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This has been at the request of those of us who are forced with the decision of who may or may not receive care. I doubt that this was the intended scenario of the participants on both sides of Treaties. This purchasing of Health Insurance by our tribal Government is supplementing the United States obligation to the Indian People to provide Health Care.

Tribal leaders are working to meet this challenge of maintaining and impr the health delivery system, and the health status of the Indian people through a multitude of creative means. The needs are being identified, programs are be developed, community members are being trained to assume leadership roles, bus profits are being invested in health care, and self-determination is engenderi a strong sense of individual responsibility. The Indian community has suffere a century of neglect and abuse. The magnitude of the changes necessary to lif this population to a position of parity with the rest of the Americans will not occur overnight. But, even in the light of current fiscal restraint, the Indian people of the Bois Forte Band of Chippewa should not have to witness th erosion of their Health Care Delivery system, year after year.

Census.

the opportunity to present a statement on behalf of Indian Health Clinic in St. Paul, Minnesota. There 500 American Indians living in Ramsey County according 39 percent. live below the poverty level. indicates that of the 2.500 persons served, two-thirds ic's Palients have incomes below the poverty level. ent of the clinic's patients have Medicaid. only 3 • any other insurance, and 60 percent have no coverage. America Indian Health Clinic provided over 5,000 tal, and mental health visits to the St. Paul American nity.

Indian ilealth clinic is supported by city, county, and Lunding, As well Ак revenuc from medicaid, insurance, The Clinic has not vet received Indian Health ing like other Urban Indian Health Clinics, Although is open Monday through Friday, the waiting time for a intment is in months and for a medical appointmer in Lional staffing is needed to meet the present patient Services reduce waiting times, and insure accessible the Local American Indian community. indian Health ding from Lie Urban Programs Branch 18 desperately

so other urban areas with a significant American Indian hat at present have no Urban Indian Health Program due funding for the IHS Urban Health Program. The IIS has study under contract. that identified eighteen other with a significant American Indian population meeting an Urban Indian Health Center. but NO funds have been le to service those over 20,000 urban American Indians.

Indian Health Clinic is seeking to meet The needs of } Indian population prior to 1998 which is the target system to be implemented. The issue is for funding in 994, 1325. 1996, and 1997. Thank you for your support A DRASHT that wil! Increase funding to meet the teeds American Indians who have relocated Lo urban

FROM: RICHARD CARPENTER

E AVENUE ST. PAUL, MINNESOTA 55101 (612) 776-9519

NORMAN DESCHAMPE - CHAIRMAN, GRAND PORTAGE BAND + VICE CHAIRMAN MINNESOTA CHIPPEWA TRIBE Grand Portage Reservation Tribal Council

P.O. Box 428

Grand Portage, Minnesota 55605

218/475-2277 OR 475-2239

For: Presentation to Senator Paul Wellstone, on May, 9th, 1994.

The Grand Portage Band of Lake Superior Chippewa health delivery system is an example of a Tribal CHS (Contract Health Service) model. The intent of this overview of our system is to provide information on the different way in which we provide services to our Indian, non Indian, and employee population.

The Grand Portage Reservation is situated in the tip of the Arrowhead. We are 150 miles from Duluth, where we must go for any specialist care. We are 36 miles from Grand Marais, which is the nearest hospital which offers a limited amount of service. We have a Clinic on the Reservation.

The Grand Portage Health Service is staffed by two PHNS and one RN, with one of the PHNS also functioning as Health Director. We have two full time CHRS (Community Health Representatives) who provide outreach, transportation, and referrals in the community. We have one Office Manager who handles all of our Contract Health Service payments which is the dollars that are paid out for primary care services not provided by our staff. At the present time Cook Co. Community Clinic, (which is a Federally Qualified Health Center), sends a physician to Grand Portage two half days a week at Grand Portage. Cook Co. Clinic uses our space and staff when providing primary physician care. Cook Co. Clinic then bills our Contract Health Service and other 3rd Party payers for services rendered. We also have a licensed ambulance service with 14 EMTS and one First Responder.

The resident Indian population of Grand Portage is around 300 individuals. In 1993 we served an additional 115 Indians which demonstrates the mobility of a segment of the Indian population. In total the Grand Portage Health staff served 696 individuals in 1993, the non-Indian portion being employees and members of Indian families and permanent residents of the Grand Portage area.

The only direct services provided by Grand Portage Health staff are not presently billable, this includes "wrap around" services such as outreach, referral, Public Health services, WIC, Mental Health, Chemical Dependency, immunization, Maternal Child Health, prenatal services and a variety of skilled and other services in the home and community. The costs for these services are partially covered by Indian Health Service funds with the balance made up by State grants and Tribal funds. All other primary care services are provided on a fee for service basis by Cook Co. Community Clinic, North Shore Hospital and a number of primary care providers in Duluth, and in some special cases Mpls.

Of the 696 clients served at Grand Portage in 1993, 383 were covered by the Self Insurance plan provided by the Grand Portage Tribal Council. Only 7 clients are presently covered by Medical Assistance and 25 are enrolled in Medicare.

The total cost of purchased services for the Grand Portage Indian service population was $478,490. This included only $184,500. in funding from Indian Health Service. The unmet needs for contract care not provided by Indian Health Service is a whopping $293,990. The portion paid by the employee health plan was $225,672. The balance of unmet need totaling $63,318. was covered directly by the Tribal Council and by other third parties.

PRIMARY CONCERNS:

1.) Tribal sovereignty must be maintained in any planning and discussion of Health Care Reform as it relates to Reservations. This includes the reality that each Tribe is a unique political entity. The way that each Tribe delivers health care is unique. 2.) 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 to be considered an Essential Community Provider separate from "Minorities".

3.) All decisions as to the inclusion of individual Tribes in Health Care Reform and health systems that are 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.

4.) Tribal participation in Health Care Reform must be an "option" and not a mandate.

5.) The Federal Government is responsible for the care of Indian people. Congress and the President needs to recognize the grossly under funded 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, e.g. Indian Gaming. The Tribes should not have to subsidize health care at all. The fact that the Grand Portage Tribe is subsidizing 70% of all the health care costs for the Indian people at Grand Portage is inexcusable. Congress and the President should be funding us at 100% of need.

6.) At the present time Grand Portage is able to purchase contract health services from providers we choose. In this method we are able to monitor quality, along with costs. 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 of special concern in the area of having providers that are culturally sensitive to the needs of Indian people and to the unique health care needs of our isolated rural population.

7.) We are concerned that the Federal Govt through Indian Health Service will not allow us to use Contract Health funds to purchase services from an integrated service network. At the present time they do not allow us to purchase insurance with Contract Health Service dollars.

8.) Can the Grand Portage population be waived? Can an ISN decide not to include us either initially or at the end of three years? Can they decide that they do not want to serve our population either due to geographic access considerations or for reasons involving the high risk population that we serve, e.g. 12% rate of diabetes among adults, high incidence of smokers?

9.) How will we be able to influence ISNS to buy services from us that are proven effective in our community? This includes our wrap around services such as transportation, outreach Home Care and Public Health Nursing. If the Tribal population at Grand Portage wants local Indian directed and Indian providers, how will we be able to continue those if an ISN chooses to not use us and instead sends in workers who are not sensitive to our unique political and cultural status?

10) Dollars for Public Health are not forthcoming either from the State or Indian Health Service. At the present time and since the start of the Public Health Program at Grand Portage Indian Health Service has provided NO direct dollars for nursing. Will Health Care Reform provide for staffing and the provision of Public Health Services at Grand Portage that is directed and staffed by the Tribal Council.

11.) We are presently self insured for our employees. Health Care Reform must address the way in which Tribes with their unique political status will purchase coverage for their Indian and nonIndian employees.

12.) Facility improvement and construction must be a priority under Health Care reform if we are going to be competitive in keeping our Indian and non-Indian clients.

13.) The dreadful shortage of professional medical staff in Indian country must be addressed. We are presently short two out of the four Doctors needed to provide health care in our County. This has an immediate influence on the kinds of preventive services we can offer. Funding for Doctors and mid-level practitioners, such as Nurse Practitioners, who are willing to work in rural areas must be provided.