Indian Health Care Improvement Act Amendments of 2007

Floor Speech

INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2007 -- (Senate - January 22, 2008)

BREAK IN TRANSCRIPT

Ms. MURKOWSKI. Mr. President, I so appreciate the passion and the advocacy of my colleague, the Senator from North Dakota, and working together on the Indian Affairs Committee on an issue in which I think both of us believe very strongly. Both of us believe in the commitment we have to the American Indians and the Alaska Natives, particularly insofar as providing them with a level of access to health care. That commitment is one that in far too many areas we have failed, and that is why it is so important that we are able to advance, as the first legislation of this new year, the Indian Health Care Improvement Act of 2007.

We just celebrated the birthday of Martin Luther King, and as a nation we think about that time in our history when we were not proud of how we treated one another based on color of skin and ethnicity. We know that in many parts of this country, we still have far to go, but we are making progress. Yet, as we look to how the American Indians, the Alaska Natives, and so many in our Native communities have been treated when it comes to the basics in health care, that is an area where I think we need to look very critically and say we can and we must do more.

When I first became the vice chair of this committee, Chairman Dorgan and I sat down, and he said to me: Lisa, what are your priorities for the Indian Affairs Committee? What is it that you would like to see advanced? He told me what his priorities were. It is awfully nice being able to walk into that new relationship and agree that the most important thing we could do was to work together in a bipartisan effort to advance legislation that has been working through the process for a number of years, for a number of Congresses, and to successfully move that through the Congress.

We have worked on this bill through three committees of jurisdiction--the Indian Affairs Committee, the Finance Committee, and the HELP

Committee--before finally bringing this here to the Senate Floor. I believe this legislation brings new hope for Indian health. It represents a step forward, a step toward the goal of providing our first Americans with health care that is on par with other Americans. It is not the end-all and be-all, but it is a first step, and I am encouraged that we have the opportunity to produce this legislation in support of that goal.

As my colleague has noted, this day has been far too long in coming. Efforts to enact comprehensive reform for the Indian Health Care Improvement Act began in 1999. This act was extended for 1 year back in 2001 through legislation introduced by Senator Thune when he was a Member of the House of Representatives. Since then, the Indian Affairs Committee has shepherded several reauthorization bills through multiple Congresses, through multiple hearings, through multiple markups, but it has yet to be reauthorized despite the very good efforts of a great many.

This bill would reauthorize and would amend the Indian Health Care Improvement Act and applicable parts of the Indian Self-Determination and Education Assistance Act, as well as the Social Security Act.

The Indian Health Care Improvement Act provides a basic framework for delivery of health care services to American Indians and Alaska Natives. As Senator Dorgan has indicated, this is a Federal responsibility arising from the Constitution, arising from the treaties and from Federal court cases.

The act itself, first enacted back in 1976, was last comprehensively reauthorized in 1992. Think about the status of health care back in 1992 and what has changed. Certainly, in my State of Alaska, we have been able to do so much more in our remote areas because of what we are able to do through Telehealth. Well, back in 1992, I can guarantee you we were not doing then what we are doing now. It is so vitally important that we provide for this authorization to update a system by passing this bill.

We recognize there are still some outstanding issues that need to be resolved. I would like to think they are not central parts to this bill, and I am very confident we can deal with them if our colleagues work with us in the same very bipartisan way that we on the committee have done to advance this.

Now, Chairman Dorgan has given good background in terms of an overview, the need for reauthorization, and he has highlighted it with stories that touch our hearts, as they should. I wish to elaborate a little bit further on the legislation, how it developed, and give that overview as well as some of the key improvements we have in S. 1200.

To really understand the framework of the Indian health care system under this act, you have to keep in mind that there is very significant interplay between this act and the Indian Self-Determination and Education Assistance Act. The Indian Self-Determination and Education Assistance Act provides the process whereby Indian tribes and the tribal organizations contract or compact to take over administration of programs from the Indian Health Service. It is the interplay between these two statutes that provides a great deal of the backdrop for many of the principles that underlie this reauthorization.

The act essentially governs programs for the recruitment and retention of Indian health professionals, for health promotion and disease prevention, for facilities, urban Indians, and a comprehensive behavioral health system. The act also governs important authorizations which increase access to care where there is third-party reimbursement. It also sets forth the administrative organization for the Indian Health Service. Finally, it contains reporting requirements and other regulatory authority for the Secretary of the Department of Health and Human Services.

The bill is intended to improve Indian health care in three areas: First, by increasing access to health care; second, by updating the authorized services and programs; and third, by facilitating innovative financing systems to help support Indian health.

So let's talk about the increase in access to care. In Alaska, we are talking about access to care all over the State. Geographically, as you know, we are very large, populations are very small, and providers are very limited. And this is throughout all systems, not necessarily just the Indian Health Service. This legislation includes programs to increase outreach and enrollment in Medicare, Medicaid, and SCHIP. We need to have aggressive outreach in order to ensure that the Native people who are eligible for these programs participate in them and so that they can navigate through a relatively challenging enrollment process.

We recognized the critical importance of the Medicare, the Medicaid, and the SCHIP programs for Indian patients. There was an Indian woman by the name of Ski who lives in southwestern Oklahoma. Along with her husband, she takes care of her three grandchildren and her great-granddaughter. About 4 years ago, Ski's doctor, after checking her x rays, found a large spot on her lungs. They also diagnosed her with thyroid cancer. Sadly, though, the IHS Contract Health Service, which is intended to provide for the kind of specialty care Ski needed, notified her that the funds aren't available to pay for it. This is very similar to some of the stories my colleague has mentioned.

Without this additional care, Ski, who is the primary caregiver for her grandchildren and great-grandchild, wondered if she would be around to watch her children and great-grandchild grow up. Fortunately, Ski won't have to face the prospect of living without health care because she did receive it--not through the Contract Health Service but through Medicare. It was these resources which allowed Ski to undergo the biopsy which ruled out lung cancer and to see a pulmonologist and receive testing on a regular basis for the pulmonary fibrosis she was eventually diagnosed to have. She had complete removal of her cancerous thyroid and since that time has been able to receive the follow-up treatments, the testing, and the examinations, all of which we know are very costly but which Medicare helped to cover so that Ski can continue her life raising her family.

She is fortunate and, unfortunately, somewhat of a rarity. Many Indian patients do not have Medicare or Medicaid to help them even though they may be eligible. In the legislation we have, S. 1200, it will help those Indian patients in accessing Medicare, Medicaid, and SCHIP through the outreach and the enrollment programs as well as other means.

Now, accessing third-party reimbursement also helps Indian health providers. The Makah Tribe is a good example of why we should include the provisions to assist tribes in participating in Medicare, Medicaid, and SCHIP. The Makah Tribe is in Washington State, and they are located on a very picturesque 44-square-mile Indian reservation filled with rich forests, wildlife, birds, and plant life--a very beautiful area.

From their home, tribal members can cross the Strait of Juan de Fuca and during the summers go fishing or boating in the Pacific. Although their home is a place of amazing beauty, it is also a very remote part of the State which presents some daunting challenges to the delivery of health services to the tribal members.

It has been reported that the tribe operates a small ambulatory clinic with over 2,000 users and only two doctors. Due to the remoteness of the clinic, the tribe has difficulty recruiting health care professionals, including dentists.

Over 70 miles away you have the nearest town with a full-service hospital, Port Angeles. But those 70 miles can be treacherous to negotiate. It is a winding road, a difficult road. There are several instances when the road has been washed out by storms, leaving no access to or from the reservation.

So there is no surprise that Port Angeles, being a larger town and a more accessible town, has salaries that are more attractive than the reservation.

The Makah Tribe administers the health care services through a self-governance compact for which the tribe should receive contract support costs. However, those contract support costs do not cover all of the indirect costs of health care services. So this impacts the tribe's ability to provide for competitive salaries and to provide for that full array of health care services. But despite all of those challenges, the Makah Tribe has remained resourceful. They are in the process of improving their third-party reimbursements, in particular the Medicare Part B access for eligible people on the reservation.

It is these additional reimbursements that assist the tribe in essentially hedging against the insufficient contract support costs. So when you hear of situations like what we are seeing with the Makah, recognize this legislation will serve to benefit the tribal health providers as well as the Indians who are served by allowing for, again, the additional reimbursement for improving access to care.

The legislation will also improve access by removing barriers to such enrollment such as the waivers of Medicaid copays and allowing the use of tribal enrollment documentation for Medicaid enrollment. These are very important to provisions in this legislation. I hope we will hear more of the good stories, the stories like Ski's, rather than the very damning stories we hear of the system currently.

Now, in updating health care services in Native communities, the bill establishes permanent authority for home and community-based services, and these are services which have been operating in the State of Alaska with very impressive results.

I mentioned just a few minutes ago Alaska's size. Many know Alaska Natives have to travel enormous distances away from their home communities to obtain any level of specialized care. Some people think we make this map up, just to show Alaska's shape over the continental United States--but this is actually true to size--the State of Alaska does stretch from just about Florida into Arizona and beyond, from Canada down to the southern area. Geographically, we are huge.

We have another chart that indicates how the distances for an individual coming from, let's say, Unalaska down here where Arizona is on the map. Unalaska is not only our State's largest fishing port, it is the largest, in terms of volume of fish, fishing community in the United States of America.

For an individual who is coming from Unalaska, which just has a small clinic, to come to Anchorage, which is where all of the points converge in the middle of the map, it is the equivalent of essentially going from Arizona to Kansas for your medical appointment to come to the Alaska Native Medical Center where you can see a specialist.

To give another example, the residents of Barrow, at the northern most part of the State, also have to travel to Anchorage to obtain specialty medical services in the Alaska Native Medical Hospital. That is the distance of coming from the Canadian border down to Kansas for medical services.

If you are coming out of the southeastern part of our State, in many of our island communities, again, you are moving from essentially Alabama or Florida into Kansas. The distances we deal with to provide access to care are realities for us in the State that other people cannot relate to.

We are not talking 100 miles, we are talking several hundred miles. When you put it in context that way, you recognize it is not just the time and the distance traveled, but it is the expense and the distance traveled.

Mr. President, as I was mentioning the distances that we deal with, I mentioned the time to travel, the expense to travel, but think about the situation if perhaps you are elderly, you are ill, or perhaps you do not know what is wrong, and you have to leave your village to go to our cities, our largest cities, which is very intimidating for many of our Alaska Natives in the first place.

They are away from their family, they are away from their community members, they are away from their traditional foods, they are away from their traditional activities. Many of our elders do not speak English, so they are coming into town where the language is different. Think about how well you would heal or how well you would feel in truly a strange and foreign place like this.

Well, the Yukon-Kuskokwim Health Corporation located out in Bethel, Alaska, in western Alaska, decided this is unacceptable, to have to pull everybody from the villages so far away. And they developed a village and a regional service structure to help the elders, to help the Alaska Native patients with chronic diseases to continue living in their homes or in their community rather than being sent hundreds of miles away to receive special nursing care.

It was their pilot program to take over all home and community-based care in their region, which resulted in a reduction in service waiting time for the disabled and the elders in the region and truly improved the patients' health status level. This legislation may enable other tribal programs around the country to also engage in home and community-based care which would allow Indian patients to remain in their homes rather than face a lengthy hospital stay or nursing home stay in a distant and, again, a strange location.

Our legislation also consolidates and coordinates the various tribal health programs into a more comprehensive approach. As we well know, alcohol and drug abuse among many of our Native communities, and methamphetamine abuse, has reached epidemic proportions in some communities.

We had a gentleman, the former chairman of the Northern Arapahoe, Mr. Richard Brannan. He testified before our joint hearing before the 109th Congress, and then again during the 110th, and told us truly a heart-breaking story of the tragic and painful and terrible unnecessary death of a beautiful little Indian girl at the hands of methamphetamine-addicted individuals.

Chairman Brannan sought our help in providing both prevention and treatment for the drug and alcohol addictions that ravage Native communities. I am pleased that this bill will authorize such assistance and more to help prevent these tragedies from happening to other Indian children.

Now, also during the committee hearing on the methamphetamine plague, we received testimony from tribal leaders about the devastation this terrible drug has brought to their communities. Kathleen Kitcheyan, the former tribal chairwoman of the San Carlos Apache Tribe in Arizona, described a very personal loss, a tragic loss of a grandson to drugs. And she stated that on her reservation, they have methamphetamine users who are as young as 9 years old.

Think about what is happening to our children. Think about drug abuse and the addictions. But to know that children as young as 9 years old are being made the victims, we should all be alarmed when we hear stories like this. And what is equally horrifying are the residual effects of methamphetamine abuse on children. The former chairwoman testified how babies were being born on the reservation, born addicted to methamphetamine, with physical deformities. She stated that on her reservation a 22-year-old methamphetamine user tried to commit suicide by stabbing himself with a 10-inch knife. So many terrible stories. There were 101 suicide attempts on her reservation during the year 2004, 101 attempts that were directly related to meth.

Now, I have described that we are seeing methamphetamine users as young as 9, but it also afflicts the middle-aged as well as the elderly. Once meth has taken hold, few can escape without considerable help. The Indian Health Service estimates it takes well over 60 days in treatment programs in order to overcome these addictions. So just separating a methamphetamine addict from the drug for a period of a few weeks or even a month is not nearly enough to provide effective treatment, not nearly enough to break the addiction. The methamphetamine addicts need the long-term treatment necessary to allow their mental and their physical state to heal and to recover.

For the children, the IHS has 11 federally funded youth regional treatment centers with 300 beds overall. In addition, there are an estimated 47 or perhaps 48 tribal and urban residential programs for adults. One program, the Native American Rehabilitation Association in Portland, OR, which is an urban Indian facility, can also house the patient's family so the patient can also receive the very necessary family support during the recovery.

These programs authorized under the Indian Health Care Improvement Act, and more importantly the Indian and Alaska Natives who are suffering from meth addiction, will benefit from the updates to the behavioral health program in this bill.

Now, we heard from Chairman Dorgan that the Indian health system is funded at approximately 60 percent of the need. And with the new health hazards, whether it is methamphetamine or whatever the hazard is, that face our Native communities, we have to be innovative in finding solutions and resources in building upon the foundations that are set forth in the Indian Health Care Improvement Act.

This legislation will establish the Native American Wellness Foundation, a federally chartered foundation to facilitate mechanisms to support but not supplant the mission of the Indian Health Service.

It is modeled after legislation which passed the Senate in the 108th Congress. I am pleased to say we will have an opportunity to advance it in this legislation as well.

I wish to mention two key provisions that have been briefly mentioned. This is regarding the issue of violence against Native women. In the substitute we hope to advance later, we will provide for authorization of prevention and treatment programs for Indian victims and the perpetrators of domestic and sexual violence. We will also provide critical incentives for Indian health providers to obtain certification and training as sexual assault nurse examiners or in other areas to serve victims of violence. Both these provisions build upon very important work this Congress did in the Violence Against Women Act, by addressing some of the systematic shortcomings to improve prosecutions, such as forensic examinations. I will speak on this a bit later.

One of the things we heard in testimony before the committee was that in many of our IHS facilities, they did not have rape kits available. They could not collect the forensic evidence. If you don't have the evidence, you cannot proceed with prosecution. When you hear stories such as this and ask for confirmation that, in fact, this is the situation, that we simply don't have the kits available--it is confirmed--it is no wonder women feel helpless in even seeking assistance after a violent act such as a rape. In addition, simply not having the training for the nurses at the clinics, these are areas of critical shortcomings and ways we can help to make a difference.

There are many good things in this bill, but I do wish to impress upon Members this is truly a national bill. It works to benefit Indians and Indian health programs in communities across the spectrum. I have mentioned that it has been a product that has been in the works for years, a very determined effort on the part of Native health leaders truly from all corners of our Nation. There are over 560 Indian tribes in this country, with 225 of those tribes in Alaska alone. Our Indian tribes and Indian health care system span the Nation from Maine to Florida, California to Washington, and, of course, to Alaska up North. According to recent information from IHS, over 1.6 million American Indians and Alaska Natives receive services in this system at over 600 facilities. These facilities are all over the board, in terms of what they can provide, ranging from inpatient hospitals, general clinics, and health stations.

There are some that look beautiful and there are some that you look at and say: We can do far better.

I mentioned earlier many Natives in the State travel into Anchorage from outlying areas to receive care at the Alaska Native Medical Center. As you can see behind me, it is a large, beautiful facility. It is designed to provide for that advanced level of care and specialty for Alaska Natives from around the entire State. But as one travels away from Anchorage, and you get off the road system out into the bush, the facilities vary in size and certainly in service and are certainly much more modest. We have a picture of the clinic in Atka, AK. It is a little rough around the edges, certainly, but they are able to provide for the basic needs in that region. I checked to identify some of the other challenges the folks in Atka face, in terms of their costs. This is a village where gas is selling for $5.09 a gallon, and home heating oil is going for $4.99 a gallon.

We have a picture of the clinic at Arctic Village which is located more in the central or interior part of the State. I checked with them this weekend on the price of gas per gallon. It is 7 bucks a gallon. Their home heating oil costs are $6.36 a gallon. So it is expensive to live out there. It is expensive to heat your home. When you are ill or need help, this clinic is where you go in Arctic Village.

We know the need is extensive. The Indian health care system has to provide everything from basic medical to dental to vision services and medical support systems. It has to include the laboratory, nutrition, pharmaceutical, diagnostic imagining, medical records. Obviously, they are not providing that there at Arctic Village.

Senator Dorgan had mentioned the history of the Indian health care system. I will not take the time today to speak to that. I do, before taking a break, wish to take time to talk about some of the updates to the current Indian health care system we have in this legislation. As I mentioned, there have been enormous changes to the medical system since the last reauthorization of the Indian Health Care Act in 1992. So in order to update and provide for an improvement in the overall status of the American Indian and Alaska Native health and well-being, we have to make sure our facilities access is better.

Chairman Dorgan mentioned some of the health statistics and mortality rates we see among American Indians and Alaska Natives. We know these populations are dying at higher rates than others within the U.S. population. On tuberculosis, for American Indians and Alaska Natives the rate is 600 percent higher; alcoholism, 510 percent higher; diabetes, 229 percent higher; unintentional injuries, 152 percent higher; homicides, suicides higher. The statistics are all so troubling as we look to what we are providing and whether we are seeing improvement.

As I say that, we have seen some gains. With passage of the Indian Health Care Improvement Act of 1976, there were some pieces of good news insofar as decreases in mortality rates over the past 35 years. The average death rate from all causes for the American Indian and Alaska Native population dropped 28 percent between 1974 and 2002. We have seen gastrointestinal disease mortality reduced. Even though the death rate for Indians is 600 percent higher than the rest of the United States, we have seen tuberculosis mortality reduced 80 percent, and cervical cancer mortality has been reduced. Infant mortality has been reduced 66 percent. We are seeing good news there. The problem is, we started at such high levels. So, the statistics are still unacceptable.

In addition, we have population growth and economic factors which are creating strong pressure on American Indian and Alaska Native communities and their health care facilities. From 1990 to 2000, the population grew at a rate of 26 percent among the American Indian and Alaska Native populations. Compared to the total U.S. population, it grew by 13 percent. But we know the health care funding for Native people simply has not kept up with the expanding population and inflation.

This effective reduction in health care funding creates our current health status level. We see the survival rate improving, but all we need to do is look at the charts, look at the statistics. We know Indians and Alaska Natives still suffer disproportionately from a number of health problems. We know, for instance, in the area of diabetes, the rates are unacceptably high. While we recognize the Indian Health Service is trying to get this diabetes crisis under control--they are providing diabetes care to greater numbers of Native people than ever before, and we see some success--is it adequate? Is it sufficient?

Another area where we are seeing some success is in the area of vaccinations. We are getting higher vaccination rates for adults over 65. These have been instrumental in helping with some of our health statistics. Screenings, such as for fetal alcohol syndrome, have been helping to reduce the burden of preventable disease.

One of the aspects we face in increasing efficiencies within the delivery of the health care system, we know we have to use new technologies, new techniques, and these are contemplated and outlined in many areas of the legislation before us. I will go back to Alaska as an example of a State that faces very unique challenges in providing for quality health care to the residents in rural Alaska. The majority of the 200 rural Alaska Native villages are not connected to a road system. We don't have the roads. We are 47 out of 50 in ranking of States for the number of road miles, but we rank first out of 50 for overall land mass. We simply don't have a road system to speak of in much of Alaska. When you don't have a road system, you fly. We fly in small bush planes. During the summer months, we rely on skiffs and riverboats to get around. But for the most part, we fly. It is not luxury travel. It is a basic need.

From the chart I have behind me, you can't see the names of all the towns there, but it is there to demonstrate what we deal with as a State. When you look at the IHS budget in Alaska, you may be surprised to see the travel budgets are unusually large, oftentimes larger than staff budgets. That gets people's attention. Are we going out to conferences? No. This is how we get around in the State of Alaska and how we move our patients, those who need to get to that medical specialist. We move them by airplane. Up in the north there you see a community of Barrow. Nuiqsut is a small village outside of Barrow. They have a small clinic. Barrow has a larger one. But in order to receive any level of specialty care, an Alaska Native would have to fly about 700 miles south to Anchorage to the Alaska Native Medical Center. The cost of that particular flight is $1,100 for that person coming out of Nuiqsut.

Over to the west, out on St. Lawrence Island, an individual who is ill in Savoonga and needs to come into Anchorage for medical care is going to pay about $1,000. This is round trip, not that that makes it any better.

Down south of Anchorage, off of Kodiak Island--and if you look at the red lines, it looks as if it must be much closer to Anchorage and therefore less costly--if you are coming from Old Harbor on Kodiak Island, your airfare is going to be about $1,350 round trip to get you to and from.

So when we factor in the budgets of doing business, travel costs are enormous. This is all about access. We also recognize it is not just the cost. Oftentimes during the winter--this time of year--travel is shut down completely. For some of our communities, because of weather conditions, fuel barges have not been able to get into the community, and they have had to fly fuel in to provide for the diesel generation that provides the power in these villages.

Whether it is the ice, the wind, the snow, oftentimes it is just too dangerous to make the trip into town. Blue Cross has estimated that it is 300 times more expensive to operate a hospital or a clinic in Alaska than it is in the continental United States. These are the expenses we deal with.

In the last 10 years, we have seen access to medical specialists and health care improve. Working with my colleague, Senator Stevens, we have seen a revolution in terms of how health care is delivered to our rural villages with the development of an advanced telehealth network. With 99 percent of the telehealth initiative coming from IHS funding and managed by the Alaska Native Tribal Health Care Consortium, the Alaska Federal Health Care Partnership is a collaboration with the Department of Veterans Affairs, the Department of Defense, and the U.S. Coast Guard. They teamed up together to develop the Alaska Federal Health Care Access Network. They developed a special telehealth cart, and they deploy these carts to small villages in rural Alaska. They are able to provide a very wide variety of clinical services, including cardiology, community health aid training, dental and oral health, dermatology, ear, nose and throat care, as well as emergency room services.

They had a demonstration cart here a couple years back to just kind of show us what it is they were doing. I had just come off a trip up north, and I was due to fly again very soon. My ears were all plugged up. I said: Well, show me how this works. Just standing right there, they put a little monitor in my ear, and they were talking to a doctor in Anchorage. He said: You just have a little inflammation there. You are fine to fly.

What we are able to do with telehealth is to connect many of our Alaska Natives in a very cost-effective way for them to have access to qualified health care specialists without necessarily leaving their village.

We continue to evaluate the cost savings we are seeing as a consequence of this telemedicine. The preliminary data suggests that 37 percent of the time, telemedicine prevented the need for a patient and family escort to travel. That saved an estimated $4.4 million in travel costs. So if you can save $4 million in travel, because we have the technology in front of us, it is a savings for all of us.

Tribal health providers in Alaska with their Federal counterparts have been extremely innovative in addressing the unique health care challenges of our State. The Alaska Federal Health Care Access Network has been working with the IHS service areas to expand quality and affordable health care to American Indians across the United States.

The new opportunities, such as expanded telehealth, found in S. 1200 serve important purposes in promoting good investments. Indian tribes and tribal organizations have performed admirably in developing their health care services and facilities. These types of efforts should be rewarded and encouraged by passage of this bill.

There are some other items I would like to speak to, and I may come back to them at another point in time. But before I conclude for now, I want to mention the importance of the program in the sanitation facilities area.

I could probably stand all day justifying the need for the reauthorization, but one area that has been demonstrated to be one of those very important functions in reducing health disparities is the Sanitation Facilities Program. This program governs the construction, operations, and maintenance of sanitation facilities providing clean water and sanitary disposal systems to Indian and Alaska Native communities.

For us in Alaska, the issue of sanitation is one we have been struggling with for far, far too many years. One in three families--one in three families--in rural Alaska has no sanitation facilities. We are not talking about upgraded sanitation facilities; we are saying no sanitation facilities. What we have in many of our villages, still, unfortunately, is a system we refer to as the honey-bucket system. It is not a very refined system. In fact, it is a system that, for those of us in the State, we look at with shame and say: For Alaska Natives, for Alaskans to have to rely on this as their sanitation system is offensive. It is close to Third World conditions, and here we are in the United States of America, and you have a system where human waste is collected in a bucket and hauled outside and dumped in a collection facility. In some areas, it is less than a collection area; it is dumped in a lagoon. You can walk through some of these communities, and you have waste that is spilled along the wayside.

I have in the Chamber this picture of these two little Native boys. It is like the equivalent of taking out the trash--taking out the honey bucket. If you do not think this does not contribute to some of our health issues in rural Alaska, you have not looked at the facts.

In testimony before the committee, we had Steven Weaver. He is from the Alaska Native Tribal Health Consortium. Steve Weaver has been very instrumental working with us in order to eliminate the honey bucket. But he spoke at that hearing to the challenges families face in communities without sanitation facilities. He said: Other folks in America have the convenience of running water and inside flushing toilets, but in too many of our Native communities we have to haul the clean water into the homes and then haul the honey buckets out of the homes as part of the household chores, part of the daily living.

I was in a community several years back and visited the health clinic there. It was a very small health clinic. It was one of the villages that still do not have running water. There was a honey bucket in the corner of the health clinic. When you think about the need for sanitation, particularly in your clinic, and you realize there is no running water and the human waste must be discarded by walking it out the door, the health consequences in communities without running water, without sewer are very real.

The Alaska Native Tribal Health Consortium reported that infants in communities without adequate sanitation are 11 times more likely to be hospitalized for respiratory infections in comparison to all U.S. infants and 5 times more likely to be hospitalized for skin infections than those in communities with adequate sanitation.

We have about 6,000 homes without potable water, about 18,650 homes that need improvements or upgrades for water, sewer, or solid waste.

This legislation, S. 1200, will maintain the Sanitation Facilities Program. For us in a State such as Alaska, this is vitally important.

Mr. President, at this time I am prepared to defer to Senator Gregg. He has been waiting some time. I do have additional comments I will make throughout the day, but I yield the floor at this time.

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