expecting that it will take-just for the current level of services and current level of need, not putting in the new services, new staffing, other types of management expertise, to fully compete in the ISN type of arrangement-it would take at least 92 million. Well, that's-you know, there's no way that we can ask for that level of funding at this present time. And it's just not in the budg

et.

However, we are asking for some increases. We bring this up because, first of all, the majority of patients that urban programs serve, aren't tribally enrolled members. As many of you know here, many of your relatives go back and forth between the city and the tribe and the reservation. We serve these people. They have little or few resources.

We are in a competitive market. Once again we're afraid of the competition; that many of our people will be reassigned, but they will still return for our services, and there will not be that level of service available for them. These people fully deserve that level of service that is available for the comprehensive benefits package, and we need to make sure that Indian people get that level of service. So they need these facilities upgraded.

There was a study done recently based on 1992 dollars, and it's like 12 million just to meet local standards, facilities standards. It doesn't even mean real expansion or anything.

And then one thing, just to touch on another experiment or study that was done in Canada-which has socialized medicine, which is something that we always say that we're trying to model our programs after in terms of universal access and comprehensive benefit package in British Columbia they did a study of urbanized people, First Nation people, and they found that their health status was lacking and far below that of the other Canadian citizens. And so the British Columbian Government went down to Seattle and looked at its whole network of community health centers, and the Seattle Indian Health Board's a part of the Indian Health Board of Minneapolis. We want our people to have that comparable a level of health status and service, and so they developed some programs to test this. That is something that needs to be pointed out that universal access is given-always been given even in developed systems such as community style system of medical delivery. Senator WELLSTONE. You may have to finish up soon. Ms. MARQUEZ-BAINES. Okay.

Well, just in closing, you know, we underscore and appreciate the fact that the President has recently met with the tribe. And we fully support the fact that the States need recognize that the governments-the government's relationship as well and should not discount the fact that there is an Indian Health Service. That they also need to recognize that tribal individuals are residents of the State, as well. And they need to open the dialog and make sure that there is adequate coverage for tribal members that may be living off the reservation, that they negotiate that with this. Senator WELLSTONE. Thank you very much.

Ms. MARQUEZ-BAINES. Thank you.

Senator WELLSTONE. And what we'll do is, we'll move on to Ms. Roy.

I do want to mention one quick thing. I forgot to at the beginning. We just-I just submitted 50 amendments to Senator Kennedy for markup starting May 18. And one of those amendmentswhich I believe will be supported which I think is very relevant of what you were talking about, Carol-says, essentially, we really wouldn't have universal coverage, not truly universal, unless the care is delivered at the communities where people live.

So when it comes to public health, community health care clinics, primary care, family doctors, nurse practitioners, community health care workers, we have to have a stable source of funding for that. That has to be viewed as a separate critical piece of a stable source of funding. And that may be one of the ways in which I think we can really provide some support. And I wanted to mention that.

Ms. Roy.

STATEMENT OF JUDY ROY, EXECUTIVE ADMINISTRATOR, RED LAKE TRIBAL COUNCIL, RED LAKE, MN

Ms. Roy. Thank you, Senator. Welcome back to Northern Minnesota. You're quite a frequent visitor, and we're always happy to see you.

Senator WELLSTONE. Thank you.

Ms. Roy. Part of the dilemma in Indian Health Service and in the health care reform is among Indian people we need to protect what we have. Dr. Annette and Chairman Dechampe talked about some of the treaty obligation and the broader picture. And as a consumer, as a reservation Indian and as an administrator for our tribe, I do recognize that the devil we know is better than the devil we don't know. And so we're careful to not tear down Indian Health Service to the extent where we can't be can't be repaired. And yet there are very obvious problems in the delivery of service in the care that Indian People receive.

Part of I notice you have choice contract services, comprehensive benefits. The major concern that I would bring forth would be the continuity of the care that is lacking in many instances. And I think what's necessary is to kind of put a human face on what's going on among Indian people and health care.

And with my husband's permission I'm going to use Vic as that human face. Victor has had two open-heart surgeries. He's had four heart attacks. He's had angioplasty. He's had every cardiac procedure known to man at this point. And last fall Vic had a stroke as well.

Now, you can imagine his chart at the hospital. Is on volume two about 2 inches thick, each one. Yet when Vic has a crisis, when he has chest pain, or when there's a need for him to go to the hospital, it's a crapshoot as to what kind of care he will receive and what kind of doctor he will see. There is not a very good chance that he'll see a doctor who knows him, or who knows much of the contents of those two volumes of his chart.

The last two times he's had to go to the emergency room, he's seen, first, a pediatrician and, second, and anesthesiologist. It's a little frightening when his problems are cardiac.

He also sees a variety of doctors for his routine care. And having had a stroke and having artificial heart values, it's very crucial

that his blood thinner is regulated at a good rate. And yet we have four or five different people tinkering with that Coumadin, that blood thinner. And so his chances of having another stroke are greatly heightened because there is no continuity of care. So what we have to do is take charge and manage his own health among ourselves. And try to stand up to the doctors, who put their egos and their 32 years of professional experience, are challenged when we try to point out, "No. That's not right. That's not the way it should be."

It's hard to complain. You know, he's alive, but we don't, you know, we want more than that, and human beings deserve better than that. So that's part of the problem.

It's generalized for entire bands of people, for entire reservations. We have seen, as Indian people, that our institutions are not ours. That sometimes there are institutions that can damage people more than repair or help. And in some-if we continue to let our health systems do this, then we're partially to blame.

We recently did a survey or we did a breakdown of our population, and even giving-even given differing birth rates, there is an appalling story in the numbers. From the age of 21 to 30, Red Lake has 1,720 people in that age group. Yet you go to the decade from 61 to 70, the numbers are already down to 334. And the next decade from 71 to 80, we're down to 141 members.

There's, you know, certainly a story behind this. I think Dr. Annette touched on the trauma and the loss of life due to accidents and other other kinds of trauma. But, I think-I often wonder where is the outrage. Where is the outcry over diabetes and the appalling effect it has on our population.

I think that's part of the story behind those statistics. And why do we have money to do amputations but not to do proper prevention? We need to-we need to take a look at where that money isis concentrated.

Also, within the public health system it needs to be more sharing with Indian health. We've sent personnel to Louisiana to the Institute for Hanson's Disease where where people with leprosy are treated, because their foot care, their circulatory problems are much the same as those with diabetes. And yet on our own initiative we needed to make connections with another service within the Public Health Service and try to translate what they've learned to dealing with diabetes among the Indian population. So that needs to be encouraged and built-in more within the entire system, so that we're not reinventing the wheel or redoing research, because many times the problems have been researched to death. And what's needed is action and not more studying.

So that's that's the bulk of my remarks.

And, again, I thank you for being here today.

Senator WELLSTONE. Thank you very much for your testimony. Dr. Mork, it's good to see you again.

Dr. MORK. Thank you.

STATEMENT OF DR. MORK, D.D.S., CASS LAKE IHS HOSPITAL, LEECH LAKE RESERVATION, CASS LAKE, MN

Dr. MORK. We had a two-chair-small two-chair clinic. And itI transferred from another branch of the Government that took

care of the military and merchant marine people. And the level of care the differences that I saw were pretty dramatic. We were doing much more comprehensive dentistry and a lot of hard bridge and dentures. And the demand just was not overwhelming. We were able to keep up with the demand.

I came here and the expectations of the adult population were at a much lower level. They mainly expected the children to be taken care of. And they just came in for emergencies and waited for the pain to, you know, bring them to the dentist. So that was quite a dramatic change.

We were able to, you know-the emphasis was on, you know, prevention and preventive activities. We got involved in fluoride mouth-rinse programs and community-water fluoridations. And the goal was to reduce the demand or the percentage of emergencies that we saw to get more of a handle on the dental needs.

But over the years, I haven't seen a dramatic change in the emergencies. The percentage of emergencies that we see is around 40 percent. And that's, you know, much different that a practice like in Minneapolis where they would see probably, you know, 1,000 children and were able to easily handle that. Were able to, and wouldn't be overwhelmed with that number. Because of the percentage of decay and abscesses, we see severe infections, and, you know, just a totally different practice than-than other areas. So, again, you can't really base the ratio of-you know, the population-to-provider ratio should be significantly different for the reservation relative to other practices.

We have had some expansion in the program, but we, you know, we're up to 22 dentists and 4 assistants, but we're just not getting the expansion that we need to meet the demand. The expectations of the population are increasing. They are more educated and, you know, the adults are expecting comprehensive care. And we're just not able to provide it.

The as far as preventive activities, you know, we're trying to provide those, but the budget decreases have even eliminated a dental position in the area. A preventive dental officer was eliminated here.

So I'm just-I just, as a testimony, we need much more expansion and funding in order to meet the needs.

Senator WELLSTONE. I think, Dr. Mork, in your own very quiet way, you've made your point, and it's well understood. It's important.

Delores Fairbanks.

STATEMENT OF DELORES FAIRBANKS

Ms. FAIRBANKS. My name is Delores Fairbanks, and I'm a CHR on the Leech Lake Reservation. And I also work 3 days a week at the diabetes center in Cass Lake.

And I want to welcome you here, and I was glad to be asked to be on this panel.

I think a big issue that I-that I am concerned with here, because I work with diabetes people, and what I see today is the people that come into our clinic are much younger, that are being diagnosed with, what I would say is, a horrible disease. And I just feel like our delivery system with Public Health Service, you know,

with the doctors that we need there because many times I have seen our clinics, our diabetes clinics, canceled because we don't have a doctor to service our people that come in. And I feel that what we have over there is very inadequate of a facility. It would be nice that if we had a building of our own where we could have our own clinics, and we could give the service or education. We could have a foot-care clinic, so we wouldn't have to be moved around from room to room and never knowing, you know, exactly where we're going to be set up when we go into the hospital as the clinic.

And also as working as a CHR and being out in the area, and on the northern part of Leech Lake Reservation, we've got a couple clinic sites, which is located in the northeast part of the Leech Lake Reservation. It's a new clinic. It's a nice clinic. But I feeland then we have another one in Ball Club, which is one of our larger sites and serves 50 or more people on a Thursday during the week.

Because of the location of where we are at it's so isolated. We have as a CHR you can only transport so much. I would feel like we need another alternative for transportation. And because of that, I just feel that the minority [sic] of these people, they don't receive, you know, the proper care, due to the fact that the transportation problem is there.

And I feel that if we had another alternative, you know-a lot of us here, we could get our elderly and the people that have their appointments, we could make these appointments if we could have something that we could call upon besides-other than the CHR's, you know, somebody that would be waiting for them, so they could get to where they have to go.

Thank you. That's all.

Senator WELLSTONE. Well, I thank you, Ms. Fairbanks.

I think that what I'm going to do is, we have some 11 or 12 people who also want to speak from the floor. And so what I won't do is ask questions now, because I want to just keep moving this along.

I would just take what you said, Ms. Fairbanks, because I think it really adds on to what others have said as well.

There is this kind of—I meant it when I said it to Dr. Mork. There is this sort of quiet way in which all of you have made the same point; which is to have this battle to sort of maintain just what funding that there's been, misses the whole point.

And the whole point is that if you just look at the conditions for the doctors and the providers, and you look at whether it be diabetes, whether it be dental care, whether it be hypertension, whether it be just basic immunization, I mean, whether it be issues dealing with substance abuse, mental health, you name it. We just simply the disparity between the commitment to resources and the needs, is just painful And it seems to me without trying to give a speech here today because I'm terribly afraid of overpromising, but I also don't want to underpromise-it just seems to me that if the focus of the country is going to be between now and early October on health care reform, it's time for our voice to be, you know, really very bold and loud and clear. And insist that there has to