U.S. Department of Health and Human Services
Fourth Annual Tribal Budget Consultation Meeting
Hubert Humphrey Building
Deputy Secretary's Conference Room, 6th Floor
200 Independence Avenue, SW
Washington, DC 20201

Wednesday, May 29, 2002

Moderator

Chris McCabe, Director, Office of Intergovernmental Affairs, DHHS

Morning Session

Opening Blessing, 8:00 - 8:05

Julia Davis, Chairperson, National Indian Health Board and Council Member, Nez Perce Tribe

Julia Davis gave the opening blessing in Nez Perce, her native tongue, and then in English.

Welcome, 8:05 - 8:10
Chris McCabe, Director, Office of Intergovernmental Affairs, HHS

Chris McCabe thanked Julia Davis for the invocation. He explained that his office plays the lead in these tribal consultations, and promised all the technical assistance they could provide to make sure this consultation meets its objectives. He apologized for the room, saying they were unable to reserve the room they ordinarily use due to the homeland security priorities. He said steps were being taken to cool down the room, and conditions should improve shortly. He then thanked all the staff who had worked very hard to get this fourth annual budget consultation together.

A brief announcement was made: airport and connection delays had prevented the moderator of the morning presentations, Mr. Tex Hall from NCAI, from getting here in time for that session. He was expected as soon as his flight could make it to Washington. In his absence, Jackie Johnson, NCAI Executive Director will fill the temporary role of moderator.

Chris McCabe introduced Janet Hale, the Assistant Secretary for Budget, Technology and Finance. He also recognized Andy Knapp, Counselor to the Secretary, who has made many trips to Indian Country working to learn about the healthcare and human service needs of Indian people all across the country. He then introduced Mr. Claude Allen, Deputy Secretary.

HHS Opening Remarks, 8:10-8:20
Claude A. Allen, Deputy Secretary, HHS

Deputy Secretary Allen commented that last year, this consultation was the first meeting he participated in after his confirmation as Deputy Secretary, and he was very happy to be here again. He said he knew everyone was cramped and it is tight in the room, but the main conference room has been taken over as part of the national security efforts. He wanted everyone in the room to know that this meeting is very important to the Department.

He welcomed and thanked Julia Davis, and the Nez Perce tribe and National Indian Health Board for sending her. He also thanked Willie Jones and all the other tribal leaders who had traveled such long distances to be able to attend this critical meeting. He said this session represents the attempt of the Department of Health and Human Services to listen to tribal leaders present heir priorities and express the needs of Indian Country. Each division in the HHS Department will have representatives here, and all will listen carefully to what you have to say.

Deputy Secretary Allen noted that the agenda summarizes the current affairs of Indian Country and also reflects. Since the last meeting, America has been attacked and we seek ways to protect all our people from harm or from further attack. HHS Secretary Tommy Thompson has asked that the tribes be made part of this effort.

After he and Secretary Thompson visited Indian Country last year, they began to discuss ways to do this, and the decision was made to reactivate the Interdepartmental Council and to set in motion a number of other activities to allow opportunities for study and dialogue. Dr. Trujillo of the Indian Health Service has been instrumental in these efforts, as well as Dr. Wade Horn and many others. Deputy Secretary Allen thanked them for delegating staff to the effort. He said so far we are working in nine of the ten regions to discuss how to proceed.

Next, Deputy Secretary Allen said that he leads the HHS effort to eliminate health disparities. He said he knows the tribal leaders in this meeting see those disparities every day - that they witness the harm done by diabetes, alcohol and substance abuse, cancer and heart disease and many other chronic and acute illnesses that afflict Indians in this country more than the population at large. He said it is critical to work together and he promised to work with this country's Indian tribes to address the needs of Indian Country.

Deputy Secretary Allen then asked attendees to go around the room and introduce themselves. These people were in attendance at the morning session:

Name/Title/Agency:

Andrew Rock, ASPE
Ann Bowker, DTS/OCS
Ann Linehan, HSB/ACYF
Anna Kanegis
Buck Martin
Buford L. Rolin, NIHB, Poarch Creek Tribe
Charles Blackwell
Charles Currie, SAMHSA
Chris Gersten, ACF
Chris McCabe, IGA
Clarence Carter, OHS Director
Deborah Drayer, ASL
Doug Hus____
Douglas Fla_____
Duke McCloud, OGC
Eric Jordan
Estelle Bowman, AANA
Gary Kodasett, NICA
Gary Kimble
Gena Tyner-Dawson, IGA
Ginny Gorman, IGA/ACF
Hilda Moss, Northern Cheyenne Tribe
Jackie Johnson, NCAI
James T. Martin, USET Inc.
James Solomon
Janet Hale, HHS - ASBTF
Jay Adams, OCSE/TCSE
Jean Flagg-Newton, NIH
Jeannie Zaemes, NIHB
Jim Cozen, Urban
Jim Knapp, NICWA, Seneca Nation
Jim Roberts, NIHB
Joan Ohl, ACYF Commissioner
John Hunt, Office of Civil Rights
Julia Davis, Nez Perce Nation, NIHB
Julie Gerberding, CDC
Karen Boyle
Laura Pen_______
Lillian Sparks
Loren Sekayumptewa, NCUIH
Mary Navanick, IHIS, Western Region
Meg Graves, AoA
Michael H. Trujillo -- IHS
Mike Ambrose, CCB/ACYF
Mike Lincoln, IHIS
Mike Carroll
Nick Burbank
Patrick Johansen
Paula Williams, HIS
Ralph Brian
Ray Apadoca, DTS/OCS/ACF
Rich Kopanda, SAMHSA
Rick Roberts
Robin Carufel, Lac du Flambeau Nation, IHIS Budget Group
Ron Allen, Title VI Study Advisory Group, Jamestown S'Klallam Tribe
Rosalind Taveapont, Northern Ute
Sharon McCully, ANA/ACF
Steve Sawmelle, SAMHSA
Stephen Smith, HRSA
Sue Rohan, CMS
Taylor McKenzie, Navajo Nation
Tex Hall, NCAI
Tim Martin, United South and Eastern Tribes
Vicki Wright, CB/ACYF
Vincent Toya, Pueblo of Jemez
Walter Williams, CDC
Willie Jones, Lummi Nation
Willis North
Yvette Joseph-Fox, NIHB

Colleen
Darlene
Karen
Linda
Maia
Phyllis
Wendy

Deputy Secretary Allen thanked all the attendees and said he wanted to make sure the entire department was represented here at this meeting - it is important that we all participate. He added that this is the first year telecommunications equipment has been used at this meeting to bring in representation from the regions. Gaye Griffin, teleconferencing from Albuquerque NM, was acknowledged, and said she could see the meeting clearly. Others may be joining the meeting via teleconference or telephone.

Tribal Opening Remarks & Overview, 8:20- 8:40
Jackie Johnson, for Tex Hall, National Congress of American Indians

Jackie Johnson greeted the group and explained that she is a member of the Tlingkit tribe from Alaska currently on detail in Washington. She said she was honored to fill in for Tex Hall. The latest word is that his connecting flight is running late but is on the board now, and he will be here soon.

She thanked the Deputy Secretary Allen for his opening remarks and thanked the other officials from the HHS and other Federal agencies in the room. On behalf of NCAI's more than 200-member tribal nations, she said she was pleased to present issues of interest to Indian Country, including NCAI's recommendations for the FY04 budget formulation process.

The HHS Department's invitation to consult with leaders of America's Indian tribes demonstrates the Department's commitment to honor the unique relationship between Indian tribal governments and the United States. She said that open and full communication about policies, programs, and services is centrally important to the tribes in furthering this relationship and they thank the government representatives for being willing to take part in dialogue in a way that recognizes our unique government-to-government relationship.

The tragic events of September 11th brought forth the strength and the determination of our nation to survive in the face of adversity. The same spirit has propelled Indian nations forward into an era of self-determination. And it is in that same spirit, she said, she and the other tribal leaders had come here today to speak on behalf of their people about honoring the federal government's treaty obligations and trust responsibilities.

General Priorities

Last year, President Bush presented Congress with a $2.13 trillion dollar budget for FY2003. That budget contained largely level funding for Indian programs, continuing the trend of consistent declines in federal per capita spending for Indians compared to per capita expenditures for the population at large. Setting up the tribes to fail and failing to address critical needs cannot be the way to make any headway in eliminating health disparities between Indians and the general population.

Indian nations and advocates agree that direct funding should be a priority in the FY2004 budget. America's treaty obligations to Indian tribes are codified as part of United States law, and they include an obligation for the protection of trust lands, an obligation to provide social services, and an obligation to assist the tribes by serving the natural functions of government. Tribes look to the government to do what it has said for the past hundred years it would do.

This year, HHS is in the process of consolidating over 50 offices into a single department. The proposal on doing this has been advanced with few details on exactly how this consolidation will affect Indian health and social services. We urge DHHS, Jackie Johnson said, to address this question and must consult with tribal leaders consistent with their national goal of eliminating disparities.

Indian Health Service

Measured in per capita dollars, expenditures planned for FY2003 are actually lower than comparable expenditures in 1977. Budgets for all Indian programs have stayed flat for a number of years now. American Indians and Alaskan Natives today can expect their expenditures to equal only 54% of those being made to benefit the health of other Americans. Yet the Federal government has an obligation to provide Native Americans with parity in health care expenditures.

Our budget committee has asked for what they consider a reasonable amount of funding to deal with current costs. The Administration's request is less than one-fifth that amount. To help address health disparities in a meaningful way, the IHS level of need funding work group has identified an $18 billion needs-based budget for IHS, including a non-recurring $8.7 billion facilities request and $10 billion to fully fund the healthcare needs of American Indians and Alaskan Natives. NCAI recommends that HHS seriously consider and produce a system to implement the needs-based budget identified by the work group. These numbers may be daunting, but they reflect a reality that will not simply go away if we ignore it through enough appropriation cycles. Indeed, the size of the shortfall directly reflects such a deferred approach to budgeting by previous administrations, and we look to you to put an end to the head-in-the sand approach to budgeting for Indian health.

Economic Development

ANA administers a basic grant program in four distinct categories: Social and Economic Development Strategies, Alaska-specific SEDS, Environmental Regulatory Enhancement, and Native Language Preservation and Revitalization. The SEDS program includes a wide range of governance projects, allowing for tribal constitution revisions and codes and ordinances development, social projects that are based upon maintaining and fostering cultural traditions, and economic development projects covering a wide range of areas. These economic development projects include not only the development of new enterprises but also the expansion of existing and successful businesses. The major economic development projects are planning grants for architectural and engineering costs or grants that provide economic development infrastructure.

Through its assistance, ANA has moved many tribal programs from dependency on Federal services and operating Federally mandated programs to developing and implementing their own discrete projects. ANA continues to serve a large and diverse base of Native American communities and organizations, many of which have had little in the way of resources and lack sustainable economic opportunities. The President's budget proposed a $1 million cut in ANA's budget, from $46 million to $45 million. We urge you to reverse this troubling trend, and seek increased funding for the ANA in FY04 so that it may assist even more tribal governments in building their administrative capacities and infrastructure.

I just wanted to add a comment here - one of the things we are working with is a multitude of different departments and Federal contact points, including the Departments of the Interior, Commerce, HHS and other organizations. As an overall economic development initiative for Indian Country, the ANA dollars are absolutely essential to us in helping with the technical assistance pieces and building the capacity for tribal governments to be able to take on self-determination and positive economic development. So it would be a good decision to join in this initiative with the other Secretaries of the other Departments.

Administration on Aging.

Without exception, our tribal cultures teach us to respect and honor Indian elders, so that our elders -- the living expression of our heritage and our highest values - can be teachers to us and to our children. Aging grants for Native Americans promote the delivery of supportive services including nutrition services to older American Indians, Alaskan Natives, and Native Hawaiians.

This program provides the key front-line services for over 200 programs serving reservation elders, including congregate and home-delivered meals, transportation, and a wide variety of other services. In recognition of the fact that grantees report significant increases in the number of elders eligible for these services, the Administration has proposed a $2 million increase for this program, to $27.7 million, in its FY03 request. We are in strong support of this increase, long overdue in light of the growing population of native elders, and further urge the Administration to seek a larger increase, to at least $30 million, in its FY04 request.

We are also pleased that the Administration has proposed the continuation of the current $5.5 million for Native Americans under the Family Caregivers program, which will provide information, respite care, and other supportive services for 250,000 families caring for loved ones who are ill or disabled.

Head Start, Child Care, and Indian Child Welfare

The health and education of our next generation is essential to the survival of our tribal nations. Head Start programs focus on the education, health and social needs of impoverished children, and have a positive impact on the health and social needs of their families and their communities. The tribal communities have benefited greatly from the Head Start program. The DHHS provides direct funding to tribes for Head Start. These funds are locally designed to meet the needs of each tribal community. This has allowed tribal Head Start programs to provide comprehensive services that reflect and enhance the cultural pride and knowledge through the promotion of tribal values and languages at a key point in the developmental process.

Many tribes opt for center-based programs, but lack adequate facilities to serve children and families in a safe environment. Increased funding is critical to ensure that our children are educated in an environment that is safe and conducive to learning. Many of our centers are located in buildings that were not designed for preschool-age children, and our communities need classrooms that are designed for this age group. For tribal nations, the ability to construct new facilities provides additional opportunities to plan and implement cultural education and child development programs for their children. By providing safe quality programs at the earliest age possible tribes will nurture each child to develop his or her full potential, as well as instill the values, positive self-esteem, and pride in their culture. In all the studies that have been done on education for American Indian students, we have found that this principle of including the cultural education piece, has been essential to their ability to perform well throughout their life in the school systems.

Regional Head Start offices and regional specialists generally carry a grant load of 8-10 cases, while the Native American and Alaskan Native program specialists carry a load of 18-20 cases - double the workload of their counterparts. Additionally, regional program specialists generally travel 3-4 states for site visits, while the AIA and branch staff travel to 27 states. As a result of the heavy workload placed on AIA and branch staffs, employee retention is difficult for tribal communities and they suffer due to the lack of financial and human resources available for consultation between tribes in the larger Head Start program.

The Head Start Act requires that our classroom teachers be certified by September 2003. Many of our teachers will be unable to meet this requirement, due to the lack of available tribal colleges who can provide this training. The Head Start currently offers a critical effort for several tribal colleges to develop and offer degree programs in this area. The effort should most certainly be maintained, and the funding should be increased to enable this important initiative to be expanded to include more colleges in order to meet the certification requirement in our communities.

The Head Start Program currently serves approximately 150 tribes out of 556 eligible communities. Recent census data clearly identifies under served populations in both Head Start and Early Head Start. Head Start has been a successful model in our communities and it is important that this opportunity be extended to reach all tribes with eligible populations.

The Head Start and Early Head Start programs offer a unique opportunity for tribes to provide a holistic and comprehensive approach to the families that we serve and to provide tools to aid their parents in best practices for child rearing throughout their children's early developmental stages and to make the critical difference between simply adequate and truly high quality childhood programs. This is truly a forward-looking program that should continue to be developed and enhanced in close consultation with tribes.

Welfare Reform

Clearly, something that is on the top of the tribal leaders' agenda this year, due for reauthorization in the 107th congress is PERORA of 1996. This represented a major change in the Federal policy concerning assistance to poor families and children. Although provided with fewer resources than state governments, PERORA has offered tribal governments with the unprecedented opportunity to administer TANF programs.

Indian tribal governments and communities are very committed to the principle of self-sufficiency at both the family and community levels, but fiscal and bureaucratic barriers remain that have impeded tribes in their uphill struggle to address the needs that exist in Indian Country.

We call upon Congress and the Administration to make the substantial investment necessary to empower tribal governments to build economic and social infrastructure, to move families to self-sufficiency in the short term, and make the reservations into thriving communities in the long term. A footnote: we are once again just looking for parity and equity in services. The fact is, we need the up front money to develop the systems that the states have long had. Department staff need to recognize that states received startup funding to develop their infrastructures back when these programs first began operating.

Homeland Security

As we face the aftermath of September 11th, the heightened public health threats have made maintaining an adequate public health system vital to our national defense. Tribes are very concerned about their exclusion from Homeland Security planning and appropriations.

Tribal sovereignty requires that issues of mutual security between the Federal government and tribes be handled directly between those two levels of government. We urge the inclusion of the tribes and the IHS in any national strategy for homeland security, including the treatment of the tribes AS states with regard to planning, coordination, capacity building, and other bioterrorism prevention and other emergency response activities.

We support a direct appropriation to tribes of homeland security resources funded through the DHHS services, including those provided to HRSA, CDC, and SAMHSA. And NCAI recognizes the difficult budget choices that must be made this year and for years to come. As a former tribal leader, I certainly understand the competing priorities that you have to weigh over the upcoming months. However, I must stress the fact that the Federal government has a solemn responsibility to address the serious needs facing Indian Country.

We at NCAI urge the Department of Health and Human Services to make a strong across-the-board commitment to meeting the Federal trust obligation by exploring ways to extend your services and programs that are vital to the creation of vibrant Indian nations. Such commitment, coupled with continued efforts to strengthen tribal governments and to clarify the government-to-government relationship truly will make a difference in helping us create stable, diversified, healthy economies in Indian Country.

Indian Health Issues, 8:40 - 9:30
Dr. Taylor McKenzie, M.D. -IHS Budget Group; Vice President, Navajo Nation

Dr. McKenzie thanked the representatives from the Department of Health and Human Services for allowing himself and his fellow tribal leaders to comment on the IHS budget and the programs that will support it. He directed the group's attention to their agenda, which lists the speakers in order of presentation. Dr. McKenzie then introduced the first to speak -- Willie Jones Sr., from the Tribal Self-Governance Advisory Committee.

Willie Jones greeted the group and said he is from the Lummi Nation and will be giving an overview of policy foundations today from the perspective of Creating Healthy Communities. He explained that from January through May of 2002, representatives from the Indian Health Service worked at the area and national levels looking at health delivery systems to over 2.5 million American Indians and Alaskan Native communities. He said that he and his peers are representing many leading organizations dedicated to Indian Health issues. We'll be presenting our recommendations for FY2004 IHS Tribal and Urban needs-based budget with the hope that it will be supported by DHHS in budget formulation with the Office of Management and Budget, thereby honoring the government-to-government commitment to provide healthcare to American Indian and Alaskan Native communities.

Policy Foundation

1. Federal Health Responsibilities

   Our first topic today is policy foundation - it is important to examine the legislative and executive policy that has been enacted to provide Indian people with quality healthcare. The Federal Government's responsibility to provide health services to American Indians and Alaskan Native people represents a prepaid entitlement paid for by the cession of over four hundred million acres of land to the United States. The foundation for the provision of healthcare services between the United States and American Indians and Alaskan Native tribes is embodied in over 800 ratified treaties, executive orders and statutory case law. Its real foundation comes from inherent sovereignty that relates to our government-to-government relationship. A number of pieces of specific legislation have recognized this. In pursuit of that goal, we all have to work together toward the goal of correcting the disparities between our people and the population in general. The major legislation supporting the government's responsibility includes:

   • The U.S. Constitution - Article 1, Section 8 - "Congress regulates commerce among states…and with Indian tribes"
   • Over 800 Ratified Treaties
   • Statutory and Case Law as exemplified by the 1921 Snyder Act, which provides the legal basis for funding health care
   • Numerous Executive Orders
   • NGA Resolution HR-31, passed in Winter of 2001-2, which
     • Acknowledges federal trust responsibility
     • Supports federal funding level without requiring state subsidy
   
   
2. Presidential and Secretarial Priorities

   There are also a number of goals and programs that are overriding administrative goals for the Department of Health and Human Services. These include specific goals for Indian healthcare as well as goals that relate directly to the dramatic disparities between the health and resources of American Indians and Alaskan natives and the general population of the United States.

   • Healthy Communities
     • Disease, Illness, and Injury Prevention
     • Diabetes, Obesity, Asthma Prevention
   • Management Improvement
   • "21st Century Health Care"
     • Technology
     • Government Performance Results Act
   • Homeland Preparedness - Bioterrorism
   • "One-HHS" Program
     • Increased Access to Health Care
     • Long-Term Care - Elder Care
     • Mental and Behavioral Health
   
   
3. Tribal Consultation
   • Executive Order 13175 - Consultation and Coordination with Indian Tribal Governments (Issued 11/06/2000)

   Addressing the priorities in Indian Country will honor Government-to-Government relationships in a number of ways. It will honor the U.S. obligations to provide health care for American Indians and Alaska Natives. It will enable I/T/U's to improve the health of their communities. It will help to eliminate racial health disparities between Indians and the rest of the U.S. population, and it will help in the restoration of Indian healthcare resources that have been continually reduced by inflation.

Creating Healthy Communities

This topic was addressed by Dr. McKenzie, Vice President of the Navajo Nation. Dr. McKenzie was previously a member of the commissioned corps of the United States Public Health Service serving the Navajo Nation until 1995, when he retired and then continued medical practice under personal services contract with the Gallup Indian Medical Center until this opportunity to become a politician came up, which he is doing today.

There are several health priorities that are driving the decisions that shaped our budget recommendations, and these are areas of focus which include chronic diseases, preventive health, and behavioral health.

Chronic illnesses have become critical for many Indian communities. The rates of diagnosis and morbidity are many times higher than the national average, and these rates continue to grow. Dr. McKenzie described the scale and colors used on a series of charts and graphs presented as slides during his presentation.

Diabetes has reached epidemic proportions within Indian communities, and even extending down to the adolescents and the young children. The incidence of diabetes is very strongly tied to family history. Almost every extended family in Indian Country has been impacted by diabetes. Funds are not available for optimal day-to-day care, such as regular blood sugar monitoring. Anecdotally, one can see the tremendous requirements that day-to-day care involves. Consequently, long-term impacts of diabetes, including kidney failure, amputation, vision problems, etc. also have reached epidemic levels. Navajo was found to have the highest rate of amputation among all the countries in the world due to diabetes. However, subsequent to the institution of podiatry services there has been a dramatic decrease in the number of amputations.

Heart disease is also a serious problem for Indian communities. Risk factors for heart disease include diabetes, cigarette smoking, obesity, high blood pressure, high cholesterol. Over 60% of all American Indian men have at least one of these risk factors, and when over age 65, typically two or more risk factors are present. Heart disease is now the number one killer among the Navajo people. Just as an anecdote - when I first went to work with the Indian Health Service, in the first two years there was only one myocardial infarction on Navajo. Now quadruple bypasses and bypass surgeries are fairly routine. This change occurred over a span of just thirty years.

General Cancer diagnosis rates within Indian Country are fairly comparable with the national average. However, when examined more closely, American Indian and Alaskan Native patients are diagnosed younger, reach a terminal stage more quickly, are diagnosed when the disease is at a more advanced stage, and access to cancer specialists and new experimental treatment programs are not available.

Chronic Disease Success Stories

Even though chronic illnesses have reached epidemic proportions, Indian health providers are working hard and have seen some success. One example is the Whirling Thunder Wellness Program implemented by the Winnebago Nebraska tribe. They have demonstrated higher-than-average success rates due to the effective combination of standard medical practice with traditional and cultural ideas. Specifically, they have focused on traditional healing and the re-introduction of traditional foods, as well as the use of talking circles to help educate patients.

Preventive Health

Within Indian communities, there are a number of health conditions that are very preventable. Among these are injuries and poisoning. Rates for both of these situations are higher than the national average. Especially when viewed regionally, American Indians and Alaskan natives have much higher rates of death due to poisoning. A number of environmental factors are at the root of this disparity, including use of pesticides, lead-based paint and poor air quality, especially for reservations near urban areas.

Accidental deaths are at a critical point. For young American Indian/Alaskan Native men, aged 12 to 17, accidents are the leading cause of death. This can be directly related to the prevalence of risky illicit behaviors. Young American Indians in this group have higher rates of drug use, binge drinking, driving under the influence, use of cigarettes, group-against-group fighting, and carrying of handguns.

Infant mortality continues to be a crisis for Indian communities. In other communities with high infant mortality, this disparity is typically due to congenital birth defects. However, among American Indians/Alaskan Natives, the rate of Sudden Infant Death Syndrome (SIDS) is two and a half times higher than the national average. Behavioral issues and lack of adequate medical care among new mothers are thought to be among the causes. Teen pregnancies among American Indians and Alaskan Natives are 75% higher than the white population. Adequate prenatal care is well documented to reduce the level of infant mortality, and specifically SIDS.

Preventive Health Success Stories.

In some areas, American Indians have taken dramatic steps to eliminate preventable health conditions. Childhood immunization is an important way to prevent a number of serious illnesses and health conditions. The HEDIS standard used by Medicaid for childhood immunizations is 80%. Currently, the rate among all races is 77%. Indian healthcare programs have worked very hard to surpass these standards. Currently, 88% of American Indian children receive their childhood immunizations. Some areas are dramatically higher, including the Phoenix area, where 96% of children are immunized. The Nation has consistently maintained very high rates of children immunized, year after year.

Attaining this level of childhood immunization will dramatically impact Indian Country in the long run by improving the overall health of children. Additionally, it will eliminate future medical care for some diseases, ultimately cutting the costs of long term health care.

Behavioral Health

It is impossible to see the complete picture of healthcare in Indian Country without examining the behavioral health situation. Behavioral issues worsen a number of other health conditions, and in turn are worsened by still other health conditions. The high rate of alcoholism among Indian peoples contributes negatively to many other health situations in Indian Country, including overall health levels, the economic situation, and accidents and injuries. The American Indian population is more likely to attempt suicide and is also more likely to be successful in their attempts. Other issues feed into this high rate, including problems with substance abuse and economic desperation.

Behavioral health issues also create other health impacts. It has been estimated that as many as 75% of Indian women have been victims of domestic violence. In addition, these women are more likely to require medical attention for injuries sustained as a result of domestic violence.

Behavioral Health Success Stories

Still, within behavioral health there are successes. A model behavioral health treatment program is the Thunderbird Treatment Center, located in Seattle, which is run by the Seattle Indian Health Board. The program offers treatment for both adults and teens, and the treatment program covers many forms of healing, including group and one-on-one therapy, spiritual and cultural programs, family involvement, nutrition and exercise and 24-hour patient supervision. Outpatient treatment is also available. I might also mention the Natnejosi Center Incorporated (NCI), which is also a behavioral health program in Gallup, New Mexico, taking care of problems among the Navajo people. Thank you very much.

IHS Budget

Next to speak on Indian Health was Robin Carufel, Tribal Co-Chairman of the IHS Budget Formulation Team and Health Director for the Lac du Flambeau Band of Chippewa Indians.

He greeted attendees from the Great Lakes and described his five years as a member of the Budget Formulation Team. He said that the emblem of the Indian Health Service was a familiar and very welcome symbol in his home as a boy, since his father had worked for IHS for over 26 years. When Deputy Secretary Allen once spoke about taking his young son with him to health meetings, I remember being that young son, accompanying my dad to bring water and sanitation facilities to Indian communities. So he said he was very pleased to be here.

The budget goals of the FY2004 Budget Formulation Team are very closely tied to those of the Administration and to the Secretary's overall goals for the DHHS. In the President's management agenda, we see that in his rhetoric that he mentions tribal governments in his discussion on e-government. We've seen that this meeting is very well attended, and the setting up of the meeting through the Division of Intergovernmental Affairs, it is clear that it was important that he included that in his management agenda.

DHHS Secretary's Priorities

Secretary Thompson has set out very specific goals for healthcare in the United States. The Budget group developed its budget to help implement those goals. We recognized the need to improve the level of preparedness for potential bioterrorist threats. We focused on improving healthy communities by preventative illness, disease and injury. We are empowering specific populations like American Indians and Alaskan Natives. We are trying to address the enormous gaps that exist in health status and the delivery of healthcare. And we are looking to improve the family well-being and the safety of our young ones and our old ones.

The goals and priorities of any community in the nation mirror those set forth by the Secretary.

Overview of FY2004 Needs-Based Budget

This budget has been consistently presented over the past five years at the level of $18 billion - an amount which demonstrates the need for healthcare funding in Indian communities. We recognize that in the President's agenda, they talk about starting with a planning base - not looking at the increases or the decreases, but look at the planning base. And that's what we do every year. We look at the President's agenda, we say 'what do we need for current services, what do we need to keep from taking steps backwards, and then what could we do, given the opportunity to really receive some true monetary enhancement and thereby improve our health?'

A handout that has been made available for your review details the specifics of the FY2004 budget proposal. What we have done is that we have acknowledged GPRA and the way it ties to performance indicators. As a health administrator, I take a look each year at the annual funding agreement for my tribe. We have to identify those GPRA indicators that we can achieve and to judge what will make an impact given the limited dollars that we receive. So each year we start at the local level, and get together to evaluate what is going on in the Great Lakes area, then come together at a national meeting to agree on specific things we all need to answer to take care of the health of the Indian people in our community. A similar process was used to develop this national budget.

These figures may look large, but I hope you are aware of the context. We don't want to go backwards. For example, under current services, we have proposed $70,798,000 in funding increases for pay costs. Part of the reason for this is that it is extremely difficult to recruit for medical personnel in the private sector. It is very difficult to recruit a doctor, for example, and to retain that person for any length of time. Thirty years ago it may have been a different story. Dr. McKenzie was committed and motivated to work in Indian Country as a doctor, and he was able to develop relationships with his patients over that time. Imagine if each of you at this meeting had to drop your current physician with whom you have a relationship and every two years had to go out and start to develop a new relationship with a new physician.

Likewise when it comes to pharmaceuticals, we are seeing the same pattern in Indian Country as folks are seeing all across the United States. Inflation and medical inflation are getting out of sight, so that even those fortunate enough to have a pharmacy in their community cannot afford to buy them. Folks are getting on busses and travelling to Canada or Mexico in order to buy affordable pharmaceuticals. The inability to pay for medicine is devastating for some of our people, and something is very wrong, as we all know about.

We have advocated for a $100 million increase in contract support costs. This is part of the outsourcing that the President advocates, and Indian communities have been raising the issue of their need for additional contract support costs for several years now.

I see that there are HRSA people at the table. We appreciate the opportunity to participate in the rural health initiative to expand health facilities as part of HRSA's goals for healthcare, but we are in desperate need of facilities that we have never had enough of. We are proposing $50 million in increases for healthcare facility construction. Right now, our facilities are 60 years old - asbestos-filled, painted with lead paint and without a single sprinkler - they couldn't meet current specifications or ADA standards. The room we are meeting in, which has a maximum capacity of 75 people, is the size of many of our tribal health clinics.

We are also requesting increases for Maternal and Child Health, for Heart Disease treatment programs, for primary care services, for additional contract health services, and for treatment of alcohol/substance abuse, diabetes, and cancer. We have seen these areas of healthcare get worse for twenty and thirty years, and now we are saying - please help us make strides to improve these conditions, and that takes money.

Indian health is the biggest HMO. We live in a capitated system. You give us peanuts to take care of a whole herd of elephants, and we can't get it done. We need some realistic support to take on these problems.

We are currently funded at only a fraction of need. There has been a 75% increase in reported denials from 1998 to 2001. "Loss of Life or Limb" rules apply. It is an ongoing problem, to the point where many of our patients do not even request certain services, since they know they will be denied treatment based on lack of resources. This is especially true when it comes to specialty care, which is severely lacking in health facilities serving I/T/U's.

HHS Response and Questions

Ms. Janet Hale, the Assistant Secretary for Budget, Technology and Finance asked for an opportunity to respond before all the presentations in this section were heard. She said that the description of the problems she had heard about is very compelling, but that HHS is faces a myriad of tradeoffs and priorities. They are working hard to meet the needs of American Indians and Alaskan Natives. The 18% increase requested may not be approved - OMB may not allow HHS to go that far. She inquired if the budget formulation committee had been part of the budgetary priority discussion process? She asked if there was enough understanding of what the HHS budget folks face when they have to make the tough choices, and further asked if there are ways to further break down the proposed budget and to set priorities on the specific program increases that had been requested.

Mr. Carufel answered that because HHS had given them the opportunity to give information on the true impacts, the committee had determined to provide a budget based on actual needs of the American Indian tribal communities. The consultation process, he said, had proved itself valuable. The committee had seen great progress with small increases in the past and they believed in the light of all the evidence, this money is what is really needed to address the real needs of the real communities. OMB's assignments are like handcuffs - to draw up what they want in the way they want it is to take a step backwards. This budget, he said, comes directly from the tribal communities. He added that he is a card-carrying Indian - someone with an official card that proves that he is a tribal member. Other American citizens do not need to prove their race or ethnicity to be allowed to receive exactly the same kind of healthcare assistance from the Government, and there are many Indians nowadays that cannot prove their descent because of the tools given us by the Federal government.

Julia Davis added that in 1995, Drs. Joe Ivy Buford and Phil Lee spoke to the tribal leaders about being involved in the budget process with DHHS. We took that a step further and started the actual beginnings of it more than seven years and this is a part of what we began. She said that having these consultations with the Department have been just tremendous and have shown the responsiveness of DHHS to listen to the tribal leaders. Some tribal leaders will tell you that sometimes we as tribal leaders feel a little slighted because we want this to be a government to government structure. We want to meet with the President and the department heads, but we know that this is only a beginning.

Jackie Johnson commented that the tribal leaders have given the Department their priorities and have told the Department what is important to them, and exactly where they think the disparities are. She said they are asking the DHHS to go to OMB and take action. If that means fighting with OMB, the tribal leaders are willing to go to OMB. However, at this stage, that isn't allowed, so the information they are giving at today's meeting is the ammunition for DHHS to use to fight on behalf of Indian people. The hope is that DHHS will become the champion at OMB and get the thresholds high enough that real progress can be made.

Some tribes, she said, are self-governance tribes and through their resources gotten by contracting with DHHS, they make decisions locally based on available funds. Other tribes receive services from IHS directly. Jointly we can work out some of the problems faced by everyone - diabetes is an example. But the process of trying to come up with a single set of priorities for both groups will require further consultation and consideration of health disparities and other issues with the help of DHHS.

Dr. Trujillo said that during the budget development process, the committee had worked with the tribal leaders in the respective areas of tribal leadership. Together they considered a range of options between one percent and 18%, as well as the possibility of a decrease, and asked what were the highest of all priorities to be funded. This information and the result of those discussions will be available to DHHS at the end of this process.

Urban Indian Health and the IHS Budget

Mr. Carufel said that an important term in talking about Indian health is the term "I/T/U". In this term, "I" stands for the direct service tribes, "T" for tribal area residents and "U" for urbans. To speak briefly about the budget proposal relating to urban Indians, he introduced the next speaker. Loren Sekayumptewa, from the Hopi tribe and the Navajo nation, greeted the DHHS officials and thanked them for being here to listen. He thanked them, and his clan brother Dr. Trujillo, for the opportunity to engage in discussions about these important subjects. Mr. Sekayumptewa described a discussion with his grandfather back when he was a little child. His grandfather, who was the chief of a village, spoke to all the children and told them that one day they would be the eyes, the ears, and the tongue of their people to speak on their behalf. He passed on a prophecy that one day someone from the tribe would go back east to a tall building with glass and speak on their behalf. "Tell them your message four times," he said, "and maybe one of those times they will listen and hear you and understand what you are talking about."

He said he would not be speaking off a script at this meeting; he was simply here to tell them about the desperate plight of urban Indians. Since 1979, when Title V first enabled the urban population of Indians to participate in health benefits, their share of benefits has gone down, declining from 1.48 % to only 1.12%. This makes no sense when this group represents 57% of Indian people throughout the nation, but receives less than 2% of the IHS budget. This is an estimated 500,000 to 700,000 people. Today for FY2003, their share is slated to be only 1.14% of IHS's total budget. This is not fair or right.

The health needs of this group are great. Right now it is getting only $5 million per year to maintain the health of so many people; they estimate a need of more like $30 million. In the needs-based budget, a request has been made to increase funding for urban Indians by $5 million. We hope you will give us this money, but even more, hope that DHHS will recognize that more is needed in future years. Right now, approximately 332,000 of the 500-700,000 American Indians living in urban areas are being served at 41 sites in 36 locations nationwide. All of these sites are falling short of being able to do what is needed for the people they serve. Mr. Sekayumtewaya closed by quoting his grandfather's comment that "we hold the lives of our children in our hands." He said that the officials at DHHS also hold the lives of Indian people in their hands. Finally, he expressed the hope that they will take that responsibility with great seriousness and give the support - not just the funding needed to confront the health problems faced by Indians in urban areas, but the spirit and intellect to help them.

Funding Inequities and Disparities

When you analyze dollars received for health needs by non-Indian Medicaid patients, an Indian person receives less than half that amount per capita for health services under current Federal spending patterns. The recommendation of the $18 billion dollars and the request for support of the proposed Senate resolution are both designed to eliminate the disparities in the delivery of health care to Indian people compared to the general population. It is a citizen-driven process and mirrors the President's vision for government reform. The needs-based budget follows three key Presidential principles:

• It is citizen-centered rather than bureaucracy-centered
• It is results-oriented, and
• It promotes innovation.

For full funding to be achieved, the plan is phased over approximately ten years, after a substantial increase at the beginning, and an annual percentage each year following. Ideally, this plan will eliminate the disparities in healthcare and allow the I/T/U's to deliver healthcare services at a level comparable to the general U.S. population.

Overview of Needs for DHHS Agencies Under the Department Level

Ms. Julia Davis greeted the honorable tribal leaders, the honorabl

She said the group was recommending that at least 1.5 percent of each agency budget be dedicated to the needs of American Indians and Alaskan Natives. More specifically, they recommended the following:

Addressing Chronic Illnesses

$24 million set aside for the National Institutes of Diabetes and Digestive/Kidney Diseases
$41.9 million within the National Institutes of Heart, Blood and Lung
$70.8 million set aside within the National Cancer Institute
$10.4 million set aside within the Centers for Disease Control for prevention activities

Preventive Health Efforts within NIH and CDC

$18.2 million allocated for child health & human development
$5.8 million for dental and craniofacial research
$59.9 million for allergies and infectious diseases
$2.9 million within CDC for injury prevention and control
$17.1 million for HIV/AIDS, STD, and TB prevention
$1.3 million for birth defects disability and health
$9.4 million for childhood immunization activities

The total recommended for setting aside for prevention activities among American Indians and Alaskan natives by the CDC is $35.3 million.

To address problems of behavioral health, the following is recommended: $6.2 million for National Institute of Alcoholism & Alcohol Abuse
$14.5 million within the National Institute of Drug Abuse
$20.3 million within the National Institute of Mental Health

It is also recommended that the Department set aside, at a minimum, the following general funds: At least 1.5% of the NIH/CDC budgets for research, prevention and control of diseases $410 million be dedicated by the National Institutes of Health for research targeted towards American Indians and Alaskan Natives. It is our understanding that out of 35,920 research project grants funded by NIH, only 12 projects were specifically targeted to this population, and we find this statistic to be quite startling.

We also recommend that $60.1 million be set aside at CDC for the variety of disease prevention and control activities that are not being addressed throughout the 110 CDC programs. We remain concerned that only 12 of these 110 programs actually provided any services to tribal communities. Our thought as tribal leaders is one of helping our people to bring their health up to the U.S. general population standard. We are tired of burying our people.

HHS Question: Assistant Secretary Janet Hale asked if participation in clinical trials is being addressed, and whether or not tribal populations were being asked to participate in these trials.

Ms. Davis answered that tribes were trying to work with universities and research institutions with which they had connections, but that they are not as sophisticated as university researchers are. She said that some other mechanism was needed to ensure this kind of participation. Another participant commented that HHS gives out grants to universities and other organizations without cultural sensitivities to Indian communities, which leaves our people with a reluctance to participate. Giving some of these grants to tribal governments themselves would allow them to contract with the Indian Health Service or universities to do the research.

Dr. Trujillo said that there has been a decrease in participation, because much of the leadership feels that research participation is merely a matter of being tested or studied - there is little in the way of direct benefit seen in the results. We are working to change some of that perception, and also working to set up institutional review boards so that when universities or other programs wish to conduct studies they can have their research plan run past the review board. Also, some of the NIH institutes have begun to work with both universities and some of the tribes in order to design studies - that approach has been quite successful.

Structural Issues Relating to the Indian Health Service.

Mr. Buford Rolin of the National Indian Health Board then stepped up to describe the restructuring initiative workgroup's involvement on "One-DHHS" and Management Initiatives and the ways in which these initiatives have impacted the IHS. Mr. Rolin thanked the Department for the opportunity to consult with the Tribes and continue with this process.

He said that consultation with the tribes by the director of the Indian Health Service has been very positive and has been helpful as part of the One-DHHS process. Dr. Trujillo originated this workgroup in February of 2002, as the second group to identify and recommend changes to the design of the Indian Health care system. The group's charge was to develop recommendations and by June the 1st of 2002 to submit them to Dr. Trujillo of the Indian Health Service and to the Indian people. That interim report has been submitted to Dr..

The first restructuring efforts at the IHS began shortly after Dr. Trujillo was appointed. The earlier effort, from 1995 to 1997, was led by the Indian Health Design Team or IHDT, which was a Tribal/Federal group of Indian health leaders. Forty draft recommendations were sent out by the to Indian health stakeholders for their review and feedback.

The second workgroup, the Restructuring Initiative Workgroup (RIW), is a total of twenty people including both Federal and tribal participants. We all know that the healthcare system must respond to change. The focus of change in today's environment has been on challenges of financing of healthcare. Dr. Trujillo asked the new Restructuring Work group to review the entire picture of Indian health in today's environment, and with consideration of future changes. The challenge: to answer the question How WILL the operators of Indian healthcare programs continue to provide healthcare services in a changing environment?

Six years after the first stakeholder redesign of the system, it IS a good time for tribes and IHS, along with DHHS, to chart a course for the immediate future. The health status disparities between American Indians/Alaskan Natives and the general population are most dramatic in American society. They warrant a major new initiative and new resources from the United States government.

The RIW has been evaluating both the internal redesign requirements for the IHIS and the impacts of the One-HHS initiative for the period from 2002 to 2007.

• The RIW is concerned that the DHHS Secretary has not formally consulted with Indian tribal governments about the One-HHS initiative as required by existing departmental policy.
  
  
• The RIW recommends that this process occur at the earliest possible time and that the consolidation should not proceed UNTIL this consultation occurs.
  
  
• The RIW does not support the consolidation of IHIS' public affairs and legislative affairs functions with DHHS. Instead, we recommend that our MOA be established to improve communications and coordination.
  
  
• The RIW does not support the consolidation of IHIS health facilities and sanitation facilities, or construction programs, with Departmental facilities management. Given the direct medical services mission of the agency and the unique status of the construction of activities funded through the IHIS budget.
  
  
• The RIW recommends that the IHIS Human Resource program should not be consolidated with DHHS Human Services, but instead should be internally redesigned for greater effectiveness and efficiencies.
  
  
• The RIW recommends that certain elements of the IHIS information technology system should be consolidated with DHHS, leaving the agency-specific operating elements under IHIS management.
  
  
• The RIW recommends that the IHIS financial management system should be integrated with the DHHS department's financial management systems.
  
  
• The RIW notes that between 1994 and 2001, the administrative portion of the IHS was already downsized by 60 percent of its administrative staff complement, transferring these savings to increase IHIS field-based health program staff and to increase funding for tribes and tribal health organizations providing healthcare under contracts and self-governance compacts.
  
  
• Because of this prior downsizing effort, the RIW recommends that the the IHS be exempt from the additional 100 FTE reductions proposed by DHHS and OMB for FY2003. These reductions should be absorbed by other DHHS operating divisions.
  
  
• Instead of continuing this long term series of reductions in funding, the RIW recommends that the five-year vision for the IHIS should include the doubling of the agency's funding level from $2.5 billion to $5 billion by fiscal year 2007.
  
  
• Staffing should be the Indian Health Service's tribal health programs and urban health programs should be increased by 15,000 FTEs.
  
  
• The RIW recommends that the agency must be funded to complete approximately the $1 billion worth of sanitation facilities on reservations and in Alaskan Native villages.
  
  
• The agency must be funded to complete a minimum of $1 billion worth of health facility construction projects documented as required throughout Indian Country.
  
  
• Major new resources need to be provided to tribal governments for Health Promotion and disease prevention initiatives and for services that traditionally have not been provided by the Indian Health Service, such as:
  
  
  • Substance Abuse Treatment
  • Elderly and Long Term Care services, and
  • Indian health research
  
  
  
• Substantial contribution of these resources should be made by other operating divisions of DHHS. These divisions need to treat the tribes in the same manner as they treat state and local governments with respect to eligibility for DHHS programs and resources.

These recommendations of the RIW are subject to revision subject to the Tribal consultation process, which will occur between June and August of this year.

In summary, the Secretary's consultation with tribal government is essential to a One-DHHS. IHIS has administratively downsized enough. Upsizing direct services will address Indian health disparities. A One-DHHS consolidation must address the uniqueness of the Indian Health Service. New One-DHHS concepts for Indian people, we believe, do hold promise.

Two questions for the DHHS Secretary:

• When does Secretary Thompson plan to consult with tribes about the One-HHS in accordance with the existing HHS consultation policy?
• Will HHS commit to reinvesting savings from ONE-HHS plans to reduce disparities to help with the health status of Indian peoples?

Conclusions:

Mr. Carufel closed this panel session by making the following comments about the proposed Needs-based budget for the Indian Health Service. He said that the recommended FY2004 budget will:

• Improve access, given the opportunity
• Improve outcomes and quality of care
• Strengthen families, including newborns and seniors
• Improve the well-being of our entire communities

We can, through this consultation process, contribute to the overall improvement of DHHS. Ultimately, the implementation of this proposed budget will directly contribute to the outcome goals of the One-HHS initiative.

It is important to recognize the way unhealthy people in unhealthy communities are directly tied into a cycle that leads to an unhealthy economy. Unhealthy communities are made up of individuals who are too ill to work or who must take care of ill family members, and therefore cannot work and cannot contribute to the local economy. Some of these individuals may need to obtain support through welfare. By investing in the FY2004 needs-based budget, the Federal government will provide tribes with the tools necessary to improve the health of their communities and in addition to honor the treaty obligations with Indian people. Such tools can not only enable tribes to improve health, but will improve the economic self-sufficiency of Indian communities.

Concluding Remarks

Ms. Hilda Moss spoke next. She is a tribally elected official of the Northern Cheyenne nation. She also represents the Billings area tribes on the Budget Formulation work group. She said she was also involved when twelve area tribal representatives came to Rockville to work on the Indian Health Service budget being presenting today. Both the tribal leaders here at this meeting and those who are not here today have been instrumental in doing this. She said she wanted to make it clear that they present this budget on a government-to-government basis. We can create healthy communities. We have the authority to make the difference for babies, childs, moms, fathers, grandmothers and grandfathers. We make decisions here for tribes across the country.

Diabetes takes its toll across all our communities. Dialysis is critical and in our "frontier states" - those where there are great distances and few population centers -- it is very expensive. It requires traveling a great distance to take part. This has made many people -- both older and younger -- sign waivers and decline to participate in today's dialysis program. This is a sad fact of healthcare disparities. She said that Indian people back home look up to the people in this room here. In fact, most Indian people see Washington DC as somewhere the money is just lying around - they sent the leaders here to collect it.

Ms. Jackie Johnson thanked all the panel, especially Julia Davis and her fellow workers at the Indian Health Board for helping to coordinate this presentation. She described the schedule challenges of the morning, asked to have the question and answer session, then another presentation from Mr. Ron Allen, and then the morning break.

Mr. Chris McCabe thanked everyone for being here and participating. He said it is a meaningful experience for the HHS staff and they are hearing the message. One of the Secretary and the Deputy Secretary's highest priorities is to address racial health disparities. Hearing about the significant problems you are having within your population with diabetes is something we will bring forward and spotlight with our policy makers here at DHHS.

Julie Gerberding from the CDC asked a process question - she said that increasingly the funding available now and in the future will be competitive. Are we doing enough to support the capacity of tribal entities and other Indian groups to compete for these funds, both with CDC funds and those from other agencies?

Jackie Johnson said that competitive applications have been a challenge for us for a long time. It is very important when Federal officials draft their RFP or their NOFA, that they get people involved who understand the Indian communities. They need to build in criteria and submittal rules that make sense for those communities.

Also, during the evaluation process, it would be extremely important to ask some reviewers from the Indian Health Service or the tribal communities who can understand the communities, their governance structures, and the reasons for the lack of certain data elements. If there is a provision for alternative demonstrations of the severity of need or the success of programs that are relevant to the data available on Indian populations, it will help to level the playing field.

Another thing important for the tribes is to make direct outreach to tribes in your initial announcements so as to provide training in the terms and requirements of the particular RFP or NOFA. And in cases where Indian tribes are proving not to be competitive in qualifying for available programs or services - especially those with a potential impact on widespread disparity problems - it would be valuable to discuss and share with those who developed the proposals or applications for funding just exactly where the weaknesses of their proposals lie.

Mr. Buford Rolin thanked CDC for its program in doing research on breast and cervical cancer. Because of that program, he has been able to serve over 300 women through that program that he otherwise wouldn't have had the resources to help. He has been able to provide mammography, information, and treatment as a result.

Ms. Julia Davis noted that the previous President passed an Executive Order for government-to-government consultation. We all need to work that order appropriately and not to delegate the responsibility to consult down to some agency minority health office eliminates tribal sovereignty and puts it down from an appropriate level. We as tribes want to access funding for our people at home.

Mr. Loren Sekayumptewa commented that this should be a two-way street. Not only do you need to come to us but we need to come to you, inform you better, and get involved earlier in the process with the policy makers. If we are left out of the planning process because the consultation is not ongoing, we will not be able to impact the programs enough to identify issues that address the pattern of health disparities we are all working to remedy.

We have heard that one major department initiative was started fifteen months ago and we still have not been formally notified of its development or asked to consult. We don't need to be at odds - we need to collaborate and work together.

Also, I see people in the room who are specialists with particular emphasis who have counterparts here in the room. I think we should be sitting down with our counterparts to discuss areas of common interest. For example, 330 funding and faith-based program initiatives affect urban Indians, but we have not been involved in those programs yet.

Dr. Trujillo commented that in some instances grants go out from many agencies' operating divisions without any mention of the eligibility of Native American communities or programs to apply. States are mentioned, but no other groups, which creates the appearance that these funds are only available to states. This can often keep Indian tribes and local groups from applying for resources that should be available to them. The Federal people may feel that even though they are not mentioned, they are not excluded, but it is a source of unclarity.

Dr. Taylor McKenzie said that competitive processes can pit one tribe against one another for finite or limited resources to address problems that are common to all of them. Some Indian tribes don't want to do that. Other tribes find themselves pulling away because of the extremely technical nature of the information that is called for. I might suggest that a lack of participation in some health areas might be a sign to you that eventually a broader and non-competitive funding process might be a better way to apply funds towards solving important problems.

A tribal leader commented that things get lost in complexity. We have been reduced to either grantees or contractors, and this is the nature of the delivery system. Last week we were in town meeting with the E.P.A. folks, and we met with the OMB, Governor Whitman and her senior staff, the state's representatives and our tribal representatives. It was a good example of a government-to-government approach and very effective. As our representative from the Navajo nation has pointed out, any time a pot of money is set out for all 580 tribes to fight over, it means that 485 of them won't get anything. It is not always the technological capacity that we lack, but sometimes it is just the system of identifying and meeting needs. We can live with being contractors or grantees as long as our leaders meet and fully understand one another.

Self-Governance Study

Jackie Johnson introduced Ron Allen, who is the chairman of the Jamestown S'Klallam Tribe, co-chair of the Title VI Study Advisory Group and the Title V Negotiated Rulemaking, and also the former Chair and Vice-Chair of NCAI.

Ron Allen said that we are cramming a lot into less than a day, but we are talking about four to five million people, living in the most impoverished communities in the nation today. Urban ghettoes have many problems, but few have the kind of disappointing, even disgusting conditions that Indian communities face today. He challenged the folks of DHHS to devote more time to this problem next year and in future years.

He said there is a constant in this equation, and that constant is US - the people sitting in this room today. The administration folks, he said, have four years to make a difference - some may say they have eight, but even if the bus stays for eight, some people may get off and get replaced by others. There is a need to make a commitment to really DO something, and right now.

He quoted the Tom Wolfe novel "The Right Stuff," about the astronaut program, in which someone commented that "it's not the fuel that makes rockets go up, it's MONEY." And we are here making a case for money, to make a difference back in our communities.

When you examine, he said, what America has done in terms of making a commitment to the Indian people, it is not a good commentary on the Nation's commitment. When people like Janet Hale say to us 'What are your priorities for the money we have?" we don't hear that as a positive commentary. We go off and we bomb a country, and we spend four billion dollars, and billions and billions into the defense industry - we understand that there is terrorism, and this is important, but we have a huge problem out here just serving our communities and keeping our people alive, and it has not been dealt with. Administration after administration have challenged us to make do with less, but we would like to challenge you to move the agenda for a change, and make a difference.

Self-governance is part of the answer to all this. What does self-governance mean with regard to HHS? It's about the tribes exercising their governmental authority. It is a status in the relationship between the Federal government and the Indian nations - 560 of us out there - who are making the difference.

We have gotten used to the fact that the Federal government will never live up to its obligations. From the origin of the country through treaty times through the statutes of today, all the rhetoric that has been in that process basically says that we will make a commitment and honor our commitments to the Indian nations. You have given up something for these services, and now you are waiting for us to give back. But the bottom line is that the Federal government has never produced the services that we needed. So right now the issue is, what can we do for ourselves?

We are asking you to give us the money for the programs that you offer and let us show you what WE can do with the money. We know that outsourcing works - it's not a new concept for us out on the reservation. In Indian country, we've been doing it for more than 25 years. Outsourcing directly to our 560 tribes or their representatives is remarkably effective, and we have shown that it works. In some cases, tribes have stumbled a little, but overall, we have shown that we can leverage the dollars you give us and create remarkable results with it.

We need to move this agenda. We moved from the Department of the Interior over to the Indian Health Service, and with only 25% of IHS' budget, we have managed to serve 33% of IHS' eligible community, which is a good rate of performance success.

In Title V, we finally got regulations passed on time, thanks to people like Dr. Trujillo and Paula Williams over at the Indian Health Service, and others. Now we are approaching Title VI, which covers the rest of HHS, with its hundreds of programs. All we are asking for is $13 million [???] for a pilot program, and we need the report on our work out, and that report sent to Congress with DHHS approval for the allocation of those funds. Because the one-size-fits-all cookie cutter approach doesn't work in Indian country - there is too much variation. Five hundred and sixty nations are not all the same -- Navajo is not the same as the village of Barrow on the northern slopes of Alaska.

So the bottom line is that if we're living in a sea of change, we need to become collective leaders in that sea, and the HHS leaders need to recognize their obligations and commitments to our communities. Self-governance is an important part of this, and it is a matter of course. Each of the 560 nations can choose how they want to deliver services to their communities, and so far between 270 and 280 nations have chosen this method.

We need to move this policy forward and we need to commit enough money to support the startup program in this area. We are basically only asking for an aircraft carrier, but as the investment is shown to be efficient, others will join. Your commitment will have tremendous benefits to millions of us in Indian country.

Chris McCabe thanked Ron Allen for his very passionate comments. He also thanked Gena Tyner-Dawson and the rest of their team for helping to make the room cool enough to keep the meeting comfortable.

BREAK

Last revised: November 10, 2003

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