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The original documents are located in Box 57, folder "9/30/76 S522 Indian Health Care
Improvement Act (1)" of the White House Records Office: Legislation Case Files at the
Gerald R. Ford Presidential Library
Copyright Notice
The copyright law of the United States (Title 17, United States Code) governs the making of
photocopies or other reproductions of copyrighted material. Gerald R. Ford donated to the United
States of America his copyrights in all of his unpublished writings in National Archives collections.
Works prepared by U.S. Government employees as part of their official duties are in the public
domain. The copyrights to materials written by other individuals or organizations are presumed to
remain with them. If you think any of the information displayed in the PDF is subject to a valid
copyright claim, please contact the Gerald R. Ford Presidential Library.
Exact duplicates within this folder were not digitized.
&9/30/76
APPROVED SEP30 1976 1976 10/1/76
THE WHITE HOUSE
ACTION
WASHINGTON
Last Day: October 1
September 30, 1976
Scalement
MEMORANDUM FOR:
THE PRESIDENT
FROM:
JIM CANNON Jun
SUBJECT:
Enrolled Bill S. 522 - Indian Health
Care Improvement Act
TOARCHIVES
10/1
This memorandum is to present for your decision enrolled
bill S. 522, the Indian Health Care Improvement Act.
PURPOSE
This bill authorizes new categorical programs and increases
appropriation authorization levels for Indian Health Service (IHS)
programs of the Department of Health, Education, and Welfare.
DISCUSSION
S. 522 is aimed at improving the health status of Indians and
Alaskan natives and includes the following major provisions:
-- establishes a new scholarship program for Indians in
health training, as well as assistance to those
serving Indians;
-- authorizes numerous new programs for the delivery of
health services;
-- authorizes funds for the construction and modernization
of health facilities, including water supply and waste
disposal facilities;
-- removes the prohibition against Medicare and Medicaid
reimbursements to Federal Indian Health Service
facilities; and
-- establishes a new program of services for non-federally-
recognized Indians living in urban areas.
FORD LIBRARY is GERALD
Digitized from Box 57 of the White House Records Office Legislation Case Files at the Gerald R. Ford Presidential Library
- 2 -
This legislation was approved in the Senate by unanimous
consent and in the House by a 310-9 vote. The Senate concurred
in the House-passed bill by a 78-0 vote on September 9, 1976.
Each of these provisions is discussed in Jim Lynn's memorandum
(attached at Tab A).
BUDGET IMPACT
S. 522 would authorize a total of $480 million for the first
three years of the bill, fiscal years 1978-1980, including
$145 million for fiscal year 1978. The clear legislative
intent is that the amounts authorized to be appropriated be
in addition to current appropriation levels. The 1977 budget
proposed $395 million for Indian health programs, but the
Interior appropriation bill for fiscal year 1977, which you
approved, contains $425 million for the IHS.
A detailed summary of the amounts authorized by S. 522 for
Indian health programs is on page 10 of Jim Lynn's memorandum
(Tab A).
ARGUMENTS IN FAVOR OF APPROVAL
1. S. 522 is designed to concentrate Federal resources on
meeting deficiencies in Indian health services and
facilities through a sustained and coordinated effort.
Health statistics and other indicators of health status --
e.g., incidence of tuberculosis, infant mortality, ratio
of physicians -- demonstrate the need for targeting
special resources on Indian health problems.
2. There are indications that the Congress believes it has
met important Administration objections, e.g., the potential
cost of S. 522 has been reduced from $1.6 billion to
$481 million in response to HEW opposition (this was
accomplished by reducing the number of years with specific
authorization amounts from seven to three and authorizing
the outyears at "such sums"). Despite the high authoriza-
tions, more realistic appropriations levels can probably
be achieved through the budget process.
3. S. 522 has broad Congressional and interest group support.
It was approved by both Houses by nearly unanimous votes
and has been endorsed by several national health organiza-
tions, including the American Dental Association, the
American Academy of Pediatrics and the American Medical
Association.
- 3 -
4. Congressional proponents, Interior and HEW suggest that
your approval of S. 522 would demonstrate a positive
commitment to solving Indian health care problems and
would signify to Indian people a recognition of one
of their priority problems and a real concern for interest
in them.
5. Although S. 522 duplicates many existing HEW programs,
it could be viewed as a follow-on step to other laws
enacted in recent years -- e.g., the Indian Financing Act,
the Indian Self-Determination and Education Assistance
Act, the Indian manpower component of the Comprehensive
Employment and Training Act of 1973 -- which have been
directed toward improving the economic, educational and
social status of Indians.
6. Although an argument against new categorical programs is
that all of the proposed program activities could be
conducted under the broad flexible legislative authorities
of the Snyder Act and other laws, in fact, many of these
program activities are not being conducted under those
legislative authorities, either because of a lack of
initiative and creativity or because of active policy
opposition.
ARGUMENTS AGAINST APPROVAL
1. OMB says that S. 522 is an example of unnecessary and
inappropriate Congressional enactments. The bill would
add some 20 new categorical programs and appropriation
authorizations to an already large array of existing
Federal activities aimed at improving the health of
Indians. The proposed program activities could be
conducted under the broad flexible legislative author-
ities of the Snyder Act and other laws.
2. OMB says that the authorization levels in S. 522 are
significantly higher than warranted because substantial
Federal funds are already being spent on Indian health.
The Administration has indicated its strong commitment
to improving the health status of Indians and Alaska
natives by approving a 1977 level of $425 million for
the Indian Health Service, a 230% increase since 1970.
- 4 -
3. Improvements have been made over the past several years
in the health status of Indians. Dramatic reductions are
apparent in such areas as Indian and infant death rates
and the incidence of tuberculosis, influenza and pneumonia,
gastritis and related diseases.
4. The provisions singling out non-reservation Indians
living in urban areas for special health programs not
only duplicate existing narrow categorical programs,
e.g., community mental health centers, which provide
services to all members of the community including
Indians and other disadvantaged groups, but are con-
ceptually at odds with your health block grant proposal
that would give the States Federal funds and clear
authority and responsibility in this area.
STAFF AND AGENCY RECOMMENDATIONS
HEW
Approval. "Approval of this bill
would reaffirm the Administration's
real concern for and interest in
Native Americans; disapproval would
adversely affect the view Native
Americans and others have as to the
Administration's commitment to Native
Americans.'
Interior
Approval. "As the Department
primarily charged with carrying
out the Federal responsibility
to Indians, and promoting their
general welfare, we believe it is
essential that the President affirm
the commitment to improved Indian
health as embodied in S. 522, and
which has received the overwhelming
endorsement of the Indian people.'
OMB
Disapproval. "We believe S. 522 is a
particularly egregious example of
unnecessary legislation that will
result in highly unrealistic ex-
pectations among the very group it
is intended to help." " We
do not find any of the arguments
sufficiently compelling to recommend
approval
particularly in light
of the special priority already
given to Indian health programs."
- 5 -
Buchen (Kilberg)
Approval. "The trust responsibility
which the Federal Government has to
federally recognized tribes is
unique and must be weighed very
carefully before turning down
programmatic legislation."
"
physical defects in Indian
health facilities are not limited
to the lack of eight foot wide halls
I think a tour of Indian health
facilities would reveal buildings and
equipment in such condition as to
raise serious questions about the
health care and safety of patients.
Also, visits indicates staff-patient
ratio that were troublesome." (Memo-
randum attached at Tab B).
Marsh
Approval.
Baroody (Patterson)
Approval.
(Memorandum attached at
Tab C).
Friedersdorf
Approval. "Rhodes and Fannin very
strong for this bill. Veto cannot
be sustained. "
Seidman
Disapproval.
RECOMMENDATION
I join HEW, Interior and most of the White House staff in
recommending that you sign S. 522.
Congressional and interest group support for this bill is
strong. Letters urging your approval have been received
from Senators Bartlett, Dole, Domenici, Fannin, Goldwater,
Hatfield, Packwood and Stevens and from Congressmen Clausen,
Rhodes and Steiger. Congressman Rhodes notes in his letter,
"Your support of this bill would go a long way towards demon-
strating that your Administration is sensitive to the health
needs of the first Americans, and supports.
.measures to
upgrade their lives. "
- 6 -
The signing statement, attached at Tab D and the veto statement,
attached at Tab E have been approved by The Counsel's Office,
Robert T. Hartmann, Jack Marsh, Max Friedersdorf, Jim Lynn
and Bill Seidman. The enrolled bill is attached at Tab F.
DECISION
JRT
Approve S. 522 and issue signing statement attached
at Tab D (HEW, Interior, Buchen, Marsh, Baroody,
Friedersdorf, Cannon)
Disapprove S. 522 and issue veto statement attached
at Tab E (OMB, Seidman)
STATEMENT BY THE PRESIDENT
I am today signing S. 522, the Indian Health Care
Improvement Act.
This bill is not without its faults, but after personal
review I have decided that the well-documented needs for
improvement in Indian health manpower, services and facilities
outweigh the defects in the bill.
While spending for Indian Health Service activities has
grown from $128 million in FY 1970 to $425 million in FY 1977,
Indian people still lag behind the American people as a whole
in achieving and maintaining good health. I am signing this
bill because of my own conviction that our First Americans
should not be last in opportunity.
Some of the authorizations in this bill are duplicative
of existing authorities and there is an unfortunate pro-
liferation of narrow categorical programs. Nevertheless,
S. 522 is a statement of direction of effort which is
commendable.
Title VII of this bill provides for future reports to the
Congress from the Secretary of Health, Education, and Welfare,
including a review of progress under the terms of the new Act.
I believe the Administration can in this way bring to the
attention of the Congress any changes needed to improve the
provisions of S. 522.
On balance, this bill is a positive step and I am pleased
to sign it.
THE WHITE HOUSE
ACTION MEMORANDUM
WASHINGTON
LOG NO.:
Date: September 30
Time:
315pm
FOR ACTION: Sarah Massengale
CC (for information): Jack Marsh
Bobbie Kilberg
Jim Connor
Max Friedersdorf
Paul O'Neill
Ed Schmults
Robert Hartmann Bill Seidman
Brad Patterson
FROM THE STAFF SECRETARY
DUE: Date:
September 30
Time: asap
SUBJECT:
Signing Statement - S.522 Indian Health Care
ACTION REQUESTED:
For Necessary Action
For Your Recommendations
Prepare Agenda and Brief
Draft Reply
X
For Your Comments
Draft Remarks
REMARKS:
please return to judy johnston, ground floor west wing
PLEASE ATTACH THIS COPY TO MATERIAL SUBMITTED.
If you have any questions or if you anticipate a
James M. Cannon
delay in submitting the required material, please
For the President
telephone the Staff Secretary immediately.
at
S. 522 - Indian Health Care Improvement Act Signing Statement
I am today signing S. 522, the Indian Health Care Improvement
Act.
This bill is not without its faults, but after personal review
decided
I have determined that the well-documented needs for improvement in
Indian health manpower, services and facilities outweigh the defects
in the bill.
While spending for Indian Health Service activities has grown
6128
1970
425
from $107 million in FY 1969 to an estimated $417 million in FY 1977,
Indian people still lag behind the American people as a whole in
achieving and maintaining good health. I am signing this bill
should
because of my own conviction that our First Americans must not be
last in opportunity.
Some of the authorizations in this bill are duplicative of existing
authorities and there is an unfortunate proliferation of narrow
categorical programs. Nevertheless, But still, S. 522 is a statement of direction
which is commendable.
of effort as such, it meets with my personal approval.
Title VII of this bill provides for future reports to the Congress
from the Secretary of Health, Education and Welfare, including a
review of progress under the terms of the new Act. I believe the
Administration can in this way bring to the attention of the Congress
any changes needed to improve the provisions of S. 522.
On balance, this bill is a positive step and I am pleased to
sign it.
Statement by the Prisident
S. 522 - Indian Health Care Improvement Act Signing Statement
]
I am today signing S. 522, the Indian Health Care Improvement
Act.
This bill is not without its faults, but after personal review
decided
I have determined that the well-documented needs for improvement in
Indian health manpower, services and facilities outweigh the defects
in the bill.
While spending for Indian Health Service activities has grown
6128
1970
425
from $107 million in FY 1969 to an estimated $417 million in FY 1977,
Indian people still lag behind the American people as a whole in
achieving and maintaining good health. I am signing this bill
should
because of my own conviction that our First Americans must not be
last in opportunity.
Some of the authorizations in this bill are duplicative of existing
authorities and there is an unfortunate proliferation of narrow
categorical programs. Nevertheless, But still, S. 522 is a statement of direction
of effort 20 such, it meets with my personal approval.
which is commendable.
Title VII of this bill provides for future reports to the Congress
from the Secretary of Health, Education and Welfare, including a
review of progress under the terms of the new Act. I believe the
Administration can in this way bring to the attention of the Congress
any changes needed to improve the provisions of S. 522.
On balance, this bill is a positive step and I am pleased to
sign it.
CREATE FRESIDENT UNITED
EXECUTIVE OFFICE OF THE PRESIDENT
OFFICE OF MANAGEMENT AND BUDGET
WASHINGTON, D.C. 20503
9-24-30 STATES
SEP 23 1976
MEMORANDUM FOR THE PRESIDENT
Subject: Enrolled Bill S. 522 - Indian Health Care
Improvement Act
Sponsor - Sen. Jackson (D) Washington and
24 others
Last Day for Action
October 1, 1976 - Friday
Purpose
Authorizes new categorical programs and substantially
increases appropriation authorization levels for Indian
Health Service programs of the Department of Health,
Education, and Welfare (HEW).
Agency Recommendations
Office of Management and Budget
Disapproval (Veto
message attached)
Department of Health, Education,
and Welfare
Approval
Department of the Interior
Approval
Discussion
S. 522 would authorize approximately 20 new categorical
programs at substantial funding levels, with the stated
objective of improving the health status of Indians and
Alaskan natives. The bill was considered by four different
Congressional committees during this Congress. The
Committees' clear intent is that the appropriation
authorizations be in addition to current funding levels.
This legislation was approved in the Senate by unanimous
consent and in the House by a 310-9 vote. The Senate
concurred in the House-passed bill by a 78-0 vote on
September 9, 1976.
Attached document was not scanned because it is duplicated elsewhere in the document
TO THE SENATE
I return without my approval, S. 522, the "Indian
Health Care Improvement Act."
I return this bill to Congress reluctantly because
I strongly support any responsible efforts that will
result in improving the health of our first Americans.
The "Interior and Related Agencies Appropriations Act,
1977," which I approved just last July, included $425
million for Indian health programs. This amounts to spending
by the Indian Health Service alone of $771 for every Indian
and Alaskan Native, or $3,084 for a family of four, and
an increase in funding levels of 230% just since 1970.
I believe this growth reflects a strong commitment to the
health needs of Indians and Alaskan Natives. No other
segment of American society receives comparable Federal
resources for health.
At the same time, I must oppose unnecessary and
undesirable legislation. S. 522 is objectionable because
it would unnecessarily authorize 20 new categorical health
programs at funding levels which can only raise unrealistic
expectations. The administration of Indian health programs--
which currently benefit from flexible and discretionary
authorities-- would be made considerably more complicated
by S. 522.
Substantial improvements have been made over the
past few years in the status of Indian health. Dramatic
reductions have been made under current authorities in
such areas as Indian adult and infant mortality rates, as
well as in the incidence of tuberculosis, influenza and
pneumonia, gastritis and related diseases. There is no
demonstrable evidence that a vast infusion of funds, such
as proposed by S. 522, would achieve better or faster
2
results than are being achieved under orderly program
growth.
Indian health programs have received, and will
continue to receive, ample funding under existing program
authorizations. I am confident that the priority given
to this area in the past will continue without S. 522.
THE WHITE HOUSE
September , 1976
THE WHITE HOUSE
Rec. 9/25/76 12:56 Pm
ACTION MEMORANDUM
WASHINGTON
LOG NO.:
Date: September 25
Time: 1000am
FOR ACTION:
Brad Patterson
CC (for information):
Jack Marsh
Max Friedersdorf
Jim Connor
Bobbie Kilberg
Ed Schmults
Robert Hartmann
(veto message attached)
Spencer Johnson
Dick Parsons
Bill Seidman
George Humphreys
FROM THE STAFF SECRETARY
DUE: Date:
Time:
September 27
500pm
SUBJECT:
S. 522-Indian Health Care Improvement Act,
ACTION REQUESTED:
For Necessary Action
For Your Recommendations
Prepare Agenda and Brief
Draft Reply
X
For Your Comments
Draft Remarks
REMARKS:
please return to judy johnston, ground floor west wing
ok
9/25/76 Copy sent for researching. RP
9/27/76 Researched copy returned up
Jetos of
PLEASE ATTACH THIS COPY TO MATERIAL SUBMITTED.
If you have any questions or if you anticipate a
delay in submitting the required material, please
James M. Cannon
telephone the Staff Secretary immediately.
For the President
TO THE SENATE
I return without my approval, S. 522, the MIndian
Health Care Improvement Act
I return this bill to Congress reluctantly because
I strongly support any responsible efforts that will
result in improving the health of our first Americans.
The "Interior and Related Agencies Appropriations Act,
1977," which I approved just last July, included $425
million for Indian health programs. This amounts to spending
by the Indian Health Service alone of $771 for every Indian
and Alaskan Native, or $3,084 for a family of four, and
an increase in funding levels of 230% just since 1970.
I believe this growth reflects a strong commitment to the
health needs of Indians and Alaskan Natives. No other
segment of American society receives comparable Federal
resources for health.
At the same time, I must oppose unnecessary and
undesirable legislation. S. 522 is objectionable because
it would unnecessarily authorize 20 new categorical health
programs at funding levels which can only raise unrealistic
expectations. The administration of Indian health programs--
which currently benefit from flexible and discretionary
authorities--would be made considerably more complicated
by S. 522.
Substantial improvements have been made over the
past few years in the status of Indian health. Dramatic
reductions have been made under current authorities in
such areas as Indian adult and infant mortality rates, as
well as in the incidence of tuberculosis, influenza and
pneumonia, gastritis and related diseases. There is no
demonstrable evidence that a vast infusion of funds, such
as proposed by S. 522, would achieve better or faster
2
results than are being achieved under orderly program
growth.
Indian health programs have received, and will
continue to receive, ample funding under existing program
authorizations. I am confident that the priority given
to this area in the past will continue without S. 522.
THE WHITE HOUSE
September / 1976
A
EXECUTIVE OFFICE OF THE PRESIDENT
STATE STATE SERVICE OFFICE
OFFICE OF MANAGEMENT AND BUDGET
WASHINGTON, D.C. 20503
SEP 23 1976
MEMORANDUM FOR THE PRESIDENT
Subject: Enrolled Bill S. 522 - Indian Health Care
Improvement Act
Sponsor - Sen. Jackson (D) Washington and
24 others
Last Day for Action
October 1, 1976 - Friday
Purpose
Authorizes new categorical programs and substantially
increases appropriation authorization levels for Indian
Health Service programs of the Department of Health,
Education, and Welfare (HEW).
Agency Recommendations
Office of Management and Budget
Disapproval (Veto
message attached)
Department of Health, Education,
and Welfare
Approval
Department of the Interior
Approval
Discussion
S. 522 would authorize approximately 20 new categorical
programs at substantial funding levels, with the stated
objective of improving the health status of Indians and
Alaskan natives. The bill was considered by four different
Congressional committees during this Congress. The
Committees' clear intent is that the appropriation
authorizations be in addition to current funding levels.
This legislation was approved in the Senate by unanimous
consent and in the House by a 310-9 vote. The Senate
concurred in the House-passed bill by a 78-0 vote on
September 9, 1976.
2
The major provisions of S. 522 would:
-- establish a new program of scholarships for
Indians desiring to pursue health training, as well
as assistance to those serving Indians,
-- authorize numerous new narrow categorical programs
for the delivery of health services,
-- authorize a specific program for the construction
and modernization of health facilities, including water
supply and waste disposal facilities,
-- remove the existing prohibition against Medicare
and Medicaid reimbursements to Federal Indian Health
Service facilities, and
-- establish a new program of services for non-
federally-recognized Indians living in urban areas.
The Senate and House Interior and Insular Affairs Committees
both expressed the view that S. 522 is needed because
Indian and Alaska natives suffer a health status con-
siderably below that of the general population. The
Committees attribute the lower health status to inadequate
and understaffed health facilities, lack of access to
health services, and lack of safe water and sanitary
waste disposal services. HEW, in testimony and reports
to the Congress, strongly opposed enactment of the
legislation, except for the extension of Medicare and
Medicaid reimbursements to eligible beneficiaries in
Indian Health Service facilities. HEW's position was
based on marked improvement in the health status of
Indians over the past decade, generally liberal funding
levels for Indian health activities, and the fact that
all of the proposed activities can be conducted under
existing legislation. Moreover, HEW stated that the
authorization levels would raise unrealistic expectations
of the resources the Federal Government could afford to
devote to this purpose.
Major provisions
Student assistance. S. 522 would authorize 5 new
programs designed to increase generally the number of
health professionals serving Indians and to increase
specifically the number of Indians receiving health
training. The programs would:
3
-- provide grants and scholarships to recruit,
prepare, and enroll Indians in health professions schools,
-- authorize scholarship grant recipients to be
employed in the Indian Health Service (IHS) during
nonacademic periods, and
-- authorize continuing education allowances to all
IHS health professionals for professional consultation
and refresher training courses.
These programs would be in addition to HEW's broad
programs of assistance to medical students and schools
under which HEW can already give priority to disadvantaged
students, including Indians.
Health services and facilities. S. 522 would authorize
a broad range of new programs and substantially increase
the numbers of health service personnel over current
levels; e.g., it would authorize an increase of 425
new personnel in 1978, 515 in 1979 and 593 in 1980--a
total of 1,533. This would be in addition to the current
IHS staffing level of 8,800. Programs specified in
S. 522 would include patient care, field health, dental
care, mental health (including community and inpatient
mental health services, model dormitory mental health
services, therapeutic and residential treatment centers,
and the training of traditional Indian practitioners
in mental health) and alcoholism treatment and control.
The bill would also direct HEW to apportion at least
1% of all funds authorized for Indian health services
for research in each health service area.
In addition, S. 522 would specifically authorize the
construction and renovation of Indian hospitals, health
centers, health stations and staff housing as well as
safe water and sanitary waste disposal facilities in
Indian homes and communities. The enrolled bill would
make eligible for federally provided sanitation facilities
certain Indian tribes currently not eligible for such
assistance, e.g., the Senecas and Mohawks of New York.
This provision would have the effect of expanding the
eligible Indian population by approximately 7,000.
Preference to Indian firms would be authorized in awarding
construction and renovation contracts for IHS facilities
and for the construction of clean water and sanitation
facilities for Indians.
4
Medicare and Medicaid reimbursements. Under current law,
IHS hospitals, as Federal facilities, cannot receive
reimbursement from Medicare or Medicaid for either
Indians or non-Indians. These facilities, however,
serve as the principal health delivery system for
reservation Indians. S. 522 would make them eligible
for Medicare and Medicaid reimbursement as long as
they meet required standards or have an acceptable plan
to bring a facility into compliance within 2 years.
HEW favored this provision, but opposed related provisions
in S. 522 that would:
-- prohibit consideration of third-party reimburse-
ments received by IHS in determining appropriation levels
for IHS facilities, and
-- require the Federal Government to reimburse
100%--rather than 50% to 80% under current law--State
Medicaid agencies which in turn reimburse IHS facilities.
The Secretary would be required to maintain a special
revolving fund into which these reimbursements would
be paid to be used solely for facilities improvement.
Urban Indian programs. S. 522 would authorize HEW to
enter into contracts with organizations of Indians
living in urban areas for the purpose of enabling the
organizations to identify and assist in providing needed
health services. The bill also specifies criteria HEW
must consider in selecting the urban Indian organizations,
contract conditions, and reporting requirements.
Other provisions. In addition, S. 522 would:
-- authorize HEW to conduct a study to determine
the need for and feasibility of establishing a school
of medicine to train Indian health professionals;
-- require HEW to promulgate regulations to implement
the Act, to develop and submit to Congress-within
eight months--a plan for implementation of the specific
authorities in S. 522, and to submit annual reports to
the Congress and additional reports on expenditures and
recommendations for additional appropriation authoriza-
tions,
5
---- authorize HEW to enter into leases of up to
20 years with Indian tribes to construct health facilities.
The purpose of this provision is to allow Indians to
construct, staff, equip and maintain health facilities
and lease them at full cost--including salaries, drugs
and equipment--to the IHS. Cost for this would be in
addition to the specific amounts authorized and would
involve long term commitments for Federal funds.
Cost and budget impact. S. 522 would authorize a total
of $480 million for the first three years of the bill,
fiscal years 1978-1980, including $145 million for
fiscal year 1978. The clear legislative intent is that
the amounts authorized to be appropriated be in addition
to current appropriation levels. The 1977 budget proposed
$395 million for Indian health programs, but the Interior
appropriation bill for fiscal year 1977, which you approved,
contains $425 million for the IHS--a 230% increase over
the 1970 appropriation of $128 million. Even if adjusted
at a liberal inflation rate of 10% per year, the increase
in funding since 1970 amounts to more than 100%.
A detailed summary of the amounts authorized by S. 522
for Indian health programs is attached to this memorandum.
Arguments in favor of approval
1. The Congressional committees believe that
S. 522 would concentrate Federal resources on meeting
deficiencies in Indian health services and facilities
through a sustained and coordinated effort. The
Committees state that health statistics and other indica-
tors of health status--e.g., incidence of tuberculosis,
infant mortality, ratio of physicians--demonstrate the
need for targeting special Federal resources on Indian
health problems.
2. There are indications that the Congress believes
it has met important Administration objections, e.g.,
the potential cost of S. 522 has been reduced from
$1.6 billion to $481 million in response to HEW opposition
(this was accomplished by reducing the number of years
with specific authorization amounts from seven to three
and authorizing the outyears at "such sums"). Despite
the high authorizations, more realistic appropriations
levels can probably be achieved through the budget
process.
3. S. 522 has broad congressional and interest
group support. It was approved by both Houses by nearly
6
unanimous votes and has been endorsed by several national
health organizations, including the American Dental
Association, the American Academy of Pediatrics and the
American Medical Association.
4. Congressional proponents, Interior and HEW
suggest that your approval of S. 522 would demonstrate
a positive commitment to solving Indian health care
problems and would signify to Indian people a recognition
of one of their priority problems and a real concern for
and interest in them.
5. Although S. 522 duplicates many existing HEW
programs, it could be viewed as a follow-on step to
other laws enacted in recent years--e.g., the Indian
Financing Act, the Indian Self-Determination and Education
Assistance Act, the Indian manpower component of the
Comprehensive Employment and Training Act of 1973--which
have been directed toward improving the economic, educa-
tional and social status of Indians.
Arguments against approval
1. S. 522 is a prime example of unnecessary and
inappropriate Congressional enactments. The bill would
add some 20 new narrow categorical programs and appro-
priation authorizations to an already large array of
existing Federal activities aimed at improving the health
of Indians. All of the proposed program activities can
be conducted under the broad flexible legislative authorities
of the Snyder Act and other laws. For example, Indians
and non-Indians desiring to serve in reservation areas
are already given special consideration under HEW's
health professions and National Health Service Scholar-
ship programs.
2. The authorization levels in S. 522 are
significantly higher than warranted and raise highly
unrealistic expectations of what the Federal Government
can or will provide. Moreover, the cost reduction
claimed by Congressional proponents of S. 522 is spurious
at best, since it was achieved by substituting "such
sums" language for specific authorization amounts for
the last 4 years of the 7-year authorization period.
Other hidden additional costs would arise from contractual
arrangements and lease agreements with Indian tribes
and Indian organizations. As the minority members of
the House Interstate and Foreign Commerce Committee
stated, "These levels are grotesque when viewed in the
light of budgetary increases totaling over 200% in
7
the past eight years, and the definite progress in
improving Indian health through priorities given to
these programs over many competing demands.'
3. Substantial Federal funds are already being
spent on Indian health. The Administration has indicated
its strong commitment to improving the health status
of Indians and Alaska natives. As noted above, you
have approved a 1977 level of $425 million for the Indian
Health Service, a 230% increase since 1970 which amounts
to $771 for each Indian or $3,084 for an Indian family
of four. These amounts do not include services provided
to the eligible Indian population from other Federal
health programs.
4. Contrary to the negative emphasis in Congressional
committee reports, very substantial improvements have
been made over the past several years in the health
status of Indians. Dramatic reductions are apparent in
such areas as Indian and infant death rates and the
incidence of tuberculosis, influenza and pneumonia,
gastritis and related diseases. No evidence has been
developed to warrant the conclusion that a vast infusion
of funds for additional and traditional health services
such as proposed in S. 522 will significantly improve
the health status of Indians.
To a large extent, alcoholism, suicide and accidents
are a part of cultural and reservation conditions not
readily amenable to traditional health and mental health
services. Moreover, it is not clear that forcing IHS
hospitals to comply to Joint Commission on Accreditation
of Hospitals (JCAH) standards at high cost will result
in improved quality of care since many of the standards
JCAH applies, e.g., requiring halls to be 8 feet in
width cannot be directly related to quality, particularly
when the small size of IHS facilities is considered.
5. The provisions singling out non-reservation
Indians living in urban areas for special health programs
not only duplicate existing narrow categorical programs,
e.g., community mental health centers, which provide
services to all members of the community including
Indians and other disadvantaged groups, but are con-
ceptually at odds with your health block grant proposal
that would give the States Federal funds and clear
authority and responsibility in this area.
8
Recommendations
HEW, in its attached views letter on S. 522, recommends
approval, stating: "At this stage
the Administration
can only approve or disapprove the bill as a whole. "
Noting that S. 522 would for the first time permit
Indians to effectively use Medicare and Medicaid benefits,
HEW states "If Native Americans are to be fully integrated
into the mainstream of the American health care system,
and in particular in terms of a future national health
insurance program, they must be given meaningful partici-
pation in, and develop familiarity with, the most
extensive programs we have in this area to date. HEW
concludes that "approval of this bill would reaffirm the
Administration's real concern for and interest in Native
Americans; disapproval would adversely affect the view
Native Americans and others have as to the Administration's
commitment to Native Americans."
Interior also recommends approval of S. 522. Interior
states
II
we believe it is essential that the President
affirm the commitment to improved Indian health as
embodied in S. 522, and which has received the over-
whelming endorsement of the Indian people.
********
We believe S. 522 is a particularly egregious example
of unnecessary legislation that will result in highly
unrealistic expectations among the very group it is intended
to help. As pointed out previously, all of the program
activities authorized by S. 522 can be accomplished under
existing legislative authority.
Moreover, funding of Indian health activities has been
increased substantially during the past few years and
has resulted in dramatic improvements in the status of
Indian health. In 1977, $425 million will be spent by a
force of over 8,800 Federal employees. No other segment
of American society receives comparable Federal resources
for health.
We do not find any of the arguments offered by the Congress
or by the Departments of HEW or Interior sufficiently
compelling to recommend approval of S. 522, particularly
9
in light of the special priority already given to Indian
health programs. Accordingly, on the merits, we
recommend that you veto S. 522 and have attached a draft
veto message for your consideration.
Paul H. O'Neill
Acting Director
Enclosures
Attachment
S. 522 Indian Health Care Improvement Act
(Budget Authority in $ millions)
Fiscal Years
2/
1978
1979
1980
Student assistance
Recruitment and post-secondary
assistance
.9
1.5
1.8
Scholarships:
Preparatory
.8
1.0
1.3
Health professions
5.5
6.3
7.2
Indian Health Service
extern program
.6
.8
1.0
Subtotal
7.8
9.6
11.3
Continuing professions education
.1
.2
.3
Health services
Patient care
-
8.5
16.2
Field health
-
3.3
5.5
Dental care
-
1.5
1.5
Mental health
-
3.4
5.1
Alcoholism
4.0
9.0
9.2
Maintenance
-
3.0
4.0
Subtotal
14.0
28.7
41.5
Health facilities
Hospitals
67.2
73.3
49.7
Health centers
7.0
6.2
3.7
Staff housing
1.2
21.7
4.1
Subtotal
75.4
101.2
57.5
Sanitation and safe water
construction
Existing homes
43.0
30.0
30.0
New homes
"such
"such
"such
sums"
sums"
sums"
=
Health services for urban
(non-reservation) Indians
5.0
10.0
15.0
Total, specific authori-
zations
145.3
179.7
155.6
Includes $10 million for all of the health services programs
other than alcoholism.
2/ The bill authorizes "such sums" for fiscal years 1981-1984.
HEALTH.
DELICATION
DEPARTMENT OF HEALTH, EDUCATION. AND WELFARE
U.S.A.
The Honorable James T. Lynn
SEP 2 3 1976
Director, Office of Management
and Budget
Washington, D. C. 20503
Dear Mr. Lynn:
This is in response to your request for a report on S. 522,
an enrolled bill "To implement the Federal responsibility
for the care and education of the Indian people by improving
the services and facilities of Federal Indian health programs
and encouraging maximum participation of Indians in such
programs, and for other purposes."
In summary, we recommend that the President sign the
enrolled bill because he will thereby affirm in the eyes
of Indians and others this Administration's strong commitment
to advancing the welfare of our Native Americans; the bill's
provisions largely overlap existing legal authority but
represent a congressional statement of support for Indian
health activities.
The enrolled bill would provide additional appropriation
authorizations of approximately $480 million for the fiscal
years 1978 through 1980 for specific Indian health programs
in the areas of manpower training, services, and facilities;
under present law, funds may be appropriated for Indian
health activities up to any amount. The Administration
recommended $395 million in appropriations for Indian health
services and facilities for fiscal year 1977. The enrolled
bill would also permit Indian Health Service (IHS) facilities
to receive Medicare and Medicaid funds for services provided
to eligible persons under those programs. Each IHS facility
not presently meeting Medicare or Medicaid standards would
be required within six months of enactment of the enrolled
bill to develop a plan to meet the requirements of those
programs. The facility could then receive Medicare and
Medicaid funds for one year without meeting the usual
requirements of those programs, but after that only if those
The Honorable James T. Lynn
2
requirements had been met. The Federal government would
completely reimburse States for Medicaid funds paid to IHS
facilities. S. 522 would in addition direct the Secretary
to conduct a study concerning the need for and feasibility
of an Indian school of medicine, to promulgate regulations
under the enrolled bill within ten months of enactment, and
to develop a plan of implementation within 240 days of enactment.
Funds appropriated under S. 522 would remain available until
expended.
We opposed this bill consistently during its consideration by
the Congress because it would authorize a number of specific
programs duplicating our present general authority in this area
and because the additional appropriation authorizations implied
a congressional desire to exceed our budget requests in the
area of Indian health. At this stage, however, we feel that
other considerations strongly suggest that the President
sign S. 522.
The enrolled bill would for the first time permit Native
Americans effectively to use Medicare and Medicaid benefits
for which they are eligible; these benefits cannot under
present law be used in Federal facilities (except in certain
restricted situations). If Native Americans are to be fully
integrated into the mainstream of the American health care
system, and in particular in terms of a future national
health insurance program, they must be given meaningful
participation in, and develop familiarity with, the most
extensive programs we have in this area to date.
The enrolled bill does not contain, as did earlier versions
of the bill, any authorizations for fiscal year 1977. In
any event, the bill's authorizations merely duplicate existing
authority. The enrolled bill, moreover, is viewed by many
Native Americans, Congressmen, and other persons concerned
with the welfare of Native Americans as a statement of Federal
commitment to advance the welfare of our Native Americans.
During congressional consideration, our objections to
provisions in the bill were part of a dialogue in developing
the best possible approach in the area of Indian health.
At this stage, however, the Administration can only approve
The Honorable James T. Lynn
3
or disapprove the bill as a whole. The President's approval
of this bill would reaffirm the Administration's real concern
for and interest in Native Americans; disapproval would adversely
affect the view Native Americans and others have as to the
Administration's commitment to Native Americans.
The enrolled bill was passed by the Senate by a vote of
78 to 0, and in an earlier version by the House by a vote
of 310 to 9.
We recommend that the President sign the enrolled bill.
Sincerely,
Marjine bynch
Under Secretary
Я
THE WHITE HOUSE
WASHINGTON
September 28, 1976
MEMORANDUM FOR: JIM CANNON
Bobbi
FROM:
BOBBIE GREENE KILBERG
SUBJECT:
S. 522 - Indian Health Care
Improvement Act
I recommend that the President sign the Indian Health
Care Improvement Act for the following reasons:
(1) S. 522 would provide Medicare and Medicaid
reimbursement for Indian Health Service hospitals.
HEW states that this would enable Native Americans to
effectively use the Medicare and Medicaid benefits for
which they are eligible.
(2) In arguing against new categorical programs,
OMB states that all of the proposed program activities
could be conducted under the broad flexible legislative
authorities of the Snyder Act and other laws. However,
in fact, many of these program activities are not being
conducted under those legislative authorities, either
because of a lack of Departmental or bureaucratic
initiative and creativity or because of active policy
opposition.
(3) The trust responsibility which the Federal
government has to federally recognized tribes is unique
and must be weighed very carefully before turning down
programmatic legislation.
(4) It is my perception that Indian life expectancy
rates are significantly lower and Indian infant mortality
rates are significantly higher than the rates for the
general population in the United States. Dan McGurk
says that this statement cannot be borne out when one
eliminates alcoholism, suicide and accident rates. Ted
Marrs, however, had consistently asserted that the figures
-2-
were still substantially different from the national
average even when alcoholism, suicide and accidents
are not counted. Further, S. 522 would authorize new
programs specifically aimed at the alcoholism, suicide
and accident rates which take such a serious toll in
Indian lives. According to the OMB memo, S. 522 pro-
grams would include mental health (including community
and inpatient mental health services, model dormitory
mental health services, therapeutic and residential
treatement centers, and the training of traditional
Indian practitioners in mental health) and alcoholism
treatment and control.
(5) I strongly agree with Brad Patterson's state-
ment that the physical defects in Indian health facili-
ties are not limited to the lack of 8 foot-wide halls,
as No. 4 of OMB's arguments against approval might imply.
From my personal experience, I think a tour of Indian
health facilities would reveal buildings and equipment
in such condition as to raise serious questions
about the health care and safety of patients.
(6) While S. 522 contains a significantly higher
authorization than OMB believes is warranted, OMB does
indicate that more realistic appropriations levels can
probably be achieved through the budget process.
(7) While I agree with OMB's criticism of the
urban Indian provision in S. 522, I would not recom-
ment veto of the bill because of it.
(8) It is my understanding that Congress will
override a Presidential veto and that a majority of
Republican Senators and Congresspersons will vote for
that override. This includes Congressman Rhodes, who
has written the President requesting that he sign the
bill; Senator Fannin, ranking minority member of the
Senate Interior & Insular Affairs Committee; and
apparently Congressman Skubitz, ranking minority member
of the House Interior & Insular Affairs Committee, and
Senators Dole, Goldwater, Bartlett, Domenici, Stevens
and Hatfield.
(9) As a political matter, a veto of this bill
will be portrayed as direct Presidential action against
the improvement of health care for the Native American
community, a group which the majority of people in this
-3-
country still has substantial empathy for. The fact
that we have made significant progress in the area of
Indian health care and are devoting substantial resources
to it will be lost in the negative headlines.
CC: Phil Buchen
p
C
THE WHITE HOUSE
WASHINGTON
September 27, 1976
MEMORANDUM FOR THE PRESIDENT
FROM:
BRADLEY H. PATTERSON, JR.M
THROUGH:
WILLIAM J. BAROODY, JR.
SUBJECT:
S. 522 -- The Indian Health Care
Improvement Act
I respectfully recommend that you sign S. 522 and issue
the attached statement (Tab A)
Most of my reasons for this recommendation are not re-
flected in the Enrolled Bill Memorandum; they are as
follows:
1. For seven years there has been an unbroken
series of Presidential actions which have
reversed and rectified the past decades of
neglect for Native Americans. It has been
a brilliant executive/legislative accomplish-
ment in which you and a bipartisan Congress
fully share. A veto of this bill would be
the first turnaround in that seven-year
record and, as such, would have symbolic
impact greater than the merits of the bill
considered by themselves.
2. This symbolic impact could not come at a
more inopportune time.
(a) Our experience with Indian matters
from Alcatraz to Wounded Knee has shown
us that while the Indian community itself
is small, the latent interest in and
sympathy for Indian people in the population
generally is widespread, is undiscriminating
and is a magnet for media exploitation.
The symbolic force of a veto here risks
galvanizing that latent sympathy into an
attention-getting political backlash among
2
conservative and independent people, as
well as among Democrats.
(b) Carter's staff is keeping close track
of Indian matters; (he has sent Messages to
all the recent Indian meetings.) A veto of
this bill will raise the whole area of Indian
affairs up into his target sights.
(c) You have just (properly) vetoed a less
important bill on early retirement for non-
Indian federal employees. The two vetoes
together will have a synergistic effect.
Three weeks from today the National Congress
of American Indians assembles in Salt Lake
City; vetoing the Indian Health bill will
convert the Conference into a minor political
disaster for us in addition to its longer
term negative opinion effect among Indian
leaders.
3. The bill is only an authorization measure. While
it is true that the Indian community and the
Indian Health Service will be encouraged by your
signature to recommend appropriations for the full
amounts, you and OMB can handle any unjustified
requests through the budget machinery, and in that
discriminating way - next December -- rather than
through the sledgehammer of a veto -- in October,
protect the budget from excesses. The draft
statement (Tab A) makes it clear that your signing
the bill does not constitute overpromising or
making a commitment to budget the amounts authorized.
4. Contrary to the impression which may be given at
the bottom of page 6 of the Enrolled Bill Memoran-
dum, Republican support for this bill is strong;
a veto (unless it is of the "pocket" variety) will
be overridden.
(a) Joe Skubitz, ranking on the House Interior
Committee, joined in the successful effort to
have the earlier version of the bill amended,
stating:
If the amendments are adopted, it is a bill
which I personally believe the President
can sign in good conscience
I can truthfully say that the Interstate
3
committee has done its best to report
a responsible bill, which in our judg-
ment, should be both fiscally and
philosophically acceptable to the
administration.'
(b) On House passage, the following members
of the Minority of the House Interior Committee
joined Mr. Skubitz in voting for the bill:
Messrs. Bauman, Clausen, Johnson, Lagomarsino,
Pettis, Smith and Symmes.
(c) Congressman Rhodes is a co-sponsor of the
bill and has written you a special letter urging
you to sign it.
(d) Senators Dole, Fannin, Goldwater, Bartlett,
Domenici, Stevens and Hatfield are supporters
of the amended bill.
5. We are on somewhat slippery grounds in opposing the
final, amended bill. In unusual steps, both Ranking
Member Skubitz and Ranking Member Fannin went out
of their way to castigate HEW generally and
Secretary Mathews personally for being unwilling
earlier on to sit down with the Committees and
staffs to work out an acceptable compromise. 53
weeks ago, Senators Fannin and Bartlett had lunch
with Secretary Mathews to start this process, but
HEW never followed up. The Skubitz and Fannin
statements are attached here as Tab B.
6. The Indian Health facilities lack more than "eight-
foot-wide halls". When the House and Senate Com-
mittee reports pointed out that 25 out of 51 IHS
hospitals failed of accreditation by the Joint
Commission on Accreditation of Hospitals, they
added:
"Many of them are old one-story, wooden
frame buildings with inadequate electricity,
ventilation, insulation and fire protection
systems and of such insufficient size as to
seriously jeopardize the health and safety
of patients and staff alike."
4
7. I share Paul O'Neill's concern about special
health programs for urban Indians, but the
draft signing statement recommended here
includes a special instruction to Secretary
Mathews to use the bill's authority to avoid
duplication.
D
D
TO THE SENATE OF THE UNITED STATES:
I return without my approval, S. 522, the Indian
Health Care Improvement Act.
I return this bill to Congress reluctantly because
I strongly support any responsible efforts that will
result in improving the health of our first Americans.
The "Interior and Related Agencies Appropriations Act,
1977," which I approved just last July, included $425
million for Indian health programs. This amounts to
spending by the Indian Health Service alone of $771
for every Indian and Alaskan Native, or $3,084 for a
family of four, and an increase in funding levels of
230% just since 1970. I believe this growth reflects
a strong commitment to the health needs of Indians and
Alaskan Natives. No other segment of American society
receives comparable Federal resources for health.
At the same time, I must oppose unnecessary and
undesirable legislation. S. 522 is objectionable because
it would unnecessarily authorize 20 new categorical health
programs at funding levels which can only raise unrealistic
expectations. The administration of Indian health
programs -- which currently benefit from flexible and
discretionary authorities -- would be made considerably
more complicated by S. 522.
Substantial improvements have been made over the
past few years in the status of Indian health. Dramatic
reductions have been made under current authorities in
such areas as Indian adult and infant mortality rates,
as well as in the incidence of tuberculosis, influensa
and pneumonia, gastritis and related diseases. There is
2
no demonstrable evidence that a vast infusion of funds,
such as proposed by S. 522, would achieve better or faster
results than are being achieved under orderly program
growth.
Indian health programs have received, and will
continue to receive, ample funding under existing program
authorizations. I am confident that the priority given
to this area in the past will continue without S. 522.
THE WHITE HOUSE,
TO THE SENATE OF THE UNITED STATES:
I return without my approval, S. 522, the Indian
Health Care Improvement Act.
I return this bill to Congress reluctantly because
I strongly support any responsible efforts that will
result in improving the health of our first Americans.
The "Interior and Related Agencies Appropriations Act,
1977," which I approved just last July, included $425
million for Indian health programs. This amounts to
spending by the Indian Health Service alone of $771
for every Indian and Alaskan Native, or $3,084 for a
family of four, and an increase in funding levels of
230% just since 1970. I believe this growth reflects
a strong commitment to the health needs of Indians and
Alaskan Natives. No other segment of American society
receives comparable Federal resources for health.
At the same time, I must oppose unnecessary and
undesirable legislation. S. 522 is objectionable because
it would unnecessarily authorize 20 new categorical health
programs at funding levels which can only raise unrealistic
expectations. The administration of Indian health
programs -- which currently benefit from flexible and
discretionary authorities -- would be made considerably
more complicated by S. 522.
Substantial improvements have been made over the
past few years in the status of Indian health. Dramatic
reductions have been made under current authorities in
such areas as Indian adult and infant mortality rates,
as well as in the incidence of tuberculosis, influenza
and pneumonia, gastritis and related diseases. There is
2
no demonstrable evidence that a vast infusion of funds,
such as proposed by S. 522, would achieve better or faster
results than are being achieved under orderly program
growth.
Indian health programs have received, and will
continue to receive, ample funding under existing program
authorizations. I am confident that the priority given
to this area in the past will continue without S. 522.
THE WHITE HOUSE,
F