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Health bill hearing raises doubts

WASHINGTON - There was no cry in the crisis of Indian health identified by speakers at a joint congressional hearing July 16, and Rep. Frank Pallone, D-N.J., questioned why in the late-going of Dr. Charles Grim's testimony.

"I just don't get the sense of crisis from your testimony," Pallone told the acting secretary for the Indian Health Service, adding that tribes are being asked to shoulder the burden for health care more than before. "You're almost building into IHS the notion that tribes will pay for their own services. ? Is there an assumption that tribes will pay?"

Grim said no and left it at that, having previously detailed several steps the Bush administration has taken toward "health promotion and disease prevention," including a well-funded round of grants against diabetes.

But Pallone's line of questioning lingered. Grim, acting secretary of IHS, and soon to be confirmed to the post permanently if his smooth sailing through the process holds, had identified behavioral problems - in brief, behavior that enhances the chances one will be stricken with disease, such as heavy alcohol consumption, a fatty diet, smoking or lack of exercise - as one cause of the current Indian health crisis, as opposed to infectious diseases of the past. Costs are another.

In a presidential administration that has advocated self-determination even beyond the point where many tribes are willing to go, one that is running a $450 billion annual deficit no less, perhaps it behooves tribes to ask when self-determination will be viewed in more individual terms. That is, will the conduct of individuals become a factor in the funding mix as behavior-based disease costs continue to spiral? Will Washington be tempted to build its case for washing its hands of those costs, on the argument that self-determined individuals can't be told how to behave?

These speculations didn't come up at the hearing, but there was plenty more to preoccupy members of the Senate Committee on Indian Affairs and the House Resources Committee, meeting jointly in an attempt to create some urgency around S. 556/H.R. 2440. Both bills would reauthorize the Indian Health Care Improvement Act, a move that has been under debate since the previous authorization expired. Continuing resolutions have kept the act in force for the fours years since then, but reauthorized programs are less apt to be tampered with in their budgeting and operations when Congress begins to look for spending cuts.

Besides the acknowledged crisis in Indian health and the effects on the health care system of transitioning from a time of mainly infectious disease to one of behaviorally enhanced disease factors, the main topic July 16 was urban Indians. By virtue of language in the bill coming out of the House of Representatives, H.R. 2440, urban clinics fear they could be absorbed into tribal budgeting processes. Currently in Oklahoma for instance, the Tulsa and Oklahoma City urban Indian clinics are non-profit organizations defined as a federal demonstration projects, meaning they are considered IHS service units for purposes of financial allocation. In particular, they can be reimbursed for Medicare and Medicaid patient care.

Carmelita Skeeter and Dr. Everett Rhoades, representing the Tulsa and Oklahoma urban Indian clinics respectively, urged the joint committees to adopt the language of the Senate bill and reject that of the House bill, which would subject them to the Indian Self-Determination and Education Assistance Act - and with that, possibly, tribal health care contracting and compacting processes. At present, Skeeter said, the clinics can treat any enrolled Indian tribal member in the state free of cost to the tribe. Uniquely within the IHS system, the entire state of Oklahoma is considered a Contract Health Service Delivery Area.

The IHS counts 1.3 million urban Natives, 58 percent of 2.2 million Native Americans and/or Alaska Natives overall. The IHS counts only enrolled tribal members as Indians. Its figures are fairly close to the 2000 census figures "only American Indian and/or Alaska Native" numbers (1.4 million urban Natives, 57 percent of 2.5 million overall).

IHS and tribal direct-contract general hospitals admit 85,000 patients annually, 40 percent of them in the IHS Navajo and Oklahoma City administrative areas. The Oklahoma City area, which includes Kansas and Texas, admits more than 13,000 patients annually.

The July 16 joint committee hearing on the Indian Health Care Improvement Act reauthorization will resume July 23.