STATEMENT OF THE INDIAN HEALTH COUNCIL, INC. The following testimony regarding the Indian Health Service Fort Mac Arthur project in San Pedro, Calif. is submitted by the Indian Health Council, Inc. and Riverside-San Bernardino County Indian Health, Inc. These two Indian controlled and Indian operated health programs serve 28 Indian reservations in rural southern Califomia and have a service population which, according to IHS, includes 15,907 Indians. Representing them here today are Dennis Magee, Program Director of Indian Health Council, Inc.; and J. Patrick Patencio, Chairman of the Board, and Adelaide Presley, Program Director of Riverside-San Bernardino County Indian Health, Inc. Accompanying them is Edward T. Arviso, Chairman of Rincon Band of Mission Indians, representing Southern California Tribal Chairmen's Association, which organization supports this testimony. We are here today to request your assistance in allowing IHS to more effectively serve the Indians of Southern California. Our specific request stems from the fact that Congress appropriated funds in FY 1978 FY 1979 for an ambulatory care facility at Fort Mac Arthur which was meant to serve the Indians of southern California. While we strongly support the provision of desperately needed health care services throughout southern California, we are here today to ask you to remove any requirement that these funds be used at the Fort Mac Arthur location and redesignate the funds for use to meet the unmet needs in southern California in order to better and more effectively serve the Indians in our areas. We make this request because (1) the Fort Mac Arthur facility, according to IHS officials, is "inaccessible" to the 16,000 Indians living on or near the 28 reservations in our areas; (2) the Fort Mac Arthur facility, surplus government property, has not been released for IHS use and we are informed that it will not be released; because the facility location was chosen solely based on the availability of the property and not on its suitability to serve the tribes in southern California, it is unreasonable to tie funds to an unuseable facility or to its location; (3) according to recent correspondence from IHS, the Fort Mac Arthur facility would be "duplicative of services available or potentially available" at our two reservation health centers, as well as at urban Indian clinics in Los Angeles; (4) IHS has taken the position that all funds meant to serve the reservation residents must be tied to the Fort Mac Arthur facility and that services provided to our reservation populations must be directed through the Fort Mac Arthur location; (5) it would not be cost-effective or energy-efficient to use a facility located in San Pedro to provide care to the reservation areas of southern California due to the immense amount of automobile travel it would require; and (6) the 16,000 Indians living on or near the reservations are in severe need of increased medical services, which need could be partially met through the use of these already appropriated funds. Therefore, we believe that the funds already appropriated for the Fort Mac Arthur facility should be redirected to serve the reservation areas of southern California. However, we wish to clarify that we do not object to a portion of the funds being used in San Pedro for urban Indians. According to IHS Congressional testimony regarding Fort Mac Arthur, a study of federally-recognized tribes and urban Indians in southern California was initiated by IHS. This study "substantiated the need for additional health care services and proposed the Fort Mac Arthur facility be converted to a comprehensive health care facility for the Indian population of this area. Indian Health Service concurs in this proposal and recommends the implementation of this study." Department of Interior and Related Agencies, Report No. 95-392, Hearings before a Sub-Committee of the Committee on Appropriations, House of Representatives, 95th Congress, 1st Session, Part 4 (March 21, 1977, p. 253). This IHS study largely ignored the needs of the Indians who are members of federally-recognized tribes and who reside on or near the 29 reservations in southern California. Moreover, to our knowledge none of these tribes (with the possible exception of the Santa Ynez Band in Santa Barbara County which is not in our service area) were directly consulted about the proposed facility at Fort Mac Arthur. We are also extremely disturbed that IHS is not following its long-standing policy of allowing Indians in California to provide care themselves, but rather is planning to establish a service unit at Fort Mac Arthur and thus remove control of the services from the local Indian people. We believe that the federal policy of self-determination is thus being wholly disregarded by IHS in their planning for this facility. This policy was first enunciated in 1968 by President Johnson, was reiterated by President Nixon in 1970, and has been a guiding principle behind virtually all legislation dealing with Indians during the last ten years. See e.g., Indian Self-Determination and Education Assistance Act (25 U.S.C. $450 et seq.). In FY 1978, IHS provided limited funding to our programs comprising hardly more than 5% of our unmet need of $9,997,200, as determined by IHS. And yet IHS provided no other funds or health services for the Indians in Our areas who are in desperate need of such services. Through the funds provided, our two programs were able to provide some limited ambulatory care for a small portion of the Indian population in our areas, but we are unable to provide badly needed inpatient care, specialized ambulatory care, field health services, alcoholism programs, mental health services, etc. There can be no question that additional funding is desperately needed to begin to provide a wide range of services in our area which presently suffers from a 95% deficiency in funding. The Fort Mac Arthur funds can be used to begin to meet these needs. Because of its location, though, Fort Mac Arthur is totally inaccessible to the Indian reservations. The nearest reservation is approximately 100 miles from Fort Mac Arthur and the majority of reservations are at an average distance of approximately 150 miles. Some reservations we serve are as far as 350 miles away. (See map attached hereto as Exhibit A.) Thus, reservation Indians would have to travel between 2 and 6 hours in each direction to reach the Fort Mac Arthur out-patient facility. However, IHS itself has set the following accessibility requirements which define the allowable travel time to reach health care services for the bulk of the population: a. Emergency care - 15 minutes b. Ambulatory care C. Basic inpatient care - 90 minutes Specialty inpatient care - 240 minutes Assuming that the Fort Mac Arthur facility provides ambulatory care as it was funded to do, then it will not be accessible to even one reservation in southern California under the IHS guidelines. IHS officials have repeatedly acknowledged this fact in correspondence and during depositions taken under oath in federal court proceedings. Thus, by virtue of its location, the Fort Mac Arthur facility can serve only urban Indians in Los Angeles. And, in fact, only a small portion of that urban population could reach the facility in the requisite 30 minutes when one considers the heavy traffic congestion always present in the Los Angeles area. should also be noted that the Fort Mac Arthur location was chosen solely because of the potential availability of the surplus government property there, not because it was a desirable location from which to provide health care services to the Indians of southern California. It Riverside-San Bernardino County Indian Health, Inc. is a nonprofit, Indian controlled and operated corporation comprised of eight tribes and which serves the members of 11 tribes. This program has its main health center on the Morongo Indian Reservation and operates a satellite facility on the Soboba Indian Reservation. Through these facilities it serves 11 Indian reservations, some of which are as far as 250 miles away. At its present level of funding, this health program is able to provide very basic ambulatory care for about 40% of its total service population of 8,732. This program received funds amounting to only about 5% of its total unmet need in 1978 which, according to IHS, was $5,295,000. And, it is the only program providing health services to reservation Indians in the vast area it serves. (See Exhibit B attached here to for a more complete description of this program.) Similarly the Indian Health Council, Inc. operates a health program at the Rincon Indian Reservation in San Diego County. It, too, is a tribally-sanctioned non-profit corporation whose board of directors is composed of tribal representatives and which is operated by Indians. Although some of the 17 Indian reservations served by the health center are nearly 100 miles distant from the facility at the Rincon Reservation, it is at present the only health care program in San Diego County receiving funds from IHS. The Indian Health Council estimates that it is able to serve only about 25% of the 7,135 Indians which IHS acknowledges are eligible for its services. In 1978 this health program received from IHS only about 5% of the $4,351,500 which IHS says it needs. These funds allowed it to porvide only a portion of those basic ambulatory care services needed by the population it presently reaches. (See Exhibit C attached here to for a more complete description of this program.) Both Congress and the Courts have recognized that the Indian Health Service has a trust obligation to provide health services to Indians residing on or near Indian reservations. See e.g. Indian Health Care Improvement Act, P.L. 94-437, 25 U.S.C. $1601 et seq.; White v. Califano, 581 F.2d 697 (8th Cir., 1978). We believe that the Indian Health Service has breached that trust obligation by failing to consider the needs of the reservation Indians in southern California in planning for Fort Mac Arthur. Moreover, the Indian Health Service is blatantly disregarding its own requirements for the provision of health services when it represents to Congress that it has considered the needs of the "federally-recognized Indian tribes" and recommends the funding of the Fort Mac Arthur project. This project very certainly cannot and will not be of benefit to the tribes in our service area. As we have discussed above, the reservation Indians of southern California are in dire need of services and were intended beneficiaries of the Fort Mac Arthur appropriation. In FY 1978 $480,000 and 15 positions were appropriated for ambulatory care operations and $150,000 for a construction study. In FY 1979, $873,500 and 30 positions were appropriated as well as about $800,000 for construction. And, it is our understanding that the FY 1980 budget was planned to include approximately $2,000,000 and 88 positions for the Fort Mac Arthur facility. Because of our repeated expressions of concern to IHS regarding the inaccessibility of the facility, IHS is now suggesting that it serve as a resource and specialty ambulatory care center for our two programs. However, the health care needs of our service population are such that we need on-site services at our present locations. A resource center more than 100 miles away is not in the best interests of our service population, nor is it cost effective. In addition to its not meeting IHS accessibility requirements, such a location would not be energyefficient due to the extensive automobile travel it would necessitate. If the gas shortage becomes more acute, the Fort Mac Arthur facility will become literally unreachable for the reservation population due to an inability to obtain sufficient gas to travel to that far distant location. Because we believe that IHS has as its first responsibility the provision of services to those Indians living on or near the reservations; we request that IHS be directed to use the majority of the funding for the Fort Mac Arthur facility to meet the pressing needs of our reservation population through existing programs. In short, we are asking that the vitally necessary medical services be provided by IHS at a location which is accessible to those federally-recognized Indians living on or near their reservations in rural southern California. We make this request in part because the physical facilities for which the funding was intended have not become available for IHS use. Therefore it makes no sense economically to tie funds to the San Pedro area which is far distant from the largest portion of the population intended to be served. We, therefore, urge you to remove any requirement for using the funds at Fort Mac Arthur, and direct IHS to use these funds in the reservation areas of southern California by providing the funds directly to the Indian programs already providing services in the areas. In closing, we would like to request that your Committee look carefully at the health situation in California because the Indian in California have long been ignored by IHS. We have just won the case of Rincon Band of Mission Indians, et al. v. Califano, et al. (U.S. District Court, N.D. Calif., No. 74-0959-CBR) which says that IHS must provide or assure the provision of the same level and range of comprehensive health care services in California as it does elsewhere in the U.S. request that you address this subject with IHS when it testifies and provide an add-on to the IHS budget to allow IHS to provide these needed services without cutting back on programs elsewhere in the country. We We are supported in our request by the Southern California Tribal Chairmen's Association, the Tri County Indian Health Project (a P.L. 93-638 consortium of the Lone Pine, Fort Independence, Big Pine, Bishop, Benton, and Bridgeport Indian Reservations), Sonoma County Indian Health, the Soboba Band of Mission Indians, the Morongo Band of Mission Indians, the Agua Caliente Band of Cahuilla Indians and numerous other Indian tribes and organizations. STATEMENT OF TULALIP TRIBES OF WASHINGTON SUMMARY: The Tulalip Tribes seeks construction funds to build ah Health PROJECT BACKGROUND: и (A more detailed description of the project is available through the Tribes, and is titled, Tulalip Tribes Health Center Facility` Proposal" ). Population: The Tulalip Tribes is the largest Indian group in Snohomish County, The proposed health center facility has been planned for primary use by Tulalip Indian community members; however, services provided will also be available to all Indians in Snohomish County regardless of Tribal affiliation. The latter group is considered the population-at-risk and is projected to be near 4,800. The target population base (1,327) represents all IHS eligible Indians living in Tulalip, Marysville, and Everett, and accounts for 94 percent of the total IHS eligible population. The center will be especially inportant to Indians presently ineligible for IHS care (approximately 3,473) and for IHS persons receiving Public Assistance who must use alternate resources first and then are frequently denied appointments because of their status. The design of the health and dental clinic elements staffing and space requirements-were determined using the 1327 population figure as a baseline and applying the Indian Health Service Resource Allocation Criteria (RAC) Guidelines. Need: Tulalip Tribes is over 60 miles from any IHS or tribal clinic and clients must relycon contract health services provided locally and paid for through IHS for primary care and hospitalization. IHS has provided direct dental care on the reservation in a small trailer. However, since August 1978 when the clinic burned down, nnothing but emergency care has been authorized. No orthodontia services have ever been possible. Despite these contract arrangements for primary care, virtually no preventive or health maintenance services are available. Furthermore, there is a severe shortage of pediatricians and OB/GYN physicians countywide whichh contractsaalone cannot overcome. In order to address these problems, and for reasons of critical health issues in the target group (high infant mortality-50/1000 live births; excessive incidence of respiratory disease), as well as the skewed age distribution ( 45.3% of the Tribes is under 16 years), the Tribes applied for and received designation by the Department of Health, Education and Welfare as a population group with a shortage of primary care and dental manpower". "... Current Program Development: With the assistance of National Health Service Corps staff a full-time Family Nurse Practitioner), the Tribes has operated a preventive oriented primary health care clinic for the last eight months. Since that time, the clinic has been under complete tribal control and finance. We have billed and received payments for care renedered. As far as we know, outside of Alaska, we are the only Tribe in Region X to develop a clinic designed to operate as an independent vendor with self-suffie cent status. Given this experience and success, we hope to model the dental clinic operation along these same lines. The health clinic is currently located in a small studio apartment After months of analysing morbidity/mortality rates, and the existing health care resources and delivery systems, a primary health care program was designed to focus on those essential services which have been underutilized or non-existent in the community. Major elements include: prenatal care/education to curb infant mortality; pediatric specialty to ensure early diagnostic/treatment; teenage counseling for individuals orrgroups on sexuality, birth control; and chronic disease monitoring. The clinic target group will remain low and moderate income persons without adequate or accessible health care resources. Due to inadequate space and privacy, many of the above services cannot be developed or must be curtailed. Adolescent health services such as pregnancy testing, abortion referral, and contraceptive counseling have been impossible to provide as have the majority of women's health care services. Although the FNP receives referrals and follow-up help from the tribal social services staff, there is no room to hire clinical nursing support personnel. Despite these facility limitations, and through concentration on home visits, the FNP has built up a considerable clientele, particularly with our target population. Thirty percent of her clients are under the age of four years, and 16 percent between 15 and24. In just six months, the FNP has seen 246 separate individuals for a total of 753 visitss, with an average of 10 clients per day -currently reaching 20. Overall, low and moderate income persons comprise 48 percent of her total patient load. Conclusion: Without an Health Center facility, program development in the short STATEMENT OF THE CHEYENNE AND ARAPAHO TRIBES OF Oklahoma HONORABLE WARREN G. MAGNUSON, CHAIRMAN, COMMITTEE ON APPROPRIATIONS, |