Chairman and Distinguished Members of the Senate Committee on Indian Affairs:

Thank you for your invitation to provide testimony regarding the unmet health care needs in Indian Country and specifically those issues associated with the provision for direct health care by Indian Health Service. We appreciate the concern of this Committee for the unmet health care needs that exist in Indian Country, today.

I am Russell D. Mason, Sr., Chairman of the Three Affiliated Tribes of the Fort Berthold Reservation of North Dakota. The Three Affiliated Tribes comprises the Arikara, Hidatsa and Mandan Nations. Our homeland is the Fort Berthold Reservation, centrally located in rural North Dakota. The Reservation covers six counties and is divided in its expanse of 1,500 square miles by Lake Sakakawea, created as a result of the construction of Garrison Reservoir in the early 1950's. 156,000 acres of trust lands were flooded in order to construct the dam. In the process, homes, schools, hospital--our way of life--were destroyed.

Today, the Fort Berthold Reservation is divided, with isolated segments in remote and rural areas of the State. Reservations and Communities throughout Indian Country have similar or other distinguishing factors that impact the delivery of health care services. Regardless of the factors, the delivery of health care services remains a glaring responsibility with which the Federal Government is entrusted.

I appreciate this opportunity to convey the concerns we have regarding a health care delivery system that fails to keep pace with existing health care needs and further fails to address the unmet need for adequate health care throughout Indian Country.

Harvard University conducted a national study on life expectancy in 1997. The study documented that the lowest life expectancy in the country, including inner city ghettos, for both men and women, exist in Indian populations. The conclusion was reached that Indian populations have the lowest life expectancy of any nation in this hemisphere, with the exception of Haiti.

Direct health care by Indian Health Service does not, nor has it ever, adequately met the need that exists throughout Indian Country. Those for whom Indian health care is intended, have just learned--and I use this term with great trepidation--to live under the extreme inadequacy of health care services.

Enrollment and affiliation with the Three Affiliated Tribes number approximately 10,200 people. More than half reside on or near the Fort Berthold Reservation. In 1993, a total of 28,000 outpatient care services were provided through Indian Health Service. In 1997, the number of patient care contacts has doubled.

We conducted a Reservation-wide survey just recently on the Fort Berthold Reservation. We asked our Tribal members to personally assess their own health status. 87 percent assessed their health as being good to excellent. Yet, over the past eight years, there has been a 73 percent increase in diagnosed diabetic patients on our Service Unit Diabetes Registry. In FY 1997, there were 28 newly diagnosed diabetic patients; so far, in FY 1998, there are 17 newly diagnosed diabetic patients. One out of every two of our Tribal members is afflicted with diabetes. There have been 4 deaths, as a result of diabetes, since the beginning of this fiscal year. The highest percentage of our diabetic population--47 percent--lies within the age range of 45 to 64. These statistics encompass the same membership that assessed its health to be of good to excellent state. My point is that Indian people, throughout Indian Country, are struggling in an environment in which ill-health has become an acceptable condition. Issues of morbidity and mortality of Indian people across this nation, continues. Yet, the delivery of direct health care by Indian Health Service, continues to decline.

I appreciate the efforts of this Committee to address the need for bridges between Tribal Governments, Federal and State Governments, and the private sectors to meet the health care needs in our Communities. I believe that most Indian Tribes, like the Three Affiliated Tribes, have gone far beyond that which should be expected in an effort to bridge the gap that exists between the fulfillment of the Government's trust responsibility to provide health care services and the reality of the deficiency in the delivery of health care. We, like other Tribes, have devoted large percentages of our overall budget for the delivery of health care services.

The inability of Indian Health Service to adequately provide direct health care is reflected by the alarming 1997 Harvard University study and is further reflected by Indian Health Services' own annual statistical reporting process. The inadequacy of the delivery of direct health care services by Indian Health Service literally cripples our Nations.

Since FY 1992, Indian Health Service has experienced an almost 20 percent loss of spending power. As a result. decreases have occurred in important primary services including:

• 23% decline in well-child services between FY 1991 and FY 1996
• 14% decline in physical examinations between FY 1994 and FY 1996



• 18% reduction in people receiving dental services between FY 1994 and FY 1996

• 38% increase in denials of health care referral services between FY 1995 and 1996.

Regardless of the crippling inadequacy of the services in the past, the funding level proposed in the FY 1999 President's Budget Request for Indian Health Service is only $19 million more than the FY 1998 appropriations. The inadequacy of this level of funding will further weaken Indian Health Service public health infrastructure. The ability of Indian Health Service to provide and sustain clinical and preventive services will be compromised, thereby making impossible the fulfillment of the Government's mission to improve the health status of Native Americans and Alaska Natives. Morbidity and mortality experienced by the American Indian and Alaska Native people will most assuredly continue.

The President's FY 1999 Budget Request for Indian Health Service contains a decrease in budgetauthorityofSl9mlillondollars,representingalossinrecurringbasefunding. We are witnessing a $10 million dollar reduction in hospitals and clinics; a $5 million dollar redistribution to health care facilities construction from sanitation facilities; and a $4 million dollar redistribution to health care facilities construction from Maintenance and Improvement.

No funding for mandatory increases is contained in the President's Budget Request. Mandatory increases total $12 million dollars, to cover pay raises, inflation, population growth and new staff for new facilities in the Aberdeen Area, alone. If this funding is not provided, it will be necessary to begin a process of laving off critically needed support staff in order to absorb the deficiency. This process will, of course, have a domino effect, impacting the delivery of direct health care services at the local community level.

We are very much in agreement with the initiatives of this Committee. We agree that we must marshall and manage the health care resources available from Federal, State, Tribal and private sectors and that we must have a comprehensive approach to address the unmet health care needs in our communities. This should not, however, diminish the responsibility to the American Indian and Alaska Native people with which the United States is entrusted.

Adequate delivery of direct health care services is an ever-increasing unmet need throughout Indian Country. The 1990 United States Census reflected that approximately 2,900 tribal members were living on or near the Fort Berthold Reservation. Today, that number has doubled.

Our health care system includes a main health center (Minne-Tohe), located in New Town, North Dakota, the "business center" of the Fort Berthold Reservation. Satellite clinics have been established at three outlying communities. Our user population has long outgrown the capacity of our main health care facility. Moreover, the facility does not provide the capacity to offer emergency medical treatment nor does the capacity exist to provide direct mental and chemical health services to a degree that would substantively address such profound need.

Alcohol and substance abuse are leading causes of degenerative health and an increasingly identifiable cause of death. An indicator that the health and social problems resulting from alcohol and substance abuse will worsen, is North Dakota's state-wide finding that reveals the use of alcohol and drugs among adolescents has increased 200 percent. Yet, direct health care services are not offered to curb or alter this travesty.

The issues of Mental and Chemical Health, which affect, directly and indirectly, every person on the Fort Berthold Reservation, must be addressed. Small and inadequate space in our facility limits the number of patients that can be seen or treated. The quality of service is immediately compromised as a result of the inadequacy of funding.

• Patient population of 5,000 people on the Fort Berthold Reservation is served by
one licensed clinical social worker;

• The entire youth population of the Three Affiliated Tribes is served by one full-time licensed addiction counselor;
• A targeted adult population of 3,000 is served by one full-time permanent licensed addiction counselor.




Indian Health Service lacks the capability to capture the statistical data for documentation of the need for Mental Health that exists--not only on the Fort Berthold Reservation, but throughout Indian Country. As a result, this area of direct health care by Indian Health Service is severely and dangerously lacking.



Indian Tribes, throughout Indian Country, have voiced their dissatisfaction with the lack of quality direct health care services by Indian Health Service. Tribes have chosen either to contract health services or to enter into self-governance compacts under the Indian Self-determination and Education Assistance Act in an effort to deliver the health care services to which Indian people are entitled.



The Three Affiliated Tribes chose to contract those areas of health care services immediately essential to the well-being of Tribal members. Because physician services, a very basic component of direct health care services, were virtually non-existent for all intent and purposes on the Fort Berthold Reservation, the Three Affiliated Tribes contracted physician recruitment functions of the Federal Government. By doing so, we were successful in recruiting and retaining physician services. (During negotiations for the contract, Aberdeen Area Office recruitment staff quoted the cost to recruit at $30,000. Although we were denied our request for access to this amount, we were successful in recruiting and retaining physician services in less than a two-week period at a fraction of the Federal Government's cost). Under physician extender contract. a function contracted by the Three Affiliated Tribes, we were able to provide physician services at the three outlying communities, as well.



Despite the fact that Tribes have chosen to enter into contracts and compacts under Self Determination, funding for contract support costs have not kept pace with increased contracting and compacting efforts of Tribes. Currently, in excess of 40 percent of Indian Health Service budget is being administered by Tribes. This reflects a 42 percent increase in contracting in the past five-year period. The FY 1999 President's Budget Request contradicts the intent of Self-determination and will result in:



• diminished health care as Tribes divert health care dollars to cover critical administrative support functions;
• the quality of patient care suffering because a weakened Tribal infrastructure diminishes the capacity of the Tribal Governments to provide quality health care;



• further impeding Self-Determination Contracting, as some Tribes will not assume Indian Health Service programs because of the lack of contract support costs;



• possible retro cessions, (numerous Tribes have indicated that returning programs back to Federal operation is being contemplated because of the lack of adequate contract support costs).




The Senate Committee on Indian Affairs intentionally focuses upon "A Partnership for a New Millennium" in addressing the unmet health care needs in Indian Country. We appreciate this focus that may be very appropriate toward the implementation of Joint Venture Demonstration initiatives. We believe strongly in this initiative A partnership must be established between



Federal and Tribal Governments if we are to bring to fruition a comprehensive approach in addressing the unmet health care needs throughout Indian Country.



Chairman and Members of the Senate Committee, I am appreciative of the opportunity to express our views in this written testimony. I am hopeful that Indian Health Service funding inequities which have developed over the past several years, are corrected and that Congress assures that the needs are addressed each year in the annual appropriations.



Thank you.