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Public Statements

Indian Health Care Improvement Act Amendments of 2007

Floor Speech

By:
Date:
Location: Washington, DC


INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2007 -- (Senate - February 14, 2008)

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Mr. COBURN. Mr. President, first of all, let me thank the chairman and ranking member, Senator Murkowski, for their work on this effort.

AMENDMENTS NOS. 4024 THROUGH 4037 TO AMENDMENT NO. 3899

Oklahoma is the No. 1 State in the country as far as tribal members. Indian health care is an issue on which we are struggling, and there are all sorts of components for it. I am going to ask unanimous consent now to bring up my amendments numbered 4024 through 4037 as if brought up individually and ask that each be set aside so they will be considered pending. I ask unanimous consent that be carried out at this time.

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Mr. COBURN. Let me start by saying, improving the health care of Indians in this country is a widely supported goal. Senator Dorgan's heart is in the right place on this issue. He knows the problems we have, and he spent countless hours trying to get to this point with this bill. I do not want to be seen--I have told him, and I committed to him my goal is not to block his progress on this bill.

However, I believe this legislation as drafted does not fix the underlying problems. He and I have had several conversations about that. It does not fix rationing that is going on today. It does not fix waiting lines that are going on today. It does not fix the inferior quality that is being applied to a lot of Native Americans and Alaskans in this country. It does not fix any of those problems. In fact, it authorizes more services without making sure the money is there to follow it. The average Native American in this country has $2,100 per year spent on them.

Now, let's put that in perspective. The average veteran we take care of has $4,300. The average individual per person, per capita, expenditure in our country is $7,000. Yet we are going to pass a bill that does not fix anything. It does not fix the real problems about addressing the No. 1 problem which is, we are not sending enough dollars to meet the treaty obligations that we have with Native Americans. So really what this bill is, it is called the Indian Health Care Improvement Act, but it improves our position with tribes because we have done something, but it does not improve health care. It is not going to improve health care. It is going to increase the availability of services without the money, without the control, without the quality, without eliminating the waiting lines.

As a matter of fact, it is going to add to the waiting lines as I read this bill, as somebody who is somewhat experienced in medicine. Those who say a failure to reauthorize the Indian Health Care Improvement Act is a violation of our trust obligations are correct. However, I believe simply reauthorizing this system with minor modifications is an even greater violation of that commitment. It is a greater violation. Dozens of tribal leaders are not expressing enthusiasm for the current structure.

Chuck Grim, an Oklahoman, head of this service, knows what is broken. I have had lots of conversations with him. We know what is broken, we know how to fix it, but we have to be bold in how we go about fixing it. We are not bold in this. We are not changing it. We are not doing the structural changes that have to happen for us to live up to the commitment that we have made to Native Americans.

The myriad of problems facing Indian health care in Indian country are many of the same issues that are facing health care delivery throughout rural America. They are compounded, however, in this system by a system that refuses to recognize its own role in holding back health care delivery for Native Americans.

In designing health care reforms, markets work when they are allowed to. They lower the price of all goods and services, and they attract much needed outside investment. Many tribes in Oklahoma are at the forefront of new and innovative health care delivery systems. They are poised to become a model for delivery throughout the system.

Congress must ensure, however, that their efforts are not discouraged or stopped altogether by the current system. Furthermore, there is no good reason that forward-thinking tribal governments should not be prevented from developing market-driven health care centers of excellence that will attract researchers, physicians, and patients for cutting edge lifesaving treatments. We do not do that in this bill.

Furthermore, this legislation fails to focus on empowering individual tribal members. Individual patients tend to receive better care and more effective care when they are empowered to make their own health care decisions. Congress should explore ways to accomplish this objective and give tribal citizens a reason to invest in their own health. Long lines, bureaucratic headaches, and rationed substandard care completely disallow this sort of investment. That is what we have.

Our Chairman has been on the Senate floor multiple times showing how we are rationing care, how we have lines, how we do not give quality care, how we take contract health care--it runs out in 4 or 5 months. And so what happens? People who need care do not get it, and we have not fixed that in this bill. Yet we are calling this health care improvement.

The health care status of tribal members ranks below the general population. The Federal Government has been providing health care to tribal members for 175 years. The first time was to give them a smallpox vaccine in 1807. That is when we started Indian health care. And what we are doing today in comparison to what our treaty obligations are--in comparison, it is the same thing we are doing to the veterans when we tell the veterans: We are going to give you health care and do not give it. It is the same thing we tell schools: We are going to have an IDEA program and then not fund it. It is morally bankrupt legislation that does not meet the commitments that we say we have.

The Snyder Act of 1921 provided a broad and permanent authorization for Federal Indian programs, including--and this is an important thing--the conservation of health; in other words, the prevention of disease, which Chuck Grim was just starting to get into, but we do not have the funding to do it the way we need to do it. We know the manifestation of diabetes and addiction and hypertension and heart disease among our tribal members is higher than any other group in our country. Yet the conservation of health has not been exploited, the paradigm shift that has to happen in Native American care to where we go to prevention instead of treatment of disease. It is not in here. We are not doing it.

Last year, we spent $3.18 billion doing this. If we just funded it at the level we fund per capita veterans care, we should be funding $6.5 billion in Native American health care. That is just on a per capita basis, let alone any structural changes on how we might make preventative care, quality care, timely care, and compassionate care a part of Native American care. But we are not doing that. Indians in comparison with the general population are 6.5 times more likely to die from alcoholism. That is a disease we need to be preventing. That is a health care problem. They are six times more likely to die from tuberculosis, a preventable disease; three times more likely to die from diabetes, a controllable and now preventable disease, it is a preventable disease; 2.5 times more likely to die from an accident.

Now, how can we look those statistics in the face and say we have met our treaty obligations? We have failed. We have absolutely failed. Only 71 percent of Native Americans receive prenatal care. That means one out of four Native American moms who get pregnant do not have any prenatal care. We ought to be ashamed. We have failed. We have failed.

Eighteen percent of Native Americans who are pregnant smoke. That is twice the rate of others. Where is our prevention? Where is our education? Where is the priority on what we can do something about?

American Indians suffer from a great death rate from chronic liver disease and cirrhosis. It is 22.7 per 100,000. That is twice what it is for Whites and three times what it is for African Americans in this country. We know what causes it. We do not put the dollars there. We have not put in a streamlined prevention program.

My words are harsh. They are not intended for either the chairman or the ranking member. I passionately care that we meet our commitments, and so I do not want you to take the words I say as directed toward you because I know you care as well.

Where we have a difference is in the ``now.'' What do we do now rather than what do we do later? I think we should be doing it all now. I think we should radically change how we approach our obligations in Native American health care in this country.

Rationing plagues Indian Health Services. It is rationed care. That is why it is not good care. That is why it is not consistent care. That is why it is not preventative care, because we don't have the resources. We haven't applied the resources to the need. Senator Dorgan has had numerous hearings. He has spoken on the floor about this rationing crisis. But if we don't radically change the system, if we don't change incentives in the system, improving the old will just bring more failure.

The job vacancy rate for dentists is 32 percent. They don't have 80 percent of the nurses they need. They don't have 85 percent of the optometrists, and they only have 86 percent of the doctors, based on the present system. I am proposing a better system with better care based on prevention, a paradigm that says it is a whole lot cheaper to prevent your illness than it is to treat it once you get it. It is common to hear in Indian Country--and I have heard the chairman say it--``don't get sick after June. Contract money is gone. If you get sick after June, nothing will happen. You will not get the referral to the center to take care of you because we don't have the money.

A quote from Dr. Charles Grim, who has been a stellar leader for the IHS:

We're only able to provide a certain level of dental services in certain populations. We're only able to refer a certain level or number or types of referrals with our contract health service budget into the private sector. ..... But I guess one generalized statement would be that we have a defined population and a defined budget. ..... But it has led to rationing in some parts of our health care system.

Here is the former head of IHS admitting we are rationing the care. When we ration care, we don't match up need with resources. We say: Here are all the resources there are regardless of what the need is. We don't get on the leading edge on prevention. We don't get on the leading edge on treatment because we are scrambling to keep the doors open. How can we have a coherent, fair health care system when we are rationing because the demand is so far greater than we are willing to supply the resources?

According to a GAO report in 2005, health care services are not always available to Native Americans. There are wait times and insufficient care. GAO visited 13 IHS-funded facilities in 2005 and found waiting times at four range from 3 to 6 months to get in to see anybody. Six months? That is worse than England. What happens when you can't get in? The disease gets worse. The complications are worse. The quality of the your health gets worse. Also, the cost to meet the need explodes. So what we have done is raised the cost of care. But more importantly, we have failed on our commitment to provide health to Native Americans.

Three IHS facilities had 90-mile one-way visits to get into a clinic, many without transportation available to them. Three of these, the average was 90 miles to get to a clinic. Even if they have the resources and there is no access because there is a distance to travel, we are going to see the same problem. Nobody is going to go until they absolutely have to. So we lose the benefit of prevention.

Most of the facilities in this GAO report did not have the staff or equipment to offer services onsite so they resorted to contract care. The contract care budget, of course, is small. So what happens? We ration contract care at 12 of the 13 facilities. This idea of rationing isn't a political statement; it is a reality. We are not doing what we are committed by treaty to do. Now we are going to bring a bill to the floor that doesn't meet that commitment. We are still not going to meet the commitment. We will improve it, but we need to overhaul it. We need a top-down, complete change in how we approach our commitment to Native Americans as far as health care. If we did that, we could offer a whole lot more care for a whole lot less money.

We have a bureaucracy that is stumbling all over itself. We are spending money. I will get to the point on the number of bureaucratic positions in IHS that don't deliver any care. Gaps in services result in diagnoses and treatment delays which, of course, make the health of the patient worse and raise the cost. IHS reports that their facilities are required to pay for all priority one services but admit that many of their facilities' available funds are expended before the end of the fiscal year and the payment isn't made.

I experienced that in my own hometown. People come to Hastings Hospital to deliver a baby. Our hospital hasn't been paid on contract care for years. So those in the rest of the community are going to pay for it. The problem is, there is no continuity in care. Prenatal care was provided. Now all of a sudden you don't have a record and you have somebody you have to take care of, let alone that the private hospital that is there isn't going to get paid for the service. Somebody is going to pay for the service, but contract health care isn't. So the fact is, one in four Native Americans in Alaska aren't getting prenatal care. And we know the risk. The average cost for a premature baby is $250,000, let alone the consequence of the problems those kids have. Why in the world would we ever allow that to happen? It is akin to pouring money down the drain because we have not addressed prenatal needs of Native Americans.

Twenty-one percent of those who do get care have less than three prenatal visits on average. That is one in four has less than three prenatal visits. That is like not having prenatal care. Yet we count that as if they had prenatal care. What do we think the consequences will be? The antenatal, postnatal, and perinatal consequences to the Native American population are higher. The birth complications are higher because we are not doing the prenatal care.

The average recommended prenatal visits by the American College of Obstetrics and Gynecology is 14. We average six with Native Americans. You can't call that care.

Under an overburdened system such as this, drastically expanded services to four broad new areas--and this is the problem I have with this bill--will only drain the resources available to the basic core medical services. We are going to expand where we can offer new services. Many of these people are already eligible under Medicaid or Medicaid anyway, but we are going to expand it. What is going to happen is, the tribal government is going to offer the service, and they are going to take the money off the top. They are going to put that into the rest of the tribal funds. So we are actually going to take money out of dollars for health care for tribal members by expanding care and not making sure there are adequate funds.

Making new promises, when we don't keep current ones, doesn't help the Native American population. Let's keep the promises we have already made before we expand services and not throw money at it. It sounds good. The tribes like to hear what we are going to do. We are going to add these four services, but we are not funding the services we are supplying now. Why would we add services knowing that? If we do it, we are going to do it on the cheap. But it feels good because they think we are doing something, when, in fact, we are not fixing the problems. It is kind of like taking a loan out on a brandnew car when you can't buy food. It is the same thing. That is what we are doing with these additional services.

The majority of the bill is more of the same. I have expressed to the chairman that I think we need to radically overhaul the care of Native Americans. I will have a lot more to say. I do have some complications with other commitments in terms of markup. My staff e-mailed me a moment ago that you have made some substantive changes in the managers' amendment on some of the Medicaid and the tribal issues related to urban Indians. I will get with you and try to discuss that because it may affect some of my amendments. I wasn't aware of that until this morning.

I will have an amendment I will talk about now. I don't know that I will when I actually bring it back up. One way to meet our commitment to Native Americans is to give them options. According to CBO, the amendment I will be offering costs no money. It is a zero cost. But what it allows Native Americans is an insurance policy that says you can apply this and go to any Indian Health Service you want to or anywhere else in the country you want to, but you get to choose. The same dollars get spent, but the services will be far superior.

There are two results. One, when we do that, it makes the Indian Health Service have to get more competitive. No. 2, and most profoundly, when we do that, we finally live up to our commitment that is embodied in every treaty we have with Native Americans. Here is the real care. It is not rationed. It is not limited to contract funds. You don't have to get in line to wait in line. You don't have to get an appointment to get an appointment. You don't have to travel 90 miles, if you don't want to. You don't have to have your care rationed. And at no cost increase to the Indian Health Service, we can give Native Americans their own health insurance policy which gives them freedom, dignity, and choice.

I know that will be controversial. It is not controversial with any Indian I have talked to. It is controversial with tribal leaders because it takes the dominance of tribal leaders away and gives freedom to members of the tribes to whom we have made a commitment for health care.

So as we offer that amendment and look at it, I know there will be objections, but it does--most importantly, with the same dollars--allow us to fulfill a commitment we are not fulfilling today. It allows a pregnant Native American to have 14 visits, allows her to have the same care anybody else would have. It allows us to get better outcomes. It allows us to get a patient into an endocrinologist, where they will manage their diabetes so they will not have complications. Kidney failure is twice as high in this population as anybody else. Why? Because diabetes is not managed. How many of you have gone into a dialysis center and watched people sit there for 8 hours a day, chained to a machine to keep them alive, because we didn't keep our commitment by having the dollars there to prevent the complications of diabetes?

This gives an equal ranking to a Native American as a Member of Congress. You can have preventative care for your diabetes so you don't end up on dialysis or with an amputation or losing your vision. It offers them hope. It offers honor and integrity because we finally keep our commitments.

I wanted to talk about a couple other things and then I will close and come back. I appreciate the chairman giving me this time. As Congress discusses Indian health care over the next several days, America as a country should take note of what a single-payer system means in terms of the quality of care we can expect. America should not go the route of a single-payer system. That is what we are seeing. That is what we have in IHS. It is a single-payer system. The promise sounds alluring, but the reality is inevitably negative.

It is negative in terms of prevention. It is negative in terms of care. It is negative in terms of complications. It is negative in terms of innovation. It is negative in terms of the paradigm of prevention.

Second, fixing the system for our Native Americans demands more than adding more new programs and services. We need a fundamental overhaul of the system. The Members of federally recognized tribes whom we have a trust obligation to provide health care for deserve better than is in this bill. Actually, I believe Chairman Dorgan believes that too. He believes this is a stepped process. They deserve a choice. They deserve the security to know they can get health care when they need it. They deserve quality. They deserve the health care outcomes the rest of this country enjoys that they presently do not have.

Throughout this debate on this bill, you will hear the same statistics on rationing, wait lines from both the Democrats and Republicans. We see it. We know it is there. Some will argue it is a solution that just involves passing this bill that has new programs. Every time we pass an Indian Health Care Improvement Act bill, we cite the same terrible statistics. We pass the bill because we need to do something. But each time we pass the Indian Health Care Improvement Act, Indian health care does not improve.

What does that mean? We pass an Indian Health Care Improvement Act, but Indian health care does not improve. Indian health care never improves because we never fix the inefficiency that plagues the IHS. We just reauthorize and add new regulations, new obligations to the same dinosaur.

Now, the statistics I was referring to earlier: The Indian Health Service has 14,392 employees, including 2,192 commissioned officers; the latter COs include 8 Assistant Attorneys General, 439 director grade individuals, 601 senior grade individuals. The salaries for the COs total $135 million. The salaries for all other IHS employees is estimated at $655 million. The IHS spent $33.7 million on travel last year. On travel? Think about what $33 million could do in terms of prevention for the complications of diabetes for American Indians and Native Alaskans.

The other significant thing is, IHS carried, in 2005--I do not have the number for 2006 or 2007 yet--their obligated balance at the end of the year was $162 million. Just efficiency in how we spend the money could improve health care in Indian Country.

I say to the Senator, Mr. Chairman, I appreciate your efforts. I know you are truly committed to trying to make a difference. I believe we need to be bold. I believe we have an obligation to do better. I believe this is short of the mark. So I am going to be voting against this bill. I am going to be offering amendments to try to make it better. I say to the Senator, I know in the long run you and I have a lot of commonality in how we go about trying to solve this problem.

I do not think Indian Country can wait for us to come back. I do not think the lady who gets on a dialysis machine today for the first time thinks we can wait. I do not think the lady who pops into the delivery room who has not had any prenatal care thinks we can wait. I do not think the person who ends up with coronary artery disease at 40 years of age, because their diabetes and their cholesterol and their hypertension have not been managed, thinks we can wait.

The body will probably think we can wait. But I think we have a moral obligation to meet our commitments, and that means radical change. When you have a cancer, you do not treat it lightly. You go in, you cut it out, you treat it, you follow it, and you aggressively change things so you make an impact in the quality of that person's life.

I think we have to do better. I appreciate the efforts of the chairman and ranking member. My hope is we will live up to our obligations.

With that, I yield back the floor.

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Mr. COBURN. Mr. President, will the chairman yield for a couple moments?

Mr. DORGAN. I am happy to.

Mr. COBURN. Mr. President, I wish to make a couple comments, and then I have to go to a markup.

You will find me an ally on appropriations if we have the courage to make priority choices on where we fund money. You know that. That has been my history. But we do not have extra money, so that means we have to take it from something else. My goal will be that we take from the waste we all know is there and we put it to the commitments.

So I look forward to that debate. I think you are right. I think we need to up the ante, and we need to add the money. But there is plenty of money for us to go get, and I hope the chairman will help me go get it so we can put it there.

Thank you.

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Mr. COBURN. Mr. President, every amendment I have has something to do with this bill. They are all germane, not meant to delay. I am happy to vote for cloture right now to prove that I don't want to delay this bill. What I am going to ask is unanimous consent for the regular order and discuss my amendment No. 4034, after which I will ask for a vote. Then if the leadership wants to stack votes, I am fine with that.

This is a simple amendment. I know the chairman is critical of it because he thinks it is false in terms of its intent. During our budget debate, I plan on adding $2 billion to Indian health care. I also plan on making us make the tough decisions on where we take it from. We don't have extra money, so it is about priorities, about keeping commitments. I will be offering that when we get to the budget to make sure there is an extra $2 billion for Native American care, and then we will decide whether we think that is a priority as we vote on the budget and on the appropriations bills.

This is a straightforward amendment. This allows tribal members to get insurance. If they want to use the IHS service, great. But if they have to wait in line to wait in line to get care, maybe they can go somewhere else. Then we are keeping our commitment. If they know that the care for a certain type of disease is terrible at IHS, they can go where it is better. We are going to put the security of our promise in real terms, and we are going to put choice, the same thing every Member of this body has, and security in health care, into the hands of the Native Americans. That is what the amendment does. The reason it doesn't cost anything is because we are going to charge IHS for what it costs. We have designed the amendment. We are waiting to see what the budget chairman does with the budget and where we are going to find this $2 billion. But I promise you, we are going to get a chance to vote on my amendment to put in $2 billion. So it is not an empty promise.

One of the things we know that improves everything is competition. One of the ways to get rid of some of the waste that is in IHS and to put a priority back in is to start competing.

Mr. DORGAN. Will the Senator yield for a question?

Mr. COBURN. I am happy to.

Mr. DORGAN. This is an authorization bill. The Senator is amending it. Does his amendment anticipate an increase by $2 billion for the authorized level because we are authorizing expenditures? The Senator will perhaps offer a $2 billion appropriations measure. I will as well. I hope we will be able to work together on that. But we will also have to increase the authorization. Does the amendment increase the authorization?

Mr. COBURN. It does not at this time. I will give a commitment to the chairman. Under our rules, when I want to take money away from something else, I have to deauthorize it. We don't have enough money in Indian health so we have to deauthorize something else. If we get it under the budget, I have every intention of making us make a choice. I will vote for an increased authorization at this point in time right now for $2 billion. But I will also come back and say we have to find the money to pay for it.

Mr. DORGAN. Mr. President, why don't we do that, provide the authorized room? The Senator this morning indicated--and I agreed--that we are about $2 billion short of fully funding Indian health care. We have full-scale rationing going on. The amendment has a restriction in it. He limits the amount of funding in his amendment to the amount of funding that currently exists in Indian health. The President has just proposed a reduction in funding, even though we are only meeting 60 percent of current need. My question is, should we not then remove that restriction and actually increase the authorization because he and I have the same goal. Let's get the amount of money in the system that provides health care for Indians that we have promised.

Mr. COBURN. I will happily vote for that. But what we have to do is deauthorize something else. I know you disagree with my thoughts on increased authorizations versus offsets. I believe we have a commitment. I believe we have a treaty obligation. I believe we have a moral obligation. But I also believe it has to be balanced with the obligation that Members of Congress refuse to do, which is to make judgments about priorities. An empty promise to authorize that is not offsetting some authorization somewhere else without coming around and doing it; tons of bills go through this place authorizing things so we can send a signal out there that we did something, knowing that we never intend to fund it.

Right now we have over $8 trillion a year in authorizations. It can't be hard to find $2 billion to deauthorize to increase the authorization for Indian health. We have to have a vote, and we have to decide what that is.

I will commit to the chairman, I will vote for that, as long as we are decreasing somewhere else. I am willing to go find where that is for the chairman. I will commit that I will offer an amendment to increase the spending for this in our budget. I also will commit that when the appropriations come through, although I may not vote for the whole appropriations bill because it is not going to just be for Indian health care, I will vote for amendments that will increase the amount of money that goes to Indian health care as long as it is within the budget. That is why I said my goal is to do that within the budget where we could have a debate about priorities.

Mr. DORGAN. If the Senator will yield further, one of the dilemmas in providing Indian health care, not so much in the State of Oklahoma but in other areas where there are reservations, is in many cases the only health care that is available is the Indian Health Service clinic, and you are 80 miles away from the nearest hospital. In many cases there will never be competition in an area where someone is desperately sick and needs to see a doctor quickly. I happen to agree the underlying notion of this amendment of providing a card to someone to say, take this card to a health care facility and get that need fixed, if you must--I happen to think that has merit. I will be working with the Senator on that with respect to the bolder approaches to Indian health care. But on page 4, line 4, is where you have budget neutrality: In conducting the program under this section, the Secretary shall ensure the aggregate payments made to carry out the program do not exceed the amount of Federal expenditures which have been made available. That is saying that we want to do all of this, which would expand contract care and so on but within the same amount of money that currently exists in Indian health care. It is kind of a chicken and egg.

Mr. COBURN. I would like to reclaim my time if I might. The fact is, we appropriate $280 billion a year in stuff that is not authorized right now. So we will not have any problem appropriating this money if we don't authorize it. A quarter of the discretionary budget is not authorized right now. We will not have any problem with that. My amendment says, on the areas the Senator just described, to do it only if it is geographically feasible. I recognize there are some places where we have isolated reservations and we have IHS. I am willing to put the money behind it, but I also realize more of the same doesn't get it done. So if we double Indian health care money, we are still going to have an inefficient system that will deliver care at a lower level than what you can get in the private sector.

What I am saying with my amendment is, let's have both. We ought to do both. I am making a statement on the Senate floor--and the Senator will recognize, I believe, that I usually keep my word about coming back and doing what I say I will do--I will work to get the extra $2 billion, but an extra $2 billion in a broken system is not just money that is broken with IHS. I believe the chairman will agree. What I wanted to do is fix the system and increase the money, increase the choice and security that Native Americans are entitled to that all the rest of us have.

The fact is, if the only place a Native American can get care is IHS, that is not freedom. That is not the promise kept in its fullest bloom. It is saying, here is the only place you can get care. If the care happens to be great, super. But if the care happens to be average and they need better, they don't have that opportunity. If the care happens to be--and sometimes we know it is, like some of the cases the chairman has presented--when it is substandard and that is the only choice they have, that is not acceptable.

Let me finish my deal, and I will let you go and you can hammer me. I hope I can get you to come around. Maybe I would not get your vote. I know I will get your commitment to work toward it in the future. But I think just adding more money to IHS doesn't fix the problem. I described that earlier when I talked about 30 or 45 minutes. What this does is, it treats Native Americans like every other American. That is what this amendment does. It gives them choice. It gets them out of the prison we have placed them in that says: You only have one place you can go. And, by the way, if we run out of contract funds, even if you need to go somewhere else, you can't go.

Contract funds actually have run out on average in June. So for 5 months of the year, when we need to send Native Americans somewhere else, we don't have the money to do it. So who suffers?

Under this system, you would not run out of contract money because you bought an insurance policy. You have given them the average cost of an individual insurance cost with what we are spending now on care.

By the way, I have another amendment where we describe what an Indian is because, in my State, we have people who are \1/512\th stepping in front of a full blood. And most people don't think somebody that is \5/11\th out of \5/12\th ought to be getting full pay for their health care. And in fact, there are .12 of 1 percent Native blood. We call that light blood in Oklahoma. We have whole blood, mixed blood, and light blood in our State. It actually is very complicated because what is happening now, we have tribes that have quantums and say: If you are not a quarter or an eighth, you are not eligible. But under the IHS system, from some of the other tribes who have members who are \1/512\th, they come down to their area and they get into IHS. So here is somebody with \1/512\th taking Indian dollars away from somebody who is a quarter or somebody who is a full blood.

What we have said is: Tribes, you have to decide who is an Indian. We actually have some people who are a thousand and 24th that we are giving full blown care to in Oklahoma. They have access to care somewhere else, but they don't want to pay the deductible or the copay. So they step in line in front of a full blood. We have to change that. We have to fix that. We have to fix that because our obligation has to be to the person with the most and then come down. So if we really have restricted dollars, what we have to say is, if you are below a certain level, you have to contribute something. That is the other way that we solve this problem. That doesn't demean the heritage of our Native Americans.

What that says is, the reality is, in 2016 in this country, we are going to be cutting spending all over the place because that is the year interest rises through the roof. That is the year we run out of Social Security with which to pay for Medicare.

That is the year in which for the projected spending, based on revenues, based on growth even at 4 percent, we start running trillion-dollar deficits--trillion-dollar deficits.

Have we ever asked ourselves why gold is worth four times more against the American dollar than it was 10 years ago? Do you think it has anything to do with people thinking we cannot pay back our debt?

So this idea that we are going to have more money in the future to do more things is not going to be there. We need to come to the reality of the situation. We need to start making some of the hard choices. To me, keeping our commitment to Native Americans has to be set up now; otherwise, it is not going to happen, and the funding is not going to get increased between now and 2016. Other than what we do this year, it is going to be hard. The money is going to be hard to get, even if we get out of Iraq.

We are going to get notice today on what I have been working on for 2 years, talking to the Census Bureau about that they are going to be out of control and spend a whole lot more money. I am getting ready to get notice by the Secretary of Commerce--I have a meeting with him this afternoon--that there is going to be a close to $3 billion more pickup to do something we have to do because it has been totally mismanaged--totally mismanaged. We have been having hearings for 2 1/2 years on it, where they have been denying it, and now they are coming to say it has been mismanaged. They are coming to agree.

It is why oversight matters. Had we gotten some of the amendments through this body that we offered on the census, we would not be here. But, instead, we are going to spend $2 billion to $3 billion more because we did not pass the amendments offered based on oversight that we did in my committee.

The whole goal--I am not perfect. I am not right, necessarily, on how I want to do that. I will admit that to the chairman and ranking member. But I know more money does not solve the problem on this, and unless we create real freedom, real choice, and real health care security for Native Americans, we will never have an efficient IHS system, and we will never meet the commitments that we say we have.

So I will ask for the yeas and nays on this amendment. I will listen to the chairman. I do have a meeting at 2 o'clock I have to be at. Whenever the chairman would like to stack the votes, if we run others, I will be happy to work with whatever is his pleasure.

Mr. President, I ask for the yeas and nays.

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Mr. COBURN. Madam President, this is a pretty simple amendment. What it says is we are going to give the Native Americans what we promised them in our treaties. We are going to give it to them in the same way we deliver security, choice, prosperity, and health care for Members of Congress. We are going to give them an insurance policy. In basics, I think my chairman agrees with it; he does not agree with the way we are doing it at this time. I understand that. What you all should know is three-quarters of the Native American population of this country lives in urban areas; it does not live on the reservation. That is three-quarters.

What this does is fulfill our commitment through giving them access to quality choice and care--not substandard care, not rationed care, but real care.

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Mr. COBURN. Madam President, amendment No. 4036 is a real simple amendment. What it says is we are going to prioritize the funds that go into the Indian Health Service. We have had debate all day on whether we are improving Indian health care when we add services but do not add money, and we have not done the structural reforms that need to happen in the Indian Health Service.

We know the Indian Health Service is plagued by rationing on a life-and-limb basis. As to the quality of care we are offering in IHS, for some places it is great, but on average it is less than what we offer other people. Instead of fixing the problem with basic medical services, this bill includes new services. We are not funding the services we do now, and the services we are funding are not at the level they need to be in terms of their quality.

This bill expands the burden of IHS to fund things that in terms of priority are not as important, No. 1, but, more importantly, most have an eligibility avenue with which to get these services through some other Government program. So by supporting this amendment, you are not denying the four new services because they are already available, just not through the IHS.

This amendment would require funding go to what has already been promised to tribal members before we expand to new promises. In other words, before we add new services, let's make sure we are funding the services we are offering now and that we are funding them at a level of quality that is acceptable.

So this would say IHS would have to prioritize basic medical services before paying for new programs. We have talked a lot about the history on this. We know where our problems are. The chairman is trying to move in a direction to help solve some of the problems.

I disagree that we are making the major steps. I think we have to totally reform IHS. I have said that to the chairman. He knows the structural problems that are there. I think when we promise health care, we ought to give it.

We talked earlier today that one in every four Native American women have a baby without any prenatal care. The average number of visits for those who have prenatal care is half what the national average is. So just in prenatal care, in pediatrics, and diabetes we know we are behind the curve. Yet we are going to add new services in the bill that are already available in other ways.

We also know, as the chairman has said, that we spend half per capita on Native Americans than we do on prisoners. We spend less than half than we do on veterans. We spend a third based on what we spend on Medicare. So we are obviously not there, and a lot of it is money. There is no question about it. But it is not all money. It is structural.

Obviously, that is the reason for my opposition to this bill because I think we have an opportunity to go much further to totally change the structure and quality and delivery and to get a lot of the bureaucracy out. I think we also need to add money. We need to do all three.

This amendment is designed to make IHS prioritize the money. So even though we authorize these programs--this does not eliminate the authorization--it just says you cannot effectively do it until you have funded adequately what you are already promising Native Americans.

What this bill will do, in my estimation, is drain resources available to basic core medical services. It is also going to do something else. Our tribes are getting to be pretty good businessmen. What it is going to do is, it is going to put into individual tribes businesses for these services.

So what is going to happen is, these services are going to be part of the tribal organization business complex but not part of the service, and so we are going to transfer funds outside IHS, transfer IHS moneys into tribal organizations with no guarantees that the money that was spent is going to come back into health care. So if we were to do this, what I would rather is these be IHS services only, rather than out for bid to be utilized that may be not at a competitive bid price so we enhance private profitability rather than tribal health care. So there is that other little problem. Again, if we make new promises, at a time when we are not funding the promises we have, we are not helping the Native American population.

This amendment is about priorities. It is not saying IHS cannot fund these new programs. It is just saying we need to focus on basic medical services first, such as prenatal care. When one in four Native Americans do not have prenatal care, and we are going to add long-term home health care, hospice, DME, and some of these other areas, when we are not taking care of the women who walk in and deliver without prenatal care, it does not make sense.

So I will put this amendment up. I am going to ask for the yeas and nays on amendment 4036. I appreciate the consideration of the chairman and his heart toward Native Americans. But a half promise fulfilled is a promise not kept, and that is where we are on health care. Making us prioritize--in some places we will be able to do this; where we have effective, efficient care, they will have the money to offer these services. In areas where we are not doing well, they should not be expanding into new services when they are not taking care of the services we have today.

So the flexibility is completely up to the IHS. Nothing limits it other than you have to meet the core basic medical needs first before you go into other areas.

With that, I yield the floor and await the response from my chairman. Then I will talk about the other amendment in a moment.

The PRESIDING OFFICER. The Senator from North Dakota.

Mr. DORGAN. Madam President, with the permission of the Senator from Oklahoma, let me ask if he might also discuss his second amendment.

Mr. COBURN. Madam President, I will be happy to.

Mr. DORGAN. Thank you very much.

The PRESIDING OFFICER. The Senator from Oklahoma.

AMENDMENT NO. 4032

Mr. COBURN. Madam President, amendment No. 4032, which the chairman has graciously allowed me to discuss at this time, which I also would like to call up and have as the pending order of business under the regular order, is real simple. We do this in a lot of other places, but we do not do it in IHS.

I ask unanimous consent for that.

The PRESIDING OFFICER. The unanimous consent has been granted.

Mr. COBURN. I thank the Chair.

This is a real straightforward amendment. It says if you are a tribal member and you have been the victim of rape or sexual assault, the right to have your assailant tested for HIV and AIDS and other sexually transmitted diseases cannot be denied you. We have done this a lot of times. Most of us agree with that. We think it is the right thing to do when somebody is an assailant and we have people at risk, and not putting those Native Americans into a period of a year waiting or taking medicines they should not have to take because they do not know the status of the person who committed an assault on them.

So it is very straightforward. I will not spend a lot of time on it. I am not trying to inflame the issue. I think it is something Native Americans ought to have that every other American today has.

I yield back and intend to ask for the yeas and nays at the appropriate time.

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Mr. COBURN. Madam President, will the Senator from North Dakota yield?

Mr. DORGAN. I am happy to yield.

Mr. COBURN. Madam President, through the Chair, would the chairman agree a large portion of people who are eligible for Indian health care service today already have these services available to them through another Federal Government program?

Mr. DORGAN. A large portion? I don't know that I would agree with that. I don't believe I would at all.

Mr. COBURN. A large portion of them are Medicaid eligible. As a matter of fact, 27 percent of the funds that go into IHS are people from Medicaid. If they are Medicaid eligible, then they are eligible for every one of these programs. A large portion are Medicare eligible. A large portion of money that comes into IHS comes from Medicare, and they are also eligible under that. So the majority of our Native American population already have these services available to them under two other programs.

The other question I would ask through the Chair of the chairman is--there are other clinics and IHS facilities, I believe, and please correct me, that are being run well and that will be able to utilize these services for that smaller portion of Native Americans because they will have the funds because they are meeting basic core medical needs now. My amendment doesn't take that away. It just says if you are in an IHS clinic and over half of them already have these services available through another government program, why would we add that when we are not taking care of the diabetes, the dialysis, and every other thing we have?

My question to the chairman is--I would love for him to consider that this is a better way to go rather than blanketly treating everybody the same and that we have to prioritize, and that by having IHS Directors make that priority--in different areas, that is true--in terms of what goes through the tribal government, what we will get is better care.

Mr. DORGAN. Madam President, we look at this and, in many ways, see the same side. I think the Senator from Oklahoma and I see a situation in which gripping poverty exists in many areas, joblessness, inadequate health care. The Senator from Oklahoma is correct there are circumstances--I have been there, I have seen them--where the health care is wonderful. I toured a clinic recently and the doctor--a wonderful doctor at that clinic working for the Indian Health Service, who is very dedicated and by all accounts a terrific doctor--said to me: You know, we are waiting for this new x-ray equipment that is supposed to come. The waiting room is full, by the way. The building is in disrepair, it is an old building, but the doctor is giving me a tour, and he says: We are waiting for this x-ray machine which is really going to help us out.

I said: How long have you been waiting?

He said: Two years.

I said: What is the trouble?

He said: Well, I wish I knew. It is paperwork. Can't get it through the regional office. The money is there. The money is there for it, but we can't get the regional office to get the paperwork done to get the x-ray machine.

So the Senator from Oklahoma and I both know there are circumstances where there is unbelievable bureaucracy that is almost shameful, and nothing gets done. There are other areas where there is sterling medical care by men and women who, in that service, get up every morning and say: I want to make a difference in the lives of people. So all of that exists.

The point I have been trying to make most of today is when you have 40 percent of the health care needs unmet, we are in a desperate situation. We need to fix that.

The Senator from Oklahoma has talked a lot about reform, and I am very anxious, when we get this bill done--we will get it out of the Senate, we will get it to conference, and hopefully get it signed into law by the President. We will, for the first time in nearly a decade, have advanced an improvement in Indian health care. I am very anxious to turn immediately--and the Senator serves on our committee--to work with him and Senator Murkowski from Alaska to say: All right, now, let's put this on a different course with a much bolder, a much bigger bite, to try to figure out how we dramatically improve health care. That would not be done unless we have substantial additional income as well. But income is not going to solve the problem by itself. You need reform.

It is interesting. When the Senator talked earlier today about giving American Indians the opportunity to go someplace with a card and say: Here is my health care coverage--I am in favor of that. But that card would not do much good for somebody who is sick and is living, for example, in Fort Yates, ND, because the only option they have is to go to that Indian Health Service or they can get in the car and drive a fairly long way to find a hospital someplace. So we need to address these issues.

I want the Indian Health Service to be better, to be more effective, to provide better health care for American Indians, and I want to reform the entire system to see if we can establish competition where competition will work. I know Senator Coburn will readily agree there are places in the country where you can't even talk about real competition because you are living way out, way away from any other facilities, and all that exists is the Indian health care facility.

If I might make one additional point I understand why--I quoted Chief Joseph this morning. I understand why American Indians are a little skeptical. They have been lied to, cheated. They have had their agreements in writing, and they haven't been worth the paper on which they are written. It is pretty unbelievable when you think about it. We have all seen this, the promises that were made but never, ever kept. The purpose of today and the purpose of our work is to say: You know what. These were the first Americans and we have certain obligations to them and we must do a better job of meeting those obligations.

So I don't know that I was particularly responsive to the Senator from Oklahoma, but both of us want the same thing, we end up wanting exactly the same goals out of this debate. And my hope is, working together during the next couple of years we will take two steps, both in the right direction and both in a constructive way to help American Indians.

The PRESIDING OFFICER. The Senator from Oklahoma is recognized.

Mr. COBURN. Madam President, I just want a few more minutes and then I am through.

The Senator from North Dakota makes a great point: that there are people who are using reservation-based IHS facilities who are essentially trapped. They are trapped. They don't get the option to go somewhere else. What this bill does--and in many of those instances, the core medical needs are not being met. What this bill does is makes sure the core medical needs are going to be met because we are going to add four new services for those people. So now they are trapped in a system that doesn't deliver the quality, doesn't deliver the service, and doesn't deliver the prevention, we are going to make it worse. We are going to make it worse because we are going to add services that are available to half of the Native American population right now through another Government program, and we are going to dilute the resources for the very people who are trapped on reservations.

But the very point is, three-quarters of Native Americans are in an urban area. They are not limited to that. They are not limited at all. They should have had the choice to be able to go wherever they wanted to go today. We turned that down. We had 29 people vote for that--or 28 people vote for that.

I know the chairman is going to work with me to try to get there someday. But that is when you give Native Americans their due and meet our commitments. When they have the same choice, the same security, the same health care that you and I have, then we will have met our commitment under our treaties, and not until then would we have met it.

Mr. DORGAN. Madam President, if the Senator would yield on that point just briefly.

Mr. COBURN. I will yield.

Mr. DORGAN. Do you know why in many cases the urban Indians are a population that is exclusive? Because we went through a period of time when we did these zigzags. At one point in this country we said to the Indian community: You know what. Yes, you are on a reservation. Here is a one-way bus ticket. We want you to leave. So we sent them to the cities. Now we promised them health care back on the reservation. Now we say: You have a bus ticket one way. Go to the city. In fact, the budget request this year once again says: By the way, we don't intend to fund any--we don't intend to fund any health care for urban Indians. Well, we should, and I think we will say to the President that we don't agree with that recommendation. But we have done a lot of egregious things in this country, even with respect to preventing Indians the right to vote for the majority of the history of this country. They didn't get the right to vote until about 90 years ago or so.

Mr. COBURN. Madam President, I would like to reclaim my time, if I might.

Mr. DORGAN. Yes, of course.

Mr. COBURN. Madam President, I want to make a couple of points because what we have heard is a lot of negative today. I want to say how proud I am of the Cherokees, the Chickasaw, the Choctaw, and the Creek in Oklahoma. I totally disagree with gaming. I think it undermines virtue. I think it is destroying a lot of society. But several of the tribes in my State have invested their dollars--not IHS dollars, their dollars--in health care, and they need to be recognized. Their facilities, most oftentimes, are fantastic, and their care is fantastic. So I don't want us to leave the debate without recognizing some of the vast improvements that where we have failed, the tribes have actually picked it up and supplied it, and that means shame on us because maybe there wouldn't be as much gaming if we were fulfilling the needs. Gaming is not without its societal consequences, regardless of how much we benefit in terms of dollars that come into the Treasury.

So I didn't want us to leave this without recognizing that we have lots of great performance in lots of great areas. We also have lots of great providers and doctors and workers in IHS, but we have some who aren't. We also have some who couldn't get a job anywhere else, some whom nobody else would hire. Yet we will hire them because we are so short, both on funds and needs. That ought not to be there either. If somebody is not competent to practice with the public, they shouldn't be competent to practice at IHS and the same at the VA and the same in our prisons and the same in other areas.

So it is my hope we will look straight forward. It is hard to run against your own chairman on amendments on a bill, and we intentionally did not put up these amendments at the request of the chairman when we were doing the markup on the Indian health care bill.

Again, I will state in finality, and then sit down, these ``improvements'' in many areas will offer some improvement but in many more areas will take away from core medical care that is offered to the very people who aren't getting adequate care today. So it ought to be flexible. It ought to be where the core medical needs are met, we are offering these, and whether or not we shouldn't be offering them because what we are doing is, we are taking that lady who is going to be on dialysis, and we could have prevented it because we are not doing the core medical things and we are looking at the wrong thing. We are taking a gal who has early diabetic neuropathy and we are going to condemn her to a life on dialysis or a kidney transplant, and most of them would not get kidney transplants. They are going to get hooked up to a machine for 8 hours a day because we are--but we are going to feel good about ourselves saying we now have hospice and long-term care, and all of these other things.

I think it is a mistake the way we have done that. It is my main opposition to the bill. I think we have an opportunity to rigorously and tremendously change the structure, the delivery of care. We have an opportunity to change the paradigm under which we treat Native Americans, to prevention. We have talked about suicide on all of the reservations. The chairman and many have been concerned about prevention of that. But we ought to be just as concerned about prevention of all of the other diseases and change the paradigm under which IHS works instead of more of the same.

So with that, I ask for the yeas and nays.

I yield the floor.

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Mr. COBURN. Madam President, this is a straightforward amendment that says when somebody has been abused or sexually assaulted, they have the right, postindictment, to have the person who assaulted them tested for HIV and sexually transmitted diseases. It is current law in many other areas, and I would appreciate your support.

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