the IHS has 701 buildings
comparable to private sector health facilities. The average age
of our health facility buildings is 36 years, ranging from
newly opened facilities this past year to the 103 year old
Pawnee Health Center. In the private sector, according to the
Almanac of Hospital Financial and Operating Indicators, the
average age of a health facility is nine years. Only 20 percent
of the IHS facilities fall within this range. To strengthen our
efforts to modernize or replace facilities, I have emphasized
additional consideration of collaborative projects between the
IHS and tribes whenever feasible, and I intend to implement a
proactive approach to assist tribes in developing project
proposals and expedite the review and approval process.
The Indian Health Service and the tribes and the urban
Indian health programs are also not alone in trying to meet the
health needs of Indian people. The Department of Health and
Human Services is a vast resource as well. As the Secretary has
stated numerous times at meetings with the tribes, during
visits to Indian country, and to all of the operating divisions
of the Department, the programs of the Department must do more
to make them work better for American Indians and Alaska
Natives and increase consultation with tribes in order to
improve the HHS policies and services to Indian communities.
To enact that philosophy, the Secretary revitalized the
Intradepartmental Council on Native American Affairs, a council
on which the Director of the Indian Health Service serves as
the vice chair, by relocating it into the Office of the
Secretary from an organizational location two levels down
within another HHS component agency. The Secretary has also
incorporated consideration of Indian programs into his ``One
Department'' initiative as benefits are derived from that
initiative throughout the Department. In previous hearings and
in my written statement, I have provided numerous examples of
those benefits.
The Secretary's One Department initiative also includes
consolidating similar functions within agencies to increase
mission effectiveness and economies of scale. I have been asked
by this committee in previous hearings whether One Department
initiatives would be good for the Indian Health Service and
Indian people. I fully support the One Department concept and
assure you that IHS and Indian people will benefit. As we gain
efficiencies in administrative management areas through
consolidations and better use of technology, we will be able to
redirect resources to our health care programs. And I can
assure you that the Department is working closely with the IHS
to assess the impact of consolidation on the programs of the
agency and the effect it will have on employees, services, and
the economic consequences to our communities.
The discussions we have been holding have been positive.
For example, since my last appearance before this committee,
the Department has finalized their decision that all IHS human
resource employees can remain at their current work sites and
continue providing personnel services to our staff, even though
the human resource positions convert to HHS positions on
October 1, 2003. Our staff can remain in place unless they
choose to apply for a position within HHS elsewhere.
We have also been informed by the Department that due to
concerns of this committee, due to concerns of tribal leaders,
and due to concerns that have been laid out to them about the
impact on Indian preference, they are working with us to ensure
that for the positions in our field locations Indian preference
will still apply to our employees there. I also anticipate that
future functional consolidations will also benefit from the
close working relationship between the Department and IHS and
the considerations of any special needs of their particular
programs.
I have heard and share the concerns that Indian programs
stand a great risk of being lost or forgotten if they are
absorbed into a larger organization and program. So to avoid
that, we must be vigilant and provide to others the information
they need in order to make wise decisions rather than make
decisions based on assumptions. Our financial, personnel, and
construction needs and requirements are nothing like any other
``inside the beltway'' agency. Laws governing self-
determination, child protection, Buy-Indian, and Indian
preference in hiring, for example, are unique to the Indian
Health Service.
The IHS is the only Federal program delivering hands-on
care to Indian people based on government-to-government
treaties. I have found this Administration and particularly
this Secretary and his staff to be receptive to receiving
factual information as well as an Indian perspective on the
interpretation of laws and regulations. I agree with this
committee and the tribes of the Nation that influence within
the Department is necessary, and I believe this Secretary has
strengthened the position of Director of IHS to increase the
degree of influence over the decisions of the Department that
impact Indian country.
I also believe now that there is an across-the-board
understanding by all the operating divisions that the
Department is responsible for the health of all the people of
the Nation; that the health of American Indians and Alaska
Natives is not the exclusive responsibility of the Indian
Health Service, and that the Department's resources and funds
need to be directed to this population group.
Today we are facing many challenges. Change and challenge
is nothing new to the history of the Nation or to our Indian
nations. Our history as a people attests to our ability to
respond to challenges, to overcome adversities that we
sometimes face, and to maximize our opportunities.
I have a great passion about this organization and our
mission to raise the health of our people to the highest level
possible. My actions will always reflect the honor of being
entrusted to provide health services to American Indian and
Alaska Native people. And I think I am ready to lead the Indian
Health Service, with honor and respect for our ancestors, and
to work with this committee who, again, has done so much for
Indian people, and this Administration and Secretary Thompson
for the benefit of American Indian and Alaska Native people.
Thank you, Mr. Chairman. I would be pleased to respond to
any questions you might have concerning this nomination.
[Prepared statement of Dr. Grim appears in appendix.]
The Chairman. Thank you, Dr. Grim. Well you hit just about
all of the high points of the health of American Indians. You
mentioned in one part some small increases in health status
with Indians. But you know as well as I do, it might not be
quite as bad as it was years ago, I might say it went from
terrible to just awful, but it is still bad. I know those who
have spent a lot of time on reservations, as I do, in fact all
our colleagues here today, and it is not an uncommon sight to
see people without legs, you mentioned the terrible, terrible
tragedy of diabetes, and that has always been one of my big
concerns as it is with many of us.
I was particularly encouraged that you are really trying to
get young Indian people involved in the health profession. I
think that is just terrific.
You also mentioned the interaction between modern medicine
and I think you said ``cultural,'' I sometimes use the word
``traditional.'' I think that is extremely important that we
try and learn from the past and recognize that some Indian
people, particularly elder Indian people, still have a little
concern about modern medicine unless there is some healer or
somebody there that they really trust from their own standpoint
and their own traditional way of healing.
You also mentioned both tribal and urban programs. I think
that is extremely important as more and more people leave the
reservation and find themselves in big cities where they are
not sure where they are supposed to go and are sometimes turned
away from normal urban health centers because people will tell
them, ``well, you are Indian, you need to go back to your
reservation,'' which may be thousands of miles away and they
cannot do it.
You also mentioned the shared reviews with tribes when you
are going to make some decisions; sometimes we call that
negotiated rule-making. I try to encourage everybody to do more
of that because it is a lot easier doing that before than
having tribes come in here before the committee afterwards and
complain that nobody asked them before they put things in
place. So, good luck with that too.
You also mentioned the One HHS proposal. What kind of a
reaction are you getting from tribes? I do not think I heard
you say that.
Mr. Grim. The reaction to the One HHS efforts, in general,
have been positive. The one that has generated the greatest
concern among tribes has been the human resource consolidation
effort, as this committee is aware. And as I said, since the
last committee hearing I was at, the Department has recognized
the issues unique to Indian Health Services and has made a
couple of decisions that were not available last time. They are
going to be allowing all of our human resource employees to
stay where they are in the locations in the field. They also
have been working with us since that decision was made to see
if there is a way that we can still allow Indian preference in
hiring, and we have got that worked out just this week that all
of our HR employees in the field, when we need to rehire them,
we will be able to use Indian preference in hiring those
positions and then transfer them to the Department at the
appropriate time.
The Chairman. Okay. That is good. Have you had a chance to
look at S. 556, the Indian Health Care Improvement
Reauthorization Act that I introduced again this year along
with Senator Inouye?
Mr. Grim. Yes, sir.
The Chairman. What is your initial feeling about that?
Mr. Grim. I think the overall bill is an outstanding bill,
a very voluminous bill.
The Chairman. I am ready to vote for your nomination right
now. [Laughter.]
Mr. Grim. Maybe I should just stop. [Laughter.]
There are three primary concerns the Administration had.
One of them was on the qualified Indian Health program and the
ability to be able to effectively manage that from a payment
perspective; Medicare and Medicaid issues. Another one was on
what appeared to be a broad use of negotiated rulemaking for a
lot of the regulations within the act and both the cost and the
time factors involved with that. And the third issue was the
extension of 100 percent F-map payments to providers other than
non-Indian health providers, like to the States and the S-chip
programs.
The Chairman. Well you will be before the committee
probably dealing with us on that bill. So I would appreciate
any insight you would have to try to make a bill that I think
is very, very important a better bill that will be acceptable
to tribes and to the Administration. So I look forward to
working with you on that.
Mr. Grim. Yes, sir.
The Chairman. You mentioned diabetes. I had one particular
problem, I think I shared it with you once before, all tribes
have problems with it too, as you know, but I get involved in
it pretty regularly, frankly, because I go home pretty
regularly, and that deals with the Northern Cheyenne diabetes.
As you know, they were able to secure dialysis machines
sometime ago. Now they tell me the IHS will not or cannot or
whatever provide trained medical personnel to operate the
machine. And to compound their frustration, in the last round
of diabetes funding they received such a small amount that it
basically did not help at all. You are aware of that I am sure.
Mr. Grim. Yes, sir; Mr. Chairman.
The Chairman. I talked to you a little bit about that. I
want to do whatever I can to help you make whatever decisions
we need to get machines. They have had a new health clinic
building up there now I guess for about 4 or 5 years and people
still have to drive all the way to I think Crow or to Billings.
They go about 100 and something miles about three times a week
back and forth. They spend one-half their time in an automobile
just to stay alive and that is not right, people should not
have to do that. So I would appreciate you looking into that
and trying to help there.
Mr. Grim. I will, Mr. Chairman.
The Chairman. Let me now go to the Ranking Member today,
Senator Conrad. Do you have an opening statement or any
questions?
STATEMENT OF HON. KENT CONRAD, U.S. SENATOR FROM NORTH DAKOTA
Senator Conrad. Thank you very much, Mr. Chairman. Thank
you, Dr. Grim, for being here. We welcome your family, I assume
this is your family behind you.
Mr. Grim. Thank you.
Senator Conrad. I enjoyed very much our opportunity to
visit the other day. You are going into a circumstance that is
I think one of the most challenging in Government. If we look
at the gap between what is being done and what needs to be
done, I do not think there is a bigger gap anywhere in the
Federal Government. When I go home and visit with people in
Indian country talking about health care, housing, the long
list of needs, health care is right at the top of the list of
concerns. The budget for Indian Health Service that has been
proposed is I think $3 billion; is that correct?
Mr. Grim. Right at $3 billion.
Senator Conrad. What do you think it would take to really
meet the needs across the country to improve Indian health
care? And I say that looking at my own State, seeing in the
Aberdeen area the life expectancy is 64.3 years, 71.1 for all
Indians in the country, average age nationwide for all parts of
our population is almost 77 years. So, 13 years less life
expectancy in the Aberdeen area for Native Americans. When we
look at disease states, 50 percent more likely to have
experienced congestive heart failure--these are Native American
elders--44 percent more likely to report asthma, 173 percent
more likely to be affected by diabetes. The need is not being
met. Would you agree with that?
Mr. Grim. I think we have prioritized as well as we have
been able to, Senator, within the resources we have to focus on
some of the highest priority needs, and they are many of the
ones you mentioned today--diabetes, unintentional injuries, and
on down the line. But we do not have all the resources
necessary to treat all of the conditions out there.
Senator Conrad. In your judgement, how much money would be
needed to really meet the need?
Mr. Grim. There are several studies, well actually one
study on personal health care expenditures that was
accomplished with tribal leadership and with Indian Health
Service, it was done with an outside actuarial firm that
provided for personal health care expenditures and compared it
to a Blue Cross-Blue Shield Federal employees health benefit
package. That particular study showed that for the personal
health care expenditures we were a little over $1 billion short
of what was necessary. The tribes have also done a needs-based
budget and worked closely with the Indian Health Service and
with the Department, and including our infrastructure needs
which include facilities, and I made some statements earlier
and in my written statement about our facilities program, they
have come up with a number of $15 billion, $7 billion of that
is facilities sorts of needs.
Senator Conrad. And $8 billion would be for?
Mr. Grim. The number I cited earlier did not address a lot
of the needs around the public health infrastructure--
sanitation facilities, safe water and sewer systems, things
like that.
Senator Conrad. Okay. Thank you for that. Let me turn to a
specific that I have just learned about that concerns me a
great deal. I have been told on the Fort Berthold Reservation
the service unit there is prohibited by IHS from ever denying a
patient authorization for a procedure that qualifies as a
contract health care priority one procedure--that would be life
or limb threatening--even if the service unit knows it has or
will soon run out of contract health care dollars for the year.
Additionally, I have been told that the service unit may not
carry over contract health care bills from one fiscal year to
the next.
So if a tribal member needs a priority one procedure, the
service unit approves it, but when the bill is received after
the contract health care funds have been exhausted the IHS
simply declares that it is now not a priority one procedure. As
a result, IHS no longer has a legal obligation to pay the bill.
Responsibility for the bill now falls on the tribal member.
Oftentimes, tribal members will not learn until weeks later
that they are responsible for the bill. If the tribal member
cannot pay the bill, which is unanticipated, their credit
rating is damaged.
To your knowledge, is this a IHS policy to reclassify
procedures if a service unit has exhausted its contract health
care funds?
Mr. Grim. No, sir; I am not aware that is a national policy
at all. There are two types of referrals that I would just
raise the issue. We have medical referrals that our medical
staff make for any patient that they feel needs a type of
service that we are not able to provide. So sometimes medical
referrals will be made whether the Indian Health Service has
sufficient funds to pay for them or not. Then there are those
medical referrals that the Indian Health Service will pay for
with contract health service funds and they make every attempt
to pay for all of the priority one cases that there are out
there.
Senator Conrad. Do they pay for all the priority one cases?
Mr. Grim. No; the problem that usually arises is that in
some service units across the Nation there are so many needs
out there that some of the things that fall into our priority
one classification system, there is a letter classification
within priority one, A, B, C, D, E, and sometimes even though
it falls in priority one, if the moneys are expended, they will
have to deny payment for priority one level cases.
Senator Conrad. Let me ask you the fundamental question. Do
you believe it is wrong to, first of all, grant that a priority
one case be funded, and then after the fact change it?
Mr. Grim. If a patient was told upon leaving the facility
that their case was going to be paid for, then, yes, I would
agree with you.
Senator Conrad. I would ask you to investigate this matter
and report back to us on what you find.
Mr. Grim. Okay. I will do that.
Senator Conrad. I take this to be a very serious matter.
Mr. Grim. I agree.
Senator Conrad. People are told that they are priority one,
that their case is to be funded, and then when they run out of
contract health care they as a regular practice reclassify,
leaving that Native American hit with a bill that they had no
idea they were going to be faced with.
The second question I would have on a specific relates to
contract health care, and this relates to something I mentioned
to you when we had a chance to meet. Mercy Hospital, Devils
Lake, North Dakota, which contracts to provide health care, a
small hospital, very good institution, really excellent, very
highly rated care, has written off more than $1 million in the
last 4 years. What sort of changes would you pursue in
contracted health care to prevent this kind of ongoing drain?
This is a small institution. They cannot handle providing care
and then having the payment denied. I cannot tell you how many
meetings I have had with your predecessors on this issue. Over
and over and over I have been promised that something is going
to be done and they go back and they make a few payments and
then we are right back in the soup. What can you tell me that
you would do.
Mr. Grim. I am happy to be able to report to you that just
since our meeting the other day we have already had some action
on that. Our staff out in that location as well as the Area
Director have looked into it and met with staff from Mercy. The
Area Director there is going to be looking into talking with
them about a different sort of contract than we have had with
them in the past, potentially a capitation based contract. So
that in advance for so many people and certain types of
services, Mercy would know how much money they were going to
receive, our patients would know what sort of services would be
available through the referral process there. So, it is a very
unique sort of process, it is not used in very many places, but
they are going to approach them and see if that might be
amenable to the leadership there at Mercy.
Senator Conrad. I welcome that initiative and I thank you
for thinking outside the box.
The final question I would have, immediately following this
hearing the committee will receive testimony on legislation
Senator Dorgan and I have authored to authorize a rural health
facility for the Three Affiliated Tribes at Fort Berthold. This
legislation fulfills a long-standing promise made by the
Federal Government to replace the hospital that was destroyed
by the construction of the Garrison Dam and Reservoir. If the
authorization passed, would you ensure that this facility is
placed on the construction priority list the Indian Health
Service is currently formulating?
Mr. Grim. Based on how the legislation is worded, Senator,
we would adhere to the legislation.
Senator Conrad. I thank you for that. Thank you, Mr.
Chairman.
The Chairman. Thank you, Senator Conrad. Before I yield to
Senator Murkowski, let me tell you that I agree with Senator
Conrad that we are never going to fix the problem if we are
going to focus just totally on bandaging, giving drugs,
operating, and so on. That is all what you do after the problem
has happened. And I am very happy to hear that you also believe
in prevention as part of the big medicine picture. Because
although there might be some problems in Indian health that are
genetic, I do not know, or some based on infrastructure with
poor water and so on, an awful lot of it has to do with
lifestyle. Asthma is related to stress as well as other things.
I am not a doctor but I know that from my readings. Diabetes is
related to diet. And I have yet to see people who have to live
on commodities call that a balanced diet. Heart disease is
related to obesity and cholesterol. Dental problems are related
to oral hygiene. It just seems to me that if we would put more
emphasis toward prevention, we would have a much better and
more efficient use of the money that we have to appropriate and
spend on Indian health.
I might mention that some tribes are really taking a lead
on that. I happen to live on the Southern Ute Reservation in
Colorado. They just recently built a building that is used for
a lot of things, as a community center, it also has a
gymnasium, but the interesting part of it is that they give
cooking classes and also lifestyle counseling classes on diet.
And if you have not had a chance to visit that, I would
recommend you do. It is a wonderful facility, widely used. In
fact, the tribe has opened it up to non-Indians too. So there
are a lot of people around the community that take advantage of
it due to the tribe's good graces. So please come and see that.
Senator Murkowski.
Senator Murkowski. Thank you, Mr. Chairman.
STATEMENT OF HON. LISA MURKOWSKI, U.S. SENATOR FROM ALASKA
Welcome, Dr. Grim. I appreciate your comments this morning,
appreciate the opportunity to speak with you yesterday and in
the previous opportunities we have had to meet. I suppose the
good word coming from my State is there is an endorsement,
certainly an enthusiastic response toward your nomination. So I
am pleased to be able to speak to that support today. The word
that I hear back from Alaska is that you are a good listener.
Mr. Grim. Thank you.
Senator Murkowski. I think that speaks a lot. And if you
listen well to the concerns and are willing then to implement
afterwards, I think we all win.
I am particularly pleased to hear your emphasis on health
promotion and disease prevention. As you know, in Alaska we
have very serious challenges when it comes to the health needs
of our Alaska Natives. We have some statistics that,
unfortunately, are off the charts when it comes to rates of
alcoholism. We have seen recently a huge increase in smoking by
Native women who are pregnant and we are seeing lower birth
rates. We are seeing more children born with FAS/FAE. We have
suicide rates that are absolutely unacceptable. The chairman
has mentioned diabetes, the obesity issues. Many of these, many
of these we can be more proactive.
One of the problems that we face in many of the Native
communities out in the bush is we have got terrible dental
problems. Part of it is because of the lack of professionals
out there. Another part is we have basic infrastructure issues.
We do not have the safe water, and so instead of children even
drinking powdered milk, they cannot do that because the water
is not safe, and we cannot get the fresh milk in because of
transportation issues, so the kids are drinking pop and their
teeth are rotting.
We need to work with our communities on that. We need to
work to push the prevention issues. So I am pleased to assist
you with that initiative because I think if we work the
prevention end, your job is made just that much easier in terms
of the health services that are provided for those in my State.
So I look forward to working with you on that and so many of
these others.
I will extend the invitation, I know you are coming up to
the State this summer, and look forward to the opportunity to
introduce you to many of our areas, some of our challenges,
and, hopefully, many of our opportunities. I do not know
whether it is in the Administration's kind of spot light, if
you will, to elevate this position as Director to perhaps an
Assistant Secretary level, but perhaps you would be the first
so named. If that is the case, I think we in Alaska would be
very supportive.
I do not have any questions for you today but just wanted
to state for the record that we are looking forward to working
with you on the health issues that relate to the Alaska Natives
as well as all Native Americans.
Mr. Grim. Thank you, Senator Murkowski.
The Chairman. Senator Dorgan, did you have any comments or
questions?
STATEMENT OF HON. BYRON L. DORGAN, U.S. SENATOR FROM NORTH
DAKOTA
Senator Dorgan. Mr. Chairman, because of the time, we want
to get on to the bill that is the subject of the next hearing.
We have an 11:15 vote. So I think I will not ask questions. Dr.
Grim, I am going to be supportive of your nomination. I think
you have very strong credentials. I am very pleased by your
nomination and I want you to succeed.
Mr. Grim. Thank you, Senator.
Senator Dorgan. My colleague Senator Conrad asked the
questions I would have asked. But let me just make a comment,
if I might. You indicated that the allocations for the IHS
within the amount of money that is available are the best that
we can do and you are trying very hard. I understand all of
that. But in both Democrat and Republican Administrations the
IHS budgets have not been sufficient to meet the health care
needs of Native Americans. The mortality in Indian country
compared to the rest of the country, for example, is seven
times higher as a result of alcoholism, it is five times higher
as a result of tuberculosis, four times higher as a result of
diabetes--on the Fort Berthold Reservation that is 12 times
higher due to diabetes--3 times higher due to injuries, twice
as high due to suicides, twice as high due to homicides.
The fact is we face an enormous challenge and it is very
serious. And the thing that angers me a bit is this: As you get
up in the morning and get ready for work, you turn on the radio
and listen to the news and you hear that this country has $26
billion to try to persuade Turkey to allow our troops to enter
Iraq from the North. And I am thinking to myself, where did the
$26 billion come from? We cannot find a half a billion dollars
or a billion dollars to address life and death issues dealing
with health care for Native Americans, all of a sudden we have
got $26 billion for Turkey. And I see that time after time
after time. It is a matter of priorities.
We have got a reservation in North Dakota. Dr. Grim, you
are a dentist, so you will particularly understand this. One
dentist is serving 4,000 people out of a trailer house. That is
not health care. That is not appropriate. On that same
reservation, there are the same batch of problems with
inadequate funding in social services, with life and health
consequences. A young girl named Tamara is beaten severely,
nose broken, arm broken, hair pulled out at the roots. Why?
Because she was put in a foster care situation by one person, a
social worker, who was working 150 cases--150 cases. So they
put this young 3 year-old girl into foster care and she is
beaten severely. It will affect her the rest of her life. Why?
Because we did not have enough money to have enough caseworkers
to make sure we protected these young children.
This is not about you, but I get angry about the priorities
here in our country. We say we do not have the money to deal
with these issues. You know, you just answered my colleague
when he asked the question about how much is needed. You know
we are desperately short of money for health care for Native
Americans. We are desperately short of money. And it is not
sufficient for a Democratic Administration or a Republican
Administration to say we are doing the best we can allocating
money within our resources. The fact is they find resources,
every Administration does, for the things they care about. And
we all ought to care about the fact that a grandmother freezes
to death in this country on the Rosebud Reservation in her home
without windows in the winter at 35 below zero--freezes to
death in her home. Or a young child is beaten severely, or
someone shows up for health care with a sick child someplace or
a severe dental problem and the fact is they do not get the
kind of health care they need.
So, I have said my piece. I preceded it by saying I am
pleased that you are nominated. I am going to be proud to
support your nomination. I will be happy to vote for you. But
we need to do better, all of us, you, me, my colleagues, the
President. These are priorities.
Mr. Chairman, I think my colleague asked the very important
questions I would have asked as well. Thank you for holding
this hearing.
Dr. Grim, you are going to be confirmed by the Senate and
then all of us are going to wish you well. We want to work with
you to make you successful in this job.
Mr. Grim. Thank you, Senator Dorgan. And thanks to all of
this committee and their support. You have done a lot for
Indian people over the years and I am honored to be working
with you.
The Chairman. Thank you, Dr. Grim.
[Whereupon, at 10:47 a.m., the committee proceeded to other
business.]
=======================================================================
A P P E N D I X
----------
Additional Material Submitted for the Record
=======================================================================
Prepared Statement of Charles W. Grim, D.D.S., Department of Health and
Human Resources
Mr. Chairman, Mr. Vice Chairman, and other distinguished members of
the Senate Committee on Indian Affairs:
It is a pleasure and an honor for me to have been nominated by the
President, supported by tribal governments across the nation, endorsed
by Secretary Thompson, and for this committee to consider me as the
seventh director of the Indian Health Service.
The opportunity to sit before you today is the culmination of
events put into motion in 1784 with the signing of the first treaty
between the Federal Government and an Indian Nation. My ancestors and
yours helped build this great nation and have brought us to this moment
and this opportunity. I pledge to both the Federal and tribal
governments that I will do my best to take full advantage of this
opportunity and to work with this committee, the Administration, and
Tribal Governments toward our shared goals and objectives.
For the benefit of guests of this committee and future researchers
of the Congressional Record, this is the description of the Indian
Health Service today: The IHS has the responsibility for the delivery
of health services to approximately 1.6 million federally recognized
American Indians and Alaska Natives [AI/ANs] through a system of IHS,
tribal, and urban 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 ensure that comprehensive, culturally
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 AI/AN people,
communities, and cultures and to honor and protect the inherent
sovereign rights of tribes.
For those on the committee and those attending this hearing, I
would like to introduce myself. I am Charles W. Grim. I am a member of
the Cherokee Nation of Oklahoma. I come from the town of Cushing,
Oklahoma. I am descended from those who walked the Trail of Tears. I am
the father of two children, Kristen and Steven, who are here with me
today. My sister, Denise Grim, is also here to celebrate this honor. My
mother, Ruth Kannady Grim, who has also traveled to be with me today,
understands how important an occasion this is for me. I would also like
to mention my father, Charles Grim, who has passed away but whose
confidence in me gave me the strength to face moments in life such as
this. As a child, both my parents, and also my aunt and uncle, Larry
and Dorothy Snake, instilled in me a sense of my heritage and culture.
With their encouragement and guidance, I grew up knowing my Indian
heritage while living in a non-Indian world. As an adolescent, I wanted
to work for the Indian Health Service as a way to help Indian people.
And after I decided on dentistry as my career field and graduated from
dental school, my aunt also encouraged me to work for the IHS as part
of my National Health Service Corps educational scholarship pay back
requirement. My first assignment with the IHS was at the Indian health
Center in Okmulgee, Oklahoma. Working there was like coming home and
fulfilling the dream I had as a teenager to help Indian people. I knew
then and I know now, just as strongly, that working for the Indian
Health Service is a part of my life. I cannot imagine being as
satisfied or having such a sense of reward working anywhere else. To be
nominated to lead the Indian Health Service, and to be in a position to
do so much for so many Indian people, is an unexpected and humbling
opportunity, as well as a great honor.
In addition to my personal connection and desire to lead the
agency, I am a Doctor of Dental Surgery and I have a Masters degree in
Health Services Administration with focus on the Management and
Administration of health services, dental care, and hospital and
ambulatory care. I have served with the U.S. Public Health Service for
20 years--through assignments to various offices and programs of the
Indian Health Service. I am ready to take on the job of Director of the
Indian Health Service.
I believe the overriding question is: How will I meet the challenge
of eliminating the disparity between the health status of AI/ANs and
the rest of the nation? I intend to focus on health promotion and
disease prevention. The rates of some health disparities are
decreasing, but the rates of most leading causes of death for Indian
people remain more than double the rates for the rest of America--for
accidents, the rate for Indian people is 280 percent of the rate for
the general U.S. population; for alcoholism, 770 percent; for diabetes,
420 percent; for homicide, 210 percent; and for suicide, 190 percent.
The number of AI/ANs enduring end stage renal disease is 2.8 times the
rate for whites. The rate of diabetic end stage renal disease for AI/
ANs is 6 times the rate for the rest of the nation. Amputations due to
circulatory consequences of diabetes have decreased significantly, but
still occur at rates 3 to 4 times the rates for the rest of the nation.
And the tragedy of Sudden Infant Death Syndrome (SIDS) and adolescent
suicide occurs within Indian families at more than twice the rate for
other families.
In the early history of the Indian Health Service, the greatest
achievements in reducing health disparities were through increased
medical care and public health efforts that included massive
vaccination programs and bringing safe water and sanitation facilities
to reservation homes and communities. I believe future reductions in
disparities of any significance will be made through health promotion
and disease prevention efforts and programs rather than through
treatment. To continue on a treatment track alone would bankrupt the
nation's health system, including the IHS. For the Indian health system
as well as all the United States health programs, there is no practical
way the health resources of this great nation can begin to meet the
health demands of an aging population whose chronic health conditions
are largely the result of a western diet and sedentary lifestyle.
For example, while the mortality rate for Indian people due to
diabetes is 420 percent of that for the rest of the nation, the
occurrence of Type 2 diabetes is 2.6 times the national average, and it
is rising faster among American Indians and Alaska Native children-and
young adults than in any other population group but with minimal
changes in diet and exercise, such as reducing body weight by 10 pounds
and walking 30-minutes a day--the onset of diabetes can be delayed and,
in some cases, can be prevented.
Cardiovascular disease is now the leading cause of mortality among
Indian people, with a rising rate that is already almost double that of
the U.S. general population; but by modifying or eliminating health
risk factors such as obesity, sedentary lifestyles, smoking, high-fat
diets, and hypertension, that trend can be reversed.
Another example, infant mortality in Indian country can be reduced
by 25 percent--25 percent--as more parents understand that placing
their infants on their back to go to sleep removes one of the major
risks for SIDS.
And we need to invest in our communities so that despair does not
fill the lives of our children. The rate of suicide among Indian youth
is twice that for the general population. There are many programs, not
just those of the Indian Health Service, which can be implemented to
reduce or eliminate the number of our children who are killing
themselves.
I believe the more we invest in promoting good health the less will
be needed for treating the consequences of poor health. The Indian
Health Service has a proud history of dramatically improving the health
of Indian people. And the greater involvement, since the passage of the
Indian Self-Determination and Education Assistance Act in 1975, of
Indian tribes and Indian people in the decisions affecting their health
has also produced significant health improvements for Indian people:
Indian life expectancy has increased by 7.1 years since 1973 (although
still 6 years below the general U.S. population) and while significant
disparities still exist, mortality rates have decreased for maternal
deaths, tuberculosis, gastrointestinal disease, infant deaths,
unintentional injuries and accidents, pneumonia and influenza,
homicide, alcoholism, and suicide.
I will continue to support the decision of tribes to contract,
compact, or retain the Indian Health Service as their provider of
choice.
In a study of indigenous people and their health, cited in the
British Medical Journal (March 2003), it was noted that lack of self-
governance, if allowed to continue, can have a devastating impact on
health indicators. The Indian Self-Determination Act gives tribe the
right to manage their own health programs. The continual increase in
the number of tribes electing to contract and compact for Indian Health
Service programs and the increased political influence of Indian tribes
and organizations at the state and national level, are having a
positive impact on health indicators. In addition, this Administration
and the Secretary have put their words into action and increased the
involvement of tribal and urban Indian representation in advising and
participating in the decisionmaking processes of the Department.
Increased tribal involvement also results in the development of an
AI/AN workforce--for example, 69 percent of the 15,000 employee Indian
Health Service workforce is AI/AN and, excluding the medical
professional employees where there is not a large Indian applicant
pool, 88 percent of the IHS workforce is American Indian or Alaska
Native. The tribal and urban Indian operated programs have similar to,
or higher, Indian workforce participation rates than the IHS. Because
of the location of many of the IHS and tribal facilities, many are the
major employer in the area. So, in addition to salaries, most of the
operating funds are spent or invested back into the local and
surrounding economies, in many cases through tribal and Indian
community businesses and operations.
We should invest wisely in our communities and in promoting good
health. We cannot increase our health promotion and disease prevention
programs at the expense of our treatment programs. And without
improvements in other areas that affect health, improvement in health
status cannot be sustained. Health status is the result of an
interwoven tapestry of factors such as socioeconomic status,
educational status, community and spiritual wellness, cultural and
family support systems, and employment opportunities, to name a few.
The connection between poverty and poor health cannot be broken just by
access to health services or treatment alone.
Based on identified trends in Indian healthcare, I believe we must
begin to lay the groundwork now for the health environment we want to
have 5, 10, or 20, years down the road. I believe we must focus on
identifying emerging infectious and chronic disease patterns, and the
related dramatically increasing cost of pharmaceuticals to treat
illness and disease. These issues can best be addressed through health
promotion and disease prevention activities, so that our people will
improve their health, which will decrease the demand for health
services and pharmaceuticals.
Preventing disease and injury is a worthwhile financial and
resource investment that will result in long-term savings by reducing
the need for providing acute and chronic care and expensive treatment
processes. It also yields the even more 11 important humanitarian
benefit of reducing pain and suffering and prolonging life.
I have mentioned my health emphasis will be on health promotion and
disease prevention. My business emphasis will be to focus on
strengthening the infrastructure of the Indian health system--the
Indian Health Service program and the tribal and urban Indian programs.
The infrastructure supports a very comprehensive public health and
clinical services delivery program, including such diverse elements as
water and sewage facilities, diabetes prevention and wellness programs,
emergency medical services, and organ transplants. The IHS is the
largest holder of real property in the Department with over 9 million
square feet of space. There are 49 hospitals, 231 health centers, 5
school health centers, and 309 health stations, satellite clinics, and
Alaska village clinics that support the deliver of health care to our
people.
Just as the health challenge has changed since 1955 when the IHS
was transferred to the Department of Health, Education, and Welfare; so
too has the infrastructure needed to meet those new health demands. In
1955, our 2,500 employees and annual appropriation, of approximately
$18 million (or $124 million in today's dollars), provided health
services for a population of 350,000 with a life expectancy 58 years.
We have since increased to a staff of approximately 15,000 and an
appropriation of $3 billion, supplemented by almost half a billion
dollars from our third-party collection efforts, which provides limited
comprehensive health services for 1.6 million AI/ANs with an average
life expectancy of 71 years.
Our collections are critical to the solvency of our programs
because these funds return to the service unit to pay for additional
staff, equipment, or other infrastructure elements to address the
health needs of that community. It is among my priorities to implement
a market-based business plan that actively promotes innovation. The
plan is expected to enhance the level of patient care through increased
revenue, reduced costs, and improved business processes. I have been
involved with this plan, developed through a joint IHS-Tribal-urban
Indian workgroup, since I served as the IHS cochair of the workgroup
when I was the Oklahoma Area Director. The plan will be implemented as
part of the reorganization of the Headquarters functions that I have
also initiated, and will mention later in my statement, in order to
also strengthen our support for infrastructure development.
Our workforce is another infrastructure element that is in crisis.
Our annual average vacancy rate for critical health professions such as
doctors, dentists, nurses, pharmacists, sanitarians, and engineers is
approximately 12 percent, ranging from 5 percent for sanitarians to a
high of 23 percent for dentists. I have initiated a review of the
various recruitment and retention tools available to the agency in
order to establish a more rigorous recruitment and retention effort.
Scholarships, recruitment and retention grants, and health career
specific collegiate programs are some of the funded tools that will
create a greater pool of potential IHS and tribal employees. However,
nationwide the demand for healthcare professionals and support staff
outpaces the supply. To augment our health workforce, particularly for
remote and isolated locations that are difficult to staff or do not
have sufficient workload to justify an onsite or local facility, the
agency will need to continue its efforts to maximize the use of
telemedicine and export the use of an electronic health record from the
few test sites today to across the IHS network as early as next year.
Another infrastructure issue is the age of the IHS buildings.
Excluding housing, the IHS has 701 buildings comparable to private
sector health facilities. The average age of our health facility
buildings is 36 years, ranging from newly opened facilities this past
year to the 103 year old Pawnee Health Center. In the private sector,
according to The Almanac of Hospital Financial and Operating
Indicators, the average age of a health facility is 9 years. Only 20
percent of the IHS facilities fall within this range. To strengthen our
efforts to modernize or replace facilities, I have emphasized
additional consideration of collaborative projects between the IHS and
tribes whenever feasible, and I intend to implement a proactive
approach to assist tribes in developing project proposals and expedite
the review and approval process.
The Indian Health Service and the tribes and urban Indian health
programs are not alone in trying to meet the health needs of Indian
people--the Department of Health and Human Service is a vast resource
as well. As the Secretary has stated numerous times at meetings with
the tribes, during visits to Indian country, and to all of the
operating Divisions of the Department--the programs of the Department
must do more to make them work better for AI/ANs and increase
consultation with tribes in order to improve the HHS policies and
services to Indian communities. To enact that philosophy, the Secretary
revitalized the Intra-departmental Council on Native American Affairs,
a Council on which the Director of the Indian Health Service serves as
the Vice-Chair, by relocating it into the office of the Secretary from
an organizational location two levels down within another HHS component
agency. The Secretary has also incorporated consideration of Indian
programs into his ``One Department'' initiative as benefits are derived
from that initiative throughout the Department. For example; I have had
the privilege of participating in the Intra-departmental Council and
the ``One Department'' initiative since my appointment last August by
the President as the Interim Director of the Indian Health Service.
Some of the benefits to Indian country have been the establishment,
as one of the four top research priorities of the Department, the
identification of the research needs in Indian health and the
conducting of such research; a proposed increase in the IHS sanitation
facilities construction program of $21 million and the contract health
services program of $18 million for Fiscal Year 2004; expanding the
responsibility of the office of Intergovernmental Affairs to increase
access of tribes to the Secretary and his regional staff; and a review
of HHS programs to determine which programs tribes are accessing and
what can be done to help tribes access more programs.
The Secretary's ``One Department'' initiative also includes
consolidating similar functions within agencies to increase mission
effectiveness and economies of scale. I have been asked by this
committee in previous hearings whether ``One Department'' initiatives
would be good for the Indian Health Service and Indian people. I fully
support the ``One Department'' concept and assure you that IHS and
Indian people will benefit. As we gain efficiencies in administrative
management areas through consolidations and better use of technology,
we will be able to redirect resources to our health care programs. I
can assure you that the Department is working closely with the IHS to
assess the impact of consolidation on the programs of the agency and
the affect it will have on employees, services, and the economic
consequences to our communities. Those discussions have been positive.
For example, since my last appearance before this committee, the
Department has finalized their decision that all IHS human resource
employees can remain at their current work sites and continue providing
personnel services to our staff--even though the human resource
position converts to HHS positions on October 1, 2003. Our staff can
remain in place unless they choose to apply for an HHS position
elsewhere. I anticipate that future functional consolidations will also
benefit from the close working relationship between the Department and
IHS and their considerations of any special needs of our particular
programs.
I have heard and share the concerns that, Indian programs stand a
great risk of being lost or forgotten if they are absorbed into larger
organizations and programs. To Avoid that we must be vigilant and
provide to others the information they need in order to make wise
decisions rather than make decisions based on assumptions. Our
financial, personnel, and construction needs and requirements are
nothing like any other ``inside the beltway'' agency. The laws
governing self-determination, child protection, Buy-Indian, and Indian
preference in hiring, for example, are unique to the Indian Health
Service and expertise with those laws and our programs will be exported
through efforts of Departmental consolidation and I believe that the
more Indian people and employees with IHS expertise who are dispersed
throughout the Department at all levels, the more likely the ``One
Department'' goal of raising the health status of AI/ANs and
eliminating health disparities for all Americans can be achieved.
The IHS is the only Federal program delivering hands-on care to
Indian people based on government-to-government treaties. I have found
this Administration and particularly this Secretary and his staff to be
receptive to receiving factual information as well as an Indian
perspective on the interpretation of laws and regulations. I agree with
this committee and the tribes of the Nation that influence within the
Department is necessary. And I believe this Secretary has strengthened
the position of Director of the Indian Health Service to increase the
degree of influence over the decisions of the Department that impact
Indian country.
I believe that now there is an across-the-board understanding by
all the Operating Divisions that the Department is responsible for the
health of all the people of the nation; that the health of AI/ANs is
not the exclusive responsibility of the Indian Health Service, and that
their resources and funds need to also be directed to this population
group. ``One Department'' is not the only restructuring effort being
undertaken within the Department that affects the Indian Health
Service. The IHS and tribes are also working together to restructure
the agency. Even before there was the ``One Department'' initiative,
the Indian Health Service entered into an IHS Restructuring Initiative
with the tribes and urban Indian representatives. Their recommendations
focused on the functions and operations of the agency at the Area
Office and field level based on projected health challenges the agency
may face in the future. I remain committed to that consultation process
and will review the recommendations of the joint workgroup.
In addition to the IHS Restructuring Initiative and the ``One
Department'' initiative, upon my interim appointment I established some
short-term management priorities to improve the responsiveness of the
agency to the tribes and to the Department. I mentioned some earlier,
and also among them was a reorganization of the IHS Headquarters
functions. This process, including Tribal consultation, is ongoing and
is designed to reflect the restructuring recommendations of the tribes,
the ``One Department'' initiative of the Department, the President's
management agenda, and the day-to-day management and operational
demands of the $3.5 billion Indian health program.
And, it is not just the Department, the tribes, or the agency
calling for change. It is also this committee and the Congress. I agree
with the Secretary when he says, about the Department: ``Any
organization that does business the same way it did 35 years ago is
obsolete.'' That applies to the Indian Health Service--the
reauthorization of the Indian Health Care Improvement Act is currently
under consideration by this committee. It was passed 28 years ago--but
we do not need to wait until 35 years have passed to realize that the
health needs of AI/ANs, much less the world, have dramatically changed
over time. The proposed language of the Act outlines a restructuring of
the authorities of the Indian Health Service to reflect the reality
that changes in the health care environment have changed the ability of
tribes, urban Indian health programs, the Indian Health Service, and
the Department to deliver high quality and much needed services. The
Department supports the purposes of the reauthorization of the Act, but
has concerns that are valid and deserve further consideration. Just as
the concerns of the tribes and this committee toward consolidation and
internal reorganization of the agency are valid and need to be
addressed.
Today we are facing many challenges. Change and challenge is
nothing new to the history of the Nation or to Indian nations. Our
history as a people attests to our ability to respond to challenges, to
overcome adversities that we sometimes face, and to maximize our
opportunities.
I have great passion about this organization and our mission to
raise the health of our people to the highest level possible. My
actions will always reflect the honor of being entrusted to provide
health services to American Indian and Alaska Native people. I am ready
to lead the Indian Health Service, with honor and respect for our
ancestors, and to work with you and the Administration for the benefit
of American Indian and Alaska Native people.
I am pleased to respond to any questions you may have concerning my
nomination.
Thank you.