Ask the Scholar
Document scope · 1 page
Scholar
Ask about this object, its catalog metadata, its source description, or the page inventory.
For page-specific OCR and visual context, open one of the page chats.
Scholar Source Context
Document identity
localId
1103379
label
Health Care Legislation - S. 522 (1)
core
doc
dtoType
document
citationUrl
pageCount
1
Source metadata
id
1103379
sourceUrl
contentType
document
title
Health Care Legislation - S. 522 (1)
citationUrl
collections
Bradley H. Patterson Files (Ford Administration)
Bradley Patterson's Native American Programs Files
subjects
Health
Legislation
Indians of North America
thumbnailUrl
largeImageUrl
imageCount
1
hasImages
yes
source
import
hasTranscription
no
Source extras
naId
1103379
coverageEndDate
logicalDate
1976-10-01
month
10
year
1976
coverageStartDate
logicalDate
1974-04-01
month
4
year
1974
levelOfDescription
fileUnit
recordType
description
ocrSource
nara-archive
Single page context
seq
1
pageIndex
0
type
document
mediaId
dc1d7abbcc304198
ocrText
The original documents are located in Box 2, folder "Health Care Legislation - S. 522 (1)"
of the Bradley H. Patterson 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 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States of America his copyrights in all of his unpublished writings in National Archives collections.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.
Digitized from Box 2 of the Bradley H. Patterson Files
at the Gerald R. Ford Presidential Library
PRESIDENT
HESE THE SEATES 8
EXECUTIVE OFFICE OF THE PRESIDENT
OFFICE OF MANAGEMENT AND BUDGET
DATE: 4/9/74
TO:
mr. Patterson
FROM:
Vim Stimpson (X 3736)
Per your request 9 any
pending a copy of the
HEV testimony on 5.2938
as revised and approved
by our program divisions.
learning Will (les value)
Street of questions.
OMB FORM 38
REV AUG 73
Mr. Chairman, I 010 pleased to have this opportunity Lo appear before you
today to discuss S. 2938, the Indian Health Care Improvement Act. This bill
provide% specific authorizations for Indian Health manpower, Health Services,
Health Facilities construction and renovation, Access to Health Services for
reservation Indians, Access to Health Services for Urban Indians and a
requirement for the Secretary to report to the President and the Congress
on progress made in effecting the purposes of the Act.
This Administration is committed to a program of Indian Self Determination,
to expanded efforts to train Indians for health careers, and to a strength-
ened Federal effort to advance the health of these first Americans. These
commitments were related to the Congress in the President's Special Indian
Message of July 8, 1970.
an important part of the
for
This Department has the central responsibility the translating this policy
into programs particularly in the area of health. We are seeking to
advance the health status of these Americans in a variety of ways.
FORD LIBRARY & GERALD
Health Care Options
First, Indian people and Alaska Natives, as American citizens, may partici-
pate in the health programs administered by the Department on the same
basis as any other citizen. We are attempting to assure that they are
aware of the broad health benefits offered through these programs, particu-
larly the benefits under Medicaid and Medicare. These programs represent
a significant health resource for the Indian people and we are attempting
to ensure that the Indian population take advantage of these benefits to
the extent possible.
-2-
Two months ago, the Administration sent to Congress the Comprehensive
Health Insurance Act (chip). CHIP will make catastrophic comprehensive
health insurance available to Indians and Alaska Natives without in any
way diminishing or affecting the health care now being provided Indian
people through the Indian Health Service (IIIS). Thus this proposal should
be considered as a supplement to presently available health services.
As with any other American, the status of Indians and Alaska Natives under
CHIP will be determined by the choice or circumstance of the individual.
Those who are full-time employees will have the choice of enrolling under
the Employee Health Insurance Plan (EHIP), or if it is economically
advantageous, in the Assisted Health Insurance Plan (AHIP), which will
require less in cost sharing charges. Of course, those who are 65 OF older
eligible to receive Medicare will have the option of enrolling in the Medi-
care plan which also will have reduced cost sharing charges.
We recognize that because of the geographical isolation of many Alaska
Natives and Indians and the cost sharing charges under CHIP, their choice
will in fact often be limited to the IHS facilities in their vicinity. How--
ever, for those within commuting distance of private facilities and practi-
tioners, the EHIP, AHIP and Medicare plans under CHIP will provide an
alternative to the IHS facilities.
Indians and Alaska Natives who elect to enroll in any of the three plans
under CHIP will receive a healthcard which will be honored for services at
virtually all non-Federal health facilities and by virtually all private
practitioners. They will also be subject to the same cost sharing and
premiums as all other enrollees under the plans.
-3--
In addition to these other health resources being available to Indians
and Alaska Natives, the Indian Health Service budget to provide health care
services has grown from million in 1968 to $200.0 200 million in 1974.
9
281
The President S budget for 1975 requests a further increase to $226.0
million.
These increases are significant because they bring real benefits in terms
of people served. They will help us meet the rapidly growing demand for
health services on the part of the Indian people- a demand that is growing
because of their increasing confidence in modern health practices, based
on positive experiences.
For example, Indian Health Service facilities expect to receive an additional
100, 000 outpatient visits in 1974, and another 100,000 in 1975, over and
above the 2.3 million visits experienced in 1973.
this
expected
increase of funds will enable us to cut into the huge backlog of united
needs for surgery and other kinds of care which built up In past decades
Good health facilities are crucial to the delivery of high-quality health
services to Indians. The fiscal year 1974 and 1975 Indian Health Service
budgets recognize this and provide for further orderly and realistic progress
in the necessarily long-range effort to replace or remodel outmoded Indian
Health Service hospitals and other facilities, and to upgrade others.
The FY 1974 construction program contained funds for replacing the old and
obsolete health facilities at Zuni, New Mexico; Owyhee, Nevada and Choctaw,
Mississippi. A replacement hospital at Tuba City, Arizona will be completed
in fiscal year 1975. Funds are also available to plan a replacement
Denn files RIA trying to
-lin
plene ont this school, A new
hailli bacility Keep
to Keeping
health facility at Bethel, Alaska, and planning funds for the [new Chemawa,
Oregon School Health Center are also contained in FY 1974's construction
program. The FY 1975 President's budget would provide construction funds
for the replacement health facility at Claremore, Oklahoma, and to replace
the school health center at Riverside, California. Funds to construct a
C
small addition to the existing health center at Tohatchi, New Mexico and to
construct 207 units of housing at Tuba City, Arizona are also contained in
the FY 1975 program.
The fiscal years 1974 and 1975 budgets also will provide for meaningful
inroads against the problems inherent in the rigorous environment which
characterize Indian country, and which contribute to disease, suffering and
premature death. Fiscal year 1974 funds of $36.2 million will enable us to
provide sanitation facilities construction, including water and waste
disposal systems, for an additional 8,500 new and improved homes, and
FORD LIBRARY & GERALD
approximately 3,500 existing homes during that year. An additional 8,000
new and improved homes, and an additional 4,900 existing homes will be so
served through the fiscal year 1975 budget of $40.5 million. These budgets
and numbers of homes served stand out in sharp contrast to the fiscal year
1968 when the budget was $10.5 million and the number of homes served was
only 7,350.
In addition to the health care provided by the Indian Health Service in its
own facilities and through contract health care, other Public Health Service
agencies are contributing more than $11 million in 1975 for a broad range
of services.
I believe the FY 1975 budget demonstrates our commitment to better Indian
health care and represents real progress toward our mutual goal.
-5-
Measures of Success of Present Programs
Econtining
The true measure of our Indian health efforts is found in the l health status
of the Indian people. The improvment impact has been both profound and enduring. It
can be illustrated by the dramatic reduction of Indian death rates between
1955 and 1972. The infant death rate has declined 67 percent; the tubercu-
losis rate is down 85 percent; the gastritis and related diseases rate has
dropped 81 percent; and the rate for influenza and pneumonia is down 58
percent.
These figures represent firm evidence that the Administration's decision to
place high priority on investing in health services for Indian people has
been a wise one, and that the methods it has employed to deliver services
FORD
have been effective.
i LIBRARY GERALD delety
Backleg Health Service
As this committee is aware, we find ourselves in the situation of having
conce
a significant unmet need which has developed over past decades. Ne have
begun to make inroads into the present backlog of unmet needs and believe
that we will be making further substantial progress in reducing this back
log especially in view of our increased budgetary requests. For example,
in fiscal year 1974 a supplemental budget request of $6.6 million has been
made of which $3.4 million is specifically for the purpose of reducing
unmet needs. The President's budget for fiscal year 1974 represents
an increase of approximately $26 million dollars primarily for medical
services. These added funds, if appropriated, will be used to continue the
1974 program, to help overcome unmet medical needs of children and adults
-6--
and to provide for mandatory cost increase such as staffing for the Tuba
City (Arizona) hospital currently under construction. This we believe
is an orderly and realistic approach to the problem sonsistent with available
Federal and community resources.
S. 2938 proposes to accelerate the process of eliminating the backlog of
health service and Dealth facilities needs of the Indian people. This
Department is firmly committed to the principle of providing fully adequate
health care to these Americans in facilities which permit the delivery NE
quality health services and the right of self-determination of Indians and
therefore support the intent of this bill. While we endorse the principles
of the bill, we are unable to recommend enactment of several provisions and
would recommend modifications in other A I would now like to comment
specifically on the provisions of S. 2938 by Litle.
Title I H Indian Health Manpower
Title I of the bill would establish a scholarship program for training
qualified Indians in the fields of medicine, optometry, osteopathy, dentistry,
pharmacy, podiatry, public health, nursing and allied health professions.
the abjective at imcouraging
We support the need for special scholarship provisions to enable Indians
to enter these health fields. and an a means of ultimately securing the
necessary medical manpower to furnish the Indian people with adequate health
care The unique relationship of Indians to the Federal Government as
expressed in the Constitution, treaties and statutes, the goal of self
determination and the lessons of the last two hundred years, nym mandate
dorsn't
mandate
mything
like education
-7-
As the President stated in his July 1970 Indian Message there
is a need
"
to expand our efforts to train Indians for health
careers". The Bureau of Indian Affairs in the Department
of Interior already conducts a scholarship program that meets the
objectives of S. 2938 in this regard. Moreover, the Indian
Health Service provides training to health workers such as
community health aides and other paraprofessionals. In addition,
the Administration has already proposed broad scholarship
authority for the health professions in the proposed National
Health Service Corps Scholarship Amendments (S. 3290) which would
provide scholarships in return for service. We intend to use
that authority fully, giving special prefer ence to students from
disadvantaged background including Indian students.
-8-
Part C of title I would provide continuing Education allowances
for Indian Health Service physicians to leave their duty
stations annually for the purpose of professional consultation
and attendance at refresher training courses. The Public
Health Service Act already provides ample authority for paying
the expenses for physician consultations and training. In
addition, the authority of the PHS Act permits the paying of
expenses for refresher training and consultations of allied
profession health employees of the Service. Accordingly, part
C of Title I, is unnecessary and duplicative. We, therefore,
oppose the enactment of this part.
Title II - Health Services and Title III - Health Facilities
&
FORD
Titles II and III provide authorization levels for health
RALD
services and health facilities construction.
As you know, Mr. Chairman, the Indian Health Service currently
does not have any specific authorization levels with respect to
its activities. Moreover, in comparison to the levels in the
Presidents' budget the proposed authorization levels for these
activities are excessive and beyond those determined by the
Department to meet the essential health needs of Federally
recognized Indians in a responsible and orderly manner.
-9-
We have taken major steps to expand the health services
and facilities for Indians and Alaska Natives over the last
several years. We cannot, however, support excessive and
unnecessary authorization levels such as provided in these two
titles. The planned incremental increased support for
expanding Indian health services initiated in the FY 1974 and
FY 1975 budgets will increase the participation of these first
Americans in their health programs. We firmly resolve to
pursue this course of action because we believe it represents
the best possible path to the objective we both seek; Indian
self-determination.
Title IV - Access to Health Services
As I have indicated, Indians and Alaskan Natives are already
entitled to participate in Medicare and Medicaid and would be
entitled to benefit from CHIP on the same basis as other
citizens. The Department is taking the necessary steps to assure
that this right to participate is in all cases fully recognized
and honored.
Because of the isolated areas in which they live and other
reasons, many Indians and Alaskan Natives only have access to IHS
health care facilities. Presently, however, IHS facilities
are not eligible to participate under Medicare and Medicaid. The
Administration has proposed that free-standing clinics generally
be eligible for Medicare and Medicaid reimbursement. Title IV
would, provide for Medicare and Medicaid reimbursements for
-10-
health services provided in IHS facilities. We believe that
Indian participation in these health resources is a key
consideration in the achievement of the self-determination
policy. This policy holds to the principle that Indians will
eventually assume total responsibility for the planning and
operation of their health care delivery system. As this occurs
there should be a proven system in place for obtaining reimburse-
ment for the delivery of health services to persons who have
established eligibility for such services under the several
National and State-operated health resource programs. Since
time will be required to prove such a system, we should begin
now to work towards this end because some Indian groups have
already expressed a desire to assume control of their health
delivery system. Consequently, we support Title IV of S. 2938
requiring Medicare and Medicaid reimbursements for services
provided to eligible beneficiaries in IHS facilities. We
oppose, however, the provision contained in Title IV that would
attempt to prohibit consideration of reimbursements in determining
appropriation levels. We believe--particularly with the advent of
comprehensive health insurance--that the Appropriations Committees
of the Congress should be able to consider receipts available to
the IHS facilities in determining overall funding requirements.
It should be stressed, however, that this provision will in no way
interfere with or diminish the health services now provided by
IHS.
-11-
Title V - Access to Health Care for Urban Indians
Title V would establish outreach programs in urban areas to
make available health services more accessible to the urban
Indian population.
We oppose a statutory enlargement of Indian Health Service
responsibilities to include urban Indians. While the
Department has supported such activities on a limited basis
through the Native Affairs Program and through the Indian
Health Service, we believe that primary reliance for social services
for urban Indians, including health services, should be on the
existing State and local social services agencies which the
&
FORD
Federal Government already supports.
ERALD
Therefore, we oppose the concept of a categorical program to
fund Indian organizations in urban areas to develop Indian
programs to interface with health services in place in these
areas. Instead, we intend to work with existing social service
agencies to assure that urban Indians are an important outreach
target as part of the ongoing activities of those agencies.
Title VI - Miscellaneous
Title VI, the last title of the bill would establish a report
requirement for the Secretary of this Department. We view such a
requirement as unnecessary. Our experience has been that
appropriations and oversight hearings by the Congress during
its regular deliberations on substantive legislation and on
appropriation requests are much more effective and informative
than lengthy reports.
-12-
General
Titles I, II, III and V of the bill provides for specific
appropriation authorizations, adding $1 billion over a
five-year period to existing program levels and commitments.
We cannot support the excessive authorizations in S. 2938. We
favor retaining the open ended appropriation authorization
contained in the Snyder Act (25 U.S.C. 13) and Public Law 568
of the 83rd Congress, as amended, the so called Indian Health
Service Transfer Act.
Conclusion
In conclusion, Mr. Chairman, I would like t, stress that we
share a common objective of better health care for Indians
and wish to assure the Committee that the Department will
continue its pursuit of this goal. Just recently, I had the
opportunity to visit a number of IHS facilities in Arizona and
New Mexico. That trip reinforced my personal conviction that
a
the Indian people do indeed present both/tremendous challenge
and a real achievement with respect to our National capacity
to provide high quality health services when and where they are
needed. I think we can meet this challenge.
Nevertheless, we believe that the Department can accomplish that
common objective without legislation such as S. 2938 for the
reasons I have stated.
Mr. Chairman, that concludes my statement. My colleagues and I
would be pleased to try to answer any questions you or
members of the Committee may have.
REVISED
Mr. Chairman, I am pleased to have this opportunity to appear before you
today to discuss S. 2938, the Indian Health Care Improvement Act. This bill
provides specific authorizations for Indian Health manpower, Health Services,
Health Facilities construction and renovation, Access to Health Services for
reservation Indians, Access to Health Services for Urban Indians and a
requirement for the Secretary to report to the President and the Congress
on progress made in effecting the purposes of the Act.
This Administration is committed to a program of Indian Self-Determination,
to expanded efforts to train Indians for health careers, and to a strength-
ened Federal effort to advance the health of these first Americans. These
commitments were related to the Congress in the President's Special Indian
Message of July 8, 1970.
This Department has the central responsibility of translating this policy
into programs particularly in the area of health. We are secking to
advance the health status of these Americans in a variety of ways.
ACRD
Health Care Options
First, Indian people and Alaska Natives, as American citizens, may partici-
pate in the health programs administered by the Department on the same
basis as any other citizen. We are attempting to assure that they are
aware of the broad health benefits offered through these programs, particu-
larly the benefits under Medicaid and Medicare. These programs represent
a significant health resource for the Indian people and we are attempting
to ensure that the Indian population take advantage of these benefits to
the extent possible.
--2-
Two months ago, the Administration sent to Congress the Comprehensive
Health Insurance Act (CHIP). CHIP will make catastrophic comprehensive
health insurance available to Indians and Alaska Natives without in any
way diminishing or affecting the health care now being provided Indian
people through the Indian Health Service (IHS). Thus this proposal should
be considered as a supplement to presently available health services.
As with any other American, the status of Indians and Alaska Natives under
CHIP will be determined by the choice or circumstance of the individual.
Those who are full-time employees will have the choice of enrolling under
the Employee Health Insurance Plan (EHIP), or if it is economically
advantageous, in the Assisted Health Insurance Plan (AHIP), which will
require less in cost sharing charges. Of course, those who are 65 or older
eligible to receive Medicare will have the option of enrolling in the Medi-
care plan which also will have reduced cost sharing charges.
We recognize that because of the geographical isolation of many Alaska
Natives and Indians and the cost sharing charges under CHIP, their choice
will in fact often be limited to the IHS facilities in their vicinity. How-
ever, for those within commuting distance of private facilities and practi-
tioners, the EHIP, AHIP and Medicare plans under CHIP will provide an
alternative to the IHS facilities.
Indians and Alaska Natives who elect to enroll in any of the three plans
under CHIP will receive a healthcard which will be honored for services at
virtually all non-Federal health facilities and by virtually all private
practitioners. They will also be subject to the same cost sharing and
premiums as all other enrollees under the plans.
-3-
In addition to these other health resources being available to Indians
and Alaska Natives, the Indian Health Service budget to provide health care
services has grown from $84.3 million in 1968 to $200.3 million in 1974.
The President's budget for 1975 requests a further increase to $226.0
million.
These increases are significant because they bring real benefits in terms
of people served. They will help us meet the rapidly growing demand for
health services on the part of the Indian people--a demand that is growing
because of their increasing confidence in modern health practices, based
on positive experiences.
For example, Indian Health Service facilities expect to receive an additional
100,000 outpatient visits in 1974, and another 100,000 in 1975, over and
above the 2.3 million visits experienced in 1973. Also, this expected
increase of funds will enable us to cut into the huge backlog of unmet
needs--for surgery and other kinds of care--which built up in past decades.
Good health facilities are crucial to the delivery of high-quality health
services to Indians. The fiscal year 1974 and 1975 Indian Health Service
budgets recognize this and provide for further orderly and realistic progress
in the necessarily long-range effort to replace or remodel outmoded Indian
Health Service hospitals and other facilities, and to upgrade others.
The FY 1974 construction program contained funds for replacing the old and
obsolete health facilities at Zuni, New Mexico; Owyhee, Nevada and Choctaw,
Mississippi. A replacement hospital at Tuba City, Arizona will be completed
in fiscal year 1975. Funds are also available to plan a replacement
-4-
health facility at Dethel, Alaska, and planning funds for the new Chemawa,
Oregon School Health Center are also contained in FY 1974's construction
program. The FY 1975 President's budget would provide construction funds
for the replacement health facility at Claremore, Oklahoma, and to replace
the school health center at Riverside, California. Funds to construct a
small addition to the existing health center at Tohatchi, New Mexico and to
construct 207 units of housing at Tuba City, Arizona are also contained in
the FY 1975 program.
The fiscal years 1974 and 1975 budgets also will provide for meaningful
inroads against the problems inherent in the rigorous environment which
characterize Indian country, and which contribute to isease, suffering and
premature death. Fiscal year 1974 funds of $36.2 million will enable us to
provide sanitation facilities construction, including water and waste
disposal systems, for an additional 8,500 new and improved homes, and
approximately 3,500 existing homes during that year. An additional 8,000
new and improved homes, and an additional 4,900 existing homes will be so
served through the fiscal year 1975 budget of $40.5 million. These budgets
and numbers of homes served stand out in sharp contrast to the fiscal year
1968 when the budget was $10.5 million and the number of homes served was
only 7,350.
In addition to the health care provided by the Indian Health Service in its
own facilities and through contract health care, other Public Health Service
agencies are contributing more than $11 million in 1975 for a broad range
of services.
I believe the FY 1975 budget demonstrates our commitment to better Indian
health care and represents real progress toward our mutual goal.
-5-
Measures of Success of Present Programs
The true measure of our Indian health efforts is found in the health status
of the Indian people. The impact has been both profound and enduring. It
can be illustrated by the dramatic reduction of Indian death rates between
1955 and 1972. The infant death rate has declined 67 percent; the tubercu-
losis rate is down 85 percent; the gastritis and related diseases rate has
dropped 81 percent; and the rate for influenza and pneumonia is down 58
percent.
These figures represent firm evidence that the Administration's decision to
place high priority on investing in health services for Indian people has
been a wise one, and that the methods it has employed to deliver services
have been effective.
Backlog of Health Service
As this committee is aware, we find ourselves in the situation of having
a significant unmet need which has developed over past decades. We have
begun to make inroads into the present backlog of unmet needs and believe
that we will be making further substantial progress in reducing this back-
log especially in view of our increased budgetary requests. For example,
in fiscal year 1974 a supplemental budget request of $6.6 million has been
made of which $3.4 million is specifically for the purpose of reducing
unmet needs. The President's budget for fiscal year 1974 represents
an increase of approximately $26 million dollars primarily for medical
services. These added funds, if appropriated, will be used to continue the
1974 program, to help overcome unmet medical needs of children and adults
-6-
and to provide for mandatory cost increase such as staffing for the Tuba
City (Arizona) hospital, currently under construction. This we believe
is an orderly and realistic approach to the problem consistent with available
Federal and community resources.
S. 2938 proposes to accelerate the process of eliminating the backlog of
health service and health facilities needs of the Indian people. This
Department is firmly committed to the principle of providing fully adequate
health care to these Americans in facilities which permit the delivery of
quality health services and the right of self-determination of Indians and
therefore support the intent of this bill. While we endorse the principles
of the bill, we are unable to recommend enactment of several provisions and
would recommend modifications in other sections. I would now like to comment
specifically on the provisions of S. 2938 by title.
Title I - Indian Health Manpower
Title I of the bill would establish a scholarship program for training
qualified Indians in the fields of medicine, optometry, osteopathy, dentistry,
pharmacy, podiatry, public health, nursing and allied health professions.
We support the need for special scholarship provisions to enable Indians
to enter these health fields and as a means of ultimately securing the
necessary medical manpower to furnish the Indian people with adequate health
care. The unique relationship of Indians to the Federal Government as
expressed in the Constitution, treaties and statutes, the goal of self-
determination and the lessons of the last two hundred years, mandate
-7-
particularized legislation in this regard. As the President stated in his
July 1970 Indian Message there is a need If
to expand our efforts to
train Indians for health careers". We therefore support this aspect of the
legislation in principle. We do, however, wish to point out that the Adminis-
tration is now in the final stages of developing an overall health manpower
program. In this regard, we believe that the legislation under consideration
today should be consistent with our forthcoming manpower legislation and
would like to work with the committee toward achieving compatibility between
this bill and the Administration proposal.
Because the Administration's program will give sufficient priority to pro-
viding service to the Indian populations, we therefor believe it is
unnecessary under this bill to provide for scholarships for persons other
than Indians and Alaskan Natives. We also would recommend that the penalty
provision for default on an obligation be significantly strengthened in
order for the bill to be more effective in achieving the goal of service
to Indians by Indians.
Further we would recommend that the preparatory scholarships be recast as
preadmission scholarships to more accurately reflect what we believe is
the intent of this provision. This section should be available to those
Indians and Alaskan Natives who have demonstrated that they have the aptitude
to successfully gain admission for graduate study in schools of medicine,
dentistry and osteopathy. The scholarship provision should thus be
specifically directed toward assistance in gaining this type of graduate
level training.
-8-
Part C of title I addresses the need for physicians to leave their duty
stations annually for the purpose of professional consultation and attend-
ance at refresher training courses. The rapid expansion of knowledge
brought about by new discoveries in the health sciences makes such consult-
ation and training mandatory if this knowledge is to be used for the benefit
of patients. The Public Health Service Act, one of the legislative author-
ities under which the Indian Health Service operates, contains ample authority
for paying the expenses for physician consultations and training. In addi-
tion, the authority of the PHS Act permits the paying of expenses for refresher
training and consultations of allied profession health employees of the
Service. Accordingly, we feel that part C of Title i is directed more
toward the solving of a budget and management problem than the provision of
new authority. We, therefore, oppose the enactment of this part.
Title II - Health Services and Title III - Health Facilities
Titles II and III set out a program with respect to Health Services and
Health Facilities. These two titles address the budgetary need to eliminate
the backlog of health services, the need for modern facilities for health
care and the need for safe domestic water supplies and sanitary waste treat-
ment facilities for Indian homes and communities. Authorizations are pro-
vided each section and part of these proposed titles.
Neither of these titles provide additional authority to eliminate the backlogs
of need for services and facilities. If appropriations are not made con-
sistent with the proposed funding authorizations, the result would be a rais-
ing of expectations of the Indian people beyond that which would be realized.
-9-
As you know, Mr. Chairman, our Nation is confronted with a great number of
critical priority needs. We in the Administration and you in the Congress
must address each of these crucial needs with reasoned, responsible actions.
While we agree that the health service and facility needs of the Indian
people are of great importance, I think that you would also agree that other
needs of our Nation may be of equal or greater significance. While we are
committed to strengthened Federal effort to expand the health services for
Indians and Alaska Natives, we cannot support an accelerated program such
as provided in these two titles. The planned incremental increased support
for expanding Indian health services initiated in the FY 1974 and FY 1975
budgets will increase the participation of these first Americans in their
health programs. We firmly resolve to pursue this course of action because
we believe it represents the best possible path to the objective we both
seek; Indian self-determination.
EERALD FORD
Title IV - Access to Health Services
As I have indicated, Indians and Alaskan Natives are entitled to participate
in Medicare and Medicaid on the same basis as other citizens. And the Depart-
ment is taking the necessary steps to assure that this right to participate
is in all cases fully recognized and honored.
Because of the isolated areas in which they live and other reasons, many
Indians and Alaskan Natives only have access to IHS health care facilities.
Presently, however, IHS facilities are not eligible to participate under Medi-
care and Medicaid. This title, however, provides for the direct participation
of Medicare and Medicaid in meeting the health care needs of those people who
only have access to IHS facilities. We believe that Indian participation in
-10-
these health resources is a key consideration in the achievement of the
Self-determination Policy. This policy holds to the principle that Indians
will eventually assume total responsibility for the planning and operation
of their health care delivery system. As this occurs there should be a
proven system in place for obtaining reimbursement for the delivery of
health services to persons who have established eligibility for such ser-
vices under the several National and State-operated health resource programs.
Since time will be required to prove such a system, we should begin now to
work towards this end because some Indian groups have already expressed a
desire to assume control of their health delivery system. Consequently,
we endorse the concept embodied in this title. It should be stressed,
however, that this provision will in no way interfere with or diminish the
R.
FORD
health services now provided by IHS.
GERALD
Title V - Access to Health Care for Urban Indians
This title proposes to establish outreach programs in urban areas to make
available health services more accessible to the urban Indian population.
The statutes under which we now operate provide ample authority for IHS to
assist in the development of outreach programs for Indians in urban areas.
In fact, we have to date provided developmental funds to Indian organiza-
tions in four urban areas for this purpose. This effort will be expanded
this year so that we will be providing this assistance in a total of 9 or 10
urban centers.
Therefore, we strongly support the concept of aiding Indian organizations in
urban areas to develop Indian programs to interface with health services in
place in these areas. Title V, however, would simply duplicate existing
authority and is therefore unnecessary.
-11-
Title VI - Miscellaneous
Title VI, the last title of the bill would establish a report requirement
for the Secretary of this Department. We view such a requirement as appro-
priate and one which could be valuable to the Congress during its delibera-
tions on substantive legislation as well as on appropriation requests.
General
Titles I, II, III and V of the bill provide for specific appropriation
authorizations. The authorizations provided in S. 2938 would limit the
existing authorities both in terms of amounts and time. Therefore, we would
recommend amending the bill to delete the authorizations in favor of clearly
retaining the open ended appropriation authorization contained in the
Snyder Act (25 U.S.C. 13) and Public Law 568 of the 83rd Congress, as
amended, the so called Indian Health Service Transfer Act.
Conclusion
In conclusion, Mr. Chairman, I would like to stress that we share a common
objective of better health care for Indians and wish to assure the Committee
that the Department will continue its pursuit of this goal. Just recently,
I had the opportunity to visit a number of IIIS facilities in Arizona and
New Mexico. That trip reinforced my personal conviction that the Indian
people do indeed present a tremendous challenge to our National capacity
to provide high quality health service when and where they are needed. I
think we can meet this challenge.
-12-
I know of this Committee's similar convictions and I would like to emphasize
that I stand ready to work as closely as possible with the Committee in
improving health care for Indian people. Although the Department does not
totally support S. 2938, I wholeheartedly endorse the objective sought by
the bill and applaud the motivation behind it. I certainly look forward to
working with this Committee on this very urgent matter.
Mr. Chairman, that concludes my statement. My colleagues and I would be
pleased to try to answer any questions you or members of the Committee may
have.
93D CONGRESS
2D SESSION
S. 2938
IN THE SENATE OF THE UNITED STATES
FEBRUARY 1, 1974
Mr. JACKSON (for himself, Mr. BARTLETT, Mr. FANNIN, Mr. HASKELL, and Mr.
METCALF) introduced the following bill; which was read twice and referred
to the Committee on Interior and Insular Affairs
A
BILL
To implement the Federal responsibility for the care and educa-
tion of the Indian people by improving the services and
facilities of Federal Indian health programs and encouraging
FORD & LIBRARY GRAVED
maximum participation of Indians in such programs, and for
other purposes.
1
Be it enacted by the Senate and House of Representa-
2 tives of the United States of America in Congress assembled,
3 That this Act may be cited as the "Indian Health Care
4 Improvement Act".
5
FINDINGS
6
SEC. 2. The Congress finds that-
7
(a) Federal Indian health services to maintain and im-
8
prove the health of the Indians are consonant with and re-
II
2
3
1 quired by the Federal Government's historical and unique
1
(1) inadequate, outdated, inefficient, and under-
2 legal relationship with, and resulting responsibility to, the
2
manned facilities. For example, only twenty-one of fifty-
3 America Indian people.
3
one Indian Health Service hospitals are accredited; only
4
(b) A major national goal of the United States is to
4
twelve meet national fire and safety codes; and fifty-
5 provide the quantity and quality of health services which
5
seven areas with Indian populations have been identified
6 will permit the health status of Indians to be raised to the
6
as requiring either new or replacement health centers
7 highest possible level and to encourage the maximum par-
7
and stations, or clinics remodeled for improved or addi-
8 ticipation of Indians in the planning and management of
8
tional service;
9 those services.
9
(2) shortage of personnel. For example, about two-
10
(c) Federal health services to Indians have resulted in
10
thirds of the Service hospitals, four-fifths of Service hos-
11 a reduced prevalence and incidence of preventable illnesses
11
pital outpatient clinics, and one-half of the Service health
12 and unnecessary and premature deaths among Indians.
12
clinics meet only 80 per centum of staffing standards
13
(d) Despite such services, the unmet health needs of
13
for their respective services;
14 the American Indian people are severe and the health
14
(3) insufficient services in such areas as laboratory,
15 status of Indians is far below that of the general population
15
hospital inpatient and outpatient, eye care and mental
16 of the United States. Illustratively, for Indians compared to
16
health services, and services available through contracts
17 all Americans in 1971, the tuberculosis death rate was over
17
with private physicians, clinics, and agencies. For ex-
18 four and one-half times greater, the influenza and pneumonia
18
ample, about 82 per centum of the surgical operations
19 death rate over one and one-half times greater, and the
19
needed for otitis medai are unperformed, over 57 per
20 infant death rate about 20 per centum greater.
20
centum of required dental services have not been pro-
21
(e) All other Federal services and programs in fulfill-
21
vided, and about 98 per centum of the need for hearing
22 ment of the Federal responsibility to Indians are jeopardized
22
aids is unmet;
23 by the low health status of the American Indian people.
23
(4) related support factors. For example, over seven
24
(f) Further improvement in Indian health is imperiled
24
hundred housing units are needed for staff at remote
25 by-
25
Service facilities;
5
4
1
(5) lack of access of Indians to health services due
1
(a) "Indian", unless otherwise designated, means a
2
to remote residences, undeveloped or underdeveloped
2 person who is a member of an Indian tribe.
3
communication and transportation systems, and difficult,
3
(b) "Indian tribe" means any Indian tribe, band, na-
4
sometimes severe, climatic conditions; and
4 tion, or other. organized group or community, including any
5
(6) lack of safe water and sanitary waste disposal
5 Alaska Native community as defined in the Alaska Native
6
services. For example, over forty thousand existing, and
6 Claims Settlement Aot (85 Stat. 688), which is recognized
sixty-two thousand planned replacement and renovated,
7 as eligible for the special programs and services provided
7
Indian housing units need new or upgraded water and
8 by the United States to Indians because of their status as
8
sanitation facilities.
9 Indians.
9
(g) The Indian people's growing confidence in Federal
10
(c) "Secretary", unless otherwise designated, means the
10
11 Indian health services is revealed by their, increasingly heavy
11 Secretary of Health, Education, and Welfare.
12 use of such services. Progress toward the goal of better In-
12
(d) "Service", unless otherwise designated, means the
13 dian health is dependent on this continued growth of con-
13 Indian Health Service.
14
TITLE I-INDIAN HEALTH MANPOWER
14 fidence. Both such progress and such confidence are de-
15 pendent on improved Federal Indian health services.
15
SEC. 101. The purpose of this title is to augment the
DECLARATION OF POLICY
16 inadequate number of health professionals serving Indians
16
17
SEC. 3. The Congress hereby declares that it is the
17 and remove the multiple barriers to the entrance of health
18 policy of this Nation, in fulfillment of its special responsi-
18 professionals into the Service and private practice among
19 bilities and legal obligation to the American Indian people,
19 Indians.
20 to meet the national goal of providing the highest possible
20
PART A-HEALTH PROFESSIONS SCHOLARSHIP
21
PROGRAM
21 health status to Indians and to provide existing Indian
22 health services with all resources necessary to effect that
22
SEC. 102. (a) The Secretary shall, in accordance with
23 policy.
23 the provisions of this title, make scholarship grants to indi-
24
DEFINITIONS
24 viduals (i) who are enrolled in medical schools; schools of
25
SEC. 4. For purposes of this Act-
25 optometry, osteopathy, dentistry, pharmacy, podiatry, pub-
6
7
1 lic health, or nursing; or schools licensed by a State to train
1
ment of the condition for scholarship assistance provided
2 persons in the allied health professions and (ii) who agree
2
in paragraph 1, and
3 to provide their professional services to Indians after com-
3
(B) the reasonable period of time said condition
4 pletion of their professional training.
4
must be complied with by such individual.
5
(b) (1) The Secretary shall, in awarding scholarship
5
(3) If any individual to whom the condition referred
6 grants under this part, accord priority to applicants as fol-
6 to in paragraph (1) is applicable fails, within the period
7 lows-
7 prescribed pursuant to regulations under paragraph (2), to
8
(A) first, to any qualified applicant who is a mem-
8 comply with such condition for the full period, the United
9
ber of an Indian tribe and resides on an Indian reser-
9 States shall be entitled to recover from such individual an
10
vation;
10 amount equal to the amount produced by multiplying-
11
(B) second, to any qualified applicant who is a
11
(A) the aggregate of (i) the amounts of the
12
member of an Indian tribe and resides in a place other
12
scholarship grant or grants (as the case may be) made
13
than an Indian reservation;
13
to such individual under this part, and (ii) the sums of
14
(C) third, to any other qualified applicant.
14
the interest which would be payable on each such schol-
15
(2) Scholarship grants under this title shall be made
15
arship grant if, at the time such grant was made, such
16
with respect to academic years.
16
grant were a loan bearing interest at a rate fixed by the
17
GERALD FORD LIBRAN
(c) (1) Any scholarship grant awarded to any indi-
17
Secretary of the Treasury, after taking into consideration
18 vidual under this title shall be awarded under the condition
18
private consumer rates of interest prevailing at the time
19 that such individual will, after the completion of his profes-
19
such grant was made, and if the interest on each such
20 sional training, provide his professional services to Indians.
20
grant had been compounded annually, by
21
(2) The Secretary shall prescribe by regulations
21
(B) a fraction the numerator of which is the num-
22
(A) the criteria for determining when an individual
22
ber obtained by subtracting from the number of months
23
is providing professional services to Indians in fulfill-
23
to which such condition is applicable a number equal
24
to one-half of the number of months with respect to
8
9
1
which compliance by such individual with such condi-
1
SEC. 103. The Secretary may enter into agreements with
2
tion was made, and the denominator of which is a num-
2 any schools referred to in section 102 (a), hospitals, or appro-
3
ber equal to the number of months with respect to
3 priate public or private agencies under which such schools,
4
which such condition is applicable.
4 hospitals, or other agencies will, as agents of the Secretary,
5 Any amount which the United States is entitled to recover
5 perform such functions in the administration of this part,
6 under this paragraph shall, within the three-year period
6 as the Secretary may specify. Any such agreement with any
7 beginning on the date the United States becomes entitled
7 such school, hospital, or agency may provide for payment
8 to recover such amount, be paid to the United States. Until
8 by the Secretary of amounts equal to the expenses actually
9 any amount due the United States under this paragraph on
9 and necessarily incurred by such school, hospital, or agency
10 account of any grant under this part is paid, there shall
10 in carrying out such agreement.
11 accrue to the United States interest on such amount at the
11
SEC. 104. There are authorized to be appropriated for
12 same rate as that fixed by the Secretary of the Treasury
12 the purpose of this part $8,000,000 for fiscal year 1975,
13 pursuant to clause (A) with respect to the grant on account
13 $16,000,000 for fiscal year 1976, $22,000,000 for fiscal
14 of which such amount is due the United States.
14 year 1977, $30,000,000 for fiscal year 1978, and $34,000,-
15
(4) (A) Any obligation of any individual to comply
15 000 for fiscal year 1979, and, for each succeeding fiscal year,
16 with the condition applicable to him under the preceding
16 such sums as may be necessary to continue to make such
17 provisions of this subsection shall be canceled upon the death
17 grants to individuals who (prior to July 1, 1979) have re-
18 of such individual.
18 reived such grants and who are eligible for such grants under
19
(B) The Secretary shall by regulations provide for the
19 this part during such succeeding fiscal year.
20 waiver or suspension of any such obligation applicable to
20
PART B-HEALTH PROFESSIONS PREPARATORY
21 any individual whenever compliance by such individual is
21
SCHOLARSHIP PROGRAM
22 impossible or would involve extreme hardship to such indi-
22
SEC. 105. (a) The Secretary shall, in accordance with
23 vidual and if enforcement of such obligation with respect
23 the provisions of this part, make scholarship grants to In-
24 to any individual would be against equity and good con-
24 dians who-
25 science.
S. 2938-2
(d)
10
11
1
(1) have successfully completed their high school
1 purpose of this section $350,000 for fiscal year 1975, $350,-
2
education; and
2 000 for fiscal year 1976, $375,000 for fiscal year 1977,
3
(2) have demonstrated an aptitude for being capa-
3 $390,000 for fiscal year 1978, and $410,000 for fiscal year
4
ble of successfully completing a premedical, predental,
4 1979.
5
or preosteopathy course of study.
5
TITLE II-HEALTH SERVICES
6
(b) A scholarship grant made under this part shall be
6
SEC. 201. (a) For the purpose of eliminating back-
7 for a period not to exceed two academic years.
7 logs in Indian health care services and to supply known,
8
(c) A scholarship grant made under this part may
8 unmet medical, surgical, dental, and other Indian health
9 cover costs of tuition, books, transportation, board, and
9 needs, the Secretary is authorized to expend, through the
10 other necessary related expenses.
10 Service, $123,500,000 over a five-fiscal-year period in ac-
11
(d) There are authorized to be appropriated for the
11 cordance with the schedule provided in subsection (c) As
12 purpose of this part $1,000,000 for fiscal year 1975;
12 such funds which are appropriated pursuant to this Act are
13 $2,000,000 for fiscal year 1976; $3,000,000 for fiscal year
13 to eliminate health services backlogs, they shall not be used
14 1977; $3,000,000 for fiscal year 1978; and $3,000,000
14 to offset or limit the appropriations required by the Service to
15 for fiscal year 1979.
15 continue to serve the health needs of Indian people during
16
PART C-CONTINUING EDUCATION ALLOWANCES
16 and subsequent to such five-fiscal-year period but shall be in
17
SEC. 106. (a) In order to encourage professionals to
17 addition to the annual appropriations required to continue
18 join the Service and to provide their services in the rural and
18 the health service program to the Indian people.
19 remote areas where a significant portion of the American
19
(b) The Secretary is also authorized to employ persons
20 Indian people reside, the Secretary may provide allowances
20 to implement the provisions of this section during the five-
21 to Service physicians to enable them for a period of time
21 fiscal-year period in accordance with the schedule provided
22 each year prescribed by regulation of the Secretary to take
22 in subsection (c) 0 Such persons shall be in addition to, and
23 leave of their duty stations for professional consultation and
23 shall not reduce the number of, the employees required to
24 refresher training courses.
24 conduct ongoing activities of the Service during and sub-
25
(b) There are authorized to be appropriated for the
25 sequent to such period.
12
13
1
(c) The following amounts and positions are author-
1
(4) Maintenance and repair (direct and indirect) :
2 ized, by fiscal year, for the specific purposes noted:
2
for fiscal year 1975, $6,000,000 and thirty positions;
3
(1) Patient care (direct and indirect) : for fiscal
3
for fiscal year 1976, $4,000,000 and thirty positions;
4
year 1975, $11,000,000 and two hundred and forty posi-
4
for fiscal year 1977, $4,000,000 and thirty positions; for
5
tions; for fiscal year 1976, $17,000,000 and five hundred
5
fiscal year 1978, $4,000,000 and thirty positions; and
6
and forty positions; for fiscal year 1977, $14,000,000
6
for fiscal year 1979, $3,000,000 and thirty positions.
7
and four hundred and ten positions; for fiscal year 1978,
7
TITLE III-HEALTH FACILITIES
8
$9,000,000 and five hundred positions; and for fiscal
8 PART A-CONSTRUCTION AND RENOVATION OF SERVICE
9
year 1979, $7,000,000 and four hundred and ninety
9
FACILITIES
10
positions;
10
SEC. 301. For the purpose of eliminating inadequate,
11
(2) Field health, excluding dental care (direct and
11 outdated, and otherwise unsatisfactory Service hospitals,
12
indirect) : for fiscal year 1975, $12,000,000 and three
12 health centers, health stations, and other Service facilities,
13
hundred positions; for fiscal year 1976, $10,000,000 and
13 the Secretary is authorized to expend $400,000,000 over a
14
two hundred twenty-five positions; for fiscal year 1977,
14 five-fiscal-year period in accordance with the following
15
$7,000,000 and two hundred positions; for fiscal year
15 schedule:
16
1978, $7,000,000 and two hundred positions; and for
16
(a) Hospitals: for fiscal year 1975, $40,000,000;
17
fiscal year 1979, $5,000,000 and one hundred positions;
17
for fiscal year 1976, $76,000,000; for fiscal year 1977,
18
(3) Dental care (direct and indirect) : for fiscal
18
$65,000,000; for fiscal year 1978, $55,000,000; and for
19
year 1975, $900,000 and sixty positions; for fiscal year
19
fiscal year 1979, $80,000,000.
20
1976, $700,000 and seventy-five positions; for fiscal
20
(b) Health centers and health stations: for fiscal
21
year 1977, $700,000 and seventy-five positions; for
21
year 1975, $4,000,000; for fiscal year 1976, $6,000,000;
22
fiscal year 1978, $600,000 and seventy-five positions;
22
for fiscal year 1977, $2,000,000; for fiscal year 1978,
23
and for fiscal year 1979, $600,000 and sixty positions;
23
$2,000,000; and for fiscal year 1979, $11,000,000.
24
and
24
(c) Staff housing: for fiscal year 1975, $13,-
14
15
1
000,000; for fiscal year 1976, $21,000,000; for fiscal
1 000,000 in fiscal year 1975; $95,000,000 in fiscal year
2
year 1977, $16,000,000; for fiscal year 1978, $5,-
2 1976; $95,000,000 in fiscal year 1977; $95,000,000 in fiscal
3
000,000; and for fiscal year 1979, $4,000,000.
3 year 1978; and $95,000,000 in fiscal year 1979.
4
SEC. 302. The Secretary is authorized to equip and staff
4
(c) The Secretary is authorized and directed to develop
5 such Service facilities at levels commensurate with their op-
5 a plan, together with the Secretaries of Housing and Urban
6 eration at optimum levels of effectiveness.
6 Development and the Interior, to assure that the schedule
7
SEC. 303. For the purpose of implementing the provi-
7 provided for in subsection (b) will be met. Such plan shall
8 sions of this part, the Secretary shall assure that the rates of
8 be submitted to the Congress no later than ninety days from
9 pay for personnel engaged in the construction or renovation
9 the date of enactment of this Act.
10 of facilities constructed or carried out in whole or in part by
10
TITLE IV-ACCESS TO HEALTH SERVICES
11 funds made available pursuant to this part are not less than
11
SEC. 401. (a) Notwithstanding any other provision of
12 the prevailing local wage rates for similar work as deter-
12 law, for the purpose of title XVIII of the Social Security
13 mined in accordance with the Act of March 3, 1921 (46
13 Act, as amended, the Service facilities used to provide health
14 Stat. 1491), as amended.
14 care and services to Indians are hereby deemed to be
15 PART B-CONSTRUCTION OF SAFE WATER AND SANITARY
15 accredited facilities, the services so provided shall be deemed
16
WASTE DISPOSAL FACILITIES
16 to be provided by licensed practitioners in their respective
17
SEC. 304. (a) For the purpose of reducing health haz-
17 fields, and the facilities may receive payment for such serv-
18 ards, the Secretary is authorized to expend, pursuant to Pub-
18 ices on the same basis as other providers of service.
19 lic Law 86-121, $470,000,000 within a five-fiscal-year pe-
19
(b) The Secretary shall undertake to improve and main-
20 riod following the enactment of this Act, in accordance with
20 tain such Service facilities such that they will, at a minimum,
21 the schedule provided in subsection (b), to supply unmet
21 meet the accreditation standards imposed on other providers
22 needs for safe water and sanitary waste disposal facilities in
22 of service.
23 existing and new Indian homes and communities.
23
(c) Any payments received for services provided to
24
(b) The following amounts are authorized, by fiscal
24 beneficiaries hereunder shall be credited to the appropriation
25 year, for the purpose prescribed in subsection (a) : $90,-
25 charged for the actual provision of care and services and shall
16
17
1 not be considered in determining appropriations for health
1 tions for the provision of health care and services to Indians.
2 care and services to Indians.
2
(e) Nothing in this section shall authorize the Secre-
3
(d) Nothing herein authorizes the Secretary to provide
3
tary to provide services to an Indian beneficiary with cover-
4 services to an Indian beneficiary with coverage under title
4 age under title XIX of the Social Security Act, as amended,
5 XVIII of the Social Security Act, as amended, in preference
5 in preference to an Indian beneficiary without such coverage.
6 to an Indian beneficiary without such coverage.
6
TITLE V-ACCESS TO HEALTH SERVICES FOR
7
SEC. 402. (a) Notwithstanding any other provision of
7
URBAN INDIANS
8 law, for the purpose of title XIX of the Social Security Act,
8
SEC. 501. The purpose of this title is to encourage the
9 as amended, the Service facilities used to provide health care
9 establishment of outreach programs in urban areas to make
10 and services to Indians are hereby deemed to be accredited
10 health services more accessible to the urban Indian
11 facilities and the services SO provided in these facilities are
11 population.
12 deemed to be provided by licensed practitioners in their
12
SEC. 502. For the purpose of this title-
13 respective fields.
13
(a) "Urban Indian" means any individual who resides
14
(b) The Secretary is authorized to enter into agreements
14 in an urban center and who is (i) an Indian as defined in
15 with the appropriate State agency for the purpose of receiv-
15 section 4 (a) of this Act or (ii) a person of Indian descent
16 ing reimbursement for health care and services provided to
16 who is considered ineligible for the special programs and
17 Indians who are beneficiaries under title XIX of the Social
17 services of the Service and the Bureau of Indian Affairs and
18 Security Act, as amended.
18 who, in accordance with regulations promulgated by the
19
(c) The Secretary shall undertake to improve such fa-
19 Secretary which take into consideration such person's health
20 cilities such that they will meet or exceed any applicable
20 needs, lack of access to health services, and other relevant
21 accredited standard.
21 factors, is identified as an appropriate recipient of assistance
22
(d) Any payments received for services provided bene-
22 from an urban Indian organization in accordance with the
23 ficiaries hereunder shall be credited to the appropriation
23 provisions of this title.
24 charged for the actual provision of care and services, which
24
(b) An "urban Indian organization" is a nonprofit
25 amount shall not be considered in determining appropria-
25 corporate body situated in an urban center, composed of
18
19
1 urban Indians, and providing the maximum participation
1 urban Indian organization pursuant to this title. Such con-
2 of all interested Indian groups, which body is capable of
2 ditions shall include, but are not limited to, requirements that
3 legally cooperating with other bodies, Federal, State, and
3 the organization successfully undertake the following tasks:
4 local, for the purpose of performing the activities described
4
(1) determine, in accordance with the regulations
5 in section 503 (c)
5
promulgated pursuant to section 502 (a), the popula-
6
(c) An "urban center" is any community which has
6
tion of urban Indians which are or could be recipients
7 a sufficient urban Indian population with unmet health needs
7
of such services;
8 to warrant assistance under this title, as determined by the
8
(2) identify all public and private health service
9 Secretary.
9
resources within the urban center in which the organiza-
10
SEC. 503. (a) The Secretary shall enter into contracts
10
tion is situated which are or may be available to urban
11 with urban Indian organizations to provide Federal assistance
11
Indians;
12 to such organizations for the purpose of establishing and
12
(3) assist such resources in providing service to such
13 administering outreach programs to make urban Indians
13
urban Indians;
14 in the urban centers in which such organizations are situated
14
(4) assist such urban Indians in becoming familiar
15 knowledgeable of the health service resources available within
15
with and utilizing such resources;
16 such centers and the means of gaining access to those
16
(5) provide basic health education to such urban
17 resources.
17
Indians;
18
(b) Urban Indian organizations shall make use of
18
(6) identify gaps between unmet health needs of
19 Federal assistance provided by contracts pursuant to this
19
urban Indians and the resources available to meet such
20 title not to provide health services to urban Indians but to
20
needs; and
21 render advice and consultation to such Indians concerning
21
(7) make recommendations to the Secretary and
22 the availability and means of access to all public and private
22
Federal, State, local, and other resource agencies on
23 health services.
23
methods of improving health service programs to meet
24
(c) The Secretary shall place such conditions as he
24
the needs of urban Indians.
25 deems necessary in any contract which he makes with any
25
(d) The Secretary shall by regulation prescribe the
20
21
1 criteria for selecting urban Indian organizations with which
1 contracting laws and regulations except that, in the discre-
2 to contract pursuant to this title. Such criteria shall, among
2 tion of the Secretary, such contracts may be negotiated
3 other factors, take into consideration-
3 without advertising and need not conform with the provi-
4
(1) the extent of the unmet health care needs
4 sions of the Act of August 24, 1935 (49 Stat. 793), as
5
of the urban Indian in the urban center in question;
5 amended.
6
(2) the size of the urban Indian population which
6
(b) Payments under any contracts pursuant to this Act
7
is to receive assistance;
7 may be made in advance or by way of reimbursement and in
8
(3) the relative accessibility which such popula-
8 such installments and on such conditions as the Secretary
9
tion has to health care services in such urban center;
9 deems necessary to carry out the purposes of this title.
10
(4) the extent, if any, that the project would dupli-
10
(c) Notwithstanding any provision of law to the con-
11
cate any previous or current public or private project
11 trary, the Secretary may, at the request or consent of an
12
funded by another source in such urban center;
12 urban Indian organization, revise or amend any contract
13
(5) the appropriateness and likely effectiveness of
13 made by him with such organization pursuant to this title
14
a project assisted pursuant to this title in such urban
14 as necessary to carry out the purposes of this title: Provided,
15
center;
15 however, That whenever an urban Indian organization re-
16
(6) the existence of an urban Indian organization
16 quests retrocession of the Secretary for any contract entered
17
capable of performing the activities set forth in sub-
17 into pursuant to this title, such retrocession shall become
18
section (c) and of entering into a contract with the
18 effective upon a date specified by the Secretary not more than
19
Secretary pursuant to this title; and
19 one hundred and twenty days from the date of the request
20
(7) the extent of existing or likely future par-
20 by the organization or at such later date as may be mutually
21
ticipation of appropriate health and health-related State,
21 agreed to by the Secretary and the organization.
22
local, and other resource agencies.
22
(d) In connection with any contract made pursuant to
23
SEC. 504. (a) Contracts with urban Indian organizations
23 this title, the Secretary may permit an urban Indian or-
24 pursuant to this title shall be in accordance with all Federal
24 ganization to utilize, in carrying out such contract, existing
22
23
1 facilities owned by the Federal Government within his juris-
1 respect to such contract or grant shall be subject to audit by
2 diction under such terms and conditions as may be agreed
2 the Secretary and the Comptroller General of the United
3 upon for their use and maintenance.
3 States.
4
(e) The contracts authorized under this title may include
4
SEC. 506. There are authorized to be appropriated for
5 provisions for the performance of personal services which
5 the purpose of this title $3,000,000 for the fiscal year 1975;
6 would otherwise be performed by Federal employees: Pro-
6 $4,000,000 for the fiscal year 1976; and $5,000,000 for
7 vided, That the Secretary shall not make any contract which
7 the fiscal year 1977.
8 would impair his ability to discharge his trust responsibilities
8
SEC. 507. Within six months after the end of fiscal year
9 to any Indian tribe or individuals.
9 1976, the Secretary shall review the program established
10
(f) Contracts with urban Indian organizations and
10 under this title and shall submit to the Congress his assess-
11 regulations adopted pursuant to this title shall include pro-
11 ment thereof and recommendations for any further legisla-
12 visions to assure the fair and uniform provision by such
12 tive efforts he deems necessary to meet the purposes of this
13 organizations of services and assistance to Indians in ,the
13 title.
14 conduct and administration of programs or activities under
14
TITLE VI-MISCELLANEOUS
15 such contracts.
15
SEC. 601. The Secretary shall report annually to the
16
SEC. 505. For each fiscal year during which an urban
16 President and the Congress on progress made in effecting the
17 Indian organization receives or expends funds pursuant to a
17 purposes of this Act. Within three months after the end
18 contract under this title, the organization which requested
18 of fiscal year 1978, the Secretary shall review the programs
19 such contract or grant shall submit to the Secretary a report
19 established or assisted under this Act and shall submit to
20 including information gathered pursuant to 503 (c) (6) and
20 the Congress his assessment thereof and recommendations of
21 (7), information on activities conducted by the organiza-
21 additional programs or additional assistance necessary to, at
22 tion pursuant to the contract, an accounting of the amounts
22 a minimum, provide health services to Indians, and insure
23 and purposes for which Federal funds were expended, and
23 a health status for Indians, which is at a parity with the
24 such other information as the Secretary may request. The
24 health services available to, and the health status of, the gen-
25 reports and records of the urban Indian organization with
25 eral population.
24
1
SEC. 602. The Secretary may prescribe such regulations
2 as he deems necessary to carry out the purposes of this Act.
3 Such regulations shall provide the opportunity for maximum
4 participation of Indians in the planning and implementation
5 of Indian health programs.
6
SEC. 603. The funds appropriated pursuant to this Act
7 shall remain available until expended.
and Insular Affairs
Read twice and referred to the Committee on Interior
FEBRUARY 1, 1974
By Mr. JACKSON, Mr. BARTLETT, Mr. FANNIN,
purposes.
2D SESSION
Mr. HASKELL, and Mr. METCALF
dians in such programs, and for other
couraging maximum participation of In-
Federal Indian health programs and en-
by improving the services and facilities of
the care and education of the Indian people
To implement the Federal responsibility for
93D CONGRESS
A BILL
S. 2938
Congressional Record
United States
of America
PROCEEDINGS AND DEBATES OF THE
CONGRESS, SECOND SESSION
Vol. 120
WASHINGTON, FRIDAY, FEBRUARY 1, 1974
No. 9
Senate
By Mr. JACKSON for himself,
The purpose of the legislation I intro-
trained medical and public health of-
Mr. METCALF, Mr. HASKELL, Mr.
duce today is to augment and expand
ficers strengthened the overall direction
FANNIN, and Mr. BARTLETT) :
upon presently established health pro-
of the Federal Indian health program,
2938. A bill to implement the Fed-
grams and services for Indian citizens.
they were unable to overcome the seri-
eral responsibility for the care and edu-
It is designed to eliminate enormous
ous health problems of Indians due to
cation of the Indian people by improving
backlogs of essential patient care, to con-
other shortcomings in the Indian health
the services and facilities of Federal In-
struct and renovate hospitals and other
program. Outdated and inadequate Fed-
dian health programs and encouraging
health facilities which at the present
eral health facilities and delivery sys-
maximum participation of Indians in
time are either nonexistent or in a state
tems were incapable of sustaining the
such programs. and for other purposes.
of general deterioration, and to provide
demands for service found on Indian res-
Referred to the Committee on Interior
financial and organizational support for
ervations. Finally, in an effort to con-
and Insular Affairs.
the development and growth of urban
solidate and expand the diverse and dis-
INDIAN HEALTH LEGISLATION
Indian health projects.
jointed programs of Indian health care
In the early history of this country,
and to accommodate Indian health needs
Mr. JACKSON. Mr. President, I am in-
troducing for appropriate reference, leg-
Federal health services provided to In-
which had grown to crisis proportions,
islation which addresses one of the most
dians were confined to those military
Congress, in 1955, transferred all author-
physicians assigned to frontier forts and
deplorable situations in the United
ity for Indian health from the Depart-
reservations. Primarily the attention of
ment of the Interior to the Public Health
States, that of the provision of basic
these physicians focused on preventing
health services to Indians.
Service.
the spread of smallpox and other con-
Earlier this Congress, the Senate
Presently, the responsibility for pro-
tagious diseases; diseases, I may point
viding adequate health and medical serv-
passed the Indian Financing Act, to pro-
out. which were virtually unknown to
ices for Indian people resides with the
vide economic assistance to enable the
Indians before their contact with the
Indian Health Service, a special branch
Indian people to design and build their
white man.
of the Public Health Service within the
own future. By unanimous vote on Janu-
In 1849, with the transfer of the Bu-
Department of Health, Education, and
ary 28 of this year, the Indian Self-De-
reau of Indian Affairs to the Department
Welfare. Of the approximately 827,000
termination and Educational Reform Act
of the Interior, Indian health policy
Indians in the United States represent-
was ordered reported to the Senate by
shifted from military to civilian admin-
ing some 260 tribes and 215 Alaskan
the Committee on Interior and Insular
istration. Although some limited progress
Native villages, more than half a million
Affairs. Both of these measures reaf-
occurred under this new administrative
Native Americans depend almost entire-
firm the policy of this body that it is the
arrangement, by 1875 there were still
ly upon the Indian Health Service for
Indian people who must decide their own
only about half as many doctors as there
medical and hospital care. To meet the
future and they provide the educational
were Indian agencies, and by 1900 the
needs of these citizens, the Service oper-
and economic tools to shape that future.
physicians serving Indians numbered
ates 51 hospitals in 13 States offering a
The most basic human right must be
only 83. During this time Indian health
total of 2,700 beds with an additional
the right to enjoy decent health. Cer-
services were financed out of miscellane-
1,000 beds provided through contract fa-
tainly. any effort to fulfill Federal re-
ous funds of the Bureau of Indian Af-
cilities with local private and public hos-
sponsibilities to the Indian people must
fairs. It was not until 1911 that general
pitals. The total manpower of these serv-
begin with the provision of health serv-
Indian health appropriations began.
ices constitutes more than 7,000 profes-
ices. In fact, health services must be
In the mid-1920's a more concerted
sional and staff personnel, including
the cornerstone upon which rest all other
effort was made to assist the health
some 450 physicians and 170 dentists in
Federal programs for the benefit of In-
needs of Indian communities, facilitated
the Commissioned Officers Corps of the
dians. Without a proper health status,
by the assignment of commissioned of-
Public Health Service. Contracts with
the Indian people will be unable to fully
ficers of the Public Health Service to In-
some 300 private and community hos-
avail themselves of the many economic,
dian health programs. Considerable im-
pitals and 500 physicians provide addi-
educational, and social programs already
provement in Indian health can be said
tional personnel and facilities.
available to them or which this Con-
to have resulted from the contributions
Although the Indian Health Service
gress will provide them.
of these officers. While these highly
has begun at long last to achieve a limited
S 1033
February 1, 1974
CONGRESSIONAL RECORD SENATE
1059
progress in improving the health status
some 530,000 Indians. Service and con-
manpower. Leading medical officials have
of Indian people. health statistics reveal
tract facilities provide some 3,700 hospi-
given truly dire warnings that any fur-
that in spite of this progress the vast ma-
tal beds. Compared with a national aver-
ther decline in manpower could have
jority of Indians live in an environment
age of 1 hospital bed per 125 persons In-
critical implications for the health of
characterized by inadequate and under-
dian facilities provide 1 bed per 132 per-
Indians.
staffed health facilities. improper or non-
sons, a shortage of more than 200 beds
By and large the problems I have de-
existent waste and water systems. and
under existing standards of service and
scribed for you are with respect to those
continuing dangers of deadly or dis-
demand. A special committee of the
Indians who live on or near reservations
abling diseases. These circumstances
American Medical Association has in-
and are members of federally recognized
have produced a situation in which the
vestigated the condition of Indian health
tribes or Indians. However, a substantial
health of Indians ranges far below that
services. It is their conclusion that only
segment of the Indian population-300,-
of other Americans. Health concerns
21 of the 51 existing Indian Health Serv-
000 to 400,000-resides away from the
which most of our communities have
ice hospitals meet their standards of
reservation, mostly in large urban cen-
forgotten as long as 25 years ago con-
accreditation (either because of insuffi-
ters.
tinue to plague Indian communities. For
cient staffing or poor physical plants),
My bill contains a provision aimed spe-
every Indian health need treated by ex-
that two-thirds of the hospitals are obso-
cifically at assisting urban Indians to
isting services, another need will go un-
lete, and that 22 need complete replace-
develop health leadership among their
met, only to arise at a later date, inhibit-
ment.
own members and to establish the kind
ing the lives and pursuits of native citi-
In order to overcome the gross defi-
of resource identification which will help
zens and strangling their development as
ciencies in the quantity and quality of
to meet the most pressing health needs
free, self-determined people.
existing facilities, more money must be
of these deserving people. An integral
Illustrative of this situation are the
allocated. Per capita expenditures for
aspect of this effort will involve an out-
following facts: the incidence of tuber-
Indian health purposes are 30 to 40 per-
reach program to seek out individuals
culosis for Indians and Alaska Natives is
cent below expenditures for the average
and faimlies who require health care and
6.4 times higher than the rate for all
American community. The greater inci-
refer them to services at the earliest pos-
citizens of the United States; the Indian
dence of disease among Indians renders
sible date.
and Alaska Natives rate for diabetes is
this deficiency all the more acute. It is
While current Indian policy prohibits
almost twice that of all races of the
further compounded by the fact that
the extension of the special Indian
United States; and while respiratory and
many of our more modern national
Health Service hospital and medical care
gall bladder illnesses are not reported in
health programs, designed to assist the
program to the urban centers, I am con-
the general population, Indian Health
general population, are difficult or im-
vinced that my proposal in this area of
Service officials state emphatically that
possible to apply to Indians. Meidcare,
concern will do much to alleviate a seri-
the rates for these diseases among Indi-
medicaid, and social security programs
ous health situation among the Indian
ans and Alaska Natives are significantly
afford little relief because, given their
people concentrated in a number of
higher than the general population.
unique social situation, few Indians
major cities throughout the United
Otitis media, an infection of the inner
either know they are eligible for medicare
States. I want to underscore the fact that
ear, affecting most commonly children
or have not worked long enough for so-
the funds designated for these programs
under the age of 2 years, continues to be
cial security eligibility.
will in no way reduce the level of fund-
a leading cause fo disability in American
At the center of this tragic set of cir-
ing I have proposed to meet the serious
Indians and Alaska Natives.
cumstances is probably the most press-
health and medical needs for thousands
Although surgical treatment is possi-
ing and serious problem facing Indian
of Indian people residing on federally
ble which can generally prevent the long-
Health Service, the manpower shortage
recognized reservations and in Indian
term and serious disabilities of deafness
among physicians and related health
communities. I want both the members
and learning deficiencies, only a fraction
personnel. At present there are 450 phy-
of federally recognized tribes and the
of this essential surgery is now being
sicians in the Indian Health Service.
urban Indians to understand that my
provided. The infant mortality rate
Simply translated this represents a ratio
bill in no way sets up a "tug of war" over
among Indians is almost 1½ times the
of one physician for 1,080 Indians as
limited financial resources and services
national average while the Indian birth
against a national average of slightly
but rather the measure addresses itself
rate soars at a ratio twice that of other
over 600 persons per physician. These
to the needs of both groups.
Americans. The frequency with which
shortages are complicated by the highly
Title I of my bill is designed to aug-
these events occur and the prevalence
dispersed and remote nature of Indian
ment the inadequate number of health
of disease in Indian communities can-
tribes, vast distances between settled
professionals serving the Indian com-
not help but have a significant impact
areas on reservations, and the lack of
munity. Part A provides scholarship
on the social and cultural fiber of In-
adequate roads and minimum emergency
grants to individuals who are enrolled in
dian societies, contributing to their gen-
transportation systems
medical schools: schools of optometry,
eral disintegration and attendant prob-
Unfortunately, the Indian people can-
osteopathy, dentistry, pharmacy, podi-
lems of mental illness, alcoholism, acci-
not look to their own tribal members for
atry, public health or nursing; or schools
dents, homicide and suicide. For exam-
relief in this vital health manpower
licensed by a State to train persons in
ple, suicide within Indian communities
shortage category. There are only 50
the allied health professions. These
is approximately twice as high as in the
known physicians of Indian descent en-
grants contain the condition that the in-
total U.S. population. The real life facts
gaged in the practice of medicine today,
dividuals who receive them must serve
of Indian health in this Nation add up to
and all but 2 or 3 are serving non-In-
the Indian community after completion
the simple yet deplorable conclusion that
dian patients. My proposed legislation
of their professional training. Part B
while every other American can expect
holds promise for opening new opportu-
provides scholarship grants to Indians
to live to the age of at least 70.4 years,
nities for young Indian men and women
who have finished high school and dem-
the Indian and Alaska Native can expect
to enter medicine and other health pro-
onstrate a capability of successfully com-
to live only to age 64.9.
fessions for service to their own people.
pleting a premedical, predental or pre-
All efforts to alter these conditions are
I find particularly disturbing the pro-
osteopathy course of study.
met with an initial and fundamental
jection that severe manpower shortages
Part C addresses the problem of main-
impediment of outdated or inadequate
are likely to become even more acute in
taining the physicians, once trained, in
health facilities. Of existing facilities,
the coming years due in large part to
the rural and remote areas where a sig-
some 38 hospitals, 66 health centers and
the decline in recruitment for the Public
nificant portion of the Indian people re-
240 other health stations are at least 20
Health Service Commissioned Officers
side. The difficulties associated with
years old.
Corps. In past years the main source of
meeting physician needs in rural Amer-
Many of them are old one-story Army-
the Service's physicians enlisting in the
ica are well known. These difficulties are
style buildings with inadequate electric-
Public Health Service has greatly de-
based on several critical factors among
ity, ventilation, insulation. and fire pro-
clined. An absence of adequate housing
which are lack of sufficient monetary re-
tection systems, and of such insufficient
facilities and the remoteness and cul-
ward, few social amenities available in
size to jeopardize the health and safety
tural isolation of assignments have added
rural communities, inadequate housing
of their occupants. To meet the needs of
to the problem of recruiting professional
and the inability to have frequent asso-
1060
CONGRESSIONAL RECORD-SENATE
February 1, 1974
ciation with professional colleagues.
available health resources within the
health status of Indians to be raised to the
While it is difficult to say with certain-
urban centers in which they are situated,
highest possible level and to encourage the
ty that any one of these factors is over-
determining the Indian population which
maximum participation of Indians in the
riding when a young physician is prepar-
are or could be recipients of health serv-
planning and management of those services.
(c) Federal health services to Indians have
ing to initiate his career, the ability to
ices; and assisting urban Indians in
resulted in a reduced prevalence and Inci-
frequently associate with professional
utilizing these available resources.
dence of preventable illnesses and unneces-
colleagues can be an important consider-
Title VI provides for an evaluation sys-
sary and premature deaths among Indians.
ation in determining where he will prac-
tem whereby the Secretary of Health, Ed-
(d) Despite such services, the unmet health
tice. Part C attempts to offset the nega-
ucation, and Welfare is required within 3
needs of the American Indian people are
tive impact of the lack of such associa-
months of the end of fiscal year 1978 to
severe and the health status of Indian is far
tional opportunities in rural areas by
submit a report containing a review and
below that of the general population of the
providing allowances to Service physici-
assessment of the programs provided
United States. Illustratively, for Indians
compared to all Americans in 1971, the tuber-
ans to enable them to leave their duty
under this bill including recommenda-
culosis death rate was over four and one-half
station for prescribed periods of time for
tions of additional programs and as-
times greater, the influenza and pneumonia
professional consultation and refresher
sistance designed to bring Indians to a
death rate over one and one-half times great-
training courses.
health status equal to that of the general
er, and the infant death rate about 20 per-
Title II provides added appropriations
population.
cent greater.
over a 5-year period to alleviate the
Mr. President, in conclusion I want to
(e) All other Federal services and programs
tremendous backlog in basic patient
state emphatically that unless our Gov-
in fulfillment of the Federal responsibility
to Indians are jeopardized by the low health
care, field health care and dental care.
ernment is willing to take affirmative
status of the American Indian people.
In addition. funds are provided for basic
action to improve the health status of
(f) Further improvement in Indian health
maintenance and repair of existing hos-
Indian people, I am convinced that many
is imperilled by-
pitals and related facilities. Also pro-
of our efforts to improve the social and
(1) inadequate, outdated, inefficient and
vided are such additional health person-
economic progress of Indians will stand
undermanned facilities. For example, only
nel and administrators necessary to im-
as mere hollow promises. I ask my col-
21 of 51 Indian Health Service hospitals are
plement this massive effort to reduce the
leagues how individual Indians and their
accredited; only 12 meet national fire and
patient backlog.
tribes whose health status is at least a
safety codes; and 57 areas with Indian popu-
Title III, part A, attacks the problem
generation behind that of the general
lations have been identified as requiring
either new or replacement health centers and
of inadequate or outdated Service hos-
population can aggressively pursue com-
stations, or clinics remodeled for improved
pitals, health centers and health stations
plex community, social and economic de-
or additional service;
by authorizing $400 million over 5 years
velopment plans when they are faced
(2) shortage of personnel. For example,
for construction of new facilities. This
with such serious health constraints?
about two-thirds of the service hospitals,
title, if enacted, would constitute a major
Mr. President, I stand on the principle
four-fifths of service hospital outpatient
effort at eliminating some of the more
that every Indian man, woman and child
clinics, and one-half of the service health
archaic health installations and at the
in this Nation has the God given right
clinics meet only 80 percent of staffing stand-
ards for their respective services;
same time providing some new facilities
to enjoy sound physical and mental
(3) insufficient services in such areas as
in geographic areas where they are crit-
health. The members of this great body
laboratory, hospital inpatient and outpa-
ically needed. The Secretary of Health,
can help Indian people to achieve that
tient, eye care and mental health services
Education, and Welfare is also author-
right. In fact we owe them that right due
and services available through contracts
ized to equip and staff these facilities at
to the Indians' unique historic and legal
with private physicians, clinics, and agen-
levels commensurate with their opera-
relationship with the Federal Govern-
cles. For example, about 82 percent of the
tion at optimum levels of effectiveness.
ment which has its basis in the Consti-
surgical operations needed for otitis media
Part B authorizes $470 million over a
tution itself. But to do so we must be
are unperformed, over 57 percent of required
prepared to provide them with appro-
dental services have not been provided, and
5-year period to supply vitally needed
about 98 percent of the need for hearing aids
safe water and sanitary waste disposal
priate tools-financial resources, facili-
is unmet;
facilities in both existing and new In-
ties, manpower training and flexible au-
(4) related support factors. For example,
dian homes and communities. It requires
thorities-to develop a health delivery
over 700 housing units are needed for staff
the Secretary of Health. Education, and
system capable of achieving this highly
at remote service facilities;
Welfare, together with the Secretaries of
desirable goal.
(5) lack of access of Indians to health
Interior and Housing and Urban Devel-
Mr. President, that concludes my for-
services due to remote residences, undevel-
opment, to come forth within 3 months
mal remarks. I ask that the bill be print-
oped or underdeveloped communication and
with a plan to provide the essential water
ed in the RECORD along with several tables
transportation systems, and difficult, some-
times severe, climatic conditions; and
and sanitation facilities in accordance
which demonstrate all too clearly the
(6) lack of safe water and sanitary waste
with the 5-year expenditure schedule.
deplorable health conditions presently
disposal services. For example, over 40,000
Title IV is designed to give Indians
existing among Indians.
existing, and 62,000 planned replacement and
greater access to and benefits from the
There being no objection, the bill and
renovated, Indian hosuing units need new
present social welfare programs presently
tables were ordered to be printed in the
or upgraded water and sanitation facilitles.
available to all Americans. To accomplish
RECORD, as follows:
(g) The Indian people's growing con-
this the bill will provide for direct medi-
S. 2938
fidence in Federal Indian health services is
A bill to implement the Federal responsibil-
revealed by their increasingly heavy use of
care and medicaid payments to Indian
ity for the care and education of the In-
such services. Progress toward the goal of
health hospitals instead of to the general
Treasury.
dian people by improving the services and
better Indian health is dependent on this
facilities of Federal Indian health pro-
continued growth of confidence. Both such
Title V encourages the establishment
grams and encouraging maximum partici-
progress and such confidence are dependent
of "outreach programs" in urban areas
pation of Indians in such programs, and
on improved Federal Indian health services.
to make health services more accessible
for other purposes
DECLARATION OF POLICY
to the urban Indian population. A few
Be it enacted by the Senate and House of
SEC. 3. The Congress hereby declares that
urban Indian organizations have already
Representatives of the United States of
it is the policy of this Nation, in fulfillment
established referral services to assist their
America in Congress assembled, That this
of its special responsibilities and legal obli-
members in securing the fullest possible
Act may be cited as the "Indian Health Care
gation to the American Indian people, to
access to adequate medical services and
Improvement Act."
meet the national goal of providing the high-
facilities. This bill gives recognition to
FINDINGS
est possible health status to Indians and to
provide existing Indian health services with
the modest success of these organizations
SEC. 2. The Congress finds that-
all resources necessary to effect that policy.
in the urban Indian community. To en-
(a) Federal Indian health services to main-
courage additional efforts, the Secretary
tain and improve the health of the Indians
DEFINITIONS
of Health, Education, and Welfare is au-
are consonant with and required by the Fed-
SEC. 4. For purposes of this Act-
eral Government's historical and unique legal
(a) "Indian", unless otherwise designated,
thorized to enter into contracts with
relationship with, the resulting responsibility
means a person who is a member of an In-
urban Indian organizations to provide
to, the American Indian people.
dian tribe.
them with financial assistance. These
(b) A major national goal of the United
(b) "Indian tribe" means any Indian
contracts are conditioned upon the urban
States is to provide the quantity and qual-
tribe, band, nation, or other organized group
Indian organizations identifying the
ity of health services which will permit the
or community, including any Alaska Native
February 1, 1974
CONGRESSIONAL RECORD-SENATE
1061
community as defined in the Alaska Native
ber of months with respect to which such
sional consultation and refresher training
Claims Settlement Act (85 Stat. 688). which
condition is applicable.
courses.
is recognized as eligible for the special pro-
Any amount which the United States is
(b) There are authorized to be appro-
grams and services provided by the United
entitled to recover under this paragraph
priated for the purpose of this section $350.-
States to Indians because of their status as
shall. within the three-year period beginning
000 for fiscal year 1975. $350,000 for fiscal
Indians.
on the date the United States becomes en-
year 1976. $375,000 for fiscal year 1977. $390.-
(c) "Secretary", unless otherwise desig-
titled to recover such amount, be paid to the
000 for fiscal year 1978. and $410,000 for fiscal
nated, means the Secretary of Health, Edu-
United States. Until any amount due the
year 1979.
cation, and Welfare.
United States under this paragraph on ac-
TITLE II-HEALTH SERVICES
(d) "Service", unless otherwise desig-
count of any grant under this part is paid,
nated, means the Indian Health Service.
there shall accrue to the United States in-
SEC. 201. (a) For the purpose of eliminating
TITLE I-INDIAN HEALTH MANPOWER
terest on such amount at the same rate as
backlogs in Indian health care services and
that fixed by the Secretary of the Treasury
to supply known, unmet medical. surgical,
SEC. 101. The purpose of this title is to
pursuant to clause (A) with respect to the
dental and other Indian health needs, the
augment the inadequate number of health
grant on account of which such amount is
Secretary is authorized to expend, through
professionals serving Indians and remove
due the United States.
the Service, $123,500,000 over a five fiscal year
the multiple barriers to the entrance of
(4) (A) Any obligation of any individual
period in accordance with the schedule pro-
health professionals into the Service and
to comply with the condition applicable to
vided in subsection (c), As such funds which
private practice among Indians.
him under the preceding provisions of this
are appropriated pursuant to this Act are
PART A-HEALTH PROFESSIONS SCHOLARSHIP
subsection shall be canceled upon the death
to eliminate health services backlogs, they
PROGRAM
of such individual.
shall not be used to offset or limit the ap-
SEC. 102 (a). The Secretary shall, in ac-
(B) The Secretary shall by regulations
propriations required by the Service to con-
cordance with the provisions of this title,
provide for the waiver or suspension of any
tinue to serve the health needs of Indian
make scholarship grants to individuals (1)
such obligation applicable to any individual
people during and subsequent to such five
who are enrolled in medical schools; schools
whenever compliance by such individual is
fiscal year period but shall be in addition to
of optometry, osteopathy, dentistry, phar-
impossible or would involve extreme hard-
the annual appropriations required to con-
macy, podiatry, public health, or nursing; or
ship to such individual and if enforcement
tinue the health service program to the In-
schools licensed by a State to train persons
of such obligation with respect to any indi-
dian people.
in the allied health professions and (ii) who
vidual would be against equity and good
(b) The Secretary is also authorized to
agree to provide their professional services
conscience.
employ persons to implement the provisions
to Indians after completion of their profes-
SEC. 103. The Secretary may enter into
of this section during the five fiscal year
sional training.
agreements with any schools referred to in
period in accordance with the schedule pro-
(b) (1) The Secretary shall, in awarding
section 102 hospitals, or appropriate pub-
vided in subsection (c). Such persons shall
scholarship grants under this part, accord
lic or private agencies under which such
be in addition to, and shall not reduce the
priority to applicants as follows-
schools, hospitals, or other agencies will, as
number of, the employees required to con-
(A) first, to any qualified applicant who
agents of the Secretary, perform such func-
duct ongoing activities of the Service during
is a member of an Indian tribe and resides
tions in the administration of this part, as
and subsequent to such period.
on an Indian reservation;
the Secretary may specify. Any such agree-
(c) The following amounts and positions
(B) second, to any qualified applicant who
ment with any such school, hospital, or
are authorized, by fiscal year, for the specific
is a member of an Indian tribe and resides
agency may provide for payment by the Sec-
purposes noted:
in a place other than an Indian reservation;
retary of amounts equal to the expenses ac-
(1) patient care (direct and indirect) for
(C) third, to any other qualified applicant.
tually and necessarily incurred by such
fiscal year 1975, $11,000,000 and 240 positions;
(2) Scholarship grants under this title
school, hospital, or agency in carrying out
for fiscal year 1976, $17,000,000 and 540 posi-
shall be made with respect to academic
such agreement.
tions; for fiscal year 1977, $14,000,000 and
SEC. 104. There are authorized to be appro-
410 positions: for fiscal year 1978, $9,000,000
years.
(c) (1) Any scholarship grant awarded to
priated for the purpose of this part $8,000,000
and 500 positions; and for fiscal year 1979,
any individual under this title shall be
for fiscal year 1975, $16,000,000 for fiscal year
$7,000,000 and 490 positions;
awarded under the condition that such in-
1976, $22,000,000 for fiscal year 1977,
(2) field health, excluding dental care (di-
dividual will, after the completion of his
$30,000,000 for fiscal year 1978, and
rect and indirect) for fiscal year, 1975, $12,-
professional training, provide his profes-
$34,000,000 for fiscal 1979, and, for each suc-
000,000 and 300 positions; for fiscal year
sional services to Indians.
ceeding fiscal year, such sums as may be
1976, $10,000,000 and 225 positions; for fiscal
(2) The Secretary shall prescribe by reg-
necessary to continue to make such grants
year 1977, $7,000,000 and 200 positions; for
ulations-
to individuals who (prior to July 1, 1979)
fiscal year 1978, $7,000,000 and 200 positions;
(A) the criteria for determining when an
have received such grants and who are eligi-
and for fiscal year 1979, $5,000,000 and 100
individual is providing professional serv-
ble for such grants under this part during
positions;
ices to Indians in fulfillment of the condi-
such succeeding fiscal year.
(3) dental care (direct and indirect) for
tion for scholarship assistance provided in
fiscal year 1975, $900,000 and 60 positions;
PART B-HEALTH PROFESSIONS PREPARATORY
paragraph 1, and
for fiscal year 1976, $700,000 and 75 positions;
SCHOLARSHIP PROGRAM
(B) the reasonable period of time said con-
for fiscal year 1977, $700,000 and 75 positions;
SEC. 105. (a) The Secretary shall, in accord-
dition must be complied with by such in-
for fiscal year 1978, $600,000 and 75 positions;
ance with the provisions of this part, make
dividual.
and for fiscal year 1979, $600,000 and 60 posi-
scholarship grants to Indians who-
(3) If any individual to whom the con-
tions; and
(1) have successfully completed their high
dition referred to in paragraph (1) is ap-
(4) maintenance and repair (direct and
school education; and
plicable fails, within the period prescribed
indirect) for fiscal year 1975, $6,000,000 and
(2) have demonstrated an aptitude for
pursuant to regulations under paragraph
30 positions; for fiscal year 1976, $4,000,000
being capable of successfully completing a
(2), to comply with such condition for the
and 30 positions; for fiscal year 1977, $4,000,-
pre-medical, pre-dental, or pre-osteopathy
full period, the United States shall be en-
000 and 30 positions; for fiscal year 1978,
course of study.
titled to recover from such individual an
$4,000,000 and 30 positions; and for fiscal
(b) A scholarship grant made under this
amount equal to the amount produced by
year 1979, $3,000,000 and 30 positions.
part shall be for a period not to exceed two
multiplying-
TITLE III-HEALTH FACILITIES
academic years.
(A) the aggregate of (1) the amounts of
PART A-CONSTRUCTION AND RENOVATION OF
the scholarship grant or grants (as the case
(c) A scholarship grant made under this
SERVICE FACILITIES
may be) made to such individual under this
part may cover costs of tuition, books, trans-
part, and (11) the sums of the interest which
portation, board, and other necessary re-
SEC. 301. For the purpose of eliminating
lated expenses.
inadequate, outdated and otherwise unsatis-
would be payable on each such scholarship
grant if, at the time such grant was made,
(d) There are authorized to be appropri-
factory Service hospitals, health centers,
such grant were a loan bearing interest at
ated for the purpose of this part $1,000,000
health stations and other Service facilities,
a rate fixed by the Secretary of the Treas-
for fiscal year 1975; $2,000,000 for fiscal year
the Secretary is authorized to expend $400,-
1976; $3,000,000 for fiscal year 1977;
000,000 over a five fiscal year period in ac-
ury, after taking into consideration private
$3,000,000 for fiscal year 1978; and $3,000,000
cordance with the following schedule:
consumer rates of interest prevailing at the
time such grant was made, and if the interest
for fiscal year 1979.
(a) hospitals: for fiscal year 1975, $40,000,-
000; for fiscal year 1976, $76,000,000; for fiscal
on each such grant had been compounded
PART C-CONTINUING EDUCATION ALLOWANCES
year 1977, $65,000,000; for fiscal year 1978,
annually, by
SEC. 106. (a) In order to encourage pro-
$55,000,000; and for fiscal year 1979, $80,-
(B) a fraction the numerator of which is
fessionals to join the Service and to provide
000,000.
the number obtained by subtracting from
their services in the rural and remote areas
(b) health centers and health stations: for
the number of months to which such con-
where a significant portion of the American
fiscal year 1975, $4,000,000; for fiscal year
dition is applicable a number equal to one-
Indian people reside, the Secretary may pro-
1976, $6,000,000; for fiscal year 1977, $2,000,-
half of the number of months with respect
vide allowances to Service physicians to en-
000; for fiscal year 1978, $2,000,000; and for
to which compliance by such individual with
able them for a period of time each year
fiscal year 1979, $11,000,000.
such condition was made, and the denomina-
prescribed by regulation of the Secretary to
(c) staff housing: for fiscal year 1975, $13,-
tor of which is a number equal to the num-
take leave of their duty stations for profes-
000,000; for fiscal year 1976, $21,000,000; for
1062
CONGRESSIONAL RECORD
February 1, 1974
Title XIX of the Social Security Act. as
(4) assist such urban Indians in becom-
fiscal year 1977, $16,000,000; for fiscal year
1978,
$5,000,000;
and
for
fiscal
year
1979,
amended.
ing familiar with and utilizing such re-
(c) The Secretary shall undertake to im-
sources;
$4,000,000.
SEC. 302. The Secretary is authorized to
prove such facilities such that they will meet
(5) provide basic health educaton to such
or exceed any applicable accredited standard.
urban Indians;
equip and staff such Service facilities at
(d) Any payments received for services
(6) identify gaps between unmet health
levels commensurate with their operation at
provided beneficiaries hereunder shall be
needs of urban Indians and the resources
optimum levels of effectiveness.
SEC. 303. For the purpose of implementing
credited to the appropriation charged for the
available to meet such needs; and
actual provision of care and services, which
(7) make recommendations to the Secre-
the provisions of this part, the Secretary
shall assure that the rates of pay for per-
amount shall not be considered in determin-
tary and Federal, State, local and other re-
ing appropriations for the provision of health
source agencies on methods of improving
sonnel engaged in the construction of renc-
vation of facilities constructed or carried out
care and services to Indians.
health service programs to meet the needs
(e) Nothing in this section shall author-
of urban Indians.
in whole or in part by funds made available
pursuant to this part are not less than the
ize the Secretary to provide services to an
(d) The Secretary shall by regulation pre-
prevailing local wage rates for similar work
Indian beneficiary with coverage under Title
scribe the criteria for selecting urban Indian
as determined in accordance with the Act
XIX of the Social Security Act, as amended,
organizations with which to contract pur-
in preference to an Indian beneficiary with-
suant to this title. Such criteria shall, among
of March 3, 1921 (48 Stat. 1491), as amended.
other factors, take into consideration-
PART B-CONSTRUCTION OF SAFE WATER AND
out such coverage.
TITLE V-ACCESS TO HEALTH SERVICES
(1) the extent of the unmet health care
SANITARY WASTE DISPOSAL FACILI-
needs of the urban Indian in the urban
FOR URBAN INDIANS
TIES
center in question;
SEC. 304. (a) For the purpose of reducing
SEC. 501. The purpose of this tltle is to
(2) the size of the urban Indian popula-
health hazards, the Secretary is authorized
encourage the establishment of outreach pro-
tion which is to receive assistance;
to expend, pursuant to Public Law 86-121,
grams in urban areas to make health serv-
(3) the relative accessibility which such
$470,000,000 within a five fiscal year period
ices more accessible to the urban Indian pop-
population has to health care services in such
following the enactment of this Act, in ac-
ulation.
urban center;
cordance with the schedule provided in sub-
SEC. 502. For the purpose of this title-
(4) the extent, if any, that the project
section (b), to supply unmet needs for safe
(a) "Urban Indian" means any individual
would duplicate any previous or current pub-
water and sanitary waste disposal facilities
who resides in an urban center and who is
lic or private project funded by another
in existing and new Indian homes and com-
(1) an Indian as defined in section 4(a) of
source in such urban center;
this Act or (11) a person of Indian descent
munities.
(5) the appropriateness and likely effec-
(b) The following amounts are authorized,
who is considered ineligible for the special
tiveness of a project assisted pursuant to this
by fiscal year, for the purpose prescribed in
programs and services of the Service and the
title in such urban center;
subsection (a) $90,000,000 in fiscal year
Bureau of Indian Affairs and who, in accor-
(6) the existence of an urban Indian or-
1975; $95,000,000 in fiscal year 1976; $95,000,-
dance with regulations promulgated by the
ganization capable of performing the activi-
000 in fiscal year 1977; $95,000,000 in fiscal
Secretary which take into consideration such
ties set forth in subsection (c) and of enter-
year 1978; and $95,000,000 in fiscal year 1979.
person's health needs, lack of access to health
ing into a contract with the Secretary pur-
(c) The Secretary is authorized and di-
services, and other relevant factors, is identi-
suant to this title; and
rected to develop a plan, together with the
fied as an appropriate recipient of assistance
(7) the extent of existing or likely future
Secretaries of Housing and Urban Devel-
from an urban Indian organization in ac-
participation of appropriate health and
opment and the Interior, to assure that the
cordance with the provisions of this title.
health-related State, local, and other resource
schedule provided for in subsection (b) will
(b) An "urban Indian organization" is a
agencies.
be met. Such plan shall be submitted to the
non-profit corporate body situated in an ur-
SEC. 504 (a) Contracts with urban Indian
Congress no later than ninety days from the
ban center, composed of urban Indians, and
organizations pursuant to this title shall be
date of enactment of this Act.
providing the maximum participation of all
in accordance with all Federal contracting
interested Indian groups, which body is cap-
TITLE IV-ACCESS TO HEALTH
laws and regulations except that, in the dis-
able of legally cooperating with other bodies,
cretion of the Secretary, such contracts may
SERVICES
Federal, State and local, for the purpose of
be negotiated without advertising and need
SEC. 401. (a) Notwithstanding any other
performing the activities described in section
not conform with the provisions of the Act
provision of law, for the purpose of Title
503(c).
of August 24, 1935 (49 Stat. 793), as amended.
XVIII of the Social Security Act, as amend-
(c) An "urban center" is any community
(b) Payments under any contracts pur-
ed, the Service facilities used to provide
which has a sufficient urban Indian popula-
suant to this Act may be made in advance
health care and services to Indians are here-
tion with unmet health needs to warrant as-
or by way of reimbursement and in such in-
by deemed to be accredited facilities, the
sistance under this title, as determined by
stallments and on such conditions as the
services so provided shall be deemed to be
the Secretary.
Secretary deems necessary to carry out the
provided by licensed practitioners in their
SEC. The Secretary shall enter into
purposes of this title.
respective fields, and the facilities may re-
contracts with urban Indian organizations to
(c) Notwithstanding any provision of law
ceive payment for such services on the same
provide Federal assistance to such organi-
to the contrary, the Secretary may, at the
basis as other providers of service.
zations for the purpose of establishing and
request or consent of an urban Indian or-
(b) The Secretary shall undertake to im-
administering outreach programs to make
ganization, revise or amend any contract
prove and maintain such service facilities
urban Indians in the urban centers in which
made by him with such organization pur-
such that they will, at a minimum, meet the
such organizations are situated knowledge-
suant to this title as necessary to carry out
accreditation standards imposed on other
able of the health service resources available
the purposes of this title: Provided, how-
providers of service.
within such centers and the means of gaining
ever, That whenever an urban Indian or-
(c) Any payments received for services pro-
access to those resources.
ganization requests retrocession of the Secre-
vided to beneficiaries hereunder shall be
(b) Urban Indian organizations shall make
tary for any contract entered into pursuant
credited to the appropriation charged for the
use of Federal assistance provided by con-
to this title, such retrocession shall become
actual provision of care and services and
tracts pursuant to this title not to provide
effective upon a date specified by the Secre-
shall not be considered in determining ap-
health services to urban Indians but to ren-
tary not more than one hundred and twenty
propriations for health care and services to
der advice and consultation to such Indians
days from the date of the request by the
Indians.
concerning the availability and means of
organization or at such later date as may
(d) Nothing herein authorizes the Secre-
access to all public and private health serv-
be mutually agreed to by the Secretary and
tary to provide services to an Indian bene-
ices.
the organization.
ficiary with coverage under Title XVIII of
(c) The Secretary shall place such condi-
(d) In connection with any contract made
the Social Security Act, as amended, in pref-
tlons as he deems necessary in any contract
pursuant to this title, the Secretary may
erence to an Indian beneficiary without such
which he makes with any urban Indian orga-
permit an urban Indian organization to uti-
nization pursuant to this title. Such condi-
coverage.
lize, in carrying out such contract, existing
SEC. 402. (a) Notwithstanding any other
tions shall include, but are not limited to,
facilities owned by the Federal Government
provision of law, for the purpose of Title
requirements that the organization success-
within his jurisdiction under such terms and
XIX of the Social Security Act, as amended,
fully undertake the following tasks:
conditions as may be agreed upon for their
the Service facilities used to provide health
(1) determine, in accordance with the reg-
use and maintenance.
care and services to Indians are hereby
ulations promulgated pursuant to section
(e) The contracts authorized under this
deemed to be accredited facilities and the
502(a), the population of urban Indians
title may include provisions for the perform-
which are or could be recipients of such
services so provided in these facilities are
ance of personal services which would other-
deemed to be provided by licensed practition-
services;
wise be performed by Federal employees:
ers in their respective fields.
(2) identify all public and private health
Provided, That the Secretary shall not make
service resources within the urban center
any contract which would impair his ability
(b) The Secretary is authorized to enter
into agreements with the appropriate State
in which the organization is situated which
to discharge his trust responsibilities to any
are or may be available to urban Indians;
Indian tribe or individuals.
agency for the purpose of receiving reim-
(3) assist such resources in providing
(f) Contracts with urban Indian organiza-
bursement for health care and services pro-
vided to Indians who are beneficiaries under
service to such urban Indians;
tions and regulations adopted pursuant to
February 1, 1974
CONGRESSIONAL RECORD-SENATE
1063
this title shall include provisions to assure
the programs established or assisted under
NUMBER OF REGISTERED NURSES AND PHYSICIANS
the fair and uniform provision by such or-
this Act and shall submit to the Congress his
INDIAN HEALTH SERVICES AND UNITED STATES, ALL
ganizations of services and assistance to In-
assessment thereof and recommendations of
RACES
dians in the conduct and administr tion of
additional programs or additional assistance
programs or activities under such contracts.
necessary to, at a minimum, provide health
Registered nurses
Physicians
SEC, 505. For each fiscal year during which
services to Indians, and ensure a health
an urban Indian organization receives or ex-
status for Indians, which is at a parity with
Rate per
Rate per
Num-
100,000
Num-
100,000
pends funds pursuant to a contract under
the health services available to, and the
ber
ber
this ttile, the organization which requested
health status of. the general population.
IHS
United
IHS
United
SEC. 602. The Secretary may prescribe such
Year
staff
IHS
States
staff
IHS
States 2
such contract or grant shall submit to the
Secretary a report including information
regulations as he deems necessary to carry
out the purposes of this Act. Such regula-
1971
1,073
228
356
458
98
170
gathered pursuant to 503(c) (6) and (7). in-
tions shall provide the opportunity for max-
1970
1,007
219
347
449
93
166
formation on activities conducted by the or-
1969
981
217
338
425
94
163
ganization pursuant to the contract. an ac-
imum participation of Indians in the plan-
1968
984
222
331
392
88
161
ning and implementation of Indian health
1967
930
213
325
357
82
158
counting of the amounts and purposes for
1966
909
212
319
335
78
156
which Federal funds were expended, and
programs.
1964
913
222
306
299
73
151
such other information as the Secretary may
SEC. 603. The funds appropriated pursuant
1962
875
221
298
256
65
NA
request. The reports and records of the urban
to this Act shall remain available until ex-
1960
809
213
282
216
57
148
pended.
1958
828
229
268
209
58
NA
Indian organization with respect to such
1956
790
230
259
195
57
NA
contract or grant shall be subject to audit bv
the Secretary and the Comptroller General
HEALTH MANPOWER STATISTICS
I Facts about Nursing.
of the United States.
The number of Indian Health Service phy-
2 Health Resources Statistics, 1971.
SEC. 506. There are authorized to be appro-
sicians and registered nurses per 100.000 per-
3 Estimated.
sons served by the Indian Health Service has
NA-Not available.
priated for the purpose of this title $3,000,-
000 for the fiscal year 1975: $4,000,000 for the
continually lagged behind the rate for the
INFANT DEATH RATES BY AGE
fiscal year 1976; and $5,000,000 for the fiscal
United States.
The 1971 Indian and Alaska native infant
year 1977.
A degree of success has been shown in clos-
SEC. 507. Within six months after the end
ing the gap between the physician rates for
death rate is 24 percent higher than the
the Indian Health Service and the United
provisional U.S. all races rate for 1971. The
of fiscal year 1976. the Secretary shall re-
States all races. The number of physicians
Indian and Alaska native infant death rate
view the program established under this title
per 100 000 population in 1971 in the Indian
was 65 percent higher than the U.S. all
and shall submit to the Congress his assess-
Health Service was 58 percent of the U.S.
races rate in 1966. Thus, we have seen con-
ment thereof and recommendations for any
rate. In 1960 the IHS rate was less than 40
siderable improvement in the Indian and
further legislative efforts he deems necessary
to meet the purposes of this title.
percent of the U.S. rate.
Alaskan native infant death rate just since
The rate for registered nurses within the
1966.
TITLE VI-MISCELLANEOUS
IHS has remained almost constant since 1967.
The neonatal death rate for the Indian and
SEC. 601. The Secretary shall report an-
The range during this period was from a
Alaska native is below that of the U.S. How-
nually to the President and the Congress on
low of 213 registered nurses per 100,000 popu-
ever, the postneonatal rate is over 2.3 times
progress made in effecting the purposes of
lation in 1967 to a high of 230 in 1956. The
the U.S. rate. This ratio, however, is improv-
this Act. Within three months after the end
rate for the United States has experienced a
ing. In 1966 the Indian and Alaska native
of fiscal year 1978, the Secretary shall review
continual increase from 1956 through 1971.
rate was 3.3 times the U.S. rate.
INFANT DEATH RATES BY AGE AT DEATH INDIANS AND ALASKA NATIVES AND UNITED STATES, ALL RACES
[Rates per 1,000 live births]
Neonatal
Postneo-
Neonatal
Postneo-
Infant
natal,
Infant
natal,
death
Under
1 to 6
7 to 27
28 days
death
Under
1 to 6
7 to 27
28 days
rate
Total
1 day
days
days
o 11 mo.
rate
Total
1 day
days
days
to 11 mo.
Indians and Alaska Natives:
United States, all races:
1971
23 8
12 5
7.4
3.4
1.7
11.4
1971
19.2
14.3
NA
NA
NA
4.9
1970
NA
NA
NA
NA
NA
NA
1970
19.8
14.9
NA
NA
NA
5.0
1969
NA
NA
NA
NA
NA
NA
1969
20.7
15.4
NA
NA
NA
5.4
1968
30.9
14.4
7.9
4.1
2.4
16.5
1968
21.8
16.1
9.5
5.1
1.5
5.7
1967
32.2
15.3
8.4
5.1
1.8
16.9
1967
22.4
16.5
9.6
5.3
1.6
5.9
1966
39.0
17.3
9.0
5.6
2.7
21.7
1966
23.7
17.2
10.0
5.6
1.6
6.5
1 Provisional, Monthly Vital Statistics Report, NCHS, vol 20, No. 11.
NA- Not available.
MEDICAL CARE COST
fees, hospital daily charges, and drugs and
hospital daily charges 66 percent, and drugs
The consumer price index for medical care
prescriptions costs increased; physician fees
and prescriptions 6 percent.
shows a continuous upward trend. Physician
were 32 percent above the base year 1967,
CONSUMER PRICE INDEX FOR URBAN WAGE EARNERS AND CLERICAL WORKERS, U.S. CITY AVERAGE
[1967=100¹]
Medical care
Physicians' fees
Hospital daily services charges
Drugs and prescriptions
Septem-
Decem-
Septem-
Decem-
Septem-
Decem-
Septem-
Decem-
Year
March
June
ber
ber
March
June
ber
ber
March
June
ber
ber
March
June
ber
ber
1961
80.8
81.4
81 9
82 3
78.3
78.9
79.4
80.2
58.9
60.8
61.8
62.7
103.4
103.7
103.1
102.7
1962
83.1
83.7
83.9
84.3
80 8
81.3
81.7
82.2
64.3
64.7
65.5
66.1
102.3
102.1
101.0
100.0
1963
84.9
85.7
86.0
86.2
82.9
831
83.4
83.8
68.1
68.9
69.8
70.4
100.8
100.8
100.8
100.0
1964
86.8
87.3
87.6
88.0
85.0
86.3
71.7
72.3
73.0
73.7
100.7
100.2
1965
88.8
89.4
89.8
90.5
88.0
88.7
89.6
75.4
76.2
77.4
78.5
100.2
100.0
100.2
1966
91.7
92.9
94.7
96.5
91.2
93.0
95.1
96.6
80.4
82.1
86.3
91.5
100.5
100.7
100.6
100.4
1967
98.5
99.7
101.3
102.7
98.5
99.8
101.3
102.5
97.1
100.0
102.0
105.6
100.1
99.8
100.0
100.2
1968
104.5
105.6
107.1
109.1
104.1
105.3
106.5
108.4
109.9
112.2
115.8
119.6
100.3
100.1
100.1
100.0
1969
111. €
113.5
115.3
115.7
110.9
113.0
114.8
116.3
124.5
126.8
130.9
133.9
100.9
101.4
101.4
101.7
1970
118.2
120.5
122.6
124.2
119.0
121.6
123.3
125.7
139.4
142.1
147.5
152.0
102.5
103.8
104.3
104.2
1971
126.8
128.6
130.4
130 1
128.0
129.9
131.5
132.2
157.1
160.5
164.4
165.5
104.9
105.7
105.7
105.0
1972
131.4
132.4
133.1
134.4
132.9
133.9
134.4
135.4
NA
NA
NA
NA
105.7
105.8
105.7
105.
DENTAL SERVICES PROVIDED BY AGE
Estimated services required for the Indian
3-19 years and 46 percent of the population
In fiscal year 1972, 72 percent of the re-
and Alaska native population in fiscal year
over age 20. The IHS dental program provided
quired services in the age group 5-14 were
1972 was over 2 million. The percentage
less than 60.2 percent of the needed services
provided. This age group has historically seen
of required services provided was 40.3.
the highest percentage of required services
It is estimated that a total dental pro-
for Indian children less than 20 years of age
provided. The percentage decreased with each
gram should provide comprehensive dental
and only 18.9 percent of the services needed
successive age group.
services to 70-80 percent of the population
for the Indian population age 20 and over.
1064
CONGRESSIONAL RECORD SENATE
February 1, 1974
PERCENT OF ESTIMATED REQUIRED DENTAL SERVICES PROVIDED, FISCAL YEAR 1972
Services
Services
Services
Services
required
Indian
Estimated
provided
Percent of
required
Indian
Estimated
provided
Percent of
per
health
services
direct
required
per
health
services
direct
required
person
service
required in
and
services
person
service
required In
and
service
Age group (in years)
examined
population
population
contract
provided
Age group (in years)
examined
population
population
contract
provided
All ages
8.06
469,632
2,098,215
844,724
40.3
25 to 34
10.72
52,148
279,513
63,727
22.8
Under 5
6.66
61,287
102,042
41,596
40.8
35 to 44
11.29
43,192
243.818
39,387
162
5 to 9
6.45
70,698
364,801
268,554
73.6
45 to 54
11.57
33,997
177,005
24,927
15.1
10 to 14
5.72
66,800
305,676
214,057
70.0
55 to 64
11.19
27,135
121,456
14,267
11.
15 to 19
7.03
53,172
261,659
119,883
45.8
65 to 74
10.91
18,086
59,195
6,603
11. 2
20 to 24
9.80
33,057
161,979
49,615
30.6
75 and over
10.47
10,060
21,065
2,108
10.0
INFANT DEATHS
by 1971. Concurrently, the U.S. general popu-
to 1.24 times the U.S. rate. The Alaska Native
The infant death rate among Indians and
lation experienced a drop of 27.3 percent. The
rate has consistently exceeded the Indian
Alaska Natives declined 61.9 percent between
1955 Indian and Alaska Native infant death
rate. In 1971 the Alaska Native rate was 17
1955 and 1971. The 1955 rate of 62.5 had been
rate was 2.37 times the U.S. All Races rate.
percent higher than the Indian rate.
reduced to 23.8 deaths per 1,000 live births
By 1971 the Indian rate had been reduced
INFANT DEATHS AND DEATH RATES INDIAN AND ALASKA NATIVES IN 24 RESERVATION STATES AND UNITED STATES ALL RACES, CALENDAR YEARS 1955-71
[Rates per 1,000 live births]
Indian and
United States
Indian and
United States
Alaska Native
Indian
Alaska Native
all races
Alaska Native
Indian
Alaska Native
all races
Year
Number
Rate
Number
Rate
Number
Rate
Number
Rate
Year
Number
Rate
Number
Rate
Number
Rate
Number
Rate
1971
56)
23.8
513
23.5
47
27.4
NA
219.2
1962
967
44.2
827
41.8
140
66.8
105,479
25.
1970
570
NA
523
NA
47
NA
NA
2 19.8
1961
961
44.4
827
42.3
134
64.0
107,956
25.3
1969
570
NA
533
NA
46
NA
75,073
21.5
1960
1,064
50.3
914
47.6
150
76.3
110,873
26.0
1968
668
30.9
606
30.2
62
40.4
76,263
L1.8
1959
1,016
49.5
870
46.7
146
76.7
112,008
26.4
1967
666
32.2
571
30.1
95
55.6
79,028
22.4
1958
1,123
58.0
983
56.7
134
69.0
113,789
26.1
1966
822
39.0
722
37.7
100
51.4
85,516
23.7
1957
1,136
60.4
989
58.2
147
80.2
112,094
26.3
1965
872
39.0
740
36.4
132
65.4
92.866
24.7
1956
1,066
59.4
900
56.1
166
87.0
108,183
26.0
1964
856
37.6
747
35.9
109
54.8
99,783
24.8
1955
1.065
62.5
936
61.2
129
74.8
106,903
26.4
1963
972
43.6
864
42.9
108
50.7
103,390
25.2
Estimated.
2 Provisional, Monthly Vital Statistics Report, NCHS, vol. 20, No. 12.
TUBERCULOSIS DEATHS AND DEATH RATES
1956 period, and the Alaska Native rate was
figure of 2.1 in 1971. As a result, the com-
Tuberculosis death rates for Indians and
only 1/16 as high RS it had been in the 1954-
bined Indian and Alaska Native rate, which
Alaska Natives, combined, declined about 86
1956 period. Concurrently, there was a decline
was 6.1 times the U.S. rate in 1955, was still
percent from 1955 to 1971. In 1971 the Indian
in the U.S. All Races rate from 9.1 deaths per
3.7 times as high in 1971.
rate was about 1/6 what it was in the 1954-
100,000 population in 1955 to a provisional
TUBERCULOSIS MORTALITY- INDIANS AND ALASKA NATIVES IN 24 RESERVATION STATES AND UNITED STATES, ALL RACES CALENDAR YEARS 1955 TO 1971, RATES PER 100,000
POPULATION
Ratio
Ratio
Indian
Indian
and
and
Indian and
United States,
Alaska
Indian and
United States,
Alaska
Alaska Native
Indian
Alaska Native
all races
Native
Alaska Native
Indian
Alaska Native
all races
Native
to United
to United
Number
Number
Number
Number
States, all
Number
Number
Number
Number
States, all
Year
of deaths
Rate
of deaths
Rate
of deaths
Rate
of deaths
Rate
races
Year
of deaths
Rate
of deaths
Rate
of deaths
Rate
of deaths
Rate
races
1971
56
7.8
51
7.6
5
9.7
24,380
22.1
3.7
1962
150
26.0
137
25.3
13
34.0
9,506
5.1
5.1
1970
NA
NA
NA
NA
NA
NA
25,560
22.7
NA
1961
120
25.4
105
24.5
15
34.8
9,938
5.4
4.7
1969
86
12.6
82
13.0
4
8.0
5,567
2.8
4.5
1960
115
26.6
98 25.1
17
43.1
10,866
6.1
4.3
1968
78
12.8
71
12.8
7
12.9
6,292
3.1
4.1
1959
163
29.0
140
27.9
23
41.8
11,456
6.5
4.5
1967
90
13.5
82
13.4
8 14.3
6,901
3.5
3.9
1958
150
34.3
138
31.5
12
65.1
12,361
7.1
4.8
1966
91
15.3
85
15.4
6 15.3
7,625
3.9
3.9
1957
186
38.2
134
34.2
43
83.3
13,324
7.8
4.9
1965
104
19.0
96
19.3
8 16.0
7,934
4.1
4.6
1956
212
46.2
171
40.2
41 116,8
14,054
8.4
5.5
1964
111
21.8
103
21.6
8 24.0
8,303
4.3
5.1
1955
253
55.1
208
47.3
45 157.5
14,940
9.1
6.1
1963
130
25.1
114
24.8
16 28.5
9,311
4.9
5.1
1 Indian and Alaska Native rates are 3-year averages through 1968. All other rates are based on
2 Provisional figures -Monthly Vital Statistics Report.
single year data.
NA Not available.
INDIAN AND ALASKA NATIVE ADMISSIONS
This Is five times as many visits as reported
PHS Indian
Contract
Admissions to IHS and contract hospitals
in 1955. Outpatient visits to field clinics have
Fiscal year
Total
hospitals
hospitals
have experlenced an upward trend since
increased almost tenfold during the period
1955. Admissions for fiscal year 1972 are more
1955-1972.
than double the admissions reported in 1955.
1968
92,186
68,086
24,100
1967
Admissions to contract hospitals have in-
89,556
65,456
24,100
NUMBER OF OUTPATIENT MEDICAL VISITS 1 TO PHS INDIAN
1966
91,799
67,049
24,750
creased more rapidly than for IHS facilities.
HOSPITALS AND FIELD HEALTH CLINICS, FISCAL YEARS
1965
91,744
67,744
24,000
The rate of increase for IHS hospitals has
1964
89,934
65,934
24,000
1955-72
been 77.9 percent as contrasted to a 257.9
1963
87,549
64,749
22,800
1962
81,476
59,976
21,500
percent increase in contract hospital admis-
1961
74,313
54,313
20,000
Field
sions.
1960
76,754
56,874
19,880
Fiscal
year
Total
Hospitals
clinics
1959
73,268
54,568
18,700
NUMBER OF ADMISSIONS TO PHS INDIAN AND CONTRACT
1958
71,859
55,649
16,210
1957
66,455
53,160
13,295
1972
2,235,881
1,275,726
960,155
HOSPITALS, FISCAL YEARS 1955-72
1956
57,975
46,218
11,757
1971
2,195,240
1,202,030
993,210
1955
50,143
42,762
7,531
1970
1,786,920
1,068,820
718,100
1969
1,661,500
982,300
679,200
PHS Indian
Contract
1968
1,575,440
926,640
648,800
Fiscal year
Total
hospitals
hospitals
1967
1,494,600
OUTPATIENT VISITS
849,800
644,800
1966
1,367,000
788,500
578,500
Outpatient visits to IHS Hospitals, Health
1965
1,325,400
757,700
567,700
1972
102,472
76,054
26,418
Centers, and Field Stations have increase 1
1964
1,295,000
742,400
552,600
1971
94,945
70,729
24,216
1963
1970
each year since fiscal year 1955. Total out-
1,271,400
721,700
549,700
92,710
67,877
24,833
1962
1,142,300
673,200
469,100
1969
94,490
69,560
24,930
patient visits in fiscal year 1972 was 2,235,881.
1961
1,022,600
628,700
393,900
February 1, 1974
CONGRESSIONAL RECORD SENATE
S 1065
ment of Health, Education, and Wel-
The decline in deaths from tuberculosis,
Field
Fiscal year
Total
Hospitals
fare to contract the services and pro-
diseases of infancy, influensa, pneumonia
clinics
grams of the Indian Health Service to
and gastro-intestinal illnesses has been
dramatic. Strides also have been made in cor-
1960
404,400
tribal organizations. But if we are to
1
989,500
585,100
recting environmental deficiencies such AS
1959
957,900
546,900
411,000
realize, to the fullest, the opportunity
inadequate housing and water and sewage
1958
900,000
533,440
366,500
which exists under the contracting pro-
disposal facilities, that give rise to a high
1957
650,000
510,000
140,000
1956 *
540,860
415,860
125,000
visions of S. 1017. we must develop In-
incidence of disease and premature deaths.
1955
455,000
355,000
100,000
dian personnel who can manage such
But Dr. Johnson also notes that:
programs and individuals who can serve
those who are in need of health serv-
Although the gap has narrowed between
1 Excludes visits for dental services.
2 Estimate.
the Indian and Alaska Native state of health
$ Decreased because of underreporting of grouped services.
ices.
and that of the rest of the Nation, it is still
President Nixon, in his Indian mes-
far below national standards. Infant death
TUBERCULOSIS MORBIDITY
sage of July 8, 1970, reminded us of the
rates are 1.4 times higher than the U.S. all
The incidence rate for tuberculosis for the
problem facing Indian control of health
races rate, gastroenteric death rate is 4
Indian and Alaska Native has declined 79
programs and facilities when he noted:
times higher, and the incidence of tubercu-
percent since 1955. The U.S. All Races rate
These and other Indian health programs
losis is 8 times as high.
has declined 72 percent during the same pe-
will be most effective if more Indians are
riod. The Indian and Alaska Native rate in
There are obviously still many chal-
involved in running them. Yet-almost un-
1971 was 9.3 times the U.S. All Races rate.
lenges confronting the Indian Health
believably-we are presently able to identify
The 1955 ratio was 12.6.
Service. There is a need to combat a wide
in this country only 30 physicians and fewer
The rates shown prior to 1962 include some
than 400 nurses of Indian descent.
range of serious diseases such as otitis
newly reported inactive cases while the later
media, alcoholism, mental illness, and
years are for newly reported active cases only.
It is my personal hope that through
nutritional problems. In addition, there
However, the trends mentioned are not af-
this legislation we will reverse such de-
is also a need for expanded sanitation
fected.
pressing statistics and report by the end
programs and other endeavors to build
TUBERCULOSOS MORBIDITY
of the decade a substantial increase in
a lasting preventive health care program
(Rates per 100,000 population]
the number of Indian doctors, nurses,
so that our Indian citizens can be re-
administrators, and other allied health
lieved of the afflictions of disease and
Indian and
United
personnel serving our Indian people.
illness.
Calendar
Alaska
Alaska
States
Yet beyond the long range effort to de-
It is in this context that the IHS ap-
year
Natives
Indian
Native
all races
velop Indian health personnel there is
pears as the chief instrument through
the immediate need to ease the shortage
which a whole range of health services
1971
157.
152.0
200.3
17.0
in doctors and other trained personnel.
1970
154.1
154.1
154.0
18.3
can be delivered. Yet, the time has come
1969
140.8
141.6
134.3
19.1
When the military draft was in exist-
to redesign that instrument to give it
1968
133.8
128.0
179.1
21.3
ence, the Indian Health Service found
1967
the strength to meet the continuing
155.8
152.7
179.8
23.0
1966
141.7
127.8
247.8
24.4
itself with a number of young health pro-
challenges of providing an environment
1965
201.5
160.5
507.8
25.3
fessionals wanting to serve reservation
and a system which will promote better
1964
237.8
184.1
630.2
26.6
1963
234.0
192.3
534.9
28.7
health facilities. In 1969, for example,
health and better health care.
1962
257.7
209.4
604.7
28.9
over 3,000 medical students sought Pub-
I am pleased to join in this major
1961
318. 8
284.8
562.8
37.0
lic Health Service jobs with many indi-
1960
322.4
292.3
547.5
39.4
legislative endeavor, and our goal must
1959
418.0
338.2
1,048.0
42.6
cating that they would serve in the In-
be the goal that Dr. Johnson set out
1958
485.0
421.8
978.7
47.5
dian Health Service program. In 1973,
1957
565.2
during his testimony on the 1974 IHS
426.9
1,649.7
51.0
1956
680.6
474.3
2,283.8
54.1
however, with the elimination of the
appropriations request when he stated
1955
758.
563.2
2,225.7
60.1
draft, the number of applications had
that:
dropped to 500 with 525 slots available
The future of the Indian Health Service
1 Provisional.
in the Indian Health Service facilities.
lies in expanded Indian community develop-
What makes the situation even worse is
ment, increased meaningful involvement of
Mr. FANNIN. Mr. President, I am
that many of the current professionals
Indian people, and a responsive high quality
pleased to join with my distinguished col-
will be ending their 2-year commitment
comprehensive health care system.
leagues, Senator JACKSON and Senator
in 1974, thus causing even further short-
Our commitment is to identify and mo-
BARTLETT, in introducing this vital piece
bilize all available Federal, State and private
ages. This problem is a critical one, es-
of legislation. The health of our Indian
resources, and through effective management
pecially when one considers that there
citizens has long been of concern to me
processes to develop those resources to max-
were 2.2 million outpatient visits in 1972
imum potential. As we continue to evolve in
and this legislation will, I believe, mark
alone. Without replacements valuable
this direction, we look forward to a signifi-
a new beginning in our Indian health
health services may need to be cut. Thus,
cantly improved health status for Indian
programs. It also represents a renewal of
this legislation has an immediate prob-
and Alaska Native people.
our long-standing commitment to the
lem to solve; one that will not be easily
Indian people to provide a program of
resolved, but which cannot be ignored.
quality health services.
Another basic objective of this legis-
This legislation is significant because
lation is to provide increased resources
its objective is to redraw the legislative
to meet the backlog in construction of
authority of the Indian Health Service
health facilities. While the Federal Gov-
so that it can meet the contemporary
ernment has made a major effort to meet
needs of the Indian people. It has become
the physical plant needs of the Indian
increasingly clear that the existing au-,
Health Service, there are still many fa-
thority of the Indian Health Service is
cilities which need substantial renovation
no longer capable of meeting the ever
and expansion. There is also a need for
pressing health problems of its clients
new facilities, not only hospitals, but out-
and clearly needs new tools, resources,
patient clinics as well. The need for qual-
and innovative programs to meet those
ity facilities is becoming increasingly
needs. That is the basic purpose of this
critical as the Joint Committee on Ac-
bill.
creditation of Hospitals has reported that
In addition, this legislation seeks to
of the 51 IHS facilities, only 22 percent
meet the objective of Indian self-deter-
are accredited. Clearly there is need to
mination by developing a program which
correct such a deficiency and it is the
will serve to increase the number of In-
objective of this bill that such deficien-
dian health personnel. Earlier this week
cies be removed.
the Senate Interior and Insular Affairs
Since the organization of the Indian
Committee ordered reported S. 1017, The
Health Service in 1955 a number of seri-
Indian Self-Determination and Educa-
ous health problems have been resolved.
tional Reform Act, which provides au-
According to Dr. Emery Johnson, the DI-
thority to the Secretary of the Depart-
rector of the Indian Health Service:
OFFICE OF MANAGEMENT AND BUDGET
ROUTE SLIP
Take necessary action
TO Mr. Patterson
Approval or signature
Room 182 - EOB
Comment
Prepare reply
Discuss with me
For your information
See remarks below
FROM
Jim Stimpson (3736)
DATE Apr. 8, 1974
REMARKS
Attached for your review is a copy of
proposed HEW testimony on S. 2938, the
Indian Health Care Improvement Act,
scheduled for delivery on Thursday,
April 11.
I would appreciate receiving your
comments as early as possible. (Please call
me or Name Aweeney X 3881)
SPECIAL
SERVICE
OMB FORM 4
REV AUG 70
985h
EMBARGOED FOR RELEASE
February 6, 1974
UNTIL 12:00 PM, EDT
Office of the White House Press Secretary
THE WHITE HOUSE
TO THE CONGRESS OF THE UNITED STATES:
One of the most cherished goals of our democracy
is to assure every American an equal opportunity to lead
a full and productive life.
In the last quarter century, we have made remarkable
progress toward that goal, opening the doors to millions
of our fellow countrymen who were seeking equal opportuni-
ties in education, jobs and voting.
Now it is time that we move forward again in still
another critical area: health care.
Without adequate health care, no one can make full
use of his or her talents and opportunities. It is thus
just as important that economic, racial and social barriers
not stand in the way of good health care as it is to eliminate
those barriers to a good education and a good job.
Three years ago, I proposed a major health insurance
program to the Congress, seeking to guarantee adequate
financing of health care on a nationwide basis. That
proposal generated widespread discussion and useful debate.
But no legislation reached my desk.
is
FORD
Today the need is even more pressing because of the
HEALD
higher costs of medical care. Efforts to control medical
costs under the New Economic Policy have been met with
encouraging success, sharply reducing the rate of infla-
tion for health care. Nevertheless, the overall cost of
health care has still risen by more than 20 percent in
the last two and one-half years, so that more and more
Americans face staggering bills when they receive medical
help today:
--- Across the Nation, the average cost of a day of
hospital care now exceeds $110.
--- The average cost of delivering a baby and providing
postnatal care approaches $1,000.
-- The average cost of health care for terminal
cancer now exceeds $20,000.
For the average family, it is clear that without
adequate insurance, even normal care can be a financial
burden while a catastrophic illness can mean catastrophic
debt.
Beyond the question of the prices of health care,
our present system of health care insurance suffers from
two major flaws:
more
2
First, even though more Americans carry health in-
surance than ever before, the 25 million Americans who
remain uninsured often need it the most and are most
unlikely to obtain it. They include many who work in
seasonal or transient occupations, high-risk cases, and
those who are ineligible for Medicaid despite low incomes.
Second, those Americans who do carry health insurance
often lack coverage which is balanced, comprehensive and
fully protective:
-- Forty percent of those who are insured are not
covered for visits to physicians on an out-patient basis,
a gap that creates powerful incentives toward high-cost
care in hospitals;
-- Few people have the option of selecting care
through prepaid arrangements offered by Health Maintenance
Organizations so the system at large does not benefit from
the free choice and creative competition this would offer;
-- Very few private policies cover preventive services;
-- Most health plans do not contain built-in incentives
to reduce waste and inefficiency. The extra costs of waste-
ful practices are passed on, of course, to consumers; and
-- Fewer than half of our citizens under 65 -- and almost
none over 65 -- have major medical coverage which pays for
the cost of catastrophic illness.
These gaps in health protection can have tragic con-
sequences. They can cause people to delay seeking medical
attention until it is too late. Then a medical crisis
ensues, followed by huge medical bills -- or worse. Delays
in treatment can end in death or lifelong disability.
Comprehensive Health Insurance Plan (CHIP)
Early last year, I directed the Secretary of Health,
Education, and Welfare to prepare a new and improved plan
for comprehensive health insurance. That plan, as I
indicated in my State of the Union message, has been
developed and I am presenting it to the Congress today.
I urge its enactment as soon as possible.
The plan is organized around seven principles:
First, it offers every American an opportunity to
obtain a balanced, comprehensive range of health insurance
benefits;
Second, it will cost no American more than he can
afford to pay;
Third, it builds on the strength and diversity of
our existing public and private systems of health financing
and harmonizes them into an overall system;
Fourth, it uses public funds only where needed and
requires no new Federal taxes;
Fifth, it would maintain freedom of choice by patients
and ensure that doctors work for their patient, not for
the Federal Government.
more
3
Sixth, it encourages more effective use of our health
care resources;
And finally, it is organized so that all parties would
have a direct stake in making the system work --- consumer,
provider, insurer, State governments and the Federal
Government.
Broad and Balanced Protection for All Americans
Upon adoption of appropriate Federal and State legislation,
the Comprehensive Health Insurance Plan would offer to every
American the same broad and balanced health protection through
one of three major programs:
-- Employee Health Insurance, covering most Americans
and offered at their place of employment, with the cost to
be shared by the employer and employee on a basis which would
prevent excessive burdens on either;
-- Assisted Health Insurance, covering low-income
persons, and persons who would be ineligible for the other
two programs, with Federal and State government paying
those costs beyond the means of the individual who is
insured; and,
-- An improved Medicare Plan, covering those 65 and
over and offered through a Medicare system that is modified
to include additional, needed benefits.
One of these three plans would be available to every
American, but for everyone, participation in the program
would be voluntary.
The benefits offered by the three plans would be
identical for all Americans, regardless of age or income.
Benefits would be provided for:
-- hospital care;
-- physicians' care in and out of the hospital;
-- prescription and life-saving drugs;
-- laboratory tests and X-rays;
--- medical devices;
-- ambulance services; and,
-- other ancillary health care.
There would be no exclusions of coverage based on
the nature of the illness. For example, a person with
heart disease would qualify for benefits as would a person
with kidney disease.
In addition, CHIP would cover treatment for mental
illness, alcoholism and drug addiction, whether that
treatment were provided in hospitals and physicians' offices
or in community-based settings.
more
4
Certain nursing home services and other convalescent
services would also be covered. For example, home health
services would be covered so that long and costly stays in
nursing homes could be averted where possible.
The health needs of children would come in for special
attention, since many conditions, if detected in childhood,
can be prevented from causing lifelong disability and
learning handicaps. Included in these services for children
would be:
-- preventive care up to age six;
-- eye examinations;
-- hearing examinations; and,
-- regular dental care up to age 13.
Under the Comprehensive Health Insurance Plan, a doctor's
decisions could be based on the health care needs of his
patients, not on health insurance coverage. This difference
is essential for quality care.
Every American participating in the program would be
insured for catastrophic illnesses that can eat away savings
and plunge individuals and families into hopeless debt for
years. No family wouldever: have annual out-of-pocket
expenses for covered health services in excess of $1,500,
and low-income families would face substantially smaller
expenses.
As part of this program, every American who participates
in the program would receive a Healthcard when the plan goes
into effect in his State. This card, similar to a credit card,
would be honored by hospitals, nursing homes, emergency rooms,
doctors, and clinics across the country. This card could also
be used to identify information on blood type and sensitivity
to particular drugs --- information which might be important
in an emergency.
Bills for the services paid for with the Healthcard would
be sent to the insurance carrier who would reimburse the
provider of the care for covered services, then bill the
patient for his share, if any.
The entire program would become effective in 1976,
assuming that the plan is promptly enacted by the Congress.
How Employee Health Insurance Would Work
Every employer would be required to offer all full-time
employees the Comprehensive Health Insurance Plan. Additional
benefits could then be added by mutual agreement. The insur-
ance plan would be jointly financed, with employers paying
65 percent of the premium for the first three years of the
plan, and 75 percent thereafter. Employees would pay the
balance of the premiums. Temporary Federal subsidies would
be used to ease the initial burden on employers who face
significant cost increases.
Individuals covered by the plan would pay the first
$150 in annual medical expenses. A separate $50 deductible
provision would apply for out-patient drugs. There would
be a maximum of three medical deductibles per family.
more
5
After satisfying this deductible limit, an enrollee
would then pay for 25 percent of additional bills. However,
$1,500 per year would be the absolute dollar limit on any
family's medical expenses for covered services in any one
year.
How Assisted Health Insurance Would Work
The program of Assisted Health Insurance is designed
to cover everyone not offered coverage under Employee Health
Insurance or Medicare, including the unemployed, the dis-
abled, the self-employed, and those with low incomes. In
addition, persons with higher incomes could also obtain
Assisted Health Insurance if they cannot otherwise get
coverage at reasonable rates. Included in this latter
group might be persons whose health status or type of work
puts them in high-risk insurance categories.
Assisted Health Insurance would thus fill many of the
gaps in our present health insurance system and would ensure
that for the first time in our Nation's history, all Americans
would have financial access to health protection regardless
of income or circumstances.
A principal feature of Assisted Health Insurance is that
it relates premiums and out-of-pocket expenses to the income
of the person or family enrolled. Working families with
incomes of up to $5,000, for instance, would pay no premiums
at all. Deductibles, co-insurance, and maximum liability
would all be pegged to income levels.
Assisted Health Insurance would replace State-run
Medicaid for most services. Unlike Medicaid, where benefits
vary in each State, this plan would establish uniform benefit
and eligibility standards for all low-income persons. It
would also eliminate artificial barriers to enrollment or
access to health care.
As an interim measure, the Medicaid program would be
continued to meet certain needs, primarily long-term
institutional care. I do not consider our current approach
to long-term care desirable because it can lead to over-
emphasis on institutional as opposed to home care. The
Secretary of Health, Education, and Welfare has undertaken
a thorough study of the appropriate institutional services
which should be included in health insurance and other
programs and will report his findings to me.
Improving Medicare
The Medicare program now provides medical protection
for over 23 million older Americans. Medicare, however,
does not cover outpatient drugs, nor does it limit total
out-of-pocket costs. It is still possible for an elderly
person to be financially devastated by a lengthy illness
even with Medicare coverage.
I therefore propose that Medicare's benefits be
improved so that Medicare would provide the same benefits
offered to other Americans under Employee Health Insurance
and Assisted Health Insurance.
more
6
Any person 65 or over, eligible to receive Medicare
payments, would ordinarily, under my modified Medicare plan,
pay the first $100 for care received during a year, and
the first $50 toward out-patient drugs. He or she would
also pay 20 percent of any bills above the deductible
limit. But in no case would any Medicare beneficiary
have to pay more than $750 in out-of-pocket costs. The
premiums and cost sharing for those with low incomes would
be reduced, with public funds making up the difference.
The current program of Medicare for the disabled would
be replaced. Those now in the Medicare for the disabled
plan would be eligible for Assisted Health Insurance, which
would provide better coverage for those with high medical
costs and low incomes.
Premiums for most people under the new Medicare program
would be roughly equal to that which is now payable under
Part B of Medicare --- the Supplementary Medical Insurance
program.
Costs of Comprehensive Health Insurance
When fully effective, the total new costs of CHIP to
the Federal and State governments would be about $6.9
billion with an additional small amount for transitional
assistance for small and low wage employers:
-- The Federal Government would add about $5.9 billion
over the cost of continuing existing programs to finance
health care for low-income or high risk persons.
--- State governments would add about $1.0 billion
over existing Medicaid spending for the same purpose,
though these added costs would be largely, if not wholly
offset by reduced State and local budgets for direct
provision of services.
-- The Federal Government would provide assistance
to small and low wage employers which would initially
cost about $450 million but be phased out over five years.
For the average American family, what all of these
figures reduce to is simply this:
-- The national average family cost for health
insurance premiums each year under Employee Health
Insurance would be about $150; the employer would pay
approximately $450 for each employee who participates
in the plan.
-- Additional family costs for medical care would
vary according to need and use, but in no case would a
family have to pay more than $1,500 in any one year for
covered services.
-- No additional taxes would be needed to pay for
the cost of CHIP. The Federal funds needed to pay for
this plan could all be drawn from revenues that would be
generated by the present tax structure. I am opposed to
any comprehensive health plan which requires new taxes.
more
7
Making the Health Care System Work Better
Any program to finance health care for the Nation must
take close account of two critical and related problems --
cost and quality.
When Medicare and Medicaid went into effect, medical
prices jumped almost twice as fast as living costs in
general in the next five years. These programs increased
demand without increasing supply proportionately and
higher costs resulted.
This escalation of medical prices must not recur when
the Comprehensive Health Insurance Plan goes into effect.
One way to prevent an escalation is to increase the supply
of physicians, which is now taking place at a rapid rate.
Since 1965, the number of first-year enrollments in
medical schools has increased 55 percent. By 1980, the
Nation should have over 440,000 physicians, or roughly
one-third more than today. We are also taking steps to
train persons in allied health occupations, who can
extend the services of the physician.
With these and other efforts already underway, the
Nation's health manpower supply will be able to meet the
additional demands that will be placed on it.
Other measures have also been taken to contain medical
prices. Under the New Economic Policy, hospital cost
increases have been cut almost in half from their post-
Medicare highs, and the rate of increase in physician
fees has slowed substantially. It is extremely important
that these successes be continued as we move toward our
goal of comprehensive health insurance protection for all
Americans. I will, therefore, recommend to the Congress
that the Cost of Living Council's authority to control
medical care costs be extended.
To contain medical costs effectively over the long
haul, however, basic reforms in the financing and delivery
of care are also needed. We need a system with built-in
incentives that operates more efficiently and reduces the
losses from waste and duplication of effort. Everyone
pays for this inefficiency through their health premiums
and medical bills.
The measure I am recommending today therefore contains
a number of proposals designed to contain costs, improve
the efficiency of the system and assure quality health
care. These proposals include:
1. Health Maintenance Organizations (HMO's)
On December 29, 1973, I signed into law legislation
designed to stimulate, through Federal aid, the establish-
ment of prepaid comprehensive care organizations. HMO's
have proved an effective means for delivering health care
and the CHIP plan requires that they be offered as an
option for the individual and the family as soon as they
become available. This would encourage more freedom of
choice for both patients and providers, while fostering
diversity in our medical care delivery system.
more
(OVER)
8
2. Professional Standards Review Organizations (PSRO's)
I also contemplate in my proposal a provision that
would place health services provided under CHIP under the
review of Professional Standards Review Organizations.
These PSRO's would be charged with maintaining high
standards of care and reducing needless hospitalization.
Operated by groups of private physicians, professional
review organizations can do much to ensure quality care
while helping to bring about significant savings in health
costs.
3. More Balanced Growth in Health Facilities
Another provision of this legislation would call on the
States to review building plans for hospitals, nursing
homes and other health facilities. Existing health insur-
ance has overemphasized the placement of patients in
hospitals and nursing homes. Under this artificial stimulus,
institutions have felt impelled to keep adding bed space.
This has produced a growth of almost 75 percent in the
number of hospital beds in the last twenty years, so that
now we have a surplus of beds in many places and a poor
mix of facilities in others. Under the legislation I am
submitting, States can begin remedying this costly imbalance.
4. State Role
Another important provision of this legislation calls
on the States to review the operation of health insurance
carriers within their jurisdiction. The States would
approve specific plans, oversee rates, ensure adequate
disclosure, require an annual audit and take other
appropriate measures. For health care providers, the
States would assure fair reimbursement for physician
services, drugs and institutional services, including a
prospective reimbursement system for hospitals.
A number of States have shown that an effective job can
be done in containing costs. Under my proposal all States
would have an incentive to do the same. Only with effective
cost control measures can States ensure that the citizens
receive the increased health care they need and at rates
they can afford. Failure on the part of States to enact
the necessary authorities would prevent them from receiving
any Federal support of their State-administered health
assistance plan.
Maintaining a Private Enterprise Approach
My proposed plan differs sharply with several of the
other health insurance plans which have been prominently
discussed. The primary difference is that my proposal
would rely extensively on private insurers.
Any insurance company which could offer those benefits
would be a potential supplier. Because private employers
would have to provide certain basic benefits to their
employees, they would have an incentive to seek out the
best insurance company proposals and insurance companies
would have an incentive to offer their plans at the lowest
possible prices. If, on the other hand, the Government
were to act as the insurer, there would be no competition
and little incentive to hold down costs.
more
9
There is a huge reservoir of talent and skill in
administering and designing health plans within the
private sector. That pool of talent should be put to
work.
It is also important to understand that the CHIP plan
preserves basic freedoms for both the patient and doctor.
The patient would continue to have a freedom of choice
between doctors. The doctors would continue to work for
their patients, not the Federal Government. By contrast,
some of the national health plans that have been proposed
in the Congress would place the entire health system under
the heavy hand of the Federal Government, would add con-
siderably to our tax burdens, and would threaten to destroy
the entire system of medical care that has been so carefully
built in America.
I firmly believe we should capitalize on the skills
and facilities already in place, not replace them and
start from scratch with a huge Federal bureaucracy to add
to the ones we already have.
Comprehensive Health Insurance Plan
---
A
Partnership
Effort
No program will work unless people want it to work.
Everyone must have a stake in the process.
This Comprehensive Health Insurance Plan has been
designed so that everyone involved would have both a stake
in making it work and a role to play in the process
consumer, provider, health insurance carrier, the States
and the Federal Government. It is a partnership program
in every sense.
By sharing costs, consumers would have a direct economic
stake in choosing and using their community's health
resources wisely and prudently. They would be assisted
by requirements that physicians and other providers of
care make available to patients full information on fees,
hours of operation and other matters affecting the quali-
fications of providers. But they would not have to go it
alone either: doctors, hospitals and other providers of
care would also have a direct stake in making the Compre-
hensive Health Insurance Plan work. This program has
been designed to relieve them of much of the red tape,
confusion and delays in reimbursement that plague them
under the bewildering assortment of public and private
financing systems that now exist. Healthcards would
relieve them of troublesome bookkeeping. Hospitals could
be hospitals, not bill collecting agencies.
Conclusion
Comprehensive health insurance is an idea whose time has
come in America.
There has long been a need to assure every American
financial access to high quality health care. As medical
costs go up, that need grows more pressing.
Now, for the first time, we have not just the need but
the will to get this job done. There is widespread support
in the Congress and in the Nation for some form of com-
prehensive health insurance.
more
10
Surely if we have the will, 1974 should also be the
year that we find the way.
The plan that I am proposing today is, I believe, the
very best way. Improvements can be made in it, of course,
and the Administration stands ready to work with the
Congress, the medical profession, and others in making
those changes.
But let us not be led to an extreme program that would
place the entire health care system under the dominion of
social planners in Washington.
Let us continue to have doctors who work for their
patients, not for the Federal Government. Let us build
upon the strengths of the medical system we have now, not
destroy it.
Indeed, let us act sensibly. And let us act now ---
in 1974 --- to assure all Americans financial access to
high quality medical care.
RICHARD NIXON
THE WHITE HOUSE,
February 6, 1974.
# # # #
EMBARGOED UNTIL 12:00 NOON, EST
February 6, 1974
WEDNESDAY, FEBRUARY 6, 1974
Office of the White House Press Secretary
THE WHITE HOUSE
FACT SHEET
THE COMPREHENSIVE HEALTH INSURANCE PLAN
I.
STRUCTURE.
2
A. Employee Health Insurance Plan
2
B. Assisted Health Insurance Plan
2
II.
BENEFITS
3
A. Reimbursable Services
3
B. Premiums and Cost-Sharing
4
III. FEDERAL PROGRAMS
6
A. Medicare
6
B. Medicaid
7
C. Indian Health
7
D. Veterans' Administration
7
IV. REIMBURSEMENT POLICY
7
A. Healthcard
7
B. Classification of Providers
8
V.
REGULATION AND ADMINISTRATION
8
A. Regulation of Insurance Carriers
8
B. Regulation of Medical Providers
9
C. Administration
9
VI. COSTS
9
VII. FINANCING
10
A. Employer Plan
10
B. Government Plan
10
C. Medicare
10
D. Medicaid
10
VIII. SPECIAL PROVISIONS TO ASSIST SMALL EMPLOYERS
10
2
MAJOR FEATURES OF THE COMPREHENSIVE HEALTH INSURANCE PLAN
I. STRUCTURE
A. Employee Health Insurance Plan (EHIP)
-
All employers would be required to offer the basic
insurance plan and Health Maintenance Organization (HMO)
coverage to each employee under age 65 who has met the
full-time hours of work test. Coverage extends to family
members under 65. Employers may self-insure.
-
Election of coverage would be voluntary at the option of
the employee.
-
The basic plan would also be available to self-employed
and non-working families, individuals, and non-employer
groups (e.g., unions or professional associations), through
private carriers.
-
Employers would be required to offer coverage meeting
the basic plan, and could offer optional plans supplementing
the basic plan. Employers could not offer non-approved
plans.
-
Employers would contribute 65 percent of premium expenses
for covered employees. However, if an employer's payroll
rises by more than 3 percent due to required contributions
to coverage, then the Federal Government would pay a
subsidy to the employer for employer premiums in excess
of the 3 percent increase in payroll expenses. The subsidy
would be 75 percent of such excess in the first year reduced
by 15 percentage points each year thereafter.
-
The employer contribution toward coverage would begin 90
days after onset of employment and continue for 90 days after
termination of full-time employment.
-
An individual or family which has been enrolled in an
Employee Health Insurance Plan would be allowed to con-
tinue coverage under the plan, at the employer's group rate,
for 90 days following the period of a required employer
contribution (a total of 180 days after termination), by
paying the premium in full themselves.
B. Assisted Health Insurance Plan (AHIP)
-
States would contract with intermediaries to offer the
basic plan to all residents of the State, except those with
family incomes of $7,500 or more who are offered the
Employee Health Insurance Plan.
more
3
- Employers who desire to do so could offer AHIP
(at 150% of the average group rate in the State) in
fulfillment of the requirement to offer a mandated plan.
Members of such employee groups could enroll in AHIP
irrespective of income level.
- Persons who would, in fact, enroll in AHIP:
a. families below $5,000 income ($3,500 for individuals)
regardless of work status
b. non-working families between $5,000 and $7,500 income
($3, 500-$5, 250 for individuals)
C. very high risk working families between $5,000 and
$7,500 income ($3, 500-$5, 250 for individuals)
d. non-working families with unusually high medical
risks (disabled and early retirees) regardless of income
e. unusually high risk employer groups.
- All persons eligible for AHIP would have the option of
obtaining coverage through an approved prepaid health
care plan.
- The premiums, deductibles, coinsurance, and maximum
liability would be related to income.
- Carriers administering AHIP coverage would be reimbursed
by the State on the basis of actual benefits paid for
covered services, less income derived from the plan,
plus a negotiated rate for administration.
- Employers would be:required to make a contribution to
AHIP for low-income employees who elect that coverage,
in the amount they would have contributed for other
employees under an Employee Health Insurance Plan.
-
For AHIP eligibles who elect coverage through a prepaid
health care plan, the State would contribute an amount equal
to the cost of providing AHIP coverage.
II. BENEFIT PACKAGE
A. Reimbursable Services
- Hospital services, not subject to a dollar limitation.
-
Physician services, not subject to a dollar limitation.
-
Prescription drugs, out-of-hospital.
more
4
-
Mental Health services
inpatient - 30 full days or 60 partial days
outpatient - 30 visits to a comprehensive community care
center or private practitioner (the latter not to exceed
15 visits)
-
Special and preventive services for children
well child care up to age 6
eye examinations, developmental vision care, and
eyeglasses up to age 13
ear examinations and hearing aids up to age 13
routine dental services up to age 13
-
Other preventive services
prenatal and maternity services
family planning
-
Home Health Services - 100 visits per year
-
Post-hospital extended care - 100 days per year
-
Blood and blood products
-
Other medical services, as in Medicare (prosthetic devices,
dialysis equipment and supplies, x-rays, laboratory,
ambulance, etc.).
B. Premiums and Cost-Sharing (EHIP and AHIP)
Employer Plan
-
Premiums for employer groups of 51 or more employees and
other families and groups being offered EHIP would be
negotiated between employer and other groups and the
insurance carrier.
-
Expenses for an insured individual which exceed $10, 000
in a year cannot be attributed to the experience rating
of the employee group through which the individual has
obtained coverage.
-
Each insurance company would be required to offer the same
rate to all employees in firms with 1 to 50 employees
(subject to the single/family rate differential).
more
5
-
Rates for coverage under the plan cannot differ on the
basis of family size and composition, except that there
must be separate rate determinations for singles and
families with the single rate being 40 percent of the
family rate.
-
The benefit package as presently constituted would result
in an approximate average group family premium of about
$600. (The single person could expect to pay a premium
of $240.) The average premium required by this coverage
per full-time employee is $415.
-
The employer would eventually pay 75% of premium costs
and employees the remaining 25%.
-
EHIP would not reimburse for services until the insured
unit has met a deductible of $150 per person (maximum of
three deductibles per family), with a separate $50 per person
deductible on reimbursement for outpatient drugs.
-
After satisfying the deductible, the enrollee pays a
coinsurance of 25 percent, with a maximum liability for
cost-sharing (deductible plus coinsurance) of $1,500 in
a year.
There would be no per year or lifetime limitation on benefits
paid by the Plan.
Assisted Health Insurance Plan (AHIP)
-
Premiums, deductibles, coinsurance, and maximum liability
would be all income-related under the AHIP. The following
schedule has been used in making cost estimates for the
Comprehensive Heal th Insurance Act of 1974.
FORD LIBRARY &
SINGLE
Annual
Per Person
Income
Contribution*
Deductible
Maximum
Drugs
Other
Coinsurance
Liability
I
$
0-1,749
$
0
$ 0
$ 0
10%
6% of income
II
1,750-3,499
0
25
50
15
9% of income
III
3,500-5,249
120
50
100
20
12% of income
IV
5,250-6,999
240
50
150
25
15% of income
V
7,000
+
360
50
150
25
$1,050
* Based on 50 percent of average group single rate in Group III, 100
percent in Group IV, and 150 percent in Group V. Expected average
group single premium rate equals $240.
more
6
FAMILY
Annual
Per Person
Maximum
Income
Contribution**
Deductible
Coinsurance
Liability
Drugs
Other
I
$
0-2,499
$
0
$
0
$ 0
10%
6% of income
II
2,500-4,999
0
25
50
15
9% of income
III
5,000-7,49
300
50
100
20
12% of income
IV
7,500-9,999
600
50
150
25
15% of income
V
10,000
+
900
50
150
25
$1,500
** Contributions based on 50 percent of average group family premium
rate in the State .for Group III, 100 percent for Group IV, and 150
percent for Group V. Expected average group family premium rate
equals $600.
III. FEDERAL PROGRAMS
A. Medicare
-
Medicare for the Aged would be retained, with the benefits
changed to conform with the mandated health plan.
-
Medicare would continue to be administered directly by the Social
Security Administration through its own system of fiscal
intermediaries.
-
The benefit package would include the full range of services as in
EHIP and AHIP. As a result, outpatient drugs and mental health
services would be covered, and the aged would have far superior
protection against catastrophic expenses -- complete hospitalization
and maximum financial liability. (Medicare now covers 90 days
of hospitalization per episode plus a lifetime reserve of 60 days.)
-
A Medicare beneficiary would face an annual per person deductible
of $100 on all services except outpatient drugs. The deductible
for outpatient drugs would be $50. Beneficiaries would pay 20
percent coinsurance on expenses above the deductible up to a
maximum annual liability of $750.
-
Medicare for the Aged would be financed from the current 1.8
percent payroll tax plus a small premium contribution by the
enrollee (about $90 per person annually, roughly equal to the
current Part B premium).
-
Federal, State, and local government employers and employees
would participate in the Medicare system and be subject to the
Medicare payroll tax.
more
7
-
Medicare beneficiaries who are low-income would be eligible
for reduced premium payments and cost-sharing. The income
testing and income definitions would be tied to SSI.
-
Dependents of Medicare beneficiaries below age 65 would be
eligible to enroll in AHIP.
-
Medicare for the Disabled (including the kidney disease
provisions) would cease as a separate program. The dis-
abled would be eligible for AHIP coverage. Most current
Medicare disabled beneficiaries would have better protec-
tion because of the catastrophic provisions and because a
high proportion would qualify for reduced cost sharing be-
cause they are low-income but have Social Security cash
payments which place them beyond Medicaid eligibility.
-
Reimbursement for Medicare services in a State would be
based on the same system as used in that State for EHIP/
AHIP services.
B. Medicaid
-
Medicaid would be terminated except for certain services
not covered by the Comprehensive Health Insurance Act.
These include (1) services in a skilled nursing facility
or intermediate care facility; (2) care in mental institutions
for persons under age 21 or over 65; and (3) home health
services.
C. Indian Health
-
The Indian Health Service would continue to provide health
care to eligible Indians.
-
Indians may also participate in State AHIP programs.
D. Veterans Administration
-
The VA would continue to operate a separate health care
system for those eligible for VA benefits.
-
The VA system would be reimbursed for services not
related to a disability incurred while in the military.
IV. REIMBURSEMENT POLICY
A. Healthcard
-
All persons (including Medicare enrollees) would receive
an identification card which would be evidence of financial
protection for all covered services.
more
8
-
Participating providers of service would be required to
accept the card as evidence of coverage and would bill
the indicated carrier for covered services.
-
The carrier would reimburse the provider and would bill
the enrollee for the applicable cost-sharing.
B. Classification of Providers
-
Full-Participating Providers - would agree to accept reimburse-
ment through the Healthcard as payment in full for all patients
(EHIP, AHIP, and Medicare). To these providers the Health-
card would reimburse the full amount of the applicable
reimbursement rates (the insured amount as well as the
patient's cost-sharing). All institutions would be required
to be full-participating providers.
-
Associate-Participating Providers - would agree to accept
reimbursement through the Healthcard as payment in full
for all AHIP and Medicare patients, and as payment of the
insured amount of an Employee Health Insurance Plan en-
rollee's bills. To collect the remainder of his fee for the
patient, the physician would bill the patient directly.
-
Non-Participating Providers - would not be reimbursed from
any approved plan for services provided.
V.
Regulation and Administration
A. State Regulation and Administration -- States must enact appro-
priate legislation fulfilling each of the following responsibilities
to be eligible for Federal financial participation in the plan. This
regulation must extend to prepaid health care plans as well as to
all private carriers and self-insured employers.
-
Carriers and self-insured employers providing the basic
plan would file their plans with the States, keeping the
State advised of the employers and employees to whom
the plan is provided. States would be required to provide
for prompt review of the plan and determination as to
whether it meets the requirements of the law.
-
Premium rates and rating structures would be reviewed
for reasonableness (file and use procedure) for all private
health insurance.
-
Enrollees would be guaranteed against noncoverage or non-
payment of claims related to the basic plan resulting from
carrier insolvency.
-
An annual CPA audit would be required for all insurance
carriers offering coverage under the plan.
more
9
-
Carriers would be required to disclose information with
regard to services covered, rates, and the relation between
premiums and benefits paid. This requirement must extend
to all private health insurance sold.
-
All capital investment over $100,000 would be approved by
a State-designated planning agency to receive reimbursement
through the plan.
-
Medical services would be subject to Professional Standards
Review Organization.
-
Physician reimbursement for covered services under the
insurance plans would be based on amounts determined
after consultation with providers and other interested parties.
Physicians would be free to bill additional charges to those
covered under the Employee Health Insurance Plan provided
the patient is notified beforehand of such additional charges.
-
States would establish prospective reimbursement systems
for hospitals.
-
Providers would make available to patients information
regarding charges for most commonly given services, hours
of operation and other matters affecting access to services,
and extent of certification, accreditation, and licensure.
-
In addition to administration and participation in financing
of the AHIP, States would be responsible for certifying
health care providers as eligible for participation in the
Comprehensive Health Insurance Plan.
B. Federal Regulation and Administration -- The Federal
Government would:
-
Establish standards for eligibility.
-
Define the services to be reimbursed by the plan.
-
Operate an expanded program of benefits for the aged.
VI. COSTS
-
Added Federal/State expenditures to finance the Assisted Health
Insurance Plan would approximate $6. 9 billion
-
Added State spending under the Government Plan would equal
about $1. 0 billion. Much of this would be offset by reductions
in other State health programs
-
Added Federal spending would equal about $5. 9 billion
-
The Federal subsidy to assist low-income employees and
their employers would equal about $0.45 billion
-
The additional cost of increased benefits for the aged would
be $1. 8 billion
more
10
VII. FINANCING
A. Employee Health Insurance Plan (EHIP)
-
Would be financed jointly by employers and employees.
-
Employers would be required to make a contribution to
the EHIP for those employees who qualify and enroll.
B. Assisted Health Insurance Plan (AHIP)
-
Costs of AHIP above the income derived from enrollees
would be shared by State and Federal governments. The
States share would be related to current levels of State
expenditures, ability to pay, and anticipated future expendi-
tures under The Comprehensive Health Insurance Plan in
that State. The total State share would be about 25%.
C. Medicare
-
The Medicare Trust Fund (plus a small premium contribution
(about $90 per year)) would pay for all services provided
under the basic Medicare plan. The cost above the basic
income aged would be borne by General Revenues and
State contributions.
D. Medicaid
-
A residual Medicaid program for long term care services
would continue with the current Federal/State Medicaid
matching formula.
VIII. SPECIAL PROVISIONS TO ASSIST SMALL EMPLOYERS
The following provisions have been incorporated, which would
particularly assist small employers, since they have a higher proportion
of low wage workers and pay higher premiums than large employers:
-
Where two members of the same family are eligible for
Employee Health Insurance Plan coverage, only one could
accept. This provision would benefit small business, which
hire a disproportionate number of secondary workers.
-
Each insurance company would be required to offer coverage
at the same premium rate to all employees in firms with up
to 50 employees. This provision would reduce the costs
associated with carriers individually rating small groups.
It also would minimize the adverse labor market effects
against hiring high medical risk individuals.
-
The Federal government will subsidize the employer whose
payroll costs increase by more than three percent as a
result of The Health Insurance Plan. The excess over three
percent will be subsidized by 75% the first year and reduced
15 percentage points each year thereafter.
#####
THE WHITE HOUSE
WASHINGTON
March 7, 1975
MEMORANDUM FOR: JACK MARSH
FROM:
TED MARRSW
Jack:
I will appreciate your personally reviewing
this one and supporting my views on it.
Any comments will be appreciated.
Attachment
oh!
FORD LIBRARY
gun
MAR 8 1975
THE WHITE HOUSE
WASHINGTON
March 7, 1975
MEMORANDUM FOR:
JIM LYNN
FROM:
TED MARRS I'm
SUBJECT:
S. 522, Indian Health Care Improvement Act
This bill:
deserves more than an ivory tower automatic negative.
strikes at the most flagrant medical inequity existing
in this country today.
does not start a new program.
can be adjusted to be responsible and realistic.
... LIBRARY is 07VN30
Attachment
FORD LIBRAD & CERALD
CC: Mr. Buchen
Mr. Marsh
Mr. Rumsfeld
Mr. Cannon
S. 522 was introduced into the Senate on February 3, 1975. This bill is
identical with S. 2938 (93rd Congress) that passed the Senate on November 25,
1974. Bills similar to S. 522 have also been introduced into the House and
assigned numbers H.R. 2525 and H.R. 2526. Co-sponsorship of these bills and
the passage of S. 2938 by the Senate in the 93rd Congress indicates there
is strong bipartisan Congressional support for passage.
The indicated position of the Administration on this proposed legislation
is to generally oppose enactment. I believe that such a position, if
FORD LIBRARY GERALD
taken, needs re-evaluation.
First, a number of studies have been made of the Indian health program. AIL
of these studies have documented the unmet needs of the Indian health
services program at essentially the same levels as identified in the pro-
posed legislation. These studies have been made by the Department of
Health, Education, and Welfare, by Congressional committees and by outside
groups, such as the American Academy of Pediatrics.
Second, to categorically oppose the legislation without an alternative pro-
posal would appear to the Congress and the Indian people that the Administration
is either unsympathetic to the health needs of Indians or is unwilling to
commit itself to meeting those needs within any reasonable time.
2
Third, when the President signed the Indian Self-Determination and Education
Assistance Act (P.L. 93-638) on January 4, 1975, he stated that the "act
gives permanence and stature of law to the objective of my Administration
of allowing indeed encouraging Indian tribes to operate programs serving
them under contract to the Federal Government." He also "pledged the support
of this Administration" to the fullest possible use of the authorities pro-
vided in the Act (P.L. 93-638).
Several provisions of the bills now pending before the Congress would con-
tribute to the achievement of the policy on Indian self-determination. If
these are not singled out for support or a reasonable alternative proposed,
the sincerity of the Administration's January 4 pledge to support the fullest
use of the authorities contained in P.L. 93-638 would certainly be subjected
to question.
To avoid these implications of denial of documented needs, unsympathetic
attitude, and insincerity, I would suggest the following alternative to
general opposition to enactment of the pending bills entitled "Indian
Health Care Improvement Act."
First, the Administration would express its concurrence with the intent of
the bills, i.e., unmet needs exist and they must be met. To meet these
needs over a five year period is not feasible with the current economic
condition of the Nation. Since forecasts are for an improved economic sit-
uation, the Administration should agree to initiate measures now to reduce
the unmet needs and propose a seven or a ten year plan to eliminate them.
3
Second, those provisions in the bills that are considered to contribute most
to Indian self-determination should be supported. In this connection, I
believe that two titles and one section of another title would make the
greatest contributions. These are Title I, Indian Health Manpower; Title IV,
Access to Health Services; and section 603 of Title VI.
Title I would contribute to self-determin tion and the Indian operation of
the health services programs by capacity building in the Indian population.
Currently, the number of Indian persons trained in the health professions
and paraprofessions is grossly inadequate to enable them to man and manage
their health services programs under contract to the Government. This health
manpower pool must be substantially increased if such contracts are to be
made. The fact that this situation exists demonstrates the inability or
failure of existing health manpower programs to fill this need. Title I of
S. 522 would be more appropriate if it would provide authority to train only
persons of Indian descent. The authorization to train non-Indians should be
opposed because this can be accomplished through existing health scholarship
authorities for the general population.
Title IV, Access to Health Services, would permit the Indian health service
program while still operated by the Government to develop and test a system
for collecting third party payment for health care provided at the Indian
health facilities. This would contribute to the policy of self-determination
by capacity building and, in the future, permit Indian medicare and medicaid
eligibles to be treated at their own facility with assurances that reimburse-
ment could be made. This Title would also waive applicable facility standards
4
providing there is a plan to bring the facility into full compliance with
the standards within two years. I'll discuss this further when consider-
ation is given to Title III of the bills.
The last section of the bills which should be supported is Section 603 of
Title VI. This section would permit the Secretary to enter into long-term
leasing agreements (up to twenty years) with the tribes. Under this author-
ity, Indian tribes could build whatever facility might be needed to operate
or manage the health program and the Secretary could lease it from them.
Such leases would assist tribes in obtaining financing for construction and
it would build the capacity of tribes to construct, operate and maintain
major physical facilities. It would also assist the Government in over-
coming the need for replacement facilities without, at the same time, making
large cash outlays.
Title II, Health Services; Title III, Health Facilities; and Title V,
Health Services for Urban Indians and sections 601 and 602 of Title VI,
Miscellaneous, are essentially unnecessary authorities or appropriation
authorizations. The appropriation authorizations are in effect limiting
in Titles II, III and V because the current authorizing law (25 U.S.C. 13,
the so called Snyder Act) is open ended.
Titles II and III propose to eliminate the health services and facilities
unmet needs during the next five fiscal years. Since these needs are well
documented, I would recommend that the Administration's position on these
titles endorse the concept of meeting the needs within a specific time
frame. The time frame proposed in the bills may, however, not be consistent
5
with the state of the economy and related budget constraints. It would
appear that a seven or possibly ten year time period might be more appro-
priate than five. A mutually agreed upon plan could be developed through
Congressional and Administration participation. The commitment to a plan
for facilities would also be consistent with the provision of Title IV
which would initially waive compliance with facility standards.
Title V proposes a three year trial program to assist urban Indians in
meeting their health needs. A review of the program would be required as
would a report to the Congress assessing the program and recommending any
further legislative efforts. There is authority to initiate such programs
subject only to appropriations. Since the late 1960's, Congress has,
through the appropriations process, requested the establishment of several
urban Indian projects. These special projects should be continued in the
future within the appropriations made by Congress. Since adequate authority
already exists for a Federal urban Indian effort, it would seem that the
continuation and/or expansion of such an effort should be decided through
discussions with Congressional and Administration personnel and not by
legislation. Consequently, this matter would be appropriate to discuss
during the development of a plan for health services and facilities con-
struction.
BRIEF EXPLANATION OF H.R. 2525, AS REPORTED BY THE
COMMITTEE ON INTERIOR, COMMITTEE ON WAYS AND MEANS,
AND COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE
Section 1 gives the title of the Act.
Section 2 are congressional findings outlining the necessity
for the legislation.
Section 3 is a declaration of policy.
Section 4 contains definitions.
"I
TITLE I - INDIAN HEALTH MANPOWER
Section 101 gives the purpose of this title, which is to
increase the number of health professionals serving Indians and to
increase the number of Indians in those health professions.
Section 102 is a health recruitment program designed to
identify those eligible Indians and to publicize existing sources
of financial aid. $4.2 million
is authorized over 3 fiscal years.
Section 103, the health professions preparatory scholarship
program, allows a student to receive scholarship grants, for up to
two years, for compensatory preprofessional education. $3.1 million
is authorized over three fiscal years.
Section 104, the health professions scholarship program, authorize:
an "Indian" program within the National Health Service Corps scholarship
program. Such scholarships will be designated Indian Health Scholarships
and will extend to physicians, dentists, nurses, optometrists, podia-
trists, pharmacists, public health personnel, and allied health personnel
$18.95 million is authorized over three fiscal years.
GENALD FORD CIGRARY
2
Section 105 allows the Indian Health Service to hire a
scholarship grantee as an intern for a period of up to 120 days to work
in the nonacademic period of the year. $2.4 million is authorized for
three fiscal years.
Section 106, the continuing education allowance provision,
authorized .55 million over three fiscal years so that physicians
and other professionals can leave their duty stations for professional
consultation and refresher training courses.
TITLE II -- HEALTH SERVICES
Section 201 (a) directs that the funds authorized under this
title shall be in addition to the level of approprations provided
in the preceding fiscal year.
Subsection (b) directs that the personnel authorized under
this title shall be in addition to the number authorized in the preceding
fiscal year.
Subsection (c) gives the following breakdown for funds and
positions over three fiscal years:
(1) Patient Care: $24.7 million & 525 positions
(2) Field Health: $8.9 million & 198 positions
(3) Dental Care: $3 million & 130 positions
(4) Mental Health:
(A) Community mental health: $3.3 million & 60 positions
(B) Inpatient mental health: $1 million & 30 positions
(C) Model dormitory: $3.125 million & 100 positions
(D) Therapeutic & residential treatment centers: $.7
million & 15 positions
(E) Training of Indian traditional practitioners: $13 million
(5) Treatment of Alcoholism: $13 million
(6) Maintenance & Repair: $7 million & 50 positions
3
Subsection (d) directs that not less than 1% of the funds
appropriated shall be used for research.
Subsection (c) authorizes that not more than $5 million
shall be expended in Fiscal Year 1977.
TITLE III - HEALTH FACILITIES
Service Facilities
Section 301 authorizes the Secretary to use these funds for
construction and renovation of hospitals, health centers, stations,
or other facilities of the Indian Health Service.
Subsection (b) authorizes the following amounts for the following
facilities:
(1) Hospitals: $190 million over three fiscal years.
(2) Health centers & stations: $16.906 million over 3 Fiscal years
(3) Staff housing: $27.083 million over 3 years
Subsection (c) directs that the Secretary shall consult with
any Indian tribe which will be significantly affected by expenditure
of these funds; and directs that the facilities constructed shall
meet JCAH standards within one year of construction.
Safe Water & Sanitary Waste Disposal Facilities
Section 302. (a) authorizes these funds to be used to provide
water and sanitation facilities in new and existing Indian homes.
Subsection (b) authorizes $103 million for this construction in
existing homes over three fiscal years. Such sums as may be necessary
are authorized for these facilities in new Indian homes.
FORD : LIBRARY 038870
4
Subsection (c) directs that former and currently federally
recognized Indian tribes in New York State shall be eligible for
assistance under this title.
Preference to Indians & Indian Firms
Section 303 (a) directs the Secretary to give preference
to Indians and Indian owned firms for construction under this title.
Subsection (b) provides that the Davis-Bacon requirements
for federal contracting shall apply.
Soboba Sanitation Facilities
Section 304 directs that the Soboba Band of Mission Indians in
California is eligible for IHS sanitation services.
TITLE IV - ACCESS TO HEALTH SERVICES
Medicare
Section 401 makes an amendment to the Medicare Act.
Section 402 further amends the Medicare Act to provide that
the IHS can be reimbursed for the care of a medicare eligible patient
in an IHS facility. The section allows all facilities to be declared
accredited for medicare purposes for a period of 18 months. The funds
which are collected by the IHS are to be used exclusively for the
purpose of bringing that facility into compliance,
5
Section 402 amends the Medicaid Act to provide that
the IHS can be reimbursed for the care of a medicare eligible patient
in an IHS facility. The section allows all facilities to be declared
accredited for medicaid purposes for a period of 18 months. The funds
which are collected by the IHS are to be used exclusively for the
purpose of bringing that facility into compliance.
Section 403 requires the Secretary to make annual reports on
the disposition of funds collected by IHS under this title.
TITLE V - URBAN INDIAN TITLE
Section 501 declares the purpose.
Section 502 authorizes the Secretary to enter into contracts
with urban Indian groups for provision of health care to urban Indians.
Section 503 establishes the criteria for contract eligibility
of an urban group.
Section 503 (a) exempts these contracts from Federal contracting
laws.
Subsection (b) declares that payments may be made in advance to
an urban group.
Subsection (c) authorizes the revision, amendment, or retrocession
of any contract.
Subsection (d) permits an urban Indian group to use existing
HEW facilities.
Subsection (e) is designed to assure fair and uniform provision
of services to urban Indians under contracts.
6
Section 506 authorizes $30 million for this program over
three fiscal years.
Section 507 authorizes the Secretary to review the contracts
at the end of FY 78 and submit an assessment to the Congress. At
that time, the Secretary is also asked to recommended further legislative
change.
Section 508 authorizes not less than 1% of these funds to
be spent on pilot projects in rural communities near Indian reservations.
TITLE VI - American Indian School of Medicine
Section 601 authorizes a one year feasibility study on the
establishment of an American Indian School of Medicine.
TITLE VII - MISCELLANEOUS
Section 701 establishes a schedule for secretarial review
of this act. Recommendations are to be made to the Congress on
additional funds needed.
Section 702 directs the Secretary to actively consult with
the Indian community before rules are promulgated, and establishes
a schedule for promulgation of the rules. The same Indian consultation
is required if the rules are revised.
Section 703 directs the Secretary to prepare, within 240 days
after enactment of this Act, a plan for implementation of this Act. This
is to include a schedule for appropriations requests.
Section 704 authorizes 20 year leases with Indian tribes.
Section 705 declares that the funds appropriated under this Act
shall remain available until expended.