attaining and exceeding the levels of the Indian Health Service. We should emphasize and support the continued development of the Indian Health Service, as the tribes and the Indian Health Service should be partners in the Indian health care system, not competitors or of lesser or greater importance. We both are capable of making significant contributions to the health of the Indian people, and these contributions could be more effectively and efficiently realized through cooperation and coordination of the part of the Indian tribal organizations and the Indian Health Service. Additional alternatives and recommendations 1) Improve present services to maximize utilization. 2) Develop and administer consumer-oriented programs and services. 3) Improve appointment system to enhance entry and lessen patient waiting time. 4) Provide adequate resources (both direct and contract) to effectively meet the health care needs of the services area population. 5) Develop and implement programs to provide for the early detection and prevention of disease, as well as, health education services to enhance individual health maintenance. 6) Educate the Indian population to effectively utilize present (and future) health care services. 7) 8) Promote more effective communications and coordination of health services among IHS providers and private health providers. Promote the hiring and retention of qualified health 9) Identify and promote the utilization of alternative and third-party reimbursement resources. HEALTH A tax incentive or a tax base of sufficient funds would allow the Indian tribes to afford the type of health care system that they wish to utilize. A separate federally-funded system has not been successful due to the limited appropriation and the lack of control. If tribes could establish their own health policies and be in a position to match Indian Health Service funds with tribal monies, then the health care system would allow for increased types of services and better quality in health care. The suggestion of an independent Indian Affairs Commission handling all executive matters still discriminates the Indian from the non-Indian and it is felt that the establishment of such a commission would not end any conflicts. Whoever is responsible for decision making should have the necessary expertise in their profession to be held accountable and credible by both the Indian people and the agency they are dealing with. In too many instances presently, tribal leaders have professional staff available in health, education, and business but they are not utilized. Also, the system still only recognizes elected tribal leadership as the only decision maker which again leads to purely selfish or political decision making. We hope these facts will be considered in the Conduct of these hearings. Thank you. Mr. MULKEY. Next, Mr. Bob Crawford, representing the Cherokee Nation. STATEMENT OF BOB CRAWFORD, DIRECTOR, CHEROKEE NATION HEALTH DEPARTMENT Mr. CRAWFORD. Mr. Chairman, the Cherokee Nation would like to take this opportunity to express our thanks for allowing us to appear before you this morning. Realizing there are some differences in various regions, Indian Health Service has the responsibility to deliver services. I am going to try to highlight some of our testimony this morning. We have taken a very serious look at the health delivery system called IHS and have really tried to come in here not requesting additional moneys, because we know the feeling of Congress. Rather, we are trying to focus on issues that can be resolved within the next year or so that will improve the ability of IHS and the tribes to provide adequate care for Indian people. Mr. Booth this morning has already mentioned the Leach amendment. To us in northeastern Oklahoma, this is probably the most critical issue we have today. With economic conditions of the country, we are finding increased demand for our services; yet the Leach amendment is prohibiting us from employing additional staff to meet those demands. We are unclear as to the impact of the Leach amendment with the new Ada Hospital that you have mentioned, also, with the additional staff going into the Miami and Sapulpa clinics. The questions that we have: Are these positions going to come off our existing allocation? If they are, it is going to create a disastrous situation for the service units in eastern Oklahoma. We would hope that this committee would not only ask for the exceptions for Indian Health Service in this amendment, but for all medical functions of the Federal Government. Because as you know, many people do utilize other agencies funded by the Federal Government to provide our health care. If it is not possible to get Indian Health Service exempt from the Leach amendment, we would ask that, at least, we be given some top priority. If not, we are going to be facing some real crisis in the springtime. This is when our crunch is really going to hit us. The second major area with Indian Health Service is: How do you administer a health delivery system that is a closed-budget system? I think this is one of the real dilemmas we are faced with. We are given a number of dollars with no consideration for demand for services. That is bad enough, but when you tighten the system more by the appropriations process, where everything is line-itemed out, everything is predetermined before it gets to the service unit level. Not only do we have to live within a closed-budget health care system, but we don't even have the flexibility to use the moneys we have the most effective and efficient way. We would hope that maybe some experiments, maybe some pilot projects would be undertaken to delegate the authority for rebudgeting and making determinations on what staff is needed to the service units. I think it is only after this occurs that we would even consider contracting under 638. We feel that the system that exists now is just not worth it for the tribes to get involved with. We feel that the block-fund-granting approach might be one answer. Some examples every year, and we have to live within the line items. In the last quarter there is a scramble to purchase equipment, if we have money left over, and equipment and supplies, and we really can't get the maximum use out of the money throughout the year. We have to make the determination on demand at the local delivery area rather than area office or headquarters or even Congress making those determinations for us. One other thing that may help remedy the problem of the closed budget, and we commend Congress with 437 making it possible for us to receive title XIX and title XVIII reimbursements to the service units. We would hope you would go a step further and also make it possible for us to receive third-party reimbursements of private insurance and other resources. This would not be to our advantage unless assurances were made that those moneys generated at the service unit or the clinic would remain at the site. This is the only way we can see where we can at least begin to get the supply and demand of the health care system somewhere close to equilibrium. Mr. MULKEY. Thank you, Mr. Crawford. Talking about a closedbudget system, could you elaborate? What is a closed-budget system? Mr. CRAWFORD. A closed-budget system is one that does not allow for any variations in demand. We are given a number of dollars to our service unit, no matter what the demand for services that year. We are locked into it. Whether we have 90,000 outpatient visits, we still have a certain amount of money to live with. Mr. MULKEY. When you talked about budget line items, and you don't have flexibility within each line is that imposed by this lack of flexibility? Is that the result of IHS or the Congress? Mr. CRAWFORD. We have been trying to find out where the cause is. We get conflicting information. We talk to IHS headquarters, and they say it's imposed by Congress through the appropriations process itself. We talk to some staff members or Congressmen, and they say it's an interpretation of IHS. We really don't know. We hope this committee could help find out where it is and what causes it. Mr. MULKEY. Thank you very much, Mr. Crawford. Next is Gloria Keliiaa, representing the California Urban Indian Health Council, Inc. Ms. KELIIAA. I am Gloria Keliiaa, and sitting with me today is George Veliz, who is a member of the board of directors of the California Indian Health Council and also director of the Bakersfield Indian health program. Mr. MULKEY. Please proceed. STATEMENT OF GLORIA KELIIAA, EXECUTIVE DIRECTOR, CALIFORNIA URBAN INDIAN HEALTH COUNCIL, INC. MS. KELIAA. Before we begin our formal testimony, I would like to share with you an anecdote that will illustrate some relevant points about the Indian Health Service and also tell you that in general, my remarks here are made on behalf of my own member health projects, as well as the United Indians of Nebraska and the Traditional Indian Alliance of Tucson, Ariz., with exceptions, which will be noted within the context. The California Urban Indian Health Council is a consortium of 9 of California's 10 urban health projects-almost one-quarter of IHS's total urban health programs. California, with almost 30 percent of the IHS urban population, receives one-quarter of its urban program funds. Because of its significant size and its heavy involvement with Indian Health Service, the council felt very strongly that its testimony at this hearing was important. Consistent with contracting requirements, we requested area office approval. On the area level, no fewer than three separate IHS staff were involved. The decision was finally made at the HSA level several days later. The ruling from HSA was to not approve any travel for urban programs apparently as a direct result of the Senate's very clear directive to IHS to avoid engaging in lobbying activities which, in our opinion, this hearing was not. We are here today to discuss the role that the Indian Health Service does play and should play in insuring and improving the provision of health care for the urban Indian community. This disapproval process is relevant to that role. Indian Health Service, as it relates to urban health programs, has no clear policy regarding the delivery of health care in urban areas, where almost half of the American Indian community now lives. IHS fails consistently to coordinate its policy and activity, fails to involve its California program area office in program decisions, fails to provide strong leadership with DHEW or with Congress to improve resources or articulate the plight of the urban Indian community and repeatedly hides behind bureaucratic buckpassing, blaming Congress or other levels of DHEW for administrative failures and unclear program objectives. The IHS treats the majority of its urban program contractors, not as allies or consumers engaged in a mutual professional effort to alleviate the health problems of this country's first citizens, but rather, IHS engages us in a day-to-day relentless adversary process that causes confusion and suspicion and that consumes time and resources, that should be used to improve health care delivery. A small number of urban programs, such as the Traditional Indian Alliance of Tucson, for example, enjoy good working relationships with their IHS area offices and headquarters staff. This type of a relationship underlines the fact that excellent rapport can and must be achieved between all urban programs and IHS. The present lack of uniformity or inconsistency in treatment of programs by IHS, in general, must be addressed. We are most anxious to participate in meeting this goal. Despite all this, we feel there is no doubt that an Indian Health Service organization should exist. The health of urban American Indian people is deplorable. The effectiveness of the present organization is debatable for a number of reasons. The Indian Health Service appears to be unable to respond or unwilling to recognize the shifting Indian population from reservation to urban areas. Almost 50 percent of all American Indians now live in urban areas. For example, the all-urban county of Los Angeles |