Indian Health Care Improvement Act Amendments of 2007

Floor Speech

INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2007 -- (Senate - January 23, 2008)

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Ms. MURKOWSKI. Mr. President, I thank the chairman of the committee for his great cooperation on this very important issue. I know we had all hoped--certainly my constituents had hoped, and I think my colleagues as well, as so many around the country who have been waiting years--literally waiting a decade--for reauthorization of this Indian Health Care Improvement Act. We are pleased that we are on the floor. We would like to see this moved through the process as quickly as possible. We understand the issues we have in front of us and what we have to do in order to get this through, but I appreciate the great leadership of the chairman of the Indian Affairs Committee and of so many who have worked to advance this legislation.

I thank Chairman Dorgan for reminding all of us of the great contributions we have had from so many of our American Indians, Alaska Natives, when it comes to serving our country. I think if you look at the demographics and look at it on a per-capita basis, we see higher numbers, certainly in Alaska, of our Alaska Natives serving in the military than any other populations in the State, serving admirably over the years, whether they be the Eskimo Scouts or whether they be the group serving from the National Guard which recently returned from Kuwait.

I had an opportunity a couple of months ago to meet those Alaskans who were returning. I met up with them in Camp Shelby and had an opportunity to talk to the men who were returning from Kuwait after well over a year. They had been in the desert. Most of these soldiers came from villages from around the State. There were some 80 villages--communities--that were represented amongst this particular unit. Many of them, when they returned back home to Alaska after coming from the desert and going home to the snow, would be returning to very small towns and very small villages that are not connected by any form of a road system. During the winter months, you have connection because the rivers are now frozen and you can take a snow machine to get from one small village to another and hopefully out to a larger hub community. But the reality is so many of these fine men who have served our country are going back to areas where health care options are very limited.

Yesterday I had an opportunity to show my colleagues a couple of pictures. There is one of the health clinic in Atka. We also had a picture of the health clinic in Arctic Village. As you look at the pictures, you can see the health clinics are small and they are clearly broken down. They are older facilities. They are very limited in terms of what they can provide. But this is what we have out in these villages. These soldiers who are returning need to go to the VA for services. They don't have a VA out in Chevak. They don't have a VA facility out there in Atka. They have the Atka Village Health Clinic. This is a two-story clinic, so it is by all standards perhaps better than some of the others in some of our villages. But what we have seen in a State like Alaska where access to care is so very limited, is the IHS facility essentially ends up being the entity that will provide for that level of care for that serviceman, for that veteran, because to get from Atka to Anchorage, to the Anchorage Native Medical Center, is costly. Sometimes the VA picks up the travel, sometimes not. It depends on your income eligibility. If there isn't any--if the Government is not there to pick up your costs, not only do you have the cost of air travel, which can be upwards of $1,000 for your roundtrip fare, but you have your expenses while you are in the city--in town.

So we look at what is provided to so many in our small clinics around the State. Now, is it right that the clinic should have to pick up or basically carry the water or carry the bag for the VA? Not necessarily, no. But is this where we can provide for a level of care that is in the village for the individual, with their family, and ultimately reducing so many of the travel costs that are there? Absolutely. So I say this to my colleagues, so people can understand that oftentimes what we are dealing with in terms of access when you are in a State where it is so rural, where you don't have roads, or the cost to travel is prohibitive, we have to be more creative in how we provide for the level of care. In Alaska, we think we are being more creative with that. But with the reauthorization of the Indian Health Care Improvement Act, it allows and facilitates greater sharing, greater cooperation, ultimately greater collaboration, that leads to greater cost savings.

I want to take a couple moments this evening--it has been mentioned by our colleague from Colorado, and certainly the chairman mentioned the provision we have in the substitute amendment regarding violence against Indian and Alaska Native women. I mentioned in my comments yesterday that we have seen some successes in Indian health, even with the very stark health statistics that have been repeated by so many on this floor. There is one area, though, where I do not believe we have made any progress, and one I am very pleased we are addressing in this bill, and that matter is the terrible violence that faces native women and children.

Back in September of 2007, the Committee on Indian Affairs held an oversight hearing on the prevalence of violence against Indian women. We had several witnesses, very compelling witnesses, at that hearing, one of whom was from Alaska, a woman by the name of Tammy Young, and she represented the Alaska Native Women's Coalition Against Domestic Violence and Sexual Assault. She testified about the intensity of such prevalence and the need for remedies to properly address the problem.

In my State, we have one major city. Anchorage holds about almost half the population of this State. The Alaska Native people make up 8 percent of the total population of Anchorage. But the percentage of Alaska Native victims in Anchorage alone was 24 percent. You can see the disparity in these numbers. Alaska has one of the highest per-capita rates of physical and sexual abuse in the Nation.

In Alaska, an Alaska Native woman has a likelihood of rape that is four times higher than a nonnative woman in the State. Our statistics are horrendous. They are deeply troubling. But we know it is not only in Alaska that there is this danger of violence that faces our Native women. Statistics show that Native women around the country are two to three times more likely to be raped than women from other populations in the United States. As I say, in Alaska it is four times higher. But even if this fact were not as disturbing as it is, it gets even worse because so many of these women who have had this violence upon them also face the prospect that the rapist may not be brought to justice.

This is for a variety of reasons. At the hearing we had a witness indicate that the health services within the Native communities simply lacked the proper infrastructure, the proper resources, to even conduct the forensic exams and therefore assist in the prosecution of the perpetrators. It is as simple as not having rape kits available in the IHS facilities in that village or that community on that reservation, simply not having the forensic equipment, not having it there. Why don't you have it there? It is a funding issue apparently. But you have a situation where you have a woman who has been violated. She comes seeking help, and she can't even have a proper exam so they can collect the evidence so she may then go on and try to prosecute the perpetrator.

In addition, it is the training. We simply do not have enough who are trained in the proper collection of the evidence. Back in 2005, we in Congress passed aggressive programs and services for the reauthorization of the Violence Against Women Act, or VAWA. The witnesses who were there at the hearing back in September advocated that we build on the foundation of VAWA. That is what this legislation does. It provides for just that. It includes programs to address domestic and sexual violence that are critical to shoring up this health infrastructure, that are necessary to support a successful prosecution, whether it is providing for rape kits at the Indian clinics and hospitals or the training for the health professionals to become the sexual assault examiners. Pretty basic stuff. But if you don't have it there, if you cannot collect the evidence, if you don't have the trained medical professionals to help facilitate that, these victims will be victimized again by simply knowing that the system has let them down.

In addition, the legislation will also require the Secretary of HHS to establish protocols and procedures for health services to victims of violence, as well as to coordinate with the Attorney General in identifying areas for improvement within the health system to support these prosecutions. I believe this aspect of the legislation is extremely important for so many. Again, our statistics in this area are devastating, unacceptable. There is more we can do about it, and this is one small step.

Mr. President, I want to talk about one aspect of the Indian health care reauthorization. I don't believe many of my colleagues have spoken to the underlying policy of self-determination and self-governance, but that is such an integral part of this reauthorization. The Federal policy of self-determination was conceived by President Nixon in the early 1970s, and it has been nurtured or improved upon by almost every administration since then. The legislation, S. 1200, embraces these policies in a very profound manner.

Indian self-determination represents one of our Nation's first enlightened Federal Indian policies. It has been by far the most successful policy in improving the lives of American Indians and Alaska Native people. This policy has been embodied in Federal legislation for over 30 years in the Indian Self-Determination and Education Assistance Act.

S. 1200 facilitates the important interplay between the Indian health care delivery system within the Department of Health and Human Services and the policy of Indian self-determination and self-governance. Beginning in the 1990s, there were a growing number of Indian tribes and Alaska Natives who have taken over the IHS programs. They have made them more efficient and responsive and, I would say, more relevant to the local needs.

In Alaska, I think we can point to what has happened in the area of self-governance as a good example, a positive example of how the Native people have embraced this policy of self-determination and self-governance.

In April 2003, the Committee on Indian Affairs held a hearing on an earlier version of this bill. We had a gentleman there from Seldovia Village, President Don Kashevaroff. He testified about how Alaska Natives began compacting IHS programs in 1997 and how, within 6 years, they had compacted virtually all of the IHS programs within the State of Alaska.

Now, within my State, the Indian health care system is almost entirely a Native-driven system. Senator Stevens, my colleague, spoke to this in his comments on the Senate floor yesterday. When you take into account that in Alaska there are about 230 separate Native villages, you manage the numbers there, and despite this large number of separate sovereign governments spread out across a State with enormous distances from each other, spread out from the State's metropolitan area, they were able to create a highly efficient and integrated health care delivery system.

I showed you the pictures earlier of the clinics in Arctic Village. Behind me in the photo is the Alaska Native Medical Center, located in Anchorage. Quite different. Yet what we have there in Anchorage at the ANMC is a model for others to view. In Alaska, we have 180 small community health centers, about 180 of what you saw with the Arctic Village clinic, and they provide primary care. We have 25 subregional midlevel care centers. There are four multiphysician health centers, six regional hospitals, and one tertiary care facility. The Alaska Native Medical Center in this picture is that one tertiary care facility. So in the entire State, the Alaska Native Medical Center is the one that provides that tertiary care.

This system was made possible through the Indian Self-Determination Act. This health care system is tailored to meet the very unique needs of the Native people. I don't believe it would have been possible within the administrative structure of the Indian Health Service itself.

Now, I don't want to spend all my time just talking about the situation in Alaska because the success story that you see there is by no means limited to my State. Self-governance is being embraced in several other areas of the country as well: in the Pacific Northwest, the Southwest, in Oklahoma, and in other parts of the country. I think it is important to note that many tribes and tribal organizations have supplemented their IHS programs with their own resources where possible. The Indian Health Service has documented the fact that Federal Indian health programs are only meeting approximately 60 percent of the need. You have heard that time and time again as we have discussed this. Only about 60 percent of that need is met.

The hearings on Indian health held by the committee and information from a 2005 GAO report demonstrated that this underfunding has led to rationing health care within the Indian community. Of course, the unfortunate result of this underfunding is exactly as you have heard many of my colleagues say. It results in many American Indians either foregoing any kind of treatment or delaying receiving medical care, which in turn, then, leads to disease progression. But ultimately it leads to higher costs, greater costs to the system.

I want to point out that several tribes have stepped up with their own resources to enter joint ventures with the Federal Government or to even supplement the Federal dollars in an effort to bridge that 60 percent gap we keep talking about between the Federal funding and the level of need. I want to show a few of the examples.

In the Cherokee Nation in Northeast Oklahoma, we have a self-governance tribe with one of the largest service populations in the country. The Cherokees have just constructed a new clinic in Muskogee, OK, using their own tribal dollars. This facility serves Indian people in northeastern Oklahoma, including members of the Osage, Muskogee Creek, Choctaw, and numerous other tribes.

We also have the Muckleshoot Tribe in Auburn, WA, which built this facility in 2005 at a cost of nearly $20 million using its own tribal dollars. The Muckleshoot facility is located near the I-5 corridor in Washington and also provides very tailored care for its patients. As you can see from the picture, they try to cater to some of the younger patients as well.

Another Oklahoma tribe in southeastern Oklahoma is the Choctaw Nation, which used their own tribal dollars to construct a 54,000-square-foot facility at a cost of $13.5 million. In this facility the average monthly patient encounter over the past 12 months has been over 3,800 patients.

Out in Oregon, located in Chiloquin, we have the Klamath Tribe Health Center built in 2004, paid for through a unique partnership between the Klamath Indian Tribe and the IHS, as a health center that primarily serves the Klamath Tribe. It serves a tribal population of 2,890 individuals and cost $3.6 million to construct.

The last one I want to share with you comes out of Bylas, AZ, and the San Carlos Apache Tribe has constructed this two-building complex on its reservation, which is about 130 miles east of Phoenix. As the main source of primary care for Indians there, this clinic provides dental, behavioral health, optometry, laboratory, pharmacy, health education, and preventive care, among other services.

I use these examples to demonstrate some of the many cases where tribal ingenuity and resourcefulness have changed the Indian health care system for the better. I think this is illustrative of what can happen when the tribes are given the flexibility to plan, to develop, and to determine the future for their own people. We promote that ingenuity in this bill through the amendment to the Indian Self-Determination Act, which will make it possible to bring private sector money into Indian communities to supplement--again, I repeat ``supplement,'' not supplant--the Federal resources that are appropriated by Congress.

S. 1200 establishes the Native American Health and Wellness Foundation, the primary purpose of which will be to support the mission of the Indian Health Service by supplementing the Federal resources with private funds and, hopefully, bringing the level of funding for Indian health care closer to that level of need.

Mr. President, I will conclude my remarks this afternoon by repeating that within the Indian health system, you have great disparity. You have seen some of the pictures of beautiful facilities and some pictures of facilities that are in desperate need of help. We have heard stories that just break your heart of people who were denied services, of people whose illness was only compounded because of failures within the system.

But we have also heard some statistics that give us cause for hope that we are making headway within the system in terms of some of the chronic diseases and how we might approach them. Through the Indian health care reauthorization, we focus on those areas that will allow us to do better, whether it is in the area of behavioral health, additional screenings, those programs that focus on prevention, those programs that focus on wellness, so that we can, A, lower our cost of health care but, B, to really allow American Indians and Alaska Natives to have a quality of health care that is at least on par with what you would get if you went to a non-IHS facility.

We have not advanced legislation that would update the Indian Health Care Act since 1992. As I have said, all one needs to do is think back to what we were doing in 1992 in terms of health care. Think how far we have come with the technology. Think how far we have come with the techniques that are utilized. Let's not leave the Indian health care system 10, 20 years ago. Let's allow them to come into a level of service that we care to enjoy.

I mentioned one way we in Alaska are able to deal with the issue of access. In a large State with a small population who are not connected by roads, we have to rely on telehealth. Telemedicine has allowed us to provide for a level of care, whether it is checking out an infant's ear to make sure how bad that ear infection is or whether it is literally videoconferencing with a suicidal teenager and counseling to make sure he is not going to do something precipitous, that he knows he has somebody who is there for him. Our technology allows us to do that, but our legislation needs to be put in place to allow us to take full advantage of the changes in these intervening years.

Again, I stand with my colleague, the chairman of the Indian Affairs Committee, and urge our colleagues, if they have amendments, if there are still issues outstanding, let's work through those, let's get the amendments, but let's work through any remaining issues. We owe it to all our constituents around the country to provide for a better level of care.

With this legislation, it is one small step forward.

I yield the floor.

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