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INDIAN HEALTH AMENDMENTS OF 1992
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fO2-573, see page 106 Stat 4526
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DATES OF CONSIDERAT~ON AND
PASSAGE
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Senate: September 18, October 7, 1992 House: September 15, October 2, 3, 1992
Cong. Record Val. 138 (1992) . 'Senate Report (Indian ~ f f a i r i ~ ' ~ o m m i t t eNo. 102-32. el Aug. %7, 1992 ', . ' . , [TO accimpaR$i~: 248.11 ...
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House Report (Interior and i n s u l a ~ Affairs Committee) No. 102-643(1). July 1, 1992 [To accompany H.R. 37241 House Report (Energy and Commerce Committee) NO. 102-643(II), duly 28, 1992 [To acc,ompany H.R. 37241
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The Senate bill was passed in lieu of the House bill. The Senate Report (this page) is set out below, and the President's Signing Slatement (page 4038) follows. '
SENATE REPORT NO. 102-392
[page 1 1
The Select Committee o n Indian Affairs, to which was referred the bill (S. 2481) having considered the same, reports favorably thereon with a n amendment and recommends that the bill as amended do pass
PURPOSE
The purpose of S. 2481 is to reauthorize the Indian Health Care Improvement Act The Indian Health Care Improvement Act defines, in terms of authorizations, the programmatic structure for the Indian Health Service. S 2481 would seek to stabilize the programs authorized by the Indian Health Care Improvement Act through t h e year 2000, in 'the same manner as the reauthorization initiatives for the National Hedlth Service Corps and Maternal1 Child Health Block Grant. Specific health care objectives s e t forth in S. 2481 a r e drawn from the Surgeon General's "Healthy People 2000 Report" of the Department of Health and Human Services which set national health promotion and disease prevention objectives. The reauthorization woutb set more stringent standards by which t o measure progress toward the goal of raising the health status of American Indians and Ataqka Natives t o t h e highest possible level.
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EXHIBIT 40
In Support of Plaintiffs Opposition to Motion to Dismiss on TPA 8 IHS Samish v. U.S., No. 02-1383L
Case 1:02-cv-01383-MMS
Document 60-44
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Page 2 of 10
LECLSLATIVE HLSTORY
SENATE REPORT NO 102-392
[page 21
BACKGROUND The United States' responsibility to Indian tribal governments and their members for the provision of health care was established in numerous treaties with Indian tribes in which the United States agreed to provide such services. For example, in Article 2 of the 1854 Treaty with the Rogue River Indians (10 Stat. 1119), the United States agreed that "* provision shall be made for a hospital, medicines, and a physician." The responsibility has been further delineated and defiued by numerous status and administrative regulations. Based upon the Constitution, historicai development, treaties, and statutes. the United States has assumed 2 !el;a! and moral obligation to provide adequate health care and services to Indian tribes and their members m - . 1 I I L C Fecierai government has provided heaith care services to American Indians since the 19th century. As early as 1802, U.S. Army doctors worked to cure smallpox outbreaks among the India n s living near military posts. In 1849, the responsibility for providing health care shifted from the military to civilian authority, when the Bureau of Indian Affairs was transferred from the War Department to the Department of Interior. With the enactment of the Snyder Act (25 U.S.C. 13) in 1921, formal authorization for Indian health appropriations became public law. The Snyder Act authorized the Bureau of Indian Affairs to provide certain services, including those for "relief of distress and conservation of health." Under this general authority, Indian health programs were administered by the Department of Interior until 1955, when they were transferred to the Division of Indian Health (now the Indian Health Service) in t h e Department of Health, Education and Welfare (now the U.S. Department of Health and Human Services), pursuant to the Transfer Act (42 u.s,c. 20011. In response to documented deficiencies in the health status of American Indians and Alaska Natives, the Congress, in 1976, enacted the Indian Health Care Improvement Act (P.L 94-437). This legislation authorized additional funds for Indian health care, in part to reduce unmet needs under existing programs, and in part to establish new program efforts, such as manpower training and urban health clinics. A major purpose of the 1976 Act was to r a s e the health status of American Indians and Alaska Natives over a seven year period, ending in fiscal year 1984, to a level comparable to that of the general population. Since the 1976 Act provided only a three-year authorization, the Congress, in 1980, revised and extended the legislation through Septemter 30. 1981 (P.L 96-5371 The Act was again revised and extended in 1988 (P.L. 100-713). In the concluding days of the lOlst Congress, three major health bills which amend the Indian Health Care Improvement Act were enacted into law (P.L. 101-630). These amendments provide statutory authorization for a comprehensive and community based mental health program, authorization For demonstration of innovative health care delivery systems and expansion of the urban Indian health programs. Unfortunately the funding to implement these new programs authorized under P L. 100-713 and P.L. 101-630, in
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INDIAN HEALTH AMENDMENTS
P.L. 102-573
[page 31
the amount of $55 million, has not been proposed in the-fiscal year 1993 President's budget request far the XHS.
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~ERIC~N .~N,D~,A.Ns. AND ALASKA. .. . . .. .: - . ' fig Federal gdvernm'&t h a s . : a . , ~ t j ~ lhistqrical and legal -relaiqh~ ti,j~$h.iiP'with Indian people,~wHosi?;health the status-is suhtantialthat the' ;i j i u ~7['he'fe:~a.r e - a ~ i~ ig
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H ~ A ~ H S T A ~ OF S U A
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s.: :J@9199?, '&partment_ 6f' ~ealt&-.+$(t the - Human: Services -iiscied >B~@lthy People.'2000,? a s&&mefit..:ijf 'he;i:lthh, ....... @rorriotion;!+nd'ldis.LM::.iirevention,objectives >'for.the niifion fijr ;the .c,o@ng decade. : Th-, : +;D .,; ,, epartmerit n o t e s . .th.at, relati,ve $0,ote !i r ~o.pulations: the ' ihtieria-n h&an and Alaska Nati;ve'-pjpulatjon is' young .md im:,y:=;;;,<$; ,yyf,c!shed,with niore than 1'. and Alaska .Natives vis-a-vis t h e :U.S. Caucasian' popula. .+, . ..y"k:~a&h 1992 'ieport e n t i t i d ' m e Stab -of Native : Gmeriean ~ ~ ~ ~ t t i : F ~ e a l t h " , ,froin. a survey of 14;000 - Indian-;youth,. re-drawn. m&&:jthat sui&de - has ,eriierged & a . way for tiative- youth t,o deal *&$$motional dstiess a h d hopelessness;that :.is.characteristic. of .- . '?@nsriioe thet.: lives.. The.. University o f ,Minnesota report further $W%4:$hat.regular use. of -tobacco.andheakrjr: rise of substa~ces, par-
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LECISLATfVE HfSTORY
SENATE REPORT NO 102-392
[page 41
titularly, alcohol and marijuana, is linked to every single risk be-
havior found in the survey. In addition, t h e survey found that 20 percent of the youth felt their health is only fair to poor. The Indian Health Care Improvement Act is administered by the Indian Health Service (IHS) within the Public Health Service of the Department of Health and Human Services. The IHS considers itself responsible for providing care to "approximately one and one half million" American Indians and Alaska Natives living on or near reservations in 33 States. In F 1992. appropriations to the Y IHS totalled $1,701,017,000. This included $1,426,666,000 for health services %th direct and c~iitract care] arid $274,551,000 for heaith facilities construction. The President's budget for fiscal year 1993 rlvpwGa a ktn! ef $!,651,453,@!2 fnr the IHS ir? h~dget authnrity, a decrease of $49.5 million or 3. percent under the,fiscal year 1992 budget in actual budget authority. The IHS delivers health care to eligible Indians through three different mechanisms. It does so directly through its own facilities, including (as of January 25, 1992) 42 hospitals, 65 health centers, 4 school health centers, and 52 smaller health stations. The tribal health delivery system administered by tribal governments and tribal groups through contracts with IHS operates 8 hospitals, 93 health centers, 3 school health centers, 63 smaller health stations and satellite clinics, and 173 Alaska village clinics In addition, the IHS funds 34 urban Indian organizations operating programs in 41 sites to deliver outpatient health and referral services to urban Indians. Where services a r e not offered directly through IHS or tribal facilities, limited funds a r e available in each area for the purchase of care on a contract basis from non-federal, non-tribal hospitals, clinics physicians and dentists. The Committee recognizes t h a t the task of improving the health status of American Indians and Alaska Natives, begun with enactment of the Indian Health Care Improvement Act in 1976. is not yet complete. The Department's "Healthy People 2000" sets forth 85 health status objectives for the U.S. population generally, including 31 targeted specifically a t American Indians and Alaska Natives. The Committee Amendment would revlse and reauthorize the Indian Health Care Improvement Act through FY 2000 to enable the IHS and the tribal governments to achieve both the targeted and some non-targeted objectives over the next 8 years.
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S. 2481 was introduced on March 25, 1992 by Chairman lnouye for himself, Vice-Chairman McCaic. Senators Daschle, Dornenici, Burdick, Murkowski, Simon, Cochran, Stevens, Akaka, DeConcini, Kassebaum, Wellstone, Reid, and Kennedy, and was referred to the Select Committee on Indian Affairs. The first hearing on S. 2481 was held in Washington, D.C. on April 1, 1992. Four field hearings were held in: Lower Brule, South Dakota (April 16, 1992); Anchorage, Alaska (May 23, 1992); Bethel, Alaska (May 24, l$92), and Phoenix, Arizona (May 29, 1992). The House companion bill, H.R. 3724, has been the subject of two Washington D.C, hearings and one field hearing in North Dakota. The House Energy and Commerce Committee's Subcommittee on Health and Environment re-
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INDIAN HEALTH.AMENDMENTS
P.L. 102-573
L~age.51
H.R. 3724 to-full committee,on March 26th, 1992 and t h e bill was considered for report in full Cornmittee,;~nApril-7, 1992. q , i ue y&o s . Interior and Insular Affairs Committee favorably reon H.R. 3725 on April 29, 1992. (H. Rept. 102-643).
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, S U M M A R Y OF MAJOR P R O V I S ~ ~ NOF S
THE' EXISTING ACT.
of- the IHCIA was designed to accornpiish two retaced increasft the'number of'Indians trained in' the health p&fkSSions. and (2)to provide a'lgrger I of health- professionals . d3e'ive;Indian Fople. TQ accor?'p@h -bee g03,ls~the title estab- ' !&h&:s+erat .programs: (a1 a r~ruitment'pra~gta~m encourage tn' i4ung-indki,ns iu pursue niedikpl cai$e;?, Cuiila_ pieparawry schoiai?Kip grogram to assist Indian studenti to or&-$:towa$d a medical da,fw> . a scholarship program 'tp, support 'Indian students in (cl gradu,aat+ schools of medicine; Xd) ,gr?- extera progtam b -pr;ovide $-&$mj%r experience ,in IHS four In&_an rn$di+l' students; and (el 'a gi$gi&-~-for continqing ,educati?n ,OFTHS personl;e'l among athers. A*.SJ&?$! nursing program and +n:Centiyes, foi.- health professionals . als(c~iActuded. "$&e 11 of the IHCIA is a congres$iohaf kanda& to.lHS to begin an,$qcremental program to raise- tbe health. status of Indians t o 'a l~vd>;ehual- t h e re& of. the Nation. Health services includes to dj& and indiiect patient care, :dental care, mental health, .altoh$fn treatment,, and maink$a$ce ',and repair, A Catastrophic HYq&h--EmergencyFund; a , D&&,tes .Preyen tion, Treat rnent- and - a Q$E$ Program; and a Mentat H e l -t h i Program .-r e also included , in?&. Act., , ,, , : - - ,): , -Title Il1,of-the. IHCIA pertainato the +~ns$~u&on health faof _ includi~ghospitah, clinics, +and. h ~ a l t hstations,including di$ig% ncwpqy staff.quart+rs, and t ~ the construr;&n of enitatiop -fa, c i l i e s $0,~ d i q n communities ,and homes. I .:,Tit& LV of the Act relates t,o the ~olleetion afld uie bf Medicare/ Medimid reimbursements by the Indian Health Service. The .Act establishes a program of grants and contracts with tribal organizatious:tp rjssisp eligible Indians in obtaining Medicare pr Medicaid benefits. :Title3 of the Act, as amended by the 1980 arnc&dments, authprizes.%rants to urban Indian organizations to. provide outreach and recerral services to Indians in urbanhand other areas.:Title VI provides for organizational improverpents in the Indian 8ealt.k S e e c e . ;Title :VII requires the Secretary t report,& khe Congress on the a s b t ,of Indian health and also provides for Miscellaneous pro~ gcams, including eligibility provkions Tor California Indians
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inThe:Committee ~ k e n d r n e n ameids section 2 & include a n addit tional-fi~din~ regarding the unmet needs .of-tribal programs opetating,.under Indian Self-Determination csntraets and. notes that these Public Law 93-638 contrhct, resources >arevaried, yet should be pmvided in a fashion which allows for maximum flexibility for
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DEC~RARTION-OF HEALTH O B J ~ X I V E S
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LEGISLATIVE HISTORY
SENATE REPORT NO 102-392
[page 61
tribal governments in carrying out health programs to address their respective local needs. The Committee Amendment reinstates the declaration of policy language to underscore the fundamental legal obligation of the United States government to raise the health status of American Indians and Alaska Natives, including urban Indians, to the highest possible level, and to provide the necessary resources to carry out this policy. The policy further provides that the Indian health Service, including tribal health care programs, is responsible for providing comprehensive health care delivery a t all developmental stages of life and must assure access to the same fundamental health care benefits for all eligible Indian patients. In a n effort to better implement this policy, the Committee included in the amendment 69 health status objectives. These objectives serve two goals: (1) they provide a measuring device for comparing the current health status of Native Americans to their health status and the health status of other Americans in the year 2000, and (2) beginning three years from the date of enactment of the Act, the health status objectives will serve as a resource driving mechanism for the Indian Health Care Improvement Fund. and other resource allocation methods. The health status objectives were derived from a publication of the U S . Department of Health and Human Services, Public Health Services, entitled "Healthy People 2000. National Health Promotion and Disease Prevention Objectives" (DHHS Publication No.' ( P H s ) 91-50212). This report was released in 1990 and involved 22 expert working groups, 300 national health organizations, and all state health departments in its development. The report recommends numerous health objectives for the general population and only 22 health status objectives specific to the Nafive American population. In a n effort to more comprehensively address all developmental stages of life and the complete array of diseases most prevalent among the Native American population, the Committee adopted additional health status objectives from the Surgeon General's report. It is the intent of the Committee that t h e Indian Health Service submit a substantial and well documented report on the progress toward achieving these objectives annually. The health status objectives will be utilized to assess the need for the resources required to allocate the Indian Health Care Improvement Fund. The Amendment provides that the Indian Health Service will be allowed a three year period to implement this new method of allocating the Fund. While the Committree expects that regulations will be developed by the agency to implement the gathering of this information, i t expects that these regulations will not be overly complex or overly burdensome for Indian tribal governments and those who a r e involved in the provision of health care services or the operation of health care programs. The Committee suggests a minimum burden be placed on Community Health Representatives and other health care providers in the field in executing duties'and that the development and updating of epidemiological data be the responslbility of the Area epidemiology centers authorized under the Amendment. Finally, because health problems and their degree of severity vary among tribal communities nationwide, each tribal
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INDIAN HEALTH AMENDMENTS
P.L. 102-573 .
Cpape'TI
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go~ecnment should determine theappropriate. tribalspec.ific health promotion and. disease-..preventiongoals.:~that. address a ,particular . . . . . . . . . . ... tribels:needs. . ..E;buic- e w definitions h a v e -been added& -the;Act, including n 'i&+ice area", ."Health .profession",. . VHeal$h: professional" and
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&!;:ayailable- to Indian a n d Alatjka. natiye_.cpm.munitie$ and i n par4ij;~la:~ acute shortagepf Native health ~professionals, o be a the t ,pi.i~rity. policy issue, The abi1,ity of .tribal governments t o provide a&&-sible and-acceptablehealth car.e..for$he+ citizens is
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LEGISLATIVE HlSTORY
SENATE REPORT NO. 102-392
[page 141
The Committee Amendment includes a new section to provide grants to public or private colleges, universities and tribally controlled community colleges to promote the development of interdisciplinary training in two or more schools or programs in optometry, pharmacy, psychology, public health, or social work. An Amendment- is included to allow the Secretary to provide grants .to any college, university, o r consortium, that ,is located in any of the three service areas determined to have the most acute health manpower shortages. The purpose of these grants is to pro-2Ac--c L VIU~: l u l Gralrttttg ot n d i h professionais using khe resources .of grant recipients, including students and faculty, to serve in service areas with noted shortages. Grant recipients shall be required to enter into formal-agreements with the tribal governments of those sewice-areas in which training is taking place.
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TITLE FI-HEALTH
SERVICE
Health status and resources deficiency ' ' En 1988, the Congress established the Indian Health Care Improvement Fund. The origins of this fund can be traced back to 1974 when California Indians tribes filed a class suiL against IHS alleging a denial of health c a r e services which were provided to all other eligible American Indians. At t h a t time, California Indians comprised 10 percent of the national IHS service population and yet, received approximately 2 percent of the funds. The District Court ruled that IHS was required to provide health care to California Indians comparable to sewices offered by IHS to Indians elsewhere in the United States. The ruling was upheld in the Ninth Circuit. Rincon Band of Missions Indians v. Harris, 618 F.2d 569 (9th Cir. 198Q).As a result, the Appropriations Committees of the House of Representatives a n d Senate established the Equity Health Care Fund through most of t h e 1980s to provide resource allocations to areas and tribes with deficient levels of health care services. In a n effort to establish a more permanent means of dealing with the resource deficiency problem, in 1988, the Congress established in subsection 201 of the Act, the Indian Health Care Improvement Fund which was to take the place of the "Equity Fund." The Fund was to be allocated based on the level of resource deficiency. The Committee Amendment provides t h a t this system of allocating the Fund shall remain in place for another three years. However, during that three years interim t h e Committee expects the Service to begin, through its Epidemiology centek, the collection of data required under the 69 health status objectives. Amendments to the IHCLA would require that IHS program activities remain consistent with the stated health objectives established in Section 3. The Committee Amendment will require the IHS to terminate its current system of allocating the Indian Health Care Improvement Fund since the alloation was based only on historical funding rather than addressing actual health care needs. The Committee believe that true equity funding should be based on addressing health status deficiencies as well as evaluating historical funding deficiencies. Language is included to require the IHS to determine health needs based on the actual costs of providing health care 3956
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INDIAN HEALTH AMENDMENTS
.P.L.- 102-573
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&&@s,:.:cl&c.thatany a n amqufits i+prppr@ed h. that \h&-&'und B~e-.~6t;..fh g & tl, bf&' . .or: t ;.et limit a n y app+@riati@* m& ..to&he::Indiah ~i ce under the'aut,hotity%of-'the A,ih.; SnydeF'.Act.:of:1921.... or , .. . .:.. ..,w ~ : . o t ~ e r . p~o:vi%ion law. .of . . . ,..-i:In?$n . . . h'eaitj, ....qffo'fi...ti,'&sur+ ..$hat fG.,*ds:-aqed$tiibut&..tb reduce the ' i ,., _ s.Ftus.-and.'reWi8e deficiency -within a. $er;iice ' uriit, t h e - .... ~ K :$to~akg~ ~ T ~ . , ~ i.h.+t: 'be : seiiribe~uriit pi'dvide&>ihai,:..th-e . . fun& used' eo igdicb,. ih<b : d ~ t ; i s th6 rce::dgflfie;;cy of trib;ai:.&o:mmu.nit'PP -&+& .-,byskch .&& . . . - .. .-ce,, ..., ... tb;.&&r& that tfie .&ndcr2in .wh-ich-.funds: :al.-.,.. $iiti.<&,d l ~ w , - : .- . ~ & j u . p ~ pi.iorities in':;coonsul~tion . i t h ~ the Wdi%'~&]&&+ice, the tiill provides that the.:all&tion of fun& .. .-.-_ b:a . m i + u.hit and. 6 :what. p,~rposes. f~n&-..shoul&.be ap;$lid.-iis:wbe dijhrrn-'in& byrth& Indian He&h . &-dCe . h-consulb... . . . . . . . . . . .. .. . . ... .t-iqn:\?ith.the affected tribal governments. . ., . . ;-i.*.m :!'health-. sht*. G'm resource Ideficiency!' ~ e a n :.the s '6itent ,to %hii&>(.I.j the health: &,etives set forth ih .section3(a).of --th&Act.$& m e n d 4 . b ~ a bhe;:bill);arenot. being achieved and:(2) t;he !ddi:& ?tribe ;lacks -the health - W u r c e s i t . rieeds.:The . he:alth - re, ' ~ ~ I I X X Savailable .to -an...Indian. ~ tribe areAimited .b. l W l health .re~sdurces used: by a.n:.lnndia~: kiibe, incl.uding:&ryices.~and, financi-ng %!skms provided by:oQh.e.r, Federal programsi .pro~ded &:at.thc-JHS in deteimin-ing available. resources shall alsq take. inir?@ acco~nt.~;the actual availability of local alternative sourcis of health care.
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LEGtSLATtVE HtSTORY SENATE REPORT NO. 102-392
[PW~ 161
Title 11 directs the Secretary to establish procedures that will allow a tribal government to petition the Secretary for a review of any determination of the extent of the health status and resoure deficiency level of the tribe. Title H makes clear that program administered by a tribal government or tribal organization under the authority of the Indian Self-Determination and Education &&ante Act are to be eligible on a n equal basis with programs that are administered directly by the Indian Health Service. If m y funds allocated to a 'tribal government or service unit are used under a n Indian Self-Ikbrmir.z)Yis:: contiact, ii reasonabie portion of such funds may be used for health planning, training, technical assistance, and,other administrative support functions. The Committee Amendment requires that, within three Yars of eszetrnent of tilt: Amendment, the k r e t a r y i to report s the Congress on the extent of health status and resource deficiency foi each Indian tribe, and the methodology by which this wai determined. The report shall set out the amount of funds necmjary to eliminate the health status and resource deficiencies of all M i a n tribes served by the IHS. In addition, the report shall include an estimate of the amount of health service .funding appropriated under the authority of the Indian Health Care Improvement Ador any other Act including the amount of any funds transferred the Service for the preceding fiscal year that is allocated to each sew ice unit, Indian tribe, or comparable entity, the number of Indians eligible for health senices in each service unit or tribal community, and the number of Indians using the Service resources made available to each service unit or tribal government. The,Co&ttee recognizes that data on health status may not be available fo?--all Indian tribes immediately. Therefore, the Committee expects that, until the necessary data becomes available, the IHS will anthue to target the amounts in the Fund on those areas most deficient in health resources. The Committee intends that funds appropriated under the authority of this-section for any fiscal year shall be included in the base budget of the Service for the purpose of determining appro priations under this section in subsequent fffical years The Cornmittee also contends that nothing in this section is intended to di minish the primary responsibility of the rtIS to eliminate existing backlogs in unmet health care needs, nor are the provisions.of this section intended to discourage the IHS from undertaking additional efforts to achieve parity among Indiqn tribes. Any funds appre prrated under the authority of section 201 shall be designated at the "Indian Health Care Improvement Fund". Over the past several years, Administration budgets for Indian health have not reflected the realities of delivering heakh s e r v i ~ on Indian lands, or the continued commitment of the Congress to maintain the Federal responsibility in the delivery of those health services. While Title I1 does not guarantee that Administration budget requests will reflect these realities, it does mandate a set of objective criteria against which to evaluate the adequacy of tine President's annual budget requests
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