A copy of the decision is part of the record. I testified yesterday on that decision.

Senator DECONCINI. Yes. I am sorry, I wasn't here.

Ms. KARSHMER. That is quite all right. And I have additional copies if you would like one also. The court issued its final opinion on February 14 and a judgment was entered on Monday, I believe, of this week. And I do not know at this point whether the legal service is going to appeal. I sort of doubt it. That remains to be seen. So the case is final in the Federal district court. There would be no further procedures there. And the opinion does stand at this point.

Senator DECONCINI. I notice under your appropriation request a substantial number of new programs or new areas that you are getting into-State planning, technical assistance, a large increase in outreach, nutrition, and health education. Why have you not addressed these problems before?

Mr. WILLIAMS. If Margo has something to add-I would like to say that in our development, you will note that we do have outreach workers that are working under the present program now. You will note that the 1979 budget, $132,000 and $175,000 in 1980, is not much of an increase, actually in dollars.

Senator DECONCINI. What about nutrition, health education?

Mr. WILLIAMS. Because in those particular areas in nutrition and health education, and optometry and audiology, there are programs-we have felt as we develop our programs, we find the input from our people and the people we serve and the lacking of those areas which contribute in health preventiveness, and so forth. Especially in the nutrition area where we are working with young mothers and young infants and knowing at the national level that this has been a real need at a national scale, not only in our community, but as we develop, we find these needs and want to reach those, want to help those people that are asking for that. That is what we need the money for at present.

Ms. KERRIGAN. Mr. Chairman, at this time, we see that these programs that are listed in our appropriation request have not been adequately addressed by the programs that have existing facilities, and would like to move into these areas.

We are aware that the Indian Health Service, California program office, potentially may begin to provide these services through field offices, traditionally coming through areas that are set aside for outside facilities.

It is our hope that programs such as these will be channeled through the existing Indian health programs that are members of CRIHB, so that we may integrate them and continue to provide comprehensive health services in the existing delivery system. Senator DECONCINI. Thank you very much.

[The statement follows:]

STATEMENT OF THE CALIFORNIA RURAL INDIAN HEALTH BOARD, INC.

DESCRIPTION AND HISTORY: In 1953, because of a request by the State of California and because of the emphasis of the federal government on termination, the federal trust relationship was ended and Indians in California were excluded access to Indian health services by the Indian Health Service. Since the inception of the California Rural Indian Health Board 'CRIHB) in 1969, CRIHB has functioned as the Indian Health Service in California by maincaining the only health service facilities specifically serving rural and reservation Indians. This achievement was and remains a major milestone marking one of the first examples of Indian self-determination impacting health care through the creation of a model delivery system. This was recognized by Mario G. Obledo, Secretary (DHEW) for the State of California, denoting CRIHB "a viable representative organization of rural California Indians....

an outstanding record of operation and sponsoring successful projects." Where no facilities existed, CRIHB was directly responsible for local health boards incorporating and establishing their own facilities to provide services to rural and reservation California Indians through funding from the IHS channeled through CRIHB.

STRUCTURE: Currently, approximately 74 reservations and rancherias are served by CRIHB Indian Health Projects, which are the only providers of medical, dental, and outreach services to 40,000 - 50,000 Indians. Each local project is governed by a democratically elected, all-Indian health consumer board, which designates 2 local representatives to sit on the CRIHB statewide Board which is made up of 30 democratically-elected members from recognized tribal governments and rural Indian communities. Thus, as a state-wide Indian controlled organization, CRIHB and its projects provide a model health care delivery system to Indians residing in the United States' most populous state and which competes for the largest Indian population, combining rural and urban areas. The CRIHB Indian health programs are of a democratic, yet non-governmental nature emphasizing self-determination in practice.

FUNCTIONS: CRIHB as an organization, provides technical assistance in the areas of planning, program administration, information coordination, property and fiscal management to its member projects and local boards, encouraging local autonomy and Indian self-determination in developing programs with limited available resources, upgrading facilities, and making health services accessible to Indian residents. Additionally, under the direction of the Board, CRIHB is undertaking special activities such as a Health Careers Awareness Program which provides information to and encourages young Indian students to pursue health career opportunities and seek careers in the health professions.

GOALS: The goal of CRIHB is to promote and support the continued operation and growth of a system of health services in rural California. CRIHB program services presently include but are not limited to:

The CRIHB Appropriations request seeks a total amount of $5,584,748 to be earmarked in FY 1980 specifically in the areas of direct delivery of health services through the local health programs, facility development for upgrading the environment in which the services are delivered and administration of the CRIHB Central Office in continuing to provide support to the existing health program network.

These appropriations will permit CRIHB to continue its existing programs throughout California and to provide additional services to address critical unmet needs in such areas as: specialty medical and dental care, nutrition, optometry, audiology, health education, environmental health, and in-service training. It also includes monies for facility development and expansion to accommodate new services.

ALLOCATION OF RESOURCES:

A. Background: The Indian Health Service has developed and makes use of Resource Allocation riteria in the form of the RAC document. Based on the 1978 RAC application, the need for federal funding of Indian health programs was estimated at $27 million dollars for the State of California. The current level of funding has been clearly inadequate, yet despite the serious lack of dollars in California, CRIHB has maintained its system of health care delivery to Indians for 10 years. FY 1978-79 earmarked $10 million for California, but the funding levels would not permit for expansion of service delivery capacity.

In January 1979 in Rincon Band of Mission Indians, et al., vs. Joseph A. Califano, Jr., et al., it was held that the present allocation of Indian Health Service funds into California is constitutionally inadequate in that it discriminates against California Indians by not-providing them with a fair share of IHS resources. The decision requires the Indian Health Service to increase its allocation to California Indians substantially. It should be noted that the category of Indians the decision benefits is defined to include all those California Indians

eligible for "contract health care services from the Indian Health Service." It therefore necessarily encompasses all those Indians presently eligible to receive CRIHB benefits.

Based on the findings of the court, the upward allocation of funds to California appears to be eminent. It would seem that CRIHB and its local programs should take an active role in formulating new criteria for allocation of IHS funds to California and how the programs should receive those funds. However, up to this point, there has been little indication by the IHS of assured local program input or CRIHB participation in the planning for new allocations 'hat will shape the future of the CRIHB programs which have afforded health services to the reservations and communities for the past ten years. This is further demonstrated by the developing Fort MacArthur Service Unit which will duplicate the existing rural and urban Indian health programs in Southern California. CRIHB opposes the expansion of Fort MacArthur and similiar facilities. It is inappropriate for the IHS to duplicate present functions provided by those Indian health programs already in existence. CRIHB strongly advocates for funding to be redirected to existing Indian health programs.

We are concerned that the Indian Health Service in implementing the Rincon decision will ignore the existing delivery system in California. This is contrary to present administration policy of minimizing the federal bureaucracy, and encouraging non-governmental, selfhelp entities.

Use of the RAC document is inconsistent with present administration policy. It phases out non-governmental Indian health programs by utilizing a traditional approach of expanding the federal bureaucracy. This action harms the existing CRIHB model network which matured out of Indian self-determination efforts.

B. Recommendations: We ask that your committee look to appropriations specifically earmarked to self-determined non-governmental Indian health programs and allocate to the existing Indian health organizations on the basis of unmet health and personnel needs as identified in the 1978 RAC application. We ask that you structure the appropriations to California o as to assure Indian self-determination in the delivery of health care in our state. 1) Line Item Appropriation Directly to CRIHB. Up until 1973, CRIHB enjoyed the status of being a line item in the IHS budget and receiving direct appropriations. That status changed when the line item became labelled as Rural Indian Health Program. We request that Congress make a specific line appropriation to CRIHB within the Rural Indian Health Program category to support CRIHB and its programs throughout the state of California. CRIHB requests that the appropriation made to it provide Indian health services through its program for the next two fiscal years be: Fiscal Year 1980 -- $5,584,748 and Fiscal Year 1981 $1.409.663

2) Appropriations Based on 1978 Application to Directly Benefit Existing CRIHB Programs. On the basis of CRIHB's analysis of the unmet health needs of California Indians and the IHS 1978 RAC application determining the unmet personnel needs, CRIHB requests that the appropriation made to California provide Indian health services through its existing CRIHB programs. These appropriations will permit CRIHB to continue its existing programs throughout California and to provide additional services to address critical unmet needs in such eas as: specialty medical and dental care, nutrition, optometry, audiology, health education, environmental health, and in-service training. It also includes monies for facility development and expansion to accommodate new services.

3-A) California Program Office Appropriation. Over the past several years, monies provided for the Rural Indian Health delivery organizations have remained virtually the same while the IHS/CPO allocation for overhead has risen dramatically. CRIHB requests that the allocation for IHS/CPO overhead not increase, that it be provided through a line item appropriation, and that increases in funding be earmarked for strengthening the EXISTING service delivery organizations rather than for supporting the IHS/CPO bureaucracy and their apparent plans to establish a separate delivery system that duplicates the existing one.

3-8) Add-On Appropriation to California. CRIHB requests that any increased funding as a result of the Rincon Case, be in the form of an add-on to the California allocation for the EXISTING Rural Indian Health Programs. We are aware of the ever-increasing needs in other IHS areas and strongly support efforts in developing Indian-controlled health services outside California.

60-400 0-80-4

STATEMENT OF BERNARD LOONS, SR., SECRETARY-TREASURER

ACCOMPANIED BY:

GEORGE F. HIMANGO, EXECUTIVE DIRECTOR

KATHY COCKBURN, HEALTH SERVICE DIRECTOR

Senator DECONCINI. Mr. Loons, your full statement will appear in the record, and if you could highlight it for us.

Mr. Loons. This is a request to the appropriation to construct a clinic on the Fond du Lac Indian Reservation in northeastern Minnesota. The cost is $1,757,837. To my left is Dr. Cockburn, our health director, and on my right is Mr. Himango, executive director of our tribe.

I would like to yield my time to Dr. Cockburn for further detailed information on this project.

Dr. COCKBURN. This amount of money that we are requesting is to construct a clinic. It is a nonrecurring cost. The health care on the Fond du Lac Reservation is poor in both quantity and quality. At the present time, the only health care we have is given by contract physicians and dentists, and this is very minimal. For 1980, Indian Health Service projects a population of 2,208 for our service area.

For this number of people we only have $122,000 and $122,085 in contract funds. This gives a total of $55.29 per person per year. This has to cover hospitalization, office visits, emergency care, and any other medical costs. One can hardly walk into the hospital at this price.

The population we have on the reservation is a young population; 59 percent of the people are under 25 years of age. This presents a unique problem in that the next 20 years, these people will be in the child bearing age, and also in a period when debilitating conditions will be manifested.

We want at this point to be able to work with this population to be able to prevent the debilitating diseases that are so devastating on our reservations. We don't want people to have legs amputated from diabetes. We don't want people to be blind from diabetes. We don't want people to commit suicide or have accidents. We want to prevent these things, and we can, if we can have a comprehensive health program on the reservation.

Dental care is in a sadder state. We have $19,500 for our population. This gives a total of $4.83 per person per year for dental care. Over half of our elderly population have no teeth or no dentures. They can't chew their food. The people, the elderly people that do have dentures, I know some that are sticking their dentures together with Elmer's glue because they can't afford anything else. They just can't afford it.

And the Indian Health Service has no funds for dentures for the elderly. We had a survey done by the students from a local college in January, and of the 31 children they surveyed, 14 of them had four or more cavities in their teeth. And this was on a very superficial examination done with a tongue blade and a flashlight. Of all of the people that have been provided for by the nutrition program from the Department of Labor, 100 percent of the applicants had nutritional deficiencies, mainly borderline anemia. What we propose to do with the clinic is to centralize services and add additional services that are not present at this time. We would like to have some mental health programs. We want to be able to prevent suicides, homicides, accidents, cirrhosis of the liver. We want to centralize the chemical dependency programs.

We have to do outreach. We have to do some prevention. We need to educate the people as to what are the symptoms to watch for. We have to help people reduce the risks for these chronic debilitating diseases.

I think I want to say too that at the present time, we do have a CETA grant, and we do have 20 people in a local college being prepared to give health care. These are reservation members. We would like to have them come back and give health care on the reservation to the people. We do not get the services from the county. The county nurses say that they don't come to the reservations because the people won't accept them. I think the people won't accept them for a very good reason. I think Mr. Himango can tell you more of the problem.

Mr. HIMANGO. Thank you, Mr. Chairman, for allowing us this time. There are three things that I want to succinctly touch on. One is some of the historical background in reference to our particular situation on Fond du Lac. We had a hospital on Fond du Lac.