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                                                       Calendar No. 421
110th Congress                                                   Report
                                 SENATE
 1st Session                                                    110-197

======================================================================



 
         INDIAN HEALTH CARE IMPROVEMENT ACT AMENDMENTS OF 2007

                                _______
                                

                October 16, 2007.--Ordered to be printed

                                _______
                                

    Mr. Dorgan, from the Committee on Indian Affairs, submitted the 
                               following

                              R E P O R T

                         [To accompany S. 1200]

    The Committee on Indian Affairs, to which was referred the 
bill (S. 1200) to amend the Indian Health Care Improvement Act 
to revise and extend that Act, having considered the same, 
reports favorably thereon without amendment and recommends that 
the bill do pass.

                                Purpose

    The purpose of the Indian Health Care Improvement Act 
Amendments of 2007 (S. 1200) is to reauthorize the Act to 
maintain and improve the Indian health care delivery system. 
This legislation is intended to raise the health status of 
American Indians and Alaska Natives\1\ to the highest possible 
level in accordance with Healthy People 2010.\2\
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    \1\The original Act defines the term ``Indian'' to include Indians 
and Alaska Natives.
    \2\Healthy People 2010 is the major health agenda for the Nation. 
``It is a statement of national health objectives designed to identify 
the most significant preventable threats to health and to establish 
national goals to reduce these threats.'' U.S. Department of Health and 
Human Services, www.healthypeople.gov.
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    S. 1200 builds upon current law to set forth policies, 
programs and procedures designed to address health care 
deficiencies in Indian and urban Indian communities, and to 
streamline service delivery to those communities. In addition, 
S. 1200 addresses the health problems and associated socio-
economic conditions in Native American communities by 
authorizing the Indian Health Service (IHS) and tribes to adopt 
current health industry ``best practices.''

                               Background

    Enacted in 1976, the Act established the first 
comprehensive framework for the delivery of health care 
services for Native people, including various health programs, 
projects, and facilities. The Act was last reauthorized in 
1992, and authorized funding for various programs through 
Fiscal Year 2000. Public Law 106-568 included a simple 
extension of the Act's authority through FY 2001. Congress has 
continued to fund programs under the Act through the general 
permanent authority under the Snyder Act (25 U.S.C. 13).

                      THE REAUTHORIZATION PROCESS

    The work on the latest reauthorization of the Indian Health 
Care Improvement Act began in 1999. Bills have been introduced 
since the 106th Congress\3\ to provide numerous improvements 
and updates to current law, many of which are contained in S. 
1200.
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    \3\S. 2526 (106th Congress), S. 212 (107th Congress), S. 556 (108th 
Congress), S. 1200 and S. 4122 (109th Congress).
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    In June, 1999, the Director of the IHS convened a National 
Tribal Steering Committee on the Reauthorization of the Indian 
Health Care Improvement Act (NSC), which was comprised of 
tribal leaders and representatives from Indian health 
organizations to facilitate the Act's reauthorization. The NSC 
held a series of meetings in 1999, during which extensive 
discussions were held between the NSC and Department of Health 
and Human Services (DHHS) officials. The NSC also received 
technical assistance from DHHS officials during these meetings.
    The NSC set out to craft a comprehensive legislative 
proposal that would reflect a consensus of the Indian tribes. 
With over 560 federally-recognized Indian tribes, each with 
unique histories, cultures, locations and needs, the NSC faced 
serious challenges. Despite the many differences, they 
coalesced around a draft document which formed the basis of the 
bills introduced, S. 2526 (106th Congress) and S. 212 (107th 
Congress). Neither bill was enacted.
    During the 108th Congress, the Committee, the NSC and the 
Administration engaged in extensive negotiations over 
reauthorization issues, but action on a final version of that 
Congress' bill, S. 556, did not occur before the conclusion of 
the 108th Congress. Several recommendations developed during 
these negotiations were incorporated into S. 1057, which was 
introduced in the 109th Congress.
    In the first session of the 109th Congress, the Indian 
Affairs Committee favorably reported an amendment in the nature 
of a substitute to S. 1057. In the ensuing months, the 
Committee engaged in discussions with the Administration--not 
only DHHS, but also the Department of Justice. Changes based on 
these discussions were made in an amendment in the nature of a 
substitute to S. 1057. In addition, the Committee worked 
extensively with the Senate Finance Committee on provisions in 
the jurisdiction of that committee, which were separately 
reported out by the Finance Committee on June 8, 2006, as S. 
3524, and incorporated in to the amendment in the nature of a 
substitute to S. 1057. Comments were also received from the 
Senate Health, Education, Labor and Pensions Committee, on 
provisions over which that Committee maintains an interest, and 
many were incorporated. A new bill, based on the amendment in 
the nature of a substitute, was introduced as S. 4122 on 
December 8, 2006, the last day of the second session of the 
109th Congress. No further consideration of that measure 
occurred.

                 OVERVIEW OF INDIAN HEALTH CARE HISTORY

    The history of the Federal responsibility for Indian health 
care is quite extensive and well-documented in numerous 
sources, including past Senate reports accompanying prior 
legislation, (see, e.g., Senate Report Nos. 94-133, 102-392, 
108-411 and 109-222).
    Based on the U.S. Constitution, treaties, statutes and the 
historical, political and legal relationship with the Indian 
tribes, the United States has assumed a trust responsibility 
for the provision of health care to Indian people. Those laws 
and relationships serve as the backdrop for the government-to-
government relationship.
    Extensive research indicates that the health of Indians 
deteriorated after contact with the European colonists, as the 
aboriginal inhabitants had no natural immunities to the 
diseases carried by the new arrivals. Decades later, when 
Federal policy forced the Indians to relocate from their 
homelands and settle on reservations and, in many cases, 
prohibited the conduct of traditional practices--including 
traditional healing--the health of Indians continued to 
plummet. Thus, health care became a particularly significant 
element of the treaties and other agreements between the Indian 
tribes and the United States.
    During the early 1800s, the health care provided was little 
more than vaccinations for the Indians around federal military 
posts in order to protect the soldiers and non-Indians from the 
possibility that Indians might spread diseases. During the late 
1800s, physicians and hospitals were added to the reservations 
and other outposts. Mention of the provision of health care was 
included in treaties. For example, the Treaty with the 
Chippewa, Red Lake and Pembina Bands, of 1864, stated in 
Article 4,

          The United States also agree[s] to furnish said bands 
        of Indians, for the period of fifteen years, one 
        blacksmith, one physician, one miller, and one farmer; 
        and will also furnish them annually, during the same 
        period, with fifteen hundred dollars' worth of iron, 
        steel, and other articles for blacksmithing purposes, 
        and one thousand dollars for carpentering, and other 
        purposes (emphasis added).\4\
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    \4\Charles J. Kappler, Indian Affairs: Laws & Treaties, Vol. II, at 
861.

    With respect to federal agencies overseeing the 
responsibility for Indian health, the task was first assigned 
to the War Department in 1803, then to the Interior Department 
in 1849, before finally being transferred to the Department of 
Health, Education and Welfare (DHEW), the predecessor of the 
DHHS, in 1955. The Division of Indian Health within DHEW had 
initial responsibility for Indian health before eventually 
being renamed the Indian Health Service.\5\
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    \5\Report on Indian Health by Task Force Six: Indian Health in the 
Final Report to the American Indian Policy Review Commission (Final 
Report) at 32.
---------------------------------------------------------------------------
    In 1921, Congress enacted the Snyder Act (25 U.S.C. 13), to 
provide for permanent appropriations authority for Indian 
health programs and services. However, the Snyder Act did not 
provide meaningful standards by which to measure progress in 
Indian health status or other improvements in services.
    The lack of standards in the Snyder Act and other organized 
efforts led the American Indian Policy Review Commission to 
conclude in 1976 that

        there [was] no clear overall direction or policy for 
        implementation of the various programs. As a result, 
        the Indian Health Services operates primarily an 
        emergency and crisis oriented service. . . . This has 
        resulted in increased prevalence of certain health 
        deficiencies which are virtually unknown in the general 
        population.\6\
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    \6\Id. at 12.

    Shortly after the responsibility for Indian health was 
transferred to DHEW, Congress passed the Indian Sanitation 
Facilities and Services Act, 42 U.S.C. 2004, which authorized 
the IHS to provide sanitation facilities to Indian communities. 
These sanitation facilities were critical to eliminating many 
health maladies associated with the lack of proper sanitation, 
such as dysentery and infectious hepatitis.
    The administration of Indian health had initially been 
managed in a piecemeal approach, then ultimately was placed 
within the IHS, an agency of the DHHS. Based on that history 
and in fulfillment of the special trust obligation to Indian 
people, Congress passed the Indian Health Care Improvement Act 
to provide coordinated programs and meaningful direction in 
Indian health care administration. The underlying 
responsibility to provide health care did not originate with 
the Act; rather, the Act was passed after Congress recognized 
that a sea-change in administration and management was needed 
to ensure improvements were achieved in Indian health status 
and services.

                   THE PRE-IHCIA INDIAN HEALTH SYSTEM

    At the time of passage of the Act in 1976, the information 
on Indian health painted a stark portrait of existence in 
Indian communities. Senate Report No. 94-133 accompanying S. 
522, the Indian Health Care Improvement Act of 1976, which was 
signed into law as Public Law 94-437, indicated that the ``vast 
majority of Indians still live in an environment characterized 
by inadequate and understaffed health facilities, improper or 
nonexistent waste disposal and water supply systems, and 
continuing dangers of deadly or disabling diseases.''\7\
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    \7\S. Rep. No. 94-133, at 36 (1976).
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    Health Status. These conclusions were based upon the 
statistics at the time. For example, the ``incidence of 
tuberculosis for Indians and Alaska Natives [was] 7.3 times 
higher than the rate for all citizens of the United States. . . 
. [T]he suicide rate . . . [was] approximately twice as high as 
in the total U.S. population.''\8\ Also troubling was the 
infant mortality rate for Indian babies, which was 
significantly higher than the national average.\9\
---------------------------------------------------------------------------
    \8\Id.
    \9\Id.
---------------------------------------------------------------------------
    Health Professionals. Compounding the low health status 
were the difficulties in recruiting and retaining qualified 
health professionals--Indian health professionals, in 
particular--to work in the Indian communities. The available 
information indicated that out of 500 doctors in the Indian 
Health Service, only 3 were Indian.\10\ Overall, ``in 1975, 
there were only 72 American Indian physicians to serve the 
needs of 1,000,000 American Indians, most of whom lived on 
Reservations.''\11\ Likewise, only half of the number of 
pharmacists needed was employed in these Indian 
communities.\12\
---------------------------------------------------------------------------
    \10\Id., at 55.
    \11\Headlands Indian Health Careers, Program History, available at 
http://www.headlands.ouhsc.edu/history.asp.
    \12\S. Rep. No. 94-133, at 42 (1976).
---------------------------------------------------------------------------
    Health Facilities. The conditions and availability of 
health facilities did not fare any better. A significant number 
of the existing facilities were over twenty years old. Many 
others were ``old one-story, wooden buildings with inadequate 
electricity, ventilation, insulation and fire protection 
systems, and of such insufficient size as to jeopardize the 
health and safety of their occupants.''\13\ The Joint Committee 
on Accreditation of Hospitals (JCAHO) found that ``only 24 of 
the 51 existing IHS hospitals'' met accreditation standards and 
``two-thirds [were] obsolete and that 22 need[ed] complete 
replacement.''\14\
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    \13\Id. at 36-37.
    \14\Id., at 37.
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    Funding. The funding available for the provision of health 
services to Indians also revealed significant disparities. For 
example, ``[p]er capita expenditures for Indian health purposes 
[were] 25 percent below per capita expenditures for health care 
in the average American community.''\15\
---------------------------------------------------------------------------
    \15\Id.
---------------------------------------------------------------------------
    Accordingly, the goals of the Act held great promise for 
the advancement of Indian health by improving the direction in 
programs and access to other programs, such as Medicare and 
Medicaid.

                      CURRENT INDIAN HEALTH SYSTEM

    Since 1976, significant improvements have been made in the 
programs and funding levels authorized for Indian health 
through the Act and the amendments thereto. Yet, a comparison 
of historic statistics with current status indicators shows 
that, while real progress has been made, significant 
disparities still persist.
    Indian Health Status. The Indian Health Service report 
2000-2001 Trends in Indian Health indicates the age-adjusted 
death rates for American Indians and Alaska Natives for 1996-
1998 was five times the rate for U.S. all-races in 1997.\16\ 
Despite a decrease of 64% over a period spanning 1972 to 1999, 
Indian infant mortality rates still remained 24% higher than 
other U.S. populations.\17\ Other Indian mortality rates far 
exceeded the mortality rates of other U.S. populations for 
causes including alcoholism (638%), diabetes mellitus (291%), 
unintentional injuries (215%), pneumonia and influenza (67%), 
gastrointestinal disease (38-40%) and heart disease (20%).
---------------------------------------------------------------------------
    \16\U.S. Department of Health and Human Services, Indian Health 
Service, 2000-2001 Trends in Indian Health, at 68.
    \17\U.S. Department of Health and Human Services, Indian Health 
Service, 2000-2001 Trends in Indian Health, at 162.
---------------------------------------------------------------------------
    Even during the short period of 1997 to 2004, the 
``prevalence of diagnosed diabetes increased by 47 percent in 
all major regions (all ages) served by the Indian Health 
Service.'' The most alarming increase, however, has occurred 
among younger American Indians and Alaska Natives, with a 160 
percent increase from 1990-2004 for young adults aged 25-34 
years, and a 128 percent increase for adolescents aged 15-19 
years from 1990-2004.\18\
---------------------------------------------------------------------------
    \18\U.S. Department of Health and Human Services, Indian Health 
Service, Fiscal Year 2008, Justification of Estimates for 
Appropriations Committees, at CJ-147.
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    Recent information also indicates that suicide rates among 
youth in Indian Country are predominately higher than for non-
Indian youth. In 2005, the Committee held two hearings on the 
issue of Indian youth suicide. A field hearing was held in 
Bismarck, N.D. on May 2, 2005, and an oversight hearing was 
held in Washington, D.C. on June 15, 2005. During the second 
session of the 109th Congress, on May 17, 2006, the Committee 
held an oversight hearing on suicide prevention programs and 
their application in Indian Country.
    According to national data for 2002, suicide was the second 
leading cause of death for Indians of both sexes in the 15-34 
year age range, and the fourth leading cause of death for both 
sexes in the 10-14 year age range. On the reservations of the 
Northern Great Plains (States of North and South Dakota, Iowa, 
Minnesota and Nebraska), the rate of Indian youth suicide is up 
to 10 times higher than it is elsewhere in the country. At 
several Indian health facilities, the demand for mental health 
care outstripped capacity.\19\ In at least one facility, the 
mental health services were to be cut by 20% in FY 2005 because 
funding had been depleted.\20\
---------------------------------------------------------------------------
    \19\United States Government Accountability Office, Report to the 
Committee on Indian Affairs, U.S. Senate, Indian Health Service: Health 
Care Services Are Not Always Available to Native Americans, GAO Report 
No. GAO-05-789, (August, 2005) at 18.
    \20\GAO Report No. GAO-05-789 at 18.
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    Another alarming and growing problem arising in Indian 
communities is the use of methamphetamines. The Committee held 
an oversight hearing on the problem of methamphetamine in 
Indian Country on April 5, 2006. According to the National 
Survey on Drug Use and Health, the past-year use rate during a 
2002-2004 survey period among American Indians and Alaska 
Natives aged 12 and older is higher than every other population 
except Native Hawaiians or other Pacific Islanders and youth 
reporting two or more races.\21\
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    \21\U.S. Department of Health and Human Services, Substance Abuse 
and Mental Health Services Administration, Office of Applied Studies, 
National Survey on Drug Use and Health, The NSDUH Report, September 16, 
2005, http://oas.samhsa.gov/2k5/meth/meth.htm.
---------------------------------------------------------------------------
    Health Facilities. According to the Indian Health Service's 
FY 2008 budget request, the IHS health care facilities system 
is made up of 163 Service Units (63 IHS, 100 tribal); 48 
Hospitals (33 IHS, 15 tribal); and 603 Ambulatory Care Centers 
(92 IHS and 511 tribal) (consisting of Health Centers, School 
Health Centers, Health Stations and Alaska Village 
Clinics).\22\
---------------------------------------------------------------------------
    \22\U.S. Department of Health and Human Services, Indian Health 
Service, Fiscal Year 2008, Justification of Estimates for 
Appropriations Committees, at CJ-251.
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    According to the IHS Health Facilities Construction 
Priority System, the estimated unfunded total cost to meet the 
need was nearly $3.5 billion as of FY 2008.\23\ In addition, 
the backlog for the maintenance and improvement needs of 
current facilities was estimated at $408,956,000.\24\
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    \23\U.S. Department of Health and Human Services, Indian Health 
Service, chart of Health Care Facilities FY 2009 Planned Construction 
Budget (March 30, 2007).
    \24\U.S. Department of Health and Human Services, Indian Health 
Service, Fiscal Year 2008, Justification of Estimates for 
Appropriations Committees, at CJ-164.
---------------------------------------------------------------------------
    However, on the positive side, ``All IHS and Tribally-
operated hospitals are accredited by the Joint Commission on 
Accreditation of Healthcare Organizations (JCAHO) or certified 
by the Centers for Medicare and Medicaid Services (CMS).''\25\
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    \25\Id., at CJ-167.
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    In addition, since the Indian Sanitation Facilities and 
Services Act, Public Law 86-121, codified at 42 U.S.C. 2004, 
was passed in 1959, ``over 270,000 Indian homes have been 
provided sanitation facilities'' which served to reduce ``[t]he 
gastroenteric and post-neonatal death rates among the Indian 
people . . . primarily because of the increased prevalence of 
safe drinking water supplies and sanitary waste disposal 
systems.''\26\ The IHS noted that ``[i]n 1955, more than 80 
percent of American Indians and Alaska Natives were living in 
homes without essential sanitation facilities.''\27\ The age-
adjusted gastrointestinal death rate was ``15.4 per 100,000 
population. . . . 4.3 times higher than that for all other 
races in the United States.''\28\ But by 1995, that death rate 
was reduced to 1.7 per 100,000, although that 1995 rate is 
still 40% higher than the rate for all races in the United 
States.\29\
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    \26\U.S. Department of Health and Human Services, Indian Health 
Service. The Sanitation Facilities Construction Program of the Indian 
Health Service, Public Law 86-121, Annual Report for 2005, at 1.
    \27\Id., at 21.
    \28\Id.
    \29\Id.
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    In FY 2005, approximately $132 million was appropriated for 
sanitation facilities construction, of which $91.7 million was 
appropriated to the Indian Health Service and more than $40.4 
million came from other Federal agencies and non-Federal 
sources such as tribes and state agencies.\30\ IHS estimated 
that in FY 2005, the Sanitation Construction Program provided 
sanitation facilities to a total of 24,072 homes.\31\ However, 
the total estimated costs needed to address the sanitation 
deficiencies in existing homes as of the end of FY 2006 totaled 
over $2.2 billion, with projects considered economically 
feasible totaling $1 billion. There were more than 155,000 
Indian and Alaska Native homes in need of sanitation 
facilities, including more than 38,000 which are without 
potable water.\32\
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    \30\U.S. Department of Health and Human Services, Indian Health 
Service. The Sanitation Facilities Construction Program of the Indian 
Health Service, Public Law 86-121, Annual Report for 2005, at 5.
    \31\Id.
    \32\U.S. Department of Health and Human Services, Indian Health 
Service, Justification of Estimates for Appropriations Committees for 
Fiscal Year 2008, at CJ-170.
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    Health Professionals. The number of Indian health 
professionals has increased since the Act was first signed into 
law. According to the latest Census information, there were 
over 1,300 Indian physicians and surgeons and over 10,000 
Indian registered nurses.\33\ These numbers suggest that the 
incentives in the Act have assisted in increasing these 
numbers. However, vacancy rates for key health professionals 
indicate that a substantial need still exists for qualified 
health professionals in the Indian health system. The December, 
2006, vacancy rates for health professions with the greatest 
shortfalls consist of Dentists (32%), Optometrists (12%), 
Nurses (17%), and Pharmacists and Physicians (both 12%).\34\
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    \33\U.S. Census Bureau, American FactFinder, Census 2000 Summary 
File 4, Table PCT86. The numbers are for individuals reporting only the 
American Indian and Alaska Native race.
    \34\U.S. Department of Health and Human Services, Indian Health 
Service, Justification of Estimates for Appropriations Committees for 
Fiscal Year 2008, at CJ-125.
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    Types and Level of Services. The IHS, tribal and urban 
Indian health programs provide an array of basic medical, 
dental and vision services, including inpatient care, and 
routine and emergency ambulatory care; and medical support 
services including laboratory, pharmacy, nutrition, diagnostic 
imaging, medical records, physical therapy, etc.,\35\ as well 
as other preventive, clinical and environmental health 
services. When these services are not available at their 
facilities, IHS, tribal and urban programs purchase medical 
care and urgent care services through the Contract Health 
Services program.
---------------------------------------------------------------------------
    \35\U.S. Department of Health and Human Services, Indian Health 
Service, Fiscal Year 2008, Justification of Estimates for 
Appropriations Committees, at CJ-71.
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    Even though basic services may be available at an Indian 
health facility, access to these services is not assured. In 
its study on the availability of health services to Indians in 
August, 2005, the Government Accountability Office (GAO) found 
that Indian patients often had to wait more than 30 days--in 
some cases two to six months--between setting the appointment 
for services and receiving the services, a time frame ``in 
excess of standards and goals identified in other federally 
operated health service delivery systems.''\36\ Moreover, 
``[t]he most frequent gaps were for services aimed at the 
diagnosis and treatment of medical conditions that caused 
discomfort, pain, or some degree of disability but that were 
not emergent or acutely urgent.''\37\ For example, in some 
cases, adult Indian patients ``could wait as long as 120 days 
to get approval for eyeglasses.''\38\ According to one tribal 
official interviewed by the GAO, these situations create an 
environment in which Indian patients become demoralized and may 
wait until their condition becomes ``an emergency that required 
a higher level of treatment.''\39\
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    \36\GAO Report No. GAO-05-789, at 15.
    \37\Id., at 19.
    \38\Id.
    \39\GAO Report No. GAO-05-789, at 16.
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    The Committee is deeply concerned with the GAO's findings 
and its conclusions that the disturbing result of these gaps 
are ``diagnosis or treatment delays that exacerbate[] the 
severity of a patient's condition and create[] a need for more 
intensive treatment.''\40\ The Committee is further concerned 
that these gaps increase the costs of health care and diminish 
the potential for prevention efforts.
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    \40\Id., at 21.
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    The Committee appreciates the Administration's efforts in 
promoting prevention as a key to reducing health care costs, 
but believes a much greater effort is needed to reduce gaps in 
health services to Indians. Improvements are needed in all 
areas of the Indian health care system to ameliorate problems 
and delays in service delivery. The improvements outlined in S. 
1200 for programs and policies, provisions in S. 1200 which 
would be new to the Act, including services for home- and 
community-based care, youth suicide prevention and convenient 
care services, and the National Bipartisan Commission on Indian 
Health Care study on the delivery of federal health care 
services to Indians are all designed to help address these 
problems.

                 THE INDIAN HEALTH CARE IMPROVEMENT ACT

    In passing the Indian Health Care Improvement Act of 1976, 
Congress set forth ambitious goals for improving the health of 
Indians, including encouraging Indian participation in ``the 
planning and management'' of health services (25 U.S.C. 
1601(b)). The Act ``would provide the direction and financial 
resources to overcome the inadequacies in the existing Federal 
Indian health care program.''\41\ These goals built upon the 
foundation laid in President Nixon's 1970 ``Special Message to 
the Congress on Indian Affairs.''\42\ In his ``Special 
Message,'' President Nixon declared that ``[t]he time ha[d] 
come to break decisively with the past and to create the 
conditions for a new era in which the Indian future is 
determined by Indians acts and Indian decisions.''\43\
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    \41\Senate Report No. 94-133, at 13.
    \42\President's Special Message to Congress on Indian Affairs, 213 
Pub. Papers 564 (July 8, 1970).
    \43\President's Special Message to Congress on Indian Affairs, 213 
Pub. Papers 565 (July 8, 1970).
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    Breaking decisively with the past meant a radical change in 
health care delivery, beginning with the administration of the 
programs and policy-making. Placing administrative and 
decision-making authority in the hands of Indian tribal 
governments, rather than solely in the agency's hands, was both 
a fundamental and logical change in the approach in health care 
delivery. Reconfirming the tribes' authority to administer 
health programs, however, took several years to achieve.\44\
---------------------------------------------------------------------------
    \44\See, e.g., U.S. General Accounting Office, now, U.S. Government 
Accountability Office, Report to the Chairman, Select Committee on 
Indian Affairs, U.S. Senate, Indian Health Service, Contracting under 
the Indian Self-Determination Act, GAO Report No. GAO/HRD-86-99, 
September, 1986.
---------------------------------------------------------------------------
    Today, nearly half of the IHS budget is administered 
through tribal contracts or compacts under the Indian Self-
Determination and Education Assistance Act of 1976 (ISDEAA), 25 
U.S.C. 450 et seq. Title I contracts and Title V compacts total 
more than $1.6 billion. The IHS currently administers contracts 
and Annual Funding Agreements with 245 tribes or tribal 
organizations, and 72 compacts and 93 funding agreements with 
322 tribes.\45\ These numbers not only reflect congressional 
policy of promoting tribal self-determination, but generate a 
higher level of cooperation among Indian health providers.
---------------------------------------------------------------------------
    \45\U.S. Department of Health and Human Services, Indian Health 
Service, Fiscal Year 2008, Justification of Estimates for 
Appropriations Committees, at CJ-258.
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               GENERAL PRINCIPLES IN THE REAUTHORIZATION

    During the reauthorization process, a critical assessment 
of the Act was undertaken by the Committee and the Indian 
health community and several basic principles emerged. The 
history of Indian health and the interplay between the ISDEAA 
and the Act are key considerations in the development of sound 
Indian health policy.
    Self-Determination. Since self-determination was declared 
to be the new direction in Federal Indian policy, tribal 
participation has significantly contributed to improving both 
health and other services for Indian people.\46\ Meaningful 
participation by tribes in administering programs through 
contracting or compacting has been a principal means of 
implementing the self-determination policy.
---------------------------------------------------------------------------
    \46\See e.g., National Indian Health Board, Tribal Perspectives on 
Indian Self-Determination and Self-Governance in Health Care 
Management, 1998.
---------------------------------------------------------------------------
    However, simply administering a program designed and handed 
down by the agency does not accomplish the vision embodied in 
self-determination. Indian and Alaska Native participation is 
critical in the development of the framework of these programs 
and services. Tribal self-determination involves tribes 
designing or modifying programs, as well as formulating new 
ideas, concepts and methodologies of how those programs or 
services should be delivered to their own communities.
    Negotiated Rulemaking and Consultation. Such participation 
means appreciable engagement between the agency and Indian 
tribes, and numerous tools have successfully increased that 
involvement. For example, negotiated rulemaking under the 
Administrative Procedures Act has been found to be useful in 
several initiatives such as education, housing and Self-
Governance.\47\
---------------------------------------------------------------------------
    \47\See, e.g., No Child Left Behind Act, Pub. L. 107-110, 25 U.S.C. 
2001, et seq.; Native American Housing Assistance and Self-
Determination Act, Pub. L. 104-330, 25 U.S.C. 4116; Indian Self-
Determination and Education Assistance Act, Pub. L. 106-477, 25 U.S.C. 
458aa-16.
---------------------------------------------------------------------------
    The Committee has received testimony from tribal 
participants in negotiated rulemaking that ``true understanding 
among tribes and with IHS is achieved''\48\ through that 
process. That ``true understanding'' is consistent with the 
Committee's desire to foster consensus-building and reduce 
obstacles that negatively impact health care service delivery, 
as well as to carry out the government-to-government 
relationship between Indian tribes and the federal government.
---------------------------------------------------------------------------
    \48\Indian Health Care Improvement Act Amendments of 2005: Joint 
Hearing on S. 1057 Before the Senate Committee on Indian Affairs and 
Senate Committee on Health, Education, Labor and Pensions, 109th Cong., 
1st Session, S. Hrg. 109-162 at 725 (July 14, 2005) (statement of Don 
Kashaveroff, President, Seldovia Village Tribe).
---------------------------------------------------------------------------
    The Administration has expressed concerns about the time 
and resource constraints involved in negotiated rulemaking. The 
Committee strongly supports fiscal accountability and decreased 
bureaucracy, but believes that the long-term benefits of 
negotiated rulemaking more than justify the costs which may be 
required in the short-term.
    The Committee believes that the Indian tribal and urban 
health providers--as first responders in the health system--
should be directly involved in developing health programs and 
the regulations that affect their service populations. Tribal 
involvement in rulemaking not only leads to a more informed 
rule, but it fosters tribal support. In addition, negotiated 
rulemaking can save costs to all parties in the long run. By 
building a higher level of consensus in the regulations, the 
IHS lowers the potential for legal challenges to the rules and 
associated litigation costs. The Committee favors consensus-
building over litigation and encourages this long-term view. 
The concerns are further abated by the limited number of 
program criteria or requirements under the Act which are 
subject to negotiated rulemaking. Section 802 outlines the 
scope for negotiated rulemaking which is limited to Titles II 
(except for section 202) and VII, a few sections in Title III, 
and section 807.
    Besides negotiated rulemaking, the Committee has favored 
consultation with tribes as another tool to increase tribal 
participation, but has generally left the manner or method of 
consultation to the discretion of the Secretary.
    For example, the ISDEAA simply requires an annual 
consultation on the budget. However, the Secretary has in the 
past implemented a rigorous regional and national schedule for 
budget consultation, holding the 9th Annual HHS Tribal Budget 
Formulation and Policy Consultation Session in Washington, DC, 
March 28 and 29, 2007.\49\
---------------------------------------------------------------------------
    \49\See www.hhs.gov/iga/tribal.
---------------------------------------------------------------------------
    The Committee recognizes that the Administration has made 
efforts to involve Indian tribes in decision-making through the 
consultation policy issued by the DHHS.\50\ The Committee also 
recognizes that the Department's policy has attempted to 
address a wide variety of matters affecting Indian communities. 
However, the Committee is concerned that the scope of the 
Department policy may not fully encompass all critical matters 
for which the Committee believes consultation should be used, 
or that comments received are fully considered.
---------------------------------------------------------------------------
    \50\U.S. Department of Health and Human Services, Department Tribal 
Consultation Policy, January, 2005, available at www.hhs.gov/ofta/docs/
FnlCnsltPlcywl.pdf.
---------------------------------------------------------------------------
    Such matters involve the development of program eligibility 
or criteria, or relate to specific tribes, Indian population 
groups (e.g., women) or to special tribal history, customs, or 
practices. Consequently, remaining committed to promoting 
tribal input by institutionalizing consultation, the Committee 
has provided for robust consultation requirements in several 
key areas, while leaving the manner of consultation to 
Secretarial discretion.
    Flexibility. In addition, the Committee believes that less 
bureaucracy and more flexibility are needed to tailor programs 
or services to address local community health needs.\51\ The 
Committee is pleased that the Administration has joined in 
supporting flexibility and new approaches to health care, and 
expanding the range of options of health services.\52\
---------------------------------------------------------------------------
    \51\Flexibility also eliminates the need to identify each and every 
program that may be administered by IHS, the tribal or urban programs 
(e.g., the definition of ``health professions'' does not identify every 
profession that may be authorized). Many of the decisions or priorities 
are left to the Indian health providers to determine to implement as 
needed. The Committee is aware that the IHS, Indian tribes and urban 
programs engage in extensive budget consultations, sometimes two years 
in advance of implementation, where programs and professions to 
emphasize for scholarships is discussed.
    \52\S. Hrg. 109-162 at 589 (statement of Dr. Grim, Director, U.S. 
Department of Health and Human Services, Indian Health Service).
---------------------------------------------------------------------------
    However, in the course of negotiating this legislation, the 
Administration has repeatedly indicated its preference to 
change mandatory programs to discretionary ones to meet 
budgetary constraints and to give the Secretary maximum 
flexibility.\53\ The Committee has accommodated these 
principles based on the understanding that Indian tribes would 
also be accorded the same flexibility under the Act and the 
ISDEAA.
---------------------------------------------------------------------------
    \53\Id., at 596, and S. Hrg. 110-53 at 38 (March 8, 2007) 
(statement of Admiral John Agwunobi).
---------------------------------------------------------------------------
    The Committee has been informed that, in the past, the 
Indian tribes had been foreclosed from implementing programs 
that the agency did not actually implement either under the Act 
or the Snyder Act, 25 U.S.C. 13. Simple program authorizations 
under the Act and the Snyder Act were deemed insufficient to 
allow the Indian tribes to administer the programs even under 
the redesign provisions of the ISDEAA.
    It is the Committee's intent, however, that simple 
authorizations are sufficient to enable tribes to implement 
programs, even if the Federal agency chooses not to, provided 
all other applicable provisions of the Act, the Snyder Act and 
the ISDEAA are met. The Committee believes that this 
interpretation is necessary to enable Indian tribes to meet the 
needs of their communities and required, if the Secretary is to 
experience the flexibility desired.
    Oversight and Reporting. In the past, the Committee has 
been reluctant to eliminate certain mandates, such as those 
requiring studies. For example, many studies and reports 
mandated by the 1976 Act have never been completed. These 
studies were intended to provide insight into the 
accomplishments and challenges in Indian health and to assist 
the Congress in seeking new approaches to service delivery. The 
Committee is troubled that the health status of Indians 
reflects many of the same problems it did in 1976, and that 
several mandated studies, reports and programs in current law 
have been disregarded.
    Consequently, the Committee has included in S. 1200 
provisions which will establish a National Bipartisan 
Commission on Indian Health Care to thoroughly review 
opportunities for improvement of the Indian health care system. 
During the 108th Congress, the bill to reauthorize the Act, S. 
556, contained provisions requiring the Bipartisan Commission 
to study the potential of funding Indian health as an 
entitlement. Based on the Administration's recommendations 
offered during the 108th Congress, the Committee modified the 
Commission's objectives to what is now included in S. 1200.
    In addition, the Committee has included authorization of 
the Native American Health and Wellness Foundation, provisions 
to promote the mission of IHS in improving Indian health. This 
Foundation is not a substitute for the federal obligation to 
provide health services to Indians, but is intended to 
complement the federal obligation in ways in which the United 
States has fallen short.
    While much discretion and flexibility is provided to the 
IHS throughout S. 1200, the Committee must preserve the 
necessary mechanisms to fulfill its oversight function. The 
primary means is through active reporting requirements by the 
Secretary. Congress simply cannot leave unfettered the 
operations of these important programs without appropriate 
assurances that Indian people are being served consistent with 
Congressional intent and priorities. Moreover, Congress should 
be informed of how and when these programs meet--or fall short 
of meeting--the basic health needs of Indian people.

                             KEY PROVISIONS

    Several key improvements to the Act contained in S. 1200 
are particularly noteworthy:
    Health Professions. Difficulties in recruiting and 
retaining qualified health professionals have long been 
recognized as a significant factor impairing Indians' access to 
health care services.\54\ Noting that many Indian communities 
are often in remote locations and lack adequate housing and 
educational and recreational opportunities for employees and 
their families,\55\ the GAO reported that some critical 
positions such as for pharmacists and dentists remained vacant 
for several years in some locations.\56\
---------------------------------------------------------------------------
    \54\See also GAO Report No. GAO-05-789, at 4.
    \55\GAO Report No. GAO-05-789, at 4.
    \56\Id.
---------------------------------------------------------------------------
    The provisions in Title I address the health professional 
shortage in Indian communities. Congress specifically included 
these provisions in 1976 because the existing programs to 
improve manpower capabilities were woefully inadequate or 
completely unsuitable for Indian health providers and 
communities.\57\
---------------------------------------------------------------------------
    \57\Senate Report No. 94-133, at 55-57.
---------------------------------------------------------------------------
    The programs existing in 1976 did ``not link the recipients 
[of scholarships] directly to the Indian Health Service,'' were 
``not designed to recruit and support Indians,'' and were too 
limited in the ``category of health professionals'' supported 
by these programs.\58\
---------------------------------------------------------------------------
    \58\Id., at 55-56.
---------------------------------------------------------------------------
    Consequently, Congress developed a new approach and the IHS 
scholarship program was born. Fears of duplication were quickly 
disproven by the obvious need for and success of these programs 
in filling vacancies and returning Indian health professionals 
to the Indian communities. Today, the program has expanded to 
include a wide variety of health professions as determined by 
the priorities set by the IHS and the Indian tribes. Besides 
the scholarships, the program also now includes loan 
repayments, a tribal scholarship program, and bonus incentive 
payments.
    These programs specifically target the needs of the Indian 
health system. For example, the scholarship priorities are 
developed through a year-long consultation process wherein the 
IHS sends the program information and request for priority to 
each Indian tribe and the tribal education and health programs. 
The comprehensive list is developed based on the IHS and tribal 
health professional projected needs, vacancies and available 
positions. By focusing on the specific needs of Indian 
communities, the Committee believes that this approach has 
significantly improved Indian health.
    Targeting the specific needs of the Indian health system 
has become the hallmark of the Indian health professional 
policy. Likewise, a continuous and seamless transitional 
approach also is a key policy component in increasing the 
number of Indian health professionals. The Committee strongly 
encourages the Secretary to evaluate all opportunities to 
improve the chances of success for Indian health professionals, 
including obtaining the licenses or certifications necessary 
for providing health care services. The Committee has been made 
aware of the need to increase the number of licensed health 
professionals in the Indian health system and included 
provisions in S. 1200 to address that need. S. 1200 provides 
for portability of current licenses for tribal health 
professionals consistent with other Federal health licensing 
provisions. In addition, S. 1200 authorizes programs to enhance 
and facilitate enrollment in and completion of courses of study 
in health professions.
    The Committee believes that the Title I programs should 
fully equip the Indian student trainees with the tools needed 
to transition into the health profession, including 
successfully completing all courses of study and passing the 
required licensing or board examinations. In addition, the 
Committee expects that the IHS would also ensure that 
scholarship recipients are provided every opportunity to 
fulfill their service obligations, including technical 
assistance in understanding their obligations.
    The remedial programs, scholarships, grants, externships, 
service obligations and advanced training established in Title 
I are all designed to provide seamless opportunities for 
successfully recruiting and training Indians for health 
professions. As part of the long-term view of Indian health 
professions, the Committee believes continuity is necessary in 
administering the Title I programs.
    The incentives fostered by scholarships, loan repayments, 
and bonuses are multiplied when combined with professional 
development programs for health professionals which the 
Committee believes to be essential components of recruitment 
and retention programs in the Indian health system. S. 1200 
establishes several professional development programs in Title 
I such as opportunities for advanced training and research, 
tribal cultural orientation, training in the administration and 
planning of tribal health programs and tribal demonstration 
projects for innovative recruitment, placement and retention 
programs, which may include professional development programs.
    Such additional training for health professionals is 
particularly important in developing leadership and 
collaboration skills and ensuring that a culturally-competent 
workforce exists within the Indian health system. The Committee 
strongly encourages the Secretary and tribal and urban Indian 
health providers to develop innovative programs or take 
advantage of existing models for such professional development 
to increase and maintain the number of Indian health 
professionals in the Indian health system.
    In addition, the Committee takes a long-term view of health 
professions in S. 1200. The most urgent placement needs are in 
the direct care positions, such as dentists, doctors, nurses, 
and pharmacists. In the long-term, Indian health professionals 
are also needed in educational positions to bolster recruitment 
levels and improve the new Indian health professionals' chances 
of success.
    The Committee has been informed that significant need 
exists at the tribal colleges and universities to increase the 
number of Indian instructors in the nursing programs.\59\ The 
Committee recognizes that Indian instructors often have 
personal knowledge of the health disparities in Indian 
communities and a deep commitment to serve these communities 
for the long-term. Indian educators increase the likelihood of 
success for Indian students and bring to the classroom the 
unique cultural competence required in the Indian health field.
---------------------------------------------------------------------------
    \59\Joseph F. McDonald, Ed.D., President, Salish-Kootenai College, 
Letter to Chairman John McCain, U.S. Senate Committee on Indian 
Affairs, September 22, 2005.
---------------------------------------------------------------------------
    With that in mind, the Committee included provisions in 
Title I of S. 1200 allowing a scholarship recipient to fulfill 
his or her service obligation (required in exchange for the 
scholarship) by teaching in a tribal college or university 
nursing or other health related program, provided the Secretary 
determines that health services to Indians will not be 
decreased. In addition, the Secretary may, prior to waiving any 
service obligation or repayment of a scholarship, consider 
placement of a scholarship recipient in a teaching capacity in 
a tribal college or university nursing or related health 
program. Other provisions for nursing grants were added to 
extend a preference in grant awards to tribal college and 
university nursing programs.
    Prior to including these provisions, the Committee 
considered the likelihood that inexperienced, new graduates 
might be placed in teaching positions. One tribal college 
president indicated that ``these [instructors] are clinically 
seasoned, mature [Bachelor of Science--Nursing] prepared nurses 
returning to school for educational and career mobility.''\60\ 
Teaching positions available for these individuals would 
include lab coordinators and clinical instructors. This tribal 
college President also indicated that ``new [registered nurse] 
graduates of associate or generic baccalaureate programs would 
not be qualified to teach.''\61\
---------------------------------------------------------------------------
    \60\Joseph F. McDonald, Ed.D., President, Salish-Kootenai College, 
Letter to Honorable Don Young, U.S. House of Representatives, November 
1, 2005.
    \61\Joseph F. McDonald, Ed.D., President, Salish-Kootenai College, 
Letter to Honorable Don Young, U.S. House of Representatives, November 
1, 2005.
---------------------------------------------------------------------------
    The Committee believes these positions should be filled by 
experienced faculty and expects that the Secretary and the 
tribal colleges or universities would coordinate these 
opportunities and be selective in placing these individuals to 
avoid compromising the quality of education and accreditation.
    The Committee strongly encourages the Secretary to examine 
the Title I programs with targeted, holistic, long-term 
approaches in mind and to develop more opportunities to 
increase the number of Indians in the health professions. The 
Committee believes that in the long-run, improving health 
educational opportunities at every level will also contribute 
to improving the health of Indian communities.
    Home Health Care. Current law authorizes a feasibility 
study to be conducted on hospice care services. However, the 
IHS has never conducted that study and, now, 14 years later, to 
conduct such a study would greatly delay what have already been 
demonstrated to be much needed services.
    The Committee has been informed that some Indian tribes and 
tribal organizations, through pilot projects, have provided 
this type of service or other services such as home health care 
with great success. The Committee is concerned that not 
authorizing these and other long-term or home health care 
services through the Indian health care system--services that 
have been an accepted part of the national health care system 
and Medicare since 1983--will prevent IHS and tribes from 
utilizing a proven, effective health delivery vehicle.
    Currently, home health care, long-term care and hospice 
care are not readily available to most Native communities. Many 
Indians must travel long distances, only to be placed in 
facilities that are far from home, culturally unfamiliar, and 
not conducive to their overall well-being. Home health care is 
crucial for these individuals. Having culturally-appropriate 
facilities close to Indian communities not only promotes the 
patient's well-being, but enables family members to more easily 
visit the patient.
    Section 213 of S. 1200 authorizes services such as home 
health care, long-term care and hospice care, which are a 
standard part of the health care industry. If the Indian health 
system is to advance into the 21st Century, then Indian health 
programs must be authorized to make these services available 
for their Indian patients, if circumstances warrant.
    However, the Department of Justice has indicated that it 
has concerns regarding the provision of services for which no 
standards exist.\62\ To address those concerns, S. 4122 in the 
109th Congress included language that required standards to be 
in place from either the Secretary or the state in which the 
Indian health program was located. This type of requirement has 
been a part of the Indian health system as required in the 
Indian Self-Determination and Education Assistance Act.\63\
---------------------------------------------------------------------------
    \62\S. Hrg. 110-53 at 41 (March 8, 2007) (statement of C. Frederick 
Beckner III, Deputy Assistant Attorney General, Civil Division, 
Department of Justice).
    \63\See 25 U.S.C. 450f(a)(2). ``The contractor shall include in the 
proposal of the contractor the standards under which the tribal 
organization will operate the contracted program, service, function, or 
activity. . . .''
---------------------------------------------------------------------------
    Indian tribes want to ensure that the services authorized 
in Section 213 are consistent with those services reimbursable 
by Medicaid and, in particular, those services already 
authorized in compacts or contracts entered into by the tribes 
or tribal organizations and the IHS pursuant to the ISDEAA.
    To that end, S. 1200 authorizes the Secretary to promulgate 
standards to govern any service in the absence of state 
standards. It is the intent of the Committee that those 
services already authorized in compacts or contracts will 
remain so authorized and that the Secretary is authorized to 
issue interim standards in the absence of either state 
standards or final Secretarial standards. The Committee expects 
the Secretary to act promptly to promulgate these standards, so 
that services to Indian patients are not disrupted or denied.
    Convenient Care Services. Section 213 also authorizes the 
Secretary to provide funding to meet the health status 
objectives of the Act for convenient care services programs 
pursuant to section 306(c)(2)(A). Section 213 further 
authorizes health care delivery demonstration projects that 
include a ``convenient care services'' program as an 
alternative means of delivering health care services to 
Indians.
    In including this new provision, the Committee seeks to 
address the lack of access to health care services that exists 
in so many tribal communities, which may be due to limited 
hours of operation at existing health care facilities, lack of 
staff, or other factors. It is the Committee's hope that these 
convenient care services projects may expand the availability 
of health care, as well as decrease the need for more-costly 
emergency room visits, thereby reducing the over-stressed 
Contract Health Services budget.
    Traditional Health Care Practices. For much of America's 
history, the federal government's policy of assimilation and 
termination sought to destroy Indian cultures and religions, as 
well as tribal legal, political and economic institutions. 
Indian people were denied the exercise of traditional practices 
or punished, should those ceremonies be practiced, as well as 
were punished for speaking their own languages and observing 
other traditional ways.
    However, federal policy toward Native people has run the 
gamut, with the policy of one period often contradicting that 
of another. An example of such a policy shift occurred 
following the 1928 Merriam Report, which generated several 
initiatives to improve health conditions for Native 
Americans.\64\ One reform was the active solicitation of 
traditional Indian healers to participate in federal health 
services to Indians.
---------------------------------------------------------------------------
    \64\Merriam, Lewis (ed.), Institute for Government Research, The 
Problem of Indian Administration (1928) (commonly referred to as the 
``Merriam Report'').
---------------------------------------------------------------------------
    The Indian Health Care Improvement Act currently contains 
provisions to promote long-practiced traditional health care 
practices of the Indian tribes served by IHS, tribal and urban 
Indian health programs, consistent with the standards for the 
provision of health care, health promotion, and disease 
prevention. Authority also exists for culturally appropriate 
health care with respect to specific programs (the Community 
Health Representative Program), specific elements of the Indian 
population (Indian youth and Indian women), and specific 
services and training (mental health). These practices 
encourage respect for and affirmation of concepts of Indian and 
Alaska Native cultural values, beliefs and traditions that 
Indian people define for themselves as a complement to western 
medical practices in promoting good health and curing illness.
    Former IHS Director Dr. Emery A. Johnson, in ``Policy and 
Procedures in reference to P.L. 95-341,'' the American Indian 
Religious Freedom Act of 1978, stated the Service's views as 
follows:

          The Indian Health Service has continued to recognize 
        the value and efficacy to [sic] traditional beliefs, 
        ceremonies, and practices of the healing of body, mind 
        and spirit. . . . It is, therefore, the policy of the 
        Indian Health Service to encourage a climate of respect 
        and acceptance in which an individual's private 
        traditional beliefs become a part of the healing and 
        harmonizing force within his/her life.

    More recently, in 1994, IHS Director Michael H. Trujillo 
issued a ``Traditional Cultural Advocacy Program Policy 
Statement'' which states:

          The Indian Health Service (IHS) recognizes the value 
        of traditional beliefs, ceremonies, and practices in 
        the healing of body, mind, and spirit. The IHS 
        encourages a climate of respect and acceptance in which 
        traditional beliefs are honored as a healing and 
        harmonizing force with individual lives, a vital 
        support for purposeful living, and an integral 
        component of the healing process. It is the policy of 
        the IHS to facilitate [sic] right of American Indian 
        and Alaska Native people to their beliefs and health 
        practices as defined by the tribe's or village's 
        traditional culture. This policy is meant to complement 
        and support previously stated IHS policy for 
        implementing the American Indian Religious Freedom Act 
        of 1978 (Public Law 95-341, as amended).

    The Department of Veterans Affairs' National Center for 
Post- Traumatic Stress Disorder is adding traditional healing 
methods, such as talking circles and healing herbs, to modern 
medical treatments for American Indian and Alaska Native 
veterans and service personnel returning from active duty in 
the Middle East and suffering from post-traumatic stress 
disorder problems.\65\ The American Cancer Society (Society) 
includes Native American healing in a section on its website 
concerning treatment decisions.\66\ The Society, in connection 
with work at Montana State University, is providing funding to 
a group of Indian women health care workers on the Crow 
Reservation in Montana to help IHS providers understand 
traditional Crow healing practices and customs.
---------------------------------------------------------------------------
    \65\See Department of Veterans Affairs' National Center for 
Posttraumatic Stress Disorder website, www.ncptsd.va.gov/ncmain/
index.jsp, and, e.g., www.adn.com/front/v-printer/story/9137819p-
9054019c.html.
    \66\www.cancer.org/docroot/ETO/content/
ETO_5_3X_Native_American_Healing.asp?sitearea=ETO.
---------------------------------------------------------------------------
    The Committee believes that health care treatment should be 
relevant to and effective for the population to be served, and 
thus regards traditional health care practices as an important 
part of culturally appropriate care for Indian people. These 
practices have been a part of the IHS, tribal and urban Indian 
health care system for years, are provided only at the request 
of the patient or family members, and are within the 
traditional culture of that individual. It is the Committee's 
understanding, based on Department of Justice testimony to the 
Committee on March 8, 2007, that no medical malpractice suit 
has ever been filed arising from a traditional health care 
practice.\67\ Thus, the risk for the United States in terms of 
liability appears to be insignificant, compared to the benefits 
of allowing Indian patients to obtain this care. DOJ's concerns 
are unfounded in light of the fact that traditional health care 
practices are based in Native healing sciences. The bill has 
the legislative purpose of providing for the highest possible 
health status for Indians without intruding on Indian self-
determination.
---------------------------------------------------------------------------
    \67\S. Hrg. 110-53 at 14 (March 8, 2007) (statement of C. Frederick 
Beckner III, Deputy Assistant Attorney General, Civil Division, 
Department of Justice). See also S. Hrg. 110-53 at 104, testimony of 
Duke McCloud.
---------------------------------------------------------------------------
    Behavioral Health. S. 1200 has a strong focus on behavioral 
health. Title VII takes a comprehensive and integrative 
approach to behavioral health, providing both prevention and 
treatment programs for Indian children, youth, women and 
elders. The bill also emphasizes the interconnectedness of 
services related to alcohol and substance abuse, child welfare, 
suicide prevention and social services. Particular programs are 
authorized for Indian youth, Indian women, those affected by 
fetal alcohol disorder in Indian communities, and both the 
victims and perpetrators of child sexual abuse in Indian 
households.
    In addition to a comprehensive approach to addressing 
behavioral health services, the Committee recognizes and 
affirms the importance of providing care within the context of 
an individual's family, community and particular tribal 
culture, such as is used by the systems of care model.
    Indian Youth Suicide Prevention. The alarming suicide rates 
among Indian youth indicate a great need for improved, 
comprehensive behavioral health care services.
    The nation was shocked in March, 2005, when a troubled 16-
year-old member of the Red Lake Band of Chippewa Indians in 
Minnesota shot and killed his grandfather, his grandfather's 
partner, five fellow high school students, a high school 
teacher and a security guard and seriously wounded several 
others at Red Lake High School on the reservation before 
killing himself. Several other young people from that 
reservation subsequently took their own lives.
    The publicity around the Red Lake incident, which was then 
the nation's second-most deadly school shooting, brought 
attention to the fact that, in Indian Country, suicide impacts 
a younger population than in the rest of the country. The 
suicide rate for Indian and Alaska Native youth, aged 15-24, is 
two and one-half times higher than the national average. Youth 
suicide ``clusters'' have also occurred on reservations in 
North and South Dakota, New Mexico and Arizona and in Native 
communities in Alaska.
    During the 109th Congress, the Committee held three 
hearings specifically on the issue of Indian youth suicide: one 
in Bismarck, North Dakota on May 2, 2005, and two oversight 
hearings in Washington, DC (on June 15, 2005, and on May 17, 
2006), to discuss the kinds of resources and services being 
provided to Indian youth who have expressed suicidal thoughts 
or attempted suicide.
    Based on the information developed through hearings, the 
Committee has included provisions in S. 1200 which address 
youth suicide as part of the behavioral health program 
provisions and in a culturally-appropriate manner. Section 708 
authorizes the Secretary to award grants for telemental health 
demonstration projects to provide counseling to Indian youth 
and health providers, training for Indian community leaders, 
and the development of culturally-relevant materials. The 
Committee recognizes that suicide prevention for Indian youth 
is a long-term effort that must address many multi-factorial 
causes. Questions such as whether the loss of cultural identity 
contributes to the youth suicide problem remain unanswered. 
Therefore, S. 1200 also makes suicide a priority for the IHS 
research agenda, particularly the identification of various 
factors that either protect the tribal community or make that 
community at risk for suicides, and the role the loss of tribal 
identity plays in suicidal behavior. Finally, provisions 
included in Title I encourage more Indian people to enter into 
the psychology profession by increasing the number of grants 
for the program commonly referred to as In-Psych (Indians into 
the Psychology) from three to nine and by authorizing a 
specific level of funding.
    Urban Indians. Providing health care services to urban 
Indians has been a part of Federal policy for nearly 40 years. 
Congress began funding urban Indian clinics in 1967 when 
$321,000 was provided for an Indian clinic in Rapid City, South 
Dakota.\68\
---------------------------------------------------------------------------
    \68\Senate Report No. 94-133, at 136. In 1972, Congress added 
funding to the IHS appropriations for a pilot program in Minneapolis. 
Others followed in 1973 in Oklahoma City, Seattle and California (which 
covered nine urban Indian organizations).
---------------------------------------------------------------------------
    Congress specifically included urban Indian health programs 
as part of the Indian health care system in the Act in 1976, 
recognizing that the Federal obligation for health care 
extended to these individuals. These provisions sought to 
correct disparities in health levels for Indians living in 
urban areas, first as pilot programs and later permanently in 
the Indian health care system.\69\
---------------------------------------------------------------------------
    \69\See Senate Report Nos. 94-133, 100-508 and 108-411.
---------------------------------------------------------------------------
    The policies and status of Indians and Indian tribes under 
Federal laws, treaties and judicial decisions provide ample 
support for continuing and improving programs for urban 
Indians. Under this varied history, the Federal Government had 
dealt with Indian tribes in a variety of ways: some by treaty, 
others not by treaty. The Federal Government had ignored some 
Indian tribes completely. Other Indian tribes were 
legislatively excluded from receiving services under some 
administrative programs, yet were allowed to exercise treaty 
rights. Some Indian tribes were ``terminated,'' yet later 
``restored'' to a government-to-government relationship with 
the United States.
    Courts have long held that Congress has the broad power to 
legislate for the benefit of Indians, even if located off of 
the reservation, and to define who is an Indian and for what 
purposes they may be provided services, even if they may not be 
an enrolled member of a federally-recognized Indian tribe.\70\
---------------------------------------------------------------------------
    \70\U.S. Const., Art. I, Sec. 8, cl. 3. See also Cohen, Felix. 
Handbook of Federal Indian Law, at 23. 1982 ed.; U.S. v. Holliday, 70 
U.S. 407, 417 (1865) (the broad power also includes Congress' dealings 
with individual Indians). As the courts suggest, Federal policy for 
Indians cannot be confined to reservation boundaries. (``The overriding 
duty of our Federal Government to deal fairly with Indians wherever 
located has been recognized by this Court on many occasions.'' Morton 
v. Ruiz, 415 U.S. 199 (1974) (citing Seminole Nation v. U.S., 316 U.S. 
286, 296 (1942); (``Patterns of cross or circular migration on and off 
the reservations make it misleading to suggest that reservations and 
urban Indians are two well-defined groups.'' U.S. v. Raszkiewicz, 169 
F.3d 459, 465 (7th Cir. 1999).)
---------------------------------------------------------------------------
    For example, Congress has enacted laws which define Indians 
in different ways for different purposes.\71\ Even the criminal 
statutes under Title 18 of the U.S. Code regarding crimes on 
Indian reservations do not define who is an Indian. In other 
cases, Congress did not define Indians, or place geographical 
limitations on the service areas in which they may be served. 
The Snyder Act, 25 U.S.C. 13, authorizes permanent funding for 
health care for ``the Indians throughout the United States.'' 
This statute does not confine the services to Indians who are 
members of current federally-recognized tribes or to those 
living only on reservations. The Snyder Act has never been 
repealed nor otherwise limited in this respect. Under this Act, 
Congress has provided a more inclusive definition of urban 
Indian than mere membership in a federally-recognized Indian 
tribe, including members of ``terminated'' tribes, that is, 
groups that once had a political government relationship with 
the United States which was ended under the ``termination'' 
policy of Federal-Indian relations.
---------------------------------------------------------------------------
    \71\See, e.g., Indian Arts and Crafts Act, Pub.L. 101-644, 25 
U.S.C. 305; No Child Left Behind Act, Pub. L. 107-110, 25 U.S.C. 7491; 
and the American Indian Probate Reform Act of 2004, Pub. L. 108-374, 25 
U.S.C. 2201.
---------------------------------------------------------------------------
    Termination was another failed Federal Indian policy 
designed to end the government-to-government relationship with 
Indian tribes and assimilate their members into the larger 
society. When that policy gave way to self-determination, 
however, and Congress sought to try to remedy the devastating 
effects of termination, Congress saw fit to continue the health 
services in the Act to those individuals. See Menominee Tribe 
v. U.S., 391 U.S. 404 (1968). Likewise, by including members of 
state-recognized tribes, Congress recognized that several 
Indian tribes had treaty relations with individual states 
before the Federal Government was established.
    Congress did not in this Act recognize either the 
``terminated tribes'' or the state-recognized tribes on the 
same basis or for the same purposes as the federally-recognized 
tribes under this Act. However, the U.S. Supreme Court has 
found that extending Federal protection for limited purposes, 
such as for services provided in this Act, is within Congress' 
power.
    Further, in adopting S. 1200, the Committee is of the 
opinion that the Congress was on firm constitutional footing 
based on long-standing precedent. Indeed, the U.S. Supreme 
Court has held that ``it is not meant . . . that Congress may 
bring a community or body of people within the range of this 
power by arbitrarily calling them an Indian tribe, but only 
that in respect of distinctly Indian communities the questions, 
whether, to what extent and for what time they shall be 
recognized and dealt with as dependent tribes requiring the 
guardianship and protection of the United States are to be 
determined by Congress, and not by the courts.'' U.S. v. 
Sandoval, 231 U.S. 28, 46 (1913) (emphasis added). Accordingly, 
the Act extends health benefits to members of these groups 
(terminated tribes and state-recognized tribes) without 
extending Federal recognition to them for all purposes.
    In enacting this Act, the Committee has found ample 
justification for extending health services to the Indians who 
ended up in these urban areas because of several major 
developments:

          First, Indians were provided an opportunity to work 
        and share in the Nation's prosperity in industries 
        prior to and during World War II; second, thousands of 
        Indian men and women served in the Armed Forces away 
        from their reservation, traditional communities or 
        Alaska Native villages; third, formal government 
        relocation programs moved many Indian families from low 
        employment, rural areas to urban areas where 
        ``employment opportunities'' were considered more 
        readily available; and fourth, countless numbers of 
        Indians attempting to escape depressed conditions on 
        their reservations voluntarily relocated.\72\
---------------------------------------------------------------------------
    \72\Senate Report 94-133, at 131.

    The comprehensive approach of this Act is needed to more 
fully implement the Federal responsibility for Indian health 
care, and, even more so today, to address health disparities 
facing the Indians who had moved from the reservations as a 
result of the relocation policies. Relocating Indians from 
reservations to urban areas was the Federal policy and program 
first begun in 1931.\73\ ``Relocation complemented other 
termination programs designed to promote rapid assimilation. 
Once relocated, Indians were cut off from the special federal 
services that had been available to them as reservation 
residents.''\74\
---------------------------------------------------------------------------
    \73\Felix Cohen, Handbook of Federal Indian Law (1982 ed.), at 169.
    \74\Id.
---------------------------------------------------------------------------
    Congress has previously recognized that the establishment 
of urban Indian health programs was necessary to rectify the 
errors of failed Federal Indian policies such as 
relocation.\75\ The Committee further found that Title V of the 
original Act ``represent[ed] a Federal policy commitment to 
provide the essential authorities and financial resources to 
permit urban Indian organizations to develop needed health 
services and to strengthen relationships with existing 
community health and medical care programs.''\76\
---------------------------------------------------------------------------
    \75\Senate Report No. 94-133, at 138.
    \76\Id., at 140.
---------------------------------------------------------------------------
    The justifications for this policy are still valid today. 
Recent statistics indicate that urban Indians suffer health 
disparities, as do Indians living on reservations. For example, 
the mortality rates are higher due to accidents (38% higher 
than other populations), chronic liver disease and cirrhosis 
(126% higher), diabetes (54% higher), alcoholism (178% higher), 
and sudden infant death syndrome (157% higher).\77\
---------------------------------------------------------------------------
    \77\The Health Status of Urban American Indians and Alaska Natives, 
Urban Indian Health Institute, March 16, 2004, at v. Available at 
www.uihi.org. See also American Journal of Public Health, August 2006, 
Vol. 96, No. 8, ``A Nationwide Population-Based Study Identifying 
Health Disparities Between American Indians/Alaska Natives and the 
General Populations Living in Select Urban Counties.''
---------------------------------------------------------------------------
    The Committee believes that continuation of services to 
urban Indians, recognized in the original Act and affirmed by 
S. 1200, makes sense from both policy and fiscal perspectives. 
The Committee has received testimony that these urban Indian 
health programs improve health services for Indians located in 
the urban centers in a highly cost-effective manner.
    In addition, the Committee has received testimony that 
without the urban Indian health programs, urban Indians would 
not seek care or could delay seeking proper medical attention 
until their health problems erupt into emergency situations or 
reach advanced stages when treatment is costlier and the rate 
of survival is much lower.
    By being located closer to the urban Indians than the 
tribal health programs on the reservations, urban Indian health 
programs reduce the number of emergency room visits by 
providing early disease prevention services.
    For example, the South Dakota Urban Indian Health Center 
operates three clinics with more than 17,500 patient encounters 
per year under the Title V program. This center provides such 
services as a foot care home visit program whereby Community 
Health Representatives conduct home visits to assess diabetic 
patients (or those at risk for diabetes). These home visits are 
a critical part of chronic disease management, particularly in 
avoiding amputations due to diabetes.
    The First Nations Community Health Source in Albuquerque, 
New Mexico provides dental, primary, and behavioral health care 
for approximately 45,000 urban Indians and handles 
approximately 12,700 patient encounters per year under the 
Title V program.
    The Native Americans for Community Action in Flagstaff, 
Arizona provides immunizations, mental health and youth 
substance abuse prevention services among several other primary 
care services for urban Indians. The Committee has received 
testimony suggesting that the patients at this urban Indian 
health center would either have to travel 100 or more miles to 
visit an IHS clinic on the reservation or wait two or three 
weeks for an appointment at the local Community Health Center. 
Either alternative would impose significantly more burdens on 
the patient, and the testimony further suggests that most 
patients would simply avoid the care altogether.
    The Tucson Indian Center in Tucson, Arizona also provides 
important disease prevention services such as substance abuse 
prevention, wellness programs and immunizations. This Center 
provides services for over 2,500 patient encounters under the 
Title V programs.
    The health program operated by the Nevada Urban Indians, 
Inc. in Reno, Nevada provides, among other things, immunization 
and diabetes education programs and experienced over 9,000 
patient encounters in 2005. The Native American Rehabilitation 
Association of the Northwest, Inc. in Portland, Oregon 
experiences nearly 9,300 patient encounters per year, including 
1,040 for mental health care and 3,400 for alcohol and drug 
treatment. The N.A.T.I.V.E. Project in Spokane, Washington 
provides a community wellness program and community outreach 
services for diabetes screening and health education for a 
community of approximately 12,000 urban Indians.
    These programs, particularly the wellness, diabetes, and 
behavioral health programs are critical to preventing the 
development of diseases which may require long-term disease 
management such as for diabetes and alcohol or drug addictions. 
In addition, the outreach, screening and home-based care 
programs are vital in ensuring the patients receive early 
intervention and care rather than waiting until they need 
emergency services which cost far more than intervention 
services.
    Urban Indian health programs provide culturally-appropriate 
health care for Indians. The Committee has received testimony 
that Indians may avoid non-Indian (or ``mainstream'') health 
providers who are unfamiliar with or insensitive to Indian 
culture. The urban Indians have confidence in the urban Indian 
health programs and are more likely to seek care when the 
provider recognizes and respects culturally-appropriate care.
    Urban Indian health programs also address continuity of 
care for Indians migrating between the urban areas and 
reservations. Even though the disavowed policy of relocation no 
longer forces such migration, moving from the reservation to 
urban areas is not uncommon for these individuals, and neither 
is their return to the reservation. For example, the urban 
Indians may travel to the reservation for traditional 
ceremonies, tribal political (elections) or cultural events 
(such as pow-wows), clan or family events, and so on. On the 
other hand, Indians may move to the urban areas for job or 
educational opportunities--and carry with them the need for 
continuity of care. The Committee has received testimony that 
these programs recognize the migration and account for it in 
their patient care, particularly for quality follow-up care.
    The urban Indian health programs provide services for the 
uninsured Indians who might not be able to obtain care 
elsewhere. With poverty rates of urban Indians hovering at 25% 
(compared to 14% for the general population), and nearly half 
living below 200% of the Federal poverty level (compared to 30% 
for the general population),\78\ it is no surprise that many 
urban Indians are uninsured. The Committee has received 
testimony that in Boston, MA, 87% of the Boston Indian Center's 
clients have no health insurance. In Arizona, nearly two out of 
three urban Indians have no insurance.
---------------------------------------------------------------------------
    \78\The Health Status of Urban American Indians and Alaska Natives, 
Urban Indian Health Institute, at v.
---------------------------------------------------------------------------
    The Committee believes that the urban Indian health 
programs are a crucial component in the overall Federal effort 
to reduce the health disparities for the urban Indians. Without 
such services by the Title V health programs, it is quite 
likely that the health disparities among the urban Indians will 
increase. This result would contradict the Congressional policy 
set forth in this Act and in other statutes of increasing 
access to health care and of remedying health disparities that 
result from the past failed Federal Indian policies.
    Dental Health Aide Therapists. Decades of inadequate access 
to dental care, along with other factors that contribute to the 
generally worse health condition of Indians as compared to the 
general population, have led to a true epidemic of dental 
disease in Indian communities, and in Alaska Native 
communities, in particular.
    During the 108th and 109th Congresses, there was 
considerable discussion surrounding the Dental Health Aide 
Therapists (DHAT) Program in Alaska Native communities. The 
Committee received testimony regarding the crisis in oral 
health care in Alaska Native communities and how the DHAT 
program was a result of Alaska Native leaders and health 
providers searching for a means of addressing it. The Committee 
believes that the use of Alaska Natives trained through the 
DHAT program to serve as dental health aide therapists in 
Alaska is a necessary response to this access to care crisis.
    The DHAT program in Alaska has been part of the Community 
Health Aide Program since 2002, and DHATs provide a wide range 
of oral health care promotion and disease prevention services. 
For the most part, the DHAT program is supported and applauded 
for its efforts in reducing the extraordinary dental crisis in 
Alaska Native communities. However, some activities have 
generated controversy because they require the performance of 
certain irreversible procedures, specifically, the treatment of 
dental caries, pulpotomies and extractions of teeth.
    In January, 2006, the American Dental Association (ADA), 
the Alaska Dental Society (ADS) and several individual dentists 
filed a lawsuit in Alaska Superior Court, seeking to stop the 
practice of dentistry and dental surgery by non-dentists by 
asking the court to declare the Alaska Native Tribal Health 
Consortium and its Dental Health Aide Therapists program in 
violation of state dental licensing laws. On June 27, 2007, the 
Alaska Superior Court dismissed the case, noting in its 
decision that DHAT is part of the Community Health Aide 
Practitioner Program and Congress clearly intended the 
utilization of paraprofessionals in providing care through both 
CHAP and DHAT.
    When the House Resources Committee marked up its version of 
the Indian health reauthorization in the second session of the 
109th Congress, the Committee agreed to an amendment offered by 
Representative Young (R-AK) regarding the Dental Health Aide 
Therapist program in Alaska. The language, which the Committee 
has been informed was agreed to by the American Dental 
Association and the Alaska Native Health Board, prohibits 
dental health aide therapists from performing all oral and jaw 
surgeries except pulpal therapy or extraction of adult teeth 
after consultation with a licensed dentist in a dental 
emergency. That agreed-upon bill language is carried forward 
and included in S. 1200.
    National Bipartisan Commission on Indian Health Care. The 
Committee intends that S. 1200 will provide many much-needed 
improvements to the Indian health system. However, adequate 
funding levels remain a significant factor in achieving those 
improvements.
    For several years, the Committee has received testimony 
regarding the substantial funding needs for Indian health.\79\ 
Federal appropriations have increased over time, but, as 
evident in the IHS Level of Need Funded Study, have not reached 
optimal levels.\80\ While the reimbursements from Medicaid and 
Medicare have been beneficial in adding additional resources, 
they are not a complete solution to the funding deficiencies.
---------------------------------------------------------------------------
    \79\See Hearing on the President's Fiscal Year 2008 Budget Request 
for Indian Programs Before the Senate Comm. on Indian Affairs, 110th 
Cong., 1st Sess., February 15, 2007, S. Hrg. 110-48; Hearings on the 
President's Fiscal Year 2007 Budget Request for Indian Programs Before 
the Senate Comm. on Indian Affairs, 109th Cong., 2nd Sess., February 
14, 2006, S. Hrg. 109-396, Pt. 1 and February 23, 2006, S. Hrg. 109-
396, Pt. 2; Hearing on the President's Fiscal Year 2006 Budget Request 
for Indian Programs Before the Senate Comm. on Indian Affairs, 109th 
Cong., 1st Sess., February 16, 2005, S. Hrg. 109-9; Hearings on the 
President's Fiscal Year 2005 Budget Request for Indian Programs Before 
the Senate Comm. on Indian Affairs, 108th Cong., 2nd Sess., February 11 
and 25, 2004, S. Hrg. 108-420; Hearing on the President's Fiscal Year 
2004 Budget Request for Indian Programs Before the Senate Comm. on 
Indian Affairs, 108th Cong., 1st Sess., February 26, 2003, S. Hrg. 108-
60; Hearings on the President's Fiscal Year 2003 Budget Request for 
Indian Programs Before the Senate Comm. on Indian Affairs, 107th Cong., 
2nd Sess., March 5, 7, and 14, 2002, S. Hrg. 107-360.
    \80\See, e.g., ``LNF Primer,'' U.S. Department of Health and Human 
Services, Indian Health Service, located at http://www.ihs.gov/
NonMedicalPrograms/Lnf/docs2003/Primer.pdf.
---------------------------------------------------------------------------
    The Committee has concluded that an overarching assessment 
of need and financing mechanisms is warranted to address the 
health disparities and financing for Indian health care. 
Accordingly, section 814 establishes the National Bipartisan 
Commission on Indian Health Care to study the optimal manner in 
which to provide and finance health care services to Indians.
    This Commission will have broad authority to conduct 
hearings and other activities needed to provide Congress with 
comprehensive and thoughtful recommendations regarding the 
optimal means of delivering health care services to Indians. 
The Committee intends that this Commission will also serve as 
an appropriate forum for addressing outstanding questions 
relative to financing, including, among others, balancing 
concerns about overutilization and deficiencies.
    Indian Health Care Facilities Construction. During the 
109th Congress, much discussion between the National Steering 
Committee and the Committee centered around section 301, which 
directs the Secretary to maintain a health care facility 
priority system for construction.
    Background: Development of the Priority System. In the 
early 1980's, the IHS developed a health care facilities 
priority system (Priority System) for construction of various 
types of health care facilities in Indian communities. In 1988, 
pursuant to Public Law 100-713 (as amended by Public Law 102-
573), Congress required the IHS to provide an annual report 
which set forth (1) the current priority system; (2) the 
planning, design, construction and renovation needs of the top-
10 priority inpatient and outpatient facilities (including 
staff quarters); (3) the justification and projected costs of 
these projects; and (4) the methodology for establishing the 
priorities.
    In this Priority System, construction projects for 
hospitals, health centers, staff quarters and youth regional 
treatment centers go through three key phases, wherein the IHS 
solicits proposals for health facility construction and ranks 
the proposals according to their relative need for 
construction.\81\
---------------------------------------------------------------------------
    \81\For a detailed discussion on the Priority System and the three 
phases, see U.S. Department of Health and Human Services, Indian Health 
Service, ``Healthcare Facilities Construction Priority System 
Methodology,'' June 3, 2004, located at http://www.ihs.gov/
TribalLeaders/triballetters/2004_Letters/06-28-2004_Enclosure.pdf; and 
``Health Care and Related Facilities,'' located at http://www.ihs.gov/
NonMedicalPrograms/DFEE/InfoSheets/infosheet.PDF.
---------------------------------------------------------------------------
    The projects are selected for inclusion on a ``Priority 
List'' after completion of Phases I and II, then move up the 
Priority List as Phase III is completed and appropriations for 
the projects are provided.
    Congressional Directive To Revise the Priority List. In 
1999, in the conference report accompanying the FY 2000 
Interior Appropriations Act (House Report 106-406), Congress 
directed the IHS, working closely with Indian tribes, to review 
and revise the Priority System. In recognizing the ``extreme 
need for new and replacement hospitals and clinics,'' Congress 
noted that ``there should be a base funding amount, which 
serves as a minimum annual amount in the budget request.'' 
Congress further noted that several issues needed to be 
considered in revising the Priority System and that ``a more 
flexible and responsive program can be developed that will more 
readily accommodate the wide variances in tribal needs and 
capabilities.''\82\
---------------------------------------------------------------------------
    \82\House Report 106-406, at 138-139.
---------------------------------------------------------------------------
    In response to this directive, the IHS Director convened a 
Facilities Appropriations Advisory Board (FAAB) and a 
Facilities Needs Assessment Workgroup to review the Priority 
System and make recommendations for revision. According to the 
IHS, the FAAB was comprised of 12 members representing Indian 
tribes and two members representing the IHS, and the Workgroup 
was established by the IHS Director to make recommendations to 
the FAAB. The Committee has been informed that, earlier this 
year, the FAAB submitted final recommendations to the IHS 
Director, but no final decision has been made on these 
recommendations.
    Meanwhile, in 1999, the National Steering Committee 
developed language regarding the Priority System contained in 
section 301 of the various iterations of bills introduced for 
the reauthorization of the Act. The language in section 301 
remained primarily the same until 2006, when the Committee 
refined certain provisions and included an additional protected 
category in section 301(c)(1)(D), referred to as the 
``grandfather'' provision, in S. 4122, introduced at the end of 
the 109th Congress.
    Grandfather Provision. The ``grandfather'' provision of 
section 301(c)(1)(D) protects the priority status of health 
care facilities (in certain categories) on the Priority List 
from being affected by changes to the Priority System being 
contemplated by the IHS, pursuant to the 1999 Interior 
Appropriations Conference Report instruction. These projects 
have been on the Priority List since at least 1991.
    Under the ``grandfather'' provision, the protected 
categories include:
    (1) Top 10 Projects. Projects in the FY 2008 IHS budget 
justification for the 10 top-priority inpatient, outpatient, 
staff quarters and Youth Regional Treatment Centers (YRTC) 
projects. Currently, those projects include:
    Inpatient: Phoenix and Whiteriver, AZ; Barrow and Nome, AK.
    Outpatient: Ft. Yuma, Red Mesa, Kayenta, San Carlos and 
Winslow-Dilkon, AZ; St. Paul, AK; Sisseton, Eagle Butte and 
Rapid City, SD.
    YRTC: Wadsworth, NV; Central-Southern and Northern 
California.
    (2) Phase I and II. Projects that have completed Phases I 
and II of the Priority System in effect on the date of 
enactment of the Indian Health Care Improvement Act Amendments. 
Currently, these projects include: Ft. Belknap, MT; Wagner, SD; 
Sells and Bodaway-Coppermine, AZ; Gallup, Alamo, Albuquerque, 
Pueblo Pintado, Crownpoint and Shiprock, NM.
    During the 109th Congress, a third category was added:
    (3) Secretarial Discretion. Projects not in the other two 
protected categories and selected on the initiative of the 
Secretary or at the request of an Indian tribe or tribal 
organization.
    During the 109th Congress, the IHS, FAAB and Workgroup 
began finalizing their recommendations and draft revisions to 
the Priority System. The Committee had been informed that these 
drafts purported to revise what would constitute Phases I and 
II of the Priority System. These proposed changes could then 
have affected what projects would be ``grandfathered'' under 
section 301(c)(1)(D) and thus change the priority of several 
projects which have been waiting on the Priority List for many 
years.
    Due to the uncertainty of when the IHS will approve the 
final changes (before or after the Act is reauthorized) and 
what those changes will consist of, the third category was 
added to ensure that the Secretary still has authority to 
prioritize projects which might no longer qualify under the 
other two protected categories.
    Innovative Approaches. Currently, construction funding 
generally has been applied to the projects on the Priority 
List. The Committee has been informed that the total cost of 
the current Priority List is in excess of $200 million as of FY 
2008, with other unmet needs in the billions of dollars. At the 
time of the congressional directive in 1999, the construction 
appropriations was over $41 million and even reached over $94 
million in FY 2004. The amount of appropriations increased 
slightly until FY 2006, after which it has decreased quite 
significantly.
    Ideally, with a continuation of the level of funding 
appropriated following the conference report directive in FY 
2000, the current Priority List should have been nearing 
completion by the time revisions to the Priority System were 
finalized. Unfortunately, significant unforeseen national 
events occurred since the Appropriations Committee's directive, 
which affected the amount of available appropriations for 
closing out the current Priority List and allowing other 
projects to be added to the List and built. Thus, the current 
Priority List has not been completed, whereas the revisions to 
the Prriority System are nearing completion.
    The Committee has been informed that while projects have 
been on the Priority List for a number of years, many other 
needed projects have never been on the Priority List. The 
Committee had been requested to include an alternative approach 
in S. 1200 to address the remaining unmet needs through the 
concept of an Area Distribution Fund. Under an Area 
Distribution Fund, a portion of construction funding could be 
devoted to IHS Area priorities. This localized approach would 
allow other smaller projects to be completed, instead of 
waiting until the entire current Priority List is completed.
    In light of the facilities backlog, section 301(f) of S. 
1200 encourages the Secretary to seek innovative approaches to 
address unmet needs for health care facility construction, and 
requires the Secretary to consult and cooperate with Indian 
tribes in developing these innovative approaches. The Committee 
recognizes that the Secretary has engaged in considerable work 
revising the Priority System thus far. These proposed revisions 
may also be useful in developing innovative approaches.
    However, the Committee encourages the Secretary, prior to 
finalizing the revisions, to take into consideration the fiscal 
circumstances under which the 1999 congressional directive 
occurred, relative to those experienced today, and how 
innovative approaches to financing construction may be 
implemented in such a manner which is fair and equitable to 
those Indian tribes to be served by the projects on the current 
Priority List and those Indian tribes which have not had the 
opportunity to have their projects placed on the list.
    The Committee expects the IHS to work with Indian tribes in 
developing the types of innovative approaches to pursue, as 
well the contours of those approaches. The Secretary has used 
broad authority to develop and maintain the Priority System 
since the 1980s, and section 301(f) also provides broad 
authority to implement innovative approaches, such as an Area 
Distribution Fund, if, after consultation with the Indian 
tribes, it is determined that this is an appropriate system to 
address the health facility needs of Indian communities. The 
Committee also expects the IHS to work with Indian tribes and 
to submit a minimum budget request consistent with the 
congressional directive which will accommodate both the current 
Priority List and any innovative approaches.
    Elevation of the IHS Director. Section 601 of S. 1200 
elevates the Director of the IHS to the position of Assistant 
Secretary for Indian Health within the Department of Health and 
Human Services. The purpose of this elevation is to foster the 
government-to-government relationship between Indian tribes and 
the United States, facilitate advocacy for Indian health 
policy, and promote consultation on Indian health matters. 
Presently, the Director of the Indian Health Service is 
appointed by the President and confirmed by the Senate pursuant 
to 25 U.S.C. 1661(a). The Director reports to the DHHS 
Secretary through the Assistant Secretary for Health.
    During the 109th Congress, the provisions elevating the 
Director to the Assistant Secretary were included in the 
introduced bill, S. 1057, but not in the final iteration, S. 
4122, due to objections by the Administration. The Committee 
has continued to receive testimony in strong support of 
elevation from the Indian tribes.\83\ The testimony received by 
the Committee and consultation with Indian tribes during the 
110th Congress have counseled in favor of including the 
provisions in S. 1200 as part of the IHCIA reauthorization.
---------------------------------------------------------------------------
    \83\Indian Health Care Improvement Act: Hearing of the Senate 
Indian Affairs Committee, 110th Cong., 1st Session, S. Hrg. 110-53 at 
74 (March 8, 2007) (statement of Rachel Joseph).
---------------------------------------------------------------------------
    Previous bills establishing this position in the Department 
have either been favorably approved by the Committee or passed 
the Senate: S. 558 (108th Congress, passed by the Senate), S. 
214 (107th Congress, ordered reported by the Committee), S. 299 
(106th Congress, passed by the Senate), S. 1770 (105th 
Congress, passed by the Senate), S. 311 (104th Congress, 
ordered reported by the Committee), and S. 2067 (103rd 
Congress, passed by the Senate).
    Like these legislative predecessors, S. 1200 facilitates 
the government-to-government relationship between the United 
States and Indian tribes by providing the necessary leadership 
within the Administration on Indian health issues to bring 
focus, priority and national attention to the health care 
status and needs of Indians. Section 601 is intended to enhance 
the Federal capacity to respond to the ongoing health crisis in 
Indian Country and the continuing frustration of Indian tribes 
and patients that their needs and concerns are not adequately 
addressed under the current administrative policy and budgetary 
processes.
    Previous Senate reports further elaborate upon the 
evolution of the IHS and the need and purposes for establishing 
this position. (See Senate Report Nos. 108-76, 107-170, 106-
148, 105-319, and 103-327.) Nevertheless, an abbreviated 
discourse is necessary to inform the continuing need for 
elevating the Director to the Assistant Secretary for Indian 
Health.
    Budgetary Improvement. The IHS operates a comprehensive 
health care delivery system nationwide through a variety of 
health care facilities and services and through contracts and 
compacts with Indian tribes under the Indian Self-Determination 
and Education Assistance Act, with Urban Indian Organizations, 
or with private health care providers through the contract 
health services program.
    Efforts to address Indian health care needs have been 
tempered by the steady decline in purchasing power of the IHS 
budget. Indeed, the IHS 2004 study on Level of Need Funding 
indicated that the funding fell short of meeting the health 
care needs of Indian people and was operating at approximately 
a 40% deficiency.
    The Committee has not seen appreciable decreases to this 
deficiency to convince it that elevation is not necessary. One 
of the principal justifications for the elevation has been past 
Administrations' failure to incorporate tribal recommendations 
in the final budget request, despite tribal participation 
throughout the budget process.
    For example, the Committee received testimony estimating 
health care needs in excess of $19.7 billion to achieve parity 
for Indian people.\84\ Past budgets have reflected marginal 
increases, even in the era of tight budgets, but these 
increases have not closed the gap on the ``level of need'' 
funding deficiency.
---------------------------------------------------------------------------
    \84\S. Hrg. 110-48 at 184 (testimony of H. Sally Smith).
---------------------------------------------------------------------------
    In addition, the Committee has also received testimony that 
Indian tribes requested continued funding for the Urban Indian 
Organizations during the annual budget formulation 
sessions.\85\ However, the FY 2007 and FY 2008 President's 
Budget Requests zeroed out funding for the Urban Indian 
Organizations.\86\ These decreases are disturbing in light of 
the alarming disparities that exist between the health status 
of the Indian population and other populations in the United 
States. These disparities have been well-documented in past 
Committee reports, legislation and testimony before the 
Committee.\87\
---------------------------------------------------------------------------
    \85\Id.
    \86\U.S. Department of Health and Human Services, Indian Health 
Service, Fiscal Year 2007, Justification of Estimates for 
Appropriations Committees, at IHS-49, and U.S. Department of Health and 
Human Services, Indian Health Service, Fiscal Year 2008, Justification 
of Estimates for Appropriations Committees, at CJ-121.
    \87\See, for example, footnotes 46 and 76, above.
---------------------------------------------------------------------------
    Although the Committee has received testimony that the 
Director has access and policy input within the DHHS, the 
health care status of Indians remains at such levels which 
necessitate a modified level of leadership and advocacy. The 
establishment of the Assistant Secretary for Indian Health will 
facilitate advocacy within DHHS and the Office of Management 
and Budget for the funding resources and policies that are 
necessary to effectively and efficiently address the health 
care needs and concerns of the Indian people.
    Regulatory and Administrative Improvement. The Indian 
health care system presents cross-cutting issues which involve 
DHHS agencies other than the IHS. The Committee recognizes the 
current attention given to Indian health issues as well as the 
revitalization of the Intra-departmental Council on Native 
American Affairs within the DHHS which would address matters in 
DHHS agencies affecting Indian health.
    Despite this revitalization, concerns have been raised with 
the Committee that broad administrative and regulatory matters 
within DHHS affecting Indian health have not been addressed 
either properly or timely. The Committee intends that this 
position would create an opportunity for the Assistant 
Secretary for Indian Health to be involved in the formulation 
of policy and regulatory authority on these larger issues which 
affect Indian health rather than simply addressing matters 
which are solely Indian in nature.
    As stated in previous Committee reports, the Committee 
continues to believe that the institutionalization of a senior 
policy official responsible for Indian health within the DHHS 
is necessary to bring parity and reduce deficiencies in the 
delivery of Indian health care services. This 
institutionalization is also important to ensure that the 
advocacy and the knowledge of the United States legal and moral 
obligations for Indian health and the mission of the IHS is 
carried forward in future Administrations.
    Third Party Reimbursements. Funding from sources other than 
IHS appropriations has been identified as a factor affecting 
the availability of health care services for Indians.\88\ Those 
funding sources include third-party reimbursements from 
Medicaid and Medicare. In some cases, these reimbursements 
constitute up to 50% of the medical care budget for a 
particular Indian health program.\89\
---------------------------------------------------------------------------
    \88\GAO Report No. GAO-05-789, at 4.
    \89\Id., at 5.
---------------------------------------------------------------------------
    With more resources, the Indian health care system could 
provide more services, and the Committee strongly encourages 
IHS and the Indian tribes to seek additional resources to 
supplement the appropriated sums provided annually.\90\ The GAO 
noted that ``[f]acilities with higher reimbursements had 
additional funds with which they could hire staff, purchase 
equipment and supplies, and renovate their buildings.''\91\ In 
one case, 31 percent of a facility's clinical providers and 
other staff was funded by third party reimbursements.\92\
---------------------------------------------------------------------------
    \90\S. 1200 includes amendments to the ISDEAA which authorize the 
Native American Health and Wellness Foundation to promote the mission 
of IHS through such means as receiving donations which supplement, not 
offset, appropriations. Offsetting in Indian health care programs is 
generally prohibited by law. See 25 U.S.C. Sec. 1641(a).
    \91\GAO Report No. GAO-05-789, at 26.
    \92\Id.
---------------------------------------------------------------------------
    S. 1200 provides for an increase in access to Medicaid by 
removing barriers through waivers of premiums and cost-sharing 
at Indian health facilities and by codifying agency regulations 
or practices which recognize the unique nature of and special 
circumstances applying to Indian property, particularly trust 
and restricted property.\93\ Likewise, S. 1200 provides other 
means of removing barriers to obtaining third-party 
reimbursements, such as the process for seeking waivers of 
sanctions, which promotes favorable state-tribal relations.
---------------------------------------------------------------------------
    \93\As a general rule, these special types of property are not 
included in eligibility calculations for income taxes or federal 
benefits.
---------------------------------------------------------------------------
    Waiver of Medicaid Co-Pays. One fundamental purpose of the 
Indian Health Care Improvement Act is to improve access to 
health care for Indian people. Removing barriers to such access 
is a critical aspect in accomplishing that purpose. To that 
end, section 204 of Title II of S. 1200 prohibits cost-sharing 
under Medicaid.\94\
---------------------------------------------------------------------------
    \94\This provision is modeled after the current Centers for 
Medicare and Medicaid Services State Children's Health Insurance 
Program regulation prohibiting cost-sharing for Indian children (42 
C.F.R. Section 457.535).
---------------------------------------------------------------------------
    Indian tribes have strongly advocated that this policy 
waiving Medicaid co-pays reflects the federal trust obligation 
for Indian health wherein the health care has been ``pre-
paid''--for example, by the treaty agreements exchanging tribal 
lands for health care. As additional justification, the Indian 
tribes contend that this policy is not unusual to the Medicaid 
system, since other Medicaid policies reflect that federal 
obligation. An example of this is the 100% FMAP or Federal 
Matching Assistance Percentage, wherein the federal government 
provides 100% of the reimbursement to states of Medicaid 
reimbursements for services provided by the IHS or tribal 
health programs.
    Moreover, Indian tribes contend that the waiver of the co-
pay is necessary to create incentives to enroll in Medicaid. 
Recognizing the federal obligation for Indian health care, the 
IHS, tribal and urban health programs do not charge the Indian 
patients cost-sharing for participating in the Indian health 
system to which Medicaid provides reimbursements. Charging the 
Indian patient a Medicaid co-pay will create a disincentive to 
enroll, essentially barring that Indian patient's access to 
Medicaid; as a result, the overall Indian health budget, along 
with the ability to provide additional services, may suffer. On 
the other hand, waiver of the co-pay will continue to encourage 
Indian patients to enroll in Medicaid programs, thus 
``stretching'' IHS appropriated dollars.
    The Committee is aware of concerns that cost sharing 
discourages overutilization of health care services, which 
should be of particular concern to a system which is 
overburdened already. However, this concern may be addressed in 
several ways.
    Cost-sharing would not achieve the intended purpose of 
modifying behavior to avoid overutilization within the Indian 
health system. Overutilization assumes that there are otherwise 
adequate levels of services available to a population of non-
overutilizers. Punitive or disincentive measures will not work 
if the service is not available or delayed. Services being 
unavailable or delayed have been documented by the GAO 
study,\95\ and the IHS Level of Need Funded (LNF) Study. The 
data in the GAO study reported that many Indian people are not 
seeking health care services until it is too late. There was no 
evidence in this GAO report that overutilization of the health 
care services occurred at the Indian health programs.
---------------------------------------------------------------------------
    \95\GAO Report No. GAO-05-789, (August, 2005).
---------------------------------------------------------------------------
    The data in the LNF Study also suggests that many Indian 
patients may have to delay seeking health care because services 
are rationed, rather than available for every health care need. 
In other words, Indian patients are not running to the clinic 
for every sniffle, but may wait until their health care needs 
become emergent problems. Thus, it is unlikely that 
overutilization occurs, so there is no problem that the cost-
sharing would obviate. Imposing cost-sharing, on the other 
hand, may serve to further exacerbate the problem of delaying 
health care by requiring a co-pay by Indian patients who can 
ill afford it.
    Removing barriers to enrollment will enable Indian patients 
to enroll in Medicaid, and the ensuing Medicaid reimbursements 
will assist the Indian health program in providing more 
services, thereby diminishing the potential of overburdening 
the system. Cost-sharing is, in reality, cost-shifting. If 
Indian patients are eligible and qualify for Medicaid, then the 
patient should take advantage of the available program. By not 
enrolling, the cost that should be borne by Medicaid continues 
to strain the IHS budget, which has been documented to be 
insufficient to meet the needs of Indian communities.
    Consequently, S. 1200 continues the policy and provisions 
regarding Medicaid co-pays that were reported favorably by the 
Senate Finance Committee in S. 3524 during the 109th Congress.
    Non-Eligibles. Congress has recognized that ``without a 
proper health status, the Indian people will be unable to fully 
avail themselves of the many economic, educational, and social 
programs already directed to them.''\96\ Providing services to 
Indian people improves the health of Indians in a direct 
manner.
---------------------------------------------------------------------------
    \96\Senate Report 94-133, at 23.
---------------------------------------------------------------------------
    However, protecting the health of Indians requires 
attention to issues other than direct services to Indians. In 
the 1800s, services such as vaccinations were provided to 
Indians located near forts to protect the health of 
soldiers.\97\ Now the tables are turned. Under certain 
circumstances, individuals not otherwise eligible for Indian 
health care may receive a limited scope of health services 
under the Act to protect the health of Indians.
---------------------------------------------------------------------------
    \97\See American Indian Policy Review Commission, Task Force Six, 
Final Report to the Commission, Vol. 6, at 28.
---------------------------------------------------------------------------
    Serving ``non-eligibles'' for these purposes comports with 
the Administration's goals of promoting ``healthy Indian . . . 
communities''\98\ and ``including new approaches to delivering 
care.''\99\ Serving non-eligibles has been a policy of the Act 
for many years and it reflects a logical and reasonable 
approach to protect Indian health.
---------------------------------------------------------------------------
    \98\S. Hrg. 109-162, at 585 (statement of Dr. Grim, Director, U.S. 
Department of Health and Human Services, Indian Health Service).
    \99\Id. at 589.
---------------------------------------------------------------------------
    For example, the Act provides that services may be provided 
to a non-eligible pregnant woman carrying an Indian's child. 25 
U.S.C. 1680c(c)(3) (Section 807(d)(3) of S. 1200). In addition, 
services may be provided to prevent the outbreak of 
communicable diseases such as tuberculosis. 25 U.S.C. 
1680c(c)(2) (Section 807(d)(2) of S. 1200).
    In including these ``non-eligible individuals'' in the 
service delivery system, Congress has set forth considerations 
for the IHS and Indian tribes to address prior to providing the 
services--the ``two-part determination'' contained at 25 U.S.C. 
1680c(b)(1)(A):
          (i) the provision of such health services will not 
        result in a denial or diminution of health services to 
        eligible Indians; and
          (ii) there is no reasonable alternative health 
        facility or services, within or without the service 
        area of such service unit, available to meet the health 
        needs of such individuals.
    However, the Committee is aware that questions have arisen 
regarding how the two-part determination applies to Indian 
tribes with contracts or compacts under ISDEAA.
    Where services are directly provided by the IHS, the Indian 
tribe(s) served by the Service Unit and the IHS jointly make 
the two-part determination (25 U.S.C. 1680c(b)(1)(A)). Section 
807 of S. 1200 provides that, for programs administered by an 
Indian tribe pursuant to a contract or compact under the 
ISDEAA, the Indian tribe is authorized to provide services to 
non-eligibles, but ``shall take into account'' the two-part 
determination.
    Congress has made it clear that the determination shall be 
made in both instances: in the case of direct services it is 
made by both IHS and the Indian tribes and, in the case of 
ISDEAA contracts or compacts, by Indian tribes. Congress did 
not provide in the Act express substantive or procedural 
provisions governing how the determinations should be made, 
given the innumerable variations in circumstances for the 
Indian communities.
    However, Section 807 does provide some guidance on how the 
parties may determine whether there will be no diminution of 
services. For example, the non-eligibles receiving services 
``shall be liable for payment of such health services under a 
schedule of charges prescribed by the Secretary'' (25 U.S.C. 
1680c(b)(2)(A)). In other words, no diminution may be 
experienced if the funded used to serve these people is 
replaced by other funding.
    In addition, health services may be provided to indigent 
non- eligibles if there is a reimbursement agreement with the 
State or local governments. These provisions, however, do not 
limit the ability of either the IHS or Indian tribes to include 
additional considerations in determining whether services would 
be decreased. Other budgetary factors, delays in services, and 
appointment waiting times,\100\ are all other considerations 
that may be appropriate, depending on the particular 
circumstances.
---------------------------------------------------------------------------
    \100\See GAO Report No. GAO-05-789.
---------------------------------------------------------------------------
    Likewise, when assessing reasonable alternatives, the IHS 
and Indian tribes may be confronted by factors such as remote 
locations, distances to other health facilities and other 
unique difficulties, which render other health care 
alternatives unavailable. Questions surrounding what is 
available should be placed in the context of the following 
policy considerations. First, services under this Act are for 
the ultimate protection of Indian health. Second, the IHS and 
tribal health programs are the payors of last resort which 
means, in this situation, that all other avenues of obtaining 
health services should be exhausted by the non- eligible 
individual prior to seeking assistance from either IHS or the 
tribal health programs.
    The Committee has been informed that some health providers 
may refuse to serve Medicaid beneficiaries, thus making any 
other health service alternatives unavailable. In those 
situations, if good faith efforts have been made to obtain 
services and all avenues have been exhausted, it appears that 
there may be an arguable case of unavailability.
    When making these determinations, Indian tribal leaders are 
placed in a difficult situation. On the one hand, the federal 
obligation for Indian health--which the Indian tribe is 
administering--is secured for the benefit of Indians. 
Authorizing services for non-eligibles is a determination not 
made lightly by Indian tribal leaders. On the other hand, 
withholding services from these non-eligibles under the limited 
circumstances enumerated in this Act may serve to do harm to 
Indian people by not eliminating general health hazards.
    Evaluations were left in S. 1200 to the IHS and Indian 
tribes based on their particular circumstances and, if 
appropriate, could be developed more fully through negotiated 
rulemaking or consultation.

                      Section-by-Section Analysis

    A significant portion of current law has been carried 
forward by S. 1200 and reorganized in the various titles 
according to subject matter. S. 1200 also adds several new 
provisions to current law which may (1) amend current law, such 
as turning a demonstration project into a permanent program, 
(2) clarify or make small additions, such as including Tribal 
Organizations in various sections, or (3) introduce brand new 
programs to the Indian health care system, such as Indian youth 
suicide prevention, intervention and treatment through the use 
of telemedicine, and convenient care services.
    The following section-by-section analysis will, where 
relevant, identify whether current law has been changed 
followed by an explanation of the current law to be 
reauthorized by S. 1200. In addition, the codified section in 
current law is also noted to provide ease of reference.

Section 1. Short title; table of contents

    Section 1 provides that this Act may be cited as the 
``Indian Health Care Improvement Act Amendments of 2007,'' and 
contains the table of contents.

                   TITLE I--AMENDMENTS TO INDIAN LAWS

    The provisions of Title I are within the jurisdiction of 
the Senate Indian Affairs Committee.

Section 101. Indian Health Care Improvement Act amended

    This section sets forth a host of provisions which 
incorporate provisions of current law and make amendments to 
the Act.

Section 1. Short title; table of contents

    This Act may be cited as the ``Indian Health Care 
Improvement Act.'' Section 1 also sets for the table of 
contents for Title I.

Section 2. Findings

    Section 2 sets out Congressional findings for the Act, 
which indicate that the health levels of Indians are below that 
of the rest of the U.S. population and that the provision of 
health care is consonant with the Federal relationship and 
responsibility to Indian people.
    Amendments: This section maintains current law.
    Current Law: This section is Section 1601 of current law.

Section 3. Declaration of national Indian health policy

    This section declares national policy, in fulfillment of 
the special trust responsibilities and legal obligations to 
Indians, to assure the highest possible health status for and 
raise the health status of Indians and Urban Indians through 
the provision of health services.
    Amendments: This section amends current law by (1) 
replacing the enumerated list of health level objectives with 
the goals contained in the Healthy People 2010 national health 
agenda; and (2) adding new language to (a) add trust to the 
responsibilities being fulfilled by the national policy, (b) 
allow Indians to set their priorities according to their needs, 
(c) increase the health profession degrees awarded to Indians 
so the levels of Indian health professionals in each Service 
Area is at least the level of the general population, (d) 
require consultation with Indian Tribes, Tribal Organizations 
and Urban Indian Organizations, consistent with the policy of 
Indian self-determination, and (e) provide funding to Indian 
tribal programs and facilities consistent with levels of IHS 
programs and facilities.
    Current Law: This section is Section 1602 of current law.

Section 4. Definitions

    Section 4 provides definitions for terms used throughout 
the Act.
    Amendments: This section maintains current law and adds 
several new definitions. Assistant Secretary, behavioral 
health, tribal college or university, telehealth, contract 
health service, and telemedicine are examples of new 
definitions not now in current law.
    Current Law: Section 1603 of current law provides 
definitions for terms used throughout the Act.

        TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT


Section 101. Purpose

    This section states the purpose of this title, which is to 
increase the number of Indians entering health professions and 
providing health services, and to assure an optimum supply of 
health professionals to provide health services to Indians.
    Amendments: This section maintains current law and adds 
language indicating congressional intent to maximize the 
number, and assure an optimum (not merely adequate) supply, of 
health professionals in the Indian health system.
    Current Law: Section 1611 of current law states the purpose 
of increasing the number of Indian health professionals and 
assuring an adequate supply of health professionals to provide 
health services to Indians.

Section 102. Health professions recruitment program for Indians

    This section authorizes grants for recruitment programs, 
including identifying Indians with potential for entering 
health professions, publicizing sources of financial aid, and 
establishing programs to facilitate enrollment in applicable 
courses of study. This section also addresses funding 
applications and amount of funding to be provided, as well as 
outlining the eligibility for these programs.
    Amendments: This section maintains current law.
    Current Law: This section is Section 1612 of current law.

Section 103. Health professions preparatory scholarship program for 
        Indians

    Section 103 authorizes scholarships to Indians for 
compensatory preprofessional education, as well as pregraduate 
education leading to a baccalaureate degree in a preparatory 
field for a health profession. This section specifies certain 
conditions on these scholarships which include costs which may 
be covered by the scholarships, and prohibits denial of a 
scholarship based solely on scholastic achievement if applicant 
has already been admitted or maintains good standing at an 
accredited institution, or if the applicant is eligible for 
assistance under another federal program.
    Amendments: This section maintains current law and adds new 
provisions, authorizing extensions of pregraduate scholarship 
award terms up to 2 years, according to Secretarial 
regulations, and authorizing regulations for determining part-
time equivalents for the compensatory preprofessional 
scholarships.
    Current Law: This section is Section 1613 in current law.

Section 104. Indian health professions scholarships

    Section 104 authorizes scholarships to Indians who are 
enrolled full- or part-time in accredited schools, pursuing 
courses of study in the health professions. Such scholarships 
are designated as Indian Health Scholarships. The section 
further sets forth how the funding for these scholarships is to 
be allocated and addresses all the requirements of the active 
duty service obligation incurred as a result of the 
scholarship, including breach of contract situations.
    Amendments: This section maintains current law and adds new 
provisions that (1) require a year-for-year service obligation 
for scholarship recipients; (2) require Secretarial guidelines 
for fulfilling the service obligation in private practice; and 
(3) allow a recipient to fulfill the service obligation by 
teaching in a tribal college or university nursing program if 
health services to Indians are not diminished
    Current Law: This section is Section 1613a of current law.

Section 105. American Indians into psychology program

    This section authorizes grants of not more than $300,000 to 
each of 9 colleges and universities for developing and 
maintaining Indian psychology career recruitment programs, 
including a Quentin N. Burdick Program Grant at the University 
of North Dakota. This section directs the Secretary to issue 
regulations for competitive funding, and specifies conditions 
of the grants and active duty service requirements. $2.7 
million is authorized for each of FY 2008 through 2017.
    Amendments: This section maintains current law and adds new 
language which (1) sets the number of colleges or universities 
that may receive grants from at least 3 to 9, and (2) 
establishes a maximum grant amount of $300,000, for a total of 
$2.7 million for each of FY 2008 through 2017.
    Current Law: The section is Section 1621p of current law.

Section 106. Scholarship programs for Indian tribes

    Section 106 authorizes the Secretary to make funds 
available to Tribal Health Programs for the purpose of 
educating Indians to serve as health professionals in Indian 
communities. The requirements for receiving such funds; the 
course of study; contract requirements; specific parameters for 
a breach of contract; the relationship of a scholarship under 
this section to the Social Security Act; and conditions of 
continuance of funding are all specified in this section. The 
recipient is required to fulfill service obligations and use 
the scholarship for tuition and reasonable education or living 
expenses. The recipient cannot discriminate against patients 
who receive assistance under Titles XVIII and XIX of the Social 
Security Act.
    Amendments: This section maintains current law and adds new 
language which (1) amends the source of funds for the 
scholarship costs by allowing 20% to be from any source instead 
of only non-federal sources; (2) requires that licensing and 
educational requirements be met for all health professions, not 
only for the doctor and nursing professions; (3) provides that 
the scholarship may allow the recipient to serve in another 
Service Area, provided the Tribal Health Program and Secretary 
approve and services are not diminished to Indians in the 
Service Area where the Tribal Health Program providing the 
scholarship is located; and (4) adds Title XXI of the Social 
Security Act to the non- discriminatory provisions.
    Current Law: This section is Section 1616m of current law.

Section 107. Indian Health Service extern programs

    Section 107 gives preference for employment with the 
Service, a Tribal Health Program, Urban Indian Organization or 
other agencies within the Department, to any recipient of a 
scholarship pursuant to section 104 or 106. The section 
specifies that such employment does not count toward any active 
duty service obligation. It specifies the timing and length of 
employment and exempts the program from any competitive 
personnel system or agency personnel limitation. The section 
further specifies that an individual employed under this 
section will receive practical experience in the health 
profession in which he or she is engaged in study.
    Amendments: This section maintains current law and adds the 
following new provisions: (1) extends the extern program to 
Tribal Health Programs, Urban Indian Organizations or urban 
Indian health providers (on a discretionary basis) or other 
Department agencies, instead of only the IHS; and (2) gives the 
extern, including an extern in a high school program, a 
preference for employment with the IHS, instead of entitling 
them to employment.
    Current Law: This section is Section 1614 of current law.

Section 108. Continuing education allowances

    This section permits the Secretary to provide programs or 
allowances to (a) transition in to an Indian Health Program, 
including licensing, board or certification examination and 
technical assistance, in fulfilling service obligations, and 
(b) health professionals employed in an Indian Health Program 
to enable them to take leave of their duty stations for a 
period of time each year for professional consultation and 
refresher training courses.
    Amendments: This section maintains current law, but also 
deletes the set-aside of not more than $1 million for 
postdoctoral training contained in current law, and adds 
language which extends the continuing education allowances to 
Tribal Health Programs and Urban Indian Organizations, in 
addition to the IHS, and includes all health professionals, 
rather than specified select health professionals.
    Current Law: This section is Section 1615 of current law.

Section 109. Community Health Representative Program

    Section 109 authorizes the Community Health Representative 
Program for training and using Indians as community health 
representatives. The section specifies the duties of the 
Service regarding this program, including providing a high 
standard of training for Community Health Representatives to 
ensure that these representatives provide quality health 
services to Indian communities served by this program. This 
program may also promote traditional health care practices 
consistent with IHS standards for health care.
    Amendments: This section maintains current law, and adds 
language which formally identifies the health paraprofessionals 
as Community Health Representatives (CHRs) and extends the use 
of CHRs to Tribal Health Programs and Urban Indian 
Organizations as well as IHS programs.
    Current Law: The section is Section 1616 of current law.

Section 110. Indian Health Service Loan Repayment Program

    This section directs the Secretary to establish and 
administer the Service Loan Repayment Program in order to 
ensure an adequate supply of trained health professionals 
needed to maintain accreditation of, and provide health care 
services to Indians through, Indian Health Programs and Urban 
Indian Organizations. The section includes provisions 
addressing eligibility for the program; application 
information; priorities; recipient contracts; deadlines for 
decisions on applications; a loan repayment program; a waiver 
from any employment ceiling; a recruitment program; non-
applicability of Section 214 of the Public Health Service Act 
(which concerns employees or officers being assigned to other 
agencies) during the period of obligated service; assignment of 
individuals; breach of contract; waiver or suspension of 
obligation; and the requirement of an annual report to Congress 
under Section 801.
    Amendments: This section maintains current law. In 
addition, it (1) eliminates the set-asides during FY 1993-1995 
for nursing and mental health professions; and (2) establishes 
priorities among applications rather than requiring the 
priorities be subject to the list of positions established by 
the Secretary, and sets a 21-day notice requirement instead of 
merely prompt notice.
    Current Law: This section is Section 1616a of current law.

Section 111. Scholarship and Loan Repayment Recovery Fund

    Section 111 establishes an Indian Health Scholarship and 
Loan Repayment Recovery Fund within the Treasury of the United 
States. The section specifies the use of these funds, the 
investment of the funds, and the sale of obligations by the 
Secretary of the Treasury.
    Amendments: This section maintains current law, and adds 
provisions expanding the source of funds for this Recovery Fund 
to include funds collected from individuals for breach of 
contract under the scholarship or loan repayment programs and 
interest, in addition to appropriations. Tribal Health Programs 
may also use payments received to provide scholarships, in 
addition to the current uses of recruitment and employment of 
health care professionals. The Secretary of Health and Human 
Services may now determine what amounts are not required to 
meet current withdrawals from the Fund, rather than the 
Secretary of the Treasury, as in current law.
    Current Law: This section is Section 1616a-1 of current 
law. It establishes an Indian Health Scholarship and Loan 
Repayment Recovery Fund within the Treasury of the United 
States, wherein funds collected for breaches of contractual 
obligations under the IHS or tribal scholarships or loan 
repayment programs are placed.

Section 112. Recruitment activities

    Section 112 permits the Secretary to reimburse certain 
travel expenses to health professionals seeking positions with 
Indian Health Programs or Urban Indian Organizations. Potential 
candidates for contracts under section 110 and their spouses 
are all eligible for such reimbursement of travel. In addition, 
this section requires the Secretary to assign one individual in 
each Area Office to have full-time responsibility for 
recruitment activities.
    Amendments: This section maintains current law and adds 
language to allow reimbursement for health professionals 
seeking positions with Tribal and Urban Indian Health Programs, 
in addition to the IHS.
    Current Law: This section is Section 1616b of current law.

Section 113. Indian recruitment and retention program

    Section 113 requires the Secretary to fund innovative 
demonstration projects to enable Tribal Health Programs and 
Urban Indian Organizations to recruit, place, and retain health 
professionals to meet their staffing needs. The section also 
specifies that any Tribal Health Program or Urban Indian 
Organization is eligible to apply for these funds.
    Amendments: This section maintains current law and adds 
language which (1) sets a time limit of three years for 
demonstration projects funded under this section instead of an 
open-ended timeframe under current law; and (2) clarifies that 
the entities eligible to compete are Tribal Health Programs and 
Urban Indian Organizations.
    Current Law: This section is Section 1616c of current law.

Section 114. Advanced training and research

    This section establishes a demonstration project to enable 
health professionals who have worked in an Indian Health 
Program or Urban Indian Organization for a substantial period 
of time to pursue advanced training or research areas of study, 
where a need exists. Each individual who participates shall 
incur a service obligation. The section also specifies equal 
opportunity for participating in the program.
    Amendments: This section maintains current law and adds 
language which limits the advanced training or research 
opportunities to health professionals who have worked for the 
IHS, tribal or urban Indian health programs for a substantial 
period of time, instead of merely being employed by one of 
these programs at the time of application.
    Current Law: This section is Section 1616d of current law.

Section 115. Quentin N. Burdick American Indians into Nursing Program

    Section 115 authorizes the Quentin N. Burdick American 
Indians into Nursing Program for the purpose of increasing the 
number of nurses, nurse midwives, and nurse practitioners who 
deliver health care services to Indians. The section specifies 
potential grant recipients; how grants may be used; information 
which must be included in applications for the grant; 
preferences for grant recipients; establishment and maintenance 
of a program at the University of North Dakota; and an active 
duty service obligation.
    Amendments: This section maintains current law and adds 
language which (1) includes advanced practice nurse programs in 
addition to nurse practitioners; (2) authorizes grants for 
midwife or nursing programs at tribal colleges and universities 
or, in their absence, other colleges and universities, instead 
of only at the other public or private institutions; and (3) 
includes tribal colleges and universities in the preferences 
among grant applicants.
    Current Law: This section is Section 1616e of current law.

Section 116. Tribal cultural orientation

    This section requires certain employees of the Service who 
serve Indian Tribes in each Service Area to receive instruction 
in the history and culture of the Indian Tribes they serve. The 
section requires that the program be developed in consultation 
with the affected Indian entities, be implemented through 
tribal colleges or universities, include instruction in 
American Indian studies, and describe the use and place of 
traditional health care practices of the Indian Tribes in the 
Service Area.
    Amendments: This section maintains current law and adds 
language which (1) ensures that employees in each Service Area 
obtain cultural orientation, rather than merely establishing a 
program for cultural orientation; (2) requires the program to 
include instruction on the relationship of the Indian Tribes 
with the IHS, rather than simply a history of the IHS, and a 
description of the traditional health care practices of the 
Indian tribes in the Service Area; and (3) requires 
consultation with affected Tribes, Tribal Organizations and 
Urban Indian Organizations.
    Current Law: This section is Section 1616f of current law.

Section 117. INMED Program

    Section 117 authorizes the Secretary to provide grants to 
colleges and universities to maintain and expand the Indian 
health careers recruitment program known as the Indians Into 
Medicine Program (INMED). The Quentin N. Burdick Grant at the 
University of North Dakota is to be one of the authorized 
grants. This section also specifies requirements for 
institutional applicants for these grants.
    Amendments: This section maintains current law and adds 
language which (1) authorizes grants to an unspecified number 
of colleges or universities instead of the previous mandate of 
at least 3 schools; (2) clarifies that the regulations govern 
the grants, including substantive provisions, such as criteria 
and application requirements, rather than govern only the 
competitive award process; and (3) eliminates an old 1988 
requirement of a report to Congress on the program and 
recommendations for changes.
    Current Law: This section is Section 1616g of current law.

Section 118. Health training programs of community colleges

    This section requires the Secretary to award grants to 
accredited, accessible community colleges to assist in 
establishing health profession education leading to a degree or 
diploma for individuals who desire to practice such profession 
on or near a reservation or in an Indian Health Program. The 
Secretary is also required to award grants to accredited, 
accessible community colleges that already have these programs. 
The Secretary must provide technical assistance to encourage 
community colleges to establish and maintain such programs. Any 
program receiving assistance under this section is required to 
provide advanced training for health professionals. Grant award 
priority is provided to tribal colleges and universities in 
Service Areas where they exist.
    Amendments: This section maintains current law and adds 
language which (1) recognizes accredited and accessible 
community colleges as eligible recipients of grants; (2) 
requires the colleges to have a relationship with a hospital, 
rather than merely having access to a hospital; (3) requires 
Indian preference for program participants; (4) increases the 
ceiling amount of the grant from $100,000 to $250,000; and (5) 
establishes priority for tribally-controlled colleges in 
Service Areas where they exist, if other requirements in the 
section are met.
    Current Law: This section is Section 1616h of current law.

Section 119. Retention bonus

    Section 119 permits the Secretary to provide retention 
bonuses to any health professional where recruitment or 
retention is difficult or is needed by Indian Health Programs 
and Urban Indian Organizations, if the individual has completed 
2 years of employment with an Indian Health Program or Urban 
Indian Organization or any service obligation from federal 
scholarships or loan repayment programs, and enters into an 
agreement with an Indian Health Program or Urban Indian 
Organization for continued employment for a period of not less 
than 1 year. Rates for retention bonuses may cover multiple 
years, but not exceed an annual rate of $25,000. Refunds shall 
be required if the health professional does not complete the 
term of service under any retention agreement, unless the 
default is not the fault of the individual.
    Amendments: This section maintains current law and adds 
language expanding the bonuses (1) to any health professional, 
rather than only doctors and nurses, so language specifying 
funding set-asides between these 2 professions has been 
deleted; and (2) to health professionals employed by the tribal 
or urban health programs, rather than employed only by the 
Service. Language also eliminates the current requirement that 
the retention bonus be paid at the beginning of the term of 
service.
    Current Law: This section is Section 1616j in current law.

Section 120. Nursing residency program

    This section establishes a program to enable Indians who 
are nurses working for an Indian Health Program or Urban Indian 
Organization to pursue advanced training. The participants are 
required to enter a service obligation to serve in an Indian 
Health Program or Urban Indian Organization. The program shall 
include a combination of education and work study leading to 
either an associate or bachelor's degree or advanced degrees or 
certifications.
    Amendments: This section maintains current law and adds 
language which establishes this program for Indian nurses and 
includes advanced degrees or certifications in nursing or 
public health as eligible programs, instead of a Master's 
degree, as appropriate post-baccalaureate training.
    Current Law: This section is Section 1616k of current law.

Section 121. Community Health Aide Program

    Section 121 directs the Secretary to develop and operate a 
Community Health Aide Program in Alaska. Requirements are 
specified for the Alaska program. Dental Health Aide Therapists 
under the Program would be prohibited from performing all oral 
and jaw surgeries except pulpal therapy or extraction of adult 
teeth after consultation with a licensed dentist in a dental 
emergency. In addition, the Secretary is directed to establish 
a neutral panel to conduct a study of the dental health aide 
therapist services provided by the Community Health Aide 
Program. Specifications of the study, which will lead to a 
report to Congress, are delineated. This section also allows 
the Secretary to establish a national Community Health Aide 
Program, which shall not include dental health aide therapist 
services, and shall not reduce funds for the Alaska program.
    Amendments: This section maintains current law and adds 
provisions which (1) require the Secretary to establish a 
neutral panel, whose membership is also set forth in this 
section, to study the dental health aide therapist program in 
Alaska Native communities and to submit a report on the study 
to appropriate Congressional Committees and (2) authorizes the 
expansion of the Community Health Aide Program, except for the 
dental health aide therapist program, to Indian communities in 
the lower 48 states.
    Current Law: This section is Section 1616l of current law.

Section 122. Tribal Health Program administration

    This section requires the Secretary to provide training for 
Indians in the administration and planning of Tribal Health 
Programs.
    Amendments: This section maintains current law and adds 
language which specifies that the training shall be for 
individuals who are Indian.
    Current Law: This section is Section 1616n of current law.

Section 123. Health professional chronic shortage demonstration 
        programs

    This section permits the Secretary to fund demonstration 
programs for Tribal Health Programs to address the chronic 
shortages of health professionals. Each demonstration program 
shall incorporate a program advisory board, which is to be 
composed of representatives from the Indian Tribes and Indian 
communities which are served by the program.
    Amendments: This section amends current law by changing a 
single pilot program at the School of Medicine at the 
University of South Dakota to address health professional 
shortages into a national demonstration project.
    Current Law: This section is Section 1616o in current law. 
Current law authorizes the Secretary to make a grant to the 
School of Medicine at the University of South Dakota to fund a 
pilot program on an Indian reservation at one or more Service 
Units in South Dakota to address the chronic manpower shortages 
in the Aberdeen Area of the IHS.

Section 124. National Health Service Corps

    This section prohibits the Secretary from removing a member 
of the National Health Service Corps from an Indian Health 
Program or Urban Indian Organization or withdrawing funding 
used to support such member, unless the Secretary ensures that 
Indians will experience no reduction in services. The section 
also exempts Corps scholars qualifying for the Commissioned 
Corps in the United States Public Health Service from full-time 
equivalent limitations when serving as a commissioned corps 
officer in a Tribal Health Program or an Urban Indian 
Organization.
    Amendments: This section maintains current law and adds 
Urban Indian organizations. Language which exempts National 
Health Service Corps scholars qualifying for the Commissioned 
Corps in the United States Public Health Service from full-time 
equivalent limitations when serving as a commissioned corps 
officer in a Tribal Health Program or an Urban Indian 
Organization is new to current law.
    Current Law: This section is Section 1680b of current law.

Section 125. Substance abuse counselor educational curricula 
        demonstration programs

    Section 125 allows the Secretary to enter into contracts 
with or make grants to accredited colleges and universities 
(including tribal) to establish demonstration programs 
developing curricula for substance abuse counseling. Duration 
and renewal of the grants is specified. The section also states 
the criteria for review and approval of the applications; 
requires the Secretary to provide technical and other 
assistance to grant recipients; requires the Secretary to 
submit an annual report to the President under section 801; and 
defines the term ``educational curriculum.''
    Amendments: This section maintains current law, and adds 
language including accredited and accessible qualifications for 
the community colleges eligible for these programs and 
extending the initial grant period from one year to three years 
and the renewal periods from one year to two years.
    Current Law: This section is Section 1665j of current law.

Section 126. Behavioral health training and community education 
        programs

    This section requires the Secretary, with the Secretary of 
the Interior and in consultation with Indian Tribes and Tribal 
Organizations, to conduct a study and compile a list of certain 
types of staff positions within the Bureau of Indian Affairs, 
the Service, Indian Tribes, Tribal Organizations and Urban 
Indian Organizations, which should include training in any 
aspect of mental illness, dysfunction, or self-destructive 
behavior.
    The Secretary is then required to provide training criteria 
appropriate for each type of position and ensure that this 
training is provided. Upon request of the appropriate Indian 
entity, the Secretary is required to develop and implement a 
program of community education on mental illness, as well as to 
provide technical assistance to tribal entities to obtain and 
develop community education materials.
    Within 90 days of enactment of this Act, the Secretary is 
required to develop a plan to increase behavioral health 
services by at least 500 staff positions within 5 years, with 
at least 200 of such positions being devoted to child, 
adolescent, and family services.
    Amendments: This section maintains current law and (1) adds 
Tribal Organizations and Urban Indian Organizations as 
participants in the program; (2) clarifies that Tribal 
Organizations are to be part of the consultation process; (3) 
changes the focus from solely on mental health to behavioral 
health; and (4) eliminates the requirement that the staff be 
assigned primarily to the IHS Service Units.
    Current Law: This section is Section 1621h(d) of current 
law.

Section 127. Authorization of appropriations

    Section 127 authorizes to be appropriated such sums as may 
be necessary to carry out this title for each fiscal year 
through 2017.
    Amendments: The section updates the authorization period 
through fiscal year 2017, instead of fiscal year 2000.
    Current Law: This section is Section 1616p of current law.

                       TITLE II--HEALTH SERVICES


Section 201. Indian Health Care Improvement Fund

    This section authorizes the use of funds for the purposes 
of eliminating the deficiencies in health status and resources 
for tribes; eliminating backlogs and meeting the needs in 
health care services; eliminating the inequities in funding for 
direct care and contract health service programs; and 
augmenting the ability of the Indian Health Service to meet its 
various responsibilities. Funding authorized by this section 
may not be used to offset appropriated funds and must be used 
to improve the health status and reduce the resource 
deficiencies of tribes.
    This section also defines ``health status and resource 
deficiency'' and requires that Tribal Health Programs be 
equally eligible for funds as programs administered by the 
Indian Health Service. A report is required to be submitted to 
Congress 3 years after enactment which addresses the current 
health status and resource deficiency for each Service Unit. 
Funds appropriated under this section are to be included in the 
base budget of the Indian Health Service for determining 
appropriations in subsequent years.
    Nothing in this section is intended to diminish the primary 
responsibility of the Indian Health Service to eliminate 
backlogs in unmet health care, or to discourage additional 
efforts of the Service to achieve equity among Tribes and 
Tribal Organizations.
    Funds appropriated under this section are to be designated 
as the ``Indian Health Care Improvement Fund.''
    Amendments: This section maintains current law and adds 
provisions clarifying that the Secretary may expend funds 
either directly or through contracts or compacts under the 
Indian Self-Determination and Education Assistance Act, as well 
as provisions regarding the use of telehealth and telemedicine. 
Language has been added specifying the kinds of injury 
prevention programs that may be offered.
    Current Law: This section is Section 1621 of current law.

Section 202. Catastrophic Health Emergency Fund

    Section 202 establishes the Catastrophic Health Emergency 
Fund (CHEF), which is to be administered by the Secretary 
through the headquarters of the Indian Health Service in order 
to meet the extraordinary medical costs associated with the 
treatment of victims of disasters or catastrophic illnesses. No 
part of the CHEF or the administration thereof is to be subject 
to contract or grant, nor shall these funds be apportioned on 
an Area Office, Service Unit, or other similar basis. The 
Secretary is required to promulgate regulations for the 
administration of these funds. This section prohibits funds 
appropriated to CHEF from being used to offset or limit other 
appropriations made to the Indian Health Service. It also 
requires that all reimbursements to which the Service is 
entitled from any source by reason of treatment rendered to any 
victim of a disaster or catastrophic illness the cost of which 
was paid from CHEF shall be deposited into CHEF.
    Amendments: This section maintains current law.
    Current Law: This section is Section 1621a in current law.

Section 203. Health promotion and disease prevention services

    This section finds that health promotion and disease 
prevention activities improve health and well-being and reduce 
the expenses for health care. It requires the Secretary to 
provide these services and, with input from the affected Tribal 
Health Programs, to report to Congress on an evaluation 
statement of the status, capacity and resources needed to 
promote health and prevent disease.
    Amendments: This section maintains current law, but moves 
the definition of health promotion and disease prevention to 
the definitions section and adds Congressional findings.
    Current Law: This section is Section 1621b of current law.

Section 204. Diabetes prevention, treatment, and control

    Section 204 requires the Secretary to determine the 
incidence of diabetes and its complications among Indians and 
the measures needed to prevent, treat and control this disease. 
The Secretary is also required, when medically indicated and 
with informed consent, to screen Indians for diabetes and for 
conditions which indicate a high risk for diabetes.
    The Secretary is required to continue to fund model 
diabetes projects and dialysis programs. To the extent that 
funding is available, the Secretary is required to work with 
each Area Office to consult with Tribes and Tribal 
Organizations regarding diabetes programs; establish patient 
registries in Area Offices; and ensure that data collected are 
disseminated to other Area Offices, subject to privacy laws. 
The Secretary is also allowed to maintain diabetes control 
officers, but if these positions and activities are 
administered by the Tribes or Tribal Organizations, then the 
funding and activities would not be divisible under the Indian 
Self-Determination and Education Assistance Act.
    Amendments: This section maintains current law and (1) adds 
(a) Tribal Organizations as eligible participants in these 
programs, (b) effective ongoing monitoring of disease 
indicators, (c) the requirement that screening shall be to the 
extent medically indicated and with informed consent, and (d) 
funding for dialysis programs; (2) changes the model diabetes 
projects into permanent programs to be continued along with any 
new programs developed with recurring funding; and (3) still 
allows for diabetes control officers in each Area Office, but 
provides that if these positions and activities are 
administered by the Tribes or Tribal Organizations, then the 
funding and activities would not be divisible under the Indian 
Self-Determination and Education Assistance Act.
    Current Law: This section is Section 1621c of current law.

Section 205. Shared services for long-term care

    This section allows the Secretary to enter into funding 
agreements with Tribes and Tribal Organizations for the 
delivery of long-term care services to Indians. Contents of 
these funding agreements are specified. Any nursing facility 
funded under this section must meet the requirements for such 
facilities under section 1919 of the Social Security Act. In 
addition, the Secretary is required to provide necessary 
technical and other assistance to enable applicants to comply 
with the provisions of this section. The Secretary shall 
encourage the use of existing underused facilities or allow the 
use of swing beds for long-term or similar care.
    Amendments: This section amends current law by changing a 
demonstration project into a permanent program and adding new 
provisions which (1) include health care services associated 
with long- term care provided in a facility for Indians; and 
(2) encourage the use of existing underused facilities or allow 
the use of swing beds for long-term or similar care.
    Current Law: This section is Section 1680l of current law.

Section 206. Health services research

    This section requires the Secretary to make funding 
available for both clinical and nonclinical research to further 
the delivery of Indian health services, and to coordinate the 
activities of other agencies within the Department to address 
this need. Tribal Health Programs are to be given equal 
opportunity to compete for these research funds. The Secretary 
shall also periodically evaluate the impact of research 
conducted under this section, and disseminate to Tribal Health 
Programs information regarding that research.
    Amendments: This section amends current law by (1) 
eliminating the specific set-aside of $200,000 for research and 
replacing it with general authority to fund research for Indian 
health programs, instead of only the IHS; (2) requiring the 
Secretary to coordinate, to the extent practical, the resources 
and activities for Indian health research needs; (3) 
authorizing funding for both clinical and nonclinical research; 
and (4) providing for a periodic evaluation and dissemination 
of the research to Tribal Health Programs.
    Current Law: This section is Section 1621g of current law.

Section 207. Mammography and other cancer screening

    This section requires the Secretary to provide for 
mammography and other cancer screening, consistent with the 
screening recommendations of the United States Preventive 
Services Task Force.
    Amendments: This section amends current law by authorizing 
other cancer screening, and eliminating the minimum age 
requirement of 35 for Indian women and opening the mammography 
screening to all Indian women, at a frequency under appropriate 
national standards.
    Current Law: This section is Section 1621k of current law.

Section 208. Patient travel costs

    Section 208 requires the Secretary to provide funds for the 
travel costs of patients and their qualified escorts, 
associated with receiving health care services. A definition of 
``qualified escort'' for purposes of accompanying a patient who 
is traveling to receive health care services is provided.
    Amendments: This section maintains current law and adds 
language which allows the use of qualified escorts and 
transportation by private vehicle (where no other 
transportation is available), specially equipped vehicle, 
ambulance or by other means required when air or motor vehicle 
transport is not available.
    Current Law: This section is Section 1621l of current law.

Section 209. Epidemiology centers

    This section directs the Secretary to establish an 
epidemiology center in each Service Area. The functions of 
these centers are delineated. The Director of the Centers for 
Disease Control and Prevention is required to provide technical 
assistance to the centers. The Secretary is also authorized to 
make grants to Tribes, Tribal Organizations, Urban Indian 
Organizations and eligible intertribal consortia to conduct 
epidemiological studies of Indian communities. Eligibility 
requirements for consortia, application requirements and use of 
grant funds are specified. This section also authorizes the 
Secretary to provide access to information in the possession of 
the Secretary to an epidemiology center operated by a grantee 
pursuant to a grant awarded under this section.
    Amendments: This section amends current law by (1) 
maintaining the centers in existence on the date of passage of 
this Act, but still requiring the establishment of centers in 
the remaining Areas; (2) allowing new centers to be operated 
under a grant under this section, but the funding under such a 
grant shall not be divisible; (3) eliminating the requirements 
in current law that the Secretary establish the data and 
formats for reporting and establish the system for monitoring 
progress toward the health objectives; and (4) providing that 
an epidemiology center operated under this section shall be 
treated as a public health authority for purposes of the Health 
Insurance Portability and Accountability Act of 1996 and 
directing the Secretary to grant grantees access to and use of 
data and other protected health information in the possession 
of the Secretary.
    Current Law: This section is Section 1621m of current law.

Section 210. Comprehensive school health education programs

    Section 210 allows the Secretary to provide grants to 
Indian Tribes, Tribal Organizations and Urban Indian 
Organizations to develop comprehensive school health education 
programs for children from pre-school through grade 12 in 
schools for the benefit of Indian and Urban Indian children. 
The specific purposes for which grant funds may be used are 
delineated. Upon request, the Secretary shall provide technical 
assistance in the development and dissemination of 
comprehensive health education plans, materials and 
information. The Secretary, through the Service and in 
consultation with Tribes, Tribal Organizations and Urban Indian 
Organizations, shall establish criteria for review and approval 
of applications for this funding. For Bureau of Indian Affairs-
funded schools, the Secretary of the Interior shall develop a 
similar school health education program.
    Amendments: This section maintains current law and adds 
language which (1) clarifies the types of purposes for which 
the funds may be used, such as for both regular school and 
after school programs, for the benefit of Indian and urban 
Indian children, for oral health programs, for violence 
prevention and for other health issues, as appropriate; (2) 
expands the grants to include Tribal Organizations and Urban 
Indian Health Organizations as eligible for funding, as well as 
Tribes; (3) deletes the reporting requirements of current law; 
and (4) requires that the application criteria be established 
in consultation with Indian Tribes, Tribal Organizations and 
Urban Indian Organizations.
    Current Law: This section is Section 1621n of current law.

Section 211. Indian youth program

    This section authorizes the Secretary to establish and 
administer a program for innovative mental and physical disease 
prevention and health promotion and treatment for Indian and 
Urban Indian preadolescent and adolescent youths. Allowable and 
prohibited uses of the funds authorized by this section are 
delineated. The Secretary is required to disseminate 
information regarding models for delivery of comprehensive 
health care services to Indian youth; to encourage the 
implementation of these models; and to provide technical 
assistance upon request. The Secretary will establish criteria 
for review and approval of applications under this section in 
consultation with Tribes, Tribal Organizations and Urban Indian 
Organizations.
    Amendments: This section maintains current law and adds 
Tribal Organizations and Urban Indian Organizations as 
participants in the program and consultation, and includes 
urban Indian youth as beneficiaries of program services. The 
specific authorization of this program in current law is 
deleted.
    Current Law: This section is Section 1621o of current law.

Section 212. Prevention, control, and elimination of communicable and 
        infectious diseases

    Section 212 authorizes the Secretary to make grants 
available to projects specifically for the purpose of 
preventing, controlling and eliminating communicable and 
infectious diseases. Funding is also authorized for public 
information and education programs; education, training and 
clinical skills improvement activities for health 
professionals; and demonstration projects for the screening, 
treatment and prevention of the hepatitis C virus. Funding 
under this section requires an application or proposal to be 
submitted. Entities which receive funding under this section 
are encouraged to coordinate their activities with the Centers 
for Disease Control and Prevention, as well as with state and 
local health agencies. Finally, in carrying out this section, 
the Secretary may provide technical assistance, upon request, 
and shall submit a biennial report to Congress on the use of 
the funds and the progress made toward prevention, control, and 
elimination of communicable and infectious diseases among 
Indians and Urban Indians.
    Amendments: This section amends current law by (1) 
including Urban Indian Organizations; (2) expanding the 
communicable diseases from simply tuberculosis to other 
communicable and infectious diseases; (3) by encouraging, 
rather than requiring, that entities funded under this section 
coordinate with the Centers for Disease Control and state and 
local health agencies; and (4) by eliminating provisions of 
current law which would reduce the grant amount for expenses 
incurred by the federal government or for supplies or equipment 
furnished to the grant recipient.
    Current Law: This section is Section 1621q of current law.

Section 213. Other authority for provision of services

    This section authorizes the Secretary to fund other 
activities which meet the objectives set forth in Section 3 of 
this Act through health care-related services and programs not 
otherwise described in the Act, including hospice care, 
assisted living, long-term health care, and home- and 
community-based services. Services are to be in provided in 
accordance with accepted and appropriate standards relating to 
the service, including any licensing term or condition. The 
Secretary is authorized to establish standards, by regulation, 
for a service provided under this section, provided that those 
standards are not more stringent than the standards required by 
the state in which the service is provided. If the Secretary 
does not establish standards by regulation, state standards 
shall apply. If a service under this section is provided by an 
Indian Tribe or Tribal Organization pursuant to the Indian 
Self-Determination and Education Assistance Act, the 
verification by the Secretary that the service meets any 
standards required by the state in which the service is or will 
be provided shall be considered to meet the terms and 
conditions required. The individuals who are eligible to 
receive long-term care under this section are specified, and 
the terms ``home- and community-based services'' and ``hospice 
care'' are defined. This section also authorizes the Secretary 
to provide funding to meet the objectives set forth in Section 
3 of this Act for convenient care services programs pursuant to 
section 306(c)(2)(A).
    Amendments: This section amends current law by making 
permanent a demonstration project for home- and community-based 
care. New provisions also (1) add standards; (2) add several 
definitions and deletes the definition of ``functionally 
disabled'' found in current law; and (3) eliminates the 
exclusion of cash payments, room and board, construction and 
nursing facility services. The provision authorizing the 
Secretary to provide funding to meet the objectives set forth 
in Section 3 of this Act for convenient care services programs 
is new.
    Current Law: Section 1680k authorizes the Secretary to 
establish not more than 24 demonstration projects for home-and 
community-based care (excluding cash payments, room and board, 
construction and nursing facility services), for functionally 
disabled Indians. Discretion is provided to the Indian Health 
Service, Indian Tribes, or Tribal Organizations to provide such 
care to persons otherwise ineligible for the health care 
benefits of the Indian Health Service (on a cost basis). The 
Secretary is required to submit to the President for inclusion 
in a report to Congress the findings of these projects. ``Home- 
and community-based services'' and ``functionally disabled'' 
are defined.

Section 214. Indian women's health care

    This section requires the Secretary, acting through the 
Service, Indian Tribes, Tribal Organizations and Urban Indian 
Organizations, to monitor and improve health care for Indian 
women of all ages through the planning and delivery of programs 
administered by the Service.
    Amendments: This section amends current law by eliminating 
the Office of Indian Women's Health and, instead, requiring the 
Secretary to monitor and improve the quality of Indian women's 
health through the various programs administered by IHS.
    Current Law: Section 1621v establishes an Office of Indian 
Women's Health Care to oversee efforts of the IHS to monitor 
and improve health care for Indian women of all ages.

Section 215. Environmental and nuclear health hazards

    Section 215 requires the Secretary, in conjunction with 
other Federal agencies and in consultation with concerned 
Tribes and Tribal Organizations, to conduct studies and ongoing 
monitoring programs to determine trends in the health hazards 
to Indian miners and other Indians as a result of environmental 
hazards, such as nuclear resource development, petroleum 
contamination, and contamination of water sources and the food 
chain. Upon completion of such studies, the Secretary shall 
develop health care plans to address these health problems. The 
Secretary is required to submit the study to Congress 18 months 
after the date of enactment and a report no later than 1 year 
after the study which shall include recommendations for the 
implementation of the health care plan and evaluation 
activities. This section establishes an Intergovernmental Task 
Force to identify environmental hazards and to take corrective 
action. The Secretary is to chair this Task Force, which shall 
meet at least twice yearly. If an Indian who is employed in or 
around any environmental hazard suffers from a work-related 
condition, the Indian Health Program which treats him may be 
reimbursed by the Indian's employer.
    Amendments: This section maintains current law and adds 
language which (1) requires ongoing monitoring of trends in 
health hazards to Indians and other environmental hazards to 
Indian communities; and (2) provides additional elements of the 
studies conducted under this section.
    Current Law: This section is Section 1677 of current law.

Section 216. Arizona as a contract health service delivery area

    This section designates the State of Arizona as a contract 
health service delivery area for providing contract health care 
services to members of federally recognized Indian Tribes of 
Arizona. The Indian Health Service is not to curtail any 
services as a result of this provision.
    Amendments: This section maintains current law and extends 
the date to 2017, instead of 2000, for the designation as a 
contract health service delivery area.
    Current Law: This section is Section 1678 of current law.

Section 216A. North Dakota and South Dakota as contract health service 
        delivery area

    This section designates the States of North Dakota and 
South Dakota as one contract health service delivery area for 
providing contract health care services to members of federally 
recognized Indian Tribes in North and South Dakota. The Indian 
Health Service is not to curtail any services as a result of 
this provision.
    Amendments: This section is new to the Act and is not 
contained in current law.

Section 217. California contract health services program

    This section authorizes the Secretary to fund a program 
using the California Rural Indian Health Board (CRIHB) as a 
contract care intermediary to improve the accessibility of 
health services to California Indians. The Secretary will 
reimburse the CRIHB for costs incurred pursuant to this 
section. Not more than 5 percent of the amounts provided under 
this section to the CRIHB in any fiscal year may be for 
administrative expenses. No payment may be made for treatment 
under this section to the extent payment may be made under the 
Indian Catastrophic Health Emergency Fund or from amounts 
appropriated or otherwise made available to the California 
contract health service delivery area. This section also 
establishes an Advisory Board to advise the CRIHB in carrying 
out this section. The Advisory Board shall be comprised of 
representatives from not less than 8 Tribal Health Programs 
serving California Indians covered under this section, and at 
least one-half of whom are not affiliated with the CRIHB.
    Amendments: This section amends current law by turning the 
demonstration project for the California Indians into a 
permanent program.
    Current Law: This section is Section 1621j of current law.

Section 218. California as a contract health service delivery area

    This section designates the State of California, excluding 
certain specified counties, as a contract health service 
delivery area for the purpose of providing contract health care 
services to California Indians. The excluded counties may be 
included only if funding is specifically provided by the Indian 
Health Service for such services in those counties.
    Amendments: This section maintains current law, but allows 
the excluded counties to become a part of the contract service 
delivery area if funding is specifically provided for such 
services in those counties.
    Current Law: This section is Section 1680 of current law.

Section 219. Contract health services for the Trenton service area

    This section directs the Secretary to provide contract 
health services to members of the Turtle Mountain Band of 
Chippewa Indians who reside in the Trenton Service Area of 
Divide, McKenzie, and Williams counties in North Dakota and the 
counties of Richland, Roosevelt, and Sheridan in Montana. 
Nothing in this section is to be construed as expanding the 
eligibility of members of the Turtle Mountain Band of Chippewa 
Indians for health services provided by the Service beyond the 
scope of eligibility for these services that applied on May 1, 
1986.
    Amendments: This section maintains current law.
    Current Law: This section is Section 1680e of current law.

Section 220. Programs operated by Indian tribes and tribal 
        organizations

    This section requires the Indian Health Service to provide 
funds to Tribal Health Programs for health care programs and 
facilities on the same basis as funds are provided to these 
programs operated directly by the Indian Health Service.
    Amendments: This section maintains current law, but 
eliminates language which specifies the particular use of funds 
for which the Indian Tribes and Tribal Organizations can 
receive funding on the same basis as the IHS.
    Current Law: Section 1680a requires the Indian Health 
Service to provide funds to tribes and tribal organizations 
health care programs and facilities to (1) maintain and repair 
clinics, (2) train employees, (3) provide cost-of-living 
expenses, and (4) provide for other expenses related to health 
services on the same basis as funds are provided to these 
programs operated directly by the Indian Health Service.

Section 221. Licensing

    Section 221 requires that health care professionals 
employed by a Tribal Health Program shall, if licensed in any 
State, be exempt from the licensing requirements of the State 
in which the Tribal Health Program provides the services.
    Amendments: This section is new to the Act and is not 
contained in current law.

Section 222. Notification of provision of emergency contract health 
        services

    This section allows 30 days (as a condition of payment) for 
an elderly or disabled Indian to notify the Service of any 
emergency medical care or services received from a non-Service 
provider or in a non-Service facility.
    Amendments: This section maintains current law.
    Current Law: This section is Section 1646 of current law.

Section 223. Prompt action on payment of claims

    Section 223 provides a deadline for the Service to respond 
to notification of a claim by a provider of a contract care 
service. The section also provides that if the Service fails to 
respond within the required time, the Service shall accept the 
claim submitted by the provider as valid. The IHS shall pay a 
valid claim within 30 days after the completion of the claim.
    Amendments: This section maintains current law, but changes 
the requirement of a completed claim to a valid claim.
    Current Law: This section is Section 1621s of current law.

Section 224. Liability for payment

    This section provides that a patient who receives 
authorized contract health care services will not be held 
liable for any charges or costs associated with those 
authorized services. The Secretary is required to notify the 
contract care provider and the patient who receives such 
services that the patient is not liable within a specified 
time. Following receipt of this notice or an acceptable claim 
under the previous section, the provider shall have no further 
recourse against the patient who received the health care.
    Amendments: This section maintains current law and adds 
language which limits the recourse against the patient if the 
claim has been deemed accepted under Section 223.
    Current Law: This section is Section 1621u of current law.

Section 225. Office of Indian Men's Health

    This section provides that the Secretary may establish the 
Office of Indian Men's Health to coordinate and promote the 
health status of Indian men. The Office will be headed by a 
director, who is to be appointed by the Secretary. The 
Secretary is also required to submit a report to Congress 
within two years of enactment, describing any activity and 
finding about the health of Indian men of the director.
    Amendments: This section is new to the Act and is not 
contained in current law.

Section 226. Authorization of appropriations

    This section authorizes to be appropriated such sums as may 
be necessary to carry out this title for each fiscal year 
through fiscal year 2017.
    Amendments: This section maintains current law, but extends 
the authorization from fiscal year 2000 to fiscal year 2017 and 
eliminates the references to specific sections which had a 
separate authorization period.
    Current Law: This section is Section 1621w of current law.

                         TITLE III--FACILITIES


Section 301. Consultation; Construction and renovation of facilities; 
        Reports

    This section requires that prior to expending construction 
funds, the Secretary shall consult with impacted Indian Tribes, 
and ensure that facilities built pursuant to this section meet 
certain construction standards within one year after the date 
on which the construction or renovation of such facility is 
completed. In addition, Section 301 sets forth requirements to 
be met prior to closing any facility.
    This section also directs the Secretary to maintain a 
health care facility priority system which shall be developed 
in consultation with Indian Tribes and Tribal Organizations and 
meet other requirements. The priority of any project 
established under the construction priority system in effect on 
the date of enactment, if the project meets certain criteria, 
is protected. Not later than 1 year after the date of enactment 
of the Indian Health Care Improvement Act Amendments of 2007, 
the Secretary shall submit to Congress a report that describes 
the comprehensive, national, ranked list of all health care 
facilities needs for the Service, Indian Tribes, and Tribal 
Organizations. Beginning in calendar year 2011, the Secretary 
shall update this report not less frequently than once every 5 
years. Annual reports are also required under this section.
    Not later than 1 year after the establishment of the health 
care facilities construction priority system under this 
section, the Comptroller General of the United States shall 
prepare and finalize a report to Congress, that reviews the 
methodologies applied, and the processes followed, by the 
Service in making each assessment of needs for the priority 
system. This section also directs the Secretary to consult and 
cooperate with Indian Tribes, Tribal Organizations, and Urban 
Indian Organizations in developing innovative approaches to 
address all or part of the total unmet need for construction of 
health facilities.
    Amendments: This section maintains current law and builds 
on it substantially. Language is added which (1) requires an 
evaluation of the impact of a proposed closure prior to 
closing; (2) requires the Secretary to maintain a health care 
facility priority system developed through consultation, which 
prioritizes certain facilities; (3) adds specific requirements 
for the initial, comprehensive report to Congress and 
subsequent annual reports; (4) requires the Secretary to 
consult and cooperate with Indian Tribes, Tribal Organizations, 
and Urban Indian Organizations in developing innovative 
approaches to meet facilities needs; and (5) requires the 
Comptroller General to prepare a report to Congress which 
reviews the methodology used for the health facilities 
construction priority list.
    Current Law: This section is Section 1631 of current law.

Section 302. Sanitation facilities

    This section provides findings, certain responsibilities of 
the Service for sanitation, authorized uses of sanitation 
funding and facilities, and reporting requirements, and 
establishes the deficiency levels for those facilities. This 
section requires training or technical assistance in the 
operation and maintenance of sanitation facilities, and 
priority funding for operation and maintenance or emergency 
repairs.
    Section 302 authorizes the Secretary to accept funds from 
any source, including funds appropriated under the Native 
American Housing Assistance and Self-Determination Act, for 
construction of sanitation facilities. The Secretary, after 
consulting with the Secretary of Housing and Urban Development 
and Indian Tribes, Tribal Organizations and tribally designated 
housing entities, is also required to submit a report to 
Congress on the sanitation facilities priority system and a 10-
year plan to provide sanitation facilities to new and renovated 
Indian homes. Deficiency levels for sanitation facilities are 
defined.
    Amendments: This section maintains current law and adds 
language which (1) establishes priority funding for emergency 
repairs and operation or maintenance to avoid imminent health 
threats or to protect the investment in health benefits gained 
through the sanitation facilities; (2) prohibits the use of IHS 
funding to provide sanitation facilities to new homes 
constructed using Department of Housing and Urban Development 
funds; (3) allows the Secretary to accept funds from any 
source, including federal and state agencies, for sanitation 
facilities and services, and to place those funds into 
contracts or compacts under the Indian Self-Determination and 
Education Assistance Act; (4) authorizes the Secretary to allow 
certain funding to be used to fund tribal loans or matching or 
cost participation requirements to construct sanitation 
facilities; (5) requires the Secretary enter into interagency 
agreements for financial assistance; (6) requires consultation 
in preparation of the report to Congress, and clarifies the 
information required to be in the annual report; and (7) 
establishes an Indian Tribe's primary responsibility for 
collecting user fees and the Secretary's responsibility in 
assisting tribes when the facility is threatened with imminent 
failure.
    Current Law: This section is Section 1632 of current law.

Section 303. Preference to Indians and Indian firms

    This section authorizes the Secretary to give preference to 
Indians or Indian or tribal enterprises or other businesses in 
the construction and renovation of Service facilities pursuant 
to section 301, and in the construction of sanitation 
facilities pursuant to section 302. Compliance with certain 
labor standards is required.
    Amendments: This section maintains current law and adds new 
language to clarify rates of pay requirements and other wage 
requirements similar to local rates as determined by the Indian 
tribes or Tribal Organizations to be served by the 
construction.
    Current Law: This section is Section 1633 of current law.

Section 304. Expenditure of non-service funds for renovation

    This section authorizes the Secretary to accept any 
expansion, renovation or modernization of any Service or tribal 
health facility funded with non-Service funds in accordance 
with certain criteria. The Secretary is required to maintain a 
separate priority list for these facilities, which shall be 
submitted to Congress as part of the annual report to Congress. 
Indian Tribes or Tribal Organizations are required to meet 
certain requirements for expansions, renovations or 
modernizations. This section also provides that if any Service 
facility which has been expanded, renovated, or modernized 
under this section ceases to be used as a Service facility 
during the 20-year period beginning on the date such expansion, 
renovation, or modernization is completed, such Indian Tribe or 
Tribal Organization shall be entitled to recover from the 
United States an amount which bears the same ratio to the value 
of such facility at the time of such cessation as the value of 
such expansion, renovation, or modernization bore to the value 
of such facility at the time of the completion of such 
expansion, renovation, or modernization.
    Amendments: This section maintains current law and adds 
language which (1) includes major expansion as an authorized 
use of funds, in addition to renovation and modernization, but 
requires the Indian Tribes or Tribal Organizations to provide 
certain information to the Secretary regarding staffing, 
equipment and other costs associated with the expansion; and 
(2) requires the methodology for determining priorities to be 
developed through regulations.
    Current Law: This section is Section 1634 of current law.

Section 305. Funding for the construction, expansion and modernization 
        of small ambulatory care facilities

    This section authorizes the Secretary to make grants to 
Indian Tribes and Tribal Organizations for the construction, 
expansion, or modernization of facilities for the provision of 
ambulatory care services. Use of funds, grant application 
requirements, priorities, and conditions for reversion of 
facilities are set forth.
    Amendments: This section maintains current law and adds 
language which (1) requires the funding to be used for the 
portion of costs which benefits the eligible population, but 
exempts from the specific eligibility requirements applicants 
whose principal health administration offices are located where 
there is no road system providing direct access to inpatient 
hospitals; (2) adds additional capacity requirements for a 
facility constructed with a grant under this section; (3) makes 
reduction of an outstanding debt for construction, expansion or 
modernization an additional allowable use of funds; and (4) 
authorizes peer review panels to be established to evaluate 
applications and proposals.
    Current Law: This section is Section 1636 of current law.

Section 306. Indian health care delivery demonstration projects

    This section authorizes the Secretary to establish a health 
care delivery demonstration project to test alternative means 
of delivering health care and services to Indians through 
facilities. There would be two kinds of demonstration projects. 
General projects would be authorized, with priority given to 
projects located in specific Service Areas, if they meet the 
specified criteria, such as the need for such facility, number 
of Indians to be served, the economic viability of the project, 
and the administrative and financial capability of Indian 
Tribes or Tribal Organizations to administer the project. 
Health care delivery demonstration projects would also be 
authorized that include a convenient care services program as 
an alternative means of delivering health care services to 
Indians. This section also requires technical assistance and 
use of the same criteria in evaluating tribal and IHS 
facilities.
    Amendments: This section maintains current law and adds 
language which (1) permits the use of IHS funds to match other 
funds; (2) authorizes the convenient care services 
demonstration projects; and (3) authorizes peer review panels 
to be established to review and evaluate applications. Language 
of current law authorizing reports to Congress on the findings 
and conclusions of the demonstration projects has been deleted.
    Current Law: This section is Section 1637 of current law.

Section 307. Land transfer

    This section authorizes the Secretary to accept any land 
and improvements transferred, at no cost, from the Bureau of 
Indian Affairs or other federal agencies for the provision of 
health care services.
    Amendments: This section amends current law by changing a 
specific authorization into a general authorization whereby 
federal agencies may transfer land and improvements to the IHS 
for the provision of health care services.
    Current Law: Section 1638 provides specific authorization 
for transferring 5 acres of land at the Chemawa Indian School 
in Salem, OR, to the IHS.

Section 308. Leases, contracts and other agreements

    This section authorizes the Secretary to enter into leases, 
contracts and other agreements with Indian Tribes and Tribal 
Organizations which have facilities for the delivery of health 
services at those facilities. The agreements may also include 
provisions for construction, renovation and compensation.
    Amendments: This section essentially maintains current law. 
The provision of current law authorizing the Secretary to enter 
into 20-year leases with Tribes that may specify reconstruction 
or renovation of property has been deleted.
    Current Law: This section is Section 1674 of current law.

Section 309. Study for loans, loan guarantees and loan repayment

    This section directs the Secretary to conduct a study to 
determine the feasibility of establishing a loan fund to 
provide Indian Tribes and Tribal Organizations direct loans or 
loan guarantees for health care facilities construction. A 
number of study requirements are delineated. The results of the 
study shall be reported to Congress.
    Amendments: This section is new and is not now contained in 
current law.

Section 310. Tribal leasing

    This section authorizes a tribal health program to lease 
permanent structures for the purpose of providing health care 
services without obtaining prior approval in appropriation 
Acts.
    Amendments: This section maintains current law, and expands 
the program to include Tribal Organizations.
    Current Law: This section is Section 1680j of current law.

Section 311. Indian Health Service/Tribal Facilities Joint Venture 
        Program.

    This section authorizes the Secretary to make arrangements 
with Indian Tribes and Tribal Organizations to establish joint 
venture demonstration projects, under which an Indian Tribe or 
Tribal Organization would expend tribal, private, or other 
available funds for the acquisition or construction of a health 
facility for a minimum of 10 years, under a no-cost lease. In 
exchange, the Service will agree to provide the equipment, 
supplies, and staffing for the operation and maintenance of 
such a health facility. Certain capabilities and other 
requirements are set forth. There are provisions for breach of 
agreement by either the Tribe or Tribal Organization or the 
IHS.
    Amendments: This section maintains current law and adds (1) 
Tribal Organizations to the eligible participants and those 
Tribes that have begun, but not completed the process of 
acquisition or construction of a health care facility; (2) 
requires negotiation for the continued operation of the 
facility at the end of the 10-year lease; (3) authorizes 
recovery in a proportional amount from the IHS if the IHS 
ceases to use the facility within the 10-year lease period; and 
(4) includes staff quarters in the definition of the health 
facilities under this section.
    Current Law: This section is Section 1680h(e) of current 
law.

Section 312. Location of facilities

    This section directs the Bureau of Indian Affairs and the 
Service to give priority to locating health care facilities and 
employment projects in economically depressed areas to Indian 
and Alaska Native lands, if requested by the Indian owner and 
Indian Tribe with jurisdiction over such lands.
    Amendments: This section maintains current law and adds 
language to (1) include lands in Alaska owned by any Alaska 
Native village, or village or regional corporation under the 
Alaska Native Claims Settlement Act, or any land allotted to 
any Alaska Native; and (2) gives top priority to Indian land 
owned by 1 or more Indian Tribes. The definition of ``Indian 
lands'' is modified from current law.
    Current Law: This section is Section 1680n of current law.

Section 313. Maintenance and improvement of health care facilities

    This section requires the Secretary to report to Congress 
on the backlog of maintenance and repair work required at both 
Service and tribal health care facilities. This section also 
authorizes an Indian Tribe or Tribal Organization to use 
maintenance and improvement funds for construction of a 
replacement facility, as well as for renovation, modernization, 
and expansion of facilities, under certain circumstances.
    Amendments: This section is new and is not now contained in 
current law.

Section 314. Tribal management of federally-owned quarters

    This section authorizes Tribal Health Programs operating a 
health care facility and federally-owned quarters pursuant to a 
contract or compact under the Indian Self-Determination and 
Education Assistance Act to establish reasonable rental rates 
for the federally-owned quarters, and to collect the rent 
directly from federal employees who occupy such quarters. These 
quarters shall remain eligible for improvement and repair funds 
as other federally-owned quarters. The Tribal Health Program 
operating the quarters is required to provide at least 60 days 
notice before changing the rental rate.
    Amendments: This section is new and is not now contained in 
current law.

Section 315. Applicability of Buy American Act requirement

    This section requires application of the Buy American Act 
for all procurements under this title. Indian Tribes and Tribal 
Organizations are exempt from this requirement.
    Amendments: This section maintains current law, but exempts 
Indian Tribes and Tribal Organizations from the requirements of 
the Buy American Act, and eliminates the reporting requirement 
contained in current law.
    Current Law: This section is Section 1638b of current law.

Section 316. Other funding for facilities

    This section authorizes the Secretary to accept funds from 
other sources for the construction of health care facilities 
and to place such funds into a contract or compact under the 
Indian Self-Determination and Education Assistance Act. The 
Secretary is also authorized to enter into interagency 
agreements with other federal or state agencies for the 
planning, design and construction of health care facilities to 
be administered by Indian Health Programs.
    Amendments: This section is new and is not now contained in 
current law.

Section 317. Authorization of appropriations

    This section authorizes to be appropriated such sums as may 
be necessary for each fiscal year through fiscal year 2017 to 
carry out this title.
    Amendments: This section maintains current law but extends 
the authorization for appropriations beyond fiscal year 2000 
through fiscal year 2017.
    Current Law: This section is Section 1638a of current law.

                  TITLE IV--ACCESS TO HEALTH SERVICES


Section 401. Treatment of payments under Social Security Act health 
        care benefits programs

    This section requires that any Medicare, Medicaid, or State 
Children's Health Insurance Program (SCHIP) payments received 
by an Indian Health Program or Urban Indian Organization for 
services provided to eligible Indians shall not be considered 
in determining appropriations for the provision of health care 
and services. Indians without Medicare, Medicaid or SCHIP 
coverage are to be given equal consideration as Indians who are 
covered by these Social Security Act health benefit programs. 
Payments to which a facility of the Service is entitled by 
reason of a provision of the Social Security Act are to be 
placed in a special fund to be held by the Secretary. In making 
payments from such fund, the Secretary is to ensure that each 
Service Unit receives 100% of the amount to which the facility 
of the Service, for which such Service Unit makes collections, 
is entitled. How funds collected from Medicare, Medicaid, or 
SCHIP are to be used is specified. This section also allows 
Tribal Health Programs to elect to directly bill for, and 
receive payment for, health care items and services provided by 
that Tribal Health Program for which payment is made under 
Medicare, Medicaid, SCHIP, or third party payors.
    Amendments: This section maintains current law and (1) adds 
Tribal Organizations and Urban Indian Organizations, in 
addition to Tribes and the IHS, for whom reimbursements would 
not be considered in determining appropriations; (2) authorizes 
the 100% pass-through of payments due to Service facilities 
from the special fund; and (3) expands the authorized uses of 
the reimbursements from improvements only to hospitals or 
skilled facilities to also include programs and the excess used 
to reduce health deficiencies, subject to consultation by the 
Indian Tribes served. However, this provision authorizing the 
Secretary to determine the uses shall not apply when the Indian 
Tribes elect to receive reimbursements directly.
    Current Law: Sections 1641 and 1642 address treatment of 
payments under Medicare or Medicaid. Section 1645 established a 
program under which tribes could elect to directly bill and be 
reimbursed for health care services provided under Medicare, 
Medicaid or other third parties.

Section 402. Grants to and contracts with the service, Indian tribes, 
        tribal organizations, and urban Indian organizations to 
        facilitate outreach, enrollment, and coverage of Indians under 
        Social Security Act health benefit programs and other health 
        benefits programs

    This section directs the Secretary to make grants to or 
enter into contracts with Tribes and Tribal Organizations to 
improve enrollment and participation in Medicare, Medicaid or 
SCHIP programs, including paying premiums or cost sharing 
(which terms are defined in this section). In doing so, the 
Secretary shall place such conditions as are deemed necessary 
to affect the purpose of this section, including certain 
requirements of the Indian Tribe or Tribal Organization. 
Specifications for applying this section to Urban Indian 
Organizations are included. This section also directs the 
Secretary, acting through the Centers for Medicare and Medicaid 
Services, to take such steps as are necessary to facilitate 
cooperation with, and agreements between, States and the 
Service, Indian Tribes, Tribal Organizations, or Urban Indian 
Organizations with respect to the provision of health care 
items and services to Indians and to improving the enrollment 
of Indians under Social Security Act health benefits programs. 
This section also provides a cross-reference to the relevant 
section of the Social Security Act for provisions related to 
agreements between the Secretary and Indian Tribes, Tribal 
Organizations, and Urban Indian Organizations for the 
collection, preparation, and submission of applications by 
Indians for assistance under Medicare, Medicaid and SCHIP.
    Amendments: This section maintains current law and adds 
provisions which outline the agreements between the Secretary 
and the Tribes, Tribal or Urban Indian Organizations to improve 
the enrollment of Indians in Social Security Act programs.
    Current Law: This section is Section 1644 of current law.

Section 403. Reimbursement from certain third parties of costs of 
        health services

    Section 403 provides that the United States, an Indian 
Tribe, or Tribal Organization has the right to recover from an 
insurance company, health maintenance organization, employee 
benefit plan, or any third party the reasonable charges billed 
by the Secretary, an Indian Tribe, or Tribal Organization in 
providing health services to any individual to the same extent 
that such individual, or any nongovernmental provider of such 
services, would be eligible to receive damages, reimbursement, 
or indemnification. This right of recovery is extended against 
any state, under certain conditions. Certain state or local 
laws are deemed nonapplicable to prevent or hinder this right 
of recovery. This section has no effect on private rights of 
action. Enforcement measures for the right of recovery, notice, 
costs and attorneys' fees are all specified in this section. 
Section 403 limits the Indian Health Service right of recovery 
against a tribal self-insured plan absent written consent from 
the Tribe. Other items covered in this section include 
nonapplication of claims filing requirements; application to 
Urban Indian Organizations; statute of limitations; and a 
savings clause.
    This section adds a new provision which would extend to 
Tribes and Tribal Organizations the same authority the U.S. has 
under the Federal Medical Care Recovery Act (FMCRA) to recover 
the costs of medical care from a tortfeasor whose action caused 
an injury or disease to a patient whom a federal health care 
provider is obliged to treat. While the Department of Justice 
brings such suits against tortfeasors for federal health care 
providers such as the IHS, it does not currently do so for 
Tribes which operate IHS-funded health programs.
    Amendments: This section maintains current law and adds 
language (1) to enable Urban Indian Organizations to seek 
recovery from third parties; (2) to require reasonable efforts 
be taken to provide notice to the patient either before or 
during the pendency of the action; (3) to limit the IHS right 
of recovery against a tribal self-insured plan absent written 
consent; (4) to include awards of reasonable attorneys' fees 
and costs of litigation; (5) to prohibit denial of 
reimbursement on the basis of a different format or form; and 
(6) to extend to Tribes and Tribal Organizations the same 
authority the U.S. has under the Federal Medical Care Recovery 
Act (FMCRA) to recover the costs of medical care from a 
tortfeasor.
    Current Law: This section is Section 1621e of current law.

Section 404. Crediting of reimbursements

    This section authorizes the retention of the reimbursements 
received or recovered under this Act, Medicare, Medicaid or 
SCHIP and other provisions of law, from third parties and 
specifies the use of those reimbursements. This section also 
disallows any offset or limitation of amount obligated to any 
Service Unit, Indian Tribe or Tribal or Urban Indian 
Organization because of the receipt of reimbursements under 
this section.
    Amendments: This section maintains current law and adds 
language which specifies which programs are included in the 
reimbursements.
    Current Law: This section is Section 1621f of current law.

Section 405. Purchasing health care coverage

    Section 405 allows Tribes, Tribal Organizations and Urban 
Indian Organizations to use funding for health benefits for 
Indians to be used to purchase health benefits coverage for 
Service beneficiaries in any manner (including through a 
tribally owned and operated health care plan, a state or 
locally authorized or licensed health care plan, a health 
insurance provider or managed care organization, or a self-
insured plan), based on the financial needs of such 
beneficiaries.
    Amendments: This section replaces a provision of current 
law which authorized a managed care feasibility study.
    Current Law: Section 1621i of current law authorized the 
Secretary to conduct a study to assess the feasibility of 
allowing an Indian Tribe to purchase managed care coverage for 
tribal members from a tribally owned and operated managed care 
plan or a state or licensed managed care plan.

Section 406. Sharing arrangements with Federal agencies

    This section allows the Secretary to enter into or expand 
arrangements to share medical facilities and services with the 
Departments of Veterans Affairs and Defense, with certain 
limitations. If health care services are provided to 
beneficiaries eligible for services from either the Department 
of Veterans Affairs or the Department of Defense, then the 
Service, Indian Tribe, or Tribal Organization providing the 
service shall be reimbursed from the appropriate Department. 
The Secretary shall not take action which would impair priority 
access to or quality of care for Indians at IHS or priority of 
veterans to care by the VA.
    Amendments: This section amends current law by (1) 
authorizing the Secretary to enter agreements for sharing of 
medical facilities with the Departments of Veterans Affairs 
(VA) and Defense, instead of merely examining the feasibility 
of entering agreements with the VA; (2) requiring consultation 
with the affected Indian Tribes prior to entering the 
agreements; (3) requiring reimbursement to the IHS, Tribes, or 
Tribal Organizations; and (4) eliminating the specific cross-
utilization of services in Utah only (expanding it, generally).
    Current Law: Section 1680f of current law authorizes the 
Secretary to examine the feasibility of entering agreements to 
share medical facilities and services with the Department of 
Veterans Affairs, with a specific agreement for Utah.

Section 407. Payor of last resort

    This section specifies that Indian Health Programs and 
health care programs operated by Urban Indian Organizations 
shall be the payor of last resort for services provided to 
eligible persons.
    Amendments: This section is new and is not contained in 
current law.

Section 408. Nondiscrimination under Federal health care programs in 
        qualifications for reimbursement for services

    Section 408 provides that a federal health care program 
must accept an entity that is operated by the Service, an 
Indian Tribe, Tribal Organization, or Urban Indian Organization 
as a provider eligible to receive payment under the program for 
health care services furnished to an Indian on the same basis 
as any other provider qualified to participate as a provider of 
health care services under the program if the entity meets 
generally applicable state or other requirements for 
participation as a provider of health care services under the 
program. This section also provides that state or local 
licensure or recognition requirements by a provider of health 
care services shall be deemed to have been met in the case of 
an entity operated by the Service, an Indian Tribe, Tribal 
Organization, or Urban Indian Organization, if the entity meets 
all the applicable standards for such licensure or recognition, 
regardless of whether the entity obtains a license or other 
documentation under such state or local law. Certain entities 
operated by the Service, an Indian Tribe, Tribal Organization, 
or Urban Indian Organization, or individuals who have been 
excluded from participation in any federal health care program 
or for which a license is under suspension or has been revoked 
by the state where the entity or individual is located, shall 
not be eligible to receive payment or reimbursement under any 
such program for health care services furnished to an Indian.
    Amendments: This section is new and is not contained in 
current law.

Section 409. Consultation

    This section provides a cross-reference to the relevant 
section of the Social Security Act for provisions related to 
consultation with representatives of Indian Health Programs and 
Urban Indian Organizations with respect to the health care 
programs established under Medicare, Medicaid and SCHIP.
    Amendments: This section is new and is not contained in 
current law.

Section 410. State Children's Health Insurance Program (SCHIP)

    This section provides cross-references to relevant sections 
of the Social Security Act for provisions relating to outreach 
to families of Indian children likely to be eligible for child 
health assistance under SCHIP, and ensuring that child health 
assistance is provided under such program to targeted low-
income children who are Indians and that payments are made 
under that program.
    Amendments: This section is new and is not contained in 
current law.

Section 411. Exclusion waiver authority for affected Indian health 
        programs and safe harbor transactions under the Social Security 
        Act

    This section provides cross-references to relevant sections 
of the Social Security Act for provisions relating to exclusion 
waiver authority for affected Indian Health Programs, and 
certain transactions involving Indian Health Programs deemed to 
be in safe harbors under the Social Security Act.
    Amendments: This section is new and is not contained in 
current law.

Section 412. Premium and cost sharing protections and eligibility 
        determinations under Medicaid and SCHIP and protection of 
        certain Indian property from Medicaid estate recovery

    This section provides cross-references to relevant sections 
of the Social Security Act for provisions relating to premiums 
or cost sharing protections for Indians furnished items or 
services directly by Indian Health Programs or through referral 
under the contract health service under Medicaid; rules 
regarding the treatment of certain property for purposes of 
determining eligibility under Social Security Act programs; and 
the protection of certain property from estate recovery 
provisions under Medicaid.
    Amendments: This section is new and is not contained in 
current law.

Section 413. Treatment under Medicaid and SCHIP managed care

    Section 413 provides cross-references to relevant sections 
of the Social Security Act for provisions relating to the 
treatment of Indians enrolled in a managed care entity under 
Medicaid, and Indian Health Programs and Urban Indian 
Organizations that are providers of items or services to such 
Indian enrollees.
    Amendments: This section is new and is not contained in 
current law.

Section 414. Navajo Nation Medicaid Agency feasibility study

    Section 414 requires the Secretary to conduct a study to 
determine the feasibility of treating the Navajo Nation as a 
State for Medicaid purposes. Considerations for a report to 
Congress on the results of the study are described in this 
section.
    Amendments: This section is new and is not contained in 
current law.

Section 415. General exceptions

    Section 415 provides that the requirements of this title 
shall not apply to any excepted benefits described in paragraph 
(1)(A) or (3) of section 2791(c) of the Public Health Service 
Act, which relates to supplemental insurance products.
    Amendments: This is a new provision and is not contained in 
current law.

Section 416. Authorization of appropriations

    Section 416 authorizes to be appropriated such sums as may 
be necessary for each fiscal year through fiscal year 2017 to 
carry out this title.
    Amendments: This section extends the authorization beyond 
FY fiscal year 2000 to fiscal year 2017.
    Current Law: The authorization of appropriations section 
for the Access to Health Services title of current law is 
Section 1647, and extends through fiscal year 2000.

               TITLE V--HEALTH SERVICES FOR URBAN INDIANS


Section 501. Purpose

    This section sets forth the purpose of the title as 
establishing and maintaining programs in Urban Centers to make 
health services more accessible and available to Urban Indians.
    Amendments: This section maintains current law and adds 
language to maintain the programs and make health services 
available, in addition to being accessible, to Urban Indians.
    Current Law: This section is Section 1651 of current law.

Section 502. Contracts with, and grants to, urban Indian organizations

    This section provides that the Secretary shall enter into 
contracts with, or make grants to, Urban Indian Organizations 
to assist such organizations in the establishment and 
administration, within Urban Centers, of programs which meet 
the requirements set forth in this title.
    Amendments: This section maintains current law.
    Current Law: This section is Section 1652 of current law.

Section 503. Contracts and grants for the provision of health care and 
        referral services

    This section sets forth the authority of the Secretary to 
enter into contracts with or make grants to Urban Indian 
Organizations to establish and administer programs under this 
title, which shall meet certain requirements. This section 
prescribes the criteria for selecting Urban Indian 
Organizations for contracts or grants. Such contracts or grants 
shall facilitate access to or provide services for health 
promotion and disease prevention, immunization services, 
behavioral health services, prevention of child abuse, and 
other services to Urban Indians.
    Amendments: This section maintains current law, generally, 
while (1) modifying contract and grant requirements and 
criteria; and (2) deleting factors to be considered for 
immunization services contracts or grants that are set forth in 
current law.
    Current Law: This section is Section 1653 of current law.

Section 504. Contracts and grants for the determination of unmet health 
        care needs

    This section authorizes the Secretary to enter into 
contracts with or make grants to Urban Indian Organizations for 
which contracts or grants have not been entered into under the 
prior section. The purpose of these contracts/grants would be 
to determine unmet health care needs of urban Indians. Grant 
and contract requirements are set forth.
    Amendments: This section maintains current law.
    Current Law: This section is Section 1654 of current law.

Section 505. Evaluations; renewals

    This section authorizes the Secretary to develop evaluation 
and renewal procedures and standards for the various contracts 
and grants entered into by Urban Indian Organizations under 
this title, including considerations for renewals of contracts/
grants. The Secretary shall also evaluate the urban Indian 
programs through onsite annual evaluations.
    Amendments: This section maintains current law and adds a 
provision which would allow the Secretary to evaluate the urban 
Indian organization through acceptance of evidence of the 
organization's accreditation as an alternative to the onsite 
annual evaluation.
    Current Law: This section is Section 1655 of current law.

Section 506. Other contract and grant requirements

    This section sets forth other specific contract and grant 
requirements, such as payment methods, revisions and amendments 
to contracts, and assurance of the fair and uniform provision 
of services to Urban Indians.
    Amendments: This section maintains current law and adds 
provisions which (1) would allow a single advance payment, 
unless the urban Indian organization is not capable of 
administering the payments in their entirety and allows the 
funding to be carried forward; and (2) would allow payments to 
be made in semiannual or quarterly payments or by way of 
reimbursement. This section deletes provisions of current law 
allowing an Urban Indian Organization to use existing federal 
facilities.
    Current Law: This section is Section 1656 of current law.

Section 507. Reports and records

    This section sets forth certain reporting and recordkeeping 
requirements for Urban Indian Organizations. This section also 
provides that not later than 18 months after the date of 
enactment, the Secretary, in consultation with Urban Indian 
Organizations, shall submit to Congress a report evaluating the 
health status of Urban Indians; the services provided to 
Indians pursuant to this title; and areas of unmet needs in the 
delivery of health services to Urban Indians. This section also 
provides that reports and records of the Urban Indian 
Organization shall be subject to audit by the Secretary and the 
Comptroller General of the United States.
    Amendments: This section maintains current law and (1) adds 
language which extends the reporting period to semi-annual, 
rather than quarterly; (2) adds the requirement of a minimum 
set of data using uniform elements; (3) adds that the audits 
may also be conducted by a certified public accounting firm; 
and (4) deletes the requirement that IHS and the Department of 
the Interior report to Congress by March 31, 1992, on the 
health status, unmet needs and welfare of urban Indian 
children.
    Current Law: This section is Section 1657 of current law.

Section 508. Limitation on contract authority

    This section limits the authority of the Secretary to enter 
into contracts or to award grants under this title to the 
extent and amount provided for in appropriations Acts.
    Amendments: This section maintains current law and adds 
language which includes the Secretary's authority to award 
grants under this title.
    Current Law: This section is Section 1658 of current law.

Section 509. Facilities

    This section provides that the Secretary, acting through 
the Service, may make grants for the lease, purchase, 
renovation, construction, or expansion of facilities. This 
section also allows the Secretary to carry out a study to 
determine the feasibility of establishing a loan fund to 
provide direct loans or guarantees for loans to Urban Indian 
Organizations for the construction of health care facilities.
    Amendments: This section replaces current law by adding 
provisions which would allow for leasing, purchasing, 
renovating, constructing and expanding, in addition to 
repairing, facilities. The provision regarding the feasibility 
study of a loan fund to construct facilities is new.
    Current Law: Section 1659 of current law authorizes the 
Secretary to make funds available to contractors or grant 
recipients to make minor renovations to the urban health 
facilities to meet or maintain compliance with the requirements 
of the Joint Commission on Accrediting Health Care 
Organizations.

Section 510. Division of Urban Indian Health

    This section establishes a Division of Urban Indian Health 
within the Service to carry out the provisions of this title, 
provide oversight of the programs, and provide technical 
assistance to Urban Indian Organizations.
    Amendments: This section maintains current law, but (1) 
changes the Branch of Urban Indian programs into an Office 
within the IHS; (2) adds technical assistance; and (3) deletes 
provisions of current law regarding staffing, services and 
equipment.
    Current Law: This section is Section 1660 of current law.

Section 511. Grants for alcohol and substance abuse-related services

    This section provides that the Secretary may make grants to 
Urban Indian Organizations for the provision of health-related 
services in prevention of, treatment of, rehabilitation of, or 
school- and community-based education regarding, alcohol and 
substance abuse in Urban Centers. Goals and criteria are set 
forth.
    Amendments: This section essentially maintains current law.
    Current Law: This section is Section 1660a of current law.

Section 512. Treatment of certain demonstration projects

    This section makes permanent the Tulsa Clinic and Oklahoma 
City Clinic demonstration projects in Oklahoma and parallels 
the language of the Interior Appropriations Act which first 
contained this provision (Public Law 108-447).
    Amendments: This section maintains provisions which make 
permanent certain demonstration projects in Oklahoma, but 
modifies the language of current law of this Act to parallel 
the language of the Interior Appropriations Act which first 
contained this provision (Public Law 108-447).
    Current Law: This section is Section 1660b of current law.

Section 513. Urban NIAAA transferred programs

    This section authorizes the Secretary, through the Division 
of Urban Indian Health, to make grants to or enter into 
contracts with Urban Indian Organizations, to take effect not 
later than September 30, 2010, for the administration of Urban 
Indian alcohol programs that were originally established under 
the National Institute on Alcoholism and Alcohol Abuse (NIAAA). 
Use of funds, eligibility and reporting requirements are set 
forth.
    Amendments: This section maintains current law, but (1) 
changes references to the Branch of Urban Indian Health to the 
Division; and (2) deletes the provision of current law allowing 
the Secretary to combine NIAAA alcohol funds with other 
substance abuse funds.
    Current Law: This section is Section 1660c of current law.

Section 514. Consultation with urban Indian organizations

    This section provides that the Secretary shall ensure that 
the Service consults, to the greatest extent practicable, with 
Urban Indian Organizations, and defines ``consultation.''
    Amendments: This section is new and is not contained in 
current law.

Section 515. Urban youth treatment center demonstration

    This section authorizes the Secretary to fund the 
construction and operation of at least 2 Indian youth 
residential treatment centers in certain states to demonstrate 
the provision of alcohol and substance abuse treatment services 
to Urban Indian youth in a culturally competent residential 
setting.
    Amendments: This section is new and is not contained in 
current law.

Section 516. Grants for diabetes prevention, treatment, and control

    This section authorizes the Secretary to make grants to 
Urban Indian Organizations to provide services for the 
prevention and treatment of, and control of the complications 
resulting from, diabetes among Urban Indians, based on certain 
grant criteria that are set forth.
    Amendments: This section is new and is not contained in 
current law.

Section 517. Community health representatives

    This section authorizes the Secretary to make grants to or 
enter into contracts with Urban Indian Organizations for the 
employment of Indians trained as health service providers 
through the Community Health Representatives Program.
    Amendments: This section is new and is not contained in 
current law.

Section 518. Effective date

    This section establishes that the amendments made by the 
Act to this title shall take effect on the date of enactment, 
regardless of whether the Secretary has promulgated regulations 
implementing these amendments.
    Amendments: This section is new and is not contained in 
current law.

Section 519. Eligibility for services

    This section provides that Urban Indians shall be eligible 
for, and the ultimate beneficiaries of, health care or referral 
services provided pursuant to this title.
    Amendments: This section is new and is not contained in 
current law.

Section 520. Authorization of appropriations

    This section authorizes to be appropriated such sums as may 
be necessary for each fiscal year through fiscal year 2017 to 
carry out this title.
    Amendments: This section maintains current law and extends 
the authorization from fiscal year 2000 to fiscal year 2017.
    Current Law: This section is Section 1660d of current law.

                 TITLE VI--ORGANIZATIONAL IMPROVEMENTS


Section 601. Establishment of the Indian Health Service as an agency of 
        the Public Health Service

    This section establishes the Indian Health Service within 
the Public Health Service of the Department, and elevates the 
position of Director of the Indian Health Service to that of 
the Assistant Secretary for Indian Health. The Assistant 
Secretary for Indian Health shall be confirmed by the Senate 
with a term of four years, and shall administer the Indian 
Health Service. This section also specifies the duties and 
responsibilities of the Assistant Secretary and deems that any 
reference to the Director of the Indian Health Service in any 
Federal law, Executive order, rule, regulation, or delegation 
of authority, is deemed to refer to the Assistant Secretary.
    Amendments: This section amends current law to (1) change 
the position of the Director into an Assistant Secretary; (2) 
provide that the individual serving in the position of Director 
of the Service on the day before the date of enactment shall 
serve as Assistant Secretary; (3) provide that the position of 
Assistant Secretary is established to facilitate advocacy and 
promote consultation on matters relating to Indian health; (4) 
give the Assistant Secretary additional duties; and (5) deem 
current law or regulatory references to the Director to refer 
to the Assistant Secretary.
    Current Law: This section is Section 1661 of current law.

Section 602. Automated management information system

    Section 602 requires the Secretary to establish automated 
management information systems for the Service and each Tribal 
Health Program which meets certain requirements. This section 
also requires that patients have access to their own health 
records, and authorizes the Secretary to enter in to contracts, 
agreements, or joint ventures with other federal agencies, 
states, private and nonprofit organizations for the purpose of 
enhancing information technology in Indian Health Programs and 
facilities.
    Amendments: This section maintains current law and adds 
Secretarial authority to enter contracts or joint ventures to 
enhance information technology in Indian health programs.
    Current Law: This section is Section 1662 of current law.

Section 603. Authorization of appropriations

    This section authorizes to be appropriated such sums as may 
be necessary to carry out this title, for each fiscal year 
through fiscal year 2017.
    Amendments: This section maintains current law and extends 
the authorization from fiscal year 2000 to fiscal year 2017.
    Current Law: This section is Section 1663 of current law.

                 TITLE VII--BEHAVIORAL HEALTH PROGRAMS


Section 701. Behavioral health prevention and treatment services

    Section 701 states the purposes of the section, including 
directing the Secretary, acting through the Service, Indian 
Tribes, Tribal Organizations, and Urban Indian Organizations, 
to develop a comprehensive behavioral health prevention and 
treatment program which emphasizes collaboration among alcohol 
and substance abuse, social services, and mental health 
programs. This section also requires the Secretary to encourage 
the development of plans for areawide Indian Behavioral Health 
Services; directs the Secretary to coordinate with existing 
national clearinghouses and information centers to include 
plans and reports of outcomes of such behavioral health plans 
developed by Indian Tribes, Tribal Organizations, Urban Indian 
Organizations, and Service Areas; directs the Secretary to 
provide comprehensive behavioral health care programs; 
facilitates the governing body of any Indian Tribe, Tribal 
Organization, or Urban Indian Organization to establish 
community behavioral health plans; requires the Secretary to 
coordinate behavioral health planning with other federal and 
state agencies; and directs the Secretary to assess the need, 
availability and cost for inpatient mental health care for 
Indians within 1 year.
    Amendments: This section maintains current law and adds 
language which (1) authorizes the Secretary, Indian Tribes, 
Tribal Organizations, and Urban Indian Organizations to develop 
programs which emphasize collaboration for behavioral health; 
(2) requires technical assistance to Indian Tribes, Tribal 
Organizations and Urban Indian Organizations; and (3) requires 
a continuum of care for behavioral health to the extent 
feasible, including acute hospitalization, detoxification, and 
emergency shelter.
    Current Law: This section is Section 1621h and Section 1665 
of current law.

Section 702. Memoranda of agreement with the Department of the Interior

    This section requires the Secretary and the Secretary of 
the Interior to develop and enter, or review and update, within 
1 year, memoranda of agreement to, among other things, make a 
comprehensive assessment, coordination, and annual review of 
all the behavioral health care needs and services available or 
unavailable to Indians. Specific provisions that are required 
in this memorandum are delineated. Each memorandum of agreement 
under this section shall be published in the Federal Register. 
This section also directs the Secretaries to address a strategy 
for the comprehensive coordination of the behavioral health 
services provided by the Bureau of Indian Affairs and the 
Service, including the coordination of alcohol and substance 
abuse programs of the Service, the BIA, and Indian Tribes and 
Tribal Organizations developed under the Indian Alcohol and 
Substance Abuse Prevention and Treatment Act of 1986 with 
behavioral health initiatives pursuant to this Act.
    Amendments: This section maintains current law and adds 
language which (1) requires the Secretary to update existing 
memoranda of agreement; and (2) includes Tribal Organizations.
    Current Law: This section is Section 1621h(b) of current 
law.

Section 703. Comprehensive behavioral health prevention and treatment 
        program

    Section 703 requires the Secretary to provide a program of 
comprehensive behavioral health, prevention, treatment, and 
aftercare. Elements to be included in this program and target 
populations are specified. The Secretary may provide these 
services through Contract Health Services.
    Amendments: This section amends current law by (1) 
expanding beyond the alcohol and substance abuse focus to 
comprehensive behavioral health; and (2) adding more specific 
types of treatment. Language of current law, authorizing a 
grant to the Standing Rock Sioux Tribe to develop a community-
based demonstration project, has been deleted.
    Current Law: This section is Section 1665a of current law.

Section 704. Mental health technician program

    This section directs the Secretary to establish and 
maintain a mental health technician program within the Service 
to train and employ Indians as mental health technicians. The 
Secretary is to provide high-standard paraprofessional training 
in mental health care, supervise and evaluate the technicians, 
and ensure that the program involves the use and promotion of 
traditional health care practices of the Indian Tribes to be 
served.
    Amendments: This section maintains current law.
    Current Law: This section is Section 1621h(g) of current 
law.

Section 705. Licensing requirement for mental health care workers

    This section requires that any individual employed as a 
psychologist, social worker, or marriage and family therapist 
for the purpose of providing mental health care services to 
Indians in a clinical setting under this Act to be licensed to 
provide these services. This section also sets forth 
requirements for individuals who may be employed as trainees in 
psychology, social work, or marriage and family therapy to 
provide mental health care services.
    Amendments: This section maintains current law.
    Current Law: This section is Section 1621h(l) of current 
law.

Section 706. Indian women treatment programs

    This section authorizes the Secretary, consistent with 
section 701, to make grants to Tribes, Tribal Organizations and 
Urban Indian Organizations to develop and implement a 
comprehensive behavioral health program of prevention, 
intervention, treatment, and relapse prevention services that 
specifically address the cultural, historical, social, and 
child care needs of Indian women. Use of grant funds, criteria 
for applications for funding, and a specified amount of funding 
for grants to Urban Indian Organizations are also specified.
    Amendments: This section maintains current law and (1) adds 
language which requires the implementation of this section to 
be consistent with section 701; (2) recognizes the behavioral 
health focus, beyond just alcohol and substance abuse; and (3) 
requires consultation with Indian Tribes and Tribal 
Organizations in establishing criteria for the review and 
approval of applications.
    Current Law: This section is Section 1665b of current law.

Section 707. Indian youth program

    This section requires the Secretary to develop and 
implement, consistent with section 701, a program for acute 
detoxification and treatment for Indian youth. The construction 
and staffing of alcohol and substance abuse treatment centers 
or facilities for Indian youths, including behavioral health 
services, is authorized. Additional provisions addressed in 
this section are: Construction and staffing of at least 1 youth 
regional treatment center in each IHS Area; the provision of 
intermediate adolescent behavioral health services; use of 
federally-owned structures for local residential or regional 
behavioral health treatment for Indian youths; the development 
and implementation of community-based rehabilitation and 
aftercare services; inclusion of family in youth treatment 
programs; programs and services to prevent and treat the abuse 
of multiple forms of substances among Indian youth; and data 
collection and a report to Congress concerning Indian youth and 
mental health services.
    Amendments: This section maintains current law and adds 
language which (1) requires implementation of this section to 
be consistent with section 701; (2) recognizes the behavioral 
health focus, beyond alcohol and substance abuse; (3) includes 
programs developed at the local tribal level; (4) includes 
treatment networks in addition to treatment programs; (5) 
includes sober or transitional housing in the intermediate 
adolescent services; (6) requires community reintegration as 
part of the rehabilitation and aftercare services; (7) 
establishes a program to prevent and treat multi-drug abuse; 
and (8) requires the Secretary to collect data for an Indian 
youth mental health report.
    Current Law: This section is Section 1665c of current law.

Section 708. Indian youth telemental health demonstration project

    This section authorizes the Secretary to carry out a four-
year demonstration project under which five Tribes or Tribal 
Organizations with telehealth capabilities could use telemental 
health services in youth suicide prevention and treatment. In 
awarding the grants, the Secretary would give priority to 
Tribes and Tribal Organizations serving a particular tribal 
community where there is a demonstrated need to address Indian 
youth suicide or which is isolated and has limited access to 
mental health services; entering into collaborative 
partnerships to provide the services; or operating a detention 
facility at which Indian youth are detained. The demonstration 
project would permit the use of telemedicine for psychotherapy, 
psychiatric assessments and diagnostic interviews of Indian 
youth; the provision of clinical expertise and other medical 
advice to frontline health care providers working with Indian 
youth; training and related support for community leaders, 
family members and health and education workers who work with 
Indian youth; the development of culturally-relevant 
educational materials on suicide prevention and intervention; 
and data collection and reporting.
    Amendments: This section is new and is not contained in 
current law.

Section 709. Inpatient and community-based mental health facilities 
        design, construction, and staffing

    This section allows the Secretary, not later than 1 year 
after the date of enactment, to provide, in each IHS Area, not 
less than 1 inpatient mental health care facility, or the 
equivalent, for Indians with behavioral health problems. The 
Secretary shall consider the possible conversion of existing 
underutilized hospital beds into psychiatric units to meet the 
needs.
    Amendments: This section amends current law by (1) 
requiring the establishment in each Area of at least 1 
inpatient mental health facility, rather than an assessment of 
the need; and (2) providing that California shall be considered 
two Area Offices.
    Current Law: Section 1621h(i) of current law provides that 
within one year after enactment, the Secretary shall make an 
assessment of the need for inpatient mental health care 
facilities.

Section 710. Training and community education

    Section 710 requires that the Secretary, in cooperation 
with the Secretary of the Interior, develop and implement, or 
assist Indian Tribes and Tribal Organizations to develop and 
implement, a program of community education and involvement in 
the area of behavioral health. This section also addresses 
specifics of instruction and the development of community-based 
training models.
    Amendments: This section maintains current law and (1) adds 
language which authorizes the Indian Tribes and Tribal 
Organizations to develop training and community education 
programs; (2) adds child sexual abuse to the types of training 
authorized; and (3) recognizes the behavioral health focus of 
the program.
    Current Law: This section is Section 1621h(d) of current 
law.

Section 711. Behavioral health program

    This section allows the Secretary, consistent with section 
701, to plan, develop, implement, and carry out programs to 
deliver innovative community-based behavioral health services 
to Indians. The section sets forth criteria to be used for 
grant awards for such programs, and requires that the same 
criteria as are used in evaluating other funding proposals be 
used for programs under this section.
    Amendments: This section maintains current law and adds 
Tribal Organizations as eligible recipients for funding under 
this section.
    Current Law: This section is Section 1621h of current law.

Section 712. Fetal alcohol disorder programs

    Section 712 authorizes the Secretary, consistent with 
section 701, to establish and operate fetal alcohol disorder 
programs, to include the development and provision of services 
for the prevention, intervention, treatment, and aftercare for 
those affected by fetal alcohol disorder in Indian communities. 
Use of funds and criteria for applications are specified. In 
addition, the Secretary is directed to establish a Fetal 
Alcohol Disorder Task Force to advise the Secretary. This 
section also authorizes funding for applied research projects 
which propose to elevate the understanding of methods to 
prevent, intervene, treat or provide rehabilitation and 
aftercare for Indians affected by this disorder. Urban Indians 
are to receive a certain amount of funds appropriated for this 
program.
    Amendments: This section maintains current law and adds 
language (1) requiring these programs to be implemented 
consistent with section 701; (2) consolidating fetal alcohol 
syndrome and fetal alcohol effects into fetal alcohol disorders 
(FAD); (3) authorizing appropriate psychological services, 
early childhood intervention projects, community-based support 
services and housing as allowable uses of funding under this 
section; and (4) including the National Institute for Child 
Health and Human Development and the Centers for Disease 
Control and Prevention in the national Fetal Alcohol Disorder 
Task Force. Provisions of current law establishing a national 
clearinghouse for prevention and educational materials and 
other information on FAS and FAE effect in Indian and Alaska 
Native communities, and requirements for a report to Congress 
contained in current law have been deleted.
    Current Law: This section is Section 1665g of current law.

Section 713. Child sexual abuse and prevention treatment programs

    This section directs the Secretary to establish, consistent 
with section 701, treatment programs in every IHS Area for both 
Indian victims of child sexual abuse and Indian perpetrators of 
child sexual abuse. This section specifies the use of funds for 
these programs, and directs that they be carried out in 
coordination with programs and services authorized under the 
Indian Child Protection and Family Violence Prevention Act (25 
U.S.C. 3201 et seq.).
    Amendments: This section amends current law by (1) turning 
two specific demonstration projects into permanent programs; 
(2) making the establishment of these programs consistent with 
section 701; (3) authorizing services for Indian child victims 
of sexual abuse and perpetrators of child sexual abuse who are 
members of an Indian household; (4) including authorized uses 
of funds such as developing community education, identifying 
and providing treatment to victims, developing culturally-
sensitive prevention models and diagnostic tools, and providing 
treatment to the perpetrators; and (5) providing that these 
programs are carried out in coordination with programs and 
services authorized under the Indian Child Protection and 
Family Violence Prevention Act.
    Current Law: Section 1680i of current law establishes 
demonstration programs involving treatment for child sexual 
abuse through the Hopi Tribe and the Assiniboine and Sioux 
Tribes of the Fort Peck Reservation. The Secretary may 
establish other demonstration projects, but must have an equal 
number of projects for the IHS Areas.

Section 714. Behavioral health research

    Section 714 authorizes the Secretary to make grants to, or 
enter into contracts with, Indian Tribes, Tribal Organizations, 
and Urban Indian Organizations or enter into contracts with, or 
make grants to appropriate institutions for, the conduct of 
research on the incidence and prevalence of behavioral health 
problems among Indians. Research priorities are specified, 
including youth suicide, the interrelationship of mental 
disorders with alcoholism, suicide, homicide, and the incidence 
of family violence, and prevention models.
    Amendments: This section maintains current law and adds 
language which emphasizes the focus on behavioral health 
instead of only mental health problems.
    Current Law: This section is Section 1621h of current law.

Section 715. Definitions

    This section provides definitions for the following terms 
used in this title: assessment; alcohol-related 
neurodevelopmental disorders or ARND; behavioral health 
aftercare; dual diagnosis; fetal alcohol disorders; fetal 
alcohol syndrome or FAS; partial FAS; rehabilitation; and 
substance abuse.
    Amendments: This section is new and is not contained in 
current law.

Section 716. Authorization of appropriations

    This section authorizes to be appropriated such sums as may 
be necessary for each fiscal year through fiscal year 2017 to 
carry out this title.
    Amendments: This section maintains current law and extends 
the authorization from fiscal year 2000 to fiscal year 2017 and 
eliminates the exceptions for sections that had specific terms 
of authorization.
    Current Law: This section is Section 1621w of current law.

                       TITLE VIII--MISCELLANEOUS


Section 801. Reports

    This section outlines requirements under this Act for 
various reports (and their contents) and audits which shall be 
submitted to Congress.
    Amendments: This section maintains current law and adds 
provisions which either establish new reporting requirements or 
consolidate the information required in other sections in one 
organized list, such as requiring as part of the annual reports 
to Congress information on services provided under Indian Self-
Determination Act agreements, loan repayment programs, 
infectious diseases, environmental hazards, status of health 
care and sanitation facilities, sharing of services between the 
IHS and other federal agencies, and urban Indian programs.
    Current Law: This section is Section 1671 of current law.

Section 802. Regulations

    This section sets forth the various requirements for 
regulations, including regulations developed through negotiated 
rulemaking, for selected titles and sections, and timelines for 
issuance of regulations under this Act. The membership of the 
negotiated rulemaking committee and its procedures are 
delineated.
    Amendments: This section is new and is not contained in 
current law.

Section 803. Plan of implementation

    This section requires the Secretary, in consultation with 
Indian Tribes, Tribal Organizations, and Urban Indian 
Organizations, to submit to Congress a plan of implementation 
of this Act within 9 months.
    Amendments: This section is new and is not contained in 
current law.

Section 804. Availability of funds

    This section authorizes funds appropriated pursuant to this 
Act to remain available until expended.
    Amendments: This section maintains current law.
    Current Law: This section is Section 1675 of current law.

Section 805. Limitation on use of funds appropriated to Indian Health 
        Service

    This section provides that any limitation on the use of 
funds contained in an Act that provides appropriations for the 
Department of Health and Human Services with respect to the 
performance of abortions shall apply for that fiscal year to 
the performance of abortions using funds contained in an Act 
providing appropriations for the Service.
    Amendments: This section maintains current law.
    Current Law: This section is Section 1676 of current law.

Section 806. Eligibility of California Indians

    This section clarifies the eligibility of California 
Indians for health services provided by the Service to include 
members of federally-recognized tribes, descendants of Indians 
residing in California as of June 1, 1852, Indians holding 
trust interests in certain types of land, and Indians listed on 
the plans for assets distribution in California.
    Amendments: This section maintains current law, but 
eliminates the report to Congress developing data on the 
Indians located in California, health status and needs and 
other information.
    Current Law: This section is Section 1679 of current law.

Section 807. Health services for ineligible persons

    This section authorizes services for certain persons (such 
as children and spouses) and other individuals otherwise 
ineligible for health services provided by the Service under 
limited circumstances, and outlines criteria for providing and 
paying for those services.
    Amendments: This section maintains current law and adds 
compacts, in addition to contracts, entered in to under the 
Indian Self-Determination Act.
    Current Law: This section is Section 1680c of current law.

Section 808. Reallocation of base services

    This section requires the Secretary to submit a report to 
Congress on any allocation of Service funds for a fiscal year 
that reduces by 5% or more from the previous fiscal year the 
funding for any recurring program, project, or activity of a 
Service Unit.
    Amendments: This section maintains current law.
    Current Law: This section is Section 1680g of current law.

Section 809. Results of demonstration projects

    This section requires the Secretary to disseminate to 
Indian Tribes, Tribal Organizations, and Urban Indian 
Organizations the findings and results of demonstration 
projects conducted under this Act.
    Amendments: This section maintains current law, and adds 
Tribal Organizations and Urban Indian Organizations.
    Current Law: This section is Section 1680m of current law.

Section 810. Provision of services in Montana

    This section recognizes a court decision governing the 
provision of services and benefits for certain Indians in 
Montana.
    Amendments: This section is new and is not contained in 
current law.

Section 811. Moratorium

    This section authorizes the Service to provide certain 
health care services according to eligibility criteria in 
effect on a certain date until the Service submits to Congress 
and the Congress enacts an appropriations Act that reflects the 
increased costs associated with the Department's proposed final 
rule, implementing other eligibility criteria.
    Amendments: This section is new and is not contained in the 
current Indian health law. However, similar language has 
appeared for several years in Interior Appropriations Acts.

Section 812. Tribal employment

    This section provides that an Indian Tribe or Tribal 
Organization carrying out a contract or compact pursuant to the 
Indian Self-Determination and Education Assistance Act shall 
not be considered an ``employer.''
    Amendments: This section is new and is not contained in 
current law.

Section 813. Severability provisions

    This section retains remaining provisions of the Act if 
other provisions are stricken by any court.
    Amendments: This section is new and is not contained in 
current law.

Section 814. Establishment of national bipartisan commission on Indian 
        health care

    This section establishes a Commission to study the delivery 
of health care services to Indians, and sets forth the duties, 
membership, compensation, and meeting, hearing and reporting 
requirements. This section also authorizes the appointment of a 
Director and staff for the Commission; establishes their 
compensation; and authorizes details of federal employees, 
hearings, use of mails, technical assistance and administrative 
support services. $4 million is authorized for the Commission.
    Amendments: This section is new and is not contained in 
current law.

Section 815. Confidentiality of medical quality assurance records; 
        qualified immunity for participants

    This section would establish requirements for quality 
assurance such as confidentiality, privacy, disclosure and 
liability. Section 815 also sets forth the limits of such 
disclosure.
    Amendments: This section is new and is not contained in 
current law.

Section 816. Appropriations; availability

    This section subjects new spending authority to amounts 
provided in appropriations Acts.
    Amendments: This section is new and is not contained in 
current law.

Section 817. Authorization of appropriations

    This section authorizes to be appropriated such sums as may 
be necessary for each fiscal year through fiscal year 2017 to 
carry out this title.
    Amendments: This section maintains current law and extends 
the authorization through fiscal year 2017.
    Current Law: Section 1680o authorizes appropriations 
through fiscal year 2000.

Section 101(b). Indian Health Care Improvement Act amended

    Section 101(b) includes provisions amending other laws for 
the references to the ``Director of Indian Health Service'' 
which would be changed to ``Assistant Secretary for Indian 
Health''.
    Amendments: This section is new and is not contained in 
current law.

Section 102. Soboba sanitation facilities

    Section 102 authorizes sanitation facilities and services 
to be provided to the Soboba Band of Mission Indians and the 
Soboba Indian Reservation.
    Amendments: This section is new and is not contained in 
current law.

Section 103. Native American Health and Wellness Foundation

    Section 103 amends the Indian Self-Determination and 
Education Assistance Act to include a new Title VIII under 
which a Native American Health and Wellness Foundation would be 
established, in the following sections:
Section 801. Definitions
    This section includes definitions for the Board, Committee, 
Foundation, and other terms used in this section.
Section 802. Native American Health and Wellness Foundation
    This section establishes the perpetual existence of the 
Foundation, the nature and duties of the Foundation and the 
place of incorporation. This section also authorizes the 
Secretary to establish an initial Committee to assist in 
establishing the Foundation. Section 802 establishes the 
authority of the Board of Directors, including their terms, the 
officers (including the extent of their liabilities) and the 
powers of the Foundation. This section also establishes limits 
on the administrative costs, audit requirements, and authorizes 
$500,000 for the fiscal years.
Section 803. Administrative services and support
    This section authorizes the Secretary to provide 
administrative support to the Foundation and initial operating 
funds on a reimbursement basis for up to five years.

    Amendments: This section is new and is not contained in 
current law.

                                Title II

    Title II of the bill is amendments to the Social Security 
Act that is under the jurisdiction of the Senate Finance 
Committee. These provisions include waivers of cost-sharing and 
premiums for Medicaid for Indians receiving services at IHS, 
tribal or urban Indian health programs, Medicaid managed care 
provisions, and safe harbor protections from the anti-kickback 
statutes.

Section 201. Expansion of payments under Medicare, Medicaid and SCHIP 
        for all covered services furnished by Indian health programs

    Section 201 authorizes IHS, tribal and urban Indian health 
programs to be reimbursed for Medicaid, if the services meet 
the conditions and requirements generally applicable to the 
delivery of such care. In addition, this section requires IHS, 
tribal or urban Indian health facilities to make improvements 
to achieve or maintain compliance. The Secretary is also 
authorized to enter into an agreement with a State to reimburse 
the State for Medicaid services provided by the IHS, tribal or 
urban Indian health programs. This section cross-references the 
special fund to which Medicaid reimbursements are placed for 
IHS and direct billing requirements for the IHS and tribal 
health programs under the Act. This section also authorizes 
Medicare payments to IHS, tribal and urban Indian health 
programs so long as they are compliant with Medicare 
requirements. The section cross-references the Act's provisions 
under which Medicare payments made are placed in a special fund 
for the purpose of making improvements to maintain compliance.

Section 202. Increased outreach to Indians under Medicaid and SCHIP and 
        improved cooperation in the provision of items and services to 
        Indians under Social Security Act health benefit programs

    Section 202 authorizes the Secretary to encourage States to 
take steps to increase enrollment and outreach for Indian 
children in the State Children's Health Insurance Program and 
requires the Secretary to facilitate cooperation between States 
and the IHS, tribal and urban Indian health programs.

Section 203. Additional provisions to increase outreach to, and 
        enrollment of, Indians in SCHIP and Medicaid for outreach

    Section 203 excludes certain activities, such as outreach 
activities for families of Indian children likely to be 
eligible for SCHIP and enrollment assistance activities, from 
the current 10% cap on certain SCHIP payments.

Section 204. Premiums and cost sharing protections under Medicaid, 
        eligibility determinations under Medicaid and SCHIP, and 
        protection of certain Indian property from Medicaid estate 
        recovery

    Section 204 prohibits the imposition of enrollment fees, 
premiums and cost-sharing on Indians served at the IHS, tribal 
or urban Indian health programs or through the referrals to 
contract health and the reduction of the reimbursement to the 
IHS, tribal or urban Indian health program for the fees or 
cost-sharing. In addition, this section exempts certain Indian 
property, such as trust land, from being included in 
determining eligibility of an individual who is an Indian for 
Medicaid, and continues protections of certain Indian property 
from Medicaid estate recovery.

Section 205. Nondiscrimination in qualifications for payment for 
        services under Federal health care programs

    Section 205 allows the IHS, Tribal or urban Indian health 
programs to be accepted on the same basis as any other provider 
eligible for reimbursement, if the program meets generally 
applicable participation requirements. The provision would 
prohibit payments if the program was excluded from any other 
Federal health care program and if any State licenses were 
suspended or revoked.

Section 206. Consultation on Medicaid, SCHIP, and other health care 
        programs funded under the Social Security Act involving Indian 
        health programs and urban Indian organizations

    Section 206 maintains the Tribal Technical Advisory Group 
established to provide technical assistance or advice to the 
Centers for Medicare and Medicaid Services. This section also 
requires the States to establish a process for consultation 
with the tribal or urban Indian health programs on matters 
relating to Medicaid which are likely to have a direct effect 
on Indians or Indian health programs.

Section 207. Exclusion waiver authority for affected Indian health 
        programs and safe harbor transactions under the Social Security 
        Act

    Section 207 establishes a process whereby the administrator 
of an Indian Health Program may request a waiver of sanctions 
imposed on a health provider. This section also specifies that 
certain transactions not be considered remuneration under 
Section 1128B(b) of the Social Security Act for certain 
transfers between the Indian health programs or patient for the 
purpose of providing necessary health care services to the 
patient.

Section 208. Rules applicable under Medicaid and SCHIP to managed care 
        entities with respect to Indian enrollees and Indian health 
        care providers and Indian managed care entities

    Section 208 allows Indians, enrolled in a non-Indian 
Medicaid managed care entity (MCE) with an Indian health 
program participating in the network, to choose the Indian 
health program as the primary care provider. It also requires 
MCEs with significant Indian enrollees to meet other 
requirements. The Indian health programs would also be required 
to comply with all generally applicable Medicaid requirements 
to the extent the requirements do not conflict with other 
Federal statutes applicable to the Indian health programs. This 
section also sets forth special rules applicable to Indian 
MCEs, such as the ability to restrict enrollment to Indians and 
other enrollment rules. In regard to a Medicaid managed care 
program, if a health care provider is required to have medical 
malpractice insurance as a condition of contracting with a 
Medicaid MCE, an Indian health care provider would be deemed to 
satisfy such a requirement if it is an FQHC covered under the 
Federal Tort Claims Act, a provider that delivers services 
pursuant to a contract under the Indian Self-Determination and 
Education Assistance Act, or the Indian Health Service, which 
is covered under the Federal Tort Claims Act.

Section 209. Annual report on Indians served by Social Security Act 
        health benefit programs

    Section 209 requires annual reports to Congress regarding 
the enrollment and health status of Indians receiving items or 
services under the health benefit programs.

                          Legislative History

    On April 24, 2007, Senators Dorgan, Thomas, Boxer, Reid, 
Cantwell, Johnson, Tester, Inouye, Domenici, Bingaman, Baucus, 
Klobuchar, Obama and Murkowski introduced S. 1200, the Indian 
Health Care Improvement Act Amendments of 2007. Senators 
Cochran and Murray were added as cosponsors on April 26, 2007; 
Senator Clinton on May 3, 2007; and Senators Brown and Stevens 
on May 21, 2007. Senator Stabenow was added as a cosponsor on 
September 4, 2007.
    The Committee held a hearing on the Indian Health Care 
Improvement Act on March 8, 2007. This was the tenth hearing 
since the 106th Congress on the reauthorization of the Act.
    On May 10, 2007, the Committee on Indian Affairs convened a 
business meeting to consider S. 1200 and other measures that 
had been referred to it, and ordered the bill favorably 
reported.

            Committee Recommendation and Tabulation of Vote

    On May 10, 2007, the Committee on Indian Affairs convened a 
business meeting to consider S. 1200 and other measures, and 
voted to have the bill favorably reported to the full Senate, 
without amendment, with the recommendation that the bill do 
pass.

               Regulatory and Paperwork Impact Statement

    Paragraph 11(b) of rule XXVI of the Standing Rules of the 
Senate requires that each report accompanying a bill evaluate 
the regulatory and paperwork impact that would be incurred in 
carrying out the bill. The Committee has concluded that S. 1200 
will not require the promulgation of regulations so the 
regulatory and paperwork impact should be minimal.

                        Executive Communications

    On May 1, 2007, Chairman Dorgan sent letters to both 
Secretary Michael Leavitt and Attorney General Gonzales, asking 
the Department of Health and Human Services and the Department 
of Justice to provide the Committee with their views on S. 
1200.
    The Department of Justice submitted a letter of comments on 
June 13, 2007, which is attached, below.

                             Department of Justice,
                             Office of Legislative Affairs,
                                     Washington, DC, June 13, 2007.
Hon. Byron L. Dorgan,
Chairman, Committee on Indian Affairs,
U.S. Senate, Washington, DC.
    Dear Mr. Chairman: Thank you for the opportunity to comment 
upon S. 1200, the Indian Health Care Improvement Act Amendments 
of 2007. The Department of Justice fully supports the purposes 
of this legislation--improving access to health care for 
American Indians and Alaska natives. The Department has worked 
with the Committee on Indian Affairs on previous versions of 
this legislation and believes that most of its prior concerns 
have been addressed by S. 1200. The Department does, however, 
continue to have a few concerns with the legislation that we 
have noted in the past. As explained below, the Department 
believes that these concerns can be addressed with relatively 
modest changes to bill language that would not detract from the 
overall goal of improving health care for Native Americans but 
would, in the Department's view, benefit both the Native 
American community specifically and taxpayers generally.
    1. The legislation authorizes funding and encourages the 
use of traditional health care practices. The Department does 
not oppose the provision of traditional health care practices 
as an adjunct to ``Western'' medical practices. We note that on 
March 8, 2007, Ms. Rachel Joseph, Co-Chairperson of the 
National Steering Committee for the Reauthorization of the 
Indian Health Care Improvement Act, testified that 
``[t]raditional health care practices are usually provided as 
complementary services to Western medical practices at the 
request of family members.'' Ms. Joseph also testified that 
``[i]n most cases, the traditional health care practitioners 
are not employees of the IHS or tribes so FTCA coverage would 
not apply in the event that a malpractice claim was ever 
filed.''
    A prior version of this legislation contained language 
clarifying that traditional health care practitioners are not 
covered by the Federal Tort Claims Act (``FTCA''), and we 
recommend that this language be added back to S. 1200. 
Specifically, we recommend the following provision as an 
addition to section 805:
    (b) No Liability.--Although the Secretary may promote 
traditional health care practices, consistent with the Service 
standards for the provision of health care, health promotion, 
and disease prevention under this Act, the United States is not 
liable for the acts or omissions of any person in providing 
traditional health care practices under this Act that result in 
damage, injury, death, or any outcome to any patient.
    This language is intended to confirm existing law that 
there is no valid cause of action under the FTCA for injuries 
resulting from traditional tribal healing practices provided 
pursuant to self determination contracts because state law 
generally does not make private parties liable for 
``malpractice'' involving traditional tribal healing practices. 
See 28 U.S.C. Sec. 2674. Thus, this provision would ensure that 
the United States would not face potential tort liability for 
the provision of treatment through traditional health care 
practices for which no state standard of care exists and would 
prevent costly litigation about whether the United States could 
be held liable under the FTCA for such practices. Moreover, it 
would preclude intrusive discovery regarding the nature and 
purpose of traditional health care practices. Such litigation 
would almost certainly raise questions as to the advisability 
of Tribal health practices and potentially create unnecessary 
conflict between these practices and Western medical standards. 
Additionally, we believe the proposed language would ameliorate 
any Tribal sovereignty concerns that would arise in FTCA 
litigation regarding inquiry into traditional health care 
practices. At the same time, this language would not scale back 
in any way the current liability protections that the Tribes 
enjoy in carrying out self-determination contracts.
    We also have concerns regarding changes made to section 213 
of the legislation. The current version of section 213(b)(1) 
was modified to provide:
    (b) Terms and Conditions.--
    (1) In general.--Any service provided under this section 
shall be in accordance with such terms and conditions as are 
consistent with accepted and appropriate standards relating to 
the service, including any licensing term or condition required 
under this Act.
    The previous version of the legislation, unlike S. 1200, 
made explicit that the Secretary ``shall require'' that any 
service provided be in accordance with terms and conditions 
that the Secretary determined to be consistent with accepted 
and appropriate standards relating to the service. We think S. 
1200 is unclear in this regard, as it fails to explicitly 
specify who is responsible for requiring that any services 
provided are in accordance ``with such terms and conditions as 
are consistent with the accepted and appropriate standards 
relating to the service.'' We suggest revising subsection 
213(b)(1) to provide:
    (1) In general.--The Secretary shall require that any 
service provided pursuant to this Act is in compliance with the 
accepted and appropriate standards relating to the service, 
including any licensing term or condition under this Act.
    Relatedly, S. 1200 made changes to the prior language of 
subsection 213(b)(2). That subsection now reads:
    (b)(2)(A) Standards.--
    In general.--The Secretary may establish, by regulation, 
the standards for a service provided under this section, 
provided that such standards shall not be more stringent than 
the standards required by the State in which the service is 
provided.
    We have concerns about this language. For the purposes of 
tort liability under the FTCA, state law provides the standards 
governing the conduct at issue. If the Secretary, by 
regulation, establishes standards that fall below the standards 
required by the State, there is a risk the United States could 
be held liable under the FTCA, even if the care complied with 
the standards promulgated by the Secretary. Moreover, and more 
likely troublesome, if the Secretary approves services for 
which there are no applicable state standards, subsection 
(b)(2), by its plain language, would appear to prevent the 
Secretary from establishing any appropriate standards because 
those standards would, by their very existence, be more 
stringent than what is required by the State. Where no state 
standards are applicable, it is in the interests of both the 
United States and the Tribes to whom such services might be 
provided to have some applicable and appropriate standards of 
care set by the Secretary. Thus, along with the Department of 
Health and Human Services, we propose working with the 
Committee to revise subsection (b)(2)(A) to address this 
concern.
    Finally, S. 1200 also includes this new provision to 
section 213:
    (b)(2)(B) Use of State Standards.--
    If the Secretary does not, by regulation, establish 
standards for a service provided under this section, the 
standards required by the State in which the service is or will 
be provided shall apply to such service.
    We agree that state standards should be applicable, since 
liability under the FTCA would be measured by those standards. 
Again, however, if there is no applicable state standard, the 
Secretary should be permitted to set some meaningful and 
appropriate standard of care, which is arguably not possible 
given the limitation of subsection (b)(2)(A).
    2. The Department believes that the legislation continues 
to raise a constitutional concern to the extent that it 
provides government benefits to individuals who are not members 
of, or closely affiliated with, a Federally recognized Indian 
tribe. As the Department has noted in the past, the Supreme 
Court has held that classifications based on affiliation with a 
Federally recognized tribe are ``political rather than 
racial,'' and therefore will be upheld as long as there is a 
rational basis for them. To the extent, however, that programs 
benefiting ``Urban Indians'' under this legislation could be 
viewed as authorizing the award of grants and other Government 
benefits on the basis of racial or ethnic criteria, rather than 
tribal affiliation, these programs would be subject to strict 
scrutiny under the equal protection component of the Due 
Process Clause. Both this bill and the current statute broadly 
define ``Urban Indian'' to include individuals who are not 
necessarily affiliated with a federally recognized Indian 
tribe. Under the Supreme Court's decisions, there is a 
substantial likelihood that legislation providing special 
benefits to individuals of Indian or Alaska Native descent who 
do not have a clear and close affiliation with a federally 
recognized tribe would be regarded by the courts as creating a 
racial preference subject to strict constitutional scrutiny, 
rather than a political preference subject to rational basis 
review. In the event the legislation is regarded as awarding 
Government benefits based on a racial classification, it would 
be constitutional only if the bill is supported by a factual 
record demonstrating that its use of race-based criteria to 
award the benefits at issue is ``narrowly tailored'' to serve a 
``compelling'' Government interest.
    The bill's extension of benefits to members of State-
recognized tribes raise the same concern. As a threshold 
matter, it is not clear whether the courts would agree that 
Congress can constitutionally delegate its tribal recognition 
authority to the States and, even if Congress can do so as a 
general matter, the delegation in this bill would allow States 
to designate as ``tribal members'' eligible for Federal 
benefits individuals who: (i) do not belong to a ``distinctly 
Indian community'' or other group that conforms to the Supreme 
Court's definitions of ``the Indian tribes'' referenced in the 
Commerce Clause, but instead are considered a member of a State 
``tribe'' solely on the basis of race or affiliation with a 
group that lacks the sovereign attributes the Supreme Court has 
identified as important to classification as an ``Indian 
tribe'' for purposes of Commerce Clause legislation; and/or 
(ii) are otherwise outside the class of beneficiaries that 
Congress intended to reach with this bill. In this regard, as 
you may know, the American Indian Heritage Support Center 
(``AIHSC''), in a March 29, 2007, letter to the Department, 
with copies to Members of Congress, voiced concerns about the 
extension of benefits under this legislation to ``state 
recognized tribes'' because, according to the AIHSC, some of 
these ``tribes'' ``have no historical background past the last 
10 to 20 years'' and simply seek ``tribal'' recognition to take 
advantage of certain recent Government benefits such as gaming 
privileges.
    The Department recommends that, consistent with the settled 
practice of avoiding unnecessary constitutional issues, 
Congress revise the bill to extend benefits only to individuals 
who, in addition to satisfying whatever other criteria Congress 
may wish to impose, qualify as ``members of, or individuals 
having a clear and close affiliation with, a federally-
recognized tribe.'' Such a revision would avoid the 
constitutional concerns outlined above in a way that the 
Department believes would not detract from the overall goal of 
improving health care for Native Americans, and might actually 
better ensure that benefits under the bill would extend only to 
the class of beneficiaries contemplated by Congress and the 
Constitution.
    Thank you for the opportunity to comment upon this very 
important legislation. We are committed to working with the 
Committee to have this legislation passed. The Office of 
Management and Budget has advised us that there is no objection 
to this letter from the perspective of the Administration's 
program.
            Sincerely,
                                       Richard A. Hertling,
                       Principal Deputy Assistant Attorney General.
    The Committee has not received any formal communication on 
S. 1200 from the Department of Health and Human Services other 
than the testimony presented to the Committee at the hearing on 
reauthorization of the Indian Health Care Improvement Act on 
March 8, 2007, which is also attached, below.

    Statement of Admiral John O. Agwunobi, MD, MBA, MPH, Assistant 
   Secretary for Health, U.S. Department of Health and Human Services

    Mr. Chairman and Members of the Committee: My name is John 
Agwunobi and I am the Assistant Secretary for Health for the 
U.S. Department of Health and Human Services (HHS). As the 
Assistant Secretary, I serve as the Secretary's primary advisor 
on matters involving the nation's public health. I also oversee 
the U.S. Public Health Service and its Commissioned Corps for 
the Secretary.
    This landmark legislation forms the backbone of the system 
through which Federal health programs serve American Indians/
Alaska Natives and encourages participation of eligible 
American Indians/Alaska Natives in these and other programs.
    The IHS has the responsibility for the delivery of health 
services to more than 1.8 million Federally-recognized American 
Indians/Alaska Natives through a system of IHS, tribal, and 
urban (I/T/U) health programs governed by judicial decisions 
and statutes. The mission of the agency is to raise the 
physical, mental, social, and spiritual health of American 
Indian/Alaska Natives to the highest level, in partnership with 
the population we serve. The agency goal is to assure that 
comprehensive, culturally acceptable personal and public health 
services are available and accessible to the service 
population. Our duty is to uphold the Federal government's 
responsibility to promote healthy American Indian and Alaska 
Native people, communities, and cultures and to honor and 
protect the inherent sovereign rights of Tribes.
    Two major statutes are at the core of the Federal 
government's responsibility for meeting the health needs of 
American Indians/Alaska Natives: The Snyder Act of 1921, P.L. 
67-85, and the Indian Health Care Improvement Act (IHCIA), P.L. 
94-437, as amended. The Snyder Act authorized regular 
appropriations for ``the relief of distress and conservation of 
health'' of American Indians/Alaska Natives. The IHCIA was 
enacted ``to implement the Federal responsibility for the care 
and education of the Indian people by improving the services 
and facilities of Federal Indian health programs and 
encouraging maximum participation of Indians in such 
programs.'' Like the Snyder Act, the IHCIA provides the 
authority for the Federal government programs that deliver 
health services to Indian people, but it also provides 
additional guidance in several areas. The IHCIA contains 
specific language addressing the recruitment and retention of 
health professionals serving Indian communities; the provision 
of health services; the construction, replacement, and repair 
of health care facilities; access to health services; and the 
provision of health services for urban Indian people.


                            dhhs activities


    Since enactment of the IHCIA in 1976, Congress has 
substantially expanded the statutory authority for programs and 
activities in order to keep pace with changes in healthcare 
services and administration. Federal funding for the IHCIA has 
contributed billions of dollars to improve the health status of 
American Indians/Alaska Natives. And, much progress has been 
made particularly in the areas of infant and maternal 
mortality.
    The Department under this Administration's leadership 
reactivated the Intradepartmental Council on Native American 
Affairs (ICNAA) to provide for a consistent HHS policy when 
working with the more than 560 Federally recognized Tribes. 
This Council's vice chairperson is the IHS Director, giving him 
a highly visible role within the Department on Indian policy.
    In January of 2005 the Department completed work ushering 
through a revised HHS Tribal consultation policy and involving 
Tribal leaders in the process. This policy further emphasizes 
the unique government-to-government relationship between Indian 
Tribes and the Federal government and assists in improving 
services to the Indian community through better communications. 
Consultation may take place at many different levels. To ensure 
the active participation of Tribes in the development of the 
Department's budget request, an HHS-wide budget consultation 
session is held annually. This meeting provides Tribes with an 
opportunity to meet directly with leadership from all 
Department agencies and identify their priorities for upcoming 
program requests. For FY 2008, Tribes identified population 
growth and increases in the cost of providing health care as 
their top budget priorities and IHS's FY 2008 budget request 
included an increase of $88 million for these items.
    Through the Centers for Medicare & Medicaid Services (CMS), 
a Technical Tribal Advisory Group was established which 
provides Tribes with a vehicle for communicating concerns and 
comments to CMS on Medicare, Medicaid and SCHIP policies 
impacting their members. And the IHS has been vigilant about 
improving outcomes for Indian children and families with 
diabetes by increasing education and physical activity programs 
aimed at preventing and addressing the needs of those 
susceptible to, or struggling with, this potentially disabling 
disease. In addition, a Tribal Leaders Diabetes Committee 
continues to meet several times a year at the direction of the 
IHS Director to review information on the progress of the 
Special Diabetes Program for Indians activities and to provide 
general recommendations to IHS.
    It is clear the Department has not been a passive observer 
of the health needs of eligible American Indians/Alaska 
Natives. Yet, we recognize that health disparities among this 
population do exist and are among some of the highest in the 
Nation for certain diseases (e.g., alcoholism, cardiovascular 
disease, diabetes, and injuries), and that improvements in 
access to IHS and other Federal and private sector programs 
will result in improved health status for Indian people.
    The IHCIA was enacted to provide primary and preventive 
services in recognition of the Federal government's unique 
relationship with members of Federally recognized Tribes. 
Members of Federally recognized Tribes and their descendants 
are also eligible for other Federal health programs (such as 
Medicare, Medicaid and SCHIP) on the same basis as other 
Americans, and many also receive health care through employer-
sponsored or other healthcare coverage.
    It is within the context of current law and programs that 
we turn our attention to reauthorization of the ``Indian Health 
Care Improvement Act.''


                            reauthorization


    We are here today to discuss reauthorization of the IHCIA, 
and its impact on programs and services provided for in current 
law. In December of 2006, the Department submitted to this 
Committee comments on proposed legislation that the 109th 
Congress was considering. These comments are the basis for our 
testimony today, and any changes introduced by the bill under 
review in the 110th Congress will be considered once we have 
had an opportunity to review newly introduced legislation. 
Improving access to healthcare for all eligible American 
Indians and Alaska Natives is a priority for all those involved 
in the administration of the IHS program. We have worked 
closely with this Committee in the past and we have made 
progress in moving toward a program supportive of existing 
authority while maintaining the Secretary's flexibility to 
effectively manage the IHS program. However, in the last bill, 
S. 1057, there continued to be provisions which could 
negatively impact our ability to provide needed access to 
services. Such provisions established program mandates and 
burdensome requirements that could, or would, divert resources 
from important services. To the extent that those provisions 
are included in the new legislation, we hope to work with you 
to continue to address these concerns.
    The Department is supportive of reauthorization of the 
IHCIA and supports provisions that maintain or increase the 
Secretary's flexibility to work with Tribes, and to increase 
the availability of health care. Committee leadership 
previously responded to some concerns raised about certain 
provisions and some of the changes went a long way toward 
improving the Secretary's ability to effectively manage the 
program within current budgetary resources.
    I would like to note for you today our particular interest 
in provisions previously reported out of this Committee.


                          overarching concerns


    We have a number of general objections to previous 
language, including, expanded requirements for negotiated 
rulemaking and consultation; new requirements using ``shall'' 
instead of ``may''; use of the term ``funding'' in place of 
``grant''; expansion of authorities for Urban Indian 
Organizations; new permissive authorities; provisions governing 
traditional health care practices; new reporting requirements; 
establishment of the Bipartisan Commission on Indian Health 
Care; and new provisions that contemplate the Secretary 
exercising authority through the Service, Tribes and Tribal 
Organizations which is not tied to agreements entered into 
under the Indian Self-Determination and Education Assistance 
Act (ISDEAA). In addition, we noted concerns in previous 
language about modifying current law with respect to Medicaid 
and the State Children's Health Insurance Program (SCHIP) and, 
in some cases, we believe maintaining the current structure of 
Medicaid and the State Children's Health Insurance Program 
(SCHIP) preserves access, delivery, efficiency, and quality of 
services to American Indians.
    We also have some more specific comments on proposals we 
have previously reviewed for comment.
    In the area of behavioral health, proposed title VII 
provisions provided for the needs of Indian women and youth and 
expands behavioral health services to include a much needed 
child sexual abuse and prevention treatment program. The 
Department supports this effort, but opposes language in 
Sections 704, 706, 711(b) and 712 that requires the 
establishment or expansion of specific additional services. The 
Department should be given the flexibility to provide for all 
Behavioral Health Programs in a manner that supports the local 
control and priorities of Tribes, and to address their specific 
needs within IHS overall budgetary levels.


                         reporting requirements


    The last version of S. 1057 that we reviewed contained 
various new requirements for reporting to Congress, including 
requirements for specific information to be included within the 
President's Budget and a new annual report to Congress by the 
Centers for Medicare & Medicaid Services and the IHS on Indians 
served by Social Security Act health benefit programs. The IHS, 
CMS, and HHS will work with Congress to provide the most 
complete and relevant information on IHS programs, activities, 
and performance and other Indian health matters. However, we 
recommend striking language that requires additional 
specificity about what should be included in the President's 
budget request and new requirements for annual reports.


                               facilities


    Sanitation facilities construction is conducted in 38 
States with Federally recognized Tribes who take ownership of 
the facilities to operate and maintain them once completed. IHS 
and Tribes operate 49 hospitals, 247 health centers, 5 school 
health centers, over 2000 units of staff housing, and 309 
health stations, satellite clinics, and Alaska village clinics 
supporting the delivery of health care to Indian people.


            health care facilities needs assessment & report


    One provision in last year's bill, section 301(d)(1), 
required Government Accountability Office (GAO) to complete a 
report, after consultation with Tribes, on the needs for health 
care facilities construction, including renovation and 
expansion needs. However, efforts are currently underway to 
develop a complete description of need similar to what would 
have been required by the bill. The IHS plan is to base our 
future facilities construction priority system methodology 
application on a more complete listing of tribal and Federal 
facilities needs for delivery of health care services funded 
through the IHS. We will continue to explore with the Tribes 
less resource intensive means for acquiring and updating the 
information that would be required in these reports.
    We recommend the deletion of the reference to the 
Government Accountability Office undertaking the report because 
it would be redundant of and a setback for IHS's current 
efforts to develop an improved facilities construction 
methodology.


       retroactive funding of joint venture construction projects


    In last year's bill, section 311(a)(1) would permit a tribe 
that has ``begun or substantially completed'' the process of 
acquisition of a facility to participate in the Joint Venture 
Program, regardless of government involvement or lack thereof 
in the facility acquisition. A Joint Venture Program agreement 
implies that all parties have participated in the development 
of a plan and have arrived at some kind of consensus regarding 
the actions to be taken. By permitting a tribe that has ``begun 
or substantially completed'' the process of acquisition or 
construction, the proposed provisions could force IHS to commit 
the government to support already completed actions that have 
not included the government in the review and approval process. 
We are concerned that this language could put the government in 
the position of accepting space that is inefficient or 
ineffective to operate. We, therefore, would oppose such a 
provision.


              sanitation facilities deficiency definitions


    Another section 302(h)(4) would provide ambiguous 
definitions of the sanitation deficiencies used to identify and 
prioritize water and sewer projects in Indian country. As 
previously proposed ``deficiency level III'' could be 
interpreted to mean all methods of service delivery (including 
methods where water and sewer service is provided by hauling 
rather than through piping systems directly into the home) are 
adequate to meet the level III requirements and only the 
operating condition, such as frequent service interruptions, 
makes that facility deficient. This description assumes that 
water haul delivery systems and piped systems provide a similar 
level of service. We believe it is important to distinguish 
between the two.
    In addition, the definition for deficiency level V and 
deficiency level IV, though phrased differently, have 
essentially the same meaning. Level IV should refer to an 
individual home or community lacking either water or wastewater 
facilities, whereas, level V should refer to an individual home 
or community lacking both water and wastewater facilities.
    We recommend retaining current law to distinguish the 
various levels of deficiencies which determine the allocation 
of existing resources.


            threshold criteria for small ambulatory program


    Yet another Section 305(b)(1) would amend current law to 
set two minimum thresholds for the Small Ambulatory Program--
one for number of patient visits and another for the number of 
eligible Indians. In order to be eligible for the Small 
Ambulatory Program under the previously proposed criteria, a 
facility must provide at least 150 patient visits annually in a 
service area with no fewer than 1,500 eligible Indians. Aside 
from the fact that these are both minimum thresholds and so 
somewhat contradictory, the proposed provisions would make 
implementation difficult. First, the IHS cannot validate 
patient visits unless the applicant participates in the 
Resource Patient Management System (RPMS). Since some tribes do 
not participate in the RPMS, it is difficult to ensure a fair 
evaluation of all applicants. Second, the term ``eligible 
Indians'' refers to the census population figures, which cannot 
be verified, since they are based on the individual's statement 
regarding ethnicity.


        new negotiated rulemaking and consultation requirements


    In addition, we are concerned about the requirements for 
negotiated rulemaking and increased requirements for 
consultation in the bill because of the high cost and staff 
time associated with this approach. We are committed to our on-
going consultation with Tribes under current Executive Orders, 
as well as using the authority of Chapter V of title 5, United 
States Code (commonly known as the Administrative Procedures 
Act) to promulgate regulations where necessary to carry out 
IHCIA.
    The comments expressed today in this testimony do not 
represent a comprehensive list of our current concerns. And, we 
will be reviewing legislation introduced in this Congress for 
any provisions that might be addressed in the future.
    I reiterate our commitment to working with you to 
reauthorize the Indian Health Care Improvement Act, and the 
strengthening of Indian health care programs. And we will 
continue to work with the Committee, other Committees of 
Congress, and representatives of Indian country to develop a 
bill that all stakeholders in these important programs can 
support. Again, I appreciate the opportunity to appear before 
you today to discuss reauthorization of the ``Indian Health 
Care Improvement Act'' and I will answer any questions that you 
may have at this time. Thank you.

                             Cost Estimates

    The Congressional Budget Office prepared a cost estimate 
for S. 1200, dated June 8, 2007. However, an error was made in 
that estimate, so a revised estimate was sent to the Committee 
on September 11, 2007, which follows.

S. 1200--Indian Health Care Improvement Act Amendments of 2007

    Summary: S. 1200 would authorize the appropriation of such 
sums as are necessary through 2017 for activities under the 
Indian Health Care Improvement Act, the primary authorizing 
legislation for the Indian Health Service (IHS). The bill also 
contains specific authorizations for a program to encourage 
Indians to pursue careers related to behavioral health, a 
demonstration project to provide suicide prevention services, a 
commission on Indian health care, and administrative costs for 
a new nonprofit corporation. Enacting the bill also would 
affect direct spending, primarily through provisions affecting 
the Medicaid program.
    CBO estimates that implementing S. 1200 would have 
discretionary costs of $2.7 billion in 2008, about $16 billion 
over the 2008-2012 period, and about $35 billion over the 2008-
2017 period, assuming appropriation of the necessary amounts. 
We also estimate that enacting the bill would increase direct 
spending by $9 million in 2008, $53 million over the 2008-2012 
period, and $129 million over the 2008-2017 period.
    S. 1200 would preempt state licensing laws in certain 
cases, and this preemption would be an intergovernmental 
mandate as defined in the Unfunded Mandates Reform Act (UMRA); 
however, CBO estimates that the costs of that mandate would be 
small and would not approach the threshold established in UMRA 
($66 million in 2007, adjusted annually for inflation). The 
bill also would place new requirements on Medicaid that would 
result in additional spending of about $80 million over the 
2008-2017 period. Those requirements, however, would not be 
intergovernmental mandates as defined by UMRA. Other provisions 
of the bill would benefit tribal governments by establishing 
new or expanding existing programs for Indian health care. This 
bill contains no private-sector mandates as defined in UMRA.
    Estimated cost to the Federal Government: The estimated 
budgetary impact of S. 1200 is summarized in Table 1. The costs 
of this legislation fall within budget function 550 (health).

                                TABLE 1.--ESTIMATED BUDGETARY EFFECTS OF S. 1200
----------------------------------------------------------------------------------------------------------------
                                                                       By fiscal year, in millions of dollars--
                                                                    --------------------------------------------
                                                                       2008     2009     2010     2011     2012
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATION

Estimated Authorization Level......................................    3,257    3,326    3,402    3,481    3,558
Estimated Outlays..................................................    2,682    3,141    3,310    3,449    3,534

                                           CHANGES IN DIRECT SPENDINGa

Estmated Budget Authority..........................................        9       10       11       12       12
Estimated Outlays..................................................        9       10       11       12       12
----------------------------------------------------------------------------------------------------------------
aDirect spending changes through 2017 are shown in Table 3.

    Basis of estimate: For the purpose of this estimate, CBO 
assumes that S. 1200 will be enacted near the start of fiscal 
year 2008 and that the necessary amounts will be appropriated 
for each year.

Spending subject to appropriation

    The estimated effects of S. 1200 on spending subject to 
appropriation for the next five years are detailed in Table 2. 
Implementing the legislation would result in discretionary 
costs of about $16 billion over the 2008-2012 period. Because 
the bill would authorize funding through 2017, such 
discretionary cost would continue, with an estimated cost of 
about $35 billion over the 2008-2017 period.

                        TABLE 2.--ESTIMATED EFFECTS OF S. 1200 ON DISCRETIONARY SPENDING
----------------------------------------------------------------------------------------------------------------
                                                                  By fiscal year, in millions of dollars--
                                                           -----------------------------------------------------
                                                              2007     2008     2009     2010     2011     2012
----------------------------------------------------------------------------------------------------------------
                                        SPENDING SUBJECT TO APPROPRIATION

IHS Spending Under Current Lawa
    Budget Authority......................................    3,169        0        0        0        0        0
    Estimated Outlays.....................................    3,203      553      164       72       12        2
Proposed Changes:
    Existing Indian Health Service Activities:
        Estimated Authorization Level.....................        0    3,247    3,320    3,396    3,475    3,554
        Estimated Outlays.................................        0    2,679    3,134    3,303    3,443    3,529
    Recruitment Program for Behavioral Health Careers:
        Authorization Level...............................        0        3        3        3        3        3
        Estimated Outlays.................................        0        2        3        3        3        3
    Mental Health Demonstration Project:
        Authorization Level...............................        0        2        2        2        2        0
        Estimated Outlays.................................        0        *        1        2        2        1
    Commission on Indian Health Care:
        Authorization Level...............................        0        4        0        0        0        0
        Estimated Outlays.................................        0        1        2        1        0        0
    Native American Health and Wellness Foundation:
        Authorization Level...............................        0        1        1        1        1        1
        Estimated Outlays.................................        0        *        1        1        1        1
        Total Changes:
            Estimated Authorization Level.................        0    3,257    3,326    3,402    3,481    3,558
            Estimated Outlays.............................        0    2,682    3,141    3,310    3,449    3,534
Spending Under S. 1200
    Estimated Authorization Levela........................    3,169    3,257    3,326    3,402    3,481    3,558
    Estimated Outlays.....................................    3,203    3,235    3,305    3,382    3,461   3,536
----------------------------------------------------------------------------------------------------------------
a.The 2007 level is the amount appropriated for that year for IHS.

*Note: *=less than $500,000.

    Existing Indian Health Service Activities. S. 1200 would 
authorize the appropriation of such sums as are necessary for 
the Indian Health Service through 2017. The agency's 
responsibilities under the bill would be broadly similar to 
those in current law. In 2007, the agency received an 
appropriation of $3.2 billion. CBO's estimate of the authorized 
level for IHS programs is the appropriated amount for 2007 
adjusted for inflation in later years. (That level would grow 
to nearly $4 billion by 2017.) The estimated outlays reflect 
historical spending patterns for IHS activities.
    Recruitment Program for Behavioral Health Careers. Section 
105 of the bill would authorize the appropriation of $2.7 
million annually through 2017 for grants to develop and 
maintain programs that encourage Indians to pursue careers in a 
field related to behavioral health. Assuming the appropriation 
of the authorized amounts, CBO estimates that implementing this 
provision would cost $2 million in 2008, $13 million over the 
2008-2012 period, and $26 million over the 2008-2017 period.
    Mental Health Demonstration Project. Section 708 would 
authorize the appropriation of $1.5 million annually for fiscal 
years 2008 through 2011 for grants to examine the feasibility 
of using telecommunication technology to provide suicide 
prevention services to Indians. Assuming the appropriation of 
the authorized amounts, CBO estimates that implementing this 
provision would cost less than $500,000 in 2008 and about $6 
million over the 2008-2012 period.
    Commission on Indian Health Care. Section 814 would 
authorize the appropriation of $4 million for a commission that 
would examine how the federal government provides health care 
services to Indians. The members of the commission would have 
to be appointed within eight months of the bill's enactment and 
would be required to submit a final report to the Congress no 
later than 18 months after that. Assuming the appropriation of 
the authorized amount, CBO estimates that implementing this 
provision would cost $1 million in 2008, $2 million in 2009, 
and $1 million in 2010.
    Native American Health and Wellness Foundation. S. 1200 
would establish a charitable and nonprofit corporation called 
the Native American Health and Wellness Foundation to assist 
federal, state, tribal, and other entities in efforts to 
further health and wellness activities and opportunities for 
Indians. The bill would authorize the appropriation of $500,000 
annually for the foundation's administrative expenses; this 
amount would be adjusted in later years for inflation. Assuming 
the appropriation of the authorized amounts, CBO estimates that 
implementing this provision would cost less than $500,000 in 
2008 and about $2 million over the 2008-2012 period.

Direct spending

    S. 1200 contains several provisions, primarily related to 
the Medicaid program, that would affect direct spending. The 
bill's estimated effects on direct spending are shown in Table 
3. Overall, CBO estimates that enacting the bill would increase 
direct spending by $9 million in 2008 and $129 million over the 
2008-2017 period.

                                                TABLE 3.--ESTIMATED EFFECTS OF S. 1200 ON DIRECT SPENDING
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                  By fiscal year, in millions of dollars--
                                                   -----------------------------------------------------------------------------------------------------
                                                     2008    2009    201O    2011    2012    2013    2014    2015    2016    2017   2008-2012  2008-2017
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                               CHANGES IN DIRECT SPENDING

Exemption from Medicaid Cost Sharing and Premiums:
    Estimated Budget Authority....................       5       6       6       7       7       8       8       9       9      10        31         74
    Estimated Outlays.............................       5       6       6       7       7       8       8       9       9      10        31         74
Consultation with Indian Health Programs:
    Estimated Budget Authority....................       *       *       1       1       1       1       1       1       1       1         3          7
    Estimated Outlays.............................       *       *       1       1       1       1       1       1       1       1         3          7
Medicaid Managed Care Provisions:
    Estimated Budget Authority....................       3       3       4       4       4       5       5       5       6       6        18         45
    Estimated Outlays.............................       3       3       4       4       4       5       5       5       6       6        18         45
Scholarship and Loan Repayment Recovery Fund:
    Estimated Budget Authority....................       *       *       *       *       *       *       *       *       *       *         2          4
    Estimated Outlays.............................       *       *       *       *       *       *       *       *       *       *         2          4
Total Changes:
    Estimated Budget Authority....................       9      10      11      12      12      14      14      15      16      17        53        129
    Estimated Outlays.............................       9      10      11      12      12      14      14      15      16      17        53        129
--------------------------------------------------------------------------------------------------------------------------------------------------------
* = costs savings of less than $500,000.

Notes: Components may not sum to totals because of rounding.

    IHS-funded health programs are commonly divided into three 
groups: those operated directly by the Indian Health Service, 
those operated by tribes and tribal organizations under self-
governance agreements, and those operated by urban Indian 
organizations. For this estimate, they are referred to 
collectively as Indian health programs.
    Exemption from Medicaid Cost Sharing and Premiums. Section 
204 would prohibit Medicaid programs from charging premiums or 
other cost-sharing payments to Indians for services that are 
provided directly or upon referral by Indian health programs. 
The provision also would prohibit states from reducing payments 
to providers for those services by the amount of cost sharing 
that Indians otherwise would pay.
    CBO anticipates that this provision's budgetary effect 
would stem largely from eliminating cost sharing for referral 
services. Current law already prohibits Indian health programs 
from charging cost sharing to Indians who use their services. 
In addition, Medicaid pays almost all facilities operated by 
IHS and tribes based on an all-inclusive rate that is not 
reduced to account for any cost sharing that Indians would 
otherwise have to pay. Finally, very few states charge premiums 
to their Medicaid enrollees.
    Using Medicaid administrative data, CBO estimates that 
about 280,000 Indians are Medicaid recipients who also use IHS, 
and that federal Medicaid spending on affected services would 
be about $225 per person annually in 2008. The amount of 
affected spending would be relatively low because Medicaid 
already prohibits cost sharing in many instances, such as long-
term care services, emergency services, and services for many 
children and pregnant women. For the affected spending, CBO 
assumes that cost-sharing payments by individuals equal 2 
percent of total spending--Medicaid law limits the extent to 
which states can impose cost sharing and that eliminating cost 
sharing would increase total spending by about 5 percent as 
individuals consume more services. Overall, CBO estimates that 
the provision would increase federal Medicaid spending by $5 
million in 2008 and by $74 million over the 2008-2017 period.
    Consultation with Indian Health Programs. Section 206 would 
encourage state Medicaid programs to consult regularly with 
Indian health programs on outstanding Medicaid issues by 
allowing states to receive federal matching funds for the cost 
of those consultations. Those costs would be treated as an 
administrative expense under Medicaid and divided equally 
between the federal government and the states. CBO anticipates 
that a small number of states would take advantage of this 
provision, increasing federal Medicaid spending by less than 
$500,000 in 2008 and by $7 million over the 2008-2017 period.
    Medicaid Managed Care Provisions. Section 208 would make 
several changes to improve the ability of Indian health 
programs to receive payments for Indians who receive Medicaid 
benefits through managed care arrangements. Those changes 
include:
     Managed care organizations (MCOs) would have to 
pay Indian health programs at least the rates used for non-
preferred providers. States also would have the option of 
making those payments directly to Indian health programs.
     MCOs would have to accept claims submitted by 
Indian health programs instead of requiring enrollees to submit 
claims personally.
     Some requirements that MCOs must now meet to 
participate in Medicaid would be waived or modified for Indian 
health programs that seek to operate as MCOs. (For example, 
MCOs run by Indian health programs would be able to limit 
enrollment to Indians only.)
     States would be required to offer contracts to 
Indian health programs seeking to operate their own MCOs.
    Based on administrative data on Medicaid enrollment and 
spending for Indians who receive benefits via managed care, CBO 
estimates that those provisions would increase federal Medicaid 
spending by $3 million in 2008 and $45 million over the 2008-
2017 period. We anticipate that the additional costs would be 
relatively modest because some states already use similar rules 
in their Medicaid managed care programs and Indian health 
programs would have a limited interest in participating as 
MCOs.
    Scholarship and Loan Repayment Recovery Fund. S. 1200 would 
allow the Secretary of Health and Human Services to spend 
amounts collected for breach of contract from recipients of 
certain IHS scholarships. Under current law, those funds are 
deposited in the Treasury and not spent. Because the 
Secretary's ability to spend those funds would not be subject 
to appropriation, the provision would increase direct spending. 
Based on historical information from IHS, CBO estimates that 
the provision would increase spending by less than $500,000 a 
year, but would total about $4 million over the 2008-2017 
period.
    Estimated impact on state, local, and tribal governments:

Intergovernmental mandates

    S. 1200 would preempt state licensing laws in cases where a 
health care professional is licensed in one state but is 
performing services in another state under a contract or 
compact with a tribal health program. This preemption would be 
an intergovernmental mandate as defined in the UMRA; however, 
CBO estimates that the loss of any licensing fees resulting 
from the mandate would be small and would not approach the 
threshold established in UMRA ($66 million in 2007, adjusted 
annually for inflation).

Other impacts

    S. 1200 would reauthorize and expand grant and assistance 
programs available to Indian tribes, tribal organizations, and 
urban Indian organizations for a range of health care programs, 
including prevention, treatment, and ongoing care. The bill 
also would allow IHS and tribal entities to share facilities, 
and it would authorize joint ventures between IHS and Indian 
tribes or tribal organizations for the construction and 
operation of health facilities. The bill would authorize 
funding for a variety of health services including hospice 
care, long-term care, public health services, and home and 
community-based services.
    The bill would prohibit states from charging cost sharing 
or premiums in the Medicaid program to Indians who receive 
services or benefits through an Indian health program. CBO 
estimates that the new requirements in the bill would result in 
additional spending by states of about $80 million over the 
2008-2017 period. Those requirements, however, would not be 
intergovernmental mandates as defined by UMRA because Medicaid 
provides states with significant flexibility to make 
programmatic adjustments to accommodate the changes. Some 
tribal entities, particularly those operating managed care 
systems, may realize some savings as a result of these 
provisions.
    Estimated impact on the private sector: This bill contains 
no private-sector mandates as defined in UMRA.
    Previous CBO estimate: This estimate supersedes the cost 
estimate for S. 1200 that CBO transmitted on June 8, 2007. Our 
June 8 cost estimate erroneously indicated that section 204 of 
the bill (exempting Indians from paying certain types of cost 
sharing and premiums) would apply to both Medicaid and the 
State Children's Health Insurance Program. The provision would 
apply only to Medicaid, and we have lowered our estimate of the 
bill's impact on direct spending by $4 million over the 2008-
2012 period and by $8 million over the 2008-2017 period as a 
result.
    On September 11, 2007, CBO also issued a revised estimate 
for H.R. 1328, the Indian Health Care Improvement Act 
Amendments of 2007, as ordered reported by the House Committee 
on Natural Resources on April 25, 2007. There are only minor 
differences between the two bills, and CBO's revised estimates 
for them are identical.
    Estimate prepared by: Federal Costs: Eric Rollins; Impact 
on State, Local, and Tribal Governments: Lisa Ramirez-Branum; 
Impact on the Private Sector: Paige Shevlin.
    Estimate approved by: Peter H. Fontaine, Assistant Director 
for Budget Analysis.

                        Changes in Existing Law

    In accordance with subsection 12 of rule XXVI of the 
Standing Rules of the Senate, changes in existing law made by 
the bill S. 1200, as ordered reported, are shown as follows 
(existing law proposed to be omitted is enclosed in black 
brackets, new language to be added in italic, existing law to 
which no change is proposed is shown in roman):

                      UNITED STATES CODE ANNOTATED

                           TITLE 25. INDIANS

                     CHAPTER 18--INDIAN HEALTH CARE

[Sec. 1601. Congressional]
S 1200 IS
110th CONGRESS
1st Session
S. 1200
To amend the Indian Health Care Improvement Act to revise and 
extend that Act.
IN THE SENATE OF THE UNITED STATES
April 24, 2007
Mr. DORGAN (for himself, Mrs. Boxer, Mr. Reid, Ms. Cantwell, 
Mr. Johnson, Mr. Tester, Mr. Inouye, Mr. Domenici, Mr. 
Bingaman, Mr. Baucus, Ms. Klobuchar, Mr. Thomas, Mr. Obama, and 
Ms. Murkowski) introduced the following bill; which was read 
twice and referred to the Committee on Indian Affairs
A BILL
To amend the Indian Health Care Improvement Act to revise and 
extend that Act.
    Be it enacted by the Senate and House of Representatives of 
the United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Indian 
Health Care Improvement Act Amendments of 2007''.
    (b) Table of Contents.--The table of contents of this Act 
is as follows:

Sec. 1. Short title; table of contents.

                   TITLE I--AMENDMENTS TO INDIAN LAWS

Sec. 101. Indian Health Care Improvement Act amended.
Sec. 102. Soboba sanitation facilities.
Sec. 103. Native American Health and Wellness Foundation.

 TITLE II--IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED UNDER THE SOCIAL 
                              SECURITY ACT

Sec. 201. Expansion of payments under Medicare, Medicaid, and SCHIP for 
          all covered services furnished by Indian Health Programs.
Sec. 202. Increased outreach to Indians under Medicaid and SCHIP and 
          improved cooperation in the provision of items and services to 
          Indians under Social Security Act health benefit programs.
Sec. 203. Additional provisions to increase outreach to, and enrollment 
          of, Indians in SCHIP and Medicaid.
Sec. 204. Premiums and cost sharing protections under Medicaid, 
          eligibility determinations under Medicaid and SCHIP, and 
          protection of certain Indian property from Medicaid estate 
          recovery.
Sec. 205. Nondiscrimination in qualifications for payment for services 
          under Federal health care programs.
Sec. 206. Consultation on Medicaid, SCHIP, and other health care 
          programs funded under the Social Security Act involving Indian 
          Health Programs and Urban Indian Organizations.
Sec. 207. Exclusion waiver authority for affected Indian Health Programs 
          and safe harbor transactions under the Social Security Act.
Sec. 208. Rules applicable under Medicaid and SCHIP to managed care 
          entities with respect to Indian enrollees and Indian health 
          care providers and Indian managed care entities.
Sec. 209. Annual report on Indians served by Social Security Act health 
          benefit programs.

                   TITLE I--AMENDMENTS TO INDIAN LAWS

SEC. 101. INDIAN HEALTH CARE IMPROVEMENT ACT AMENDED.

    (a) In General.--The Indian Health Care Improvement Act (25 
U.S.C. 1601 et seq.) is amended to read as follows:

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Indian 
Health Care Improvement Act''.
    (b) Table of Contents.--The table of contents for this Act 
is as follows:

Sec. 1. Short title; table of contents.
Sec. 2. Findings.
Sec. 3. Declaration of national Indian health policy.
Sec. 4. Definitions.

        TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT

Sec. 101. Purpose.
Sec. 102. Health professions recruitment program for Indians.
Sec. 103. Health professions preparatory scholarship program for 
          Indians.
Sec. 104. Indian health professions scholarships.
Sec. 105. American Indians Into Psychology Program.
Sec. 106. Scholarship programs for Indian Tribes.
Sec. 107. Indian Health Service extern programs.
Sec. 108. Continuing education allowances.
Sec. 109. Community Health Representative Program.
Sec. 110. Indian Health Service Loan Repayment Program.
Sec. 111. Scholarship and Loan Repayment Recovery Fund.
Sec. 112. Recruitment activities.
Sec. 113. Indian recruitment and retention program.
Sec. 114. Advanced training and research.
Sec. 115. Quentin N. Burdick American Indians Into Nursing Program.
Sec. 116. Tribal cultural orientation.
Sec. 117. INMED Program.
Sec. 118. Health training programs of community colleges.
Sec. 119. Retention bonus.
Sec. 120. Nursing residency program.
Sec. 121. Community Health Aide Program.
Sec. 122. Tribal Health Program administration.
Sec. 123. Health professional chronic shortage demonstration programs.
Sec. 124. National Health Service Corps.
Sec. 125. Substance abuse counselor educational curricula demonstration 
          programs.
Sec. 126. Behavioral health training and community education programs.
Sec. 127. Authorization of appropriations.

                        TITLE II--HEALTH SERVICES

Sec. 201. Indian Health Care Improvement Fund.
Sec. 202. Catastrophic Health Emergency Fund.
Sec. 203. Health promotion and disease prevention services.
Sec. 204. Diabetes prevention, treatment, and control.
Sec. 205. Shared services for long-term care.
Sec. 206. Health services research.
Sec. 207. Mammography and other cancer screening.
Sec. 208. Patient travel costs.
Sec. 209. Epidemiology centers.
Sec. 210. Comprehensive school health education programs.
Sec. 211. Indian youth program.
Sec. 212. Prevention, control, and elimination of communicable and 
          infectious diseases.
Sec. 213. Other authority for provision of services.
Sec. 214. Indian women's health care.
Sec. 215. Environmental and nuclear health hazards.
Sec. 216. Arizona as a contract health service delivery area.
Sec. 216A. North Dakota and South Dakota as contract health service 
          delivery area.
Sec. 217. California contract health services program.
Sec. 218. California as a contract health service delivery area.
Sec. 219. Contract health services for the Trenton service area.
Sec. 220. Programs operated by Indian Tribes and Tribal Organizations.
Sec. 221. Licensing.
Sec. 222. Notification of provision of emergency contract health 
          services.
Sec. 223. Prompt action on payment of claims.
Sec. 224. Liability for payment.
Sec. 225. Office of Indian Men's Health.
Sec. 226. Authorization of appropriations.

                          TITLE III--FACILITIES

Sec. 301. Consultation; construction and renovation of facilities; 
          reports.
Sec. 302. Sanitation facilities.
Sec. 303. Preference to Indians and Indian firms.
Sec. 304. Expenditure of non-Service funds for renovation.
Sec. 305. Funding for the construction, expansion, and modernization of 
          small ambulatory care facilities.
Sec. 306. Indian health care delivery demonstration projects.
Sec. 307. Land transfer.
Sec. 308. Leases, contracts, and other agreements.
Sec. 309. Study on loans, loan guarantees, and loan repayment.
Sec. 310. Tribal leasing.
Sec. 311. Indian Health Service/tribal facilities joint venture program.
Sec. 312. Location of facilities.
Sec. 313. Maintenance and improvement of health care facilities.
Sec. 314. Tribal management of Federally-owned quarters.
Sec. 315. Applicability of Buy American Act requirement.
Sec. 316. Other funding for facilities.
Sec. 317. Authorization of appropriations.

                   TITLE IV--ACCESS TO HEALTH SERVICES

Sec. 401. Treatment of payments under Social Security Act health 
          benefits programs.
Sec. 402. Grants to and contracts with the Service, Indian Tribes, 
          Tribal Organizations, and Urban Indian Organizations to 
          facilitate outreach, enrollment, and coverage of Indians under 
          Social Security Act health benefit programs and other health 
          benefits programs.
Sec. 403. Reimbursement from certain third parties of costs of health 
          services.
Sec. 404. Crediting of reimbursements.
Sec. 405. Purchasing health care coverage.
Sec. 406. Sharing arrangements with Federal agencies.
Sec. 407. Payor of last resort.
Sec. 408. Nondiscrimination under Federal health care programs in 
          qualifications for reimbursement for services.
Sec. 409. Consultation.
Sec. 410. State Children's Health Insurance Program (SCHIP).
Sec. 411. Exclusion waiver authority for affected Indian Health Programs 
          and safe harbor transactions under the Social Security Act.
Sec. 412. Premium and cost sharing protections and eligibility 
          determinations under Medicaid and SCHIP and protection of 
          certain Indian property from Medicaid estate recovery.
Sec. 413. Treatment under Medicaid and SCHIP managed care.
Sec. 414. Navajo Nation Medicaid Agency feasibility study.
Sec. 415. General exceptions.
Sec. 416. Authorization of appropriations.

               TITLE V--HEALTH SERVICES FOR URBAN INDIANS

Sec. 501. Purpose.
Sec. 502. Contracts with, and grants to, Urban Indian Organizations.
Sec. 503. Contracts and grants for the provision of health care and 
          referral services.
Sec. 504. Contracts and grants for the determination of unmet health 
          care needs.
Sec. 505. Evaluations; renewals.
Sec. 506. Other contract and grant requirements.
Sec. 507. Reports and records.
Sec. 508. Limitation on contract authority.
Sec. 509. Facilities.
Sec. 510. Division of Urban Indian Health.
Sec. 511. Grants for alcohol and substance abuse-related services.
Sec. 512. Treatment of certain demonstration projects.
Sec. 513. Urban NIAAA transferred programs.
Sec. 514. Consultation with Urban Indian Organizations.
Sec. 515. Urban youth treatment center demonstration.
Sec. 516. Grants for diabetes prevention, treatment, and control.
Sec. 517. Community Health Representatives.
Sec. 518. Effective date.
Sec. 519. Eligibility for services.
Sec. 520. Authorization of appropriations.

                  TITLE VI--ORGANIZATIONAL IMPROVEMENTS

Sec. 601. Establishment of the Indian Health Service as an agency of the 
          Public Health Service.
Sec. 602. Automated management information system.
Sec. 603. Authorization of appropriations.

                  TITLE VII--BEHAVIORAL HEALTH PROGRAMS

Sec. 701. Behavioral health prevention and treatment services.
Sec. 702. Memoranda of agreement with the Department of the Interior.
Sec. 703. Comprehensive behavioral health prevention and treatment 
          program.
Sec. 704. Mental health technician program.
Sec. 705. Licensing requirement for mental health care workers.
Sec. 706. Indian women treatment programs.
Sec. 707. Indian youth program.
Sec. 708. Indian youth telemental health demonstration project.
Sec. 709. Inpatient and community-based mental health facilities design, 
          construction, and staffing.
Sec. 710. Training and community education.
Sec. 711. Behavioral health program.
Sec. 712. Fetal alcohol disorder programs.
Sec. 713. Child sexual abuse and prevention treatment programs.
Sec. 714. Behavioral health research.
Sec. 715. Definitions.
Sec. 716. Authorization of appropriations.

                        TITLE VIII--MISCELLANEOUS

Sec. 801. Reports.
Sec. 802. Regulations.
Sec. 803. Plan of implementation.
Sec. 804. Availability of funds.
Sec. 805. Limitation on use of funds appropriated to Indian Health 
          Service.
Sec. 806. Eligibility of California Indians.
Sec. 807. Health services for ineligible persons.
Sec. 808. Reallocation of base resources.
Sec. 809. Results of demonstration projects.
Sec. 810. Provision of services in Montana.
Sec. 811. Moratorium.
Sec. 812. Tribal employment.
Sec. 813. Severability provisions.
Sec. 814. Establishment of National Bipartisan Commission on Indian 
          Health Care.
Sec. 815. Confidentiality of medical quality assurance records; 
          qualified immunity for participants.
Sec. 816. Appropriations; availability.
Sec. 817. Authorization of appropriations.

SEC. 2. FINDINGS.

    Congress makes the following findings:
    [The Congress finds the following:
          [(a] (1) Federal health services to maintain and 
        improve the health of the Indians are consonant with 
        and required by the Federal Government's historical and 
        unique legal relationship with, and resulting 
        responsibility to, the American Indian people.
          [(b] (2) A major national goal of the United States 
        is to provide the quantity and quality of health 
        services which will permit the health status of Indians 
        to be raised to the highest possible level and to 
        encourage the maximum participation of Indians in the 
        planning and management of those services.
          [(c] (3) Federal health services to Indians have 
        resulted in a reduction in the prevalence and incidence 
        of preventable illnesses among, and unnecessary and 
        premature deaths of, Indians.
          [(d] (4) Despite such services, the unmet health 
        needs of the American Indian people are severe and the 
        health status of the Indians is far below that of the 
        general population of the United States.

[Sec. 1602. Declaration of health objectives]

SEC. 3. DECLARATION OF NATIONAL INDIAN HEALTH POLICY.

    [(a) The] Congress [hereby] declares that it is the policy 
of this Nation, in fulfillment of its special trust 
responsibilities and legal [obligation to the American Indian 
people,] obligations to Indians--
          (1) to assure the highest possible health status for 
        Indians and [urban]Urban Indians and to provide all 
        resources necessary to effect that policy[.];
    [(b) It is the intent of the Congress that the Nation meet 
the following health status objectives with respect to Indians 
and urban Indians by the year 2000:
          [(1) Reduce coronary heart disease deaths to a level 
        of no more than 100 per 100,000.
          [(2) Reduce the prevalence of overweight individuals 
        to no more than 30 percent.
          [(3) Reduce the prevalence of anemia to less than 10 
        percent among children aged 1 through 5.
          [(4) Reduce the level of cancer deaths to a rate of 
        no more than 130 per 100,000.
          [(5) Reduce the level of lung cancer deaths to a rate 
        of no more than 42 per 100,000.
          [(6) Reduce the level of chronic obstructive 
        pulmonary disease related deaths to a rate of no more 
        than 25 per 100,000.
          [(7) Reduce deaths among men caused by alcohol-
        related motor vehicle crashes to no more than 44.8 per 
        100,000.
          [(8) Reduce cirrhosis deaths to no more than 13 per 
        100,000.
          [(9) Reduce drug-related deaths to no more than 3 per 
        100,000.
          [(10) Reduce pregnancies among girls aged 17 and 
        younger to no more than 50 per 1,000 adolescents.
          [(11) Reduce suicide among men to no more than 12.8 
        per 100,000.
          [(12) Reduce by 15 percent the incidence of injurious 
        suicide attempts among adolescents aged 14 through 17.
          [(13) Reduce to less than 10 percent the prevalence 
        of mental disorders among children and adolescents.
          [(14) Reduce the incidence of child abuse or neglect 
        to less than 25.2 per 1,000 children under age 18.
          [(15) Reduce physical abuse directed at women by male 
        partners to no more than 27 per 1,000 couples.
          [(16) Increase years of healthy life to at least 65 
        years.
          [(17) Reduce deaths caused by unintentional injuries 
        to no more than 66.1 per 100,000.
          [(18) Reduce deaths caused by motor vehicle crashes 
        to no more than 39.2 per 100,000.
          [(19) Among children aged 6 months through 5 years, 
        reduce the prevalence of blood lead levels exceeding 
        15ug/dl and reduce to zero the prevalence of blood lead 
        levels exceeding 25 ug/dl.
          [(20) Reduce dental caries (cavities) so that the 
        proportion of children with one or more caries (in 
        permanent or primary teeth) is no more than 45 percent 
        among children aged 6 through 8 and no more than 60 
        percent among adolescents aged 15.
          [(21) Reduce untreated dental caries so that the 
        proportion of children with untreated caries (in 
        permanent or primary teeth) is no more than 20 percent 
        among children aged 6 through 8 and no more than 40 
        percent among adolescents aged 15.
          [(22) Reduce to no more than 20 percent the 
        proportion of individuals aged 65 and older who have 
        lost all of their natural teeth.
          [(23) Increase to at least 45 percent the proportion 
        of individuals aged 35 to 44 who have never lost a 
        permanent tooth due to dental caries or periodontal 
        disease.
          [(24) Reduce destructive periodontal disease to a 
        prevalence of no more than 15 percent among individuals 
        aged 35 to 44.
          [(25) Increase to at least 50 percent the proportion 
        of children who have received protective sealants on 
        the occlusal (chewing) surfaces of permanent molar 
        teeth.
          [(26) Reduce the prevalence of gingivitis among 
        individuals aged 35 to 44 to no more than 50 percent.
          [(27) Reduce the infant mortality rate to no more 
        than 8.5 per 1,000 live births.
          [(28) Reduce the fetal death rate (20 or more weeks 
        of gestation) to no more than 4 per 1,000 live births 
        plus fetal deaths.
          [(29) Reduce the maternal mortality rate to no more 
        than 3.3 per 100,000 live births.
          [(30) Reduce the incidence of fetal alcohol syndrome 
        to no more than 2 per 1,000 live births.
          [(31) Reduce stroke deaths to no more than 20 per 
        100,000.
          [(32) Reverse the increase in end-stage renal disease 
        (requiring maintenance dialysis or transplantation) to 
        attain an incidence of no more than 13 per 100,000.
          [(33) Reduce breast cancer deaths to no more than 
        20.6 per 100,000 women.
          [(34) Reduce deaths from cancer of the uterine cervix 
        to no more than 1.3 per 100,000 women.
          [(35) Reduce colorectal cancer deaths to no more than 
        13.2 per 100,000.
          [(36) Reduce to no more than 11 percent the 
        proportion of individuals who experience a limitation 
        in major activity due to chronic conditions.
          [(37) Reduce significant hearing impairment to a 
        prevalence of no more than 82 per 1,000.
          [(38) Reduce significant visual impairment to a 
        prevalence of no more than 30 per 1,000.
          [(39) Reduce diabetes-related deaths to no more than 
        48 per 100,000.
          [(40) Reduce diabetes to an incidence of no more than 
        2.5 per 1,000 and a prevalence of no more than 62 per 
        1,000.
          [(41) Reduce the most severe complications of 
        diabetes as follows:
                  [(A) End-stage renal disease, 1.9 per 1,000.
                  [(B) Blindness, 1.4 per 1,000.
                  [(C) Lower extremity amputation, 4.9 per 
                1,000.
                  [(D) Perinatal mortality, 2 percent.
                  [(E) Major congenital malformations, 4 
                percent.
          [(42) Confine annual incidence of diagnosed AIDS 
        cases to no more than 1,000 cases.
          [(43) Confine the prevalence of HIV infection to no 
        more than 100 per 100,000.
          [(44) Reduce gonorrhea to an incidence of no more 
        than 225 cases per 100,000.
          [(45) Reduce chlamydia trachomatis infections, as 
        measured by a decrease in the incidence of 
        nongonococcal urethritis to no more than 170 cases per 
        100,000.
          [(46) Reduce primary and secondary syphilis to an 
        incidence of no more than 10 cases per 100,000.
          [(47) Reduce the incidence of pelvic inflammatory 
        disease, as measured by a reduction in hospitalization 
        for pelvic inflammatory disease to no more than 250 per 
        100,000 women aged 15 through 44.
          [(48) Reduce viral hepatitis B infection to no more 
        than 40 per 100,000 cases.
          [(49) Reduce indigenous cases of vaccine-preventable 
        diseases as follows:
                  [(A) Diphtheria among individuals aged 25 and 
                younger, 0.
                  [(B) Tetanus among individuals aged 25 and 
                younger, 0.
                  [(C) Polio (wild-type virus), 0.
                  [(D) Measles, 0.
                  [(E) Rubella, 0.
                  [(F) Congenital Rubella Syndrome, 0.
                  [(G) Mumps, 500.
                  [(H) Pertussis, 1,000.
          [(50) Reduce epidemic-related pneumonia and influenza 
        deaths among individuals aged 65 and older to no more 
        than 7.3 per 100,000.
          [(51) Reduce the number of new carriers of viral 
        hepatitis B among Alaska Natives to no more than 1 
        case.
          [(52) Reduce tuberculosis to an incidence of no more 
        than 5 cases per 100,000.
          [(53) Reduce bacterial meningitis to no more than 8 
        cases per 100,000.
          [(54) Reduce infectious diarrhea by at least 25 
        percent among children.
          [(55) Reduce acute middle ear infections among 
        children aged 4 and younger, as measured by days of 
        restricted activity or school absenteeism, to no more 
        than 105 days per 100 children.
          [(56) Reduce cigarette smoking to a prevalence of no 
        more than 20 percent.
          [(57) Reduce smokeless tobacco use by youth to a 
        prevalence of no more than 10 percent.
          [(58) Increase to at least 65 percent the proportion 
        of parents and caregivers who use feeding practices 
        that prevent baby bottle tooth decay.
          [(59) Increase to at least 75 percent the proportion 
        of mothers who breast feed their babies in the early 
        postpartum period, and to at least 50 percent the 
        proportion who continue breast feeding until their 
        babies are 5 to 6 months old.
          [(60) Increase to at least 90 percent the proportion 
        of pregnant women who receive prenatal care in the 
        first trimester of pregnancy.
          [(61) Increase to at least 70 percent the proportion 
        of individuals who have received, as a minimum within 
        the appropriate interval, all of the screening and 
        immunization services and at least one of the 
        counseling services appropriate for their age and 
        gender as recommended by the United States Preventive 
        Services Task Force.]
          (2) to raise the health status of Indians and Urban 
        Indians to at least the levels set forth in the goals 
        contained within the Healthy People 2010 or successor 
        objectives;
          (3) to the greatest extent possible, to allow Indians 
        to set their own health care priorities and establish 
        goals that reflect their unmet needs;
          [(c) It is the intent of the Congress that the 
        Nation] (4) to increase the proportion of all degrees 
        in the health professions and allied and associated 
        health [profession fields awarded to Indians to 0.6 
        percent.]professions awarded to Indians so that the 
        proportion of Indian health professionals in each 
        Service Area is raised to at least the level of that of 
        the general population;
    [(d) The Secretary shall submit to the President, for 
inclusion in each report required to be transmitted to the 
Congress under section 1671 of this title, a report on the 
progress made in each area of the Service toward meeting each 
of the objectives described in subsection (b) of this section.]
          (5) to require meaningful consultation with Indian 
        Tribes, Tribal Organizations, and Urban Indian 
        Organizations to implement this Act and the national 
        policy of Indian self-determination; and

[Sec. 1603. Definitions]

          (6) to provide funding for programs and facilities 
        operated by Indian Tribes and Tribal Organizations in 
        amounts that are not less than the amounts provided to 
        programs and facilities operated directly by the 
        Service.

SEC. 4. DEFINITIONS.

    For purposes of this [chapter--]Act:
          (1) The term ``accredited and accessible'' means on 
        or near a reservation and accredited by a national or 
        regional organization with accrediting authority.
          (2) The term ``Area Office'' means an administrative 
        entity, including a program office, within the Service 
        through which services and funds are provided to the 
        Service Units within a defined geographic area.
          (3) The term ``Assistant Secretary'' means the 
        Assistant Secretary for Indian Health.
          (4)(A) The term ``behavioral health'' means the 
        blending of substance (alcohol, drugs, inhalants, and 
        tobacco) abuse and mental health prevention and 
        treatment, for the purpose of providing comprehensive 
        services.
          (B) The term ``behavioral health'' includes the joint 
        development of substance abuse and mental health 
        treatment planning and coordinated case management 
        using a multidisciplinary approach.
          (5) The term ``California Indians'' means those 
        Indians who are eligible for health services of the 
        Service pursuant to section 806.
          (6) The term ``community college'' means--
                  (A) a tribal college or university, or
                  (B) a junior or community college.
          (7) The term ``contract health service'' means health 
        services provided at the expense of the Service or a 
        Tribal Health Program by public or private medical 
        providers or hospitals, other than the Service Unit or 
        the Tribal Health Program at whose expense the services 
        are provided.
          [(a) ``Secretary''] (8) The term ``Department'' 
        means, unless otherwise designated, [means the 
        Secretary]the Department of Health and Human Services.
    [(b) ``Service'' means the Indian Health Service.]
          (9) The term ``disease prevention'' means the 
        reduction, limitation, and prevention of disease and 
        its complications and reduction in the consequences of 
        disease, including--
                  (A) controlling--
                          (i) the development of diabetes;
                          (ii) high blood pressure;
                          (iii) infectious agents;
                          (iv) injuries;
                          (v) occupational hazards and 
                        disabilities;
                          (vi) sexually transmittable diseases; 
                        and
                          (vii) toxic agents; and
                  (B) providing--
                          (i) fluoridation of water; and
                          (ii) immunizations.
          (10) The term ``health profession'' means allopathic 
        medicine, family medicine, internal medicine, 
        pediatrics, geriatric medicine, obstetrics and 
        gynecology, podiatric medicine, nursing, public health 
        nursing, dentistry, psychiatry, osteopathy, optometry, 
        pharmacy, psychology, public health, social work, 
        marriage and family therapy, chiropractic medicine, 
        environmental health and engineering, allied health 
        professions, and any other health profession.
          (11) The term ``health promotion'' means--
                  (A) fostering social, economic, 
                environmental, and personal factors conducive 
                to health, including raising public awareness 
                about health matters and enabling the people to 
                cope with health problems by increasing their 
                knowledge and providing them with valid 
                information;
                  (B) encouraging adequate and appropriate 
                diet, exercise, and sleep;
                  (C) promoting education and work in 
                conformity with physical and mental capacity;
                  (D) making available safe water and sanitary 
                facilities;
                  (E) improving the physical, economic, 
                cultural, psychological, and social 
                environment;
                  (F) promoting culturally competent care; and
                  (G) providing adequate and appropriate 
                programs, which may include--
                          (i) abuse prevention (mental and 
                        physical);
                          (ii) community health;
                          (iii) community safety;
                          (iv) consumer health education;
                          (v) diet and nutrition;
                          (vi) immunization and other 
                        prevention of communicable diseases, 
                        including HIV/AIDS;
                          (vii) environmental health;
                          (viii) exercise and physical fitness;
                          (ix) avoidance of fetal alcohol 
                        disorders;
                          (x) first aid and CPR education;
                          (xi) human growth and development;
                          (xii) injury prevention and personal 
                        safety;
                          (xiii) behavioral health;
                          (xiv) monitoring of disease 
                        indicators between health care provider 
                        visits, through appropriate means, 
                        including Internet-based health care 
                        management systems;
                          (xv) personal health and wellness 
                        practices;
                          (xvi) personal capacity building;
                          (xvii) prenatal, pregnancy, and 
                        infant care;
                          (xviii) psychological well-being;
                          (xix) reproductive health and family 
                        planning;
                          (xx) safe and adequate water;
                          (xxi) healthy work environments;
                          (xxii) elimination, reduction, and 
                        prevention of contaminants that create 
                        unhealthy household conditions 
                        (including mold and other allergens);
                          (xxiii) stress control;
                          (xxiv) substance abuse;
                          (xxv) sanitary facilities;
                          (xxvi) sudden infant death syndrome 
                        prevention;
                          (xxvii) tobacco use cessation and 
                        reduction;
                          (xxviii) violence prevention; and
                          (xxix) such other activities 
                        identified by the Service, a Tribal 
                        Health Program, or an Urban Indian 
                        Organization, to promote achievement of 
                        any of the objectives described in 
                        section 3(2).
          [(c) ``Indians'' or] (12) The term ``Indian'', unless 
        otherwise designated, means any person who is a member 
        of an Indian [tribe, as defined in subsection (d) of 
        this section,] Tribe or is eligible for health services 
        under section 806, except that, for the purpose of 
        sections [1612 and 1613 of this title, such terms shall 
        mean] 102 and 103, the term also means any individual 
        who [(1),]--
                  (A)(i) irrespective of whether [he or she] 
                the individual lives on or near a reservation, 
                is a member of a tribe, band, or other 
                organized group of Indians, including those 
                tribes, bands, or groups terminated since 1940 
                and those recognized now or in the future by 
                the State in which they reside[,]; or [who]
                  (ii) is a descendant, in the first or second 
                degree, of any such member[, or (2)];
                  (B) is an Eskimo or Aleut or other Alaska 
                Native[, or (3)];
                  (C) is considered by the Secretary of the 
                Interior to be an Indian for any purpose[, or 
                (4)]; or
                  (D) is determined to be an Indian under 
                regulations promulgated by the Secretary.
          (13) The term ``Indian Health Program'' means--
                  (A) any health program administered directly 
                by the Service;
                  (B) any Tribal Health Program; or
                  (C) any Indian Tribe or Tribal Organization 
                to which the Secretary provides funding 
                pursuant to section 23 of the Act of June 25, 
                1910 (25 U.S.C. 47) (commonly known as the 
                ``Buy Indian Act'').
          (14) The term ``Indian Tribe'' has the meaning given 
        the term in the Indian Self-Determination and Education 
        Assistance Act (25 U.S.C. 450 et seq.).
          (15) The term ``junior or community college'' has the 
        meaning given the term by section 312(e) of the Higher 
        Education Act of 1965 (20 U.S.C. 1058(e)).
          [(d) ``Indian tribe'' means any Indian tribe, band, 
        nation, or other organized group or community, 
        including any Alaska Native village or group or 
        regional or village corporation as defined in or] (16) 
        The term ``reservation'' means any federally recognized 
        Indian Tribe's reservation, Pueblo, or colony, 
        including former reservations in Oklahoma, Indian 
        allotments, and Alaska Native Regions established 
        pursuant to the Alaska Native Claims Settlement Act 
        ([85 Stat. 688) []43 U.S.C.[A Sec. 1601 et seq.], which 
        is recognized as eligible for the special programs and 
        services provided by the United States to Indians 
        because of their status as Indians.] 1601 et seq.).
    [(e) ``Tribal organization'' means the elected governing 
body of any Indian tribe or any legally established 
organization of Indians which is controlled by one or more such 
bodies or by a board of directors elected or selected by one or 
more such bodies (or elected by the Indian population to be 
served by such organization) and which includes the maximum 
participation of Indians in all phases of its activities.
    [(f) ``Urban Indian'' means any individual who resides in 
an urban center, as defined in subsection (g) hereof, and who 
meets one or more of the four criteria in subsection (c)(1) 
through (4) of this section.]
          (17) The term ``Secretary'', unless otherwise 
        designated, means the Secretary of Health and Human 
        Services.
          (18) The term ``Service'' means the Indian Health 
        Service.
          (19) The term ``Service Area'' means the geographical 
        area served by each Area Office.
          (20) The term ``Service Unit'' means an 
        administrative entity of the Service, or a Tribal 
        Health Program through which services are provided, 
        directly or by contract, to eligible Indians within a 
        defined geographic area.
          (21) The term ``telehealth'' has the meaning given 
        the term in section 330K(a) of the Public Health 
        Service Act (42 U.S.C. 254c-16(a)).
          (22) The term ``telemedicine'' means a 
        telecommunications link to an end user through the use 
        of eligible equipment that electronically links health 
        professionals or patients and health professionals at 
        separate sites in order to exchange health care 
        information in audio, video, graphic, or other format 
        for the purpose of providing improved health care 
        services.
          (23) The term ``tribal college or university'' has 
        the meaning given the term in section 316(b)(3) of the 
        Higher Education Act (20 U.S.C. 1059c(b)(3)).
          (24) The term ``Tribal Health Program'' means an 
        Indian Tribe or Tribal Organization that operates any 
        health program, service, function, activity, or 
        facility funded, in whole or part, by the Service 
        through, or provided for in, a contract or compact with 
        the Service under the Indian Self-Determination and 
        Education Assistance Act (25 U.S.C. 450 et seq.).
          (25) The term ``Tribal Organization'' has the meaning 
        given the term in the Indian Self-Determination and 
        Education Assistance Act (25 U.S.C. 450 et seq.).
          [(g)] (26) [``]The term ``Urban [center''] Center'' 
        means any community which has a sufficient [urban] 
        Urban Indian population with unmet health needs to 
        warrant assistance under [subchapter IV] title V of 
        this [chapter] Act, as determined by the Secretary.
          (27) The term ``Urban Indian'' means any individual 
        who resides in an Urban Center and who meets 1 or more 
        of the following criteria:
                  (A) Irrespective of whether the individual 
                lives on or near a reservation, the individual 
                is a member of a tribe, band, or other 
                organized group of Indians, including those 
                tribes, bands, or groups terminated since 1940 
                and those tribes, bands, or groups that are 
                recognized by the States in which they reside, 
                or who is a descendant in the first or second 
                degree of any such member.
                  (B) The individual is an Eskimo, Aleut, or 
                other Alaska Native.
                  (C) The individual is considered by the 
                Secretary of the Interior to be an Indian for 
                any purpose.
                  (D) The individual is determined to be an 
                Indian under regulations promulgated by the 
                Secretary.
          [(h)] (28) The term ``Urban Indian [organization''] 
        Organization'' means a nonprofit corporate body that 
        (A) is situated in an [urban center,] Urban Center; (B) 
        is governed by an [urban] Urban Indian-controlled board 
        of directors[, and providing]; (C) provides for the 
        [maximum] participation of all interested Indian groups 
        and individuals[, which body]; and (D) is capable of 
        legally cooperating with other public and private 
        entities for the purpose of performing the activities 
        described in section [1653] 503(a).

        TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT

SEC. 101. PURPOSE.

    The purpose of this title[.]
    [(i) ``Area office'' means an administrative entity 
including a program office, within the Indian Health Service 
through which services and funds are provided to the service 
units within a defined geographic area.
    [(j) ``Service unit'' means--
          [(1) an administrative entity within the Indian 
        Health Service, or
          [(2) a tribe or tribal organization operating health 
        care programs or facilities with funds from the Service 
        under the Indian Self-Determination Act [25 U.S.C.A. 
        Sec. 450f et seq.], through which services are 
        provided, directly or by contract, to the eligible 
        Indian population within a defined geographic area.
    [(k) ``Health promotion'' includes--
          [(1) cessation of tobacco smoking,
          [(2) reduction in the misuse of alcohol and drugs,
          [(3) improvement of nutrition,
          [(4) improvement in physical fitness,
          [(5) family planning,
          [(6) control of stress, and
          [(7) pregnancy and infant care (including prevention 
        of fetal alcohol syndrome).
    [(l) ``Disease prevention'' includes--
          [(1) immunizations,
          [(2) control of high blood pressure,
          [(3) control of sexually transmittable diseases,
          [(4) prevention and control of diabetes,
          [(5) control of toxic agents,
          [(6) occupational safety and health,
          [(7) accident prevention,
          [(8) fluoridation of water, and
          [(9) control of infectious agents.
    [(m) ``Service area'' means the geographical area served by 
each area office.
    [(n) ``Health profession'' means allopathic medicine, 
family medicine, internal medicine, pediatrics, geriatric 
medicine, obstetrics and gynecology, podiatric medicine, 
nursing, public health nursing, dentistry, psychiatry, 
osteopathy, optometry, pharmacy, psychology, public health, 
social work, marriage and family therapy, chiropractic 
medicine, environmental health and engineering, an allied 
health profession, or any other health profession.
    [(o) ``Substance abuse'' includes inhalant abuse.
    [(p) ``FAE'' means fetal alcohol effect.
    [(q) ``FAS'' means fetal alcohol syndrome.
    [Sec. 1611. Congressional statement of purpose The purpose 
of this subchapter] is to increase, to the maximum extent 
feasible, the number of Indians entering the health professions 
and providing health services, and to assure an [adequate] 
optimum supply of health professionals to the [Service, Indian 
tribes, tribal organizations, and urban Indian organizations] 
Indian Health Programs and Urban Indian Organizations involved 
in the provision of health [care] services to [Indian people] 
Indians.

[Sec. 1612. Health professions recruitment program for Indians]

SEC. 102. HEALTH PROFESSIONS RECRUITMENT PROGRAM FOR INDIANS.

    [(a) Grants for education and training]
    (a) In General.--The Secretary, acting through the Service, 
shall make grants to public or nonprofit private health or 
educational entities, Tribal Health Programs, or Urban Indian 
[tribes or tribal organizations] Organizations to assist such 
entities in meeting the costs of--
          (1) identifying Indians with a potential for 
        education or training in the health professions and 
        encouraging and assisting them--
                  (A) to enroll in courses of study in such 
                health professions; or
                  (B) if they are not qualified to enroll in 
                any such courses of study, to undertake such 
                postsecondary education or training as may be 
                required to qualify them for enrollment;
          (2) publicizing existing sources of financial aid 
        available to Indians enrolled in any course of study 
        referred to in paragraph (1) [of this subsection] or 
        who are undertaking training necessary to qualify them 
        to enroll in any such course of study; or
          (3) establishing other programs which the Secretary 
        determines will enhance and facilitate the enrollment 
        of Indians in, and the subsequent pursuit and 
        completion by them of, courses of study referred to in 
        paragraph (1) [of this subsection].
    [(b) Application for grant; submittal and approval; 
preference; payment]
    (b) Grants.--
          [(1) No] (1) Application.--The Secretary shall not 
        make a grant [may be made] under this section unless an 
        application [therefor] has been submitted to, and 
        approved by, the Secretary. Such application shall be 
        in such form, submitted in such manner, and contain 
        such information, as the Secretary shall by regulation 
        prescribe pursuant to this Act. The Secretary shall 
        give a preference to applications submitted by [Indian 
        tribes or tribal organizations] Tribal Health Programs 
        or Urban Indian Organizations.
          (2) Amount of grants; payment.--The amount of [any] a 
        grant under this section shall be determined by the 
        Secretary. Payments pursuant to [grants under] this 
        section may be made in advance or by way of 
        reimbursement, and at such intervals and on such 
        conditions as [the Secretary finds necessary] provided 
        for in regulations issued pursuant to this Act. To the 
        extent not otherwise prohibited by law, grants shall be 
        for 3 years, as provided in regulations issued pursuant 
        to this Act.

[Sec. 1613. Health professions preparatory scholarship program for 
                    Indians]

SEC. 103. HEALTH PROFESSIONS PREPARATORY SCHOLARSHIP PROGRAM FOR 
                    INDIANS.

    [(a) Requirements]
    (a) Scholarships Authorized._The Secretary, acting through 
the Service, shall [make] provide scholarship grants to Indians 
who--
          (1) have successfully completed their high school 
        education or high school equivalency; and
          (2) have demonstrated the [capability] potential to 
        successfully complete courses of study in the health 
        professions.
    (b) Purposes. [and duration of grants; preprofessional and 
pregraduate education]--Scholarship grants [made] provided 
pursuant to this section shall be for the following purposes:
          (1) Compensatory preprofessional education of any 
        [grantee] recipient, such scholarship not to exceed 
        [two] 2 years on a full-time basis (or the part-time 
        equivalent thereof, as determined by the Secretary 
        pursuant to regulations issued under this Act).
          (2) Pregraduate education of any [grantee] recipient 
        leading to a baccalaureate degree in an approved course 
        of study preparatory to a field of study in a health 
        profession, such scholarship not to exceed 4 years. An 
        extension of up to 2 years (or the part-time equivalent 
        thereof, as determined by the Secretary[).] pursuant to 
        regulations issued pursuant to this Act) may be 
        approved.
    [(c) Covered Expenses]
    [Scholarship grants made] (c) Other Conditions.--
Scholarships under this section--
          (1) may cover costs of tuition, books, 
        transportation, board, and other necessary related 
        expenses of a [grantee] recipient while attending 
        school[.];
    [(d) Basis for Denial of Assistance]
          [The Secretary] (2) shall not [deny scholarship 
        assistance to an eligible applicant under this section] 
        be denied solely on the basis of the applicant's 
        scholastic achievement if such applicant has been 
        admitted to, or maintained good standing at, an 
        accredited institution[.]; and
    [(e) Eligibility for Assistance Under Other Federal 
Programs]
          [The Secretary] (3) shall not [deny scholarship 
        assistance to an eligible applicant under this section] 
        be denied solely by reason of such applicant's 
        eligibility for assistance or benefits under any other 
        Federal program.

[Sec. 1613a. Indian health professions scholarships]

SEC. 104. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS.

    [(a) General Authority] (a) In General.--
          [In order to provide health professionals to Indians, 
        Indian tribes, tribal organizations, and urban Indian 
        organizations, the] (1) Authority.--The Secretary, 
        acting through the Service [and in accordance with this 
        section], shall make scholarship grants to Indians who 
        are enrolled full or part time in [appropriately] 
        accredited schools [and] pursuing courses of study in 
        the health professions. Such scholarships shall be 
        designated Indian Health Scholarships and shall be made 
        in accordance with section [254l of Title 42,] 338A of 
        the Public Health Services Act (42 U.S.C. 254l), except 
        as provided in subsection (b) of this section.
    [(b) Recipients; active duty service obligation]
          [(1)] (2) Determinations by secretary.--The 
        Secretary, acting through the Service, shall 
        determine--
                  (A) who shall receive [scholarships] 
                scholarship grants under subsection (a); and 
                [shall determine]
                  (B) the distribution of [such] the 
                scholarships among [such] health professions on 
                the basis of the relative needs of Indians for 
                additional service in [such] the health 
                professions. [(2) An individual shall be 
                eligible for a scholarship under subsection (a) 
                of this section in any year in which such 
                individual is enrolled full or part time in a 
                course of study referred to in subsection (a) 
                of this section.]
          (3) Certain delegation not allowed.--The 
        administration of this section shall be a 
        responsibility of the Assistant Secretary and shall not 
        be delegated in a contract or compact under the Indian 
        Self-Determination and Education Assistance Act (25 
        U.S.C. 450 et seq.).
    (b) Active Duty Service Obligation_
          [(3)(A)] (1) Obligation met.--The active duty service 
        obligation under a written contract with the Secretary 
        under this section [254l of Title 42] that an 
        [individual] Indian has entered into [under that 
        section] shall, if that individual is a recipient of an 
        Indian Health Scholarship, be met in full-time 
        practice[, by service--] equal to 1 year for each 
        school year for which the participant receives a 
        scholarship award under this part, or 2 years, 
        whichever is greater, by service in 1 or more of the 
        following:
                  [(i) in the Indian Health Service;]
                  [(ii) in a program conducted under a contract 
                entered into under the Indian Self-
                Determination Act [25 U.S.C.A. Sec. 450f et 
                seq.];]
                  (A) In an Indian Health Program.
                  [(iii)] (B) [in] In a program assisted under 
                [subchapter IV of this chapter;] title V of 
                this Act.
                  [(iv)] (C) [in]In the private practice of the 
                applicable profession if, as determined by the 
                Secretary, in accordance with guidelines 
                promulgated by the Secretary, such practice is 
                situated in a physician or other health 
                professional shortage area and addresses the 
                health care needs of a substantial number of 
                Indians[; or].
                  (D) In a teaching capacity in a tribal 
                college or university nursing program (or a 
                related health profession program) if, as 
                determined by the Secretary, the health service 
                provided to Indians would not decrease.
          [(B)] (2) Obligation deferred.--At the request of any 
        individual who has entered into a contract referred to 
        in [subparagraph (A]paragraph (1) and who receives a 
        degree in medicine (including osteopathic or allopathic 
        medicine), dentistry, optometry, podiatry, or pharmacy, 
        the Secretary shall defer the active duty service 
        obligation of that individual under that contract, in 
        order that such individual may complete any internship, 
        residency, or other advanced clinical training that is 
        required for the practice of that health profession, 
        for an appropriate period (in years, as determined by 
        the Secretary), subject to the following conditions:
                  [(i)] (A) No period of internship, residency, 
                or other advanced clinical training shall be 
                counted as satisfying any period of obligated 
                service [that is required] under this 
                [section]subsection.
                  [(ii)] (B) The active duty service obligation 
                of that individual shall commence not later 
                than 90 days after the completion of that 
                advanced clinical training (or by a date 
                specified by the Secretary).
                  [(iii)] (C) The active duty service 
                obligation will be served in the health 
                profession of that individual, in a manner 
                consistent with [clauses (i) through (v) of 
                subparagraph (A)] paragraph (1).
                  [(C)] (D) A recipient of [an Indian Health 
                Scholarship]a scholarship under this section 
                may, at the election of the recipient, meet the 
                active duty service obligation described in 
                [subparagraph (A)] paragraph (1) by service in 
                a program specified [in] under that 
                [subparagraph] paragraph that--
                          (i) is located on the reservation of 
                        the [tribe] Indian Tribe in which the 
                        recipient is enrolled; or
                          (ii) serves the [tribe] Indian Tribe 
                        in which the recipient is enrolled.
          [(D)] (3) Priority when making assignments.--Subject 
        to [subparagraph (C] paragraph (2), the Secretary, in 
        making assignments of Indian Health Scholarship 
        recipients required to meet the active duty service 
        obligation described in [subparagraph (A)] paragraph 
        (1), shall give priority to assigning individuals to 
        service in those programs specified in [subparagraph 
        (A)] paragraph (1) that have a need for health 
        professionals to provide health care services as a 
        result of individuals having breached contracts entered 
        into under this section.
    [(4)] (c) Part-Time Students.--In the case of an individual 
receiving a scholarship under this section who is enrolled part 
time in an approved course of study--
          [(A)] (1) such scholarship shall be for a period of 
        years not to exceed the part-time equivalent of 4 
        years, as determined by the Secretary;
          [(B)] (2) the period of obligated service described 
        in [paragraph (3)(A)] subsection (b)(1) shall be equal 
        to the greater of--
                  [(i)] (A) the part-time equivalent of [one] 1 
                year for each year for which the individual was 
                provided a scholarship (as determined by the 
                Secretary); or
                  [(ii)] (B) [two] 2 years; and
          [(C)] (3) the amount of the monthly stipend specified 
        in section 338A(g)(1)(B) of the Public Health Service 
        Act (42 U.S.C. 254l(g)(1)(B) [of Title 42]) shall be 
        reduced pro rata (as determined by the Secretary) based 
        on the number of hours such student is enrolled.
          [(5)(A) An individual who has, on or after October 
        29, 1992, entered into a written contract with the 
        Secretary under this section and who--]
      (d) Breach of Contract.--
          (1) Specified breaches.--An individual shall be 
        liable to the United States for the amount which has 
        been paid to the individual, or on behalf of the 
        individual, under a contract entered into with the 
        Secretary under this section on or after the date of 
        enactment of the Indian Health Care Improvement Act 
        Amendments of 2007 if that individual--
                  [(i)] (A) fails to maintain an acceptable 
                level of academic standing in the educational 
                institution in which he or she is enrolled 
                (such level determined by the educational 
                institution under regulations of the 
                Secretary)[,];
                  [(ii)] (B) is dismissed from such educational 
                institution for disciplinary reasons[,];
                  [(iii)] (C) voluntarily terminates the 
                training in such an educational institution for 
                which he or she is provided a scholarship under 
                such contract before the completion of such 
                training[,]; or
                  [(iv)] (D) fails to accept payment, or 
                instructs the educational institution in which 
                he or she is enrolled not to accept payment, in 
                whole or in part, of a scholarship under such 
                contract, in lieu of any service obligation 
                arising under such contract[, shall be liable 
                to the United States for the amount which has 
                been paid to him, or on his behalf, under the 
                contract].
          [(B)] (2) Other breaches.--If for any reason not 
        specified in [subparagraph (A)] paragraph (1) an 
        individual breaches [his] a written contract by failing 
        either to begin such individual's service obligation 
        required under [this section] such contract or to 
        complete such service obligation, the United States 
        shall be entitled to recover from the individual an 
        amount determined in accordance with the formula 
        specified in subsection (l) of section [1616a(l) of 
        this title] 110 in the manner provided for in such 
        subsection.
          [(C)] (3) Cancellation upon death of recipient.--Upon 
        the death of an individual who receives an Indian 
        Health Scholarship, any outstanding obligation of that 
        individual for service or payment that relates to that 
        scholarship shall be canceled.
          (4) Waivers and suspensions.--
                  [(D)] (A) In general.--The Secretary shall 
                provide for the partial or total waiver or 
                suspension of any obligation of service or 
                payment of a recipient of an Indian Health 
                Scholarship if the Secretary determines that--
                          (i) it is not possible for the 
                        recipient to meet that obligation or 
                        make that payment;
                          (ii) requiring that recipient to meet 
                        that obligation or make that payment 
                        would result in extreme hardship to the 
                        recipient; or
                          (iii) the enforcement of the 
                        requirement to meet the obligation or 
                        make the payment would be 
                        unconscionable.
                  (B) Factors for consideration.--Before 
                waiving or suspending an obligation of service 
                or payment under subparagraph (A), the 
                Secretary shall consult with the affected Area 
                Office, Indian Tribes, Tribal Organizations, or 
                Urban Indian Organizations, and may take into 
                consideration whether the obligation may be 
                satisfied in a teaching capacity at a tribal 
                college or university nursing program under 
                subsection (b)(1)(D).
          [(E)] (5) Extreme hardship.--Notwithstanding any 
        other provision of law, in any case of extreme hardship 
        or for other good cause shown, the Secretary may waive, 
        in whole or in part, the right of the United States to 
        recover funds made available under this section.
          [(F)] (6) Bankruptcy.--Notwithstanding any other 
        provision of law, with respect to a recipient of an 
        Indian Health Scholarship, no obligation for payment 
        may be released by a discharge in bankruptcy under 
        [Title] title 11, United States Code, unless that 
        discharge is granted after the expiration of the 5-year 
        period beginning on the initial date on which that 
        payment is due, and only if the bankruptcy court finds 
        that the nondischarge of the obligation would be 
        unconscionable.
    [(c) Placement Office]

SEC. 105. AMERICAN INDIANS INTO PSYCHOLOGY PROGRAM.

    (a) Grants Authorized.--The Secretary, acting through the 
Service, shall make grants of not more than $300,000 to each of 
9 colleges and universities for the purpose of developing and 
maintaining Indian psychology career recruitment programs as a 
means of encouraging Indians to enter the behavioral health 
field. These programs shall be located at various locations 
throughout the country to maximize their availability to Indian 
students and new programs shall be established in different 
locations from time to time.
    (b) Quentin N. Burdick Program Grant.--The Secretary shall 
provide a grant authorized under subsection (a) to develop and 
maintain a program at the University of North Dakota to be 
known as the `Quentin N. Burdick American Indians Into 
Psychology Program'. Such program shall, to the maximum extent 
feasible, coordinate with the Quentin N. Burdick Indian Health 
Programs authorized under section 117(b), the Quentin N. 
Burdick American Indians Into Nursing Program authorized under 
section 115(e), and existing university research and 
communications networks.
    (c) Regulations.--The Secretary shall issue regulations 
pursuant to this Act for the competitive awarding of grants 
provided under this section.
    (d) Conditions of Grant.--Applicants under this section 
shall agree to provide a program which, at a minimum--
          (1) provides outreach and recruitment for health 
        professions to Indian communities including elementary, 
        secondary, and accredited and accessible community 
        colleges that will be served by the program;
          (2) incorporates a program advisory board comprised 
        of representatives from the tribes and communities that 
        will be served by the program;
          (3) provides summer enrichment programs to expose 
        Indian students to the various fields of psychology 
        through research, clinical, and experimental 
        activities;
          (4) provides stipends to undergraduate and graduate 
        students to pursue a career in psychology;
          (5) develops affiliation agreements with tribal 
        colleges and universities, the Service, university 
        affiliated programs, and other appropriate accredited 
        and accessible entities to enhance the education of 
        Indian students;
          (6) to the maximum extent feasible, uses existing 
        university tutoring, counseling, and student support 
        services; and
          (7) to the maximum extent feasible, employs qualified 
        Indians in the program.
    [The Secretary shall, acting through the Service, establish 
a Placement Office to develop and implement a national policy 
for the placement, to available vacancies within the Service, 
of Indian Health Scholarship recipients required to meet the 
active duty service obligation prescribed under section 254m of 
Title 42 without regard to any competitive personnel system, 
agency personnel limitation, or Indian preference policy.]
    (e) Active Duty Service Requirement.--The active duty 
service obligation prescribed under section 338C of the Public 
Health Service Act (42 U.S.C. 254m) shall be met by each 
graduate who receives a stipend described in subsection (d)(4) 
that is funded under this section. Such obligation shall be met 
by service--
          (1) in an Indian Health Program;
          (2) in a program assisted under title V of this Act; 
        or
          (3) in the private practice of psychology if, as 
        determined by the Secretary, in accordance with 
        guidelines promulgated by the Secretary, such practice 
        is situated in a physician or other health professional 
        shortage area and addresses the health care needs of a 
        substantial number of Indians.
    (f) Authorization of Appropriations.--There is authorized 
to be appropriated to carry out this section $2,700,000 for 
each of fiscal years 2008 through 2017.

SEC. 106. SCHOLARSHIP PROGRAMS FOR INDIAN TRIBES.

    (a) In General.--
          (1) Grants authorized.--The Secretary, acting through 
        the Service, shall make grants to Tribal Health 
        Programs for the purpose of providing scholarships for 
        Indians to serve as health professionals in Indian 
        communities.
          (2) Amount.--Amounts available under paragraph (1) 
        for any fiscal year shall not exceed 5 percent of the 
        amounts available for each fiscal year for Indian 
        Health Scholarships under section 104.
          (3) Application.--An application for a grant under 
        paragraph (1) shall be in such form and contain such 
        agreements, assurances, and information as consistent 
        with this section.
    (b) Requirements.--
          (1) In general.--A Tribal Health Program receiving a 
        grant under subsection (a) shall provide scholarships 
        to Indians in accordance with the requirements of this 
        section.
          (2) Costs.--With respect to costs of providing any 
        scholarship pursuant to subsection (a)--
                  (A) 80 percent of the costs of the 
                scholarship shall be paid from the funds made 
                available pursuant to subsection (a)(1) 
                provided to the Tribal Health Program; and
                  (B) 20 percent of such costs may be paid from 
                any other source of funds.
    (c) Course of Study.--A Tribal Health Program shall provide 
scholarships under this section only to Indians enrolled or 
accepted for enrollment in a course of study (approved by the 
Secretary) in 1 of the health professions contemplated by this 
Act.
    (d) Contract.--
          (1) In general.--In providing scholarships under 
        subsection (b), the Secretary and the Tribal Health 
        Program shall enter into a written contract with each 
        recipient of such scholarship.
          (2) Requirements.--Such contract shall--
                  (A) obligate such recipient to provide 
                service in an Indian Health Program or Urban 
                Indian Organization, in the same Service Area 
                where the Tribal Health Program providing the 
                scholarship is located, for--
                          (i) a number of years for which the 
                        scholarship is provided (or the part-
                        time equivalent thereof, as determined 
                        by the Secretary), or for a period of 2 
                        years, whichever period is greater; or
                          (ii) such greater period of time as 
                        the recipient and the Tribal Health 
                        Program may agree;
                  (B) provide that the amount of the 
                scholarship--
                          (i) may only be expended for--
                                  (I) tuition expenses, other 
                                reasonable educational 
                                expenses, and reasonable living 
                                expenses incurred in attendance 
                                at the educational institution; 
                                and
                                  (II) payment to the recipient 
                                of a monthly stipend of not 
                                more than the amount authorized 
                                by section 338(g)(1)(B) of the 
                                Public Health Service Act (42 
                                U.S.C. 254m(g)(1)(B)), with 
                                such amount to be reduced pro 
                                rata (as determined by the 
                                Secretary) based on the number 
                                of hours such student is 
                                enrolled, and not to exceed, 
                                for any year of attendance for 
                                which the scholarship is 
                                provided, the total amount 
                                required for the year for the 
                                purposes authorized in this 
                                clause; and
                          (ii) may not exceed, for any year of 
                        attendance for which the scholarship is 
                        provided, the total amount required for 
                        the year for the purposes authorized in 
                        clause (i);
                  (C) require the recipient of such scholarship 
                to maintain an acceptable level of academic 
                standing as determined by the educational 
                institution in accordance with regulations 
                issued pursuant to this Act; and
                  (D) require the recipient of such scholarship 
                to meet the educational and licensure 
                requirements appropriate to each health 
                profession.
          (3) Service in other service areas.--The contract may 
        allow the recipient to serve in another Service Area, 
        provided the Tribal Health Program and Secretary 
        approve and services are not diminished to Indians in 
        the Service Area where the Tribal Health Program 
        providing the scholarship is located.
      (e) Breach of Contract.--
          (1) Specific breaches.--An individual who has entered 
        into a written contract with the Secretary and a Tribal 
        Health Program under subsection (d) shall be liable to 
        the United States for the Federal share of the amount 
        which has been paid to him or her, or on his or her 
        behalf, under the contract if that individual--
                  (A) fails to maintain an acceptable level of 
                academic standing in the educational 
                institution in which he or she is enrolled 
                (such level as determined by the educational 
                institution under regulations of the 
                Secretary);
                  (B) is dismissed from such educational 
                institution for disciplinary reasons;
                  (C) voluntarily terminates the training in 
                such an educational institution for which he or 
                she is provided a scholarship under such 
                contract before the completion of such 
                training; or
                  (D) fails to accept payment, or instructs the 
                educational institution in which he or she is 
                enrolled not to accept payment, in whole or in 
                part, of a scholarship under such contract, in 
                lieu of any service obligation arising under 
                such contract.
          (2) Other breaches.--If for any reason not specified 
        in paragraph (1), an individual breaches a written 
        contract by failing to either begin such individual's 
        service obligation required under such contract or to 
        complete such service obligation, the United States 
        shall be entitled to recover from the individual an 
        amount determined in accordance with the formula 
        specified in subsection (l) of section 110 in the 
        manner provided for in such subsection.
          (3) Cancellation upon death of recipient.--Upon the 
        death of an individual who receives an Indian Health 
        Scholarship, any outstanding obligation of that 
        individual for service or payment that relates to that 
        scholarship shall be canceled.
          (4) Information.--The Secretary may carry out this 
        subsection on the basis of information received from 
        Tribal Health Programs involved or on the basis of 
        information collected through such other means as the 
        Secretary deems appropriate.
      (f) Relation to Social Security Act.--The recipient of a 
scholarship under this section shall agree, in providing health 
care pursuant to the requirements herein--
          (1) not to discriminate against an individual seeking 
        care on the basis of the ability of the individual to 
        pay for such care or on the basis that payment for such 
        care will be made pursuant to a program established in 
        title XVIII of the Social Security Act or pursuant to 
        the programs established in title XIX or title XXI of 
        such Act; and
          (2) to accept assignment under section 
        1842(b)(3)(B)(ii) of the Social Security Act for all 
        services for which payment may be made under part B of 
        title XVIII of such Act, and to enter into an 
        appropriate agreement with the State agency that 
        administers the State plan for medical assistance under 
        title XIX, or the State child health plan under title 
        XXI, of such Act to provide service to individuals 
        entitled to medical assistance or child health 
        assistance, respectively, under the plan.
    (g) Continuance of Funding.--The Secretary shall make 
payments under this section to a Tribal Health Program for any 
fiscal year subsequent to the first fiscal year of such 
payments unless the Secretary determines that, for the 
immediately preceding fiscal year, the Tribal Health Program 
has not complied with the requirements of this section.

[Sec. 1614. Indian Health Service extern programs]

SEC. 107. INDIAN HEALTH SERVICE EXTERN PROGRAMS.

    (a) Employment [of scholarship grantees during nonacademic 
periods] Preference.--Any individual who receives a scholarship 
[grant] pursuant to section [1613a of this title] 104 or 106 
shall be [entitled to] given preference for employment in the 
Service [during any nonacademic period of the year.], or may be 
employed by a Tribal Health Program or an Urban Indian 
Organization, or other agencies of the Department as available, 
during any nonacademic period of the year.
    (b) Not Counted Toward Active Duty Service Obligation.--
Periods of employment pursuant to this subsection shall not be 
counted in determining [the] fulfillment of the service 
obligation incurred as a condition of the scholarship [grant].
    [(b)](c) Timing; Length of Employment [of medical and other 
students during nonacademic periods].--Any individual enrolled 
in a [course of study in the health professions] program, 
including a high school program, authorized under section 
102(a) may be employed by the Service or by a Tribal Health 
Program or an Urban Indian Organization during any nonacademic 
period of the year. Any such employment shall not exceed [one 
hundred and twenty] 120 days during any calendar year.
    [(c) Employment without regard to competitive personnel 
system or agency personnel limitation; compensation] (d) 
Nonapplicability of Competitive Personnel System.--Any 
employment pursuant to this section shall be made without 
regard to any competitive personnel system or agency personnel 
limitation and to a position which will enable the individual 
so employed to receive practical experience in the health 
profession in which he or she is engaged in study. Any 
individual so employed shall receive payment for his or her 
services comparable to the salary he or she would receive if he 
or she were employed in the competitive system. Any individual 
so employed shall not be counted against any employment ceiling 
affecting the Service or the Department[of Health and Human 
Services].

[Sec. 1615. Continuing education allowances]

SEC. 108. CONTINUING EDUCATION ALLOWANCES.

    [(a) Discretionary authority; scope of activities]
    In order to encourage [physicians, dentists, nurses, and 
other] scholarship and stipend recipients under sections 104, 
105, 106, and 115 and health professionals, including community 
health representatives and emergency medical technicians, to 
join or continue in [the Service] an Indian Health Program and 
to provide their services in the rural and remote areas where a 
significant portion of [the Indian people resides] Indians 
reside, the Secretary, acting through the Service, may 
[provide]--
          (1) provide programs or allowances to transition into 
        an Indian Health Program, including licensing, board or 
        certification examination assistance, and technical 
        assistance in fulfilling service obligations under 
        sections 104, 105, 106, and 115; and
          (2) provide programs or allowances to health 
        professionals employed in [the Service] an Indian 
        Health Program to enable them for a period of time each 
        year prescribed by regulation of the Secretary to take 
        leave of their duty stations for professional 
        consultation, management, leadership, and refresher 
        training courses.
    [(b) Limitation
    [Of amounts appropriated under the authority of this 
subchapter for each fiscal year to be used to carry out this 
section, not more than $1,000,000 may be used to establish 
postdoctoral training programs for health professionals.

[Sec. 1616. Community Health Representative Program]

SEC. 109. COMMUNITY HEALTH REPRESENTATIVE PROGRAM.

    (a) In General.--Under the authority of the Act of November 
2, 1921 (25 U.S.C. 13)[, popularly] (commonly known as the 
``Snyder Act''), the Secretary, acting through the Service, 
shall maintain a Community Health Representative Program under 
which [the Service]Indian Health Programs--
          (1) [provides] provide for the training of Indians as 
        [health paraprofessionals, and] community health 
        representatives; and
          [(2) uses such paraprofessionals] (2) use such 
        community health representatives in the provision of 
        health care, health promotion, and disease prevention 
        services to Indian communities.
    [(b) The Secretary, acting through the Community Health 
Representative Program of the Service, shall--]
    (b) Duties.--The Community Health Representative Program of 
the Service, shall--
          (1) provide a high standard of training for 
        [paraprofessionals to Community Health Representatives] 
        community health representatives to ensure that the 
        [Community Health Representatives] community health 
        representatives provide quality health care, health 
        promotion, and disease prevention services to the 
        Indian communities served by [such] the Program[,];
          (2) in order to provide such training, develop and 
        maintain a curriculum that--
                  (A) combines education in the theory of 
                health care with supervised practical 
                experience in the provision of health care[,]; 
                and
                  (B) provides instruction and practical 
                experience in health promotion and disease 
                prevention activities, with appropriate 
                consideration given to lifestyle factors that 
                have an impact on Indian health status, such as 
                alcoholism, family dysfunction, and poverty[,];
          (3) maintain a system which identifies the needs of 
        [Community Health Representatives] community health 
        representatives for continuing education in health 
        care, health promotion, and disease prevention and 
        develop programs that meet the needs for [such] 
        continuing education[,];
          (4) maintain a system that provides close supervision 
        of Community Health Representatives[,];
          (5) maintain a system under which the work of 
        Community Health Representatives is reviewed and 
        evaluated[,]; and
          (6) promote traditional health care practices of the 
        Indian [tribes] Tribes served consistent with the 
        Service standards for the provision of health care, 
        health promotion, and disease prevention.

[Sec. 1616a. Indian Health Service Loan Repayment Program]

SEC. 110. INDIAN HEALTH SERVICE LOAN REPAYMENT PROGRAM.

    (a) Establishment.--[(1)]The Secretary, acting through the 
Service, shall establish and administer a program to be known 
as the [Indian Health] Service Loan Repayment Program 
(hereinafter referred to as the [``]`Loan Repayment 
Program['']') in order to [assure] ensure an adequate supply of 
trained health professionals necessary to maintain 
accreditation of, and provide health care services to Indians 
through, Indian [health programs] Health Programs and Urban 
Indian Organizations.
    [(2) For the purposes of this section--]
          [(A) the term ``Indian health program'' means any 
        health program or facility funded, in whole or part, by 
        the Service for the benefit of Indians and 
        administered--
                  [(i) directly by the Service;
                  [(ii) by any Indian tribe or tribal or Indian 
                organization pursuant to a contract under--
                          [(I) the Indian Self-Determination 
                        Act [25 U.S.C.A. Sec. 450f et seq.], or
                          [(II) section 23 of the Act of April 
                        30, 1908 (25 U.S.C. 47), popularly 
                        known as the ``Buy-Indian'' Act; or
                  [(iii) by an urban Indian organization 
                pursuant to subchapter IV of this chapter; and
          [(B) the term ``State'' has the same meaning given 
        such term in section 254d of Title 42.]
    [(b) Eligibility] (b) Eligible Individuals.--To be eligible 
to participate in the Loan Repayment Program, an individual 
must--
          (1)(A) be enrolled--
                  (i) in a course of study or program in an 
                accredited educational institution[,] (as 
                determined by the Secretary[, within any State] 
                under section 338B(b)(1)(c)(i) of the Public 
                Health Service Act (42 U.S.C. 254l-
                1(b)(1)(c)(i))) and be scheduled to complete 
                such course of study in the same year such 
                individual applies to participate in such 
                program; or
                  (ii) in an approved graduate training program 
                in a health profession; or
          (B) have--
                  (i) a degree in a health profession; and
                  (ii) a license to practice a health 
                profession [in a State];
          (2)(A) be eligible for, or hold, an appointment as a 
        commissioned officer in the Regular or Reserve Corps of 
        the Public Health Service;
          (B) be eligible for selection for civilian service in 
        the Regular or Reserve Corps of the Public Health 
        Service;
          (C) meet the professional standards for civil service 
        employment in the [Indian Health] Service; or
          (D) be employed in an Indian [health program] Health 
        Program or Urban Indian Organization without a service 
        obligation; and
          (3) submit to the Secretary an application for a 
        contract described in subsection [(f) of this section] 
        (e).
    (c) Application [and Contract Forms].--
          [(1)] (1) Information to be included with forms.--In 
        disseminating application forms and contract forms to 
        individuals desiring to participate in the Loan 
        Repayment Program, the Secretary shall include with 
        such forms a fair summary of the rights and liabilities 
        of an individual whose application is approved (and 
        whose contract is accepted) by the Secretary, including 
        in the summary a clear explanation of the damages to 
        which the United States is entitled under subsection 
        [(1)] (l) [of this section] in the case of the 
        individual's breach of [the] contract. The Secretary 
        shall provide such individuals with sufficient 
        information regarding the advantages and disadvantages 
        of service as a commissioned officer in the Regular or 
        Reserve Corps of the Public Health Service or a 
        civilian employee of the [Indian health] Service to 
        enable the individual to make a decision on an informed 
        basis.
          (2) Clear language.--The application form, contract 
        form, and all other information furnished by the 
        Secretary under this section shall be written in a 
        manner calculated to be understood by the average 
        individual applying to participate in the Loan 
        Repayment Program.
          [(3)] (3) Timely availability of forms.--The 
        Secretary shall make such application forms, contract 
        forms, and other information available to individuals 
        desiring to participate in the Loan Repayment Program 
        on a date sufficiently early to ensure that such 
        individuals have adequate time to carefully review and 
        evaluate such forms and information.
    [(d) Vacancies; priority]
    (d) Priorities.--
          (1) List.--Consistent [with paragraph (3), the 
        Secretary, acting through the Service and in 
        accordance] with subsection (k) [of this section], the 
        Secretary shall annually--
                  (A) identify the positions in each Indian 
                [health program] Health Program or Urban Indian 
                Organization for which there is a need or a 
                vacancy[,]; and
                  (B) rank those positions in order of 
                priority.
          (2) [Consistent with] Approvals.--Notwithstanding the 
        priority determined under paragraph (1), the Secretary, 
        in determining which applications under the Loan 
        Repayment Program to approve (and which contracts to 
        accept), shall--
                  (A) give first priority to applications made 
                by[-- (A)] individual Indians; and
                  (B) after making determinations on all 
                applications submitted by individual Indians as 
                required under subparagraph (A), give priority 
                to--
                          [(B)] (i) individuals recruited 
                        through the efforts of an Indian 
                        [tribes or tribal or Indian 
                        organizations.]
          [(3)(A) Subject to subparagraph (B), of the total 
        amounts appropriated for each of the fiscal years 1993, 
        1994, and 1995 for loan repayment contracts under this 
        section, the Secretary shall provide that--
                          [(i) not less than 25 percent be 
                        provided to applicants who are nurses, 
                        nurse practitioners, or nurse midwives] 
                        Health Program or Urban Indian 
                        Organization; and
                          [(ii) not less than 10 percent be 
                        provided to applicants who are mental 
                        health professionals (other than 
                        applicants described in clause (i)).
                  [(B) The requirements specified in clause (i) 
                or clause (ii) of subparagraph (A) shall not 
                apply if the Secretary does not receive the 
                number of applications from the individuals 
                described in clause (i) or clause (ii), 
                respectively, necessary to meet such 
                requirements.
    [(e) Approval]
                          (ii) other individuals based on the 
                        priority rankings under paragraph (1).
    (e) Recipient Contracts._
          (1) Contract required._An individual becomes a 
        participant in the Loan Repayment Program only upon the 
        Secretary and the individual entering into a written 
        contract described in [subsection (f) of this section.] 
        paragraph (2).
          [(2) The Secretary shall provide written notice to an 
        individual promptly on--
                  [(A) the Secretary's approving, under 
                paragraph (1), of the individual's 
                participation in the Loan Repayment Program, 
                including extensions resulting in an aggregate 
                period of obligated service in excess of 4 
                years; or
                  [(B) the Secretary's disapproving an 
                individual's participation in such Program.
    [(f) Contract terms]
          (2) Contents of contract.--The written contract 
        referred to in this section between the Secretary and 
        an individual shall contain--
                  [(1)] (A) an agreement under which--
                          [(A)] (i) subject to [paragraph (3)] 
                        subparagraph (C), the Secretary 
                        agrees--
                                  [(i)] (I) to pay loans on 
                                behalf of the individual in 
                                accordance with the provisions 
                                of this section[,]; and
                                  [(ii)](II) to accept (subject 
                                to the availability of 
                                appropriated funds for carrying 
                                out this section) the 
                                individual into the Service or 
                                place the individual with a 
                                [tribe] Tribal Health Program 
                                or Urban Indian [organization] 
                                Organization as provided in 
                                [subparagraph (B)(iii),] clause 
                                (ii)(III); and
                          [(B] (ii) subject to [paragraph (3] 
                        subparagraph (C), the individual 
                        agrees--
                                  [(i)] (I) to accept loan 
                                payments on behalf of the 
                                individual;
                                  [(ii)] (II) in the case of an 
                                individual described in 
                                subsection (b)(1)--
                                          [(I)] (aa) to 
                                        maintain enrollment in 
                                        a course of study or 
                                        training described in 
                                        subsection (b)(1)(A) 
                                        [of this section] until 
                                        the individual 
                                        completes the course of 
                                        study or training[,]; 
                                        and
                                          [(II)] (bb) while 
                                        enrolled in such course 
                                        of study or training, 
                                        to maintain an 
                                        acceptable level of 
                                        academic standing (as 
                                        determined under 
                                        regulations of the 
                                        Secretary by the 
                                        educational institution 
                                        offering such course of 
                                        study or training); and
                                  [(iii)] (III) to serve for a 
                                time period (hereinafter in 
                                this section referred to as the 
                                ``period of obligated 
                                service'') equal to 2 years or 
                                such longer period as the 
                                individual may agree to serve 
                                in the full-time clinical 
                                practice of such individual's 
                                profession in an Indian [health 
                                program] Health Program or 
                                Urban Indian Organization to 
                                which the individual may be 
                                assigned by the Secretary;
                          [(2)] (B) a provision permitting the 
                        Secretary to extend for such longer 
                        additional periods, as the individual 
                        may agree to, the period of obligated 
                        service agreed to by the individual 
                        under [paragraph (1)(B)(iii)] 
                        subparagraph (A)(ii)(III);
                          [(3)] (C) a provision that any 
                        financial obligation of the United 
                        States arising out of a contract 
                        entered into under this section and any 
                        obligation of the individual which is 
                        conditioned thereon is contingent upon 
                        funds being appropriated for loan 
                        repayments under this section;
                          [(4)] (D) a statement of the damages 
                        to which the United States is entitled 
                        under subsection ([1]l) [of this 
                        section] for the individual's breach of 
                        the contract; and
                          [(5)] (E) such other statements of 
                        the rights and liabilities of the 
                        Secretary and of the individual, not 
                        inconsistent with this section.
    [(g) Loan repayment purposes; maximum amount; tax liability 
reimbursement; schedule of payments]
    (f) Deadline for Decision on Application.--The Secretary 
shall provide written notice to an individual within 21 days 
on--
          (1) the Secretary's approving, under subsection 
        (e)(1), of the individual's participation in the Loan 
        Repayment Program, including extensions resulting in an 
        aggregate period of obligated service in excess of 4 
        years; or
          (2) the Secretary's disapproving an individual's 
        participation in such Program.
    (g) Payments.--
          [(1)] (1) In general.--A loan repayment provided for 
        an individual under a written contract under the Loan 
        Repayment Program shall consist of payment, in 
        accordance with paragraph (2), on behalf of the 
        individual of the principal, interest, and related 
        expenses on government and commercial loans received by 
        the individual regarding the undergraduate or graduate 
        education of the individual (or both), which loans were 
        made for--
                  (A) tuition expenses;
                  (B) all other reasonable educational 
                expenses, including fees, books, and laboratory 
                expenses, incurred by the individual; and
                  (C) reasonable living expenses as determined 
                by the Secretary.
          (2) [(A)] Amount.--For each year of obligated service 
        that an individual contracts to serve under subsection 
        ([f]e), the Secretary may pay up to $35,000 [(]or an 
        amount equal to the amount specified in section [254l-
        l]338B(g)(2)(A) of [Title 42] the Public Health Service 
        Act, whichever is more, on behalf of the individual for 
        loans described in paragraph (1). In making a 
        determination of the amount to pay for a year of such 
        service by an individual, the Secretary shall consider 
        the extent to which each such determination--
                  [(i)] (A) affects the ability of the 
                Secretary to maximize the number of contracts 
                that can be provided under the Loan Repayment 
                Program from the amounts appropriated for such 
                contracts;
                  [(ii)] (B) provides an incentive to serve in 
                Indian [health programs]Health Programs and 
                Urban Indian Organizations with the greatest 
                shortages of health professionals; and
                  [(iii)] (C) provides an incentive with 
                respect to the health professional involved 
                remaining in an Indian [health program] Health 
                Program or Urban Indian Organization with such 
                a health professional shortage, and continuing 
                to provide primary health services, after the 
                completion of the period of obligated service 
                under the Loan Repayment Program.
          [(B)] (3) Timing.--Any arrangement made by the 
        Secretary for the making of loan repayments in 
        accordance with this subsection shall provide that any 
        repayments for a year of obligated service shall be 
        made no later than the end of the fiscal year in which 
        the individual completes such year of service.
          [(3)] (4) Reimbursements for tax liability.--For the 
        purpose of providing reimbursements for tax liability 
        resulting from [payments] a payment under paragraph (2) 
        on behalf of an individual, the Secretary--
                  (A) in addition to such payments, may make 
                payments to the individual in an amount equal 
                to not less than 20 percent and not more than 
                39 percent of the total amount of loan 
                repayments made for the taxable year involved; 
                and
                  (B) may make such additional payments as the 
                Secretary determines to be appropriate with 
                respect to such purpose.
          [(4)] (5) Payment schedule.--The Secretary may enter 
        into an agreement with the holder of any loan for which 
        payments are made under the Loan Repayment Program to 
        establish a schedule for the making of such payments.
    [(h) Effect on Employment Ceiling of Department of Health 
and Human Services]
    (h) Employment Ceiling.--Notwithstanding any other 
provision of law, individuals who have entered into written 
contracts with the Secretary under this section[, while 
undergoing academic training,] shall not be counted against any 
employment ceiling affecting the Department [of Health and 
Human Services] while those individuals are undergoing academic 
training.
    (i) [Recruiting programs] Recruitment.--The Secretary shall 
conduct recruiting programs for the Loan Repayment Program and 
other [health professional] manpower programs of the Service at 
educational institutions training health professionals or 
specialists identified in subsection (a)[of this section].
    (j) [Prohibition of assignment to other government 
departments.--Section 215 of Title 42] Applicability of Law.--
Section 214 of the Public Health Service Act (42 U.S.C. 215) 
shall not apply to individuals during their period of obligated 
service under the Loan Repayment Program.
    [(k) Staff needs of health programs administered by Indian 
tribes] (k) Assignment of Individuals.--The Secretary, in 
assigning individuals to serve in Indian [health programs] 
Health Programs or Urban Indian Organizations pursuant to 
contracts entered into under this section, shall--
          (1) ensure that the staffing needs of [Indian health 
        programs administered by an Indian tribe or tribal or 
        health organization] Tribal Health Programs and Urban 
        Indian Organizations receive consideration on an equal 
        basis with programs that are administered directly by 
        the Service; and
          (2) give priority to assigning individuals to Indian 
        [health programs] Health Programs and Urban Indian 
        Organizations that have a need for health professionals 
        to provide health care services as a result of 
        individuals having breached contracts entered into 
        under this section.
    [(l) Voluntarily termination of study or dismissal from 
educational institution; collection of damages]
    (l) Breach of Contract.--
          (1) Specific breaches.--An individual who has entered 
        into a written contract with the Secretary under this 
        section and [who--] has not received a waiver under 
        subsection (m) shall be liable, in lieu of any service 
        obligation arising under such contract, to the United 
        States for the amount which has been paid on such 
        individual's behalf under the contract if that 
        individual--
                  (A) is enrolled in the final year of a course 
                of study and [who]--
                          (i) fails to maintain an acceptable 
                        level of academic standing in the 
                        educational institution in which he or 
                        she is enrolled (such level determined 
                        by the educational institution under 
                        regulations of the Secretary);
                          (ii) voluntarily terminates such 
                        enrollment; or
                          (iii) is dismissed from such 
                        educational institution before 
                        completion of such course of study; or
                  (B) is enrolled in a graduate training 
                program[,] and fails to complete such training 
                program[, and does not receive a waiver from 
                the Secretary under subsection (b)(1)(B)(ii), 
                shall be liable, in lieu of any service 
                obligation arising under such contract, to the 
                United States for the amount which has been 
                paid on such individual's behalf under the 
                contract.].
          [(2)] (2) Other breaches; formula for amount owed.--
        If, for any reason not specified in paragraph (1), an 
        individual breaches his or her written contract under 
        this section by failing either to begin, or complete, 
        such individual's period of obligated service in 
        accordance with subsection [(f) of this section] 
        (e)(2), the United States shall be entitled to recover 
        from such individual an amount to be determined in 
        accordance with the following formula: A=3Z(t-s/t) in 
        which--
                  (A) ``A'' is the amount the United States is 
                entitled to recover;
                  (B) ``Z'' is the sum of the amounts paid 
                under this section to, or on behalf of, the 
                individual and the interest on such amounts 
                which would be payable if, at the time the 
                amounts were paid, they were loans bearing 
                interest at the maximum legal prevailing rate, 
                as determined by the [Treasurer] Secretary of 
                the [United States] Treasury;
                  (C) ``t'' is the total number of months in 
                the individual's period of obligated service in 
                accordance with subsection (f) [of this 
                section]; and
                  (D) ``s'' is the number of months of such 
                period served by such individual in accordance 
                with this section.
          (3) Deductions in medicare Payments.--Amounts not 
        paid within such period shall be subject to collection 
        through deductions in Medicare payments pursuant to 
        section [1395ccc of Title 42.] 1892 of the Social 
        Security Act.
          [(3)(A)] (4) Time period for repayment.--Any amount 
        of damages which the United States is entitled to 
        recover under this subsection shall be paid to the 
        United States within the 1-year period beginning on the 
        date of the breach or such longer period beginning on 
        such date as shall be specified by the Secretary.
          (5) Recovery of delinquency.--
                  [(B)] (A) In general.--If damages described 
                in [subparagraph (A)] paragraph (4) are 
                delinquent for 3 months, the Secretary shall, 
                for the purpose of recovering such damages--
                          (i) [utilize] use collection agencies 
                        contracted with by the Administrator of 
                        [the] General Services 
                        [Administration]; or
                          (ii) enter into contracts for the 
                        recovery of such damages with 
                        collection agencies selected by the 
                        Secretary.
                  [(C)] (B) Report.--Each contract for 
                recovering damages pursuant to this subsection 
                shall provide that the contractor will, not 
                less than once each 6 months, submit to the 
                Secretary a status report on the success of the 
                contractor in collecting such damages. Section 
                3718 of [Title 31] title 31, United States 
                Code, shall apply to any such contract to the 
                extent not inconsistent with this subsection.
    [(m) Cancellation or waiver of obligations; bankruptcy 
discharge
          [(1) Any obligation of an individual under the Loan 
        Repayment Program for service or payment of damages 
        shall be canceled upon the death of the individual.]
    (m) Waiver or Suspension of Obligation._
          [(2)](1) In general.--The Secretary shall by 
        regulation provide for the partial or total waiver or 
        suspension of any obligation of service or payment by 
        an individual under the Loan Repayment Program whenever 
        compliance by the individual is impossible or would 
        involve extreme hardship to the individual and if 
        enforcement of such obligation with respect to any 
        individual would be unconscionable.
          (2) Canceled upon death.--Any obligation of an 
        individual under the Loan Repayment Program for service 
        or payment of damages shall be canceled upon the death 
        of the individual.
          (3) Hardship waiver.--The Secretary may waive, in 
        whole or in part, the rights of the United States to 
        recover amounts under this section in any case of 
        extreme hardship or other good cause shown, as 
        determined by the Secretary.
          (4) Bankruptcy.--Any obligation of an individual 
        under the Loan Repayment Program for payment of damages 
        may be released by a discharge in bankruptcy under 
        [Title] title 11 of the United States Code only if such 
        discharge is granted after the expiration of the 5-year 
        period beginning on the first date that payment of such 
        damages is required, and only if the bankruptcy court 
        finds that nondischarge of the obligation would be 
        unconscionable.
    (n) [Annual report] Report.--The Secretary shall submit to 
the President, for inclusion in [each] the report required to 
be submitted to [the] Congress under section [1671 of this 
title,] 801, a report concerning the previous fiscal year which 
sets forth[--] by Service Area the following:
          (1) A list of the health professional positions 
        maintained by [the Service or by tribal or Indian 
        organizations] Indian Health Programs and Urban Indian 
        Organizations for which recruitment or retention is 
        difficult[;].
          (2) [the] The number of Loan Repayment Program 
        applications filed with respect to each type of health 
        profession[;].
          (3) [the] The number of contracts described in 
        subsection [(f) of this section] (e) that are entered 
        into with respect to each health profession[;].
          (4) [the] The amount of loan payments made under this 
        section, in total and by health profession[;].
          (5) [the] The number of [scholarship grants] 
        scholarships that are provided under [section 1613a of 
        this title] sections 104 and 106 with respect to each 
        health profession[;].
          (6) [the] The amount of scholarship grants provided 
        under section [1613a of this title,] 104 and 106, in 
        total and by health profession[;].
          (7) [the] The number of providers of health care that 
        will be needed by Indian [health programs] Health 
        Programs and Urban Indian Organizations, by location 
        and profession, during the [three] 3 fiscal years 
        beginning after the date the report is filed[; and].
          (8) [the] The measures the Secretary plans to take to 
        fill the health professional positions maintained by 
        [the Service or by tribes or tribal or Indian 
        organizations] Indian Health Programs or Urban Indian 
        Organizations for which recruitment or retention is 
        difficult.

[Sec. 1616a-1. Scholarship and Loan Repayment Recovery Fund]

SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOVERY FUND.

    (a) Establishment.--There is established in the Treasury of 
the United States a fund to be known as the Indian Health 
Scholarship and Loan Repayment Recovery Fund (hereafter in this 
section referred to as the [``Fund''] ``LRRF''). The [Fund] 
LRRF shall consist of such amounts as may be [appropriated to 
the Fund under subsection (b) of this section. Amounts 
appropriated for the Fund] collected from individuals under 
section 104(d), section 106(e), and section 110(l) for breach 
of contract, such funds as may be appropriated to the LRRF, and 
interest earned on amounts in the LRRF. All amounts collected, 
appropriated, or earned relative to the LRRF shall remain 
available until expended.
    [(b) Authorization of appropriations
    [For each fiscal year, there is authorized to be 
appropriated to the Fund an amount equal to the sum of--
          [(1) the amount collected during the preceding fiscal 
        year by the Federal Government pursuant to--
                  [(A) the liability of individuals under 
                subparagraph (A) or (B) of section 1613a(b)(5) 
                of this title for the breach of contracts 
                entered into under 1613a of this title; and
                  [(B) the liability of individuals under 
                section 1616a(l) of this title for the breach 
                of contracts entered into under section 1616a 
                of this title; and
          [(2) the aggregate amount of interest accruing during 
        the preceding fiscal year on obligations held in the 
        Fund pursuant to subsection (d) of this section and the 
        amount of proceeds from the sale or redemption of such 
        obligations during such fiscal year.
    [(c)] (b) Use of [funds] Funds.--
          (1) By secretary.--Amounts in the [Fund and available 
        pursuant to appropriation Acts] LRRF may be expended by 
        the Secretary, acting through the Service, to make 
        payments to an Indian [tribe or tribal organization 
        administering a health care program pursuant to a 
        contract entered into under the Indian Self-
        Determination Act [25 U.S.C.A. Sec. 450f et seq.]--] 
        Health Program--
                  (A) to which a scholarship recipient under 
                section [1613a of this title] 104 and 106 or a 
                loan repayment program participant under 
                section [1616a of this title] 110 has been 
                assigned to meet the obligated service 
                requirements pursuant to such sections; and
                  (B) that has a need for a health professional 
                to provide health care services as a result of 
                such recipient or participant having breached 
                the contract entered into under section [1613a 
                of this title, or section 1616a of this title.] 
                104, 106, or section 110.
          [(2) An Indian tribe or tribal organization] (2) By 
        tribal health programs.--A Tribal Health Program 
        receiving payments pursuant to paragraph (1) may expend 
        the payments to provide scholarships or recruit and 
        employ, directly or by contract, health professionals 
        to provide health care services.
    [(d)] (c) Investment of [excess funds (1)] Funds.--The 
Secretary of the Treasury shall invest such amounts of the 
[Fund] LRRF as [such] the Secretary of Health and Human 
Services determines are not required to meet current 
withdrawals from the [Fund] LRRF. Such investments may be made 
only in interest-bearing obligations of the United States. For 
such purpose, such obligations may be acquired on original 
issue at the issue price, or by purchase of outstanding 
obligations at the market price.
    [(2)] (d) Sale of Obligations.--Any obligation acquired by 
the [Fund] LRRF may be sold by the Secretary of the Treasury at 
the market price.

[Sec. 1616b. Recruitment activities]

SEC. 112. RECRUITMENT ACTIVITIES.

    (a) Reimbursement for Travel.--The Secretary, acting 
through the Service, may reimburse health professionals seeking 
positions [in the Service] with Indian Health Programs or Urban 
Indian Organizations, including individuals considering 
entering into a contract under section [1616a of this title,] 
110 and their spouses, for actual and reasonable expenses 
incurred in traveling to and from their places of residence to 
an area in which they may be assigned for the purpose of 
evaluating such area with respect to such assignment.
    [(b)] (b) Recruitment Personnel.--The Secretary, acting 
through the Service, shall assign [one] 1 individual in each 
[area office] Area Office to be responsible on a full-time 
basis for recruitment activities.

[Sec. 1616c. Tribal recruitment and retention program]

SEC. 113. INDIAN RECRUITMENT AND RETENTION PROGRAM.

    [(a) Projects funded on competitive basis]
    (a) In General.--The Secretary, acting through the Service, 
shall fund, on a competitive basis, innovative demonstration 
projects for a period not to exceed 3 years to enable [Indian 
tribes and tribal and Indian organizations] Tribal Health 
Programs and Urban Indian Organizations to recruit, place, and 
retain health professionals to meet [the] their staffing needs 
[of Indian health programs (as defined in section 1616a(a)(2) 
of this title)].
    [(b) Eligibility]
    [(1) Any Indian tribe or tribal or Indian organization](b) 
Eligible Entities; Application.--Any Tribal Health Program or 
Urban Indian Organization may submit an application for funding 
of a project pursuant to this section.
    [(2) Indian tribes and tribal and Indian organizations 
under the authority of the Indian Self-Determination Act [25 
U.S.C.A. Sec. 450f et seq.] shall be given an equal opportunity 
with programs that are administered directly by the Service to 
compete for, and receive, grants under subsection (a) of this 
section for such projects.

[Sec. 1616d. Advanced training and research]

SEC. 114. ADVANCED TRAINING AND RESEARCH

    [(a) Establishment of program]
    (a) Demonstration Program.--The Secretary, acting through 
the Service, shall establish a [program] demonstration project 
to enable health professionals who have worked in an Indian 
Health Program or Urban Indian Organization for a substantial 
period of time to pursue advanced training or research [in] 
areas of study for which the Secretary determinates a need 
exists. [In selecting participants for a program established 
under this subsection, the Secretary, acting through the 
Service, shall give priority to applicants who are employed by 
the Indian Health Service, Indian tribes, tribal organizations, 
and urban Indian organizations, at the time of the submission 
of the applications.]
    [(b) Obligated service]
    (b) Service Obligation.--An individual who participates in 
a program under subsection (a) [of this section], where the 
educational costs are borne by the Service, shall incur an 
obligation to serve in an Indian [health program (as defined in 
section 1616a(a)(2) of this title)] Health Program or Urban 
Indian Organization for a period of obligated service equal to 
at least the period of time during which the individual 
participates in such program. In the event that the individual 
fails to complete such obligated service, the individual shall 
be liable to the United States for the period of service 
remaining. In such event, with respect to individuals entering 
the program after [October 29, 1992,] the date of enactment of 
the Indian Health Care Improvement Act Amendments of 2007, the 
United States shall be entitled to recover from such individual 
an amount to be determined in accordance with the formula 
specified in subsection (1) of section [1616a of this title] 
110 in the manner provided for in such subsection.
    [(c) Eligibility]
    (c) Equal Opportunity for Participation.--Health 
professionals from [Indian tribes and tribal and Indian 
organizations under the authority of the Indian Self 
Determination Act [25 U.S.C.A. Sec. 450f et seq.] Tribal Health 
Programs and Urban Indian Organizations shall be given an equal 
opportunity to participate in the program under subsection 
(a)[of this section].

[Sec. 1616e. Nursing program]

SEC. 115. QUENTIN N. BURDICK AMERICAN INDIANS INTO NURSING PROGRAM.

    (a) Grants.
    [The Secretary, acting through the Service, shall provide 
grants to--
          [(1) public or private schools of nursing,
          [(2) tribally controlled community colleges and 
        tribally controlled postsecondary vocational 
        institutions (as defined in section 2397h(2) of Title 
        20), and]
          [(3) nurse midwife programs, and nurse practitioner 
        programs, that are provided by any public or private 
        institution, for] Authorized.--For the purpose of 
        increasing the number of nurses, nurse midwives, and 
        nurse practitioners who deliver health care services to 
        Indians, the Secretary, acting through the Service, 
        shall provide grants to the following:
          (1) Public or private schools of nursing.
          (2) Tribal colleges or universities.
          (3) Nurse midwife programs and advanced practice 
        nurse programs that are provided by any tribal college 
        or university accredited nursing program, or in the 
        absence of such, any other public or private 
        institutions.
    (b) [Purposes] Use of Grants._Grants provided under 
subsection (a) [of this section] may be used [to--] for 1 or 
more of the following:
          (1) To recruit individuals for programs which train 
        individuals to be nurses, nurse midwives, or [nurse 
        practitioners,] advanced practice nurses.
          (2) To provide scholarships to [individuals] Indians 
        enrolled in such programs that may pay the tuition 
        charged for such program and other expenses incurred in 
        connection with such program, including books, fees, 
        room and board, and stipends for living expenses[,].
          (3) To provide a program that encourages nurses, 
        nurse midwives, and [nurse practitioners] advanced 
        practice nurses to provide, or continue to provide, 
        health care services to Indians[,].
          (4) To provide a program that increases the skills 
        of, and provides continuing education to, nurses, nurse 
        midwives, and [nurse practitioners, or] advanced 
        practice nurses.
          (5) To provide any program that is designed to 
        achieve the purpose described in subsection (a) [of 
        this section].
    (c) [Application] Applications._Each application for a 
grant under subsection (a) [of this section] shall include such 
information as the Secretary may require to establish the 
connection between the program of the applicant and a health 
care facility that primarily serves Indians.
    [(d) Preference]
    (d) Preferences for Grant Recipients._In providing grants 
under subsection (a) [of this section], the Secretary shall 
extend a preference to[--] the following:
          (1) [programs] Programs that provide a preference to 
        Indians[,].
          (2) [programs] Programs that train nurse midwives or 
        [nurse practitioners,] advanced practice nurses.
          (3) [programs] Programs that are interdisciplinary[, 
        and].
          (4) [programs] Programs that are conducted in 
        cooperation with a [center] program for gifted and 
        talented Indian students [established under section 
        2624(a) of this title].
          (5) Programs conducted by tribal colleges and 
        universities.
    (e) Quentin N. Burdick [American Indians Into Nursing] 
Program Grant._The Secretary shall provide [one] 1 of the 
grants authorized under subsection (a)[of this section] to 
establish and maintain a program at the University of North 
Dakota to be known as the ``Quentin N. Burdick American Indians 
Into Nursing Program''. Such program shall, to the maximum 
extent feasible, coordinate with the Quentin N. Burdick Indian 
Health Programs established under section [1616g] 117(b) [of 
this title] and the Quentin N. Burdick American Indians Into 
Psychology Program established under section [1621p] 105(b) [of 
this title].
    (f) Active Duty Service [obligation] Obligation._The active 
duty service obligation prescribed under section [254m of this 
title] 338C of the Public Health Service Act (42 U.S.C. 254m) 
shall be met by each individual who receives training or 
assistance described in paragraph (1) or (2) of subsection (b) 
[of this section] that is funded by a grant provided under 
subsection (a) [of this section]. Such obligation shall be met 
by service--
          [(A)] (1) in the [Indian Health] Service;
          [(B)] (2) in a program of an Indian Tribe or Tribal 
        Organization conducted under [a contract entered into 
        under] the Indian Self-Determination and Education 
        Assistance Act [[](25 U.S.C.[A. Sec. ] 450[f et seq.]; 
        (C]  et seq.) (including programs under agreements with 
        the Bureau of Indian Affairs);
          (3) in a program assisted under [subchapter IV] title 
        V of this [chapter; or] Act;
          [(D)](4) in the private practice of nursing if, as 
        determined by the Secretary, in accordance with 
        guidelines promulgated by the Secretary, such practice 
        is situated in a physician or other health 
        [professional] shortage area and addresses the health 
        care needs of a substantial number of Indians[.]; or
    [(g) Authorization of appropriations
    [Beginning with fiscal year 1993, of the amounts 
appropriated under the authority of this subchapter for each 
fiscal year to be used to carry out this section, not less than 
$1,000,000 shall be used to provide grants under subsection (a) 
of this section for the training of nurse midwives, nurse 
anesthetists, and nurse practitioners.

[Sec. 1616e-1. Nursing school clinics

    [(a) Grants
    [In addition to the authority of the Secretary under 
section 1616e(a)(1) of this title, the Secretary, acting 
through the Service, is authorized to provide grants to public 
or private schools of nursing for the purpose of establishing, 
developing, operating, and administering clinics to address the 
health care needs of Indians, and to provide primary health 
care services to Indians who reside on or within 50 miles of 
Indian country, as defined in section 1151 of Title 18.
    [(b) Purposes
    [Grants provided under subsection (a) of this section may 
be used to--
          [(1) establish clinics, to be run and staffed by the 
        faculty and students of a grantee school, to provide 
        primary care services in areas in or within 50 miles of 
        Indian country (as defined in section 1151 of Title 
        18);
          [(2) provide clinical training, program development, 
        faculty enhancement, and student scholarships in a 
        manner that would benefit such clinics; and
          [(3) carry out any other activities determined 
        appropriate by the Secretary.
    [(c) Amount and conditions
    [The Secretary may award grants under this section in such 
amounts and subject to such conditions as the Secretary deems 
appropriate.
    [(d) Design
    [The clinics established under this section shall be 
designed to provide nursing students with a structured clinical 
experience that is similar in nature to that provided by 
residency training programs for physicians.
    [(e) Regulations
    [The Secretary shall prescribe such regulations as may be 
necessary to carry out the provisions of this section.
    [(f) Authorization to use amounts
    [Out of amounts appropriated to carry out this subchapter 
for each of the fiscal years 1993 through 2000 not more than 
$5,000,000 may be used to carry out this section.]
          (5) in a teaching capacity in a tribal college or 
        university nursing program (or a related health 
        profession program) if, as determined by the Secretary, 
        health services provided to Indians would not decrease.

[Sec. 1616f. Tribal culture and history]

SEC. 116. TRIBAL CULTURAL ORIENTATION.

    [(a) Program established]
    (a) Cultural Education of Employees.--The Secretary, acting 
through the Service, shall [establish a program under 
which]require that appropriate employees of the Service who 
serve [particular] Indian [tribes shall]Tribes in each Service 
Area receive educational instruction in the history and culture 
of such [tribes and in the history of]Indian Tribes and their 
relationship to the Service.
    (b) [Tribally-controlled community collegesTo the extent 
feasible, the program established under subsection (a) of this 
section shall] Program.--In carrying out subsection (a), the 
Secretary shall establish a program which shall, to the extent 
feasible--
          [(1) be carried out through tribally-controlled 
        community colleges (within the meaning of section 
        1801(4) of this title) and tribally controlled 
        postsecondary vocational institutions (as defined in 
        section 2397h(2) of Title 20),
          [(2) be developed in consultation with the affected 
        tribal government, and]
          (1) be developed in consultation with the affected 
        Indian Tribes, Tribal Organizations, and Urban Indian 
        Organizations;
          (2) be carried out through tribal colleges or 
        universities;
          (3) include instruction in Native American Indian 
        studies; and
          (4) describe the use and place of traditional health 
        care practices of the Indian Tribes in the Service 
        Area.

[Sec. 1616g.]

SEC. 117. INMED [PROGRAM] PROGRAM.

    (a) Grants Authorized.--The Secretary, acting through the 
Service, is authorized to provide grants to [at least 3] 
colleges and universities for the purpose of maintaining and 
expanding the [Native American] Indian health careers 
recruitment program known as the [``]`Indians [into] Into 
Medicine Program''' (hereinafter in this section referred to as 
```INMED''') as a means of encouraging Indians to enter the 
health professions.
    [(b) University of North Dakota]
    (b) Quentin N. Burdick Grant.--The Secretary shall provide 
one1 of the grants authorized under subsection (a) to maintain 
the INMED program at the University of North Dakota, to be 
known as the [``]`Quentin N. Burdick Indian Health 
Programs['']', unless the Secretary makes a determination, 
based upon program reviews, that the program is not meeting the 
purposes of this section. Such program shall, to the maximum 
extent feasible, coordinate with the Quentin N. Burdick 
American Indians Into Psychology Program established under 
section [1621p] 105(b) [of this title] and the Quentin N. 
Burdick American Indians Into Nursing Program established under 
section [1616e(e) of this title.] 115.
    (c) Regulations[; contents of recruitment program (1)].--
The Secretary, pursuant to this Act, shall develop regulations 
[for the competitive awarding of the] to govern grants 
[provided under] pursuant to this section.
    [(2)] (d) Requirements.--Applicants for grants provided 
under this section shall agree to provide a program which--
          [(A)] (1) provides outreach and recruitment for 
        health professions to Indian communities including 
        elementary[,] and secondary schools and community 
        colleges located on [Indian] reservations which will be 
        served by the program[,];
          [(B)] (2) incorporates a program advisory board 
        comprised of representatives from the [tribes] Indian 
        Tribes and Indian communities which will be served by 
        the program[,];
          [(C)] (3) provides summer preparatory programs for 
        Indian students who need enrichment in the subjects of 
        math and science in order to pursue training in the 
        health professions[,];
          [(D)] (4) provides tutoring, counseling, and support 
        to students who are enrolled in a health career program 
        of study at the respective college or university[,]; 
        and
          [(E)] (5) to the maximum extent feasible, employs 
        qualified Indians in the program.
    [(d) Report to Congress
    [By no later than the date that is 3 years after November 
23, 1988, the Secretary shall submit a report to the Congress 
on the program established under this section including 
recommendations for expansion or changes to the program.

[Sec. 1616h. Health training programs of community colleges]

SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY COLLEGES.

    (a) Grants to Establish Programs.--
          (1) In general.--The Secretary, acting through the 
        Service, shall award grants to accredited and 
        accessible community colleges for the purpose of 
        assisting [the community college] such community 
        colleges in the establishment of programs which provide 
        education in a health profession leading to a degree or 
        diploma in a health profession for individuals who 
        desire to practice such profession on [an Indian] or 
        near a reservation or in [a tribal clinic] an Indian 
        Health Program.
          (2) Amount of grants.--The amount of any grant 
        awarded to a community college under paragraph (1) for 
        the first year in which such a grant is provided to the 
        community college shall not exceed $[100,000.] 250,000.
    [(b) Eligibility]
    (b) Grants for Maintenance and Recruiting.--
          [(1)] (1) In general.--The Secretary, acting through 
        the Service, shall award grants to accredited and 
        accessible community colleges that have established a 
        program described in subsection (a)(1) [of this 
        section] for the purpose of maintaining the program and 
        recruiting students for the program.
          (2) Requirements.--Grants may only be made under this 
        section to a community college which--
                  (A) is accredited[,];
                  (B) has [access to] a relationship with a 
                hospital facility, Service facility, or 
                hospital that could provide training of nurses 
                or health professionals[,];
                  (C) has entered into an agreement with an 
                accredited college or university medical 
                school, the terms of which--
                          (i) provide a program that enhances 
                        the transition and recruitment of 
                        students into advanced baccalaureate or 
                        graduate programs [which] that train 
                        health professionals[,]; and
                          (ii) stipulate certifications 
                        necessary to approve internship and 
                        field placement opportunities at 
                        [service unit facilities of the Service 
                        or at tribal health facilities,] Indian 
                        Health Programs;
                  (D) has a qualified staff which has the 
                appropriate certifications[, and];
                  (E) is capable of obtaining State or regional 
                accreditation of the program described in 
                subsection (a)(1) [of]; and
                  (F) agrees to provide for Indian preference 
                for applicants for programs under this section.
    [(c) Agreements and technical assistance]
    (c) Technical Assistance.--The Secretary shall encourage 
community colleges described in subsection (b)(2) [of this 
section] to establish and maintain programs described in 
subsection (a)(1) [of this section] by--
          (1) entering into agreements with such colleges for 
        the provision of qualified personnel of the Service to 
        teach courses of study in such programs[,]; and
          (2) providing technical assistance and support to 
        such colleges.
    (d) Advanced [training] Training.--
          (1) Required.--Any program receiving assistance under 
        this section that is conducted with respect to a health 
        profession shall also offer courses of study which 
        provide advanced training for any health professional 
        who--
                  [(1)] (A) has already received a degree or 
                diploma in such health profession[,]; and
                  [(2)] (B) provides clinical services on [an 
                Indian] or near a reservation[, at a Service 
                facility, or at a tribal clinic] or for an 
                Indian Health Program.
          (2) May be offered at alternate site.--Such courses 
        of study may be offered in conjunction with the college 
        or university with which the community college has 
        entered into the agreement required under subsection 
        (b)(2)(C) [of this section].
    [(e) Definitions
    [For purposes of this section--
          [(1) The term ``community college'' means--
                  [(A) a tribally controlled community college, 
                or
                  [(B) a junior or community college.
          [(2) The term ``tribally controlled community 
        college'' has the meaning given to such term by section 
        1801(4) of this title.
          [(3) The term ``junior or community college'' has the 
        meaning given to such term by section 1058(e) of Title 
        20.]
    (e) Priority.--Where the requirements of subsection (b) are 
met, grant award priority shall be provided to tribal colleges 
and universities in Service Areas where they exist.

[Sec. 1616i. Additional incentives for health professionals]

SEC. 119. RETENTION BONUS.

    [(a) Incentive special pay
    [The Secretary may provide the incentive special pay 
authorized under section 302(b) of Title 37, to civilian 
medical officers of the Indian Health Service who are assigned 
to, and serving in, positions included in the list established 
under subsection (b)(1) of this section for which recruitment 
or retention of personnel is difficult.
    [(b) List of positions; bonus pay
          [(1) The Secretary shall establish and update on an 
        annual basis a list of positions of health care 
        professionals] (a) Bonus Authorized.--The Secretary may 
        pay a retention bonus to any health professional 
        employed by, or assigned to, [the Service for which 
        recruitment or retention is difficult.
          [(2)(A) The Secretary may pay a bonus to any 
        commissioned officer or civil service employee, other 
        than a commissioned medical officer, dental officer, 
        optometrist, and veterinarian, who is employed in or 
        assigned to, and serving in, a position in the Service 
        included in the list established by the Secretary under 
        paragraph (1).
          [(B) The total amount of bonus payments made by the 
        Secretary under this paragraph to any employee during 
        any 1-year period shall not exceed $2,000.
    [(c) Work schedules
    [The Secretary may establish programs to allow the use of 
flexible work schedules, and compressed work schedules, in 
accordance with the provisions of subchapter II of chapter 61 
of Title 5, for health professionals employed by, or assigned 
to, the Service.

[Sec. 1616j. Retention bonus

    [(a) Eligibility.--The Secretary may pay a retention bonus 
to any physician or nurse employed by, or assigned to, and 
serving in, the Service] and serving in, an Indian Health 
Program or Urban Indian Organization either as a civilian 
employee or as a commissioned officer in the Regular or Reserve 
Corps of the Public Health Service who--
          (1) is assigned to, and serving in, a position 
        [included in the list established under section 
        1616i(b)(1) of this title] for which recruitment or 
        retention of personnel is difficult[,];
          (2) the Secretary determines is needed by [the 
        Service,] Indian Health Programs and Urban Indian 
        Organizations;
          (3) has--
                  (A) completed [3] 2 years of employment with 
                [the Service, or] an Indian Health Program or 
                Urban Indian Organization; or
                  (B) completed any service obligations 
                incurred as a requirement of--
                          (i) any Federal scholarship 
                        program[,]; or
                          (ii) any Federal education loan 
                        repayment program[,]; and
          (4) enters into an agreement with [the Service] an 
        Indian Health Program or Urban Indian Organization for 
        continued employment for a period of not less than 1 
        year.
    [(b) Minimum award percentage to nurses
    [Beginning with fiscal year 1993, not less than 25 percent 
of the retention bonuses awarded each year under subsection (a) 
of this section shall be awarded to nurses.
    [(c)] (b) Rates[; maximum rate].--The Secretary may 
establish rates for the retention bonus which shall provide for 
a higher annual rate for multiyear agreements than for single 
year agreements referred to in subsection (a)(4)[of this 
section], but in no event shall the annual rate be more than 
$25,000 per annum.
    [(d) Time of payment
    [The retention bonus for the entire period covered by the 
agreement described in subsection (a)(4) of this section shall 
be paid at the beginning of the agreed upon term of service.
    [(e) Refund; interest
    [Any physician or nurse] (c) Default of Retention 
Agreement.--Any health professional failing to complete the 
agreed upon term of service, except where such failure is 
through no fault of the individual, shall be obligated to 
refund to the Government the full amount of the retention bonus 
for the period covered by the agreement, plus interest as 
determined by the Secretary in accordance with section [1616a] 
110(l)(2)(B)[of this title].
    [(f) Physicians and nurses employed under Indian Self-
Determination Act] (d) Other Retention Bonus.--The Secretary 
may pay a retention bonus to any [physician or nurse employed 
by an organization providing health care services to Indians 
pursuant to a contract under the Indian Self-Determination Act 
[25 U.S.C.A. Sec. 450f et seq.] if such physician or nurse] 
health professional employed by a Tribal Health Program if such 
health professional is serving in a position which the 
Secretary determines is--
          (1) a position for which recruitment or retention is 
        difficult; and
          (2) necessary for providing health care services to 
        Indians.

[Sec. 1616k. Nursing residency program]

SEC. 120. NURSING RESIDENCY PROGRAM.

    (a) Establishment of Program.--The Secretary, acting 
through the Service, shall establish a program to enable 
Indians who are licensed practical nurses, licensed vocational 
nurses, and registered nurses who are working in an Indian 
[health program (as defined in section 1616a(a)(2)(A) of this 
title] Health Program or Urban Indian Organization, and have 
done so for a period of not less than [one] 1 year, to pursue 
advanced training.
    [(b) Program components]Such program shall include a 
combination of education and work study in an Indian [health 
program (as defined in section 1616a(a)(2)(A) of this title)] 
Health Program or Urban Indian Organization leading to an 
associate or bachelor's degree (in the case of a licensed 
practical nurse or licensed vocational nurse)[or], a bachelor's 
degree (in the case of a registered nurse)[or a Master's 
degree], or advanced degrees or certifications in nursing and 
public health.
    [(c)] (b) Service [obligation of program 
participant]Obligation.-- An individual who participates in a 
program under subsection (a) [of this section], where the 
educational costs are paid by the Service, shall incur an 
obligation to serve in an Indian [health program] Health 
Program or Urban Indian Organization for a period of obligated 
service equal to [at least three times the period of time 
during which the individual] 1 year for every year that 
nonprofessional employee (licensed practical nurses, licensed 
vocational nurses, nursing assistants, and various health care 
technicals), or 2 years for every year that professional nurse 
(associate degree and bachelor-prepared registered nurses), 
participates in such program. In the event that the individual 
fails to complete such obligated service, the United States 
shall be entitled to recover from such individual an amount 
determined in accordance with the formula specified in 
subsection (l) of section [1616a of this title] 110 in the 
manner provided for in such subsection.

[Sec. 1616l. Community Health Aide Program for Alaska]

SEC. 121. COMMUNITY HEALTH AIDE PROGRAM.

    [(a) Maintenance of program]
    (a) General Purposes of Program.--Under the authority of 
[section 13 of this title] the Act of November 2, 1921 (25 
U.S.C. 13) (commonly known as the ``Snyder Act'', the 
Secretary, acting through the Service, shall [maintain] develop 
and operate a Community Health Aide Program in Alaska under 
which the Service--
          (1) provides for the training of Alaska Natives as 
        health aides or community health practitioners;
          (2) uses such aides or practitioners in the provision 
        of health care, health promotion, and disease 
        prevention services to Alaska Natives living in 
        villages in rural Alaska; and
          (3) provides for the establishment of 
        teleconferencing capacity in health clinics located in 
        or near such villages for use by community health aides 
        or community health practitioners.
    [(b) Training; curriculum; Certification Board]
    (b) Specific Program Requirements.--The Secretary, acting 
through the Community Health Aide Program of the Service, 
shall--
          (1) using trainers accredited by the Program, provide 
        a high standard of training to community health aides 
        and community health practitioners to ensure that such 
        aides and practitioners provide quality health care, 
        health promotion, and disease prevention services to 
        the villages served by the Program;
          (2) in order to provide such training, develop a 
        curriculum that--
                  (A) combines education in the theory of 
                health care with supervised practical 
                experience in the provision of health care;
                  (B) provides instruction and practical 
                experience in the provision of acute care, 
                emergency care, health promotion, disease 
                prevention, and the efficient and effective 
                management of clinic pharmacies, supplies, 
                equipment, and facilities; and
                  (C) promotes the achievement of the health 
                status objectives specified in section [1602(b) 
                of this title] 3(2);
          (3) establish and maintain a Community Health Aide 
        Certification Board to certify as community health 
        aides or community health practitioners individuals who 
        have successfully completed the training described in 
        paragraph (1) or can demonstrate equivalent experience;
          (4) develop and maintain a system which identifies 
        the needs of community health aides and community 
        health practitioners for continuing education in the 
        provision of health care, including the areas described 
        in paragraph (2)(B), and develop programs that meet the 
        needs for such continuing education;
          (5) develop and maintain a system that provides close 
        supervision of community health aides and community 
        health practitioners; [and]
          (6) develop a system under which the work of 
        community health aides and community health 
        practitioners is reviewed and evaluated to assure the 
        provision of quality health care, health promotion, and 
        disease prevention services[.]; and
          (7) ensure that pulpal therapy (not including 
        pulpotomies on deciduous teeth) or extraction of adult 
        teeth can be performed by a dental health aide 
        therapist only after consultation with a licensed 
        dentist who determines that the procedure is a medical 
        emergency that cannot be resolved with palliative 
        treatment, and further that dental health aide 
        therapists are strictly prohibited from performing all 
        other oral or jaw surgeries, provided that 
        uncomplicated extractions shall not be considered oral 
        surgery under this section.
     (c) Program Review.--
          (1) Neutral panel.--
                  (A) Establishment.--The Secretary, acting 
                through the Service, shall establish a neutral 
                panel to carry out the study under paragraph 
                (2).
                  (B) Membership.--Members of the neutral panel 
                shall be appointed by the Secretary from among 
                clinicians, economists, community 
                practitioners, oral epidemiologists, and Alaska 
                Natives.
          (2) Study.--
                  (A) In general.--The neutral panel 
                established under paragraph (1) shall conduct a 
                study of the dental health aide therapist 
                services provided by the Community Health Aide 
                Program under this section to ensure that the 
                quality of care provided through those services 
                is adequate and appropriate.
                  (B) Parameters of study.--The Secretary, in 
                consultation with interested parties, including 
                professional dental organizations, shall 
                develop the parameters of the study.
                  (C) Inclusions.--The study shall include a 
                determination by the neutral panel with respect 
                to--
                          (i) the ability of the dental health 
                        aide therapist services under this 
                        section to address the dental care 
                        needs of Alaska Natives;
                          (ii) the quality of care provided 
                        through those services, including any 
                        training, improvement, or additional 
                        oversight required to improve the 
                        quality of care; and
                          (iii) whether safer and less costly 
                        alternatives to the dental health aide 
                        therapist services exist.
                  (D) Consultation.--In carrying out the study 
                under this paragraph, the neutral panel shall 
                consult with Alaska Tribal Organizations with 
                respect to the adequacy and accuracy of the 
                study.
          (3) Report.--The neutral panel shall submit to the 
        Secretary, the Committee on Indian Affairs of the 
        Senate, and the Committee on Natural Resources of the 
        House of Representatives a report describing the 
        results of the study under paragraph (2), including a 
        description of--
                  (A) any determination of the neutral panel 
                under paragraph (2)(C); and
                  (B) any comments received from an Alaska 
                Tribal Organization under paragraph (2)(D).
      (d) Nationalization of Program.--
          (1) In general.--Except as provided in paragraph (2), 
        the Secretary, acting through the Service, may 
        establish a national Community Health Aide Program in 
        accordance with the program under this section, as the 
        Secretary determines to be appropriate.

[Sec. 1616m. Matching grants to tribes for scholarship programs]

          (2) Exception.--The national Community Health Aide 
        Program under paragraph (1) shall not include dental 
        health aide therapist services.
    [(a) In general
          [(1) The Secretary shall make grants to Indian tribes 
        and tribal organizations for the purpose of assisting 
        such tribes and tribal organizations in educating 
        Indians to serve as health professionals in Indian 
        communities.
          [(2) Amounts available for grants under paragraph (1) 
        for any fiscal year shall not exceed 5 percent of 
        amounts available for such fiscal year for Indian 
        Health Scholarships under section 1613a of this title.
          [(3) An application for a grant under paragraph (1) 
        shall be in such form and contain such agreements, 
        assurances, and information as the Secretary determines 
        are necessary to carryout this section.
    [(b) Compliance with requirements
          [(1) An Indian tribe or tribal organization receiving 
        a grant under subsection (a) of this section shall 
        agree to provide scholarships to Indians pursuing 
        education in the health professions in accordance with 
        the requirements of this section.
          [(2) With respect to the costs of providing any 
        scholarship pursuant to paragraph (1)--
                  [(A) 80 percent of the costs of the 
                scholarship shall be paid from the grant made 
                under subsection (a) of this section to the 
                Indian tribe or tribal organization; and
                  [(B) 20 percent of such costs shall be paid 
                from non-Federal contributions by the Indian 
                tribe or tribal organization through which the 
                scholarship is provided.
          [(3) In determining the amount of non-Federal 
        contributions that have been provided for purposes of 
        subparagraph (B) of paragraph (2), any amounts provided 
        by the Federal Government to the Indian tribe or tribal 
        organization involved or to any other entity shall not 
        be included.
          [(4) Non-Federal contributions required by 
        subparagraph (B) of paragraph (2) may be provided 
        directly by the Indian tribe or tribal organization 
        involved or through donations from public and private 
        entities.
    [(c) Course of study in health professions
    An Indian tribe or tribal organization shall provide 
scholarships under subsection (b) of this section only to 
Indians enrolled or accepted for enrollment in a course of 
study (approved by the Secretary) in one of the health 
professions described in section 1613a(a) of this title.
    [(d) Contract requirements
    In providing scholarships under subsection (b) of this 
section, the Secretary and the Indian tribe or tribal 
organization shall enter into a written contract with each 
recipient of such scholarship.
    Such contract shall--
          [(1) obligate such recipient to provide service in an 
        Indian health program (as defined in section 
        1616a(a)(2)(A) of this title), in the same service area 
        where the Indian tribe or tribal organization providing 
        the scholarship is located, for--
                  [(A) a number of years equal to the number of 
                years for which the scholarship is provided (or 
                the part-time equivalent thereof, as determined 
                by the Secretary), or for a period of 2 years, 
                whichever period is greater; or
                  [(B) such greater period of time as the 
                recipient and the Indian tribe or tribal 
                organization may agree;
          [(2) provide that the amount of such scholarship--
                  [(A) may be expended only for--
                          [(i) tuition expenses, other 
                        reasonable educational expenses, and 
                        reasonable living expenses incurred in 
                        attendance at the educational 
                        institution; and
                          [(ii) payment to the recipient of a 
                        monthly stipend of not more than the 
                        amount authorized by section 
                        254m(g)(1)(B) of Title 42, such amount 
                        to be reduced pro rata (as determined 
                        by the Secretary) based on the number 
                        of hours such student is enrolled; and
                  [(B) may not exceed, for any year of 
                attendance for which the scholarship is 
                provided, the total amount required for the 
                year for the purposes authorized in 
                subparagraph (A);
          [(3) require the recipient of such scholarship to 
        maintain an acceptable level of academic standing (as 
        determined by the educational institution in accordance 
        with regulations issued by the Secretary); and
          [(4) require the recipient of such scholarship to 
        meet the educational and licensure requirements 
        necessary to be a physician, certified nurse 
        practitioner, certified nurse midwife, or physician 
        assistant.
    [(e) Breach of contract
          [(1) An individual who has entered into a written 
        contract with the Secretary and an Indian tribe or 
        tribal organization under subsection (d) of this 
        section and who--
                  [(A) fails to maintain an acceptable level of 
                academic standing in the educational 
                institution in which he is enrolled (such level 
                determined by the educational institution under 
                regulations of the Secretary),
                  [(B) is dismissed from such educational 
                institution for disciplinary reasons,
                  [(C) voluntarily terminates the training in 
                such an educational institution for which he is 
                provided a scholarship under such contract 
                before the completion of such training, or
                  [(D) fails to accept payment, or instructs 
                the educational institution in which he is 
                enrolled not to accept payment, in whole or in 
                part, of a scholarship under such contract, in 
                lieu of any service obligation arising under 
                such contract, shall be liable to the United 
                States for the Federal share of the amount 
                which has been paid to him, or on his behalf, 
                under the contract.
          [(2) If for any reason not specified in paragraph 
        (1), an individual breaches his written contract by 
        failing either to begin such individual's service 
        obligation required under such contract or to complete 
        such service obligation, the United States shall be 
        entitled to recover from the individual an amount 
        determined in accordance with the formula specified in 
        subsection (l) of section 1616a(l) of this title in the 
        manner provided for in such subsection.
          [(3) The Secretary may carryout this subsection on 
        the basis of information submitted by the tribes or 
        tribal organizations involved, or on the basis of 
        information collected through such other means as the 
        Secretary determines to be appropriate.
    [(f) Nondiscriminatory practice
        The recipient of a scholarship under subsection (b) of 
        this section shall agree, in providing health care 
        pursuant to the requirements of subsection (d)(1) of 
        this section--
          [(1) not to discriminate against an individual 
        seeking such care on the basis of the ability of the 
        individual to pay for such care or on the basis that 
        payment for such care will be made pursuant to the 
        program established in title XVIII of the Social 
        Security Act [42 U.S.C.A. Sec. 1395 et seq] or pursuant 
        to the program established in title XIX of such Act [42 
        U.S.C.A. Sec. 1396 et seq.]; and
          [(2) to accept assignment under section 
        1842(b)(3)(B)(ii) of the Social Security Act [42 
        U.S.C.A. Sec. 1395u(b)(3)(B)(ii)] for all services for 
        which payment may be made under part B of title XVIII 
        of such Act [42 U.S.C.A. Sec. 1395j et seq.], and to 
        enter into an appropriate agreement with the State 
        agency that administers the State plan for medical 
        assistance under title XIX of such Act [42 U.S.C.A. 
        Sec. 1396 et seq.] to provide service to individuals 
        entitled to medical assistance under the plan.
    [(g) Payments for subsequent fiscal years
    [The Secretary may not make any payments under subsection 
(a) of this section to an Indian tribe or tribal organization 
for any fiscal year subsequent to the first fiscal year of such 
payments unless the Secretary determines that, for the 
immediately preceding fiscal year, the Indian tribe or tribal 
organization has complied with requirements of this section.]
          (3) Requirement.--In establishing a national program 
        under paragraph (1), the Secretary shall not reduce the 
        amount of funds provided for the Community Health Aide 
        Program described in subsections (a) and (b).

[Sec. 1616n. Tribal health program administration]

SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION.

    [The Secretary] The Secretary, acting through the Service, 
shall, by contract or otherwise, provide training for 
[individuals] Indians in the administration and planning of 
[tribal health programs] Tribal Health Programs.

SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE DEMONSTRATION PROGRAMS.

[Sec. 1616o. University of South Dakota pilot program]

    (a) Demonstration Programs Authorized.--The Secretary, 
acting through the Service, may fund demonstration programs for 
Tribal Health Programs to address the chronic shortages of 
health professionals.
    [(a) Establishment
    [The Secretary may make a grant to the School of Medicine 
of the University of South Dakota (hereafter in this section 
referred to as ``USDSM'') to establish a pilot program on an 
Indian reservation at one or more service units in South Dakota 
to address the chronic manpower shortage in the Aberdeen Area 
of the Service.]
    (b) Purposes of Programs._The purposes of [the program 
established pursuant to a grant provided] demonstration 
programs funded under subsection (a) [are] shall be--
          (1) to provide direct clinical and practical 
        experience at a [service unit to medical] Service Unit 
        to health profession students and residents from [USDSM 
        and other] medical schools;
          (2) to improve the quality of health care for Indians 
        by assuring access to qualified health care 
        professionals; and
          (3) to provide academic and scholarly opportunities 
        for physicians, [physician assistants, nurse 
        practitioners, nurses, and other allied] health 
        professionals serving [Indian people] Indians by 
        identifying [and utilizing] all academic and scholarly 
        resources of the region.
    [(c) Composition; designation
    [The pilot program] (c) Advisory Board._The demonstration 
programs established pursuant to a [grant provided under] 
subsection (a) shall[--(1)] incorporate a program advisory 
board composed of representatives from the [tribes] Indian 
Tribes and Indian communities in the area which will be served 
by the program[; and].
          [(2) shall be designated as an extension of the USDSM 
        campus and program participants shall be under the 
        direct supervision and instruction of qualified medical 
        staff serving at the service unit who shall be members 
        of the USDSM faculty.
    [(d) Coordination with other schools
    [The USDSM shall coordinate the program established 
pursuant to a grant provided under subsection (a) of this 
section with other medical schools in the region, nursing 
schools, tribal community colleges, and other health 
professional schools.
    [(e) Development of additional professional opportunities
    [The USDSM, in cooperation with the Service, shall develop 
additional professional opportunities for program participants 
on Indian reservations in order to improve the recruitment and 
retention of qualified health professionals in the Aberdeen 
Area of the Service.]

SEC. 124. NATIONAL HEALTH SERVICE CORPS.

    (a) No Reduction in Services.--The Secretary shall not--
          (1) remove a member of the National Health Service 
        Corps from an Indian Health Program or Urban Indian 
        Organization; or
          (2) withdraw funding used to support such member, 
        unless the Secretary, acting through the Service, has 
        ensured that the Indians receiving services from such 
        member will experience no reduction in services.
    (b) Exemption From Limitations--National Health Service 
Corps scholars qualifying for the Commissioned Corps in the 
Public Health Service shall be exempt from the full-time 
equivalent limitations of the National Health Service Corps and 
the Service when serving as a commissioned corps officer in a 
Tribal Health Program or an Urban Indian Organization.

SEC. 125. SUBSTANCE ABUSE COUNSELOR EDUCATIONAL CURRICULA DEMONSTRATION 
                    PROGRAMS.

    (a) Contracts and Grants.--The Secretary, acting through 
the Service, may enter into contracts with, or make grants to, 
accredited tribal colleges and universities and eligible 
accredited and accessible community colleges to establish 
demonstration programs to develop educational curricula for 
substance abuse counseling.
    (b) Use of Funds.--Funds provided under this section shall 
be used only for developing and providing educational 
curriculum for substance abuse counseling (including paying 
salaries for instructors). Such curricula may be provided 
through satellite campus programs.
    (c) Time Period of Assistance; Renewal.--A contract entered 
into or a grant provided under this section shall be for a 
period of 3 years. Such contract or grant may be renewed for an 
additional 2-year period upon the approval of the Secretary.
    (d) Criteria for Review and Approval of Applications.--Not 
later than 180 days after the date of enactment of the Indian 
Health Care Improvement Act Amendments of 2007, the Secretary, 
after consultation with Indian Tribes and administrators of 
tribal colleges and universities and eligible accredited and 
accessible community colleges, shall develop and issue criteria 
for the review and approval of applications for funding 
(including applications for renewals of funding) under this 
section. Such criteria shall ensure that demonstration programs 
established under this section promote the development of the 
capacity of such entities to educate substance abuse 
counselors.
    (e) Assistance.--The Secretary shall provide such technical 
and other assistance as may be necessary to enable grant 
recipients to comply with the provisions of this section.
    (f) Report.--Each fiscal year, the Secretary shall submit 
to the President, for inclusion in the report which is required 
to be submitted under section 801 for that fiscal year, a 
report on the findings and conclusions derived from the 
demonstration programs conducted under this section during that 
fiscal year.
    (g) Definition.--For the purposes of this section, the term 
``educational curriculum'' means 1 or more of the following:
          (1) Classroom education.
          (2) Clinical work experience.
          (3) Continuing education workshops.

SEC. 126. BEHAVIORAL HEALTH TRAINING AND COMMUNITY EDUCATION PROGRAMS.

    (a) Study; List.--The Secretary, acting through the 
Service, and the Secretary of the Interior, in consultation 
with Indian Tribes and Tribal Organizations, shall conduct a 
study and compile a list of the types of staff positions 
specified in subsection (b) whose qualifications include, or 
should include, training in the identification, prevention, 
education, referral, or treatment of mental illness, or 
dysfunctional and self destructive behavior.
    (b) Positions.--The positions referred to in subsection (a) 
are--
          (1) staff positions within the Bureau of Indian 
        Affairs, including existing positions, in the fields 
        of--
                  (A) elementary and secondary education;
                  (B) social services and family and child 
                welfare;
                  (C) law enforcement and judicial services; 
                and
                  (D) alcohol and substance abuse;
          (2) staff positions within the Service; and
          (3) staff positions similar to those identified in 
        paragraphs (1) and (2) established and maintained by 
        Indian Tribes, Tribal Organizations (without regard to 
        the funding source), and Urban Indian Organizations.
    (c) Training Criteria.--
          (1) In general.--The appropriate Secretary shall 
        provide training criteria appropriate to each type of 
        position identified in subsection (b)(1) and (b)(2) and 
        ensure that appropriate training has been, or shall be 
        provided to any individual in any such position. With 
        respect to any such individual in a position identified 
        pursuant to subsection (b)(3), the respective 
        Secretaries shall provide appropriate training to, or 
        provide funds to, an Indian Tribe, Tribal Organization, 
        or Urban Indian Organization for training of 
        appropriate individuals. In the case of positions 
        funded under a contract or compact under the Indian 
        Self-Determination and Education Assistance Act (25 
        U.S.C. 450 et seq.), the appropriate Secretary shall 
        ensure that such training costs are included in the 
        contract or compact, as the Secretary determines 
        necessary.
          (2) Position specific training criteria.--Position 
        specific training criteria shall be culturally relevant 
        to Indians and Indian Tribes and shall ensure that 
        appropriate information regarding traditional health 
        care practices is provided.
    (d) Community Education on Mental Illness.--The Service 
shall develop and implement, on request of an Indian Tribe, 
Tribal Organization, or Urban Indian Organization, or assist 
the Indian Tribe, Tribal Organization, or Urban Indian 
Organization to develop and implement, a program of community 
education on mental illness. In carrying out this subsection, 
the Service shall, upon request of an Indian Tribe, Tribal 
Organization, or Urban Indian Organization, provide technical 
assistance to the Indian Tribe, Tribal Organization, or Urban 
Indian Organization to obtain and develop community educational 
materials on the identification, prevention, referral, and 
treatment of mental illness and dysfunctional and self-
destructive behavior.

[Sec. 1616p. Authorization of appropriations]

    (e) Plan.--Not later than 90 days after the date of 
enactment of the Indian Health Care Improvement Act Amendments 
of 2007, the Secretary shall develop a plan under which the 
Service will increase the health care staff providing 
behavioral health services by at least 500 positions within 5 
years after the date of enactment of this section, with at 
least 200 of such positions devoted to child, adolescent, and 
family services. The plan developed under this subsection shall 
be implemented under the Act of November 2, 1921 (25 U.S.C. 13) 
(commonly known as the ``Snyder Act'').

SEC. 127. AUTHORIZATION OF APPROPRIATIONS.

    There are authorized to be appropriated such sums as may be 
necessary for each fiscal year through fiscal year [2000] 2017 
to carry out this [subchapter] title.

                       TITLE II--HEALTH SERVICES


[Sec. 1621. Indian Health Care Improvement Fund]

SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND.

    [(a) Approved expenditures]
    (a) Use of Funds.--The Secretary, acting through the 
Service, is authorized to expend funds, directly or under the 
authority of the Indian Self-Determination and Education 
Assistance Act (25 U.S.C. 450 et seq.), which are appropriated 
under the authority of this section, [through the Service,] for 
the purposes of--
          (1) eliminating the deficiencies in health status and 
        health resources of all Indian [tribes,] Tribes;
          (2) eliminating backlogs in the provision of health 
        care services to Indians[,];
          (3) meeting the health needs of Indians in an 
        efficient and equitable manner, [and] including the use 
        of telehealth and telemedicine when appropriate;
          (4) eliminating inequities in funding for both direct 
        care and contract health service programs; and
          [(4)] (5) augmenting the ability of the Service to 
        meet the following health service responsibilities[, 
        either through direct or contract care or through 
        contracts entered into pursuant to the Indian Self-
        Determination Act [25 U.S.C.A. Sec. 450f et seq.],] 
        with respect to those Indian [tribes] Tribes with the 
        highest levels of health status deficiencies and 
        resource deficiencies:
                  (A) [clinical] Clinical care [(direct and 
                indirect)], including inpatient care, 
                outpatient care (including audiology, clinical 
                eye, and vision care[;]), primary care, 
                secondary and tertiary care, and long-term 
                care.
                  (B) [preventive] Preventive health, including 
                [screening] mammography and other cancer 
                screening in accordance with section [1621k of 
                this title;] 207.
                  [(C) dental care (direct and indirect);] (C) 
                Dental care.
                  (D) [mental] Mental health, including 
                community mental health services, inpatient 
                mental health services, dormitory mental health 
                services, therapeutic and residential treatment 
                centers, and training of traditional [Indian] 
                health care practitioners[;].
                  (E) [emergency] Emergency medical 
                services[;].
                  (F) [treatment] Treatment and control of, and 
                rehabilitative care related to, alcoholism and 
                drug abuse (including fetal alcohol syndrome) 
                among Indians[;].
                  (G) [accident] Injury prevention programs[;], 
                including data collection and evaluation, 
                demonstration projects, training, and capacity 
                building.
                  (H) [home] Home health care[;].
                  (I) [community] Community health 
                representatives[; and].
                  [(J) maintenance and repair.]
    [(b) Effect of other appropriations; allocation to service 
units]
                  (J) Maintenance and improvement.
    [(1)] (b) No Offset or Limitation._Any funds appropriated 
under the authority of this section shall not be used to offset 
or limit any other appropriations made to the Service under 
[section 13 of this title] this Act or the Act of November 2, 
1921 (25 U.S.C. 13) (commonly known as the ``Snyder Act''), or 
any other provision of law.
    (c) Allocation; Use.--
          [(2)] (1)[(A)] In general._Funds appropriated under 
        the authority of this section [may] shall be allocated 
        [on a service unit basis] to Service Units, Indian 
        Tribes, or Tribal Organizations. The funds allocated to 
        each [service unit] Indian Tribe, Tribal Organization, 
        or Service Unit under this [subparagraph] paragraph 
        shall be used by the [service unit to reduce] Indian 
        Tribe, Tribal Organization, or Service Unit under this 
        paragraph to improve the health status and reduce the 
        resource deficiency of each [tribe] Indian Tribe served 
        by such [service unit] Service Unit, Indian Tribe, or 
        Tribal Organization.
          [B] (2) Apportionment of allocated funds._The 
        apportionment of funds allocated to a [service unit 
        under subparagraph (A)] Service Unit, Indian Tribe, or 
        Tribal Organization under paragraph (1) among the 
        health service responsibilities described in subsection 
        (a)[(4) of this section] (5) shall be determined by the 
        Service in consultation with, and with the active 
        participation of, the affected Indian [tribes] Tribes 
        and Tribal Organizations.
    [(c) Health Resources Deficiency Levels.--For] (d) 
Provisions Relating to Health Status and Resource 
Deficiencies._For the purposes of this section--, the following 
definitions apply:
          (1) Definition._The term ``health status and resource 
        deficiency'' means the extent to which--
                  (A) the health status objectives set forth in 
                section [1602(b) of this title] 3(2) are not 
                being achieved; and
                  (B) the Indian [tribe] Tribe or Tribal 
                Organization does not have available to it the 
                health resources it needs, taking into account 
                the actual cost of providing health care 
                services given local geographic, climatic, 
                rural, or other circumstances.
          (2) Available resources._The health resources 
        available to an Indian [tribe] Tribe or Tribal 
        Organization include health resources provided by the 
        Service as well as health resources used by the Indian 
        [tribe] Tribe or Tribal Organization, including 
        services and financing systems provided by any Federal 
        programs, private insurance, and programs of State or 
        local governments.
          (3) Process for review of determinations._The 
        Secretary shall establish procedures which allow any 
        Indian [tribe] Tribe or Tribal Organization to petition 
        the Secretary for a review of any determination of the 
        extent of the health status and resource deficiency of 
        such [tribe] Indian Tribe or Tribal Organization.
    [(d) Programs administered by Indian tribe]
          [(1) Programs administered by any Indian tribe or 
        tribal organization under the authority of the Indian 
        Self-Determination Act] (e) Eligibility for Funds._
        Tribal Health Programs shall be eligible for funds 
        appropriated under the authority of this section on an 
        equal basis with programs that are administered 
        directly by the Service.
          [(2) If any funds allocated to a tribe or service 
        unit under the authority of this section are used for a 
        contract entered into under the Indian Self-
        Determination Act [25 U.S.C.A. Sec. 450f et seq.], a 
        reasonable portion of such funds may be used for health 
        planning, training, technical assistance, and other 
        administrative support functions.]
    [(e)] (f) Report [to Congress].--By no later than the date 
that is 3 years after [October 29, 1992,] the date of enactment 
of the Indian Health Care Improvement Act Amendments of 2007, 
the Secretary shall submit to the Congress the current health 
status and resource deficiency report of the Service for each 
[Indian tribe or service unit] Service Unit, including newly 
recognized or acknowledged [tribes] Indian Tribes. Such report 
shall set out--
          (1) the methodology then in use by the Service for 
        determining [tribal] Tribal health status and resource 
        deficiencies, as well as the most recent application of 
        that methodology;
          (2) the extent of the health status and resource 
        deficiency of each Indian [tribe] Tribe served by the 
        Service or a Tribal Health Program;
          (3) the amount of funds necessary to eliminate the 
        health status and resource deficiencies of all Indian 
        [tribes] Tribes served by the Service or a Tribal 
        Health Program; and
          (4) an estimate of--
                  (A) the amount of health service funds 
                appropriated under the authority of this 
                [chapter] Act, or any other Act, including the 
                amount of any funds transferred to the 
                Service[,] for the preceding fiscal year which 
                is allocated to each [service unit] Service 
                Unit, Indian [tribe] Tribe, or [comparable 
                entity] Tribal Organization;
                  (B) the number of Indians eligible for health 
                services in each [service unit] Service Unit or 
                Indian [tribe; and] Tribe or Tribal 
                Organization; and
                  (C) the number of Indians using the Service 
                resources made available to each [service unit 
                or Indian tribe.] Service Unit, Indian Tribe or 
                Tribal Organization, and, to the extent 
                available, information on the waiting lists and 
                number of Indians turned away for services due 
                to lack of resources.
    [(f) Appropriated funds included in base budget of Service]
    (g) Inclusion in Base Budget._Funds appropriated under 
[authority of] this section for any fiscal year shall be 
included in the base budget of the Service for the purpose of 
determining appropriations under this section in subsequent 
fiscal years.
    [(g) Continuation of Service responsibilities for backlogs 
and parity ]
    (h) Clarification._Nothing in this section is intended to 
diminish the primary responsibility of the Service to eliminate 
existing backlogs in unmet health care needs, nor are the 
provisions of this section intended to discourage the Service 
from undertaking additional efforts to achieve [parity] equity 
among Indian [tribes.] Tribes and Tribal Organizations.
    [(h) Authorization of appropriations]
    (i) Funding Designation._Any funds appropriated under the 
authority of this section shall be designated as the 
[``]`Indian Health Care Improvement Fund.['']'

[Sec. 1621a. Catastrophic Health Emergency Fund]

SEC. 202. CATASTROPHIC HEALTH EMERGENCY FUND.

    (a) Establishment[; administration; purpose (1)].--There is 
[hereby] established an Indian Catastrophic Health Emergency 
Fund (hereafter in this section referred to as the [``Fund''] 
``CHEF'') consisting of--
          [(A)] (1) the amounts deposited under subsection [(d) 
        of this section,] (f); and
          [(B)] (2)) the amounts appropriated to [the Fund] 
        CHEF under this section.
          [(2) The Fund](b) Administration._CHEF shall be 
        administered by the Secretary, acting through the 
        [central office] headquarters of the Service, solely 
        for the purpose of meeting the extraordinary medical 
        costs associated with the treatment of victims of 
        disasters or catastrophic illnesses who are within the 
        responsibility of the Service.
          [(3) The Fund shall not] (c) Conditions on Use of 
        Fund._No part of CHEF or its administration shall be 
        subject to contract or grant under any law, including 
        the Indian Self-Determination and Education Assistance 
        Act (25 U.S.C. 450 et seq.), nor shall CHEF funds be 
        allocated, apportioned, or delegated on [a service 
        unit, area office, or any other] an Area Office, 
        Service Unit, or other similar basis.
          [(4) No part of the Fund or its administration shall 
        be subject to contract or grant under any law, 
        including the Indian Self-Determination Act [25 
        U.S.C.A. Sec. 450f et seq.].]
    [(b) Regulations; procedures for payment]
    (d) Regulations._The Secretary shall[, through the 
promulgation of] promulgate regulations consistent with the 
provisions of this section to--
          (1) establish a definition of disasters and 
        catastrophic illnesses for which the cost of the 
        treatment provided under contract would qualify for 
        payment from [the Fund] CHEF;
          (2) provide that a [service unit] Service Unit shall 
        not be eligible for reimbursement for the cost of 
        treatment from [the Fund] CHEF until its cost of 
        treating any victim of such catastrophic illness or 
        disaster has reached a certain threshold cost which the 
        Secretary shall establish at--
                  [(A) for 1993, not less than $15,000 or not 
                more than $25,000; and]
                  (A) the 2000 level of $19,000; and
                  (B) for any subsequent year, not less than 
                the threshold cost of the previous year 
                increased by the percentage increase in the 
                medical care expenditure category of the 
                consumer price index for all urban consumers 
                (United States city average) for the 12-month 
                period ending with December of the previous 
                year;
          (3) establish a procedure for the reimbursement of 
        the portion of the costs that exceeds such threshold 
        cost incurred by--
                  [(A) service units or facilities of the 
                Service, or]
                  (A) Service Units; or
                  (B) whenever otherwise authorized by the 
                Service, non-Service facilities or providers[, 
                in rendering treatment that exceeds such 
                threshold cost];
          (4) establish a procedure for payment from [the Fund] 
        CHEF in cases in which the exigencies of the medical 
        circumstances warrant treatment prior to the 
        authorization of such treatment by the Service; and
          (5) establish a procedure that will ensure that no 
        payment shall be made from [the Fund] CHEF to any 
        provider of treatment to the extent that such provider 
        is eligible to receive payment for the treatment from 
        any other Federal, State, local, or private source of 
        reimbursement for which the patient is eligible.
    [(c) Effect on other appropriations]
    (e) No Offset or Limitation._Amounts appropriated to [the 
Fund] CHEF under this section shall not be used to offset or 
limit appropriations made to the Service under the authority of 
[section 13 of this title] the Act of November 2, 1921 (25 
U.S.C. 13) (commonly known as the ``Snyder Act''), or any other 
law.
    [(d) Reimbursements to fund]
    (f) Deposit of Reimbursement Funds._There shall be 
deposited into [the Fund] CHEF all reimbursements to which the 
Service is entitled from any Federal, State, local, or private 
source (including third party insurance) by reason of treatment 
rendered to any victim of a disaster or catastrophic illness 
the cost of which was paid from [the Fund] CHEF.

SEC. 203. HEALTH PROMOTION AND DISEASE PREVENTION SERVICES.

    (a) Findings.--Congress finds that health promotion and 
disease prevention activities--
          (1) improve the health and well-being of Indians; and

[Sec. 1621b. Health promotion and disease prevention services]

          (2) reduce the expenses for health care of Indians.
    [(a) Authorization]
    (b) Provision of Services._The Secretary, acting through 
the Service and Tribal Health Programs, shall provide health 
promotion and disease prevention services to Indians [so as] to 
achieve the health status objectives set forth in section 
[1602(b) of this title]3(2).
    [(b)](c) Evaluation [statement for Presidential budget].--
The Secretary, after obtaining input from the affected Tribal 
Health Programs, shall submit to the President for inclusion in 
[each statement] the report which is required to be submitted 
to [the] Congress under section [1671 of this title] 801 an 
evaluation of--
          (1) the health promotion and disease prevention needs 
        of Indians[,];
          (2) the health promotion and disease prevention 
        activities which would best meet such needs[,];
          (3) the internal capacity of the Service and Tribal 
        Health Programs to meet such needs[,]; and
          (4) the resources which would be required to enable 
        the Service and Tribal Health Programs to undertake the 
        health promotion and disease prevention activities 
        necessary to meet such needs.

[Sec. 1621c. Diabetes prevention, treatment, and control]

SEC. 204. DIABETES PREVENTION, TREATMENT, AND CONTROL.

    [(a) Incidence and complications]
    (a) Determinations Regarding Diabetes.--The Secretary, 
acting through the Service, and in consultation with [the 
tribes] Indian Tribes and Tribal Organizations, shall 
determine--
          (1) by [tribe] Indian Tribe and by Service [unit of 
        the Service] Unit, the incidence of, and the types of 
        complications resulting from, diabetes among Indians; 
        and
          (2) based on the determinations made pursuant to 
        paragraph (1), the measures (including patient 
        education and effective ongoing monitoring of disease 
        indicators) each Service [unit] Unit should take to 
        reduce the incidence of, and prevent, treat, and 
        control the complications resulting from, diabetes 
        among [tribes] Indian Tribes within that Service [unit] 
        Unit.
    (b) Diabetes Screening.--[The]To the extent medically 
indicated and with informed consent, the Secretary shall screen 
each Indian who receives services from the Service for diabetes 
and for conditions which indicate a high risk that the 
individual will become diabetic and establish a cost-effective 
approach to ensure ongoing monitoring of disease indicators. 
Such screening [may be done by a tribe or tribal organization 
operating health care programs or facilities with funds from 
the Service under the Indian Self-Determination Act [25 
U.S.C.A. Sec. 450f et seq.].] and monitoring may be conducted 
by a Tribal Health Program and may be conducted through 
appropriate Internet-based health care management programs.
    [(c) Model diabetes projects]
    [(1)] (c) Diabetes projects.--The Secretary shall continue 
to maintain through [fiscal year 2000] each model diabetes 
project in existence on [October 29, 1992 and located--] the 
date of enactment of the Indian Health Care Improvement Act 
Amendments of 2007, any such other diabetes programs operated 
by the Service or Tribal Health Programs, and any additional 
diabetes projects, such as the Medical Vanguard program 
provided for in title IV of Public Law 108-87, as implemented 
to serve Indian Tribes. Tribal Health Programs shall receive 
recurring funding for the diabetes projects that they operate 
pursuant to this section, both at the date of enactment of the 
Indian Health Care Improvement Act Amendments of 2007 and for 
projects which are added and funded thereafter.
                 [(A) at the Claremore Indian Hospital in 
                Oklahoma;
                 [(B) at the Fort Totten Health Center in North 
                Dakota;
                 [(C) at the Sacaton Indian Hospital in 
                Arizona;
                 [(D) at the Winnebago Indian Hospital in 
                Nebraska;
                 [(E) at the Albuquerque Indian Hospital in New 
                Mexico;
                 [(F) at the Perry, Princeton, and Old Town 
                Health Centers in Maine;
                 [(G) at the Bellingham Health Center in 
                Washington;
                 [(H) at the Fort Berthold Reservation;
                 [(I) at the Navajo Reservation;
                 [(J) at the Papago Reservation;
                 [(K) at the Zuni Reservation; or
                 [(L) in the States of Alaska, California, 
                Minnesota, Montana, Oregon, or Utah.
         [(2) The Secretary may establish new model diabetes 
        projects under this section taking into consideration 
        applications received under this section from all 
        service areas, except that the Secretary may not 
        establish a greater number of such projects in one 
        service area than in any other service area until there 
        is an equal number of such projects established with 
        respect to all service areas from which the Secretary 
        receives qualified applications during the application 
        period (as determined by the Secretary).
    [(d) Control officer; registry of patients
    [The Secretary shall--]
    (d) Dialysis Programs.--The Secretary is authorized to 
provide, through the Service, Indian Tribes, and Tribal 
Organizations, dialysis programs, including the purchase of 
dialysis equipment and the provision of necessary staffing.
    (e) Other Duties of the Secretary.--
         (1) In general.--The Secretary shall, to the extent 
        funding is available--
          [(1) employ in each area office of the Service at 
        least one diabetes control officer who shall coordinate 
        and manage on a full-time basis activities within that 
        area office] (A) in each Area Office, consult with 
        Indian Tribes and Tribal Organizations regarding 
        programs for the prevention, treatment, and control of 
        diabetes;
          [(2) establish in each area office of the Service] 
        (B) establish in each Area Office a registry of 
        patients with diabetes to track the incidence of 
        diabetes and the complications from diabetes in that 
        area; and
          [(3)](C) ensure that data collected in each [area 
        office] Area Office regarding diabetes and related 
        complications among Indians [is] are disseminated to 
        all other [area offices; and (4) evaluate the 
        effectiveness of services provided through model 
        diabetes projects established under this section] Area 
        Offices, subject to applicable patient privacy laws.
    [(e) Authorization of appropriations
    [Funds appropriated under this section in any fiscal year 
shall be in addition to base resources appropriated to the 
Service for that year.]
          (2) Diabetes control officers.--
                 (A) In general.--The Secretary may establish 
                and maintain in each Area Office a position of 
                diabetes control officer to coordinate and 
                manage any activity of that Area Office 
                relating to the prevention, treatment, or 
                control of diabetes to assist the Secretary in 
                carrying out a program under this section or 
                section 330C of the Public Health Service Act 
                (42 U.S.C. 254c-3).
                  (B) Certain activities.--Any activity carried 
                out by a diabetes control officer under 
                subparagraph (A) that is the subject of a 
                contract or compact under the Indian Self-
                Determination and Education Assistance Act (25 
                U.S.C. 450 et seq.), and any funds made 
                available to carry out such an activity, shall 
                not be divisible for purposes of that Act.

SEC. 205. SHARED SERVICES FOR LONG-TERM CARE.

    (a) Long-Term Care.--Notwithstanding any other provision of 
law, the Secretary, acting through the Service, is authorized 
to provide directly, or enter into contracts or compacts under 
the Indian Self-Determination and Education Assistance Act (25 
U.S.C. 450 et seq.) with Indian Tribes or Tribal Organizations 
for, the delivery of long-term care (including health care 
services associated with long-term care) provided in a facility 
to Indians. Such agreements shall provide for the sharing of 
staff or other services between the Service or a Tribal Health 
Program and a long-term care or related facility owned and 
operated (directly or through a contract or compact under the 
Indian Self-Determination and Education Assistance Act (25 
U.S.C. 450 et seq.)) by such Indian Tribe or Tribal 
Organization.
    (b) Contents of Agreements.--An agreement entered into 
pursuant to subsection (a)--

[Sec. 1621d. Hospice care feasibility study]

          (1) may, at the request of the Indian Tribe or Tribal 
        Organization, delegate to such Indian Tribe or Tribal 
        Organization such powers of supervision and control 
        over Service employees as the Secretary deems necessary 
        to carry out the purposes of this section;
    [(a) Duty of Secretary
    [The Secretary, acting through the Service and in 
consultation with representatives of Indian tribes, tribal 
organizations, Indian Health Service personnel, and hospice 
providers, shall conduct a study--
          [(1) to assess the feasibility and desirability of 
        furnishing hospice care to terminally ill Indians; and
          [(2) to determine the most efficient and effective 
        means of furnishing such care.
    [(b) Functions of study
    [Such study shall--
          [(1) assess the impact of Indian culture and beliefs 
        concerning death and dying on the provision of hospice 
        care to Indians;
          [(2) estimate the number of Indians for whom hospice 
        care may be appropriate and determine the geographic 
        distribution of such individuals;
          [(3) determine the most appropriate means to 
        facilitate the participation of Indian tribes and 
        tribal organizations in providing hospice care;
          [(4) identify and evaluate various means for 
        providing hospice care, including--
                  [(A) the provision of such care by the 
                personnel of a Service hospital pursuant to a 
                hospice program established by the Secretary at 
                such hospital; and
                  [(B) the provision of such care by a 
                community-based hospice program under contract 
                to the Service; and
          [(5) identify and assess any difficulties in 
        furnishing such care and the actions needed to resolve 
        such difficulties.
    [(c) Report to Congress
    [Not later than the date which is 12 months after October 
29, 1992, the Secretary shall transmit to the Congress a report 
containing--
          [(1) a detailed description of the study conducted 
        pursuant to this section; and
          [(2) a discussion of the findings and conclusions of 
        such study.
    [(d) Definitions
    [For the purposes of this section--
          [(1) the term ``terminally ill'' means any Indian who 
        has a medical prognosis (as certified by a physician) 
        of a life expectancy of six months or less; and
          [(2) the term ``hospice program'' means any program 
        which satisfies the requirements of section 
        1395x(dd)(2) of Title 42; and
          [(3) the term ``hospice care'' means the items and 
        services specified in subparagraphs (A) through (H) of 
        section 1395x(dd)(1) of Title 42.]
          (2) shall provide that expenses (including salaries) 
        relating to services that are shared between the 
        Service and the Tribal Health Program be allocated 
        proportionately between the Service and the Indian 
        Tribe or Tribal Organization; and

[Sec. 1621e. Reimbursement from certain third parties of costs of 
                    health services]

          (3) may authorize such Indian Tribe or Tribal 
        Organization to construct, renovate, or expand a long-
        term care or other similar facility (including the 
        construction of a facility attached to a Service 
        facility).
    [(a) Right of recovery
    [Except as provided in subsection (f) of this section, the 
United States, an Indian tribe, or a tribal organization shall 
have the right to recover the reasonable expenses incurred by 
the Secretary, an Indian tribe, or a tribal organization in 
providing health services, through the Service, an Indian 
tribe, or a tribal organization, to any individual to the same 
extent that such individual, or any nongovernmental provider of 
such services, would be eligible to receive reimbursement or 
indemnification for such expenses if--
          [(1) such services had been provided by a 
        nongovernmental provider, and
          [(2) such individual had been required to pay such 
        expenses and did pay such expenses.
    [(b) Recovery against State with workers' compensation laws 
or no-fault automobile accident insurance program
    [Subsection (a) of this section shall provide a right of 
recovery against any State only if the injury, illness, or 
disability for which health services were provided is covered 
under--
          [(1) workers' compensation laws, or
          [(2) a no-fault automobile accident insurance plan or 
        program.
    [(c) Prohibition of State law or contract provision 
impeding right of recovery
    [No law of any State, or of any political subdivision of a 
State, and no provision of any contract entered into or renewed 
after November 23, 1988, shall prevent or hinder the right of 
recovery of the United States, an Indian tribe, or a tribal 
organization under subsection (a) of this section.
    [(d) Right to damages
    [No action taken by the United States, an Indian tribe, or 
a tribal organization to enforce the right of recovery provided 
under subsection (a) of this section shall affect the right of 
any person to any damages (other than damages for the cost of 
health services provided by the Secretary through the Service).
    [(e) Intervention or separate civil action
    [The United States, an Indian tribe, or a tribal 
organization may enforce the right of recovery provided under 
subsection (a) of this section by--
          [(1) intervening or joining in any civil action or 
        proceeding brought--
                  [(A) by the individual for whom health 
                services were provided by the Secretary, an 
                Indian tribe, or a tribal organization, or
                  [(B) by any representative or heirs of such 
                individual, or
          [(2) instituting a separate civil action, after 
        providing to such individual, or to the representative 
        or heirs of such individual, notice of the intention of 
        the United States, an Indian tribe, or a tribal 
        organization to institute a separate civil action.
    [(f) Right of recovery for services when self-insurance 
plan provides coverage
    [The United States shall not have a right of recovery under 
this section if the injury, illness, or disability for which 
health services were provided is covered under a self-insurance 
plan funded by an Indian tribe or tribal organization.]
    (c) Minimum Requirement.--Any nursing facility provided for 
under this section shall meet the requirements for nursing 
facilities under section 1919 of the Social Security Act.

[Sec. 1621f. Crediting of reimbursements]

    (d) Other Assistance.--The Secretary shall provide such 
technical and other assistance as may be necessary to enable 
applicants to comply with the provisions of this section.
    [(a) Except as provided in section 1621a(d) of this title, 
subchapter III-A of this chapter, and section 1680c of this 
title, all reimbursements received or recovered, under 
authority of this chapter, Public Law 87-693 (42 U.S.C. 2651, 
et seq.), or any other provision of law, by reason of the 
provision of health services by the Service or by a tribe or 
tribal organization under a contract pursuant to the Indian 
Self-Determination Act [25 U.S.C.A. Sec. 450f et seq.] shall be 
retained by the Service or that tribe or tribal organization 
and shall be available for the facilities, and to carry out the 
programs, of the Service or that tribe or tribal organization 
to provide health care services to Indians.
    [(b) The Service may not offset or limit the amount of 
funds obligated to any service unit or any entity under 
contract with the Service because of the receipt of 
reimbursements under subsection (a) of this section.]
    (e) Use of Existing or Underused Facilities.--The Secretary 
shall encourage the use of existing facilities that are 
underused or allow the use of swing beds for long-term or 
similar care.

[Sec. 1621g. Health services research]

SEC. 206. HEALTH SERVICES RESEARCH.

    [Of the amounts appropriated for]
    (a) In General.--The Secretary, acting through the Service 
[in any fiscal year, other than amounts made available for the 
Indian Health Care Improvement Fund, not less than $200,000 
shall be available only], shall make funding available for 
research to further the performance of the health service 
responsibilities of [the Service. Indian tribes and tribal 
organizations contracting with the Service under the authority 
of the Indian Self-Determination Act [25 U.S.C.A. Sec. 450f et 
seq.]] Indian Health Programs.
    (b) Coordination of Resources and Activities.--The 
Secretary shall also, to the maximum extent practicable, 
coordinate departmental research resources and activities to 
address relevant Indian Health Program research needs.
    (c) Availability.--Tribal Health Programs shall be given an 
equal opportunity to compete for, and receive, research funds 
under this section.

[Sec. 1621h. Mental health prevention and treatment services

    [(a) National plan for Indian Mental Health Services
          [(1) Not later than 120 days after November 28, 1990, 
        the Secretary, acting through the Service, shall 
        develop and publish in the Federal Register a final 
        national plan for Indian Mental Health Services. The 
        plan shall include--
                  [(A) an assessment of the scope of the 
                problem of mental illness and dysfunctional and 
                self-destructive behavior, including child 
                abuse and family violence, among Indians, 
                including--
                          [(i) the number of Indians served by 
                        the Service who are directly or 
                        indirectly affected by such illness or 
                        behavior, and
                          [(ii) an estimate of the financial 
                        and human cost attributable to such 
                        illness or behavior;
                  [(B) an assessment of the existing and 
                additional resources necessary for the 
                prevention and treatment of such illness and 
                behavior; and
                  [(C) an estimate of the additional funding 
                needed by the Service to meet its 
                responsibilities under the plan.
          [(2) The Secretary shall submit a copy of the 
        national plan to the Congress.
    [(b) Memorandum of agreement
    [Not later than 180 days after November 28, 1990, the 
Secretary and the Secretary of the Interior shall develop and 
enter into a memorandum of agreement under which the 
Secretaries shall, among other things--
          [(1) determine and define the scope and nature of 
        mental illness and dysfunctional and self-destructive 
        behavior, including child abuse and family violence, 
        among Indians;
          [(2) make an assessment of the existing Federal, 
        tribal, State, local, and private services, resources, 
        and programs available to provide mental health 
        services for Indians;
          [(3) make an initial determination of the unmet need 
        for additional services, resources, and programs 
        necessary to meet the needs identified pursuant to 
        paragraph (1);
          [(4)(A) ensure that Indians, as citizens of the 
        United States and of the States in which they reside, 
        have access to mental health services to which all 
        citizens have access;
          [(B) determine the right of Indians to participate 
        in, and receive the benefit of, such services; and
          [(C) take actions necessary to protect the exercise 
        of such right;
          [(5) delineate the responsibilities of the Bureau of 
        Indian Affairs and the Service, including mental health 
        identification, prevention, education, referral, and 
        treatment services (including services through 
        multidisciplinary resource teams), at the central, 
        area, and agency and service unit levels to address the 
        problems identified in paragraph (1);
          [(6) provide a strategy for the comprehensive 
        coordination of the mental health services provided by 
        the Bureau of Indian Affairs and the Service to meet 
        the needs identified pursuant to paragraph (1), 
        including--
                  [(A) the coordination of alcohol and 
                substance abuse programs of the Service, the 
                Bureau of Indian Affairs, and the various 
                tribes (developed under the Indian Alcohol and 
                Substance Abuse Prevention and Treatment Act of 
                1986) [25 U.S.C.A. Sec. 2401 et seq.] with the 
                mental health initiatives pursuant to this Act, 
                particularly with respect to the referral and 
                treatment of dually-diagnosed individuals 
                requiring mental health and substance abuse 
                treatment; and
                  [(B) ensuring that Bureau of Indian Affairs 
                and Service programs and services (including 
                multidisciplinary resource teams) addressing 
                child abuse and family violence are coordinated 
                with such non-Federal programs and services;
          [(7) direct appropriate officials of the Bureau of 
        Indian Affairs and the Service, particularly at the 
        agency and service unit levels, to cooperate fully with 
        tribal requests made pursuant to subsection (d) of this 
        section; and
          [(8) provide for an annual review of such agreement 
        by the two Secretaries.
    [(c) Community mental health plan
          [(1) The governing body of any Indian tribe may, at 
        its discretion, adopt a resolution for the 
        establishment of a community mental health plan 
        providing for the identification and coordination of 
        available resources and programs to identify, prevent, 
        or treat mental illness or dysfunctional and self-
        destructive behavior, including child abuse and family 
        violence, among its members.
          [(2) In furtherance of a plan established pursuant to 
        paragraph (1) and at the request of a tribe, the 
        appropriate agency, service unit, or other officials of 
        the Bureau of Indian Affairs and the Service shall 
        cooperate with, and provide technical assistance to, 
        the tribe in the development of such plan. Upon the 
        establishment of such a plan and at the request of the 
        tribe, such officials, as directed by the memorandum of 
        agreement developed pursuant to subsection (c), of this 
        section, shall cooperate with the tribe in the 
        implementation of such plan.
          [(3) Two or more Indian tribes may form a coalition 
        for the adoption of resolutions and the establishment 
        and development of a joint community mental health plan 
        under this subsection.
          [(4) The Secretary, acting through the Service, may 
        make grants to Indian tribes adopting a resolution 
        pursuant to paragraph (1) to obtain technical 
        assistance for the development of a community mental 
        health plan and to provide administrative support in 
        the implementation of such plan.
    [(d) Mental health training and community education 
programs
          [(1) The Secretary and the Secretary of the Interior, 
        in consultation with representatives of Indian tribes, 
        shall conduct a study and compile a list, of the types 
        of staff positions specified in paragraph (2) whose 
        qualifications include, or should include, training in 
        the identification, prevention, education, referral, or 
        treatment of mental illness or dysfunctional and self-
        destructive behavior.
          [(2) The positions referred to in paragraph (1) are--
                  [(A) staff positions within the Bureau of 
                Indian Affairs, including existing positions, 
                in the fields of--
                          [(i) elementary and secondary 
                        education;
                          [(ii) social services and family and 
                        child welfare;
                          [(iii) law enforcement and judicial 
                        services; and
                          [(iv) alcohol and substance abuse;
                  [(B) staff positions with the Service; and
                  [(C) staff positions similar to those 
                identified in subparagraphs (A) and (B) 
                established and maintained by Indian tribes, 
                including positions established in contracts 
                entered into under the Indian Self-
                Determination Act [25 U.S.C.A. Sec. 450f et 
                seq.].
          [(3)(A) The appropriate Secretary shall provide 
        training criteria appropriate to each type of position 
        identified in paragraph (2)(A) and ensure that 
        appropriate training has been, or will be, provided to 
        any individual in any such position. With respect to 
        any such individual in a position identified pursuant 
        to paragraph (2)(C), the respective Secretaries shall 
        provide appropriate training to, or provide funds to an 
        Indian tribe for the training of, such individual. In 
        the case of positions funded under a contract entered 
        into under the Indian Self-Determination Act [25 
        U.S.C.A. Sec. 450f et seq.], the appropriate Secretary 
        shall ensure that such training costs are included in 
        the contract, if necessary.
          [(B) Funds authorized to be appropriated pursuant to 
        this section may be used to provide training authorized 
        by this paragraph for community education programs 
        described in paragraph (5) if a plan adopted pursuant 
        to subsection (d) of this section identifies 
        individuals or employment categories, other than those 
        identified pursuant to paragraph (1), for which such 
        training or community education is deemed necessary or 
        desirable.
          [(4) Position-specific training criteria described in 
        paragraph (3) shall be culturally relevant to Indians 
        and Indian tribes and shall ensure that appropriate 
        information regarding traditional Indian healing and 
        treatment practices is provided.
          [(5) The Service shall develop and implement or, upon 
        the request of an Indian tribe, assist such tribe to 
        develop and implement, a program of community education 
        on mental illness and dysfunctional and self-
        destructive behavior for individuals, as determined in 
        a plan adopted pursuant to subsection (d) of this 
        section. In carrying out this paragraph, the Service 
        shall provide, upon the request of an Indian tribe, 
        technical assistance to the Indian tribe to obtain or 
        develop community education and training materials on 
        the identification, prevention, referral, and treatment 
        of mental illness and dysfunctional and self-
        destructive behavior.
    [(e) Staffing
          [(1) Within 90 days after November 28, 1990, the 
        Secretary shall develop a plan under which the Service 
        will increase the health care staff providing mental 
        health services by at least 500 positions within five 
        years after November 28, 1990, with at least 200 of 
        such positions devoted to child, adolescent, and family 
        services. Such additional staff shall be primarily 
        assigned to the service unit level for services which 
        shall include outpatient, emergency, aftercare and 
        follow-up, and prevention and education services.
        [(2) The plan developed under paragraph (1) shall be 
        implemented section 13 of this title.
    [(f) Staff recruitment and retention
          [(1) The Secretary shall provide for the recruitment 
        of the additional personnel required by subsection (f) 
        of this section and the retention of all Service 
        personnel providing mental health services. In carrying 
        out this subsection, the Secretary shall give priority 
        to practitioners providing mental health services to 
        children and adolescents with mental health problems.
          [(2) In carrying out paragraph (1), the Secretary 
        shall develop a program providing for--
                  [(A) the payment of bonuses (which shall not 
                be more favorable than those provided for under 
                sections 1616i and 1616j of this title) for 
                service in hardship posts;
                  [(B) the repayment of loans (for which the 
                provisions of repayment contracts shall not be 
                more favorable than the repayment contracts 
                under section 1616a of this title) for health 
                professions education as a recruitment 
                incentive; and
                  [(C) a system of postgraduate rotations as a 
                retention incentive.
          [(3) This subsection shall be carried out in 
        coordination with the recruitment and retention 
        programs under subchapter I of this chapter.
    [(g) Mental Health Technician program
          [(1) Under the authority of section 13 of this title, 
        the Secretary shall establish and maintain a Mental 
        Health Technician program within the Service which--
                  [(A) provides for the training of Indians as 
                mental health technicians; and
                  [(B) employs such technicians in the 
                provision of community-based mental health care 
                that includes identification, prevention, 
                education, referral, and treatment services.
          [(2) In carrying out paragraph (1)(A), the Secretary 
        shall provide high standard paraprofessional training 
        in mental health care necessary to provide quality care 
        to the Indian communities to be served. Such training 
        shall be based upon a curriculum developed or approved 
        by the Secretary which combines education in the theory 
        of mental health care with supervised practical 
        experience in the provision of such care.
          [(3) The Secretary shall supervise and evaluate the 
        mental health technicians in the training program.
          [(4) The Secretary shall ensure that the program 
        established pursuant to this subsection involves the 
        utilization and promotion of the traditional Indian 
        health care and treatment practices of the Indian 
        tribes to be served.
    [(h) Mental health research
    [The Secretary, acting through the Service and in 
consultation with the National Institute of Mental Health, 
shall enter into contracts with, or make grants to, appropriate 
institutions for the conduct of research on the incidence and 
prevalence of mental disorders among Indians on Indian 
reservations and in urban areas. Research priorities under this 
subsection shall include--
          [(1) the inter-relationship and inter-dependence of 
        mental disorders with alcoholism, suicide, homicides, 
        accidents, and the incidence of family violence, and
          [(2) the development of models of prevention 
        techniques.
    [The effect of the inter-relationships and 
interdependencies referred to in paragraph (1) on children, and 
the development of prevention techniques under paragraph (2) 
applicable to children, shall be emphasized.
    [(i) Facilities assessment
    [Within one year after November 28, 1990, the Secretary, 
acting through the Service, shall make an assessment of the 
need for inpatient mental health care among Indians and the 
availability and cost of inpatient mental health facilities 
which can meet such need. In making such assessment, the 
Secretary shall consider the possible conversion of existing, 
under-utilized service hospital beds into psychiatric units to 
meet such need.
    [(j) Annual report
    [The Service shall develop methods for analyzing and 
evaluating the overall status of mental health programs and 
services for Indians and shall submit to the President, for 
inclusion in each report required to be transmitted to the 
Congress under section 1671 of this title, a report on the 
mental health status of Indians which shall describe the 
progress being made to address mental health problems of Indian 
communities.
    [(k) Mental health demonstration grant program
          [(1) The Secretary, acting through the Service, is 
        authorized to make grants to Indian tribes and inter-
        tribal consortia to pay 75 percent of the cost of 
        planning, developing, and implementing programs to 
        deliver innovative community-based mental health 
        services to Indians. The 25 percent tribal share of 
        such cost may be provided in cash or through the 
        provision of property or services.
          [(2) The Secretary may award a grant for a project 
        under paragraph (1) to an Indian tribe or inter-tribal 
        consortium which meets the following criteria:
                  [(A) The project will address significant 
                unmet mental health needs among Indians.
                  [(B) The project will serve a significant 
                number of Indians.
                  [(C) The project has the potential to deliver 
                services in an efficient and effective manner.
                  [(D) The tribe or consortium has the 
                administrative and financial capability to 
                administer the project.
                  [(E) The project will deliver services in a 
                manner consistent with traditional Indian 
                healing and treatment practices.
                  [(F) The project is coordinated with, and 
                avoids duplication of, existing services.
          [(3) For purposes of this subsection, the Secretary 
        shall, in evaluating applications for grants for 
        projects to be operated under any contract entered into 
        with the Service under the Indian Self-Determination 
        Act [25 U.S.C.A. Sec. 450f et seq.], use the same 
        criteria that the Secretary uses in evaluating any 
        other application for such a grant.
          [(4) The Secretary may only award one grant under 
        this subsection with respect to a service area until 
        the Secretary has awarded grants for all service areas 
        with respect to which the Secretary receives 
        applications during the application period, as 
        determined by the Secretary, which meet the criteria 
        specified in paragraph (2).
          [(5) Not later than 180 days after the close of the 
        term of the last grant awarded pursuant to this 
        subsection, the Secretary shall submit to the Congress 
        a report evaluating the effectiveness of the innovative 
        community-based projects demonstrated pursuant to this 
        subsection. Such report shall include findings and 
        recommendations, if any, relating to the reorganization 
        of the programs of the Service for delivery of mental 
        health services to Indians.
          [(6) Grants made pursuant to this section may be 
        expended over a period of three years and no grant may 
        exceed $1,000,000 for the fiscal years involved.
    [(l) Licensing requirement for mental health care workers
    [Any person employed as a psychologist, social worker, or 
marriage and family therapist for the purpose of providing 
mental health care services to Indians in a clinical setting 
under the authority of this chapter or through a contract 
pursuant to the Indian Self-Determination Act [25 U.S.C.A. 
Sec. 450f et seq.] shall--
          [(1) in the case of a person employed as a 
        psychologist, be licensed as a clinical psychologist or 
        working under the direct supervision of a licensed 
        clinical psychologist;
          [(2) in the case of a person employed as a social 
        worker, be licensed as a social worker or working under 
        the direct supervision of a licensed social worker; or
          [(3) in the case of a person employed as a marriage 
        and family therapist, be licensed as a marriage and 
        family therapist or working under the direct 
        supervision of a licensed marriage and family 
        therapist.
    [(m) Intermediate adolescent mental health services
          [(1) The Secretary, acting through the Service, may 
        make grants to Indian tribes and tribal organizations 
        to provide intermediate mental health services to 
        Indian children and adolescents, including--
                  [(A) inpatient and outpatient services;
                  [(B) emergency care;
                  [(C) suicide prevention and crisis 
                intervention; and
                  [(D) prevention and treatment of mental 
                illness, and dysfunctional and self-destructive 
                behavior, including child abuse and family 
                violence.
          [(2) Funds provided under this subsection may be 
        used--
                  [(A) to construct or renovate an existing 
                health facility to provide intermediate mental 
                health services;
                  [(B) to hire mental health professionals;
                  [(C) to staff, operate, and maintain an 
                intermediate mental health facility, group 
                home, or youth shelter where intermediate 
                mental health services are being provided; and
                  [(D) to make renovations and hire appropriate 
                staff to convert existing hospital beds into 
                adolescent psychiatric units.
          [(3) Funds provided under this subsection may not be 
        used for the purposes described in section 1625o(b)(1) 
        of this title.
          [(4) An Indian tribe or tribal organization receiving 
        a grant under this subsection shall ensure that 
        intermediate adolescent mental health services are 
        coordinated with other tribal, Service, and Bureau of 
        Indian Affairs mental health, alcohol and substance 
        abuse, and social services programs on the reservation 
        of such tribe or tribal organization.
          [(5) The Secretary shall establish criteria for the 
        review and approval of applications for grants made 
        pursuant to this subsection.
          [(6) There are authorized to be appropriated to carry 
        out this section $10,000,000 for fiscal year 1993 and 
        such sums as may be necessary for each of the fiscal 
        years 1994, 1995, 1996, 1997, 1998, 1999, and 2000.
    (d) Use of Funds.--This funding may be used for both 
clinical and nonclinical research.

[Sec. 1621i. Managed care feasibility study]

    (e) Evaluation and Dissemination.--The Secretary shall 
periodically--
    [(a) The Secretary, acting through the Service, shall 
conduct a study to assess the feasibility of allowing an Indian 
tribe to purchase, directly or through the Service, managed 
care coverage for all members of the tribe from--
          [(1) a tribally owned and operated managed care plan; 
        or
          [(2) a State licensed managed care plan.
    [(b) Not later than the date which is 12 months after 
October 29, 1992, the Secretary shall transmit to the Congress 
a report containing--
          [(1) a detailed description of the study conducted 
        pursuant to this section; and
          [(2) a discussion of the findings and conclusions of 
        such study.
          (1) evaluate the impact of research conducted under 
        this section; and

[Sec. 1621j. California contract health services demonstration program]

          (2) disseminate to Tribal Health Programs information 
        regarding that research as the Secretary determines to 
        be appropriate.
    [(a) Establishment
    [The Secretary shall establish a demonstration program to 
evaluate the use of a contract care intermediary to improve the 
accessibility of health services to California Indians.
    [(b) Agreement with California Rural Indian Health Board
          [(1) In establishing such program, the Secretary 
        shall enter into an agreement with the California Rural 
        Indian Health Board to reimburse the Board for costs 
        (including reasonable administrative costs) incurred, 
        during the period of the demonstration program, in 
        providing medical treatment under contract to 
        California Indians described in section 1679(b) of this 
        title throughout the California contract health 
        services delivery area described in section 1680 of 
        this title with respect to high-cost contract care 
        cases.
          [(2) Not more than 5 percent of the amounts provided 
        to the Board under this section for any fiscal year may 
        be for reimbursement for administrative expenses 
        incurred by the Board during such fiscal year.
          [(3) No payment may be made for treatment provided 
        under the demonstration program to the extent payment 
        may be made for such treatment under the Catastrophic 
        Health Emergency Fund described in section 1621a of 
        this title or from amounts appropriated or otherwise 
        made available to the California contract health 
        service delivery area for a fiscal year.
    [(c) Advisory board
    [There is hereby established an advisory board which shall 
advise the California Rural Indian Health Board in carrying out 
the demonstration pursuant to this section. The advisory board 
shall be composed of representatives, selected by the 
California Rural Indian Health Board, from not less than 8 
tribal health programs serving California Indians covered under 
such demonstration, at least one half of whom are not 
affiliated with the California Rural Indian Health Board.
    [(d) Commencement and termination dates
    [The demonstration program described in this section shall 
begin on January 1, 1993, and shall terminate on September 30, 
1997.
    [(e) Report
    [Not later than July 1, 1998, the California Rural Indian 
Health Board shall submit to the Secretary a report on the 
demonstration program carried out under this section, including 
a statement of its findings regarding the impact of using a 
contract care intermediary on--
          [(1) access to needed health services;
          [(2) waiting periods for receiving such services; and
          [(3) the efficient management of high-cost contract 
        care cases.
    [(f) ``High-cost contract care cases'' defined
    [For the purposes of this section, the term ``high-cost 
contract care cases'' means those cases in which the cost of 
the medical treatment provided to an individual--
          [(1) would otherwise be eligible for reimbursement 
        from the Catastrophic Health Emergency Fund established 
        under section 1621a of this title, except that the cost 
        of such treatment does not meet the threshold cost 
        requirement established pursuant to section 1621a(b)(2) 
        of this title; and
          [(2) exceeds $1,000.
    [(g) Authorization of appropriations
    [There are authorized to be appropriated for each of the 
fiscal years 1996 through 2000 such sums as may be necessary to 
carry out the purposes of this section.]

SEC. 207. MAMMOGRAPHY AND OTHER CANCER SCREENING.

[Sec. 1621k. Coverage of screening mammography]

    The Secretary, acting through the Service or Tribal Health 
Programs, shall provide for screening as follows:
          [The Secretary, through the Service, shall provide 
        for screening] (1) Screening mammography (as defined in 
        section 1861(jj) of the Social Security Act [[42 
        U.S.C.A. Sec. 1395x(jj)]]) for Indian [and urban Indian 
        women 35 years of age or older at a frequency, 
        determined by the Secretary (in consultation with the 
        Director of the National Cancer Institute),] women at a 
        frequency appropriate to such women under accepted and 
        appropriate national standards, and under such terms 
        and conditions as are consistent with standards 
        established by the Secretary to [assure] ensure the 
        safety and accuracy of screening mammography under part 
        B of title XVIII of [the Social Security Act [42 
        U.S.C.A. Sec. 1395j et seq.].] such Act.
          (2) Other cancer screening that receives an A or B 
        rating as recommended by the United States Preventive 
        Services Task Force established under section 915(a)(1) 
        of the Public Health Service Act (42 U.S.C. 299b-
        4(a)(1)). The Secretary shall ensure that screening 
        provided for under this paragraph complies with the 
        recommendations of the Task Force with respect to--
                  (A) frequency;
                  (B) the population to be served; 
                  (C) the procedure or technology to be used;
                  (D) evidence of effectiveness; and
                  (E) other matters that the Secretary 
                determines appropriate.

SEC. 208. PATIENT TRAVEL COSTS.

    (a) Definition of Qualified Escort.--In this section, the 
term `qualified escort' means--
          (1) an adult escort (including a parent, guardian, or 
        other family member) who is required because of the 
        physical or mental condition, or age, of the applicable 
        patient;
          (2) a health professional for the purpose of 
        providing necessary medical care during travel by the 
        applicable patient; or

[Sec. 1621l. Patient travel costs]

          (3) other escorts, as the Secretary or applicable 
        Indian Health Program determines to be appropriate.
    [(a) The Secretary, acting through the Service, shall 
provide funds for the following patient travel costs] (b) 
Provision of Funds.--The Secretary, acting through the Service 
and Tribal Health Programs, is authorized to provide funds for 
the following patient travel costs, including qualified 
escorts, associated with receiving health care services 
provided (either through direct or contract care or through 
[contracts entered into pursuant to the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.]) under this 
Act--] a contract or compact under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et 
seq.)) under this Act--
          (1) emergency air transportation[;] and [(2) 
        nonemergency] non-emergency air transportation where 
        ground transportation is infeasible[.];
    [(b) There are authorized to be appropriated to carry out 
this section $15,000,000 for fiscal year 1993 and such sums as 
may be necessary for each of the fiscal years 1994, 1995, 1996, 
1997, 1998, 1999, and 2000.]
          (2) transportation by private vehicle (where no other 
        means of transportation is available), specially 
        equipped vehicle, and ambulance; and
          (3) transportation by such other means as may be 
        available and required when air or motor vehicle 
        transportation is not available.

[Sec. 1621m. Epidemiology centers]

SEC. 209. EPIDEMIOLOGY CENTERS.

    (a)[(1)] Establishment of Centers.--The Secretary shall 
establish an epidemiology center in each Service [area] Area to 
carry out the functions described in [paragraph (3).] 
subsection (b). Any new center established after the date of 
enactment of the Indian Health Care Improvement Act Amendments 
of 2007 may be operated under a grant authorized by subsection 
(d), but funding under such a grant shall not be divisible.
          [(2) To assist such centers in carrying out such 
        functions, the Secretary shall perform the following:
                  [(A) In consultation with the Centers for 
                Disease Control and Indian tribes, develop sets 
                of data (which to the extent practicable, shall 
                be consistent with the uniform data sets used 
                by the States with respect to the year 2000 
                health objectives) for uniformly defining 
                health status for purposes of the objectives 
                specified in section 1602(b) of this title. 
                Such sets shall consist of one or more 
                categories of information. The Secretary shall 
                develop formats for the uniform collecting and 
                reporting of information on such categories.
                  [(B) Establish and maintain a system for 
                monitoring the progress made toward meeting 
                each of the health status objectives described 
                in section 1602(b) of this title.
          [(3) In consultation with Indian tribes and urban 
        Indian communities, each area epidemiology center 
        established under this subsection shall, with respect 
        to such area--
    (b) Functions of Centers.--In consultation with and upon 
the request of Indian Tribes, Tribal Organizations, and Urban 
Indian Organizations, each Service Area epidemiology center 
established under this section shall, with respect to such 
Service Area--
        [A] (1) collect data relating to, and monitor progress 
        made toward meeting, each of the health status 
        objectives [described in section 1602(b) of this title 
        using the data sets and monitoring system developed by 
        the Secretary pursuant to paragraph (2);] of the 
        Service, the Indian Tribes, Tribal Organizations, and 
        Urban Indian Organizations in the Service Area;
          [(B)](2) evaluate existing delivery systems, data 
        systems, and other systems that impact the improvement 
        of Indian health;
          [(C)](3) assist [tribes and urban Indian communities] 
        Indian Tribes, Tribal Organizations, and Urban Indian 
        Organizations in identifying their highest priority 
        health status objectives and the services needed to 
        achieve such objectives, based on epidemiological data;
          [(D)](4) make recommendations for the targeting of 
        services needed by [tribal, urban, and other Indian 
        communities] the populations served;
          [(E)](5) make recommendations to improve health care 
        delivery systems for Indians and [urban] Urban Indians;
          [(F) work cooperatively with tribal providers of 
        health and social services in order to avoid 
        duplication of existing services; and]
          [(G)] (6) provide requested technical assistance to 
        Indian [tribes and urban Indian organizations] Tribes, 
        Tribal Organizations, and Urban Indian Organizations in 
        the development of local health service priorities and 
        incidence and prevalence rates of disease and other 
        illness in the community[.]; and
          [(4) Epidemiology centers established under this 
        subsection shall be subject to the provisions of the 
        Indian Self-Determination Act (25 U.S.C. 450f et 
        seq.).]
          (7) provide disease surveillance and assist Indian 
        Tribes, Tribal Organizations, and Urban Indian 
        Organizations to promote public health.
    [(5)] (c) Technical Assistance.--The [director] Director of 
the Centers for Disease Control and Prevention shall provide 
technical assistance to the centers in carrying out the 
requirements of this [subsection] section.
          [(6) The Service shall assign one epidemiologist from 
        each of its area offices to each area epidemiology 
        center to provide such center with technical assistance 
        necessary to carry out this subsection.]
    (d) Grants for Studies.--
          [(b)] (1) In general.--The Secretary may make grants 
        to Indian [tribes, tribal organizations] Tribes, Tribal 
        Organizations, Urban Indian Organizations, and eligible 
        intertribal consortia [or Indian organizations] to 
        conduct epidemiological studies of Indian communities.
          [(2)] (2) Eligible intertribal consortia.--An 
        intertribal [consortia or Indian organization] 
        consortium is eligible to receive a grant under this 
        subsection if--
                  [(A) it] (A) the intertribal consortium is 
                incorporated for the primary purpose of 
                improving Indian health; and
                  [(B) it] (B) the intertribal consortium is 
                representative of the [tribes] Indian Tribes or 
                urban Indian communities in which [it] the 
                intertribal consortium is located.
          (3) Applications.--An application for a grant under 
        this subsection shall be submitted in such manner and 
        at such time as the Secretary shall prescribe.
          [(4) Applicants for grants] (4) Requirements.--An 
        applicant for a grant under this subsection shall--
                  (A) demonstrate the technical, 
                administrative, and financial expertise 
                necessary to carry out the functions described 
                in paragraph (5);
                  (B) consult and cooperate with providers of 
                related health and social services in order to 
                avoid duplication of existing services; and
                  (C) demonstrate cooperation from Indian 
                [tribes] Tribes or [urban] Urban Indian 
                [organizations] Organizations in the area to be 
                served.
          (5) Use of funds.--A grant awarded under paragraph 
        (1) may be used [to]--
                  (A) to carry out the functions described in 
                subsection ([a]b);
                  [(3) of this section;] (B) to provide 
                information to and consult with tribal leaders, 
                urban Indian community leaders, and related 
                health staff[,] on health care and health 
                [services]service management issues; and
                  (C) [provide,] in collaboration with [tribes] 
                Indian Tribes, Tribal Organizations, and urban 
                Indian communities, to provide the Service with 
                information regarding ways to improve the 
                health status of [Indian people] Indians.
          [(6) There are authorized to be appropriated to carry 
        out the purposes of this subsection not more than 
        $12,000,000 for fiscal year 1993 and such sums as may 
        be necessary for each of the fiscal years 1994, 1995, 
        1996, 1997, 1998, 1999, and 2000.]
    (e) Access to Information.--An epidemiology center operated 
by a grantee pursuant to a grant awarded under subsection (d) 
shall be treated as a public health authority for purposes of 
the Health Insurance Portability and Accountability Act of 1996 
(Public Law 104-191; 110 Stat. 2033), as such entities are 
defined in part 164.501 of title 45, Code of Federal 
Regulations (or a successor regulation). The Secretary shall 
grant such grantees access to and use of data, data sets, 
monitoring systems, delivery systems, and other protected 
health information in the possession of the Secretary.

[Sec. 1621n. Comprehensive school health education programs]

SEC. 210. COMPREHENSIVE SCHOOL HEALTH EDUCATION PROGRAMS.

    [(a) Award of grants
    [The] (a) Funding for Development of Programs.--In addition 
to carrying out any other program for health promotion or 
disease prevention, the Secretary, acting through the Service 
[and in consultation with the Secretary of the Interior, may], 
is authorized to award grants to Indian [tribes] Tribes, Tribal 
Organizations, and Urban Indian Organizations to develop 
comprehensive school health education programs for children 
from [preschool] pre-school through grade 12 in schools 
[located on] for the benefit of Indian [reservations.] and 
Urban Indian children.
    (b) Use of [grantsGrants] Grant Funds.--A grant awarded 
under this section may be used [to--] for purposes which may 
include, but are not limited to, the following:
          [(1) develop health education curricula;]
          (1) Developing health education materials both for 
        regular school programs and afterschool programs.
          (2) [train] Training teachers in comprehensive school 
        health education [curricula;] materials.
          (3) [integrate] Integrating school-based, community-
        based, and other public and private health promotion 
        efforts[;].
          (4) [encourage] Encouraging healthy, tobacco-free 
        school environments[;].
          (5) [coordinate] Coordinating school-based health 
        programs with existing services and programs available 
        in the community[;].
          (6) [develop] Developing school programs on nutrition 
        education, personal health, oral health, and 
        fitness[;].
          [(7) develop mental] (7) Developing behavioral health 
        wellness programs[;].
          (8) [develop] Developing chronic disease prevention 
        programs[;].
          (9) [develop] Developing substance abuse prevention 
        programs[;].
          (10) [develop accident] Developing injury prevention 
        and safety education programs[;].
          (11) [develop] Developing activities for the 
        prevention and control of communicable diseases[; and].
          (12) [develop] Developing community and environmental 
        health education programs that include traditional 
        health care practitioners.
          (13) Violence prevention.
          (14) Such other health issues as are appropriate.
    (c) Technical Assistance [The].--Upon request, the 
Secretary, acting through the Service, shall provide technical 
assistance to Indian [tribes] Tribes, Tribal Organizations, and 
Urban Indian Organizations in the development of comprehensive 
health education plans[,] and the dissemination of 
comprehensive health education materials and information on 
existing health programs and resources.
    (d) Criteria for [review and approval of applications. The 
Secretary] Review and Approval of Applications._The Secretary, 
acting through the Service, and in consultation with Indian 
Tribes, Tribal Organizations, and Urban Indian Organizations, 
shall establish criteria for the review and approval of 
applications for grants [made pursuant to this section.] 
awarded under this section.
    (e) [Report] Development of [recipient]
    [Recipients of grants under this section shall submit to 
the Secretary an annual report on activities undertaken with 
funds provided under this section. Such reports shall include a 
statement of--
          [(1) the number of preschools, elementary schools, 
        and secondary schools served;
          [(2) the number of students served;
          [(3) any new curricula established with funds 
        provided under this section;
          [(4) the number of teachers trained in the health 
        curricula; and
          [(5) the involvement of parents, members of the 
        community, and community health workers in programs 
        established with funds provided under this section.]
    [(f)] Program [development] for BIA-Funded Schools.--
          (1) In general.--The Secretary of the Interior, 
        acting through the Bureau of Indian Affairs and in 
        cooperation with the Secretary, acting through the 
        Service, and affected Indian Tribes and Tribal 
        Organizations, shall develop a comprehensive school 
        health education program for children from preschool 
        through grade 12 in schools [operated] for which 
        support is provided by the Bureau of Indian Affairs.
          [(2) Such program shall include--]
          (2) Requirements for programs._Such programs shall 
        include-- 
                  (A) school programs on nutrition education, 
                personal health, oral health, and fitness;
                  (B) [mental] behavioral health wellness 
                programs;
                  (C) chronic disease prevention programs;
                  (D) substance abuse prevention programs;
                  (E) [accident] injury prevention and safety 
                education programs; and
                  (F) activities for the prevention and control 
                of communicable diseases.
          [(3) The Secretary of the Interior shall--]
          (3) Duties of the secretary._The Secretary of the 
        Interior shall--
                  [(A) provide training to teachers in 
                comprehensive school health education 
                [curricula;] materials;
                  (B) ensure the integration and coordination 
                of school-based programs with existing services 
                and health programs available in the community; 
                and
                  (C) encourage healthy, tobacco-free school 
                environments.
    [(g) Authorization of appropriations
    [There are authorized to be appropriated to carry out this 
section $15,000,000 for fiscal year 1993 and such sums as may 
be necessary for each of the fiscal years 1994, 1995, 1996, 
1997, 1998, 1999, and 2000.

[Sec. 1621o. Indian youth grant program]

SEC. 211. INDIAN YOUTH PROGRAM.

    [(a) Grants]
    (a) Program Authorized._The Secretary, acting through the 
Service, is authorized to [make] establish and administer a 
program to provide grants to Indian [tribes, tribal 
organizations, and urban Indian organizations] Tribes, Tribal 
Organizations, and Urban Indian Organizations for innovative 
mental and physical disease prevention and health promotion and 
treatment programs for Indian and Urban Indian preadolescent 
and adolescent youths.
    (b) Use of [funds] Funds.--
          (1) Allowable Uses.--Funds made available under this 
        section may be used to--
                  (A) develop prevention and treatment programs 
                for Indian youth which promote mental and 
                physical health and incorporate cultural 
                values, community and family involvement, and 
                traditional [healers] health care 
                practitioners; and
                  (B) develop and provide community training 
                and education.
          (2) Prohibited Use.--Funds made available under this 
        section may not be used to provide services described 
        in section [1621h(m) of this title.] 707(c).
    [(c) Models for delivery of comprehensive health care 
services
    [The]
    (c) Duties of the Secretary[shall].--The Secretary shall--
          (1) disseminate to Indian [tribes] Tribes, Tribal 
        Organizations, and Urban Indian Organizations 
        information regarding models for the delivery of 
        comprehensive health care services to Indian and 
        [urban] Urban Indian adolescents;
          (2) encourage the implementation of such models; and
          (3) at the request of an Indian [tribe] Tribe, Tribal 
        Organization, or Urban Indian Organization, provide 
        technical assistance in the implementation of such 
        models.
    (d) Criteria for [the review and approval of applications] 
Review and Approval of Applications.--The Secretary, in 
consultation with Indian Tribes, Tribal Organizations, and 
Urban Indian Organizations, shall establish criteria for the 
review and approval of applications or proposals under this 
section.
    [(e) Authorization of appropriations
    [There are authorized to be appropriated to carry out this 
section $5,000,000 for fiscal year 1993 and such sums as may be 
necessary for each of the fiscal years 1994, 1995, 1996, 1997, 
1998, 1999, and 2000.

[Sec. 1621p. American Indians Into Psychology Program

    [(a) Grants
    [The Secretary may provide grants to at least 3 colleges 
and universities for the purpose of developing and maintaining 
American Indian psychology career recruitment programs as a 
means of encouraging Indians to enter the mental health field.
    [(b) Quentin N. Burdick American Indians Into Psychology 
Program
    [The Secretary shall provide one of the grants authorized 
under subsection (a) of this section to develop and maintain a 
program at the University of North Dakota to be known as the 
``Quentin N. Burdick American Indians Into Psychology 
Program''. Such program shall, to the maximum extent feasible, 
coordinate with the Quentin N. Burdick Indian Health Programs 
authorized under section 1616g(b) of this title, the Quentin N. 
Burdick American Indians Into Nursing Program authorized under 
section 1616e(e) of this title, and existing university 
research and communications networks.
    [(c) Issuance of regulations
          [(1) The Secretary shall issue regulations for the 
        competitive awarding of the grants provided under this 
        section.
          [(2) Applicants for grants under this section shall 
        agree to provide a program which, at a minimum--
                  [(A) provides outreach and recruitment for 
                health professions to Indian communities 
                including elementary, secondary and community 
                colleges located on Indian reservations that 
                will be served by the program;
                  [(B) incorporates a program advisory board 
                comprised of representatives from the tribes 
                and communities that will be served by the 
                program;
                  [(C) provides summer enrichment programs to 
                expose Indian students to the varied fields of 
                psychology through research, clinical, and 
                experiential activities;
                  [(D) provides stipends to undergraduate and 
                graduate students to pursue a career in 
                psychology;
                  [(E) develops affiliation agreements with 
                tribal community colleges, the Service, 
                university affiliated programs, and other 
                appropriate entities to enhance the education 
                of Indian students;
                  [(F) to the maximum extent feasible, utilizes 
                existing university tutoring, counseling and 
                student support services; and
                  [(G) to the maximum extent feasible, employs 
                qualified Indians in the program.
    [(d) Active duty service obligation
    [The active duty service obligation prescribed under 
section 254m of Title 42 shall be met by each graduate student 
who receives a stipend described in subsection (c)(2)(D) of 
this section that is funded by a grant provided under this 
section. Such obligation shall be met by service--
          [(1) in the Indian Health Service;
          [(2) in a program conducted under a contract entered 
        into under the Indian Self-Determination Act [25 
        U.S.C.A. Sec. 450f et seq.];
          [(3) in a program assisted under subchapter IV of 
        this chapter; or
          [(4) in the private practice of psychology if, as 
        determined by the Secretary, in accordance with 
        guidelines promulgated by the Secretary, such practice 
        is situated in a physician or other health professional 
        shortage area and addresses the health care needs of a 
        substantial number of Indians.

[Sec. 1621q. Prevention, control, and elimination of tuberculosis

SEC. 212. PREVENTION, CONTROL, AND ELIMINATION OF COMMUNICABLE AND 
                    INFECTIOUS DISEASES.

    [(a) Grants]
    (a) Grants Authorized.--The Secretary, acting through the 
Service, and after consultation with the Centers for Disease 
Control and Prevention, may make grants [to Indian tribes and 
tribal organizations for--] available to Indian Tribes, Tribal 
Organizations, and Urban Indian Organizations for the 
following:
          [(1) projects for the prevention, control, and 
        elimination of tuberculosis;
          [(2) public information and education programs for 
        the prevention, control, and elimination of 
        tuberculosis; and]
          (1) Projects for the prevention, control, and 
        elimination of communicable and infectious diseases, 
        including tuberculosis, hepatitis, HIV, respiratory 
        syncytial virus, hanta virus, sexually transmitted 
        diseases, and H. Pylori.
          (2) Public information and education programs for the 
        prevention, control, and elimination of communicable 
        and infectious diseases.
          (3) [education] Education, training, and clinical 
        skills improvement activities in the prevention, 
        control, and elimination of [tuberculosis] communicable 
        and infectious diseases for health professionals, 
        including allied health professionals.
          (4) Demonstration projects for the screening, 
        treatment, and prevention of hepatitis C virus (HCV).
    (b) Application [for grant] Required.--The Secretary may 
[make a grant] provide funding under subsection (a) [of this 
section] only if an application [for the grant] or proposal for 
funding is submitted to the Secretary [and the application is 
in such form, is made in such manner, and contains the 
assurances required by subsection (c) of this section and such 
other agreements, assurances, and information as the Secretary 
may require.].
    [(c) Eligibility for grant
    [To be eligible for a grant under subsection (a) of this 
section, an applicant must provide assurances satisfactory to 
the Secretary that--]
          [(1) the applicant will coordinate its activities for 
        the prevention, control, and elimination of 
        tuberculosis with activities of] (c) Coordination With 
        Health Agencies.--Indian Tribes, Tribal Organizations, 
        and Urban Indian Organizations receiving funding under 
        this section are encouraged to coordinate their 
        activities with the Centers for Disease Control[,] and 
        Prevention and State and local health agencies[; and].
          [(2) the applicant will submit to the Secretary an 
        annual report on its activities for the prevention, 
        control, and elimination of tuberculosis.
    [(d) Duty of Secretary]
    (d) Technical Assistance; Report._In carrying out this 
section, the Secretary--
          [(1) shall establish criteria for the review and 
        approval of applications for grants under subsection 
        (a) of this section, including requirement of public 
        health qualifications of applicants;
          [(2) shall, subject to available appropriations, make 
        at least one grant under subsection (a) of this section 
        within each area office;
          [(3] (1) may, at the request of an Indian [tribe or 
        tribal organization] Tribe, Tribal Organization, or 
        Urban Indian Organization, provide technical 
        assistance; and
          [(4] (2) shall prepare and submit a report to [the 
        Committee on Energy and Commerce and the Committee on 
        Natural Resources of the House and the Committee on 
        Indian Affairs of the Senate not later than February 1, 
        1994, and biennially thereafter,] Congress biennially 
        on the use of funds under this section and on the 
        progress made toward the prevention, control, and 
        elimination of [tuberculosis among Indian tribes and 
        tribal organizations.] communicable and infectious 
        diseases among Indians and Urban Indians.
    [(e) Reduction of amount of grant
    [The Secretary may, at the request of a recipient of a 
grant under subsection (a) of this section, reduce the amount 
of such grant by--
          [(1) the fair market value of any supplies or 
        equipment furnished the grant recipient; and
          [(2) the amount of the pay, allowances, and travel 
        expenses of any officer or employee of the Government 
        when detailed to the grant recipient and the amount of 
        any other costs incurred in connection with the detail 
        of such officer or employee,
        when the furnishing of such supplies or equipment or 
        the detail of such an officer or employee is for the 
        convenience of and at the request of such grant 
        recipient and for the purpose of carrying out a program 
        with respect to which the grant under subsection (a) of 
        this section is made. The amount by which any such 
        grant is so reduced shall be available for payment by 
        the Secretary of the costs incurred in furnishing the 
        supplies or equipment, or in detailing the personnel, 
        on which the reduction of such grant is based, and such 
        amount shall be deemed as part of the grant and shall 
        be deemed to have been paid to the grant recipient.]

SEC. 213. OTHER AUTHORITY FOR PROVISION OF SERVICES.

    (a) Funding Authorized.--The Secretary, acting through the 
Service, Indian Tribes, and Tribal Organizations, may provide 
funding under this Act to meet the objectives set forth in 
section 3 of this Act through health care-related services and 
programs not otherwise described in this Act, including--
          (1) hospice care;
          (2) assisted living;
          (3) long-term care; and
          (4) home- and community-based services.
    (b) Terms and Conditions.--
          (1) In general.--Any service provided under this 
        section shall be in accordance with such terms and 
        conditions as are consistent with accepted and 
        appropriate standards relating to the service, 
        including any licensing term or condition under this 
        Act.
          (2) Standards.--
                  (A) In general.--The Secretary may establish, 
                by regulation, the standards for a service 
                provided under this section, provided that such 
                standards shall not be more stringent than the 
                standards required by the State in which the 
                service is provided.
                  (B) Use of state standards.--If the Secretary 
                does not, by regulation, establish standards 
                for a service provided under this section, the 
                standards required by the State in which the 
                service is or will be provided shall apply to 
                such service.
                  (C) Indian tribes.--If a service under this 
                section is provided by an Indian Tribe or 
                Tribal Organization pursuant to the Indian 
                Self-Determination and Education Assistance Act 
                (25 U.S.C. 450 et seq.), the verification by 
                the Secretary that the service meets any 
                standards required by the State in which the 
                service is or will be provided shall be 
                considered to meet the terms and conditions 
                required under this subsection.
          (3) Eligibility.--The following individuals shall be 
        eligible to receive long-term care under this section:
                  (A) Individuals who are unable to perform a 
                certain number of activities of daily living 
                without assistance.
                  (B) Individuals with a mental impairment, 
                such as dementia, Alzheimer's disease, or 
                another disabling mental illness, who may be 
                able to perform activities of daily living 
                under supervision.
                  (C) Such other individuals as an applicable 
                Indian Health Program determines to be 
                appropriate.
    (c) Definitions.--For the purposes of this section, the 
following definitions shall apply:
          (1) The term ``home- and community-based services'' 
        means 1 or more of the services specified in paragraphs 
        (1) through (9) of section 1929(a) of the Social 
        Security Act (42 U.S.C. 1396t(a)) (whether provided by 
        the Service or by an Indian Tribe or Tribal 
        Organization pursuant to the Indian Self-Determination 
        and Education Assistance Act (25 U.S.C. 450 et seq.)) 
        that are or will be provided in accordance with the 
        standards described in subsection (b).
          (2) The term ``hospice care'' means the items and 
        services specified in subparagraphs (A) through (H) of 
        section 1861(dd)(1) of the Social Security Act (42 
        U.S.C. 1395x(dd)(1)), and such other services which an 
        Indian Tribe or Tribal Organization determines are 
        necessary and appropriate to provide in furtherance of 
        this care.
    (d) Authorization of Convenient Care Services.--The 
Secretary, acting through the Service, Indian Tribes, and 
Tribal Organizations, may also provide funding under this Act 
to meet the objectives set forth in section 3 of this Act for 
convenient care services programs pursuant to section 
306(c)(2)(A).

SEC. 214. INDIAN WOMEN'S HEALTH CARE.

    The Secretary, acting through the Service and Indian 
Tribes, Tribal Organizations, and Urban Indian Organizations, 
shall monitor and improve the quality of health care for Indian 
women of all ages through the planning and delivery of programs 
administered by the Service, in order to improve and enhance 
the treatment models of care for Indian women.

SEC. 215. ENVIRONMENTAL AND NUCLEAR HEALTH HAZARDS.

    (a) Studies and Monitoring.--The Secretary and the Service 
shall conduct, in conjunction with other appropriate Federal 
agencies and in consultation with concerned Indian Tribes and 
Tribal Organizations, studies and ongoing monitoring programs 
to determine trends in the health hazards to Indian miners and 
to Indians on or near reservations and Indian communities as a 
result of environmental hazards which may result in chronic or 
life threatening health problems, such as nuclear resource 
development, petroleum contamination, and contamination of 
water source and of the food chain. Such studies shall 
include--
          (1) an evaluation of the nature and extent of health 
        problems caused by environmental hazards currently 
        exhibited among Indians and the causes of such health 
        problems;
          (2) an analysis of the potential effect of ongoing 
        and future environmental resource development on or 
        near reservations and Indian communities, including the 
        cumulative effect over time on health;
          (3) an evaluation of the types and nature of 
        activities, practices, and conditions causing or 
        affecting such health problems, including uranium 
        mining and milling, uranium mine tailing deposits, 
        nuclear power plant operation and construction, and 
        nuclear waste disposal; oil and gas production or 
        transportation on or near reservations or Indian 
        communities; and other development that could affect 
        the health of Indians and their water supply and food 
        chain;
          (4) a summary of any findings and recommendations 
        provided in Federal and State studies, reports, 
        investigations, and inspections during the 5 years 
        prior to the date of enactment of the Indian Health 
        Care Improvement Act Amendments of 2007 that directly 
        or indirectly relate to the activities, practices, and 
        conditions affecting the health or safety of such 
        Indians; and
          (5) the efforts that have been made by Federal and 
        State agencies and resource and economic development 
        companies to effectively carry out an education program 
        for such Indians regarding the health and safety 
        hazards of such development.
    (b) Health Care Plans.--Upon completion of such studies, 
the Secretary and the Service shall take into account the 
results of such studies and develop health care plans to 
address the health problems studied under subsection (a). The 
plans shall include--
          (1) methods for diagnosing and treating Indians 
        currently exhibiting such health problems;
          (2) preventive care and testing for Indians who may 
        be exposed to such health hazards, including the 
        monitoring of the health of individuals who have or may 
        have been exposed to excessive amounts of radiation or 
        affected by other activities that have had or could 
        have a serious impact upon the health of such 
        individuals; and
          (3) a program of education for Indians who, by reason 
        of their work or geographic proximity to such nuclear 
        or other development activities, may experience health 
        problems.
    (c) Submission of Report and Plan to Congress.--The 
Secretary and the Service shall submit to Congress the study 
prepared under subsection (a) no later than 18 months after the 
date of enactment of the Indian Health Care Improvement Act 
Amendments of 2007. The health care plan prepared under 
subsection (b) shall be submitted in a report no later than 1 
year after the study prepared under subsection (a) is submitted 
to Congress. Such report shall include recommended activities 
for the implementation of the plan, as well as an evaluation of 
any activities previously undertaken by the Service to address 
such health problems.
    (d) Intergovernmental Task Force.--
          (1) Establishment; members.--There is established an 
        Intergovernmental Task Force to be composed of the 
        following individuals (or their designees):
                  (A) The Secretary of Energy.
                  (B) The Secretary of the Environmental 
                Protection Agency.
                  (C) The Director of the Bureau of Mines.
                  (D) The Assistant Secretary for Occupational 
                Safety and Health.
                  (E) The Secretary of the Interior.
                  (F) The Secretary of Health and Human 
                Services.
                  (G) The Assistant Secretary.
          (2) Duties.--The Task Force shall--
                  (A) identify existing and potential 
                operations related to nuclear resource 
                development or other environmental hazards that 
                affect or may affect the health of Indians on 
                or near a reservation or in an Indian 
                community; and
                  (B) enter into activities to correct existing 
                health hazards and ensure that current and 
                future health problems resulting from nuclear 
                resource or other development activities are 
                minimized or reduced.
          (3) Chairman; meetings.--The Secretary of Health and 
        Human Services shall be the Chairman of the Task Force. 
        The Task Force shall meet at least twice each year.
    (e) Health Services to Certain Employees.--In the case of 
any Indian who--
          (1) as a result of employment in or near a uranium 
        mine or mill or near any other environmental hazard, 
        suffers from a work-related illness or condition;
          (2) is eligible to receive diagnosis and treatment 
        services from an Indian Health Program; and
          (3) by reason of such Indian's employment, is 
        entitled to medical care at the expense of such mine or 
        mill operator or entity responsible for the 
        environmental hazard, the Indian Health Program shall, 
        at the request of such Indian, render appropriate 
        medical care to such Indian for such illness or 
        condition and may be reimbursed for any medical care so 
        rendered to which such Indian is entitled at the 
        expense of such operator or entity from such operator 
        or entity. Nothing in this subsection shall affect the 
        rights of such Indian to recover damages other than 
        such amounts paid to the Indian Health Program from the 
        employer for providing medical care for such illness or 
        condition.

SEC. 216. ARIZONA AS A CONTRACT HEALTH SERVICE DELIVERY AREA.

    (a) In General.--For fiscal years beginning with the fiscal 
year ending September 30, 1983, and ending with the fiscal year 
ending September 30, 2016, the State of Arizona shall be 
designated as a contract health service delivery area by the 
Service for the purpose of providing contract health care 
services to members of federally recognized Indian Tribes of 
Arizona.
    (b) Maintenance of Services.--The Service shall not curtail 
any health care services provided to Indians residing on 
reservations in the State of Arizona if such curtailment is due 
to the provision of contract services in such State pursuant to 
the designation of such State as a contract health service 
delivery area pursuant to subsection (a).

SEC. 216A. NORTH DAKOTA AND SOUTH DAKOTA AS CONTRACT HEALTH SERVICE 
                    DELIVERY AREA.

    (a) In General.--Beginning in fiscal year 2003, the States 
of North Dakota and South Dakota shall be designated as a 
contract health service delivery area by the Service for the 
purpose of providing contract health care services to members 
of federally recognized Indian Tribes of North Dakota and South 
Dakota.
    (b) Limitation.--The Service shall not curtail any health 
care services provided to Indians residing on any reservation, 
or in any county that has a common boundary with any 
reservation, in the State of North Dakota or South Dakota if 
such curtailment is due to the provision of contract services 
in such States pursuant to the designation of such States as a 
contract health service delivery area pursuant to subsection 
(a).

SEC. 217. CALIFORNIA CONTRACT HEALTH SERVICES PROGRAM.

    (a) Funding Authorized.--The Secretary is authorized to 
fund a program using the California Rural Indian Health Board 
(hereafter in this section referred to as the ``CRIHB") as a 
contract care intermediary to improve the accessibility of 
health services to California Indians.
    (b) Reimbursement Contract.--The Secretary shall enter into 
an agreement with the CRIHB to reimburse the CRIHB for costs 
(including reasonable administrative costs) incurred pursuant 
to this section, in providing medical treatment under contract 
to California Indians described in section 806(a) throughout 
the California contract health services delivery area described 
in section 218 with respect to high cost contract care cases.
    (c) Administrative Expenses.--Not more than 5 percent of 
the amounts provided to the CRIHB under this section for any 
fiscal year may be for reimbursement for administrative 
expenses incurred by the CRIHB during such fiscal year.
    (d) Limitation on Payment.--No payment may be made for 
treatment provided hereunder to the extent payment may be made 
for such treatment under the Indian Catastrophic Health 
Emergency Fund described in section 202 or from amounts 
appropriated or otherwise made available to the California 
contract health service delivery area for a fiscal year.
    (e) Advisory Board.--There is established an advisory board 
which shall advise the CRIHB in carrying out this section. The 
advisory board shall be composed of representatives, selected 
by the CRIHB, from not less than 8 Tribal Health Programs 
serving California Indians covered under this section at least 
\1/2\ of whom of whom are not affiliated with the CRIHB.

SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE DELIVERY AREA.

    The State of California, excluding the counties of Alameda, 
Contra Costa, Los Angeles, Marin, Orange, Sacramento, San 
Francisco, San Mateo, Santa Clara, Kern, Merced, Monterey, 
Napa, San Benito, San Joaquin, San Luis Obispo, Santa Cruz, 
Solano, Stanislaus, and Ventura, shall be designated as a 
contract health service delivery area by the Service for the 
purpose of providing contract health services to California 
Indians. However, any of the counties listed herein may only be 
included in the contract health services delivery area if 
funding is specifically provided by the Service for such 
services in those counties.

SEC. 219. CONTRACT HEALTH SERVICES FOR THE TRENTON SERVICE AREA.

    (a) Authorization for Services.--The Secretary, acting 
through the Service, is directed to provide contract health 
services to members of the Turtle Mountain Band of Chippewa 
Indians that reside in the Trenton Service Area of Divide, 
McKenzie, and Williams counties in the State of North Dakota 
and the adjoining counties of Richland, Roosevelt, and Sheridan 
in the State of Montana.
    (b) No Expansion of Eligibility.--Nothing in this section 
may be construed as expanding the eligibility of members of the 
Turtle Mountain Band of Chippewa Indians for health services 
provided by the Service beyond the scope of eligibility for 
such health services that applied on May 1, 1986.

SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND TRIBAL ORGANIZATIONS.

    The Service shall provide funds for health care programs 
and facilities operated by Tribal Health Programs on the same 
basis as such funds are provided to programs and facilities 
operated directly by the Service.

SEC. 221. LICENSING.

    Health care professionals employed by a Tribal Health 
Program shall, if licensed in any State, be exempt from the 
licensing requirements of the State in which the Tribal Health 
Program performs the services described in its contract or 
compact under the Indian Self-Determination and Education 
Assistance Act (25 U.S.C. 450 et seq.).

[Sec. 1621r. Contract health services payment study]

SEC. 222. NOTIFICATION OF PROVISION OF EMERGENCY CONTRACT HEALTH 
                    SERVICES.

    [(a) Duties of Secretary
    [The Secretary, acting through the Service and in 
consultation with representatives of Indian tribes and tribal 
organizations operating contract health care programs under the 
Indian Self-Determination Act (25 U.S.C. 450f et seq.) or under 
self-governance compacts, Service personnel, private contract 
health services providers, the Indian Health Service Fiscal 
Intermediary, and other appropriate experts, shall conduct a 
study--
          [(1) to assess and identify administrative barriers 
        that hinder the timely payment for services delivered 
        by private contract health services providers to 
        individual Indians by the Service and the Indian Health 
        Service Fiscal Intermediary;
          [(2) to assess and identify the impact of such 
        delayed payments upon the personal credit histories of 
        individual Indians who have been treated by such 
        providers; and
          [(3) to determine the most efficient and effective 
        means of improving the Service's contract health 
        services payment system and ensuring the development of 
        appropriate consumer protection policies to protect 
        individual Indians who receive authorized services from 
        private contract health services providers from billing 
        and collection practices, including the development of 
        materials and programs explaining patients' rights and 
        responsibilities.
    [(b) Functions of study
    [The study required by subsection (a) of this section 
shall--
          [(1) assess the impact of the existing contract 
        health services regulations and policies upon the 
        ability of the Service and the Indian Health Service 
        Fiscal Intermediary to process, on a timely and 
        efficient basis, the payment of bills submitted by 
        private contract health services providers;
          [(2) assess the financial and any other burdens 
        imposed upon individual Indians and private contract 
        health services providers by delayed payments;
          [(3) survey the policies and practices of collection 
        agencies used by contract health services providers to 
        collect payments for services rendered to individual 
        Indians;
          [(4) identify appropriate changes in Federal 
        policies, administrative procedures, and regulations, 
        to eliminate the problems experienced by private 
        contract health services providers and individual 
        Indians as a result of delayed payments; and
          [(5) compare the Service's payment processing 
        requirements with private insurance claims processing 
        requirements to evaluate the systemic differences or 
        similarities employed by the Service and private 
        insurers.
    [(c) Report to Congress
    [Not later than 12 months after October 29, 1992, the 
Secretary shall transmit to the Congress a report that 
includes--
          [(1) a detailed description of the study conducted 
        pursuant to this section; and
          [(2) a discussion of the findings and conclusions of 
        such study.]
    With respect to an elderly Indian or an Indian with a 
disability receiving emergency medical care or services from a 
non-Service provider or in a non-Service facility under the 
authority of this Act, the time limitation (as a condition of 
payment) for notifying the Service of such treatment or 
admission shall be 30 days.

[Sec. 1621s. Prompt action on payment of claims]

SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS.

    [(a) Time of response]
    (a) Deadline for Response._The Service shall respond to a 
notification of a claim by a provider of a contract care 
service with either an individual purchase order or a denial of 
the claim within 5 working days after the receipt of such 
notification.
    [(b) Failure to timely respond]
    (b) Effect of Untimely Response._If the Service fails to 
respond to a notification of a claim in accordance with 
subsection (a) [of this section], the Service shall accept as 
valid the claim submitted by the provider of a contract care 
service.
    [(c) Time of payment]
    (c) Deadline for Payment of Valid Claim._The Service shall 
pay a [completed] valid contract care service claim within 30 
days after the completion of the claim.

[Sec. 1621t. Demonstration of electronic claims processing]

    [(a) Not later than June 15, 1993, the Secretary shall 
develop and implement, directly or by contract, 2 projects to 
demonstrate in a pilot setting the use of claims processing 
technology to improve the accuracy and timeliness of the 
billing for, and payment of, contract health services.
    [(b) The Secretary shall conduct one of the projects 
authorized in subsection (a) of this section in the Service 
area served by the area office located in Phoenix, Arizona.]

SEC. 224. LIABILITY FOR PAYMENT. 

[Sec. 1621u.]

    (a) No Patient Liability[for payment (a)].--A patient who 
receives contract health care services that are authorized by 
the Service shall not be liable for the payment of any charges 
or costs associated with the provision of such services.
    (b) Notification._[The Secretary shall notify a contract 
care provider and any patient who receives contract health care 
services authorized by the Service that such patient is not 
liable for the payment of any charges or costs associated with 
the provision of such services not later than 5 business days 
after receipt of a notification of a claim by a provider of 
contract care services.
    (c) No Recourse.--Following receipt of the notice provided 
under subsection (b), or, if a claim has been deemed accepted 
under section 223(b), the provider shall have no further 
recourse against the patient who received the services.

SEC. 225. OFFICE OF INDIAN MEN'S HEALTH.

    (a) Establishment.--The Secretary may establish within the 
Service an office to be known as the ``Office of Indian Men's 
Health'' (referred to in this section as the ``Office'').
    (b) Director.--
          (1) In general.--The Office shall be headed by a 
        director, to be appointed by the Secretary.
          (2) Duties.--The director shall coordinate and 
        promote the status of the health of Indian men in the 
        United States.
    (c) Report.--Not later than 2 years after the date of 
enactment of the Indian Health Care Improvement Act Amendments 
of 2007, the Secretary, acting through the director of the 
Office, shall submit to Congress a report describing--

[Sec. 1621v. Office of Indian Women's Health Care]

          (1) any activity carried out by the director as of 
        the date on which the report is prepared; and 
          [There is established within the Service an Office of 
        Indian Women's Health Care to oversee efforts of the 
        Service to monitor and improve the quality of health 
        care for Indian women of all ages through the planning 
        and delivery of programs administered by the Service, 
        in order to improve and enhance the treatment models of 
        care for Indian women.]
          (2) any finding of the director with respect to the 
        health of Indian men.

[Sec. 1621w. Authorization of appropriations]

SEC. 226. AUTHORIZATION OF APPROPRIATIONS.

    [Except as provided in sections 1621h(m), 1621j, 1621l, 
1621m(b)(5), 1621n, and 1621o of this title, there] There are 
authorized to be appropriated such sums as may be necessary for 
each fiscal year through fiscal year [2000 to carry out this 
subchapter] 2017 to carry out this title.

[Sec. 1621x. Limitation on use of funds

    [Amounts appropriated to carry out this subchapter may not 
be used in a manner inconsistent with the Assisted Suicide 
Funding Restriction Act of 1997 [42 U.S.C.A. Sec. 14401 et 
seq.].]

                         TITLE III--FACILITIES


[Sec. 1631. Consultation; closure of facilities; reports]

SEC. 301. CONSULTATION; CONSTRUCTION AND RENOVATION OF FACILITIES; 
                    REPORTS.

    [(a) Consultation; standards for accreditation]
    (a) Prerequisites for Expenditure of Funds._Prior to the 
expenditure of, or the making of any [firm] binding commitment 
to expend, any funds appropriated for the planning, design, 
construction, or renovation of facilities pursuant to the Act 
of November 2, 1921 (25 U.S.C. 13)[,] [popularly] (commonly 
known as the ``Snyder Act''), the Secretary, acting through the 
Service, shall--
          (1) consult with any Indian [tribe] Tribe that would 
        be significantly affected by such expenditure for the 
        purpose of determining and, whenever practicable, 
        honoring tribal preferences concerning size, location, 
        type, and other characteristics of any facility on 
        which such expenditure is to be made[,]; and
          (2) ensure, whenever practicable and applicable, that 
        such facility meets the construction standards of [the 
        Joint Commission on Accreditation of Health Care 
        Organizations] any accrediting body recognized by the 
        Secretary for the purposes of the Medicare, Medicaid, 
        and SCHIP programs under titles XVIII, XIX, and XXI of 
        the Social Security Act by not later than 1 year after 
        the date on which the construction or renovation of 
        such facility is completed.
    [(b) Closure; report on proposed closure]
    (b) Closures.--
          (1) Evaluation required._Notwithstanding any other 
        provision of law [other than this subsection], no 
        facility operated by the Service [hospital or 
        outpatient health care facility of the Service], or any 
        portion of such [a hospital or] facility, may be closed 
        if the Secretary has not submitted to [the Congress at 
        least 1 year prior to the date such hospital or 
        facility (or portion thereof) is proposed to be closed 
        on evaluation of the impact of such proposed closure 
        which] Congress not less than 1 year, and not more than 
        2 years, before the date of the proposed closure an 
        evaluation, completed not more than 2 years before the 
        submission, of the impact of the proposed closure that 
        specifies, in addition to other considerations--
                  (A) the accessibility of alternative health 
                care resources for the population served by 
                such [hospital or] facility;
                  (B) the cost-effectiveness of such closure;
                  (C) the quality of health care to be provided 
                to the population served by such [hospital or] 
                facility after such closure;
                  (D) the availability of contract health care 
                funds to maintain existing levels of service;
                  (E) the views of the Indian [tribes] Tribes 
                served by such [hospital or] facility 
                concerning such closure;
                  (F) the level of [utilization] use of such 
                [hospital or] facility by all eligible Indians; 
                and
                  (G) the distance between such [hospital or] 
                facility and the nearest operating Service 
                hospital.
          (2) Exception for certain temporary closures._
        Paragraph (1) shall not apply to any temporary closure 
        of a facility or [of] any portion of a facility if such 
        closure is necessary for medical, environmental, or 
        construction safety reasons.
    [(c) Annual report on health facility priority system
          [(1) The Secretary shall submit to the President, for 
        inclusion in each report required to be transmitted to 
        the Congress under section 1671 of this title, a report 
        which sets forth--
                  [(A) the current health facility priority 
                system of the Service,
                  [(B) the planning, design, construction, and 
                renovation needs for the 10 top-priority 
                inpatient care facilities and the 10 top-
                priority ambulatory care facilities (together 
                with required staff quarters),
                  [(C) the justification for such order of 
                priority,
                  [(D) the projected cost of such projects, and
                  [(E) the methodology adopted by the Service 
                in establishing priorities under its health 
                facility priority system.
          [(2) In preparing each report required under 
        paragraph (1) (other than the initial report), the 
        Secretary shall--
                  [(A) consult with Indian tribes and tribal 
                organizations including those tribes or tribal 
                organizations operating health programs or 
                facilities under any contract entered into with 
                the Service under the Indian Self-Determination 
                Act [25 U.S.C.A. Sec. 450f et seq.], and
                  [(B) review the needs of such tribes and 
                tribal organizations for inpatient and 
                outpatient facilities, including their needs 
                for renovation and expansion of existing 
                facilities.
          [(3) For purposes of this subsection, the Secretary 
        shall, in evaluating the needs of facilities operated 
        under any contract entered into with the Service under 
        the Indian Self-Determination Act [25 U.S.C.A. 
        Sec. 450f et seq.], use the same criteria that the 
        Secretary uses in evaluating the needs of facilities 
        operated directly by the Service.]
    (c) Health Care Facility Priority System.--
          (1) In general.--
                  (A) Priority system.--The Secretary, acting 
                through the Service, shall maintain a health 
                care facility priority system, which--
                          (i) shall be developed in 
                        consultation with Indian Tribes and 
                        Tribal Organizations;
                          (ii) shall give Indian Tribes' needs 
                        the highest priority;
                          (iii)(I) may include the lists 
                        required in paragraph (2)(B)(ii); and
                          (II) shall include the methodology 
                        required in paragraph (2)(B)(v); and
                          (III) may include such other 
                        facilities, and such renovation or 
                        expansion needs of any health care 
                        facility, as the Service, Indian 
                        Tribes, and Tribal Organizations may 
                        identify; and
                          (iv) shall provide an opportunity for 
                        the nomination of planning, design, and 
                        construction projects by the Service, 
                        Indian Tribes, and Tribal Organizations 
                        for consideration under the priority 
                        system at least once every 3 years, or 
                        more frequently as the Secretary 
                        determines to be appropriate.
                  [(4)] (B) Needs of facilities under ISDEAA 
                agreements.--The Secretary shall ensure that 
                the planning, design, construction, [and] 
                renovation, and expansion needs of Service and 
                non-Service facilities [which are the subject 
                of a contract for health services entered into 
                with the Service under] operated under 
                contracts or compacts in accordance with the 
                Indian Self-Determination and Education 
                Assistance Act [[](25 U.S.C.[A. Sec. 450f] 450 
                et seq.[]])are fully and equitably integrated 
                into the [development of the] health care 
                facility priority system.
    [(d) Funds appropriated subject to section 450f of this 
title]
                  (C) Criteria for evaluating needs.--For 
                purposes of this subsection, the Secretary, in 
                evaluating the needs of facilities operated 
                under a contract or compact under the Indian 
                Self-Determination and Education Assistance Act 
                (25 U.S.C. 450 et seq.), shall use the criteria 
                used by the Secretary in evaluating the needs 
                of facilities operated directly by the Service.
                  (D) Priority of certain projects protected.--
                The priority of any project established under 
                the construction priority system in effect on 
                the date of enactment of the Indian Health Care 
                Improvement Act Amendments of 2007 shall not be 
                affected by any change in the construction 
                priority system taking place after that date if 
                the project--
                          (i) was identified in the fiscal year 
                        2008 Service budget justification as--
                                  (I) 1 of the 10 top-priority 
                                inpatient projects;
                                  (II) 1 of the 10 top-priority 
                                outpatient projects;
                                  (III) 1 of the 10 top-
                                priority staff quarters 
                                developments; or
                                  (IV) 1 of the 10 top-priority 
                                Youth Regional Treatment 
                                Centers;
                          (ii) had completed both Phase I and 
                        Phase II of the construction priority 
                        system in effect on the date of 
                        enactment of such Act; or
                          (iii) is not included in clause (i) 
                        or (ii) and is selected, as determined 
                        by the Secretary--
                                  (I) on the initiative of the 
                                Secretary; or
                                  (II) pursuant to a request of 
                                an Indian Tribe or Tribal 
                                Organization.
          (2) Report; contents.--
                  (A) Initial comprehensive report.--
                          (i) Definitions.--In this 
                        subparagraph:
                                  (I) Facilities appropriation 
                                advisory board.--The term 
                                ``Facilities Appropriation 
                                Advisory Board'' means the 
                                advisory board, comprised of 12 
                                members representing Indian 
                                tribes and 2 members 
                                representing the Service, 
                                established at the discretion 
                                of the Assistant Secretary--
                                          (aa) to provide 
                                        advice and 
                                        recommendations for 
                                        policies and procedures 
                                        of the programs funded 
                                        pursuant to facilities 
                                        appropriations; and
                                          (bb) to address other 
                                        facilities issues.
                                  (II) Facilities needs 
                                assessment workgroup.--The term 
                                ``Facilities Needs Assessment 
                                Workgroup'' means the workgroup 
                                established at the discretion 
                                of the Assistant Secretary--
                                          (aa) to review the 
                                        health care facilities 
                                        construction priority 
                                        system; and
                                          (bb) to make 
                                        recommendations to the 
                                        Facilities 
                                        Appropriation Advisory 
                                        Board for revising the 
                                        priority system.
                          (ii) Initial report.--
                                  (I) In general.--Not later 
                                than 1 year after the date of 
                                enactment of the Indian Health 
                                Care Improvement Act Amendments 
                                of 2007, the Secretary shall 
                                submit to the Committee on 
                                Indian Affairs of the Senate 
                                and the Committee on Natural 
                                Resources of the House of 
                                Representatives a report that 
                                describes the comprehensive, 
                                national, ranked list of all 
                                health care facilities needs 
                                for the Service, Indian Tribes, 
                                and Tribal Organizations 
                                (including inpatient health 
                                care facilities, outpatient 
                                health care facilities, 
                                specialized health care 
                                facilities (such as for long-
                                term care and alcohol and drug 
                                abuse treatment), wellness 
                                centers, staff quarters and 
                                hostels associated with health 
                                care facilities, and the 
                                renovation and expansion needs, 
                                if any, of such facilities) 
                                developed by the Service, 
                                Indian Tribes, and Tribal 
                                Organizations for the 
                                Facilities Needs Assessment 
                                Workgroup and the Facilities 
                                Appropriation Advisory Board.
                                  (II) Inclusions.--The initial 
                                report shall include--
                                          (aa) the methodology 
                                        and criteria used by 
                                        the Service in 
                                        determining the needs 
                                        and establishing the 
                                        ranking of the 
                                        facilities needs; and
                                          (bb) such other 
                                        information as the 
                                        Secretary determines to 
                                        be appropriate.
                          (iii) Updates of report.--Beginning 
                        in calendar year 2011, the Secretary 
                        shall--
                                  (I) update the report under 
                                clause (ii) not less frequently 
                                than once every 5 years; and
                                  (II) include the updated 
                                report in the appropriate 
                                annual report under 
                                subparagraph (B) for submission 
                                to Congress under section 801.
                  (B) Annual reports.--The Secretary shall 
                submit to the President, for inclusion in the 
                report required to be transmitted to Congress 
                under section 801, a report which sets forth 
                the following:
                          (i) A description of the health care 
                        facility priority system of the Service 
                        established under paragraph (1).
                          (ii) Health care facilities lists, 
                        which may include--
                                  (I) the 10 top-priority 
                                inpatient health care 
                                facilities;
                                  (II) the 10 top-priority 
                                outpatient health care 
                                facilities;
                                  (III) the 10 top-priority 
                                specialized health care 
                                facilities (such as long-term 
                                care and alcohol and drug abuse 
                                treatment);
                                  (IV) the 10 top-priority 
                                staff quarters developments 
                                associated with health care 
                                facilities; and
                                  (V) the 10 top-priority 
                                hostels associated with health 
                                care facilities.
                          (iii) The justification for such 
                        order of priority.
                          (iv) The projected cost of such 
                        projects.
                          (v) The methodology adopted by the 
                        Service in establishing priorities 
                        under its health care facility priority 
                        system.
          (3) Requirements for preparation of reports.--In 
        preparing the report required under paragraph (2), the 
        Secretary shall--
                  (A) consult with and obtain information on 
                all health care facilities needs from Indian 
                Tribes, Tribal Organizations, and Urban Indian 
                Organizations; and
                  (B) review the total unmet needs of all 
                Indian Tribes, Tribal Organizations, and Urban 
                Indian Organizations for health care facilities 
                (including hostels and staff quarters), 
                including needs for renovation and expansion of 
                existing facilities.
    (d) Review of Methodology Used for Health Facilities 
Construction Priority System.-- 
          (1) In general.--Not later than 1 year after the 
        establishment of the priority system under subsection 
        (c)(1)(A), the Comptroller General of the United States 
        shall prepare and finalize a report reviewing the 
        methodologies applied, and the processes followed, by 
        the Service in making each assessment of needs for the 
        list under subsection (c)(2)(A)(ii) and developing the 
        priority system under subsection (c)(1), including a 
        review of--
                  (A) the recommendations of the Facilities 
                Appropriation Advisory Board and the Facilities 
                Needs Assessment Workgroup (as those terms are 
                defined in subsection (c)(2)(A)(i)); and
                  (B) the relevant criteria used in ranking or 
                prioritizing facilities other than hospitals or 
                clinics.
          (2) Submission to congress.--The Comptroller General 
        of the United States shall submit the report under 
        paragraph (1) to--
                  (A) the Committees on Indian Affairs and 
                Appropriations of the Senate;
                  (B) the Committees on Natural Resources and 
                Appropriations of the House of Representatives; 
                and
                  (C) the Secretary.
    (e) Funding Condition._ All funds appropriated under the 
Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the 
``Snyder Act''), for the planning, design, construction, or 
renovation of health facilities for the benefit of [an] 1 or 
more Indian [tribe or tribes] Tribes shall be subject to the 
provisions of [section 102 of] the Indian Self-Determination 
and Education Assistance Act [(25 U.S.C.[A. Sec. 450f].] 450 et 
seq.).
    (f) Development of Innovative Approaches.--The Secretary 
shall consult and cooperate with Indian Tribes, Tribal 
Organizations, and Urban Indian Organizations in developing 
innovative approaches to address all or part of the total unmet 
need for construction of health facilities, including those 
provided for in other sections of this title and other 
approaches.

[Sec. 1632. Safe water and sanitary waste disposal facilities]

SEC. 302. SANITATION FACILITIES.

    [(a) Congressional findings
    [The] (a) Findings._Congress [hereby] finds [and declares 
that--] the following:
          (1) [the]The provision of [safe water supply systems 
        and sanitary sewage and solid waste disposal 
        systems]sanitation facilities is primarily a health 
        consideration and function[;].
          (2) Indian people suffer an inordinately high 
        incidence of disease, injury, and illness directly 
        attributable to the absence or inadequacy of [such 
        systems;]sanitation facilities.
          (3) [the]The long-term cost to the United States of 
        treating and curing such disease, injury, and illness 
        is substantially greater than the short-term cost of 
        providing [such systems]sanitation facilities and other 
        preventive health measures[;].
          (4) [many]Many Indian homes and Indian communities 
        still lack [safe water supply systems and sanitary 
        sewage and solid waste disposal systems; and]sanitation 
        facilities.
          (5) [it]It is in the interest of the United States, 
        and it is the policy of the United States, that all 
        Indian communities and Indian homes, new and existing, 
        be provided with [safe and adequate water supply 
        systems and sanitary sewage waste disposal systems as 
        soon as possible]sanitation facilities.
    [(b) Authority; assistance; transfer of funds]
    [(1)](b) Facilities and Services.--In furtherance of the 
findings [and declarations] made in subsection (a) [of this 
section] , Congress reaffirms the primary responsibility and 
authority of the Service to provide the necessary sanitation 
facilities and services as provided in section [2004a of Title 
42. (2) The] 7 of the Act of August 5, 1954 (42 U.S.C. 2004a). 
Under such authority, the Secretary, acting through the 
Service, is authorized to provide [under section 2004a of Title 
42--] the following:
          [(A) financial](1) Financial and technical assistance 
        to Indian [tribes and]Tribes, Tribal Organizations, and 
        Indian communities in the establishment, training, and 
        equipping of utility organizations to operate and 
        maintain [Indian sanitation facilities;]sanitation 
        facilities, including the provision of existing plans, 
        standard details, and specifications available in the 
        Department, to be used at the option of the Indian 
        Tribe, Tribal Organization, or Indian community.
          [(B)] (2) [ongoing]Ongoing technical assistance and 
        training to Indian Tribes, Tribal Organizations, and 
        Indian communities in the management of utility 
        organizations which operate and maintain sanitation 
        facilities[; and].
          [(C)](3) Priority funding for operation and 
        maintenance assistance for, and emergency repairs to, 
        [tribal] sanitation facilities operated by an Indian 
        Tribe, Tribal Organization or Indian community when 
        necessary to avoid [a] an imminent health [hazard] 
        threat or to protect the [Federal] investment in 
        sanitation facilities[.] and the investment in the 
        health benefits gained through the provision of 
        sanitation facilities.
    [(3)](c) Funding._Notwithstanding any other provision of 
law--
                  [(A) the Secretary of Housing and Urban 
                Affairs is authorized to transfer funds 
                appropriated under the Housing and Community 
                Development Act of 1974 (42 U.S.C. 5301, et 
                seq.) to the Secretary of Health and Human 
                Services; and]
          (1) the Secretary of Housing and Urban Development is 
        authorized to transfer funds appropriated under the 
        Native American Housing Assistance and Self-
        Determination Act of 1996 (25 U.S.C. 4101 et seq.) to 
        the Secretary of Health and Human Services;
          [(B)](2) the Secretary of Health and Human Services 
        is authorized to accept and use such funds for the 
        purpose of providing sanitation facilities and services 
        for Indians under section [2004a of Title 42.] 7 of the 
        Act of August 5, 1954 (42 U.S.C. 2004a);
    [(c) 10-year plan
    [Beginning in fiscal year 1990, the Secretary, acting 
through the Service, shall develop and begin implementation of 
a 10-year plan to provide safe water supply and sanitation 
sewage and solid waste disposal facilities to existing Indian 
homes and communities and to new and renovated Indian homes
    [(d) Tribal capability]
          (3) unless specifically authorized when funds are 
        appropriated, the Secretary shall not use funds 
        appropriated under section 7 of the Act of August 5, 
        1954 (42 U.S.C. 2004a), to provide sanitation 
        facilities to new homes constructed using funds 
        provided by the Department of Housing and Urban 
        Development;
          (4) the Secretary of Health and Human Services is 
        authorized to accept from any source, including Federal 
        and State agencies, funds for the purpose of providing 
        sanitation facilities and services and place these 
        funds into contracts or compacts under the Indian Self-
        Determination and Education Assistance Act (25 U.S.C. 
        450 et seq.);
          (5) except as otherwise prohibited by this section, 
        the Secretary may use funds appropriated under the 
        authority of section 7 of the Act of August 5, 1954 (42 
        U.S.C. 2004a), to fund up to 100 percent of the amount 
        of an Indian Tribe's loan obtained under any Federal 
        program for new projects to construct eligible 
        sanitation facilities to serve Indian homes;
          (6) except as otherwise prohibited by this section, 
        the Secretary may use funds appropriated under the 
        authority of section 7 of the Act of August 5, 1954 (42 
        U.S.C. 2004a) to meet matching or cost participation 
        requirements under other Federal and non-Federal 
        programs for new projects to construct eligible 
        sanitation facilities;
          (7) all Federal agencies are authorized to transfer 
        to the Secretary funds identified, granted, loaned, or 
        appropriated whereby the Department's applicable 
        policies, rules, and regulations shall apply in the 
        implementation of such projects;
          (8) the Secretary of Health and Human Services shall 
        enter into interagency agreements with Federal and 
        State agencies for the purpose of providing financial 
        assistance for sanitation facilities and services under 
        this Act;
          (9) the Secretary of Health and Human Services shall, 
        by regulation, establish standards applicable to the 
        planning, design, and construction of sanitation 
        facilities funded under this Act; and
          (10) the Secretary of Health and Human Services is 
        authorized to accept payments for goods and services 
        furnished by the Service from appropriate public 
        authorities, nonprofit organizations or agencies, or 
        Indian Tribes, as contributions by that authority, 
        organization, agency, or tribe to agreements made under 
        section 7 of the Act of August 5, 1954 (42 U.S.C. 
        2004a), and such payments shall be credited to the same 
        or subsequent appropriation account as funds 
        appropriated under the authority of section 7 of the 
        Act of August 5, 1954 (42 U.S.C. 2004a).
    (d) Certain Capabilities Not Prerequisite.--The financial 
and technical capability of an Indian [tribe or] Tribe, Tribal 
Organization, or Indian community to safely operate, manage, 
and maintain a sanitation facility shall not be a prerequisite 
to the provision or construction of sanitation facilities by 
the Secretary.
    [(e) Amount of assistance]
    [(1)] (e) Financial Assistance.--The Secretary is 
authorized to provide financial assistance to Indian [tribes 
and communities in an amount equal to the Federal share of the 
costs of operating, managing, and maintaining the facilities 
provided under the plan described in subsection (c) of this 
section.] Tribes, Tribal Organizations, and Indian communities 
for operation, management, and maintenance of their sanitation 
facilities.
          [(2) For the purposes of paragraph (1), the term 
        ``Federal share'' means 80 percent of the costs 
        described in paragraph (1).
          [(3) With respect to Indian tribes with fewer than 
        1,000 enrolled members, the non-Federal portion of the 
        costs of operating, managing, and maintaining such 
        facilities may be provided, in part, through cash 
        donations or in kind property, fairly evaluated.
    [(f) Eligibility of programs administered by Indian tribes
    [Programs administered by Indian tribes or tribal 
organizations under the authority of the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.] shall be 
eligible for--
          [(1) any funds appropriated pursuant to this section, 
        and
          [(2) any funds appropriated for the purpose of 
        providing water supply or sewage disposal services,
[on an equal basis with programs that are administered directly 
by the Service.
    [(g) Annual]
    (f) Operation, Management, and Maintenance of Facilities.--
The Indian Tribe has the primary responsibility to establish, 
collect, and use reasonable user fees, or otherwise set aside 
funding, for the purpose of operating, managing, and 
maintaining sanitation facilities. If a sanitation facility 
serving a community that is operated by an Indian Tribe or 
Tribal Organization is threatened with imminent failure and 
such operator lacks capacity to maintain the integrity or the 
health benefits of the sanitation facility, then the Secretary 
is authorized to assist the Indian Tribe, Tribal Organization, 
or Indian community in the resolution of the problem on a 
short-term basis through cooperation with the emergency 
coordinator or by providing operation, management, and 
maintenance service.
    (g) ISDEAA Program Funded on Equal Basis.--Tribal Health 
Programs shall be eligible (on an equal basis with programs 
that are administered directly by the Service) for--
          (1) any funds appropriated pursuant to this section; 
        and
          (2) any funds appropriated for the purpose of 
        providing sanitation facilities.
    (h) Report.--
          (1) Required; contents.--The Secretary, in 
        consultation with the Secretary of Housing and Urban 
        Development, Indian Tribes, Tribal Organizations, and 
        tribally designated housing entities (as defined in 
        section 4 of the Native American Housing Assistance and 
        Self-Determination Act of 1996 (25 U.S.C. 4103)) shall 
        submit to the President, for inclusion in the report[; 
        sanitation deficiency levels]
          [(1) The Secretary shall submit to the President, for 
        inclusion in each report required to be transmitted to 
        the [Congress under section 1671 of this title,] 
        Congress under section 801, a report which sets forth--
                  [(A) the current Indian sanitation facility 
                priority system of the Service;]
                  (A) the current Indian sanitation facility 
                priority system of the Service;
                  (B) the methodology for determining 
                sanitation deficiencies[;]
                  [(C) the level of sanitation deficiency for 
                each sanitation facilities project of each 
                Indian tribe or community;
                  [(D) the amount of funds necessary to raise 
                all Indian tribes and communities to a level I 
                sanitation deficiency; and
                  [(E) the amount of funds necessary to raise 
                all Indian tribes and communities to zero 
                sanitation deficiency.
          [(2) In preparing each report required under 
        paragraph (1) (other than the initial report), the 
        Secretary shall consult with Indian tribes and tribal 
        organizations (including those tribes or tribal 
        organizations operating health care programs or 
        facilities under any contract entered into with the 
        Service under the Indian Self-Determination Act [25 
        U.S.C.A. Sec. 450f et seq.]) to determine the 
        sanitation needs of each tribe.] and needs;
                  (C) the criteria on which the deficiencies 
                and needs will be evaluated;
                  (D) the level of initial and final sanitation 
                deficiency for each type of sanitation facility 
                for each project of each Indian Tribe or Indian 
                community;
                  (E) the amount and most effective use of 
                funds, derived from whatever source, necessary 
                to accommodate the sanitation facilities needs 
                of new homes assisted with funds under the 
                Native American Housing Assistance and Self-
                Determination Act (25 U.S.C. 4101 et seq.), and 
                to reduce the identified sanitation deficiency 
                levels of all Indian Tribes and Indian 
                communities to level I sanitation deficiency as 
                defined in paragraph (3)(A); and
                  (F) a 10-year plan to provide sanitation 
                facilities to serve existing Indian homes and 
                Indian communities and new and renovated Indian 
                homes.
          [(3)] (2) Uniform methodology.--The methodology used 
        by the Secretary in determining, preparing cost 
        estimates for, and reporting sanitation deficiencies 
        for purposes of paragraph (1) shall be applied 
        uniformly to all Indian [tribes and] Tribes and Indian 
        communities.
          [(4)] (3) Sanitation deficiency levels.--For purposes 
        of this subsection, the sanitation deficiency levels 
        for an [Indian tribe or community are] individual, 
        Indian Tribe, or Indian community sanitation facility 
        to serve Indian homes are determined as follows:
                  [(A) level I is an Indian tribe or community 
                with a sanitation system--]
                  (A) A level I deficiency exists if a 
                sanitation facility serving an individual, 
                Indian Tribe, or Indian community--
                          (i) [which] complies with all 
                        applicable water supply [and,] 
                        pollution control, and solid waste 
                        disposal laws[,]; and
                          (ii) [in which the] deficiencies 
                        relate to routine replacement, repair, 
                        or maintenance needs[;].
                  (B) A level II [is an Indian tribe or 
                community with a sanitation system--]
                          [(i) which complies] deficiency 
                        exists if a sanitation facility serving 
                        an individual, Indian Tribe, or Indian 
                        community substantially or recently 
                        complied with all applicable water 
                        supply [and], pollution control [laws, 
                        and (ii) in which the], and solid waste 
                        laws and any deficiencies relate to--
                          (i) small or minor capital 
                        improvements needed to bring the 
                        facility back into compliance;
                          (ii) capital improvements that are 
                        necessary to enlarge or improve the 
                        facilities in order to meet the current 
                        needs [of such tribe or community] for 
                        domestic sanitation facilities; or
                          (iii) the lack of equipment or 
                        training by an Indian Tribe, Tribal 
                        Organization, or an Indian community to 
                        properly operate and maintain the 
                        sanitation facilities.
                  (C) A level III [is an Indian tribe or 
                community with a sanitation system which--] 
                deficiency exists if a sanitation facility 
                serving an individual, Indian Tribe or Indian 
                community meets 1 or more of the following 
                conditions--
                          [(i) has an inadequate or partial 
                        water supply and a sewage disposal 
                        facility that does not comply with 
                        applicable water supply and pollution 
                        control laws, or
                          [(ii) has no solid waste disposal 
                        facility;
                  [(D) level IV is an Indian tribe or community 
                with a sanitation system which lacks either a 
                safe water supply system or a sewage disposal 
                system; and
                  [(E) level V is an Indian tribe or community 
                that lacks a safe water supply and a sewage 
                disposal system.
          [(5) For purposes of this subsection, any Indian 
        tribe or community that lacks the operation and 
        maintenance capability to enable its sanitation system 
        to meet pollution control laws may not be treated as 
        having a level I or II sanitation deficiency.]
                          (i) water or sewer service in the 
                        home is provided by a haul system with 
                        holding tanks and interior plumbing;
                          (ii) major significant interruptions 
                        to water supply or sewage disposal 
                        occur frequently, requiring major 
                        capital improvements to correct the 
                        deficiencies; or
                          (iii) there is no access to or no 
                        approved or permitted solid waste 
                        facility available.
                  (D) A level IV deficiency exists--
                          (i) if a sanitation facility for an 
                        individual home, an Indian Tribe, or an 
                        Indian community exists but--
                                  (I) lacks--
                                          (aa) a safe water 
                                        supply system; or
                                          (bb) a waste disposal 
                                        system;
                                  (II) contains no piped water 
                                or sewer facilities; or
                                  (III) has become inoperable 
                                due to a major component 
                                failure; or
                          (ii) if only a washeteria or central 
                        facility exists in the community.
                  (E) A level V deficiency exists in the 
                absence of a sanitation facility, where 
                individual homes do not have access to safe 
                drinking water or adequate wastewater 
                (including sewage) disposal.
                          (i) Definitions.--For purposes of 
                        this section, the following terms 
                        apply:
          (1) Indian community.--The term ``Indian community'' 
        means a geographic area, a significant proportion of 
        whose inhabitants are Indians and which is served by or 
        capable of being served by a facility described in this 
        section.
          (2) Sanitation facilities.--The terms ``sanitation 
        facility'' and ``sanitation facilities'' mean safe and 
        adequate water supply systems, sanitary sewage disposal 
        systems, and sanitary solid waste systems (and all 
        related equipment and support infrastructure).

[Sec. 1633. Preference to Indians and Indian firms]

SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS.

    [(a) Discretionary authority; covered activities]
    (a) Buy Indian Act.--The Secretary, acting through the 
Service, may [utilize] use the negotiating authority of section 
[47 of this title] 23 of the Act of June 25, 1910 (25 U.S.C. 
47, commonly known as the ``Buy Indian Act''), to give 
preference to any Indian or any enterprise, partnership, 
corporation, or other type of business organization owned and 
controlled by an Indian or Indians including former or 
currently federally recognized Indian [tribes] Tribes in the 
State of New York (hereinafter referred to as an ``Indian 
firm'') in the construction and renovation of Service 
facilities pursuant to section [1631 of this title and in the 
construction of safe water and sanitary waste disposal] 301 and 
in the construction of sanitation facilities pursuant to 
section [1632 of this title.] 302. Such preference may be 
accorded by the Secretary unless [he] the Secretary finds, 
pursuant to [rules and] regulations [promulgated by him], that 
the project or function to be contracted for will not be 
satisfactory or such project or function cannot be properly 
completed or maintained under the proposed contract. The 
Secretary, in arriving at [his] such a finding, shall consider 
whether the Indian or Indian firm will be deficient with 
respect to--
          (1) ownership and control by Indians[,];
          (2) equipment[,];
          (3) bookkeeping and accounting procedures[,];
          (4) substantive knowledge of the project or function 
        to be contracted for[,];
          (5) adequately trained personnel[,]; or
          (6) other necessary components of contract 
        performance.
    [(b) Pay rates]
    (b) Labor Standards.--
          (1) In general.--For the [purpose] purposes of 
        implementing the provisions of this [subchapter, the 
        Secretary shall assure that the rates of pay for 
        personnel engaged in] title, contracts for the 
        construction or renovation of [facilities constructed 
        or renovated] health care facilities, staff quarters, 
        and sanitation facilities, and related support 
        infrastructure, funded in whole or in part [by] with 
        funds made available pursuant to this title [[25 
        U.S.C.A. Sec. Sec. 1631 et seq.] are not less than the 
        prevailing local wage rates for similar work as 
        determined in accordance with the Act of March 3, 1931 
        (40 U.S.C. 276a to 276a-5, known as the Davis-Bacon 
        Act).], shall contain a provision requiring compliance 
        with subchapter IV of chapter 31 of title 40, United 
        States Code (commonly known as the ``Davis-Bacon 
        Act''), unless such construction or renovation--
                  (A) is performed by a contractor pursuant to 
                a contract with an Indian Tribe or Tribal 
                Organization with funds supplied through a 
                contract or compact authorized by the Indian 
                Self-Determination and Education Assistance Act 
                (25 U.S.C. 450 et seq.), or other statutory 
                authority; and
                  (B) is subject to prevailing wage rates for 
                similar construction or renovation in the 
                locality as determined by the Indian Tribes or 
                Tribal Organizations to be served by the 
                construction or renovation.
          (2) Exception.--This subsection shall not apply to 
        construction or renovation carried out by an Indian 
        Tribe or Tribal Organization with its own employees.

[Sec. 1634. Expenditure of non-Service funds for renovation]

SEC. 304. EXPENDITURE OF NON-SERVICE FUNDS FOR RENOVATION.

    [(a) Authority of Secretary]
    [(1)] (a) In General.--Notwithstanding any other provision 
of law, [the Secretary]if the requirements of subsection (c) 
are met, the Secretary, acting through the Service, is 
authorized to accept any major [renovation] expansion, 
renovation, or modernization by any Indian [tribe of any 
Service facility,] Tribe or Tribal Organization of any Service 
facility or of any other Indian health facility operated 
pursuant to a contract [entered into] or compact under the 
Indian Self-Determination [Act[] and Education Assistance Act 
(25 U.S.C.[A. Sec. ] [450](f) et seq.[]]), including--
          [(A)] (1) any plans or designs for such expansion, 
        renovation, or modernization; and
          [(B)] (2) any expansion, renovation, or modernization 
        for which funds appropriated under any Federal law were 
        lawfully expended[, but only if the requirements of 
        subsection (b) of this section are met].
    (b) Priority List.--
          [(2)] (1) In general.--The Secretary shall maintain a 
        separate priority list to address the needs [of such 
        facilities] for increased operating expenses, 
        personnel, or equipment[.] for such facilities. The 
        methodology for establishing priorities shall be 
        developed through regulations. The list of priority 
        facilities will be revised annually in consultation 
        with Indian Tribes and Tribal Organizations.
          [(3)](2) Report._The Secretary shall submit to the 
        President, for inclusion in [each] the report required 
        to be transmitted to [the] Congress under section [1671 
        of this title,] 801, the priority list maintained 
        pursuant to paragraph ([2]1).
    ([b]c) Requirements.--The requirements of this subsection 
are met with respect to any expansion, renovation, or 
modernization if--
          (1) the [tribe or tribal organization] Indian Tribe 
        or Tribal Organization--
                  (A) provides notice to the Secretary of its 
                intent to expand, renovate, or modernize; and
                  (B) applies to the Secretary to be placed on 
                a separate priority list to address the needs 
                of such new facilities for increased operating 
                expenses, personnel [or equipment; and], or 
                equipment; and
          (2) the [renovation] expansion, renovation, or 
        modernization--
                    (A) is approved by the appropriate area 
                director of the Service[; and] for Federal 
                facilities; and
                  (B) is administered by the [tribe] Indian 
                Tribe or Tribal Organization in accordance with 
                [the rules and] any applicable regulations 
                prescribed by the Secretary with respect to 
                construction or renovation of Service 
                facilities.
    [(c) Recovery for non-use as Service facility]
    (d) Additional Requirement for Expansion.--In addition to 
the requirements under subsection (c), for any expansion, the 
Indian Tribe or Tribal Organization shall provide to the 
Secretary additional information pursuant to regulations, 
including additional staffing, equipment, and other costs 
associated with the expansion.
    (e) Closure or Conversion of Facilities._If any Service 
facility which has been expanded, renovated, or modernized by 
an Indian [tribe] Tribe or Tribal Organization under this 
section ceases to be used as a Service facility during the 20-
year period beginning on the date such expansion, renovation, 
or modernization is completed, such Indian [tribe] Tribe or 
Tribal Organization shall be entitled to recover from the 
United States an amount which bears the same ratio to the value 
of such facility at the time of such cessation as the value of 
such expansion, renovation, or modernization (less the total 
amount of any funds provided specifically for such facility 
under any Federal program that were expended for such 
expansion, renovation, or modernization) bore to the value of 
such facility at the time of the completion of such expansion, 
renovation, or modernization.

SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION, AND MODERNIZATION OF 
                    SMALL AMBULATORY CARE FACILITIES.

[Sec. 1636. Grant program for the construction, expansion, and 
                    modernization of small ambulatory care facilities]

    (a) Grants._
    [(a) Authorization]
          (1) In general._The Secretary, acting through the 
        Service, shall make grants to [tribes and tribal 
        organizations] Indian Tribes and Tribal Organizations 
        for the construction, expansion, or modernization of 
        facilities for the provision of ambulatory care 
        services to eligible Indians (and noneligible persons 
        [as provided in subsection] pursuant to subsections 
        (b)(2) and (c)(1)(C)[ of this section]). A grant made 
        under this section may cover up to 100 percent of the 
        costs of such construction, expansion, or 
        modernization. For the purposes of this section, the 
        term ``construction'' includes the replacement of an 
        existing facility.
          (2) Grant agreement required._A grant under paragraph 
        (1) may only be made [to a tribe or tribal 
        organization] available to a Tribal Health Program 
        operating an Indian health facility (other than a 
        facility owned or constructed by the Service, including 
        a facility originally owned or constructed by the 
        Service and transferred to [a tribe or tribal 
        organization) pursuant to a contract entered into under 
        the Indian Self-Determination Act [25 U.S.C.A. 
        Sec. 450f et seq.].] an Indian Tribe or Tribal 
        Organization).
    [(b) Use of grant
          (1) A grant provided under this section may be used 
        only for the construction, expansion, or modernization 
        (including the planning and design of such 
        construction, expansion, or modernization) of an 
        ambulatory care facility--]
    (b) Use of Grant Funds.--
          (1) Allowable uses.--A grant awarded under this 
        section may be used for the construction, expansion, or 
        modernization (including the planning and design of 
        such construction, expansion, or modernization) of an 
        ambulatory care facility--
                  (A) located apart from a hospital;
                  (B) not funded under section [1631] 301 or 
                section [1637 of this title] 306; and
                  (C) which, upon completion of such 
                construction[, expansion,] or modernization 
                will--
                          (i) have a total capacity appropriate 
                        to its projected service population;
                          [(ii) serve no less than 500](ii) 
                        provide annually no fewer than 150 
                        patient visits by eligible Indians 
                        [annually;] and other users who are 
                        eligible for services in such facility 
                        in accordance with section 807(c)(2); 
                        and
                          (iii) provide ambulatory care in a 
                        [service area] Service Area (specified 
                        in the contract [entered into] or 
                        compact under the Indian Self-
                        Determination and Education Assistance 
                        Act [[](25 U.S.C.[A. Sec. ]450[f et 
                        seq.]] et seq.)) with a population of 
                        [not less than 2,000] no fewer than 
                        1,500 eligible Indians[.] and other 
                        users who are eligible for services in 
                        such facility in accordance with 
                        section 807(c)(2).
          (2) Additional allowable use.--The Secretary may also 
        reserve a portion of the funding provided under this 
        section and use those reserved funds to reduce an 
        outstanding debt incurred by Indian Tribes or Tribal 
        Organizations for the construction, expansion, or 
        modernization of an ambulatory care facility that meets 
        the requirements under paragraph (1). The provisions of 
        this section shall apply, except that such applications 
        for funding under this paragraph shall be considered 
        separately from applications for funding under 
        paragraph (1).
          [(2)] (3) Use only for certain portion of costs._A 
        grant provided under this section may be used only for 
        the cost of that portion of a construction, expansion, 
        or modernization project that benefits the Service 
        population identified above in subsection (b)(1)(C) 
        (ii) and (iii). The requirements of clauses (ii) and 
        (iii) of paragraph (1)(C) shall not apply to [a tribe 
        or tribal organization] an Indian Tribe or Tribal 
        Organization applying for a grant under this section 
        [whose tribal government offices are located on an 
        island] for a health care facility located or to be 
        constructed on an island or when such facility is not 
        located on a road system providing direct access to an 
        inpatient hospital where care is available to the 
        Service population.
    [(c) Application of grant]
    (c) Grants.--
          (1) Application._No grant may be made under this 
        section unless an application or proposal for [such a] 
        the grant has been[ submitted to and] approved by the 
        Secretary[. An application for a grant under this 
        section shall be submitted in such form and manner as 
        the Secretary shall by regulation prescribe and shall] 
        in accordance with applicable regulations and has set 
        forth reasonable assurance by the applicant that, at 
        all times after the construction, expansion, or 
        modernization of a facility carried out [pursuant to] 
        using a grant received under this section--
                  (A) adequate financial support will be 
                available for the provision of services at such 
                facility;
                  (B) such facility will be available to 
                eligible Indians without regard to ability to 
                pay or source of payment; and
                  (C) such facility will, as feasible without 
                diminishing the quality or quantity of services 
                provided to eligible Indians, serve noneligible 
                persons on a cost basis.
          (2) Priority.--In awarding grants under this section, 
        the Secretary shall give priority to [tribes and tribal 
        organizations]Indian Tribes and Tribal Organizations 
        that demonstrate--
                  (A) a need for increased ambulatory care 
                services; and
                  (B) insufficient capacity to deliver such 
                services.
          (3) Peer review panels.--The Secretary may provide 
        for the establishment of peer review panels, as 
        necessary, to review and evaluate applications and 
        proposals and to advise the Secretary regarding such 
        applications using the criteria developed pursuant to 
        subsection (a)(1).
    (d) [Transfer of interest to United States upon cessation 
of facility]Reversion of Facilities._If any facility (or 
portion thereof) with respect to which funds have been paid 
under this section, ceases, at any time after completion of the 
construction, expansion, or modernization carried out with such 
funds, to be [utilized] used for the purposes of providing 
[ambulatory] health care services to eligible Indians, all of 
the right, title, and interest in and to such facility (or 
portion thereof) shall transfer to the United States unless 
otherwise negotiated by the Service and the Indian Tribe or 
Tribal Organization.
    (e) Funding Nonrecurring.--Funding provided under this 
section shall be nonrecurring and shall not be available for 
inclusion in any individual Indian Tribe's tribal share for an 
award under the Indian Self-Determination and Education 
Assistance Act (25 U.S.C. 450 et seq.) or for reallocation or 
redesign thereunder.

[Sec. 1637. Indian health care delivery demonstration project]

SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRATION PROJECTS.

    [(a) Health care delivery demonstration projects]
    (a) In General.--The Secretary, acting through the Service, 
is authorized to carry out, or to enter into contracts [with, 
or make grants to, Indian tribes or tribal organizations for 
the purpose of carrying out]under the Indian Self-Determination 
and Education Assistance Act (25 U.S.C. 450 et seq.) with 
Indian Tribes or Tribal Organizations to carry out, a health 
care delivery demonstration project to test alternative means 
of delivering health care and services to Indians through 
[health] facilities [to Indians].
    (b) Use of [funds]Funds.--The Secretary, in approving 
projects pursuant to this section, may authorize [funding] such 
contracts for the construction and renovation of hospitals, 
health centers, health stations, and other facilities to 
deliver health care services and is authorized to--
          (1) waive any leasing prohibition;
          (2) permit carryover of funds appropriated for the 
        provision of health care services;
          (3) permit the use of [non-Service Federal funds and 
        non-Federal]other available funds;
          (4) permit the use of funds or property donated from 
        any source for project purposes; [and]
          (5) provide for the reversion of donated real or 
        personal property to the donor[.]; and
    [(c) Criteria]
          (6) permit the use of Service funds to match other 
        funds, including Federal funds.
    (c) Health Care Demonstration Projects.--
          (1) General projects.--
          [(1) Within 180 days after November 28, 1990, the 
        Secretary, after consultation with Indian tribes and 
        tribal organizations, shall develop and publish in the 
        Federal Register criteria for the review and approval 
        of applications submitted under this section. The 
        Secretary may enter into a contract or award a grant 
        under this section for projects which]
                  (A) Criteria._The Secretary may approve under 
                this section demonstration projects that meet 
                the following criteria:
                          [(A)] (i)There is a need for a new 
                        facility or program, such as a program 
                        for convenient care services, or the 
                        reorientation of an existing facility 
                        or program.
                          [(B)] (ii) A significant number of 
                        Indians, including [those] Indians with 
                        low health status, will be served by 
                        the project.
                          [(C) The project has the potential to 
                        address the health needs of Indians in 
                        an innovative manner.]
                          [(D)] (iii) The project has the 
                        potential to deliver services in an 
                        efficient and effective manner.
                          [(E)] (iv) The project is 
                        economically viable.
                          [(F)] (v) [The Indian tribe or tribal 
                        organization] For projects carried out 
                        by an Indian Tribe or Tribal 
                        Organization, the Indian Tribe or 
                        Tribal Organization has the 
                        administrative and financial capability 
                        to administer the project.
                          [(G)] (vi) The project is integrated 
                        with providers of related health and 
                        social services and is coordinated 
                        with, and avoids duplication of, 
                        existing services in order to expand 
                        the availability of services.
          [(2) The Secretary may provide for the establishment 
        of peer review panels, as necessary, to review and 
        evaluate applications and to advise the Secretary 
        regarding such applications using the criteria 
        developed pursuant to paragraph (1).
          [(3)(A) On or before September 30, 1995, the 
        Secretary shall enter into contracts or award grants 
        under this section for a demonstration project in each 
        of the following service units which meets the criteria 
        specified in paragraph (1) and for which a completed 
        application has been received by the Secretary:]
                  (B) Priority.--In approving demonstration 
                projects under this paragraph, the Secretary 
                shall give priority to demonstration projects, 
                to the extent the projects meet the criteria 
                described in subparagraph (A), located in any 
                of the following Service Units:
                          (i) Cass Lake, Minnesota.
                  (ii[) Clinton, Oklahoma.
                          [(iii) Harlem, Montana.
                          (iv]) Mescalero, New Mexico.
                          ([v]iii) Owyhee, Nevada.
                          [(vi) Parker, Arizona.]
                          ([vii]iv) Schurz, Nevada.
                          [(viii) Winnebago, Nebraska.]
                          ([ix]v) Ft. Yuma, California.
                  [(B) The Secretary may also enter into 
                contracts or award grants under this section 
                taking into consideration applications received 
                under this section from all service areas. The 
                Secretary may not award a greater number of 
                such contracts or grants in one service area 
                than in any other service area until there is 
                an equal number of such contracts or grants 
                awarded with respect to all service areas from 
                which the Secretary receives applications 
                during the application period (as determined by 
                the Secretary) which meet the criteria 
                specified in paragraph (1).]
          (2) Convenient care service projects.--
                  (A) Definition of convenient care service.--
                In this paragraph, the term ``convenient care 
                service'' means any primary health care 
                service, such as urgent care services, 
                nonemergent care services, prevention services 
                and screenings, and any service authorized by 
                sections 203 or 213(d), that is--
                          (i) provided outside the regular 
                        hours of operation of a health care 
                        facility; or
                          (ii) offered at an alternative 
                        setting.
                  (B) Approval.--In addition to projects 
                described in paragraph (1), in any fiscal year, 
                the Secretary is authorized to approve not more 
                than 10 applications for health care delivery 
                demonstration projects that--
                          (i) include a convenient care 
                        services program as an alternative 
                        means of delivering health care 
                        services to Indians; and
                          (ii) meet the criteria described in 
                        subparagraph (C).
                  (C) Criteria.--The Secretary shall approve 
                under subparagraph (B) demonstration projects 
                that meet all of the following criteria:
                          (i) The criteria set forth in 
                        paragraph (1)(A).
                          (ii) There is a lack of access to 
                        health care services at existing health 
                        care facilities, which may be due to 
                        limited hours of operation at those 
                        facilities or other factors.
                          (iii) The project--
                                  (I) expands the availability 
                                of services; or
                                  (II) reduces--
                                          (aa) the burden on 
                                        Contract Health 
                                        Services; or
                                          (bb) the need for 
                                        emergency room visits.
    (d) Peer Review Panels.--The Secretary may provide for the 
establishment of peer review panels, as necessary, to review 
and evaluate applications using the criteria described in 
paragraphs (1)(A) and (2)(C) of subsection (c).
    ([d]e) Technical [assistance] Assistance._The Secretary 
shall provide such technical and other assistance as may be 
necessary to enable applicants to comply with [the provisions 
of] this section.
    ([e]f) Service to [ineligible persons The]Ineligible 
Persons._ Subject to section 807, the authority to provide 
services to persons otherwise ineligible for the health care 
benefits of the Service, and the authority to extend hospital 
privileges in [service]Service facilities to non-Service health 
[care] practitioners as provided in section [1680c of this 
title] 807, may be included, subject to the terms of [such] 
that section, in any demonstration project approved pursuant to 
this section.
    ([f]g) Equitable [treatment] Treatment._For purposes of 
subsection (c)[(1)(A) of this section,] the Secretary [shall], 
in evaluating facilities operated under any contract [entered 
into with the Service] or compact under the Indian Self-
Determination and Education Assistance Act[ [](25 U.S.C.[A. 
Sec. ]450[f] et seq.],), shall use the same criteria that the 
Secretary uses in evaluating facilities operated directly by 
the Service.
    ([g]h Equitable [integration of facilities] Integration of 
Facilities._The Secretary shall ensure that the planning, 
design, construction, [and] renovation, and expansion needs of 
Service and non-Service facilities [which] that are the subject 
of a contract [for health services entered into with the 
Service]or compact under the Indian Self-Determination and 
Education Assistance Act [[](25 U.S.C.[A. Sec. ]450[f] et 
seq.],) for health services are fully and equitably integrated 
into the implementation of the health care delivery 
demonstration projects under this section.
    [(h) Reports to Congress
          [(1) The Secretary shall submit to the President, for 
        inclusion in the report which is required to be 
        submitted to the Congress under section 1671 of this 
        title for fiscal year 1997, an interim report on the 
        findings and conclusions derived from the demonstration 
        projects established under this section.
          [(2) The Secretary shall submit to the President, for 
        inclusion in the report which is required to be 
        submitted to the Congress under section 1671 of this 
        title for fiscal year 1999, a final report on the 
        findings and conclusions derived from the demonstration 
        projects established under this section, together with 
        legislative recommendations.

SEC. 307. LAND TRANSFER.

    Notwithstanding any other provision of law, the Bureau of 
Indian Affairs and all other agencies and departments of the 
United States are authorized to transfer, at no cost, land and 
improvements to the Service for the provision of health care 
services. The Secretary is authorized to accept such land and 
improvements for such purposes.

SEC. 308. LEASES, CONTRACTS, AND OTHER AGREEMENTS.

    The Secretary, acting through the Service, may enter into 
leases, contracts, and other agreements with Indian Tribes and 
Tribal Organizations which hold (1) title to, (2) a leasehold 
interest in, or (3) a beneficial interest in (when title is 
held by the United States in trust for the benefit of an Indian 
Tribe) facilities used or to be used for the administration and 
delivery of health services by an Indian Health Program. Such 
leases, contracts, or agreements may include provisions for 
construction or renovation and provide for compensation to the 
Indian Tribe or Tribal Organization of rental and other costs 
consistent with section 105(l) of the Indian Self-Determination 
and Education Assistance Act (25 U.S.C. 450j(l)) and 
regulations thereunder.

SEC. 309. STUDY ON LOANS, LOAN GUARANTEES, AND LOAN REPAYMENT.

    (a) In General.--The Secretary, in consultation with the 
Secretary of the Treasury, Indian Tribes, and Tribal 
Organizations, shall carry out a study to determine the 
feasibility of establishing a loan fund to provide to Indian 
Tribes and Tribal Organizations direct loans or guarantees for 
loans for the construction of health care facilities, 
including--
          (1) inpatient facilities;
          (2) outpatient facilities;
          (3) staff quarters;
          (4) hostels; and
          (5) specialized care facilities, such as behavioral 
        health and elder care facilities.
    (b) Determinations.--In carrying out the study under 
subsection (a), the Secretary shall determine--
          (1) the maximum principal amount of a loan or loan 
        guarantee that should be offered to a recipient from 
        the loan fund;
          (2) the percentage of eligible costs, not to exceed 
        100 percent, that may be covered by a loan or loan 
        guarantee from the loan fund (including costs relating 
        to planning, design, financing, site land development, 
        construction, rehabilitation, renovation, conversion, 
        improvements, medical equipment and furnishings, and 
        other facility-related costs and capital purchase (but 
        excluding staffing));
          (3) the cumulative total of the principal of direct 
        loans and loan guarantees, respectively, that may be 
        outstanding at any one time;
          (4) the maximum term of a loan or loan guarantee that 
        may be made for a facility from the loan fund;
          (5) the maximum percentage of funds from the loan 
        fund that should be allocated for payment of costs 
        associated with planning and applying for a loan or 
        loan guarantee;
          (6) whether acceptance by the Secretary of an 
        assignment of the revenue of an Indian Tribe or Tribal 
        Organization as security for any direct loan or loan 
        guarantee from the loan fund would be appropriate;
          (7) whether, in the planning and design of health 
        facilities under this section, users eligible under 
        section 807(c) may be included in any projection of 
        patient population;
          (8) whether funds of the Service provided through 
        loans or loan guarantees from the loan fund should be 
        eligible for use in matching other Federal funds under 
        other programs;
          (9) the appropriateness of, and best methods for, 
        coordinating the loan fund with the health care 
        priority system of the Service under section 301; and
          (10) any legislative or regulatory changes required 
        to implement recommendations of the Secretary based on 
        results of the study.
    (c) Report.--Not later than September 30, 2009, the 
Secretary shall submit to the Committee on Indian Affairs of 
the Senate and the Committee on Natural Resources and the 
Committee on Energy and Commerce of the House of 
Representatives a report that describes--
          (1) the manner of consultation made as required by 
        subsection (a); and
          (2) the results of the study, including any 
        recommendations of the Secretary based on results of 
        the study.

SEC. 310. TRIBAL LEASING.

    A Tribal Health Program may lease permanent structures for 
the purpose of providing health care services without obtaining 
advance approval in appropriation Acts.

SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES JOINT VENTURE 
                    PROGRAM.

    (a) In General.--The Secretary, acting through the Service, 
shall make arrangements with Indian Tribes and Tribal 
Organizations to establish joint venture demonstration projects 
under which an Indian Tribe or Tribal Organization shall expend 
tribal, private, or other available funds, for the acquisition 
or construction of a health facility for a minimum of 10 years, 
under a no-cost lease, in exchange for agreement by the Service 
to provide the equipment, supplies, and staffing for the 
operation and maintenance of such a health facility. An Indian 
Tribe or Tribal Organization may use tribal funds, private 
sector, or other available resources, including loan 
guarantees, to fulfill its commitment under a joint venture 
entered into under this subsection. An Indian Tribe or Tribal 
Organization shall be eligible to establish a joint venture 
project if, when it submits a letter of intent, it--
          (1) has begun but not completed the process of 
        acquisition or construction of a health facility to be 
        used in the joint venture project; or
          (2) has not begun the process of acquisition or 
        construction of a health facility for use in the joint 
        venture project.
    (b) Requirements.--The Secretary shall make such an 
arrangement with an Indian Tribe or Tribal Organization only 
if--
          (1) the Secretary first determines that the Indian 
        Tribe or Tribal Organization has the administrative and 
        financial capabilities necessary to complete the timely 
        acquisition or construction of the relevant health 
        facility; and
          (2) the Indian Tribe or Tribal Organization meets the 
        need criteria determined using the criteria developed 
        under the health care facility priority system under 
        section 301, unless the Secretary determines, pursuant 
        to regulations, that other criteria will result in a 
        more cost-effective and efficient method of 
        facilitating and completing construction of health care 
        facilities.
    (c) Continued Operation.--The Secretary shall negotiate an 
agreement with the Indian Tribe or Tribal Organization 
regarding the continued operation of the facility at the end of 
the initial 10 year no-cost lease period.
    (d) Breach of Agreement.--An Indian Tribe or Tribal 
Organization that has entered into a written agreement with the 
Secretary under this section, and that breaches or terminates 
without cause such agreement, shall be liable to the United 
States for the amount that has been paid to the Indian Tribe or 
Tribal Organization, or paid to a third party on the Indian 
Tribe's or Tribal Organization's behalf, under the agreement. 
The Secretary has the right to recover tangible property 
(including supplies) and equipment, less depreciation, and any 
funds expended for operations and maintenance under this 
section. The preceding sentence does not apply to any funds 
expended for the delivery of health care services, personnel, 
or staffing.
    (e) Recovery for Nonuse.--An Indian Tribe or Tribal 
Organization that has entered into a written agreement with the 
Secretary under this subsection shall be entitled to recover 
from the United States an amount that is proportional to the 
value of such facility if, at any time within the 10-year term 
of the agreement, the Service ceases to use the facility or 
otherwise breaches the agreement.
    (f) Definition.--For the purposes of this section, the term 
``health facility'' or ``health facilities'' includes quarters 
needed to provide housing for staff of the relevant Tribal 
Health Program.

SEC. 312. LOCATION OF FACILITIES.

    (a) In General.--In all matters involving the 
reorganization or development of Service facilities or in the 
establishment of related employment projects to address 
unemployment conditions in economically depressed areas, the 
Bureau of Indian Affairs and the Service shall give priority to 
locating such facilities and projects on Indian lands, or lands 
in Alaska owned by any Alaska Native village, or village or 
regional corporation under the Alaska Native Claims Settlement 
Act (43 U.S.C. 1601 et seq.), or any land allotted to any 
Alaska Native, if requested by the Indian owner and the Indian 
Tribe with jurisdiction over such lands or other lands owned or 
leased by the Indian Tribe or Tribal Organization. Top priority 
shall be given to Indian land owned by 1 or more Indian Tribes.
    (b) Definition.--For purposes of this section, the term 
``Indian lands'' means--
          (1) all lands within the exterior boundaries of any 
        reservation; and
          (2) any lands title to which is held in trust by the 
        United States for the benefit of any Indian Tribe or 
        individual Indian or held by any Indian Tribe or 
        individual Indian subject to restriction by the United 
        States against alienation.

SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH CARE FACILITIES.

    (a) Report.--The Secretary shall submit to the President, 
for inclusion in the report required to be transmitted to 
Congress under section 801, a report which identifies the 
backlog of maintenance and repair work required at both Service 
and tribal health care facilities, including new health care 
facilities expected to be in operation in the next fiscal year. 
The report shall also identify the need for renovation and 
expansion of existing facilities to support the growth of 
health care programs.
    (b) Maintenance of Newly Constructed Space.--The Secretary, 
acting through the Service, is authorized to expend maintenance 
and improvement funds to support maintenance of newly 
constructed space only if such space falls within the approved 
supportable space allocation for the Indian Tribe or Tribal 
Organization. Supportable space allocation shall be defined 
through the health care facility priority system under section 
301(c).
    (c) Replacement Facilities.--In addition to using 
maintenance and improvement funds for renovation, 
modernization, and expansion of facilities, an Indian Tribe or 
Tribal Organization may use maintenance and improvement funds 
for construction of a replacement facility if the costs of 
renovation of such facility would exceed a maximum renovation 
cost threshold. The maximum renovation cost threshold shall be 
determined through the negotiated rulemaking process provided 
for under section 802.

SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY-OWNED QUARTERS.

    (a) Rental Rates.--
          (1) Establishment.--Notwithstanding any other 
        provision of law, a Tribal Health Program which 
        operates a hospital or other health facility and the 
        federally-owned quarters associated therewith pursuant 
        to a contract or compact under the Indian Self-
        Determination and Education Assistance Act (25 U.S.C. 
        450 et seq.) shall have the authority to establish the 
        rental rates charged to the occupants of such quarters 
        by providing notice to the Secretary of its election to 
        exercise such authority.
          (2) Objectives.--In establishing rental rates 
        pursuant to authority of this subsection, a Tribal 
        Health Program shall endeavor to achieve the following 
        objectives:
                  (A) To base such rental rates on the 
                reasonable value of the quarters to the 
                occupants thereof.
                  (B) generate sufficient funds to prudently 
                provide for the operation and maintenance of 
                the quarters, and subject to the discretion of 
                the Tribal Health Program, to supply reserve 
                funds for capital repairs and replacement of 
                the quarters.
         (3) Equitable funding.--Any quarters whose rental 
        rates are established by a Tribal Health Program 
        pursuant to this subsection shall remain eligible for 
        quarters improvement and repair funds to the same 
        extent as all federally-owned quarters used to house 
        personnel in Services-supported programs.
          (4) Notice of rate change.--A Tribal Health Program 
        which exercises the authority provided under this 
        subsection shall provide occupants with no less than 60 
        days notice of any change in rental rates.
    (b) Direct Collection of Rent.--
          (1) In general.--Notwithstanding any other provision 
        of law, and subject to paragraph (2), a Tribal Health 
        Program shall have the authority to collect rents 
        directly from Federal employees who occupy such 
        quarters in accordance with the following:
                  (A) The Tribal Health Program shall notify 
                the Secretary and the subject Federal employees 
                of its election to exercise its authority to 
                collect rents directly from such Federal 
                employees.
                  (B) Upon receipt of a notice described in 
                subparagraph (A), the Federal employees shall 
                pay rents for occupancy of such quarters 
                directly to the Tribal Health Program and the 
                Secretary shall have no further authority to 
                collect rents from such employees through 
                payroll deduction or otherwise.
                  (C) Such rent payments shall be retained by 
                the Tribal Health Program and shall not be made 
                payable to or otherwise be deposited with the 
                United States.
                  (D) Such rent payments shall be deposited 
                into a separate account which shall be used by 
                the Tribal Health Program for the maintenance 
                (including capital repairs and replacement) and 
                operation of the quarters and facilities as the 
                Tribal Health Program shall determine.
          (2) Retrocession of authority.--If a Tribal Health 
        Program which has made an election under paragraph (1) 
        requests retrocession of its authority to directly 
        collect rents from Federal employees occupying 
        federally-owned quarters, such retrocession shall 
        become effective on the earlier of--

[Sec. 1638. Land transfer]

                  (A) the first day of the month that begins no 
                less than 180 days after the Tribal Health 
                Program notifies the Secretary of its desire to 
                retrocede; or
    [The Bureau of Indian Affairs is authorized to transfer, at 
no cost, up to 5 acres of land at the Chemawa Indian School, 
Salem, Oregon, to the Service for the provision of health care 
services. The land authorized to be transferred by this section 
is that land adjacent to land under the jurisdiction of the 
Service and occupied by the Chemawa Indian Health Center.]
                 (B) such other date as may be mutually agreed 
                by the Secretary and the Tribal Health Program.

[Sec. 1638a. Authorization of appropriations]

    (c) Rates in Alaska.--To the extent that a Tribal Health 
Program, pursuant to authority granted in subsection (a), 
establishes rental rates for federally-owned quarters provided 
to a Federal employee in Alaska, such rents may be based on the 
cost of comparable private rental housing in the nearest 
established community with a year-round population of 1,500 or 
more individuals.
    [There are authorized to be appropriated such sums as may 
be necessary for each fiscal year through fiscal year 2000 to 
carry out this subchapter.]

SEC. 315. APPLICABILITY OF BUY AMERICAN ACT REQUIREMENT.

[Sec. 1638b.]

    (a) Applicability [of Buy American requirement (a) Duty of 
Secretary].--The Secretary shall ensure that the requirements 
of the Buy American Act [[41 U.S.C.A. Sec. 10a et seq.]] apply 
to all procurements made with funds provided pursuant to [the 
authorization contained in section 1638a of this title.] 
section 317. Indian Tribes and Tribal Organizations shall be 
exempt from these requirements.
    [(b) Report to Congress
    [The Secretary shall submit to the Congress a report on the 
amount of procurements from foreign entities made in fiscal 
years 1993 and 1994 with funds provided pursuant to the 
authorization contained in section 1638a of this title. Such 
report shall separately indicate the dollar value of items 
procured with such funds for which the Buy American Act [41 
U.S.C.A. Sec. 10a et seq.] was waived pursuant to the Trade 
Agreement Act of 1979 [19 U.S.C.A. Sec. 250 et seq.] or any 
international agreement to which the United States is a party.
    [(c) Fraudulent use of Made-in-America label]
    (b) Effect of Violation.--If it has been finally determined 
by a court or Federal agency that any person intentionally 
affixed a label bearing a ``Made in America'' inscription[,] or 
any inscription with the same meaning, to any product sold in 
or shipped to the United States that is not made in the United 
States, such person shall be ineligible to receive any contract 
or subcontract made with funds provided pursuant to [the 
authorization contained in] section [1638a of this title,] 317, 
pursuant to the debarment, suspension, and ineligibility 
procedures described in sections 9.400 through 9.409 of title 
48, Code of Federal Regulations.
    [(d) ``Buy American Act'' defined] (c) Definitions.--For 
purposes of this section, the term [``Buy American Act''] ``Buy 
American Act'' means title III of the Act entitled ``An Act 
making appropriations for the Treasury and Post Office 
Departments for the fiscal year ending June 30, 1934, and for 
other purposes'', approved March 3, 1933 (41 U.S.C. 10a et 
seq.).

[Sec. 1638c. Contracts for provision of personal services in Indian 
                    Health Service facilities

    [In fiscal year 1995 and thereafter--]

SEC. 316. OTHER FUNDING FOR FACILITIES.

    [(a) In general
    [The Secretary may enter into personal services contracts 
with entities, either individuals or organizations, for the 
provision of services in facilities owned, operated or 
constructed under the jurisdiction of the Indian Health 
Service.]
    (a) Authority To Accept Funds.--The Secretary is authorized 
to accept from any source, including Federal and State 
agencies, funds that are available for the construction of 
health care facilities and use such funds to plan, design, and 
construct health care facilities for Indians and to place such 
funds into a contract or compact under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et 
seq.). Receipt of such funds shall have no effect on the 
priorities established pursuant to section 301.
    [(b) Exemption from competitive contracting requirements
    [The Secretary may exempt such a contract from competitive 
contracting requirements upon adequate notice of contracting 
opportunities to individuals and organizations residing in the 
geographic vicinity of the health facility.]
    (b) Interagency Agreements.--The Secretary is authorized to 
enter into interagency agreements with other Federal agencies 
or State agencies and other entities and to accept funds from 
such Federal or State agencies or other sources to provide for 
the planning, design, and construction of health care 
facilities to be administered by Indian Health Programs in 
order to carry out the purposes of this Act and the purposes 
for which the funds were appropriated or for which the funds 
were otherwise provided.
    [(c) Consideration of individuals and organizations
    [Consideration of individuals and organizations shall be 
based solely on the qualifications established for the contract 
and the proposed contract price.]
    (c) Establishment of Standards.--The Secretary, through the 
Service, shall establish standards by regulation for the 
planning, design, and construction of health care facilities 
serving Indians under this Act.
    [(d) Liability
    [Individuals providing health care services pursuant to 
these contracts are covered by the Federal Tort Claims Act.]

SEC. 317. AUTHORIZATION OF APPROPRIATIONS.

[Sec. 1638d. Crediting of money collected for meals served at Indian 
                    Health Service facilities]

    There are authorized to be appropriated such sums as may be 
necessary for each fiscal year through fiscal year 2017 to 
carry out this title.
    [Money heretofore and hereafter collected for meals served 
at Indian Health Service facilities will be credited to the 
appropriations from which the services were furnished and shall 
be credited to the appropriation when received.]

                  TITLE IV--ACCESS TO HEALTH SERVICES


[Sec. 1641. Treatment of payments under medicare program]

SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SECURITY ACT HEALTH 
                    BENEFITS PROGRAMS.

    [(a) Determination of appropriations
    [Any payments received by a hospital or skilled nursing 
facility of the Service (whether operated by the Service or by 
an Indian tribe or tribal organization pursuant to a contract 
under the Indian Self-Determination Act [25 U.S.C.A. Sec. 450f 
et seq.])]
    (a) Disregard of Medicare, Medicaid, and SCHIP Payments in 
Determining Appropriations.--Any payments received by an Indian 
Health Program or by an Urban Indian Organization under title 
XVIII, XIX, or XXI of the Social Security Act for services 
provided to Indians eligible for benefits under [title XVIII of 
the Social Security Act [42 U.S.C.A. Sec. 1395 et seq.]] such 
respective titles shall not be considered in determining 
appropriations for [health care and services to Indians.] the 
provision of health care and services to Indians.
    [(b) Preferences]
    (b) Nonpreferential Treatment.--Nothing in this [chapter] 
Act authorizes the Secretary to provide services to an Indian 
[beneficiary] with coverage under title XVIII, XIX, or XXI of 
the Social Security [Act [42 U.S.C.A. Sec. 1395 et seq.], as 
amended,] Act in preference to an Indian [beneficiary] without 
such coverage.
    (c) Use of Funds.--

[Sec. 1642. Treatment of payments under medicaid program]

          (1) Special fund.--
    [(a) Payments to special fund]
                  (A) 100 percent pass-through of payments due 
                to facilities.--Notwithstanding any other 
                provision of law, [payments to which any 
                facility of the Service (including a hospital, 
                nursing facility, intermediate care facility 
                for the mentally retarded, or any other type of 
                facility which provides services for which 
                payment is available under title XIX of the 
                Social Security Act [42 U.S.C.A. Sec. 1396 et 
                seq.]) is entitled under a State plan by reason 
                of section 1911 of such Act [42 U.S.C.A. 
                Sec. 1396j]]but subject to paragraph (2), 
                payments to which a facility of the Service is 
                entitled by reason of a provision of the Social 
                Security Act shall be placed in a special fund 
                to be held by the Secretary [and used by him 
                (to such extent or in such amounts as are 
                provided in appropriation Acts) exclusively for 
                the purpose of making any improvements in the 
                facilities of such Service which may be 
                necessary to achieve compliance with the 
                applicable conditions and requirements of such 
                title]. In making payments from such fund, the 
                Secretary shall ensure that each [service unit] 
                Service Unit of the Service receives [at least 
                80] 100 percent of the [amounts] amount to 
                which the facilities of the Service, for which 
                such [service unit] Service Unit makes 
                collections, are entitled by reason of [section 
                1911 of the Social Security Act [42 U.S.C.A. 
                Sec. 1396j].] a provision of the Social 
                Security Act.
    [(b) Determination of appropriation
    [Any payments received by such facility for services 
provided to Indians eligible for benefits under title XIX of 
the Social Security Act [42 U.S.C.A. Sec. 1396 et seq.] shall 
not be considered in determining appropriations for the 
provision of health care and services to Indians.

[Sec. 1643. Amount and use of funds reimbursed through medicare and 
                    medicaid available to Indian Health Service]

    [The Secretary shall submit to the President, for inclusion 
in the report required to be transmitted to the Congress under 
section 1671 of this title, an accounting on the amount and use 
of funds made available to the Service pursuant to this 
subchapter as a result of reimbursements through titles XVIII 
and XIX of the Social Security Act [42 U.S.C.A. Sec. Sec. 1395 
et seq., 1396 et seq.], as amended.]

[Sec. 1644. Grants to and contracts with tribal organizations]

                  (B) Use of funds.--Amounts received by a 
                facility of the Service under subparagraph (A) 
                shall first be used (to such extent or in such 
                amounts as are provided in appropriation Acts) 
                for the purpose of making any improvements in 
                the programs of the Service operated by or 
                through such facility which may be necessary to 
                achieve or maintain compliance with the 
                applicable conditions and requirements of 
                titles XVIII and XIX of the Social Security 
                Act. Any amounts so received that are in excess 
                of the amount necessary to achieve or maintain 
                such conditions and requirements shall, subject 
                to consultation with the Indian Tribes being 
                served by the Service Unit, be used for 
                reducing the health resource deficiencies (as 
                determined under section 201(d)) of such Indian 
                Tribes.
    [(a) Access to health services
    [The Secretary, acting through the Service, shall make 
grants to or enter into contracts with tribal organizations to 
assist such organizations in establishing and administering 
programs on or near Federal Indian reservations and trust areas 
and in or near Alaska Native villages to assist individual 
Indians to--
          [(1) enroll under section 1818 of part A and sections 
        1836 and 1837 of part B of title XVIII of the Social 
        Security Act [42 U.S.C.A. Sec. Sec. 1395i-2, 1395o, and 
        1395p];
          [(2) pay monthly premiums for coverage due to 
        financial need of such individual; and
          [(3) apply for medical assistance provided pursuant 
        to title XIX of the Social Security Act [42 U.S.C.A. 
        Sec. 1396 et seq.].
    [(b) Terms and conditions
    [The Secretary, acting through the Service, shall place 
conditions as deemed necessary to effect the purpose of this 
section in any contract or grant which the Secretary makes with 
any tribal organization pursuant to this section. Such 
conditions shall include, but are not limited to, requirements 
that the organization successfully undertake to--
          [(1) determine the population of Indians to be served 
        that are or could be recipients of benefits under 
        titles XVIII and XIX of the Social Security Act [42 
        U.S.C.A. Sec. Sec. 1395 et seq., 1396 et seq.];
          [(2) assist individual Indians in becoming familiar 
        with and utilizing such benefits;
          [(3) provide transportation to such individual 
        Indians to the appropriate offices for enrollment or 
        application for medical assistance;
          [(4) develop and implement--
                  [(A) a schedule of income levels to determine 
                the extent of payments of premiums by such 
                organizations for coverage of needy 
                individuals; and
                  [(B) methods of improving the participation 
                of Indians in receiving the benefits provided 
                under titles XVIII and XIX of the Social 
                Security Act [42 U.S.C.A. Sec. Sec. 1395 et 
                seq., 1396 et seq.].
    [(c) Application for medical assistance
    [The Secretary, acting through the Service, may enter into 
an agreement with an Indian tribe, tribal organization, or 
urban Indian organization which provides for the receipt and 
processing of applications for medical assistance under title 
XIX of the Social Security Act [42 U.S.C.A. Sec. Sec. 1396 et 
seq.] and benefits under title XVIII of the Social Security Act 
[42 U.S.C.A. Sec. Sec. 1395 et seq.] at a Service facility or a 
health care facility administered by such tribe or organization 
pursuant to a contract under the Indian Self-Determination Act 
[25 U.S.C.A. Sec. 450f et seq.].
          (2) Direct payment option.--Paragraph (1) shall not 
        apply to a Tribal Health Program upon the election of 
        such Program under subsection (d) to receive payments 
        directly. No payment may be made out of the special 
        fund described in such paragraph with respect to 
        reimbursement made for services provided by such 
        Program during the period of such election.

[Sec. 1645. Direct billing of Medicare, Medicaid, and other third party 
                    payors]

    (d) Direct Billing.--
    [(a) Establishment of direct billing program
          [(1) In general
          [The Secretary shall establish a program under which 
        Indian tribes, tribal organizations, and Alaska Native 
        health organizations that contract or compact for the 
        operation of a hospital or clinic of the Service under 
        the Indian Self-Determination and Education Assistance 
        Act]
          (1) In general.--Subject to complying with the 
        requirements of paragraph (2), a Tribal Health Program 
        may elect to directly bill for, and receive payment 
        for, health care items and services provided by such 
        [hospital or clinic] Program for which payment is made 
        under title XVIII or XIX of the Social Security Act 
        [(42 U.S.C. 1395 et seq.) (in this section referred to 
        as the ``medicare program''), under a State plan for 
        medical assistance approved under title XIX of the 
        Social Security Act (42 U.S.C. 1396 et seq.) (in this 
        section referred to as the ``medicaid program''),] or 
        from any other third party payor.
          [(2) Application of 100 percent FMAP
          [The third sentence of section 1396d(b) of Title 42 
        shall apply for purposes of reimbursement under the 
        medicaid program for health care services directly 
        billed under the program established under this 
        section.
    [(b) Direct reimbursement
          [(1) Use of funds]
          (2) Direct reimbursement.--
          [Each hospital or clinic participating in the program 
        described in subsection (a) of this section]
                  (A) Use of funds.--Each Tribal Health Program 
                making the election described in paragraph (1) 
                with respect to a program under a title of the 
                Social Security Act shall be reimbursed 
                directly [under the medicare and medicaid 
                programs for services furnished, without regard 
                to the provisions of section 1395qq(c) of Title 
                42 and sections 602(a) and 1013(b)(2)(A) of 
                Title 42, but all funds] by that program for 
                items and services furnished without regard to 
                subsection (c)(1), but all amounts so 
                reimbursed shall [first] be used by [the 
                hospital or clinic] Tribal Health Program for 
                the purpose of making any improvements in the 
                [hospital or clinic] facilities of the Tribal 
                Health Program that may be necessary to achieve 
                or maintain compliance with the conditions and 
                requirements applicable generally to 
                [facilities of such type under the medicare or 
                medicaid programs. Any funds so reimbursed 
                which are in excess of the amount necessary to 
                achieve or maintain such conditions shall be 
                used--] such items and services under the 
                program under such title and to provide 
                additional health care services, improvements 
                in health care facilities and Tribal Health 
                Programs, any health care related purpose, or 
                otherwise to achieve the objectives provided in 
                section 3 of this Act.
                  [(A) solely for improving the health 
                resources deficiency level of the Indian tribe; 
                and
                  [(B) in accordance with the regulations of 
                the Service applicable to funds provided by the 
                Service under any contract entered into under 
                the Indian Self-Determination Act (25 U.S.C. 
                450f et seq.).
          [(2) Audits
          [The amounts paid to the hospitals and clinics 
        participating in the program established under this 
        section]
                  (B) Audits.--The amounts paid to a Tribal 
                Health Program making the election described in 
                paragraph (1) with respect to a program under a 
                title of the Social Security Act shall be 
                subject to all auditing requirements applicable 
                to [programs administered directly by the 
                Service and to facilities participating in the 
                medicare and medicaid programs.
          [(3) Secretarial oversight
          [The Secretary shall monitor the performance of 
        hospitals and clinics participating in the program 
        established under this section, and shall require such 
        hospitals and clinics to submit reports on the program 
        to the Secretary on an annual basis.
          [(4) No payments from special funds
          [Notwithstanding section 1395qq(c) of Title 42 or 
        section 602(a) of Title 42, no payment may be made out 
        of the special funds described in such sections for the 
        benefit of any hospital or clinic during the period 
        that the hospital or clinic participates in the program 
        established under this section.
    [(c) Requirements for participation
          [(1) Application
          [Except as provided in paragraph (2)(B), in order to 
        be eligible for participation in the program 
        established under this section, an Indian tribe, tribal 
        organization, or Alaska Native health organization 
        shall submit an application to the Secretary that 
        establishes to the satisfaction of the [Secretary 
        that--
                  [(A) the Indian tribe, tribal organization, 
                or Alaska Native health organization contracts 
                or compacts for the operation of a facility of 
                the Service;
                  [(B) the facility is eligible to participate 
                in the medicare or medicaid programs under 
                section 1395qq or 1396j of Title 42;
                  [(C) the facility meets the requirements that 
                apply to programs operated directly by the 
                Service; and
                  [(D) the facility--
                          [(i) is accredited by an accrediting 
                        body as eligible for reimbursement 
                        under the medicare or medicaid 
                        programs; or
                          [(ii) has submitted a plan, which has 
                        been approved by the Secretary, for 
                        achieving such accreditation.
          [(2) Approval
                  [(A) In general
    [The Secretary shall review and approve a qualified 
application not later than 90 days after the date the 
application is submitted to the Secretary unless the Secretary 
determines that any of the criteria set forth in paragraph (1) 
are not met.
                  [(B) Grandfather of demonstration program 
                participants
    [Any participant in the demonstration program authorized 
under this section as in effect on the day before the date of 
enactment of the Alaska Native and American Indian Direct 
Reimbursement Act of 1999 shall be deemed approved for 
participation in the program established under this section and 
shall not be required to submit an application in order to 
participate in the program.
                  [(C) Duration
    [An approval by the Secretary of a qualified application 
under subparagraph (A), or a deemed approval of a demonstration 
program under subparagraph (B), shall continue in effect as 
long as the approved applicant or the deemed approved 
demonstration program meets the requirements of this section.
    [(d) Examination and implementation of changes
          [(1) In general] the program under such title, as 
        well as all auditing requirements applicable to 
        programs administered by an Indian Health Program. 
        Nothing in the preceding sentence shall be construed as 
        limiting the application of auditing requirements 
        applicable to amounts paid under title XVIII, XIX, or 
        XXI of the Social Security Act.
                  (C) Identification of source of payments.--
                Any Tribal Health Program that receives 
                reimbursements or payments under title XVIII, 
                XIX, or XXI of the Social Security Act, shall 
                provide to the Service a list of each provider 
                enrollment number (or other identifier) under 
                which such Program receives such reimbursements 
                or payments.
          (3) Examination and implementation of changes._
                  (A) In general.--The Secretary, acting 
                through the Service, and with the assistance of 
                the Administrator of the [Health Care Financing 
                Administration] Centers for Medicare & Medicaid 
                Services, shall examine on an ongoing basis and 
                implement[-- (A)] any administrative changes 
                that may be necessary to facilitate direct 
                billing and reimbursement under the program 
                established under this [section] subsection, 
                including any agreements with States that may 
                be necessary to provide for direct billing 
                under the [medicaid] a program[; and] under a 
                title of the Social Security Act.
                  [(B) any changes that may be necessary to 
                enable participants in the program established 
                under this section to provide to the Service 
                medical records information on patients served 
                under the program that is consistent with the 
                medical records information system of the 
                Service.
        [(2) Accounting information
    [The accounting information that a participant in the 
program established under this section shall be required to 
report shall be the same as the information required to be 
reported by participants in the demonstration program 
authorized under this section as in effect on the day before 
the date of enactment of the Alaska Native and American Indian 
Direct Reimbursement Act of 1999. The Secretary may from time 
to time, after consultation with the program participants, 
change the accounting information submission requirements.
    [(e) Withdrawal from program]
                  (B) Coordination of information.--The Service 
                shall provide the Administrator of the Centers 
                for Medicare & Medicaid Services with copies of 
                the lists submitted to the Service under 
                paragraph (2)(C), enrollment data regarding 
                patients served by the Service (and by Tribal 
                Health Programs, to the extent such data is 
                available to the Service), and such other 
                information as the Administrator may require 
                for purposes of administering title XVIII, XIX, 
                or XXI of the Social Security Act.
    [A participant in]
          (4) Withdrawal from program.--A Tribal Health Program 
        that bills directly under the program established under 
        this [section] subsection may withdraw from 
        participation in the same manner and under the same 
        conditions that [a tribe or tribal organization] an 
        Indian Tribe or Tribal Organization may retrocede a 
        contracted program to the Secretary under the authority 
        of the Indian Self-Determination and Education 
        Assistance Act (25 U.S.C. 450 et seq.). All cost 
        accounting and billing authority under the program 
        established under this [section] subsection shall be 
        returned to the Secretary upon the Secretary's 
        acceptance of the withdrawal of participation in this 
        program.
          (5) Termination for failure to comply with 
        requirements.--The Secretary may terminate the 
        participation of a Tribal Health Program or in the 
        direct billing program established under this 
        subsection if the Secretary determines that the Program 
        has failed to comply with the requirements of paragraph 
        (2). The Secretary shall provide a Tribal Health 
        Program with notice of a determination that the Program 
        has failed to comply with any such requirement and a 
        reasonable opportunity to correct such noncompliance 
        prior to terminating the Program's participation in the 
        direct billing program established under this 
        subsection.
    (e) Related Provisions Under the Social Security Act.--For 
provisions related to subsections (c) and (d), see sections 
1880, 1911, and 2107(e)(1)(D) of the Social Security Act.

SEC. 402. GRANTS TO AND CONTRACTS WITH THE SERVICE, INDIAN TRIBES, 
                    TRIBAL ORGANIZATIONS, AND URBAN INDIAN 
                    ORGANIZATIONS TO FACILITATE OUTREACH, ENROLLMENT, 
                    AND COVERAGE OF INDIANS UNDER SOCIAL SECURITY ACT 
                    HEALTH BENEFIT PROGRAMS AND OTHER HEALTH BENEFITS 
                    PROGRAMS.

    (a) Indian Tribes and Tribal Organizations.--From funds 
appropriated to carry out this title in accordance with section 
416, the Secretary, acting through the Service, shall make 
grants to or enter into contracts with Indian Tribes and Tribal 
Organizations to assist such Tribes and Tribal Organizations in 
establishing and administering programs on or near reservations 
and trust lands to assist individual Indians--
          (1) to enroll for benefits under a program 
        established under title XVIII, XIX, or XXI of the 
        Social Security Act and other health benefits programs; 
        and
          (2) with respect to such programs for which the 
        charging of premiums and cost sharing is not prohibited 
        under such programs, to pay premiums or cost sharing 
        for coverage for such benefits, which may be based on 
        financial need (as determined by the Indian Tribe or 
        Tribes or Tribal Organizations being served based on a 
        schedule of income levels developed or implemented by 
        such Tribe, Tribes, or Tribal Organizations).
    (b) Conditions.--The Secretary, acting through the Service, 
shall place conditions as deemed necessary to effect the 
purpose of this section in any grant or contract which the 
Secretary makes with any Indian Tribe or Tribal Organization 
pursuant to this section. Such conditions shall include 
requirements that the Indian Tribe or Tribal Organization 
successfully undertake--
          (1) to determine the population of Indians eligible 
        for the benefits described in subsection (a);
          (2) to educate Indians with respect to the benefits 
        available under the respective programs;
          (3) to provide transportation for such individual 
        Indians to the appropriate offices for enrollment or 
        applications for such benefits; and
          (4) to develop and implement methods of improving the 
        participation of Indians in receiving benefits under 
        such programs.
    (c) Application to Urban Indian Organizations.--
          (1) In general.--The provisions of subsection (a) 
        shall apply with respect to grants and other funding to 
        Urban Indian Organizations with respect to populations 
        served by such organizations in the same manner they 
        apply to grants and contracts with Indian Tribes and 
        Tribal Organizations with respect to programs on or 
        near reservations.
          (2) Requirements.--The Secretary shall include in the 
        grants or contracts made or provided under paragraph 
        (1) requirements that are--
                  (A) consistent with the requirements imposed 
                by the Secretary under subsection (b);
                  (B) appropriate to Urban Indian Organizations 
                and Urban Indians; and
                  (C) necessary to effect the purposes of this 
                section.
    (d) Facilitating Cooperation.--The Secretary, acting 
through the Centers for Medicare & Medicaid Services, shall 
take such steps as are necessary to facilitate cooperation 
with, and agreements between, States and the Service, Indian 
Tribes, Tribal Organizations, or Urban Indian Organizations 
with respect to the provision of health care items and services 
to Indians under the programs established under title XVIII, 
XIX, or XXI of the Social Security Act.
    (e) Agreements Relating to Improving Enrollment of Indians 
Under Social Security Act Health Benefits Programs.--For 
provisions relating to agreements between the Secretary, acting 
through the Service, and Indian Tribes, Tribal Organizations, 
and Urban Indian Organizations for the collection, preparation, 
and submission of applications by Indians for assistance under 
the Medicaid and State children's health insurance programs 
established under titles XIX and XXI of the Social Security 
Act, and benefits under the Medicare program established under 
title XVIII of such Act, see subsections (a) and (b) of section 
1139 of the Social Security Act.
    (f) Definition of Premiums and Cost Sharing.--In this 
section:
          (1) Premium.--The term ``premium'' includes any 
        enrollment fee or similar charge.
          (2) Cost sharing.--The term ``cost sharing'' includes 
        any deduction, deductible, copayment, coinsurance, or 
        similar charge.

SEC. 403. REIMBURSEMENT FROM CERTAIN THIRD PARTIES OF COSTS OF HEALTH 
                    SERVICES.

    (a) Right of Recovery.--Except as provided in subsection 
(f), the United States, an Indian Tribe, or Tribal Organization 
shall have the right to recover from an insurance company, 
health maintenance organization, employee benefit plan, third-
party tortfeasor, or any other responsible or liable third 
party (including a political subdivision or local governmental 
entity of a State) the reasonable charges billed by the 
Secretary, an Indian Tribe, or Tribal Organization in providing 
health services through the Service, an Indian Tribe, or Tribal 
Organization to any individual to the same extent that such 
individual, or any nongovernmental provider of such services, 
would be eligible to receive damages, reimbursement, or 
indemnification for such charges or expenses if--
          (1) such services had been provided by a 
        nongovernmental provider; and
          (2) such individual had been required to pay such 
        charges or expenses and did pay such charges or 
        expenses.
    (b) Limitations on Recoveries From States.--Subsection (a) 
shall provide a right of recovery against any State, only if 
the injury, illness, or disability for which health services 
were provided is covered under--
          (1) workers' compensation laws; or
          (2) a no-fault automobile accident insurance plan or 
        program.
    (c) Nonapplication of Other Laws.--No law of any State, or 
of any political subdivision of a State and no provision of any 
contract, insurance or health maintenance organization policy, 
employee benefit plan, self-insurance plan, managed care plan, 
or other health care plan or program entered into or renewed 
after the date of the enactment of the Indian Health Care 
Amendments of 1988, shall prevent or hinder the right of 
recovery of the United States, an Indian Tribe, or Tribal 
Organization under subsection (a).
    (d) No Effect on Private Rights of Action.--No action taken 
by the United States, an Indian Tribe, or Tribal Organization 
to enforce the right of recovery provided under this section 
shall operate to deny to the injured person the recovery for 
that portion of the person's damage not covered hereunder.
    (e) Enforcement.--
          (1) In general.--The United States, an Indian Tribe, 
        or Tribal Organization may enforce the right of 
        recovery provided under subsection (a) by--
                  (A) intervening or joining in any civil 
                action or proceeding brought--
                          (i) by the individual for whom health 
                        services were provided by the 
                        Secretary, an Indian Tribe, or Tribal 
                        Organization; or
                          (ii) by any representative or heirs 
                        of such individual, or
                  (B) instituting a civil action, including a 
                civil action for injunctive relief and other 
                relief and including, with respect to a 
                political subdivision or local governmental 
                entity of a State, such an action against an 
                official thereof.
          (2) Notice.--All reasonable efforts shall be made to 
        provide notice of action instituted under paragraph 
        (1)(B) to the individual to whom health services were 
        provided, either before or during the pendency of such 
        action.
          (3) Recovery from tortfeasors.--
                  (A) In general.--In any case in which an 
                Indian Tribe or Tribal Organization that is 
                authorized or required under a compact or 
                contract issued pursuant to the Indian Self-
                Determination and Education Assistance Act (25 
                U.S.C. 450 et seq.) to furnish or pay for 
                health services to a person who is injured or 
                suffers a disease on or after the date of 
                enactment of the Indian Health Care Improvement 
                Act Amendments of 2007 under circumstances that 
                establish grounds for a claim of liability 
                against the tortfeasor with respect to the 
                injury or disease, the Indian Tribe or Tribal 
                Organization shall have a right to recover from 
                the tortfeasor (or an insurer of the 
                tortfeasor) the reasonable value of the health 
                services so furnished, paid for, or to be paid 
                for, in accordance with the Federal Medical 
                Care Recovery Act (42 U.S.C. 2651 et seq.), to 
                the same extent and under the same 
                circumstances as the United States may recover 
                under that Act.
                  (B) Treatment.--The right of an Indian Tribe 
                or Tribal Organization to recover under 
                subparagraph (A) shall be independent of the 
                rights of the injured or diseased person served 
                by the Indian Tribe or Tribal Organization.
    (f) Limitation.--Absent specific written authorization by 
the governing body of an Indian Tribe for the period of such 
authorization (which may not be for a period of more than 1 
year and which may be revoked at any time upon written notice 
by the governing body to the Service), the United States shall 
not have a right of recovery under this section if the injury, 
illness, or disability for which health services were provided 
is covered under a self-insurance plan funded by an Indian 
Tribe, Tribal Organization, or Urban Indian Organization. Where 
such authorization is provided, the Service may receive and 
expend such amounts for the provision of additional health 
services consistent with such authorization.
    (g) Costs and Attorneys' Fees.--In any action brought to 
enforce the provisions of this section, a prevailing plaintiff 
shall be awarded its reasonable attorneys' fees and costs of 
litigation.
    (h) Nonapplication of Claims Filing Requirements.--An 
insurance company, health maintenance organization, self-
insurance plan, managed care plan, or other health care plan or 
program (under the Social Security Act or otherwise) may not 
deny a claim for benefits submitted by the Service or by an 
Indian Tribe or Tribal Organization based on the format in 
which the claim is submitted if such format complies with the 
format required for submission of claims under title XVIII of 
the Social Security Act or recognized under section 1175 of 
such Act.
    (i) Application to Urban Indian Organizations.--The 
previous provisions of this section shall apply to Urban Indian 
Organizations with respect to populations served by such 
Organizations in the same manner they apply to Indian Tribes 
and Tribal Organizations with respect to populations served by 
such Indian Tribes and Tribal Organizations.
    (j) Statute of Limitations.--The provisions of section 2415 
of title 28, United States Code, shall apply to all actions 
commenced under this section, and the references therein to the 
United States are deemed to include Indian Tribes, Tribal 
Organizations, and Urban Indian Organizations.
    (k) Savings.--Nothing in this section shall be construed to 
limit any right of recovery available to the United States, an 
Indian Tribe, or Tribal Organization under the provisions of 
any applicable, Federal, State, or Tribal law, including 
medical lien laws.

SEC. 404. CREDITING OF REIMBURSEMENTS.

    (a) Use of Amounts.--
          (1) Retention by program.--Except as provided in 
        section 202(f) (relating to the Catastrophic Health 
        Emergency Fund) and section 807 (relating to health 
        services for ineligible persons), all reimbursements 
        received or recovered under any of the programs 
        described in paragraph (2), including under section 
        807, by reason of the provision of health services by 
        the Service, by an Indian Tribe or Tribal Organization, 
        or by an Urban Indian Organization, shall be credited 
        to the Service, such Indian Tribe or Tribal 
        Organization, or such Urban Indian Organization, 
        respectively, and may be used as provided in section 
        401. In the case of such a service provided by or 
        through a Service Unit, such amounts shall be credited 
        to such unit and used for such purposes.
          (2) Programs covered.--The programs referred to in 
        paragraph (1) are the following:
                  (A) Titles XVIII, XIX, and XXI of the Social 
                Security Act.
                  (B) This Act, including section 807.
                  (C) Public Law 87-693.
                  (D) Any other provision of law.
    (b) No Offset of Amounts.--The Service may not offset or 
limit any amount obligated to any Service Unit or entity 
receiving funding from the Service because of the receipt of 
reimbursements under subsection (a).

SEC. 405. PURCHASING HEALTH CARE COVERAGE.

    (a) In General.--Insofar as amounts are made available 
under law (including a provision of the Social Security Act, 
the Indian Self-Determination and Education Assistance Act (25 
U.S.C. 450 et seq.), or other law, other than under section 
402) to Indian Tribes, Tribal Organizations, and Urban Indian 
Organizations for health benefits for Service beneficiaries, 
Indian Tribes, Tribal Organizations, and Urban Indian 
Organizations may use such amounts to purchase health benefits 
coverage for such beneficiaries in any manner, including 
through--
          (1) a tribally owned and operated health care plan;
          (2) a State or locally authorized or licensed health 
        care plan;
          (3) a health insurance provider or managed care 
        organization; or
          (4) a self-insured plan.
    The purchase of such coverage by an Indian Tribe, Tribal 
Organization, or Urban Indian Organization may be based on the 
financial needs of such beneficiaries (as determined by the 
Indian Tribe or Tribes being served based on a schedule of 
income levels developed or implemented by such Indian Tribe or 
Tribes).
    (b) Expenses for Self-Insured Plan.--In the case of a self-
insured plan under subsection (a)(4), the amounts may be used 
for expenses of operating the plan, including administration 
and insurance to limit the financial risks to the entity 
offering the plan.
    (c) Construction.--Nothing in this section shall be 
construed as affecting the use of any amounts not referred to 
in subsection (a).

SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGENCIES.

    (a) Authority.--
          (1) In general.--The Secretary may enter into (or 
        expand) arrangements for the sharing of medical 
        facilities and services between the Service, Indian 
        Tribes, and Tribal Organizations and the Department of 
        Veterans Affairs and the Department of Defense.
          (2) Consultation by secretary required.--The 
        Secretary may not finalize any arrangement between the 
        Service and a Department described in paragraph (1) 
        without first consulting with the Indian Tribes which 
        will be significantly affected by the arrangement.
    (b) Limitations.--The Secretary shall not take any action 
under this section or under subchapter IV of chapter 81 of 
title 38, United States Code, which would impair--
          (1) the priority access of any Indian to health care 
        services provided through the Service and the 
        eligibility of any Indian to receive health services 
        through the Service;
          (2) the quality of health care services provided to 
        any Indian through the Service;
          (3) the priority access of any veteran to health care 
        services provided by the Department of Veterans 
        Affairs;
          (4) the quality of health care services provided by 
        the Department of Veterans Affairs or the Department of 
        Defense; or
          (5) the eligibility of any Indian who is a veteran to 
        receive health services through the Department of 
        Veterans Affairs.
    (c) Reimbursement.--The Service, Indian Tribe, or Tribal 
Organization shall be reimbursed by the Department of Veterans 
Affairs or the Department of Defense (as the case may be) where 
services are provided through the Service, an Indian Tribe, or 
a Tribal Organization to beneficiaries eligible for services 
from either such Department, notwithstanding any other 
provision of law.
    (d) Construction.--Nothing in this section may be construed 
as creating any right of a non-Indian veteran to obtain health 
services from the Service.

SEC. 407. PAYOR OF LAST RESORT.

    Indian Health Programs and health care programs operated by 
Urban Indian Organizations shall be the payor of last resort 
for services provided to persons eligible for services from 
Indian Health Programs and Urban Indian Organizations, 
notwithstanding any Federal, State, or local law to the 
contrary.

SEC. 408. NONDISCRIMINATION UNDER FEDERAL HEALTH CARE PROGRAMS IN 
                    QUALIFICATIONS FOR REIMBURSEMENT FOR SERVICES.

    (a) Requirement To Satisfy Generally Applicable 
Participation Requirements.--
          (1) In general.--A Federal health care program must 
        accept an entity that is operated by the Service, an 
        Indian Tribe, Tribal Organization, or Urban Indian 
        Organization as a provider eligible to receive payment 
        under the program for health care services furnished to 
        an Indian on the same basis as any other provider 
        qualified to participate as a provider of health care 
        services under the program if the entity meets 
        generally applicable State or other requirements for 
        participation as a provider of health care services 
        under the program.
          (2) Satisfaction of state or local licensure or 
        recognition requirements.--Any requirement for 
        participation as a provider of health care services 
        under a Federal health care program that an entity be 
        licensed or recognized under the State or local law 
        where the entity is located to furnish health care 
        services shall be deemed to have been met in the case 
        of an entity operated by the Service, an Indian Tribe, 
        Tribal Organization, or Urban Indian Organization if 
        the entity meets all the applicable standards for such 
        licensure or recognition, regardless of whether the 
        entity obtains a license or other documentation under 
        such State or local law. In accordance with section 
        221, the absence of the licensure of a health care 
        professional employed by such an entity under the State 
        or local law where the entity is located shall not be 
        taken into account for purposes of determining whether 
        the entity meets such standards, if the professional is 
        licensed in another State.
    (b) Application of Exclusion From Participation in Federal 
Health Care Programs.--
          (1) Excluded entities.--No entity operated by the 
        Service, an Indian Tribe, Tribal Organization, or Urban 
        Indian Organization that has been excluded from 
        participation in any Federal health care program or for 
        which a license is under suspension or has been revoked 
        by the State where the entity is located shall be 
        eligible to receive payment or reimbursement under any 
        such program for health care services furnished to an 
        Indian.
          (2) Excluded individuals.--No individual who has been 
        excluded from participation in any Federal health care 
        program or whose State license is under suspension 
        shall be eligible to receive payment or reimbursement 
        under any such program for health care services 
        furnished by that individual, directly or through an 
        entity that is otherwise eligible to receive payment 
        for health care services, to an Indian.
          (3) Federal health care program defined.--In this 
        subsection, the term, `Federal health care program' has 
        the meaning given that term in section 1128B(f) of the 
        Social Security Act (42 U.S.C. 1320a-7b(f)), except 
        that, for purposes of this subsection, such term shall 
        include the health insurance program under chapter 89 
        of title 5, United States Code.
          (c) Related provisions.--For provisions related to 
        nondiscrimination against providers operated by the 
        Service, an Indian Tribe, Tribal Organization, or Urban 
        Indian Organization, see section 1139(c) of the Social 
        Security Act (42 U.S.C. 1320b-9(c)).

SEC. 409. CONSULTATION.

    For provisions related to consultation with representatives 
of Indian Health Programs and Urban Indian Organizations with 
respect to the health care programs established under titles 
XVIII, XIX, and XXI of the Social Security Act, see section 
1139(d) of the Social Security Act (42 U.S.C. 1320b-9(d)).

SEC. 410. STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP).

    For provisions relating to--
          (1) outreach to families of Indian children likely to 
        be eligible for child health assistance under the State 
        children's health insurance program established under 
        title XXI of the Social Security Act, see sections 
        2105(c)(2)(C) and 1139(a) of such Act (42 U.S.C. 
        1397ee(c)(2), 1320b-9); and
          (2) ensuring that child health assistance is provided 
        under such program to targeted low-income children who 
        are Indians and that payments are made under such 
        program to Indian Health Programs and Urban Indian 
        Organizations operating in the State that provide such 
        assistance, see sections 2102(b)(3)(D) and 
        2105(c)(6)(B) of such Act (42 U.S.C. 1397bb(b)(3)(D), 
        1397ee(c)(6)(B)).

SEC. 411. EXCLUSION WAIVER AUTHORITY FOR AFFECTED INDIAN HEALTH 
                    PROGRAMS AND SAFE HARBOR TRANSACTIONS UNDER THE 
                    SOCIAL SECURITY ACT.

    For provisions relating to--
          (1) exclusion waiver authority for affected Indian 
        Health Programs under the Social Security Act, see 
        section 1128(k) of the Social Security Act (42 U.S.C. 
        1320a-7(k)); and
          (2) certain transactions involving Indian Health 
        Programs deemed to be in safe harbors under that Act, 
        see section 1128B(b)(4) of the Social Security Act (42 
        U.S.C. 1320a-7b(b)(4)).

SEC. 412. PREMIUM AND COST SHARING PROTECTIONS AND ELIGIBILITY 
                    DETERMINATIONS UNDER MEDICAID AND SCHIP AND 
                    PROTECTION OF CERTAIN INDIAN PROPERTY FROM MEDICAID 
                    ESTATE RECOVERY.

    For provisions relating to--
          (1) premiums or cost sharing protections for Indians 
        furnished items or services directly by Indian Health 
        Programs or through referral under the contract health 
        service under the Medicaid program established under 
        title XIX of the Social Security Act, see sections 
        1916(j) and 1916A(a)(1) of the Social Security Act (42 
        U.S.C. 1396o(j), 1396o-1(a)(1));
          (2) rules regarding the treatment of certain property 
        for purposes of determining eligibility under such 
        programs, see sections 1902(e)(13) and 2107(e)(1)(B) of 
        such Act (42 U.S.C. 1396a(e)(13), 1397gg(e)(1)(B)); and
          (3) the protection of certain property from estate 
        recovery provisions under the Medicaid program, see 
        section 1917(b)(3)(B) of such Act (42 U.S.C. 
        1396p(b)(3)(B)).

SEC. 413. TREATMENT UNDER MEDICAID AND SCHIP MANAGED CARE.

    For provisions relating to the treatment of Indians 
enrolled in a managed care entity under the Medicaid program 
under title XIX of the Social Security Act and Indian Health 
Programs and Urban Indian Organizations that are providers of 
items or services to such Indian enrollees, see sections 
1932(h) and 2107(e)(1)(H) of the Social Security Act (42 U.S.C. 
1396u-2(h), 1397gg(e)(1)(H)).

SEC. 414. NAVAJO NATION MEDICAID AGENCY FEASIBILITY STUDY.

    (a) Study.--The Secretary shall conduct a study to 
determine the feasibility of treating the Navajo Nation as a 
State for the purposes of title XIX of the Social Security Act, 
to provide services to Indians living within the boundaries of 
the Navajo Nation through an entity established having the same 
authority and performing the same functions as single-State 
medicaid agencies responsible for the administration of the 
State plan under title XIX of the Social Security Act.
    (b) Considerations.--In conducting the study, the Secretary 
shall consider the feasibility of--
          (1) assigning and paying all expenditures for the 
        provision of services and related administration funds, 
        under title XIX of the Social Security Act, to Indians 
        living within the boundaries of the Navajo Nation that 
        are currently paid to or would otherwise be paid to the 
        State of Arizona, New Mexico, or Utah;
          (2) providing assistance to the Navajo Nation in the 
        development and implementation of such entity for the 
        administration, eligibility, payment, and delivery of 
        medical assistance under title XIX of the Social 
        Security Act;
          (3) providing an appropriate level of matching funds 
        for Federal medical assistance with respect to amounts 
        such entity expends for medical assistance for services 
        and related administrative costs; and
          (4) authorizing the Secretary, at the option of the 
        Navajo Nation, to treat the Navajo Nation as a State 
        for the purposes of title XIX of the Social Security 
        Act (relating to the State children's health insurance 
        program) under terms equivalent to those described in 
        paragraphs (2) through (4).
    (c) Report.--Not later than 3 years after the date of 
enactment of the Indian Health Care Improvement Act Amendments 
of 2007, the Secretary shall submit to the Committee on Indian 
Affairs and Committee on Finance of the Senate and the 
Committee on Natural Resources and Committee on Energy and 
Commerce of the House of Representatives a report that 
includes--
          (1) the results of the study under this section;
          (2) a summary of any consultation that occurred 
        between the Secretary and the Navajo Nation, other 
        Indian Tribes, the States of Arizona, New Mexico, and 
        Utah, counties which include Navajo Lands, and other 
        interested parties, in conducting this study;
          (3) projected costs or savings associated with 
        establishment of such entity, and any estimated impact 
        on services provided as described in this section in 
        relation to probable costs or savings; and
          (4) legislative actions that would be required to 
        authorize the establishment of such entity if such 
        entity is determined by the Secretary to be feasible.

[Sec. 1646. Authorization for emergency contract health services]

SEC. 415. GENERAL EXCEPTIONS.

    [With respect to an elderly or disabled Indian receiving 
emergency medical care or services from a non-Service provider 
or in a non-Service facility under the authority of this Act, 
the time limitation (as a condition of payment) for notifying 
the Service of such treatment or admission shall be 30 days.]
    The requirements of this title shall not apply to any 
excepted benefits described in paragraph (1)(A) or (3) of 
section 2791(c) of the Public Health Service Act (42 U.S.C. 
300gg-91).

[Sec. 1647. Authorization of appropriations]

SEC. 416. AUTHORIZATION OF APPROPRIATIONS.

    There are authorized to be appropriated such sums as may be 
necessary for each fiscal year through fiscal year [2000] 2017 
to carry out this [subchapter] title. 

               TITLE V--HEALTH SERVICES FOR URBAN INDIANS


[Sec. 1651. Purpose]

SEC. 501. PURPOSE.

    The purpose of this [subchapter] title is to establish and 
maintain programs in [urban centers] Urban Centers to make 
health services more accessible and available to [urban] Urban 
Indians.

[Sec. 1652. Contracts with, and grants to, urban Indian organizations]

SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN INDIAN ORGANIZATIONS.

    Under authority of the Act of November 2, 1921 (25 U.S.C. 
13), [popularly] (commonly known as the ``Snyder Act''), the 
Secretary, acting through the Service, shall enter into 
contracts with, or make grants to, [urban] Urban Indian 
[organizations] Organizations to assist such organizations in 
the establishment and administration, within [the urban centers 
in which such organizations are situated] Urban Centers, of 
programs which meet the requirements set forth in this 
[subchapter. The] title. Subject to section 506, the Secretary, 
acting through the Service, shall include such conditions as 
the Secretary considers necessary to effect the purpose of this 
[subchapter] title in any contract into which the Secretary 
enters [into] with, or in any grant the Secretary makes to, any 
[urban] Urban Indian [organization] Organization pursuant to 
this [subchapter] title.

[Sec. 1653. Contracts and grants for the provision of health care and 
                    referral services]

SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION OF HEALTH CARE AND 
                    REFERRAL SERVICES.

    (a) Requirements for Grants and Contracts.--Under authority 
of the Act of November 2, 1921 (25 U.S.C. 13)[, popularly] 
(commonly known as the ``Snyder Act''), the Secretary, acting 
through the Service, shall enter into contracts with, [or] and 
make grants to, [urban] Urban Indian [organizations] 
Organizations for the provision of health care and referral 
services for [urban Indians residing in the urban centers in 
which such organizations are situated] Urban Indians. Any such 
contract or grant shall include requirements that the [urban] 
Urban Indian [organization] Organization successfully undertake 
to--
          (1) estimate the population of [urban] Urban Indians 
        residing in the [urban center in which such] Urban 
        Center or centers that the organization [is situated] 
        proposes to serve who are or could be recipients of 
        health care or referral services;
          (2) estimate the current health status of [urban] 
        Urban Indians residing in such [urban center] Urban 
        Center or centers;
          (3) estimate the current health care needs of [urban] 
        Urban Indians residing in such [urban center] Urban 
        Center or centers;
          [(4) identify all public and private health services 
        resources within such urban center which are or may be 
        available to urban Indians;
          [(5) determine the use of public and private health 
        services resources by the urban Indians residing in 
        such urban center;
          [(6) assist such health services resources in 
        providing services to urban Indians;
          [(7) assist urban Indians in becoming familiar with 
        and utilizing such health services resources;]
          [(8)] (4) provide basic health education, including 
        health promotion and disease prevention education, to 
        [urban] Urban Indians;
          [(9) establish and implement training programs to 
        accomplish the referral and education tasks set forth 
        in paragraphs (6) through (8) of this subsection;
          [(10) identify gaps between unmet health needs of 
        urban Indians and the resources available to meet such 
        needs;]
          [(11)] (5) make recommendations to the Secretary and 
        Federal, State, local, and other resource agencies on 
        methods of improving health service programs to meet 
        the needs of [urban] Urban Indians; and
          [(12)] (6) where necessary, provide, or enter into 
        contracts for the provision of, health care services 
        for [urban] Urban Indians.
    (b) Criteria for Selection of Organizations To Enter Into 
Contracts or Receive Grants.--The Secretary, acting through the 
Service, shall, by regulation, prescribe the criteria for 
selecting [urban] Urban Indian [organizations] Organizations to 
enter into contracts or receive grants under this section. Such 
criteria shall, among other factors, include--
          (1) the extent of unmet health care needs of [urban] 
        Urban Indians in the [urban center] Urban Center or 
        centers involved;
          (2) the size of the [urban] Urban Indian population 
        in the [urban center] Urban Center or centers involved;
          [(3) the accessibility to, and utilization of, health 
        care services (other than services provided under this 
        subchapter) by urban Indians in the urban center 
        involved;]
          [(4)] (3) the extent, if any, to which the activities 
        set forth in subsection (a) [of this section] would 
        duplicate[-- (A) any previous or] any project funded 
        under this title, or under any current public [or 
        private health services project in an urban center that 
        was or is] health service project funded in a manner 
        other than pursuant to this [subchapter; or] title;
          [(B) any project funded under this subchapter;]
          [(5)] (4) the capability of an [urban] Urban Indian 
        [organization] Organization to perform the activities 
        set forth in subsection [(a) of this section] and to 
        enter into a contract with the Secretary or to meet the 
        requirements for receiving a grant under this section;
          [(6)] (5) the satisfactory performance and successful 
        completion by an [urban] Urban Indian [organization] 
        Organization of other contracts with the Secretary 
        under this [subchapter;] title;
          [(7)] (6) the appropriateness and likely 
        effectiveness of conducting the activities set forth in 
        subsection (a) [of this section in an urban center; 
        and] in an Urban Center or centers; and
          [(8)] (7) the extent of existing or likely future 
        participation in the activities set forth in subsection 
        (a) [of this section] by appropriate health and health-
        related Federal, State, local, and other agencies.
    [(c) Grants for health promotion and disease prevention 
services]
    (c) Access to Health Promotion and Disease Prevention 
Programs.--The Secretary, acting through the Service, shall 
facilitate access to, or provide, health promotion and disease 
prevention services for [urban] Urban Indians through grants 
made to [urban] Urban Indian [organizations] Organizations 
administering contracts entered into [pursuant to this section] 
or receiving grants under subsection (a) [of this section].
    [(d) Grants for immunization services]
    (d) Immunization Services.--
          [(1)] (1) Access or services provided.--The 
        Secretary, acting through the Service, shall facilitate 
        access to, or provide, immunization services for 
        [urban] Urban Indians through grants made to [urban] 
        Urban Indian [organizations] Organizations 
        administering contracts entered into [pursuant to this 
        section] or receiving grants under [subsection (a) of] 
        this section.
          [(2) In making any grant to carry out this 
        subsection, the Secretary shall take into 
        consideration--
                  [(A) the size of the urban Indian population 
                to be served;
                  [(B) the immunization levels of the urban 
                Indian population, particularly the 
                immunization levels of infants, children, and 
                the elderly;
                  [(C) the utilization by the urban Indians of 
                alternative resources from State and local 
                governments for no-cost or low-cost 
                immunization services to the general 
                population; and
                  [(D) the capability of the urban Indian 
                organization to carry out services pursuant to 
                this subsection.]
          [(3)] (2) Definition.--For purposes of this 
        subsection, the term ``immunization services'' means 
        services to provide without charge immunizations 
        against vaccine-preventable diseases.
    [(e) Grants for mental health services]
    (e) Behavioral Health Services.--
          [(1)] (1) Access or services provided.--The 
        Secretary, acting through the Service, shall facilitate 
        access to, or provide, [mental] behavioral health 
        services for [urban] Urban Indians through grants made 
        to [urban] Urban Indian [organizations] Organizations 
        administering contracts entered into [pursuant to this 
        section] or receiving grants under subsection [(a) of 
        this section].
          [(2)A] (2) Assessment required.--Except as provided 
        by paragraph (3)(A), a grant may not be made under this 
        subsection to an [urban] Urban Indian [organization] 
        Organization until that organization has prepared, and 
        the Service has approved, an assessment of the [mental] 
        following:
                  (A) The behavioral health needs of the 
                [urban] Urban Indian population concerned, [the 
                mental].
                  (B) The behavioral health services and other 
                related resources available to that 
                population[, the] .
                  (C) The barriers to obtaining those services 
                and resources, [and the] .
                  (D) The needs that are unmet by such services 
                and resources.
          (3) Purposes of grants.--Grants may be made under 
        this subsection[--]for the following:
                  (A) [to] To prepare assessments required 
                under paragraph (2)[;] .
                  (B) [to] To provide outreach, educational, 
                and referral services to [urban] Urban Indians 
                regarding the availability of direct [mental] 
                behavioral health services, to educate [urban] 
                Urban Indians about [mental] behavioral health 
                issues and services, and effect coordination 
                with existing [mental] behavioral health 
                providers in order to improve services to 
                [urban] Urban Indians[;] .
                  (C) [to] To provide outpatient [mental] 
                behavioral health services to [urban] Urban 
                Indians, including the identification and 
                assessment of illness, therapeutic treatments, 
                case management, support groups, family 
                treatment, and other treatment[; and] .
                  (D) [to] To develop innovative [mental] 
                behavioral health service delivery models which 
                incorporate Indian cultural support systems and 
                resources.
    [(f) Grants for prevention and treatment of child abuse]
    (f) Prevention of Child Abuse._
          [(1)] (1) Access or services provided.--The 
        Secretary, acting through the Service, shall facilitate 
        access to[,] or provide[,] services for [urban] Urban 
        Indians through grants to [urban] Urban Indian 
        [organizations] Organizations administering contracts 
        entered into [pursuant to this section] or receiving 
        grants under subsection (a) [of this section] to 
        prevent and treat child abuse (including sexual abuse) 
        among [urban] Urban Indians.
          [(2) A] (2) Evaluation required.--Except as provided 
        by paragraph (3)(A), a grant may not be made under this 
        subsection to an [urban] Urban Indian [organization] 
        Organization until that organization has prepared, and 
        the Service has approved, an assessment that documents 
        the prevalence of child abuse in the [urban] Urban 
        Indian population concerned and specifies the services 
        and programs (which may not duplicate existing services 
        and programs) for which the grant is requested.
          (3) Purposes of grants.--Grants may be made under 
        this subsection[--] for the following:
                  (A) [to] To prepare assessments required 
                under paragraph (2)[;] .
                  (B) [for] For the development of prevention, 
                training, and education programs for [urban 
                Indian populations] Urban Indians, including 
                child education, parent education, provider 
                training on identification and intervention, 
                education on reporting requirements, prevention 
                campaigns, and establishing service networks of 
                all those involved in Indian child protection[; 
                and] .
                  (C) [to] To provide direct outpatient 
                treatment services (including individual 
                treatment, family treatment, group therapy, and 
                support groups) to [urban] Urban Indians who 
                are child victims of abuse (including sexual 
                abuse) or adult survivors of child sexual 
                abuse, to the families of such child victims, 
                and to [urban] Urban Indian perpetrators of 
                child abuse (including sexual abuse).
          [(4)] (4) Considerations when making grants.--In 
        making grants to carry out this subsection, the 
        Secretary shall take into consideration--
                  (A) the support for the [urban] Urban Indian 
                [organization] Organization demonstrated by the 
                child protection authorities in the area, 
                including committees or other services funded 
                under the Indian Child Welfare Act of 1978 (25 
                U.S.C. 1901 et seq.), if any;
                  (B) the capability and expertise demonstrated 
                by the [urban] Urban Indian [organization] 
                Organization to address the complex problem of 
                child sexual abuse in the community; and
                  (C) the assessment required under paragraph 
                (2).
    (g) Other Grants.--The Secretary, acting through the 
Service, may enter into a contract with or make grants to an 
Urban Indian Organization that provides or arranges for the 
provision of health care services (through satellite 
facilities, provider networks, or otherwise) to Urban Indians 
in more than 1 Urban Center.

SEC. 504. CONTRACTS AND GRANTS FOR THE DETERMINATION OF UNMET HEALTH 
                    CARE NEEDS.

                  [(C) the assessment required under paragraph 
                (2).]

[Sec. 1654. Contracts and grants for determination of unmet health care 
                    needs]

    [(a) Authority] (a) Grants and Contracts Authorized.--Under 
authority of the Act of November 2, 1921 (25 U.S.C. 13)[, 
popularly] (commonly known as the ``Snyder Act''), the 
Secretary, acting through the Service, may enter into contracts 
with[,] or make grants to[, urban] Urban Indian [organizations] 
Organizations situated in [urban centers] Urban Centers for 
which contracts have not been entered into[,] or grants have 
not been made[,] under section [1653 of this title.] 503.
    (b) Purpose.--The purpose of a contract or grant made under 
this section shall be the determination of the matters 
described in subsection [(b)] (c)(1) in order to assist the 
Secretary in assessing the health status and health care needs 
of [urban] Urban Indians in the [urban center] Urban Center 
involved and determining whether the Secretary should enter 
into a contract or make a grant under section [1653 of this 
title] 503 with respect to the [urban] Urban Indian 
[organization] Organization which the Secretary has entered 
into a contract with, or made a grant to, under this section.
    [(b)] (c) Grant and Contract Requirements.--Any contract 
entered into, or grant made, by the Secretary under this 
section shall include requirements that--
          (1) the [urban] Urban Indian [organization] 
        Organization successfully [undertake] undertakes to--
                  (A) document the health care status and unmet 
                health care needs of [urban] Urban Indians in 
                the [urban center] Urban Center involved; and
                  (B) with respect to [urban] Urban Indians in 
                the [urban center] Urban Center involved, 
                determine the matters described in [clauses] 
                paragraphs (2), (3), (4), and [(8)] (7) of 
                section [1653] 503(b) [of this title]; and
          (2) the [urban] Urban Indian [organization] 
        Organization complete performance of the contract, or 
        carry out the requirements of the grant, within [one] 1 
        year after the date on which the Secretary and such 
        organization enter into such contract, or within [one] 
        1 year after such organization receives such grant, 
        whichever is applicable.
    [(c) Renewal] (d) No Renewals.--The Secretary may not renew 
any contract entered into[,] or grant made[,] under this 
section.

SEC. 505. EVALUATIONS; RENEWALS.

    [Sec. 1655.] (a) Procedures for Evaluations[; renewals]
    [(a) Contract compliance and performance].--The Secretary, 
acting through the Service, shall develop procedures to 
evaluate compliance with grant requirements [under this 
subchapter] and compliance with[,] and performance of contracts 
entered into by [urban] Urban Indian [organizations] 
Organizations under this [subchapter] title. Such procedures 
shall include provisions for carrying out the requirements of 
this section.
    [(b) Annual onsite evaluation]
    (b) Evaluations.--The Secretary, acting through the 
Service, shall [conduct an annual onsite evaluation of each 
urban Indian organization] evaluate the compliance of each 
Urban Indian Organization which has entered into a contract or 
received a grant under section [1653 of this title for purposes 
of determining the compliance of such organization with, and 
evaluating the performance of such organization under, such 
contract or the terms of such] 503 with the terms of such 
contract or grant. For purposes of this evaluation, the 
Secretary shall--
          (1) acting through the Service, conduct an annual 
        onsite evaluation of the organization; or
          (2) accept in lieu of such onsite evaluation evidence 
        of the organization's provisional or full accreditation 
        by a private independent entity recognized by the 
        Secretary for purposes of conducting quality reviews of 
        providers participating in the Medicare program under 
        title XVIII of the Social Security Act.
    (c) Noncompliance [or unsatisfactory performance]; 
Unsatisfactory Performance.--If, as a result of the evaluations 
conducted under this section, the Secretary determines that an 
[urban] Urban Indian [organization] Organization has not 
complied with the requirements of a grant or complied with or 
satisfactorily performed a contract under section [1653 of this 
title,] 503, the Secretary shall, prior to renewing such 
contract or grant, attempt to resolve with [such] the 
organization the areas of noncompliance or unsatisfactory 
performance and modify [such] the contract or grant to prevent 
future occurrences of [such] noncompliance or unsatisfactory 
performance. If the Secretary determines that [such] the 
noncompliance or unsatisfactory performance cannot be resolved 
and prevented in the future, the Secretary shall not renew 
[such] the contract or grant with [such] the organization and 
is authorized to enter into a contract or make a grant under 
section [1653 of this title] 503 with another [urban] Urban 
Indian [organization] Organization which is situated in the 
same [urban center] Urban Center as the [urban] Urban Indian 
[organization] Organization whose contract or grant is not 
renewed under this section.
    [(d) Contract and grant renewals]
    (d) Considerations for Renewals.--In determining whether to 
renew a contract or grant with an [urban] Urban Indian 
[organization] Organization under section [1653 of this title] 
503 which has completed performance of a contract or grant 
under section [1654 of this title,] 504, the Secretary shall 
review the records of the [urban] Urban Indian [organization] 
Organization, the reports submitted under section [1657 of this 
title, and, in the case of a renewal of a contract or grant 
under section 1653 of this title,] 507, and shall consider the 
results of the onsite evaluations [conducted] or accreditations 
under subsection (b) [of this section].

[Sec. 1656. Other contract and grant requirements]

SEC. 506. OTHER CONTRACT AND GRANT REQUIREMENTS.

    [(a) Federal regulations; exceptions]
    (a) Procurement.--Contracts with [urban Indian 
organizations] Urban Indian Organizations entered into pursuant 
to this [subchapter] title shall be in accordance with all 
Federal contracting laws and regulations relating to 
procurement except that, in the discretion of the Secretary, 
such contracts may be negotiated without advertising and need 
not conform to the provisions of [the Act of August 24, 1935 
(40 U.S.C 270a, et seq.).] sections 1304 and 3131 through 3133 
of title 40, United States Code.
    [(b) Payment]
    (b) Payments Under Contracts or Grants.--
          (1) In general.--Payments under any contracts or 
        grants pursuant to this [subchapter may be made in 
        advance or by way of reimbursement and in such 
        installments and on such conditions as the Secretary 
        deems necessary to carry out the purposes of this 
        subchapter.] title, notwithstanding any term or 
        condition of such contract or grant--
                  (A) may be made in a single advance payment 
                by the Secretary to the Urban Indian 
                Organization by no later than the end of the 
                first 30 days of the funding period with 
                respect to which the payments apply, unless the 
                Secretary determines through an evaluation 
                under section 505 that the organization is not 
                capable of administering such a single advance 
                payment; and
                  (B) if any portion thereof is unexpended by 
                the Urban Indian Organization during the 
                funding period with respect to which the 
                payments initially apply, shall be carried 
                forward for expenditure with respect to 
                allowable or reimbursable costs incurred by the 
                organization during 1 or more subsequent 
                funding periods without additional 
                justification or documentation by the 
                organization as a condition of carrying forward 
                the availability for expenditure of such funds.
          (2) Semiannual and quarterly payments and 
        reimbursements.--If the Secretary determines under 
        paragraph (1)(A) that an Urban Indian organization is 
        not capable of administering an entire single advance 
        payment, on request of the Urban Indian Organization, 
        the payments may be made--
                  (A) in semiannual or quarterly payments by 
                not later than 30 days after the date on which 
                the funding period with respect to which the 
                payments apply begins; or
                  (B) by way of reimbursement.
      (c) Revision or [amendment] Amendment of Contracts.--
Notwithstanding any provision of law to the contrary, the 
Secretary may, at the request [or] and consent of an [urban] 
Urban Indian [organization] Organization, revise or amend any 
contract entered into by the Secretary with such organization 
under this [subchapter] title as necessary to carry out the 
purposes of this [subchapter] title.
    [(d) Existing Government facilities]
    [In connection with any contract or grant entered into 
pursuant to this subchapter, the Secretary may permit an urban 
Indian organization to utilize, in carrying out such contract 
or grant, existing facilities owned by the Federal Government 
within the Secretary's jurisdiction under such terms and 
conditions as may be agreed upon for the use and maintenance of 
such facilities.]
    [(e)] (d) Fair and Uniform [provision of services and 
assistance] Services and Assistance.--Contracts with, or grants 
to[, urban] Urban Indian [organizations] Organizations and 
regulations adopted pursuant to this [subchapter] title shall 
include provisions to assure the fair and uniform provision to 
[urban] Urban Indians of services and assistance under such 
contracts or grants by such organizations.
    [(f) Eligibility for health care or referral services
    [Urban Indians, as defined in section 1603(f) of this 
title, shall be eligible for health care or referral services 
provided pursuant to this subchapter.]

SEC. 507. REPORTS AND RECORDS.

    [Sec. 1657.] (a) Reports [and records].--
    [(a) Quarterly reports]
          (1) In general.--For each fiscal year during which an 
        [urban] Urban Indian [organization] Organization 
        receives or expends funds pursuant to a contract 
        entered into[,] or a grant received[,] pursuant to this 
        [subchapter] title, such [organization] Urban Indian 
        Organization shall submit to the Secretary [a quarterly 
        report including--] not more frequently than every 6 
        months, a report that includes the following:
                  [(1)] (A) [in] In the case of a contract or 
                grant under section [1653 of this title, 
                information gathered pursuant to clauses (10) 
                and (11) of subsection (a) of such section;] 
                503, recommendations pursuant to section 
                503(a)(5).
                  [(2) information] (B) Information on 
                activities conducted by the organization 
                pursuant to the contract or grant[;].
                  [(3)] (C) [an] An accounting of the amounts 
                and [purposes] purpose for which Federal funds 
                were expended[; and].
                  [(4) such other information as the Secretary 
                may request.]
                  (D) A minimum set of data, using uniformly 
                defined elements, as specified by the Secretary 
                after consultation with Urban Indian 
                Organizations.
          (2) Health status and services.--
                  (A) In general.--Not later than 18 months 
                after the date of enactment of the Indian 
                Health Care Improvement Act Amendments of 2007, 
                the Secretary, acting through the Service, 
                shall submit to Congress a report evaluating--
                          (i) the health status of Urban 
                        Indians;
                          (ii) the services provided to Indians 
                        pursuant to this title; and
                          (iii) areas of unmet needs in the 
                        delivery of health services to Urban 
                        Indians.
                  (B) Consultation and contracts.--In preparing 
                the report under paragraph (1), the Secretary--
                          (i) shall consult with Urban Indian 
                        Organizations; and
                          (ii) may enter into a contract with a 
                        national organization representing 
                        Urban Indian Organizations to conduct 
                        any aspect of the report.
    (b) Audit [by Secretary and Comptroller General].--The 
reports and records of the [urban] Urban Indian [organization] 
Organization with respect to a contract or grant under this 
[subchapter] title shall be subject to audit by the Secretary 
and the Comptroller General of the United States.
    (c) [Cost] Costs of [annual private audit] Audits.--The 
Secretary shall allow as a cost of any contract or grant 
entered into or awarded under section [1653 of this title] 502 
or 503 the cost of an annual [private] independent financial 
audit conducted by--
          (1) a certified public accountant[.] ; or
    [(d) Health status, services, and areas of unmet needs; 
child welfare
          [(1) The Secretary, acting through the Service, shall 
        submit a report to the Congress not later than March 
        31, 1992, evaluating--
                  [(A) the health status of urban Indians;
                  [(B) the services provided to Indians through 
                this subchapter;
                  [(C) areas of unmet needs in urban areas 
                served under this subchapter; and
                  [(D) areas of unmet needs in urban areas not 
                served under this subchapter.
          [(2) In preparing the report under paragraph (1), the 
        Secretary shall consult with urban Indian health 
        providers and may contract with a national organization 
        representing urban Indian health concerns to conduct 
        any aspect of the report.
          [(3) The Secretary and the Secretary of the Interior, 
        shall]
          (2) a certified public accounting firm qualified to 
        conduct Federal compliance audits.

SEC. 508. LIMITATION ON CONTRACT AUTHORITY.

                  [(A) assess the status of the welfare of 
                urban Indian children, including the volume of 
                child protection cases, the prevalence of child 
                sexual abuse, and the extent of urban Indian 
                coordination with tribal authorities with 
                respect to child sexual abuse; and
                  [(B) submit a report on the assessment 
                required under subparagraph (A), together with 
                recommended legislation to improve Indian child 
                protection in urban Indian populations, to the 
                Congress no later than March 31, 1992.]

[Sec. 1658. Limitation on contract authority]

    The authority of the Secretary to enter into contracts or 
to award grants under this title shall be to the extent, and in 
an amount, provided for in appropriation Acts.

[Sec. 1659. Facilities renovation]

SEC. 509. FACILITIES.

    (a) Grants.--The Secretary, acting through the Service, may 
make [funds available] grants to contractors or grant 
recipients under this [subchapter for minor renovations to] 
title for the lease, purchase, renovation, construction, or 
expansion of facilities, including leased facilities, in order 
to assist such contractors or grant recipients in [meeting or 
maintaining the Joint Commission for Accreditation of Health 
Care Organizations (JCAHO) standards] complying with applicable 
licensure or certification requirements.
    (b) Loan Fund Study.--The Secretary, acting through the 
Service, may carry out a study to determine the feasibility of 
establishing a loan fund to provide to Urban Indian 
Organizations direct loans or guarantees for loans for the 
construction of health care facilities in a manner consistent 
with section 309, including by submitting a report in 
accordance with subsection (c) of that section.

[Sec. 1660. Urban Health Programs Branch]

SEC. 510. DIVISION OF URBAN INDIAN HEALTH.

    [(a) Establishment
    There is [hereby] established within the Service a [Branch] 
Division of Urban Indian Health[Programs], which shall be 
responsible for--
          (1) carrying out the provisions of this [subchapter 
        and for] title;
          (2) providing central oversight of the programs and 
        services authorized under this [subchapter.] title; and
    [(b) Staff, services, and equipment
    [The Secretary shall appoint such employees to work in the 
branch, including a program director, and shall provide such 
services and equipment, as may be necessary for it to carry out 
its responsibilities. The Secretary shall also analyze the need 
to provide at least one urban health program analyst for each 
area office of the Indian Health Service and shall submit his 
findings to the Congress as a part of the Department's fiscal 
year 1993 budget request.]
          (3) providing technical assistance to Urban Indian 
        Organizations.

[Sec. 1660a. Grants for alcohol and substance abuse related services

SEC. 511. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE-RELATED SERVICES.

    [(a) Grants]
    [The Secretary] (a) Grants Authorized.--The Secretary, 
acting through the Service, may make grants for the provision 
of health-related services in prevention of, treatment of, 
rehabilitation of, or school- and community-based education 
[in] regarding, alcohol and substance abuse in [urban centers] 
Urban Centers to those [urban] Urban Indian [organizations] 
Organizations with [whom] which the Secretary has entered into 
a contract under this [subchapter] title or under section [1621 
of this title.] 201.
    (b) Goals [of grant].--Each grant made pursuant to 
subsection (a) [of this section] shall set forth the goals to 
be accomplished pursuant to the grant. The goals shall be 
specific to each grant as agreed to between the Secretary and 
the grantee.
    (c) Criteria.--The Secretary shall establish criteria for 
the grants made under subsection (a) of this section, including 
criteria relating to the[--] following:
          (1) The size of the [urban] Urban Indian 
        population[;].
          [(2) accessibility to, and utilization of, other 
        health resources available to such population;
          [(3) duplication of existing Service or other Federal 
        grants or contracts;
          [(4) capability of the organization to adequately 
        perform the activities required under the grant;]
          (2) Capability of the organization to adequately 
        perform the activities required under the grant.
          [(5) satisfactory] (3) Satisfactory performance 
        standards for the organization in meeting the goals set 
        forth in such grant[, which]. The standards shall be 
        negotiated and agreed to between the Secretary and the 
        grantee on a grant-by-grant basis[; and].
          [(6) identification of] (4) Identification of the 
        need for services.
    (d) Allocation of Grants.--The Secretary shall develop a 
methodology for allocating grants made pursuant to this section 
based on [such] the criteria established pursuant to subsection 
(c).
    [(d) Treatment of funds received by urban Indian 
organizationsAny funds]
    (e) Grants Subject to Criteria.--Any grant received by an 
[urban] Urban Indian [organization] Organization under this 
[chapter] Act for substance abuse prevention, treatment, and 
rehabilitation shall be subject to the criteria set forth in 
subsection (c)[of this section].

[Sec. 1660b. Treatment of certain demonstration projects]

SEC. 512. TREATMENT OF CERTAIN DEMONSTRATION PROJECTS.

    [(a)] Notwithstanding any other provision of law, the Tulsa 
Clinic and Oklahoma City Clinic demonstration [project and the 
Tulsa Clinic demonstration project shall be treated as service 
units] projects shall--
          (1) be permanent programs within the Service's direct 
        care program;
          (2) continue to be treated as Service Units and 
        Operating Units in the allocation of resources and 
        coordination of care; and
          (3) continue to meet the requirements and definitions 
        of an Urban Indian Organization in this Act, and shall 
        not be subject to the provisions of the Indian Self-
        Determination and Education Assistance Act [[](25 
        U.S.C.[A. Sec. 450f et seq.] for the term of such 
        projects. The Secretary shall provide assistance to 
        such projects in the development of resources and 
        equipment and facility needs.] 450 et seq.).
    [(b) The Secretary shall submit to the President, for 
inclusion in the report required to be submitted to the 
Congress under section 1671 of this title for fiscal year 1999, 
a report on the findings and conclusions derived from the 
demonstration projects specified in subsection (a) of this 
section.
    [(c) In addition to the amounts made available under 
section 1660d of this title to carry out this section through 
fiscal year 2000, there are authorized to be appropriated such 
sums as may be necessary to carry out this section for each of 
fiscal years 2001 and 2002.]

[Sec. 1660c. Urban NIAAA transferred programs]

SEC. 513. URBAN NIAAA TRANSFERRED PROGRAMS.

    [(a) Duty of Secretary
    [The Secretary shall, within]
    (a) Grants and Contracts.--The Secretary, through the 
[Branch] Division of Urban [Health Programs of the Service,] 
Indian Health, shall make grants or enter into contracts with 
Urban Indian Organizations, to take effect not later than 
September 30, 2010, for the administration of [urban] Urban 
Indian alcohol programs that were originally established under 
the National Institute on Alcoholism and Alcohol Abuse 
(hereafter in this section referred to as ``NIAAA'') and 
transferred to the Service.
    (b) Use of [grants] Funds.--Grants provided or contracts 
entered into under this section shall be used to provide 
support for the continuation of alcohol prevention and 
treatment services for [urban] Urban Indian populations and 
such other objectives as are agreed upon between the Service 
and a recipient of a grant or contract under this section.
    (c) Eligibility [for grants].--Urban Indian [organizations] 
Organizations that operate Indian alcohol programs originally 
funded under the NIAAA and subsequently transferred to the 
Service are eligible for grants or contracts under this 
section.
    [(d) Combination of funds
    [For the purpose of carrying out this section, the 
Secretary may combine NIAAA alcohol funds with other substance 
abuse funds currently administered through the Branch of Urban 
Health Programs of the Service.
    [(e) Evaluation and report to Congress]
    (d) Report.--The Secretary shall evaluate and report to 
[the] Congress on the activities of programs funded under this 
section [at least] not less than every 5 years.

SEC. 514. CONSULTATION WITH URBAN INDIAN ORGANIZATIONS.

    (a) In General.--The Secretary shall ensure that the 
Service consults, to the greatest extent practicable, with 
Urban Indian Organizations.
    (b) Definition of Consultation.--For purposes of subsection 
(a), consultation is the open and free exchange of information 
and opinions which leads to mutual understanding and 
comprehension and which emphasizes trust, respect, and shared 
responsibility.

SEC. 515. URBAN YOUTH TREATMENT CENTER DEMONSTRATION.

    (a) Construction and Operation.--The Secretary, acting 
through the Service, through grant or contract, is authorized 
to fund the construction and operation of at least 2 
residential treatment centers in each State described in 
subsection (b) to demonstrate the provision of alcohol and 
substance abuse treatment services to Urban Indian youth in a 
culturally competent residential setting.
    (b) Definition of State.--A State described in this 
subsection is a State in which--
          (1) there resides Urban Indian youth with need for 
        alcohol and substance abuse treatment services in a 
        residential setting; and
          (2) there is a significant shortage of culturally 
        competent residential treatment services for Urban 
        Indian youth.

SEC. 516. GRANTS FOR DIABETES PREVENTION, TREATMENT, AND CONTROL.

    (a) Grants Authorized.--The Secretary may make grants to 
those Urban Indian Organizations that have entered into a 
contract or have received a grant under this title for the 
provision of services for the prevention and treatment of, and 
control of the complications resulting from, diabetes among 
Urban Indians.
    (b) Goals.--Each grant made pursuant to subsection (a) 
shall set forth the goals to be accomplished under the grant. 
The goals shall be specific to each grant as agreed to between 
the Secretary and the grantee.
    (c) Establishment of Criteria.--The Secretary shall 
establish criteria for the grants made under subsection (a) 
relating to--
          (1) the size and location of the Urban Indian 
        population to be served;
          (2) the need for prevention of and treatment of, and 
        control of the complications resulting from, diabetes 
        among the Urban Indian population to be served;
          (3) performance standards for the organization in 
        meeting the goals set forth in such grant that are 
        negotiated and agreed to by the Secretary and the 
        grantee;
          (4) the capability of the organization to adequately 
        perform the activities required under the grant; and
          (5) the willingness of the organization to 
        collaborate with the registry, if any, established by 
        the Secretary under section 204(e) in the Area Office 
        of the Service in which the organization is located.
    (d) Funds Subject to Criteria.--Any funds received by an 
Urban Indian Organization under this Act for the prevention, 
treatment, and control of diabetes among Urban Indians shall be 
subject to the criteria developed by the Secretary under 
subsection (c).

SEC. 517. COMMUNITY HEALTH REPRESENTATIVES.

    The Secretary, acting through the Service, may enter into 
contracts with, and make grants to, Urban Indian Organizations 
for the employment of Indians trained as health service 
providers through the Community Health Representatives Program 
under section 109 in the provision of health care, health 
promotion, and disease prevention services to Urban Indians.

SEC. 518. EFFECTIVE DATE.

    The amendments made by the Indian Health Care Improvement 
Act Amendments of 2007 to this title shall take effect 
beginning on the date of enactment of that Act, regardless of 
whether the Secretary has promulgated regulations implementing 
such amendments.

SEC. 519. ELIGIBILITY FOR SERVICES.

    Urban Indians shall be eligible for, and the ultimate 
beneficiaries of, health care or referral services provided 
pursuant to this title.

[Sec. 1660d. Authorization of appropriations]

SEC. 520. AUTHORIZATION OF APPROPRIATIONS.

    There are authorized to be appropriated such sums as may be 
necessary for each fiscal year through fiscal year [2000] 2017 
to carry out this [subchapter] title.

                 TITLE VI--ORGANIZATIONAL IMPROVEMENTS

[Sec. 1661. Establishment of the Indian Health Service as an agency of 
                    Public Health Service]

SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERVICE AS AN AGENCY OF 
                    THE PUBLIC HEALTH SERVICE.

    (a) Establishment.--
          (1) In general._In order to more effectively and 
        efficiently carry out the responsibilities, 
        authorities, and functions of the United States to 
        provide health care services to Indians and Indian 
        [tribes] Tribes, as are or may be [on and after 
        November 23, 1988,] hereafter provided by Federal 
        statute or treaties, there is established within the 
        Public Health Service of the Department [of Health and 
        Human Services] the Indian Health Service.
          (2) Assistant secretary for indian health._The 
        [Indian Health] Service shall be administered by [a 
        Director] an Assistant Secretary for Indian Health, who 
        shall be appointed by the President, by and with the 
        advice and consent of the Senate. The [Director of the 
        Indian Health Service] Assistant Secretary shall report 
        to the Secretary [through the Assistant Secretary for 
        Health of the Department of Health and Human Services]. 
        Effective with respect to an individual appointed by 
        the President, by and with the advice and consent of 
        the Senate, after January 1, [1993,] 2007, the term of 
        service of the [Director] Assistant Secretary shall be 
        4 years. [A Director] An Assistant Secretary may serve 
        more than 1 term.
          (3) Incumbent.--The individual serving in the 
        position of Director of the Service on the day before 
        the date of enactment of the Indian Health Care 
        Improvement Act Amendments of 2007 shall serve as 
        Assistant Secretary.
          (4) Advocacy and consultation.--The position of 
        Assistant Secretary is established to, in a manner 
        consistent with the government-to-government 
        relationship between the United States and Indian 
        Tribes--
                  (A) facilitate advocacy for the development 
                of appropriate Indian health policy; and
                  (B) promote consultation on matters relating 
                to Indian health.
    (b) Agency.--[status] The [Indian Health]Service shall be 
an agency within the Public Health Service of the Department 
[of Health and Human Services], and shall not be an office, 
component, or unit of any other agency of the Department.
    (c) Duties.--The Assistant Secretary shall [carry out 
through the Director of the Indian Health Service]--
          (1) perform all functions [which] that were, on the 
        day before [November 23, 1988,] the date of enactment 
        of the Indian Health Care Improvement Act Amendments of 
        2007, carried out by or under the direction of the 
        individual serving as Director of the [Indian 
        Health]Service on[such] that day;
          (2) perform all functions of the Secretary relating 
        to the maintenance and operation of hospital and health 
        facilities for Indians and the planning for, and 
        provision and utilization of, health services for 
        Indians;
          (3) administer all health programs under which health 
        care is provided to Indians based upon their status as 
        Indians which are administered by the Secretary, 
        including[(but not limited to)]programs under--
                  (A) this[chapter] Act;
                  (B) the Act of November 2, 1921 (25 U.S.C. 
                13);
                  (C) the Act of August 5, 1954 (42 U.S.C. 
                [2001,] 2001 et seq.);
                  (D) the Act of August 16, 1957 (42 U.S.C. 
                2005 et seq.); and
                  (E) the Indian Self-Determination and 
                Education Assistance Act (25 U.S.C. 450[f] et 
                seq.); [and]
          (4) administer all scholarship and loan functions 
        carried out under [subchapter I of this chapter.] title 
        I;
          (5) report directly to the Secretary concerning all 
        policy- and budget-related matters affecting Indian 
        health;
          (6) collaborate with the Assistant Secretary for 
        Health concerning appropriate matters of Indian health 
        that affect the agencies of the Public Health Service;
          (7) advise each Assistant Secretary of the Department 
        concerning matters of Indian health with respect to 
        which that Assistant Secretary has authority and 
        responsibility;
          (8) advise the heads of other agencies and programs 
        of the Department concerning matters of Indian health 
        with respect to which those heads have authority and 
        responsibility;
          (9) coordinate the activities of the Department 
        concerning matters of Indian health; and
          (10) perform such other functions as the Secretary 
        may designate.
    (d) Authority [of Secretary].--
          (1) In general._The Secretary, acting through the 
        [Director of the Indian Health Service] Assistant 
        Secretary, shall have the authority--
                  (A) except to the extent provided for in 
                paragraph (2), to appoint and compensate 
                employees for the Service in accordance with 
                [Title 5] title 5, United States Code;
                  (B) to enter into contracts for the 
                procurement of goods and services to carry out 
                the functions of the Service; and
                  (C) to manage, expend, and obligate all funds 
                appropriated for the Service.
          (2) Personnel actions._Notwithstanding any other 
        provision of law, the provisions of section [472 of 
        this title] 12 of the Act of June 18, 1934 (48 Stat. 
        986; 25 U.S.C. 472), shall apply to all personnel 
        actions taken with respect to new positions created 
        within the Service as a result of its establishment 
        under subsection (a)[of this section].
    (e) References.--Any reference to the Director of the 
Indian Health Service in any other Federal law, Executive 
order, rule, regulation, or delegation of authority, or in any 
document of or relating to the Director of the Indian Health 
Service, shall be deemed to refer to the Assistant Secretary.

[Sec. 1662. Automated management information system]

SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYSTEM.

    (a) Establishment.--
          (1) In general._The Secretary shall establish an 
        automated management information system for the 
        Service.
          (2) Requirements of system._The information system 
        established under paragraph (1) shall include--
                  (A) a financial management system[,];
                  (B) a patient care information system for 
                each area served by the Service[,];
                  (C) a privacy component that protects the 
                privacy of patient information held by, or on 
                behalf of, the Service[, and];
                  (D) a services-based cost accounting 
                component that provides estimates of the costs 
                associated with the provision of specific 
                medical treatments or services in each [area] 
                Area office of the Service;
                  (E) an interface mechanism for patient 
                billing and accounts receivable system; and
                  (F) a training component.
    (b) Provision [to Indian tribes and organizations; 
reimbursement (1) The Secretary shall provide each Indian tribe 
and tribal organization that provides health services under a 
contract entered into with the Service under the Indian Self-
Determination Act [25 U.S.C.A. Sec. 450f et seq.] of Systems to 
Tribes and Organizations._The Secretary shall provide each 
Tribal Health Program automated management information systems 
which--
          [(A)] (1) meet the management information needs of 
        such [Indian tribe or tribal organization]Tribal Health 
        Program with respect to the treatment by the [Indian 
        tribe or tribal organization] Tribal Health Program of 
        patients of the Service[,]; and
          [(B)] (2) meet the management information needs of 
        the Service.
          [(2) The Secretary shall reimburse each Indian tribe 
        or tribal organization for the part of the cost of the 
        operation of a system provided under paragraph (1) 
        which is attributable to the treatment by such Indian 
        tribe or tribal organization of patients of the 
        Service. 
          [(3) The Secretary shall provide systems under 
        paragraph (1) to Indian tribes and tribal organizations 
        providing health services in California by no later 
        than September 30, 1990.]
    (c) Access to [records] Records._Notwithstanding any other 
provision of law, each patient shall have reasonable access to 
the medical or health records of such patient which are held 
by, or on behalf of, the Service.
    (d) Authority to Enhance Information Technology.--The 
Secretary, acting through the Assistant Secretary, shall have 
the authority to enter into contracts, agreements, or joint 
ventures with other Federal agencies, States, private and 
nonprofit organizations, for the purpose of enhancing 
information technology in Indian Health Programs and 
facilities.

[Sec. 1663. Authorization of appropriations]

SEC. 603. AUTHORIZATION OF APPROPRIATIONS.

    There [are] is authorized to be appropriated such sums as 
may be necessary for each fiscal year through fiscal year 
[2000] 2017 to carry out this [subchapter] title.

                 TITLE VII--BEHAVIORAL HEALTH PROGRAMS

SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREATMENT SERVICES.

    (a) Purposes.--The purposes of this section are as follows:
          (1) To authorize and direct the Secretary, acting 
        through the Service, Indian Tribes, Tribal 
        Organizations, and Urban Indian Organizations, to 
        develop a comprehensive behavioral health prevention 
        and treatment program which emphasizes collaboration 
        among alcohol and substance abuse, social services, and 
        mental health programs.
          (2) To provide information, direction, and guidance 
        relating to mental illness and dysfunction and self-
        destructive behavior, including child abuse and family 
        violence, to those Federal, tribal, State, and local 
        agencies responsible for programs in Indian communities 
        in areas of health care, education, social services, 
        child and family welfare, alcohol and substance abuse, 
        law enforcement, and judicial services.
          (3) To assist Indian Tribes to identify services and 
        resources available to address mental illness and 
        dysfunctional and self-destructive behavior.
          (4) To provide authority and opportunities for Indian 
        Tribes and Tribal Organizations to develop, implement, 
        and coordinate with community-based programs which 
        include identification, prevention, education, 
        referral, and treatment services, including through 
        multidisciplinary resource teams.
          (5) To ensure that Indians, as citizens of the United 
        States and of the States in which they reside, have the 
        same access to behavioral health services to which all 
        citizens have access.
          (6) To modify or supplement existing programs and 
        authorities in the areas identified in paragraph (2).
    (b) Plans.--
          (1) Development.--The Secretary, acting through the 
        Service, Indian Tribes, Tribal Organizations, and Urban 
        Indian Organizations, shall encourage Indian Tribes and 
        Tribal Organizations to develop tribal plans, and Urban 
        Indian Organizations to develop local plans, and for 
        all such groups to participate in developing areawide 
        plans for Indian Behavioral Health Services. The plans 
        shall include, to the extent feasible, the following 
        components:
                  (A) An assessment of the scope of alcohol or 
                other substance abuse, mental illness, and 
                dysfunctional and self-destructive behavior, 
                including suicide, child abuse, and family 
                violence, among Indians, including--
                          (i) the number of Indians served who 
                        are directly or indirectly affected by 
                        such illness or behavior; or
                          (ii) an estimate of the financial and 
                        human cost attributable to such illness 
                        or behavior.
                  (B) An assessment of the existing and 
                additional resources necessary for the 
                prevention and treatment of such illness and 
                behavior, including an assessment of the 
                progress toward achieving the availability of 
                the full continuum of care described in 
                subsection (c).
                  (C) An estimate of the additional funding 
                needed by the Service, Indian Tribes, Tribal 
                Organizations, and Urban Indian Organizations 
                to meet their responsibilities under the plans.
          (2) National clearinghouse.--The Secretary, acting 
        through the Service, shall coordinate with existing 
        national clearinghouses and information centers to 
        include at the clearinghouses and centers plans and 
        reports on the outcomes of such plans developed by 
        Indian Tribes, Tribal Organizations, Urban Indian 
        Organizations, and Service Areas relating to behavioral 
        health. The Secretary shall ensure access to these 
        plans and outcomes by any Indian Tribe, Tribal 
        Organization, Urban Indian Organization, or the 
        Service.
          (3) Technical Assistance.--The Secretary shall 
        provide technical assistance to Indian Tribes, Tribal 
        Organizations, and Urban Indian Organizations in 
        preparation of plans under this section and in 
        developing standards of care that may be used and 
        adopted locally.
    (c) Programs.--The Secretary, acting through the Service, 
Indian Tribes, and Tribal Organizations, shall provide, to the 
extent feasible and if funding is available, programs including 
the following:
          (1) Comprehensive care.--A comprehensive continuum of 
        behavioral health care which provides--
                  (A) community-based prevention, intervention, 
                outpatient, and behavioral health aftercare;
                  (B) detoxification (social and medical);
                  (C) acute hospitalization;
                  (D) intensive outpatient/day treatment;
                  (E) residential treatment;
                  (F) transitional living for those needing a 
                temporary, stable living environment that is 
                supportive of treatment and recovery goals;
                  (G) emergency shelter;
                  (H) intensive case management; and
                  (I) diagnostic services.
          (2) Child care.--Behavioral health services for 
        Indians from birth through age 17, including--
                  (A) preschool and school age fetal alcohol 
                disorder services, including assessment and 
                behavioral intervention;
                  (B) mental health and substance abuse 
                services (emotional, organic, alcohol, drug, 
                inhalant, and tobacco);
                  (C) identification and treatment of co-
                occurring disorders and comorbidity;
                  (D) prevention of alcohol, drug, inhalant, 
                and tobacco use;
                  (E) early intervention, treatment, and 
                aftercare;
                  (F) promotion of healthy approaches to risk 
                and safety issues; and
                  (G) identification and treatment of neglect 
                and physical, mental, and sexual abuse.
          (3) Adult care.--Behavioral health services for 
        Indians from age 18 through 55, including--
                  (A) early intervention, treatment, and 
                aftercare;
                  (B) mental health and substance abuse 
                services (emotional, alcohol, drug, inhalant, 
                and tobacco), including sex specific services;
                  (C) identification and treatment of co-
                occurring disorders (dual diagnosis) and 
                comorbidity;
                  (D) promotion of healthy approaches for risk-
                related behavior;
                  (E) treatment services for women at risk of 
                giving birth to a child with a fetal alcohol 
                disorder; and
                  (F) sex specific treatment for sexual assault 
                and domestic violence.
          (4) Family care.--Behavioral health services for 
        families, including--
                  (A) early intervention, treatment, and 
                aftercare for affected families;
                  (B) treatment for sexual assault and domestic 
                violence; and
                  (C) promotion of healthy approaches relating 
                to parenting, domestic violence, and other 
                abuse issues.
          (5) Elder care.--Behavioral health services for 
        Indians 56 years of age and older, including--
                  (A) early intervention, treatment, and 
                aftercare;
                  (B) mental health and substance abuse 
                services (emotional, alcohol, drug, inhalant, 
                and tobacco), including sex specific services;
                  (C) identification and treatment of co-
                occurring disorders (dual diagnosis) and 
                comorbidity;
                  (D) promotion of healthy approaches to 
                managing conditions related to aging;
                  (E) sex specific treatment for sexual 
                assault, domestic violence, neglect, physical 
                and mental abuse and exploitation; and
                  (F) identification and treatment of dementias 
                regardless of cause.
    (d) Community Behavioral Health Plan.--
          (1) Establishment.--The governing body of any Indian 
        Tribe, Tribal Organization, or Urban Indian 
        Organization may adopt a resolution for the 
        establishment of a community behavioral health plan 
        providing for the identification and coordination of 
        available resources and programs to identify, prevent, 
        or treat substance abuse, mental illness, or 
        dysfunctional and self-destructive behavior, including 
        child abuse and family violence, among its members or 
        its service population. This plan should include 
        behavioral health services, social services, intensive 
        outpatient services, and continuing aftercare.
          (2) Technical assistance.--At the request of an 
        Indian Tribe, Tribal Organization, or Urban Indian 
        Organization, the Bureau of Indian Affairs and the 
        Service shall cooperate with and provide technical 
        assistance to the Indian Tribe, Tribal Organization, or 
        Urban Indian Organization in the development and 
        implementation of such plan.
          (3) Funding.--The Secretary, acting through the 
        Service, may make funding available to Indian Tribes 
        and Tribal Organizations which adopt a resolution 
        pursuant to paragraph (1) to obtain technical 
        assistance for the development of a community 
        behavioral health plan and to provide administrative 
        support in the implementation of such plan.
    (e) Coordination for Availability of Services.--The 
Secretary, acting through the Service, Indian Tribes, Tribal 
Organizations, and Urban Indian Organizations, shall coordinate 
behavioral health planning, to the extent feasible, with other 
Federal agencies and with State agencies, to encourage 
comprehensive behavioral health services for Indians regardless 
of their place of residence.
    (f) Mental Health Care Need Assessment.--Not later than 1 
year after the date of enactment of the Indian Health Care 
Improvement Act Amendments of 2007, the Secretary, acting 
through the Service, shall make an assessment of the need for 
inpatient mental health care among Indians and the availability 
and cost of inpatient mental health facilities which can meet 
such need. In making such assessment, the Secretary shall 
consider the possible conversion of existing, underused Service 
hospital beds into psychiatric units to meet such need.

SEC. 702. MEMORANDA OF AGREEMENT WITH THE DEPARTMENT OF THE INTERIOR.

    (a) Contents.--Not later than 12 months after the date of 
enactment of the Indian Health Care Improvement Act Amendments 
of 2007, the Secretary, acting through the Service, and the 
Secretary of the Interior shall develop and enter into a 
memoranda of agreement, or review and update any existing 
memoranda of agreement, as required by section 4205 of the 
Indian Alcohol and Substance Abuse Prevention and Treatment Act 
of 1986 (25 U.S.C. 2411) under which the Secretaries address 
the following:
          (1) The scope and nature of mental illness and 
        dysfunctional and self-destructive behavior, including 
        child abuse and family violence, among Indians.
          (2) The existing Federal, tribal, State, local, and 
        private services, resources, and programs available to 
        provide behavioral health services for Indians.
          (3) The unmet need for additional services, 
        resources, and programs necessary to meet the needs 
        identified pursuant to paragraph (1).
          (4)(A) The right of Indians, as citizens of the 
        United States and of the States in which they reside, 
        to have access to behavioral health services to which 
        all citizens have access.
          (B) The right of Indians to participate in, and 
        receive the benefit of, such services.
          (C) The actions necessary to protect the exercise of 
        such right.
          (5) The responsibilities of the Bureau of Indian 
        Affairs and the Service, including mental illness 
        identification, prevention, education, referral, and 
        treatment services (including services through 
        multidisciplinary resource teams), at the central, 
        area, and agency and Service Unit, Service Area, and 
        headquarters levels to address the problems identified 
        in paragraph (1).
          (6) A strategy for the comprehensive coordination of 
        the behavioral health services provided by the Bureau 
        of Indian Affairs and the Service to meet the problems 
        identified pursuant to paragraph (1), including--
                  (A) the coordination of alcohol and substance 
                abuse programs of the Service, the Bureau of 
                Indian Affairs, and Indian Tribes and Tribal 
                Organizations (developed under the Indian 
                Alcohol and Substance Abuse Prevention and 
                Treatment Act of 1986 (25 U.S.C. 2401 et seq.)) 
                with behavioral health initiatives pursuant to 
                this Act, particularly with respect to the 
                referral and treatment of dually diagnosed 
                individuals requiring behavioral health and 
                substance abuse treatment; and
                  (B) ensuring that the Bureau of Indian 
                Affairs and Service programs and services 
                (including multidisciplinary resource teams) 
                addressing child abuse and family violence are 
                coordinated with such non-Federal programs and 
                services.
          (7) Directing appropriate officials of the Bureau of 
        Indian Affairs and the Service, particularly at the 
        agency and Service Unit levels, to cooperate fully with 
        tribal requests made pursuant to community behavioral 
        health plans adopted under section 701(c) and section 
        4206 of the Indian Alcohol and Substance Abuse 
        Prevention and Treatment Act of 1986 (25 U.S.C. 2412).

[Sec. 1665. Indian Health Service responsibilities]

          (8) Providing for an annual review of such agreement 
        by the Secretaries which shall be provided to Congress 
        and Indian Tribes and Tribal Organizations.
    [The Memorandum of Agreement]
    (b) Specific Provisions Required._The memoranda of 
agreement updated or entered into pursuant to [section 2411 of 
this title] subsection (a) shall include specific provisions 
pursuant to which the Service shall assume responsibility for--
          (1) the determination of the scope of the problem of 
        alcohol and substance abuse among [Indian people] 
        Indians, including the number of Indians within the 
        jurisdiction of the Service who are directly or 
        indirectly affected by alcohol and substance abuse and 
        the financial and human cost;
          (2) an assessment of the existing and needed 
        resources necessary for the prevention of alcohol and 
        substance abuse and the treatment of Indians affected 
        by alcohol and substance abuse; and
          (3) an estimate of the funding necessary to 
        adequately support a program of prevention of alcohol 
        and substance abuse and treatment of Indians affected 
        by alcohol and substance abuse.
    (c) Publication.--Each memorandum of agreement entered into 
or renewed (and amendments or modifications thereto) under 
subsection (a) shall be published in the Federal Register. At 
the same time as publication in the Federal Register, the 
Secretary shall provide a copy of such memoranda, amendment, or 
modification to each Indian Tribe, Tribal Organization, and 
Urban Indian Organization.

SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PREVENTION AND TREATMENT 
                    PROGRAM.

[Sec. 1665a. Indian Health Service program]

    (a) Establishment._
    [(a) Comprehensive prevention and treatment program]
          (1) In general.--The Secretary, acting through the 
        Service, Indian Tribes, and Tribal Organizations, shall 
        provide a program of comprehensive [alcohol and 
        substance abuse prevention and treatment] behavioral 
        health, prevention, treatment, and aftercare, which 
        shall include--
                  (A) prevention, through educational 
                intervention, in Indian communities;
                  (B) acute detoxification [and treatment;], 
                psychiatric hospitalization, residential, and 
                intensive outpatient treatment;
                  (C) community-based rehabilitation[;] and 
                aftercare;
                  (D) community education and involvement, 
                including extensive training of health care, 
                educational, and community-based personnel; 
                [and]
                  (E) specialized residential treatment 
                programs for high-risk populations, including 
                pregnant and [post partum] postpartum women and 
                their children; and
                  (F) diagnostic services.
          (2) Target populations.--The target population of 
        such [program] programs shall be members of Indian 
        [tribes] Tribes. Efforts to train and educate key 
        members of the Indian community shall also target 
        employees of health, education, judicial, law 
        enforcement, legal, and social service programs.
    (b) Contract [health services] Health Services.--
          (1) In general.--The Secretary, acting through the 
        Service, Indian Tribes, and Tribal Organizations, may 
        enter into contracts with public or private providers 
        of [alcohol and substance abuse] behavioral health 
        treatment services for the purpose of [assisting the 
        Service in] carrying out the program required under 
        subsection (a) [of this section].
          (2) Provision of assistance.--In carrying out this 
        subsection, the Secretary shall provide assistance to 
        Indian [tribes] Tribes and Tribal Organizations to 
        develop criteria for the certification of [alcohol and 
        substance abuse] behavioral health service providers 
        and accreditation of service facilities which meet 
        minimum standards for such services and facilities [as 
        may be determined pursuant to section 2411(a)(3) of 
        this title].
    [(c) Grants for model program
          [(1) The Secretary, acting through the Service shall 
        make a grant to the Standing Rock Sioux Tribe to 
        develop a community-based demonstration project to 
        reduce drug and alcohol abuse on the Standing Rock 
        Sioux Reservation and to rehabilitate Indian families 
        afflicted by such abuse.
          [(2) Funds shall be used by the Tribe to--
                  [(A) develop and coordinate community-based 
                alcohol and substance abuse prevention and 
                treatment services for Indian families;
                  [(B) develop prevention and intervention 
                models for Indian families;
                  [(C) conduct community education on alcohol 
                and substance abuse; and
                  [(D) coordinate with existing Federal, State, 
                and tribal services on the reservation to 
                develop a comprehensive alcohol and substance 
                abuse program that assists in the 
                rehabilitation of Indian families that have 
                been or are afflicted by alcoholism.
          [(3) The Secretary shall submit to the President for 
        inclusion in the report to be transmitted to the 
        Congress under section 1671 of this title for fiscal 
        year 1995 an evaluation of the demonstration project 
        established under paragraph (1).]

SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM.

    (a) In General.--Under the authority of the Act of November 
2, 1921 (25 U.S.C. 13) (commonly known as the ``Snyder Act''), 
the Secretary shall establish and maintain a mental health 
technician program within the Service which--
          (1) provides for the training of Indians as mental 
        health technicians; and
          (2) employs such technicians in the provision of 
        community-based mental health care that includes 
        identification, prevention, education, referral, and 
        treatment services.
    (b) Paraprofessional Training.--In carrying out subsection 
(a), the Secretary, acting through the Service, Indian Tribes, 
and Tribal Organizations, shall provide high-standard 
paraprofessional training in mental health care necessary to 
provide quality care to the Indian communities to be served. 
Such training shall be based upon a curriculum developed or 
approved by the Secretary which combines education in the 
theory of mental health care with supervised practical 
experience in the provision of such care.
    (c) Supervision and Evaluation of Technicians.--The 
Secretary, acting through the Service, Indian Tribes, and 
Tribal Organizations, shall supervise and evaluate the mental 
health technicians in the training program.
    (d) Traditional Health Care Practices.--The Secretary, 
acting through the Service, shall ensure that the program 
established pursuant to this subsection involves the use and 
promotion of the traditional health care practices of the 
Indian Tribes to be served.

SEC. 705. LICENSING REQUIREMENT FOR MENTAL HEALTH CARE WORKERS.

    (a) In General.--Subject to the provisions of section 221, 
and except as provided in subsection (b), any individual 
employed as a psychologist, social worker, or marriage and 
family therapist for the purpose of providing mental health 
care services to Indians in a clinical setting under this Act 
is required to be licensed as a psychologist, social worker, or 
marriage and family therapist, respectively.
    (b) Trainees.--An individual may be employed as a trainee 
in psychology, social work, or marriage and family therapy to 
provide mental health care services described in subsection (a) 
if such individual--
          (1) works under the direct supervision of a licensed 
        psychologist, social worker, or marriage and family 
        therapist, respectively;
          (2) is enrolled in or has completed at least 2 years 
        of course work at a post-secondary, accredited 
        education program for psychology, social work, marriage 
        and family therapy, or counseling; and
          (3) meets such other training, supervision, and 
        quality review requirements as the Secretary may 
        establish.

[Sec. 1665b. Indian women treatment programs]

SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS.

    [(a) Grants
    [The Secretary]
    (a) Grants._The Secretary, consistent with section 701, may 
make grants to Indian [tribes and tribal organizations] Tribes, 
Tribal Organizations, and Urban Indian Organizations to develop 
and implement a comprehensive [alcohol and substance abuse] 
behavioral health program of prevention, intervention, 
treatment, and relapse prevention services that specifically 
addresses the cultural, historical, social, and child care 
needs of Indian women, regardless of age.
    (b) Use of [grantsGrants] Grant Funds._A grant made 
pursuant to this section may be used to--
          (1) develop and provide community training, 
        education, and prevention programs for Indian women 
        relating to [alcohol and substance abuse] behavioral 
        health issues, including fetal alcohol [syndrome and 
        fetal alcohol effect] disorders;
          (2) identify and provide [appropriate] psychological 
        services, counseling, advocacy, support, and relapse 
        prevention to Indian women and their families; and
          (3) develop prevention and intervention models for 
        Indian women which incorporate traditional [healers] 
        health care practices, cultural values, and community 
        and family involvement.
    (c) Criteria [for the review and approval of grant 
applications].--The Secretary, in consultation with Indian 
Tribes and Tribal Organizations, shall establish criteria for 
the review and approval of applications and proposals for 
[grants] funding under this section.
    [(d) Authorization of appropriations
    [There are authorized to be appropriated to carry out this 
section $10,000,000 for fiscal year 1993 and such sums as are 
necessary for each of the fiscal years 1994, 1995, 1996, 1997, 
1998, 1999, and 2000.
    [(2)] (d) Earmark of Certain Funds._Twenty percent of the 
funds appropriated pursuant to this [subsection] section shall 
be used to make grants to [urban] Urban Indian [organizations 
funded under subchapter IV of this chapter] Organizations.

[Sec. 1665c. Indian Health Service youth program]

SEC. 707. INDIAN YOUTH PROGRAM.

    (a) Detoxification and [rehabilitation] Rehabilitation._The 
Secretary, acting through the Service, consistent with section 
701, shall develop and implement a program for acute 
detoxification and treatment for Indian [youth who are alcohol 
and substance abusers] youths, including behavioral health 
services. The program shall include regional treatment centers 
designed to include detoxification and rehabilitation for both 
sexes on a referral basis. [These regional] and programs 
developed and implemented by Indian Tribes or Tribal 
Organizations at the local level under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et 
seq.). Regional centers shall be integrated with the intake and 
rehabilitation programs based in the referring Indian 
community.
    (b) Alcohol and Substance Abuse Treatment [centers or 
facilities] Centers or Facilities.--
          (1) Establishment.--
                  (A) In general.--The Secretary, acting 
                through the Service, Indian Tribes, and Tribal 
                Organizations, shall construct, renovate, or, 
                as necessary, purchase, and appropriately staff 
                and operate, [a] at least 1 youth regional 
                treatment center or treatment network in each 
                area under the jurisdiction of an [area office] 
                Area Office.
                  (B) Area office in california._For the 
                purposes of this subsection, the [area offices 
                of the Service in Tucson and Phoenix, Arizona, 
                shall be considered one area office and the 
                area office] Area Office in California shall be 
                considered to be [two area offices, one] 2 Area 
                Offices, 1 office whose jurisdiction shall be 
                considered to encompass the northern area of 
                the State of California, and [one] 1 office 
                whose jurisdiction shall be considered to 
                encompass the remainder of the State of 
                California for the purpose of implementing 
                California treatment networks.
          (2) Funding._For the purpose of staffing and 
        operating such centers or facilities, funding shall be 
        pursuant to the Act of November 2, 1921 (25 U.S.C. 13).
          (3) Location._A youth treatment center constructed or 
        purchased under this subsection shall be constructed or 
        purchased at a location within the area described in 
        paragraph (1) agreed upon (by appropriate tribal 
        resolution) by a majority of the [tribes] Indian Tribes 
        to be served by such center.
          (4) Specific provision of funds._
          (4A) [(A)] In general._Notwithstanding any other 
        provision of this [subchapter] title, the Secretary 
        may, from amounts authorized to be appropriated for the 
        purposes of carrying out this section, make funds 
        available to--
                  (i) the Tanana Chiefs Conference, 
                Incorporated, for the purpose of leasing, 
                constructing, renovating, operating[,] and 
                maintaining a residential youth treatment 
                facility in Fairbanks, Alaska; and
                  (ii) the Southeast Alaska Regional Health 
                Corporation to staff and operate a residential 
                youth treatment facility without regard to the 
                proviso set forth in section [450b(l) of this 
                title] 4(l) of the Indian Self-Determination 
                and Education Assistance Act (25 U.S.C. 
                450b(l)).
          (B) Provision of services to eligible youths._Until 
        additional residential youth treatment facilities are 
        established in Alaska pursuant to this section, the 
        facilities specified in subparagraph (A) shall make 
        every effort to provide services to all eligible Indian 
        youths residing in Alaska.
          [(B) Until additional residential youth treatment 
        facilities are established in Alaska pursuant to this 
        section, the facilities specified in subparagraph (A) 
        shall make every effort to provide services to all 
        eligible Indian youth residing in such State.]
    (c) Intermediate Adolescent Behavioral Health Services.--
          (1) In general.--The Secretary, acting through the 
        Service, Indian Tribes, and Tribal Organizations, may 
        provide intermediate behavioral health services to 
        Indian children and adolescents, including--
                  (A) pretreatment assistance;
                  (B) inpatient, outpatient, and aftercare 
                services;
                  (C) emergency care;
                  (D) suicide prevention and crisis 
                intervention; and
                  (E) prevention and treatment of mental 
                illness and dysfunctional and self-destructive 
                behavior, including child abuse and family 
                violence.
          (2) Use of funds.--Funds provided under this 
        subsection may be used--
                  (A) to construct or renovate an existing 
                health facility to provide intermediate 
                behavioral health services;
                  (B) to hire behavioral health professionals;
                  (C) to staff, operate, and maintain an 
                intermediate mental health facility, group 
                home, sober housing, transitional housing or 
                similar facilities, or youth shelter where 
                intermediate behavioral health services are 
                being provided;
                  (D) to make renovations and hire appropriate 
                staff to convert existing hospital beds into 
                adolescent psychiatric units; and
                  (E) for intensive home- and community-based 
                services.
          (3) Criteria.--The Secretary, acting through the 
        Service, shall, in consultation with Indian Tribes and 
        Tribal Organizations, establish criteria for the review 
        and approval of applications or proposals for funding 
        made available pursuant to this subsection.
    [(c)] (d) Federally[owned structures]-Owned Structures.--
          (1) In general._The Secretary, [acting through the 
        Service, shall,] in consultation with Indian [tribes] 
        Tribes and Tribal Organizations, shall--
                  (A) identify and use, where appropriate, 
                federally-owned structures suitable [as] for 
                local residential or regional [alcohol and 
                substance abuse] behavioral health treatment 
                [centers] for Indian [youth] youths; and
                  (B) establish guidelines for determining the 
                suitability of any such federally-owned 
                structure to be used [as a] for local 
                residential or regional [alcohol and substance 
                abuse] behavioral health treatment [center] for 
                Indian [youth] youths.
    [(2)] (2) Terms and conditions for use of structure._Any 
structure described in paragraph (1) may be used under such 
terms and conditions as may be agreed upon by the Secretary and 
the agency having responsibility for the structure and any 
Indian Tribe or Tribal Organization operating the program.
    [(d)] (e) Rehabilitation and [aftercare services] Aftercare 
Services.--
          (1) In general._The Secretary, Indian Tribes, or 
        Tribal Organizations, in cooperation with the Secretary 
        of the Interior, shall develop and implement within 
        each Service [service unit] Unit, community-based 
        rehabilitation and follow-up services for Indian [youth 
        who are alcohol or substance abusers which are designed 
        to integrate] youths who are having significant 
        behavioral health problems, and require long-term 
        treatment, community reintegration, and monitoring to 
        [monitor and] support the Indian [youth] youths after 
        their return to their home community.
          (2) Administration._Services under paragraph (1) 
        shall be [administered within each service unit] 
        provided by trained staff within the community who can 
        assist the Indian [youth] youths in their continuing 
        development of self-image, positive problem-solving 
        skills, and nonalcohol or substance abusing behaviors. 
        Such staff [shall] may include alcohol and substance 
        abuse counselors, mental health professionals, and 
        other health professionals and paraprofessionals, 
        including community health representatives.
    [(e)] (f) Inclusion of [family in youth treatment program] 
Family in Youth Treatment Program.--In providing the treatment 
and other services to Indian [youth] youths authorized by this 
section, the Secretary, acting through the Service, Indian 
Tribes, and Tribal Organizations, shall provide for the 
inclusion of family members of such [youth] youths in the 
treatment programs or other services as may be appropriate. Not 
less than 10 percent of the funds appropriated for the purposes 
of carrying out subsection [(d) of this section] (e) shall be 
used for outpatient care of adult family members related to the 
treatment of an Indian youth under that subsection.
    [(f) Multidrug abuse study (1) The Secretary shall conduct 
a study to determine the incidence and prevalence of] (g) 
Multidrug Abuse Program.--The Secretary, acting through the 
Service, Indian Tribes, Tribal Organizations, and Urban Indian 
Organizations, shall provide, consistent with section 701, 
programs and services to prevent and treat the abuse of 
multiple forms of [drugs] substances, including alcohol, drugs, 
inhalants, and tobacco, among Indian [youth] youths residing 
[on Indian] in Indian communities, on or near reservations, and 
in urban areas and [the interrelationship of such abuse with] 
provide appropriate mental health services to address the 
incidence of mental illness among such [youth] youths.
    [(2) The Secretary shall submit a report detailing the 
findings of such study, together with recommendations based on 
such findings, to the Congress no later than two years after 
October 29, 1992.]
    (h) Indian Youth Mental Health.--The Secretary, acting 
through the Service, shall collect data for the report under 
section 801 with respect to--
          (1) the number of Indian youth who are being provided 
        mental health services through the Service and Tribal 
        Health Programs;
          (2) a description of, and costs associated with, the 
        mental health services provided for Indian youth 
        through the Service and Tribal Health Programs;
          (3) the number of youth referred to the Service or 
        Tribal Health Programs for mental health services;
          (4) the number of Indian youth provided residential 
        treatment for mental health and behavioral problems 
        through the Service and Tribal Health Programs, 
        reported separately for on- and off-reservation 
        facilities; and
          (5) the costs of the services described in paragraph 
        (4).

SEC. 708. INDIAN YOUTH TELEMENTAL HEALTH DEMONSTRATION PROJECT.

    (a) Purpose.--The purpose of this section is to authorize 
the Secretary to carry out a demonstration project to test the 
use of telemental health services in suicide prevention, 
intervention and treatment of Indian youth, including through--
          (1) the use of psychotherapy, psychiatric 
        assessments, diagnostic interviews, therapies for 
        mental health conditions predisposing to suicide, and 
        alcohol and substance abuse treatment;
          (2) the provision of clinical expertise to, 
        consultation services with, and medical advice and 
        training for frontline health care providers working 
        with Indian youth;
          (3) training and related support for community 
        leaders, family members and health and education 
        workers who work with Indian youth;
          (4) the development of culturally-relevant 
        educational materials on suicide; and
          (5) data collection and reporting.
    (b) Definitions.--For the purpose of this section, the 
following definitions shall apply:
          (1) Demonstration project.--The term ``demonstration 
        project'' means the Indian youth telemental health 
        demonstration project authorized under subsection (c).
          (2) Telemental health.--The term ``telemental 
        health'' means the use of electronic information and 
        telecommunications technologies to support long 
        distance mental health care, patient and professional-
        related education, public health, and health 
        administration.
    (c) Authorization.--
          (1) In general.--The Secretary is authorized to award 
        grants under the demonstration project for the 
        provision of telemental health services to Indian youth 
        who--
                  (A) have expressed suicidal ideas;
                  (B) have attempted suicide; or
                  (C) have mental health conditions that 
                increase or could increase the risk of suicide.
          (2) Eligibility for grants.--Such grants shall be 
        awarded to Indian Tribes and Tribal Organizations that 
        operate 1 or more facilities--
                  (A) located in Alaska and part of the Alaska 
                Federal Health Care Access Network;
                  (B) reporting active clinical telehealth 
                capabilities; or
                  (C) offering school-based telemental health 
                services relating to psychiatry to Indian 
                youth.
          (3) Grant period.--The Secretary shall award grants 
        under this section for a period of up to 4 years.
          (4) Awarding of grants.--Not more than 5 grants shall 
        be provided under paragraph (1), with priority 
        consideration given to Indian Tribes and Tribal 
        Organizations that--
                  (A) serve a particular community or 
                geographic area where there is a demonstrated 
                need to address Indian youth suicide;
                  (B) enter into collaborative partnerships 
                with Indian Health Service or Tribal Health 
                Programs or facilities to provide services 
                under this demonstration project;
                  (C) serve an isolated community or geographic 
                area which has limited or no access to 
                behavioral health services; or
                  (D) operate a detention facility at which 
                Indian youth are detained.
    (d) Use of Funds.--
          (1) In general.--An Indian Tribe or Tribal 
        Organization shall use a grant received under 
        subsection (c) for the following purposes:
                  (A) To provide telemental health services to 
                Indian youth, including the provision of--
                          (i) psychotherapy;
                          (ii) psychiatric assessments and 
                        diagnostic interviews, therapies for 
                        mental health conditions predisposing 
                        to suicide, and treatment; and
                          (iii) alcohol and substance abuse 
                        treatment.
                  (B) To provide clinician-interactive medical 
                advice, guidance and training, assistance in 
                diagnosis and interpretation, crisis counseling 
                and intervention, and related assistance to 
                Service, tribal, or urban clinicians and health 
                services providers working with youth being 
                served under this demonstration project.
                  (C) To assist, educate and train community 
                leaders, health education professionals and 
                paraprofessionals, tribal outreach workers, and 
                family members who work with the youth 
                receiving telemental health services under this 
                demonstration project, including with 
                identification of suicidal tendencies, crisis 
                intervention and suicide prevention, emergency 
                skill development, and building and expanding 
                networks among these individuals and with State 
                and local health services providers.
                  (D) To develop and distribute culturally 
                appropriate community educational materials 
                on--
                          (i) suicide prevention;
                          (ii) suicide education;
                          (iii) suicide screening;
                          (iv) suicide intervention; and
                          (v) ways to mobilize communities with 
                        respect to the identification of risk 
                        factors for suicide.
                  (E) For data collection and reporting related 
                to Indian youth suicide prevention efforts.
          (2) Traditional health care practices.--In carrying 
        out the purposes described in paragraph (1), an Indian 
        Tribe or Tribal Organization may use and promote the 
        traditional health care practices of the Indian Tribes 
        of the youth to be served.
    (e) Applications.--To be eligible to receive a grant under 
subsection (c), an Indian Tribe or Tribal Organization shall 
prepare and submit to the Secretary an application, at such 
time, in such manner, and containing such information as the 
Secretary may require, including--
          (1) a description of the project that the Indian 
        Tribe or Tribal Organization will carry out using the 
        funds provided under the grant;
          (2) a description of the manner in which the project 
        funded under the grant would--
                  (A) meet the telemental health care needs of 
                the Indian youth population to be served by the 
                project; or
                  (B) improve the access of the Indian youth 
                population to be served to suicide prevention 
                and treatment services;
          (3) evidence of support for the project from the 
        local community to be served by the project;
          (4) a description of how the families and leadership 
        of the communities or populations to be served by the 
        project would be involved in the development and 
        ongoing operations of the project;
          (5) a plan to involve the tribal community of the 
        youth who are provided services by the project in 
        planning and evaluating the mental health care and 
        suicide prevention efforts provided, in order to ensure 
        the integration of community, clinical, environmental, 
        and cultural components of the treatment; and
          (6) a plan for sustaining the project after Federal 
        assistance for the demonstration project has 
        terminated.
    (f) Collaboration; Reporting to National Clearinghouse--
          (1) Collaboration.--The Secretary, acting through the 
        Service, shall encourage Indian Tribes and Tribal 
        Organizations receiving grants under this section to 
        collaborate to enable comparisons about best practices 
        across projects.
          (2) Reporting to national clearinghouse.--The 
        Secretary, acting through the Service, shall also 
        encourage Indian Tribes and Tribal Organizations 
        receiving grants under this section to submit relevant, 
        declassified project information to the national 
        clearinghouse authorized under section 701(b)(2) in 
        order to better facilitate program performance and 
        improve suicide prevention, intervention, and treatment 
        services.
    (g) Annual Report.--Each grant recipient shall submit to 
the Secretary an annual report that--
          (1) describes the number of telemental health 
        services provided; and
          (2) includes any other information that the Secretary 
        may require.
    (h) Report to Congress.--Not later than 270 days after the 
termination of the demonstration project, the Secretary shall 
submit to the Committee on Indian Affairs of the Senate and the 
Committee on Natural Resources and Committee on Energy and 
Commerce of the House of Representatives a final report, based 
on the annual reports provided by grant recipients under 
subsection (h), that--
          (1) describes the results of the projects funded by 
        grants awarded under this section, including any data 
        available which indicates the number of attempted 
        suicides;
          (2) evaluates the impact of the telemental health 
        services funded by the grants in reducing the number of 
        completed suicides among Indian youth;
          (3) evaluates whether the demonstration project 
        should be--
                  (A) expanded to provide more than 5 grants; 
                and
                  (B) designated a permanent program; and
          (4) evaluates the benefits of expanding the 
        demonstration project to include Urban Indian 
        Organizations.
    (i) Authorization of Appropriations.--There is authorized 
to be appropriated to carry out this section $1,500,000 for 
each of fiscal years 2008 through 2011.

SEC. 709. INPATIENT AND COMMUNITY-BASED MENTAL HEALTH FACILITIES 
                    DESIGN, CONSTRUCTION, AND STAFFING.

    Not later than 1 year after the date of enactment of the 
Indian Health Care Improvement Act Amendments of 2007, the 
Secretary, acting through the Service, Indian Tribes, and 
Tribal Organizations, may provide, in each area of the Service, 
not less than 1 inpatient mental health care facility, or the 
equivalent, for Indians with behavioral health problems. For 
the purposes of this subsection, California shall be considered 
to be 2 Area Offices, 1 office whose location shall be 
considered to encompass the northern area of the State of 
California and 1 office whose jurisdiction shall be considered 
to encompass the remainder of the State of California. The 
Secretary shall consider the possible conversion of existing, 
underused Service hospital beds into psychiatric units to meet 
such need.

[Sec. 1665d. Training and community education]

SEC. 710. TRAINING AND COMMUNITY EDUCATION.

    [(a) Community education]
    (a) Program.--The Secretary, in cooperation with the 
Secretary of the Interior, shall develop and implement or 
assist Indian Tribes and Tribal Organizations to develop and 
implement, within each [service unit] Service Unit or tribal 
program, a program of community education and involvement which 
shall be designed to provide concise and timely information to 
the community leadership of each tribal community. Such program 
shall include education [in alcohol and substance abuse] about 
behavioral health issues to political leaders, [tribal] Tribal 
judges, law enforcement personnel, members of tribal health and 
education boards, health care providers including traditional 
practitioners, and other critical members of each tribal 
community. Such program may also include community-based 
training to develop local capacity and tribal community 
provider training for prevention, intervention, treatment, and 
aftercare.
    (b) [Training] Instruction.--The Secretary, acting through 
the Service, shall, either directly or [by contract] through 
Indian Tribes and Tribal Organizations, provide instruction in 
the area of [alcohol and substance abuse] behavioral health 
issues, including instruction in crisis intervention and family 
relations in the context of alcohol and substance abuse, child 
sexual abuse, youth alcohol and substance abuse, and the causes 
and effects of fetal alcohol [syndrome] disorders to 
appropriate employees of the Bureau of Indian Affairs and the 
Service, and to personnel in schools or programs operated under 
any contract with the Bureau of Indian Affairs or the Service, 
including supervisors of emergency shelters and halfway houses 
described in section [2433 of this title] 4213 of the Indian 
Alcohol and Substance Abuse Prevention and Treatment Act of 
1986 (25 U.S.C. 2433).
    [(c) Community-based training models] (c) Training 
Models.--In carrying out the education and training programs 
required by this section, the Secretary, [acting through the 
Service and] in consultation with [tribes] Indian Tribes, 
Tribal Organizations, Indian behavioral health experts, and 
Indian alcohol and substance abuse prevention experts, shall 
develop and provide community-based training models. Such 
models shall address--
          [(1) the elevated risk of alcohol and [substance 
        abuse] behavioral health problems faced by children of 
        alcoholics;
          [(2) the cultural, spiritual, and multigenerational 
        aspects of [alcohol and substance abuse] behavioral 
        health problem prevention and recovery; and
          [(3) community-based and multidisciplinary strategies 
        for preventing and treating [alcohol and substance 
        abuse] behavioral health problems.

SEC. 711. BEHAVIORAL HEALTH PROGRAM.

    (a) Innovative Programs.--The Secretary, acting through the 
Service, Indian Tribes, and Tribal Organizations, consistent 
with section 701, may plan, develop, implement, and carry out 
programs to deliver innovative community-based behavioral 
health services to Indians.
    (b) Awards; Criteria.--The Secretary may award a grant for 
a project under subsection (a) to an Indian Tribe or Tribal 
Organization and may consider the following criteria:
          (1) The project will address significant unmet 
        behavioral health needs among Indians.
          (2) The project will serve a significant number of 
        Indians.
          (3) The project has the potential to deliver services 
        in an efficient and effective manner.
          (4) The Indian Tribe or Tribal Organization has the 
        administrative and financial capability to administer 
        the project.

[Sec. 1665e. Gallup alcohol and substance abuse treatment center]

          (5) The project may deliver services in a manner 
        consistent with traditional health care practices.
    [(a) Grants for residential treatment
    [The Secretary shall make grants to the Navajo Nation for 
the purpose of providing residential treatment for alcohol and 
substance abuse for adult and adolescent members of the Navajo 
Nation and neighboring tribes.
    [(b) Purposes of grants
    [Grants made pursuant to this section shall (to the extent 
appropriations are made available) be used to--
          [(1) provide at least 15 residential beds each year 
        for adult long-term treatment, including beds for 
        specialized services such as polydrug abusers, dual 
        diagnosis, and specialized services for women with 
        fetal alcohol syndrome children;
          [(2) establish clinical assessment teams consisting 
        of a clinical psychologist, a part-time 
        addictionologist, a master's level assessment 
        counselor, and a certified medical records technician 
        which shall be responsible for conducting individual 
        assessments and matching Indian clients with the 
        appropriate available treatment;
          [(3) provide at least 12 beds for an adolescent 
        shelterbed program in the city of Gallup, New Mexico, 
        which shall serve as a satellite facility to the Acoma/
        Canoncito/Laguna Hospital and the adolescent center 
        located in Shiprock, New Mexico, for emergency crisis 
        services, assessment, and family intervention;
          [(4) develop a relapse program for the purposes of 
        identifying sources of job training and job opportunity 
        in the Gallup area and providing vocational training, 
        job placement, and job retention services to recovering 
        substance abusers; and
          [(5) provide continuing education and training of 
        treatment staff in the areas of intensive outpatient 
        services, development of family support systems, and 
        case management in cooperation with regional colleges, 
        community colleges, and universities.
    [(c) Contract for residential treatment
    [The Navajo Nation, in carrying out the purposes of this 
section, shall enter into a contract with an institution in the 
Gallup, New Mexico, area which is accredited by the Joint 
Commission of the Accreditation of Health Care Organizations to 
provide comprehensive alcohol and drug treatment as authorized 
in subsection (b) of this section.
    [(d) Authorization of appropriations
    [There are authorized to be appropriated, for each of 
fiscal years 1996 through 2000, such sums as may be necessary 
to carry out subsection (b) of this section.]
          (6) The project is coordinated with, and avoids 
        duplication of, existing services.

[Sec. 1665f. Reports]

    (c) Equitable Treatment.--For purposes of this subsection, 
the Secretary shall, in evaluating project applications or 
proposals, use the same criteria that the Secretary uses in 
evaluating any other application or proposal for such funding.
    [(a) Compilation of data
    [The Secretary, with respect to the administration of any 
health program by a service unit, directly or through contract, 
including a contract under the Indian Self-Determination Act 
[25 U.S.C.A. Sec. 450f et seq.], shall require the compilation 
of data relating to the number of cases or incidents in which 
any Service personnel or services were involved and which were 
related, either directly or indirectly, to alcohol or substance 
abuse. Such report shall include the type of assistance 
provided and the disposition of these cases.
    [(b) Referral of data
    [The data compiled under subsection (a) of this section 
shall be provided annually to the affected Indian tribe and 
Tribal Coordinating Committee to assist them in developing or 
modifying a Tribal Action Plan under section 2412 of this 
title.
    [(c) Comprehensive report
    [Each service unit director shall be responsible for 
assembling the data compiled under this section and section 
2434 of this title into an annual tribal comprehensive report. 
Such report shall be provided to the affected tribe and to the 
Director of the Service who shall develop and publish a 
biennial national report based on such tribal comprehensive 
reports.]

SEC. 712. FETAL ALCOHOL DISORDER PROGRAMS.

[Sec. 1665g. Fetal alcohol syndrome and fetal alcohol effect grants]

    (a) Programs.--
    [(a) Award; use; review; criteria]
          [(1) The Secretary may make grants to Indian tribes 
        and tribal organizations to establish fetal alcohol 
        syndrome and fetal alcohol effect] (1) Establishment.--
        The Secretary, consistent with section 701, acting 
        through the Service, Indian Tribes, and Tribal 
        Organizations, is authorized to establish and operate 
        fetal alcohol disorder programs as provided in this 
        section for the purposes of meeting the health status 
        objectives specified in section [1602(b) of this 
        title.] 3.
          [(2) Grants made pursuant to this section shall be 
        used 
        to--]
          (2) Use of funds.--
                  (A) In general.--Funding provided pursuant to 
                this section shall be used for the following:
                  [(A) develop and provide] (i) To develop and 
                provide for Indians community and in-school 
                training, education, and prevention programs 
                relating to [FAS and FAE;] fetal alcohol 
                disorders.
                  [(B) identify and provide alcohol and 
                substance abu