as an Indian person, is the potential that some of our sites may not be competitive and continue to exist. And these sites are local. We have had culturally sensitive systems set up. And if they are not competitive under health care reform, will they continue to exist.

It concerns me now that as the system exists, we have not had the resources to really plan for the future and actually plan for now. If you look at our population in Indian country, we have a huge pediatric population, and we have, hopefully, a blossoming elderly population. And if you look at the services that currently exist for our elderly, we don't have what's needed. We don't have the nursing homes. We don't have the systems in place locally. And I'm saying this on an overall basis. Although you know certain tribes have, indeed, worked diligently to set up programs, but it's beyond the realm of Indian Health Service. As an Indian person, this concerns me.

As a physician, again, I think resources are brought up. We have so many diseases and health issues that impact our people at four, five, six times the rate of the rest of the country. And yet you look at the resources for the rest houses are very, very limited. Tribes have worked, again, diligently trying to really coordinate any number of systems to help provide these services. Indian Health Service has been just one small part of this.

As a physician we need to look at the specific health issues. They concern me. When you're working and practicing and I see you have the providers in the audience when you're practicing locally and day after day face that and as Indian people face that, you say, "Why aren't things improving? What needs to be done?"

Now, as a Federal employee and working for the Indian Health Service on that level is quite an interesting challenge. The relationship between the Federal Government and Indian tribes has waxed and waned. And over the years I think it's on the upswing in terms of how we deal with tribal governments. More and more we have to recognize that we, as the Indian Health Service, as an agency, we're here because of the Indian people. And what we are must be defined, in my opinion, by Indian tribes. What is the need and what is it going to be in the future? It's not just the unilateral Federal Government deciding what Indian people need.

There is a swing in the pendulum now where Indian people have to sit down and define if there is going to be Indian Health Service, which there appears there is. The voice nationally is support for such an agency. The challenge now becomes, for us as Federal employees for Indian Health Service, is to sit down with tribes and talk to them and work with them to define what this agency ought to be, and what needs they need from us. And particularly under 638 self-governments and the fact that some of the tribes may choose not to go under 638 of self-government.

What is the role of the Federal Government, specifically, Indian health care, in that whole process.

And those are some of the challenges that we have right now.
Senator WELLSTONE. Thank you very much, Doctor.

Mr. Chairman, do you-what would you recommend, as Dr. Annette said, "This is the time to redefine this." What would you recommend is the best way to improve communications between tribal leadership and Indian Health Service?

Chairman DESCHAMPE. I think we need-I'm not sure what the structure of this is going to be when it is all done. I know recently there's been talk of closing the Bemidji office and moving things to Aberdeen, based on the cuts that were earlier proposed. I understand half of those have been

Senator WELLSTONE. That's correct.

Chairman DESCHAMPE [continuing]. Restored.

Senator WELLSTONE. I do want to let you know that it came, Dr. Annette, in part from the visit I had back out here earlier. And some of us really-and we have a ways to go we really were very angry about those cuts. But we still haven't gotten in, but we still haven't talked about any real expansion. But we were at least able to fight some of those cuts.

Chairman DESCHAMPE. Yes; we would like to thank you for that. Senator WELLSTONE. Yes; well, you don't even have to because we're not where we should be anyway.

Chairman DESCHAMPE. Yes; I think that one problem is-is-it's not meeting the needs now. I think in any situation where we can't meet the needs, you end up working under pressure in places. And I think if we can get IHS more funds where we have time to look ahead and time to do some of these things that we ought to, improve maybe communications, those kinds of things, so we're not always kind of trying to keep our head above water, can make a big difference.

Senator WELLSTONE. Doctor, now two questions for you. One is, you were mentioning some very specific health issues, which you said if you look at Indian country you see in a most dramatic way, huge serious problems.

Could you maybe be a little more specific in some of the mostwhat you would consider to be the really decisive priority areas?

Dr. ANNETTE. Yes; one of the areas is cardiovascular disease. Particularly in the northern-tiered States, which includes this area, cardiovascular disease occurs in a much higher rate.

We also look, of course, at injuries. Injury control, injury prevention have to be a focus for us. And if you look at any list and compare us to the general population, if you look at the top five or six, depending upon the age group, injuries, death due to injuries is on our list, but it's usually not on the top five or six for other categories.

We could go at any number of things in this area. Lung cancer. A real concern for us. It's on the rise, particularly in women. Exponentially particularly in this area. How are we addressing these? There are any number of specific health issues that we can look at that need to be-have a focus and addressed and changes, and would have a tremendous impact on our health care.

I guess another thing is prevention. We talk prevention, but we barely have enough money to provide acute care. And unless it's focused, it doesn't pay.

Senator WELLSTONE. I thank you. And the last question is for the two of you. And the reason that I'll keep moving along on the panel is for those of you here, I also want to make sure that we allow time for open-mike testimony.

Part of I think I was hearing this, and I'd like to kind of get a comment from both of you-part of your general concern is that

you're going to be able to move toward some sort of structure of these integrated service networks. You want to make sure that the Indian Health Services are going to be kept separate. With the theory being, I guess as an A and B, and Part A to that theory is that actually that's essentially what leadership in Indian country has been saying they want to see happen. They don't want to lose that. But what you're saying is, in order for us to be able to compete, we have to have the same access to resources. We have to be able to deliver the same quality of care.

Is that is that a large part of your fear about where this reform might take place or are there other aspects, or are there other things that you're also very worried about?

Chairman DESCHAMPE. I think we when we're talking about quality of care, I think to some people that may mean different things.

We want to make sure Indian people are part of that-those wraparound services on the reservation. The nursing services community, health representatives, those types of services.

What I was talking about was a traditional service giver may not look at those as being cost effective. Mostly based on the fact they don't understand how those services are provided in the community and what they mean to Indian people.

I think they may look at strictly dollars and cents when they talk about cost effectiveness or quality of service, and not Indians helping Indians and those unique services that Indians have to have. Dr. ANNETTE. I'll comment on the wraparound services because I think he's really hit the nail on the head, per se, on that.

Senator WELLSTONE. We will also, and I'd ask the panel to focus on that as well.

Dr. ANNETTE. It's just that I look at wraparound services as really, in many ways, putting the emphasis on prevention programs. Whether it's the CHR program

Senator WELLSTONE. Doctor, would you do you want to define wraparound services? Sometimes we all use this lingo and maybe everybody here knows what it means, but we want to sort of

Dr. ANNETTE. All right. Wraparound services is a-are those programs that really have been developed quite successfully in many ways to deal with special issues or health issues that Indian people have had. For example, we have an environmental health system. We have water and sewer. Underfunded, but it's programmed that that's cut from the basic health package that Indian people get that could have devastating impact on our people.

Public health nursing. Many of our public health nursing program is based on prevention. Getting out and working in the community hand in hand with the CHR or community health reps. So when I say, "wraparound," it's those services that really are not defined in the basic benefit package in any way now because these are separate programs that have been developed to provide that

care on reservations.

I just wanted to mention other health care reform also whysome of the concerns we have. We're not competitive. You asked a question on that.

We're not competitive. No. 1, we don't have the facilities right now to even perhaps starting to start to provide some of the

broad-based benefits package. We have we have things that we do in quality of care that I think we do well, but it is not broad scoped because we just never had the resources.

But I want to say that I think the thing that the tribe and Indian Health Services have worked on locally have been done well. But it does not have the breadth. It may have the depth.

Senator WELLSTONE. Mr. Chairman and Dr. Annette, thank you very much for your testimony. I appreciate it. I take it to heart, and it will be part of the record. And I'll do my very, very best as a Senator to follow up on this.

We're going to move to the second panel, Indian health care consumer concerns, contract services, comprehensive benefits, adequate facilities.

We're going to be talking about the delivery of care. And we're going to have with us Carol Marquez-Baines, director of Indian Care Associations, St. Paul, MN; Judy Roy, executive administrator, Red Lake Band; as well as Dr. Mork, a dentist at the Cass Lake IHS Hospital.

I thank each of you for being here today.

Have I left anybody out?

Ms. FAIRBANKS. My name is Delores Fairbanks.

Senator WELLSTONE. You're all welcome. No problem at all. There is no tension in the room. We're pleased to have you.

Why don't we start with Carol Marquez-Baines.

And, again, to each of you, my sincere apology. I think the best way we can make use of our time would be if we tried to stay within 5 minutes.

All your written testimony will be part of the record. And that way everybody here can participate as we go to open mike, as well. STATEMENT OF CAROL MARQUEZ-BAINES, EXECUTIVE DIRECTOR, AMERICAN INDIAN HEALTH CARE ASSOCIATION, ST. PAUL, MN

Ms. MARQUEZ-BAINES. Thank you, Senator Wellstone, Diane, and Mark for allowing me to participate in this hearing.

My name is Carol Marquez-Baines, and I'm the executive director of the American Indian Health Care Association, which is a national consortium of 34 urban Indian health programs that are, in part-are totally funded by title V, which is the urban Indian health section of the Indian Health Care Improvement Act.

I've also been a recent board member of the Indian Health Board in Minneapolis. So I wear a couple of caps when I come to speak to you today. One being the direct impact within Minneapolis, within the State of Minnesota, of potential health care reform, the integrated services network, and its impact on the urban program very directly.

But also I have other concerns as health care reform is occurring within the several States. At the present time, I understand that almost 16 States have a proposal approved or in the process of review by Higfelt (phonetic) for waivers of the freedom of choice. As an urban Indian health program, we do not always have the same protections that the tribal governments have, but we serve tribally enrolled members. And within the Bemidji area we have five urban Indian health programs funded. They are located in Minneapolis,

Detroit, Chicago, Milwaukee, and Green Bay, and they cover a broad range of services.

Two of our programs are quite comprehensive in the scope of primary care; but, as Dr. Annette indicated, we provide certain levels. of services. Some prevention, some primary care. But we do not, by any stretch of the imagination, cover the full range of comprehensive services projected or proposed by the President's health care reform package. And that is a major concern, as many of the people are going to address to you today, that how do we compete with these services. And for us as urban Indian health programs, we are particularly vulnerable.

We are, kind of like, first in line of defense for Indian people when they come into the city and they have very little resources. And they may not even be enrolled in Medicaid programs. They come to these clinics. They have no resources. Maybe 45 to 50 percent of our patients at the urban programs, including the Indian Health Board, have Medicaid coverage. This is important to know because of the uninsured.

At the best, most of the clinics have only less than 5 percent of insurance coverage insurance-covered patients. So our primary source of revenue, outside of Indian health care and possibly other sources of Federal funding and possibly a little State or county funding, come from Medicaid. It's an important resource, and I wanted to make that statement up front.

We're very concerned that we finally be allowed to participate in federally qualified health center programs. However, resources have not been available through Indian Health Service or other mechanisms to help our programs even get up to the level of service that is required under the Federally Qualified Health Center Act. So many of our programs, you know, maybe across the country there's about eight programs that have applicable services to actively compete in that arena that's going to put up with a tremendous shortfall when plans come or ISN's come. Minneapolis is in a good position but many of the other programs are not.

Right now in Michigan, which is also part of the Bemidji area, the Detroit program has lost several clients that have been reassigned to other clinics. And when these patients, Indian patients, come back to the Detroit clinic, the clinic cannot be reimbursed from Medicaid for services rendered. It's just that many of these patients elect to go back to the Detroit clinic, and other Indian people are unclear about this reassignment because of the State's demonstration programs through Medicaid. People come back for culturally appropriate services. They don't have a long waiting line. They don't have what they need. They know the services. They appreciate the providers, and they want to elect to be in that system. The other concern I have is that, as I mentioned before, we are not competitive, for the most part, because of lack of funding. As you indicated, you have a good knowledge of the level of funding, and I think you've done your homework well in the terms of understanding.

According to IHS 1994 estimates, this is just at the current level of need. This is prior to actuarial estimates for the studies that have been done for services. IHS estimates that 22 percent of the urban level of need is funded at the present time. And we're fully