I think later on today, Dr. Frizzell, who is the health planner, will be talking about health status. And I would hope that national health care reform supplemental dollars would be put in place for access to such things as health status and living in a medically underserved area and so on.

The other thing is, under national health care reform, I think it's important that there be something in place where tribes and Indian Health Services health sites are not mandated to participate in ISN's, or be mandated to be under the jurisdiction of a Minnesota health plan, for example. I think my involvement that the Indian Health Service sites or tribal health sites would have with the states would be at our option, at our discretion. The Indian Health Service, you know, has historically consulted with the tribe on such matters, and we would expect that that continue.

This other thing on health care reform is, if at some point down the line the tribes or the Indian Health Service makes services comprehensive benefits package available to the non-Indian population, you know, we don't have the resources, as Dr. Annette had pointed out earlier, to be competitive in terms of staffing and space. And at Cass Lake, we're-we're providing health care out of an old building that was built in 1938, and the building is busting out at the seams with patients and a high number of patients. At Cass Lake, we have 11,500 outpatient visits per year, and we have only six doctors to try and provide care.

And I think I'll leave spacing concerns for Luella to take about. She works there and is more familiar with that.

But those are the points that I want to make about health care reform.

Thank you.

Senator WELLSTONE. Thank you, Mr. Hunt.

And, Ms. Brown, thank you. It's good to see you again. And, of course, I've seen some of this firsthand, too, as we talk about some of the issues.

STATEMENT OF LUELLA BROWN, ADMINISTRATOR, CASS LAKE INDIAN HOSPITAL, LEECH LAKE RESERVATION, CASS LAKE, MN

Ms. BROWN. My name is Luella Brown, and I am pleased to be here to address the health issues at the Cass Lake Indian Hospital, meeting with your staff and yourself, and your previous visit over to Cass Lake addressing our 1938 facility.

I have a background as an Indian person using the facility, as a nurse once working with the facility, and now as the administrator. And let me tell you, it's been a real trick to try to balance out the unmet needs for a patient over there and make sure that they've gotten quality patient care, plus trying to retain a staff with the sources being inadequate. It's been difficult to manage a budget and dealing with a shortage. It's always been a major concern of mine when I have to tell people they cannot receive health care to meet their unmet needs.

At some times we have to only take care of what we call the running priorities, which are life-threatening situations. Patients that need preventive care are never addressed at Cass Lake. We don't have the budget. We sit week to week and our medical staff needs

to sit there and decide who needs care that week. And we have to turn some people away or put them on a deferred waiting list in order for them to, when we do get adequate funding coming in, then we're able to take care of some of those needs.

But it's been difficult for me to have elderly people coming in, when these are very proud native Americans coming in, and I've got to send them to the system-the medical assistance program, in order for them to take care of their health needs.

And they've come in and got very upset with me. I've had to talk with them, informing them that this is something that I am notit's not easy for me to do. But this is how I need to provide health care, in order for the moneys to stretch for acute patients coming to our emergency room.

The continuity of care has been a big issue for us, since our shortage of medical staff at the Cass Lake Hospital cannot take care of our emergency room on the weekends. So we have had to have a contract in place for different physicians to come through our-to work at our hospital during the weekends. And they do not address the sensitivity and cultural need of our population. And some of them are turned away with their care unmet. And in turn, they end up in further damage to their condition by presenting at another hospital in which we have to turn around and try to figure out how we are going to pay that bill, for that individual to qualify for services.

And it's difficult for me, as an Indian person, to adjust the elderly, as they are living longer. They have more complicated health problems. A lot of them are now on renal dialysis. We do have a small unit at the hospital. We have a waiting list. Some individuals are being transferred a hundred and some miles every 3 days for them to get their dialysis to keep their life going.

I've been trying to set some of my priority to recruitment and retention at the Cass Lake Hospital. And let me tell you, it's really difficult to compete with the outside. We need to have some kind of a stable source of funding so we know that we don't have to balance our budget in order to pay for our doctors every year as they come through to the hospital.

The health care reform and wrap-around services has been a concern of mine. Are we going to be able-are we going to be better off with providing health care? Is our health care going to improve to native Americans through the health care program?

The health care status is less than the rest of the country, and I could produce a lot of data informing you of what our unmet needs are and our conditions of our patients.

And we have not even touched on the preventative issues. There's no money there for prevention. There's only money there for sometimes taking care of some acute patient care. And that's limited.

Indian people have many conditions that need to be addressed. It's painful for me to do my job as an administrator. And in this new health care reform, my hopes are that you will come up with a plan that our status of the American Indian will meet the quality of care that other individuals in the country are receiving.

Thank you.

Senator WELLSTONE. Thank you very much for your powerful testimony. Mr. Hawk.

STATEMENT OF RAY HAWK, CLINIC DIRECTOR, FORT BAND, NETT LAKE, MN

Mr. HAWK. My name is Raymond Hawk. I'm a physician's assistant, and also, clinical director for the Bois Fort Band of Chippewa, which is located at Nett Lake, MN, up by Orr. And I've been there for 13 years now, and I've seen a lot of changes in the Indian health delivery system and as the foregoing testimony has said, we have suffered quite a bit of loss, as far as erosion of our annual budget.

One thing that needs to be pointed out in particular is, as we try to elevate the health benefits of the Indian people, that it's been estimated that we are going to receive approximately only about 29 percent of the area budget, which would compare to what it would take us to have an HMO level of health care. And when you take the comparative health status of American Indians as it stands now, it is difficult to imagine that the trend in fiscal policy can have anything but a detrimental effect on those that most need assistance. And from those who have sound promises to take care of their health care needs.

And the tribes' Indian Health Service must now operate a system which is providing health care to a matter of rationing. This hasn't happened to us before at Nett Lake. But one of the things that we have had to do recently is, we now restrict all our eye care to nondiabetics and children. Which means that we do not have any adult eyewear authorized at all. And this has been different in the past years as we have followed the Medicaid guidelines, for those who are dependent on our contract health services weren't able to get an eye exam and eyewear every 2 years. We have denied that service to some people.

And while the Indian Health Service suffers from this nationwide, in particular that is distressing to the area here in Bemidji because of the demographic and geographics of our area. As you know we are there are a lot of us in the smaller tribes that have a long distance between our providers and particular for Nett Lake, it's 40 miles to the nearest hospital where the X-ray unit and where the internal medicine doctor is.

Which brings us to another problem, in particular, generating work load and how we get credit for the amount of work that we've done, which is directly related to our financing. Because of this distance Cook is the nearest hospital. Then there's also Virginia, Hibbing, which are both about 75 miles away, and we're 125 miles north of Duluth-our tribe has had to purchase three vehicles in order to take care of some of the health care. Because it's estimated that probably about 60 percent of the people on the reservation have insufficient transportation to travel that distance.

This increased cost that it is taking us to keep up with the outside health care from our tribe has cost-has been estimated to be about 30 to 40 percent more expensive than what we pay for it by hiring people to do it ourselves. And in the last 2 years that erosion of the purchasing power for our contract health service dollars,

which is care that we cannot provide on our reservation, has cost us two ancillary personnel jobs on the reservation.

And, in particular, what should be noted, I think, is the work load is not given any credence as far as prevention, as stated before. So I won't need to address that further then.

I'd also like to emphasize an appointment of financing of the Indian Health Service that recently it was, for our area, 86 million dollars was stated that that's going to come is going to come off our based budget authority, based on our collections from thirdparty resources. And one of the problems that we had in our tribe is that our tribe, in order to try to keep up with some of that, has had to purchase insurance. And this was voiced by Chairman Deschampe, that we are in a position now at Bois Fort of supplementing the government's trust responsibility for the health care. And of this $86 million, the question that our tribal chairman Gary Donnell [phonetic] handed to us when we met was this, "What Indians are going to be insured this year that were not insured last year?"

You know, what's the basis of saying there is going to be $86 million throughout these throughout 62,000 users in the Bemidji area?

So that would be, I guess, a point of emphasis that we would like to see is that the erosion of the base authority should not be based by our third-party collections. Those third-party collections is what is, right now, paying for four providers in our clinic. Nurses, that type. We just won't be able to keep up with it the way it is going right now.

Senator WELLSTONE. Well, I thank you, Mr. Hawk. I'm-it wasyour testimony was clear and was heard.

Mr. Beaulieu, let me also thank you for the letter from Chairman Brown and that tribal Red Lake Band. Your letter and the attachments will be included in the official record.

STATEMENT OF OREN BEAULIEU, HEALTH DIRECTOR, RED LAKE BAND OF CHIPPEWA INDIANS, RED LAKE, MN

Mr. BEAULIEU. Okay. For the record, my name is Oran Beaulieu. I'm the tribal health director for the Red Lake Band of Chippewa Indians. I'm a Red Lake Chippewa, and I've been in the health care business for 17 years now. Almost 17 years I've been providing health care and services for Red Lake people.

The Red Lake Chippewa nation, again, has given up land, minerals, and other natural resources as the prepayment for health services. We refuse to be identified as part of the minority population or a special organization that receives health care. We cannot support health care reform if it threatens our sovereignty, ignores or relieves the Federal Government of its trust responsibilities, and the government-government to government relationships between the Red Lake Band of Chippewa Indians and the U.S. Government, or if the Federal Government authorized the State's control over tribes in providing health care.

Health care reform will only work if the Federal Government provides 100 percent funding for all tribes based on the health care needs as identified by each Indian nation. Not as identified by the

Indian Health Services, but as identified by the tribal governments and their health providers on that reservation.

All tribes should have the opportunity to provide a wide range of health care services for their tribal members, offering prenatal care to long-term nursing home care.

As health care reform progresses we need to assure that the Snyder Act, the Indian Self-Determination Act, the Health Care Improvement Act, and other acts regarding health care remain as law and policy. We, as a sovereign nation, reserve the right to automatically enroll all our persons receiving services in our health facilities in 638 health programs. The individuals may thereafter elect to enroll with another alliance or program.

We need to assure that all health services that we are currently provided are funded annually with the increases, not decreases. And, again, we should no longer be subject to annualized budget

cuts.

All tribal businesses should remain exempt from having to pay employer health insurance premiums. It should be left up to the tribal governments to determine if non-Indians can receive health care services in their respective reservation hospitals and clinics.

The current eligibility regulations must continue for health care-health services. All services that we currently provide must be included as part of the comprehensive benefits package for wraparound benefits. We need to have direct access to third-party reimbursements. And all tribal members should be eligible fordual eligibility for Indian patients should continue. That means they should-they all receive services wherever they are also in the State of Minnesota.

The Federal Government cannot give States jurisdiction over our health care programs. We do not want the State of Minnesota to have control over our health care services. If we are forced to join the Minnesota plan, we would be identified as an essential care provider. This is only if the commissioner of Minnesota accepted the tribe as an ECP. Under the system we would only be an ECP for 3 years. And during the 3-year period Minnesota would work with the tribe to assimilate our health services into the general population system. After this 3-year period expired, we would have no right or privileges. Through the Red Lake Band this mean termination. As an ECP we would also have to serve all Indian people not included without any recommendations from the tribal govern

ments.

I only have 2 minutes left or something like that. So one of things I'd like to address is our

Senator WELLSTONE. He actually doesn't have any time. But he reserved himself another 2 minutes. I know this man. I know how he operates. [Laughter.]

Mr. BEAULIEU. I would like to address the status on the 1995 Indian Health Service budget. You know President Clinton generously gave us $125 billion back in our budgets, but what thatSenator WELLSTONE. You said $125 billion. You meant $85 billion?

Mr. BEAULIEU. No; $125 million.

Senator WELLSTONE. Because if it had been $125 billion, it would truly have been generous.