NATIONAL HEALTH CARE REFORM AND ITS IMPLICATIONS FOR INDIAN HEALTH CARE

The committee met, pursuant to notice, at 10 a.m. in the Holiday Inn, Maple Room, Bemidji, MN, Paul Wellstone (acting chairman of the committee) presiding. Present: Senator Wellstone.

STATEMENT OF HON. PAUL WELLSTONE, U.S. SENATOR FROM MINNESOTA

Senator WELLSTONE. Let me thank all of you for being here. I'm very pleased to be here in Bemidji this morning and have the opportunity to hear from tribal leaders, tribal members, and health care professionals about issues of Indian health and health care reform.

This is a formal hearing of the Senate Committee on Indian Affairs. There has been one such hearing, I believe, held in Oklahoma and another in San Diego, CA. And as a Senator from Minnesota who sits on the Labor and Human Resources Committee, which will be one of the two committees in the Senate that will be marking or writing the health care bill-and we started that work May 18, which is just around the corner-and also as a Senator from Minnesota, who sits on the Committee on Indian Affairs, I consider this testimony to be extremely important to me.

In exchange for tens of millions of acres ceded to the United States, the Federal Government, through treaties, promised to provide housing, health, and educational services to native Americans. Sadly, as all too many of you know all too well, many of these promises were not always kept and people in Indian country have suffered as a result of it.

Despite the administration's pledge to native American issues, I think we really have to be very vigilant and keep a real focus. It was, I think, important-it hadn't happened for about a hundred years that the President of the United States met with tribal leaders and people from Indian country. That was a truly historic meeting.

But if we are going to say that by early October of this Congress we're going to pass a major health care reform bill that is going to provide universal coverage that is to say each and every person will be covered with a really good package of benefits, high-quality care then we have to make certain that that same high-quality

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care and that same principle of each and every person covered with that high-quality care, applies to Indian country. Indian Health Service will be kept separate, and that is perhaps as it should be. But what we want to make sure of is that we have care delivered in a culturally sensitive way. And what we also want to make sure of is that, as a matter of fact, we have the same, really, opportunities. Right now, that's not the case. All too often with Indian Health Service, it's marginalized and the family doctors get paid an average of $30,000 less than other doctors.

We sometimes have a huge problem in terms of both recruiting and retaining good doctors. And I have learned from many of you, as I have traveled around Indian country just here in Minnesota, the struggle of really having adequate support for out clinics and our hospitals, our facilities, not only our doctors, our nurses, but other care professionals as well.

So today in this hearing we're going to be looking at a number of different important aspects of Indian Health Service. And the only commitment that I make to you all, which I hope you believe is an important commitment, is to try and do everything I can as a U.S. Senator to make sure that in this very, very important next 4 months, Indian Health Service does not fall between the cracks. That we fight very, very hard to have a really adequate budget.

I mean, right now at best-and we'll hear from the experts, I'm not the expert-but probably at best, around 50 percent of the people who are residents in the sovereign nations and reservations are served. And if you talk about the urban population, where really now probably 50 percent of the people in Indian country live, I think it drops way down to, maybe, we'd be lucky if 10, 15, 20 percent of the people are adequately served.

So this is the time for us to have the focus. This is the time for this testimony, and I am very, anxious to be a strong voice with people in Indian country to get a commitment from the President and the administration of the Congress for adequate investment of resources and a commitment to a commitment to the Indian Health Service.

Now, the first panel is going to be looking at the history of Indian Health Service, treaty obligations, and the Federal tribal relationship. Representatives of the tribes recently had the opportunity to meet with President Clinton. As I said, this was the first such meeting in over a century, and I hope it represents a real commitment on the part of President Clinton to revitalize the relationship between the Federal Government and the sovereign nations in our issues.

Our first panel represents the tribal and the Indian Health Service leadership here in our region. We have Norman Deschampe, who is district representative serving on the Grand Portage Tribal Council. Norman is vice chairman of the Minnesota Chippewa Tribe.

And we have Kathleen-I know her as Kathy Annette, area director of the Indian Health Service with the Indian Health Service regional office here in Bemidji.

I'd like to start, first of all, with you, Mr. Deschampe. And thank you very much for being here.

And I will make one request of the witnesses. Your full written testimony will be part of the record. If you can, we would want to try and keep you within 5 minutes or so. We want to have testimony from everyone, and we also want to have open mike.

Thank you.

Chairman DESCHAMPE. Thank you for allowing us time to come here and discuss health issues with you today.

One correction. I'm not the district representative of Grand Portage. I'm the tribal chairman for Grand Portage Reservation. Senator WELLSTONE. I apologize, very much. Norman Deschampe, tribal chairman.

STATEMENT OF NORMAN DESCHAMP, CHAIRMAN, GRAND PORTAGE TRIBAL COUNCIL, GRAND PORTAGE, MN

Chairman DESCHAMPE. I would just like to start off with maybe just a list of some concerns that we have in Grand Portage that, I hope, relate to other reservations in-regarding Indian health care in Minnesota.

I think the first point that has to be made is that tribal sovereignty has to be maintained throughout this process, in planning or discussing of the health care reform as it relates to reservations. This includes the reality that each tribe has unique political entities.

The way each tribe delivers their health care on their different respective reservations is different and unique. The inclusion of tribal entities in lists of minority populations that can be considered essential community providers is unacceptable. Tribes are political entities, not minorities, and for the purpose of health care reform, they should be singled out and considered-to be considered an essential community provider separate of minorities.

All decisions as to the inclusion of individual tribes and health care reform and health systems that have developed must be left up to individual tribes. Each tribe may very well decide on different courses of action that will affect both the Indian people they serve and their non-Indian employees. Tribal participation in health care reform must be an option and not a mandate.

The Federal Government is responsible for the care of Indian people. Congress and the President needs to recognize the grossly underfunded status of Indian health care. They must also recognize that tribal subsidies for health care may not last if political forces in the State and nationally have negative effects on tribal economies; example, Indian gaming.

The tribe should not have to subsidize health care at all. The fact that the Grant Portage tribe is subsidizing 70 percent of all health care costs for the Indian people at Grand Portage is inexcusable. Congress and the President should be funding a set 100 percent of need.

At the present time we are able to purchase contract health services from providers we choose. In this method we are able to monitor quality along with cost. The concern is that we may not have any control over the quality and suitability of the services provided by health care reform.

This is a special concern in the area of having providers that are culturally sensitive to the needs of Indian people, and the unique health care needs of our isolated world population.

We have several other concerns regarding Integrated Service Network. Right now Indian Health Service is not allowed to purchase insurance-purchase private insurance with contract health care dollars. Can Grand Portage population be waived? Can ISN decide not to include us initially or at the end of 3 years? We understand that for 3 years they have to. What happens after that if they decide that the reservation population, for some reason, is too expensive? The administration is too expensive? What are the alternatives if that decision is made?

Dollars from public health are not forthcoming either from the State for Indian Health Service. At the present time, since the start of the public health program in Grand Portage, Indian Health Service is provided no direct dollars for nursing.

The nursing program at Grand Portage, I think, along with the community health representatives, are in direct service to the people. They're the people that go into the homes and do the day-today service that we aren't sure is going to be available under the health plan. Or are there going to be provisions that are going to protect that service that we currently have?

Facility improvement. Improvements in construction. How are Indian Health Services facilities, clinics on reservations going to be updated, maintained? Are there dollars in the health reform package to provide for that?

And also, as you touched on it, the shortfall of professional medical staff in Indian country. We're in a very rural area and it is very hard to attract doctors. Right now, we have a need in Cook County of four doctors. We only have two. It's kind of a revolving door. We can't seem to get doctors and keep them there on a permanent basis. I think we have to look at the need in rural areas of how to attract doctors and how to keep doctors.

I guess that's all I have for now.

I'd like to thank you for taking the time.

Senator WELLSTONE. Thank you, Mr. Chairman. And I will come back with some questions for you after hearing from Dr. Annette. STATEMENT OF KATHY ANNETTE, M.D., AREA DIRECTOR, BEMIDJI AREA INDIAN HEALTH SERVICE, BEMIDJI, MN Dr. ANNETTE. Thank you, Senator Wellstone. Indeed it is a privilege to speak to you on issues that have been concerning me.

I guess I'd like to do my presentation on a three-tiered level, if I could. I'd like to present some thoughts and concerns that I've had as an Indian person. Some thoughts and concerns that I have as a physician. I have practiced on the reservation and now very much, have a very close working relationship with several of the reservations in our area. And I guess, finally, talk a little bit about being a Federal employee and what that means being an Indian person working in the Indian Health Service.

As an Indian person, I must agree with Mr. Deschampe. Several of his comments and yours, I think, that having access to culturally sensitive medical care is something we have to continue to push for. One of the things that concerns me with health care reform,