Indian health professions.-The Committee recommends $27,406,000, the same as the budget estimate and the House allowance. The Committee understands that the budget includes $1,635,000 for the nursing program authorized in section 112 of the Indian Health Care Improvement Act. Within the funds provided, consideration should be given to tribal colleges that have worked to develop college nursing programs. The Committee notes that many of the nursing programs at tribally controlled colleges meet the primary mandate of the statute requiring Indian control in the planning and management of Indian health services.

Tribal management.-The Committee recommends $5,285,000, the same as the budget estimate and the House allowance.

Direct operations.-The Committee recommends a decrease of $1,600,000, which will maintain the direct operations functions at the fiscal year 1993 level. The Committee does not agree with the proposal in the budget to direct administrative and staffing reductions to specified object class categories, so as to minimize the impact to headquarters functions.

Self-governance.-The Committee recommends an increase of $3,000,000, as proposed by the House, to fund shortfalls associated with the switch to compact funding. In implementing these compacts, there may be situations where the transfer of a portion of a program's funds to a compact tribe could jeopardize the continuation of services for noncompact tribes. These funds are provided to address these situations and in the future, IHS should budget for these costs. As more compacts are implemented, the Committee expects IHS to identify where operational and staffing reductions might be made as the tribes assume even greater responsibility and oversight of their programs.

Contract support.-The Committee recommends an increase of $22,000,000 for contract support. This provides 85 percent of the estimated shortfall, which is the same percentage as is provided in the allocation of staffing resources for new facilities. The Committee is very concerned about the escalating costs of the contract support program and encourages the tribes and the IHS to carefully review contract support costs so that the increases in contract support costs do not soon overwhelm the Committee's ability to provide program increases.

Other. The Committee concurs in the House recommendation of a decrease of $458,000 in the "Health services" account, which reflects a transfer to the "Facilities” account to correct a discrepancy between the President's budget request and the budget justification supplied by IHS.

As recommended by the House, the Committee does not object, in limited circumstances, to the use of excess services funds carried over from previous years for the purpose of purchasing or renovating modular buildings to provide needed services, within the scope of the dollars provided in existing contracts. As recognized by the House, it may be more cost-effective in some instances to renovate existing space. Bill language is included to allow for these limited uses. The IHS should address these types of problems in advance by properly budgeting for needed services and repair and renovation requirements in the appropriate accounts.

The Committee has amended the language proposed by the House with respect to the funding for the Indian self-determination fund. The Committee recommendation includes $7,000,000 for this purpose, as part of the $22,000,000 contract support increase.

The Committee has also agreed to language proposed by the House to ensure that self-governance compact funds remain available to the tribes without fiscal year limitation. Language is also included to ensure Federal Tort Claims Act protection is extended to tribal employees under self-governance compacts, as is currently provided for self-determination contracts.

The Committee is concerned about the failure of Indian Health Service to adequately investigate allegations of mismanagement, possible fraud and interference with self-governance at the Owyhee service unit in Nevada. Within 60 days of this report, IHS shall provide the Committee with a full report pertaining to these matters. As part of this report, IHS shall also outline the steps it will take to ensure an orderly transition to self-governance at Owyhee.

The Committee recommends an appropriation of $293,682,000, an increase of $14,871,000 above the budget estimate, $3,315,000 below the House allowance, and $39,958,000 below the fiscal year 1993 appropriation. The following table summarizes the Committee's recommendations:

Repair, maintenance, and improvement.-The Committee recommends $32,940,000, the same as the budget estimate.

New and replacement hospitals.-The Committee recommends a decrease of $16,500,000, which includes a decrease of $17,000,000 for the Alaska Native Medical Center, and an increase of $500,000 to initiate planning and design activities for the replacement facility at Winnebago, NE. The decrease still leaves $58,000,000 for the ANMC, with the balance of $17,000,000 to be provided in fiscal year 1995. IHS should include this amount in next year's budget request.

With respect to Winnebago, the Committee has included bill language which precludes the use of these funds until a program justification document [PJD] has been approved by the Assistant Secretary for Health. The Committee understands that tentative agreement has been reached on the scope of the new facility, but that a final decision will not be made pending completion of a review of the birthing center. The Committee urges IHS to complete this review as expeditiously as possible. In addition, the Committee is aware of differing estimates by the Aberdeen area and IHS headquarters as to the amount of time needed for development, review, and approval of the PJD. In the interest of ensuring that continued progress be made on this project, the Committee has recommended the funding discussed above in the event the necessary steps associated with achieving an approved PJD are completed this fiscal year. As noted by the bill language, these funds are not to be made available until the PJD has been approved.

The Committee expects IHS to include, in its fiscal year 1995 budget, the funding amounts necessary for those projects on the priority list ready to proceed to construction or planning and design.

The IHS should explore options for expanding the Gallup Indian Medical Center at its existing location. The Committee does not object to the reprogramming of funds, consistent with the Committee's guidelines, for the purchase of land and improvements thereon if the IHS identifies an acceptable source of funds to reprogram. The purchase price should not exceed appraised market value.

Outpatient care facilities.-The Committee recommends an increase of $708,000 to complete the planning and design for Hopi, Second Mesa. The Committee urges the Indian Health Service to proceed with completion and approval of the PJD for the Parker Outpatient Clinic. Planning and design funds have been available for the project since fiscal year 1988 yet the PJD is still in draft and undergoing revision. The Committee notes that the second ranked outpatient clinic project is due to be approved shortly while Parker, the No. 1 project, is not ready for PJD approval. Both projects are under the Phoenix area which should make all efforts to move all proposed projects in priority order and avoid long delays.

Regional youth treatment centers.-The Committee recommends $2,780,000 to complete the construction of the Portland area regional youth treatment center for alcohol and substance abuse treatment in Spokane, WA. The IHS should include the necessary funds for operation of the center in the budget in conjunction with the anticipated completion of this facility.

The Committee has not included additional funds at this time for planning and design for the satellite youth treatment center for the Phoenix area. This satellite facility, to be located in Nevada, is to be a referral site for intake, screening, limited identification, and aftercare. It is not to be an inpatient facility. The Committee expects the IHS Phoenix area, in conjunction with the tribes, to submit a revised PJD to headquarters within 90 days after enactment of this bill. The Committee expects the IHS to work toward a more reasonable scope for this facility and to reduce the estimated cost. Once a PJD is approved, $465,000 remains from funds previously

appropriated for the Phoenix area satellite facility to begin planning and design. The Committee will address any additional construction needs after completion of the PJD and planning and design. As with other facilities funded by the Committee, operational funding will be addressed in conjunction with project completion and anticipated opening.

Staff quarters.-The Committee recommends $16,396,000 to complete the construction of staff quarters for the Kotzebue, AK, hospital. In constructing the water and sewer lines for the Maniilaq Medical Center quarters, the Service should consult with the city of Kotzebue to ensure proper integration into Kotzebue's existing water and sewer system. If unobligated funds remain from the Pine Ridge quarters project, the Committee has no objection to the use of up to $400,000 to complete the equipment purchases for the new Pine Ridge Hospital.

Dental units.-The Committee recommends $1,000,000 for the replacement of modular dental units. As recommended by the House, IHS should incorporate modular dental units in its strategic plan for facilities, and the increased funds recommended by the Committee should be included in the base in future budget requests.

Sanitation facilities.-The Committee recommends an increase of $3,000,000. Within their fair share of these increased funds, the Committee urges the Navajo and Alaska areas to place a priority on the needs associated with the former Bennett freeze area, and the deteriorated conditions in the Yukon-Kuskokwim delta region. Given the absence of water and sewer infrastructure development in the Bennett freeze area since 1980, the Committee urges that IHS evaluate proposed projects in this area to ensure that those which are feasible and have the potential for providing significant health benefits are placed appropriately on the Navajo area sanitation deficiencies priority list. Additional consideration should be given to planning, such as aerial surveys, test well drilling, and the like, in order to prepare for future projects. It is the Committee's understanding that within the amounts included in the budget estimate, IHS estimates that $1,000,000 of the Navajo allocation would be prioritized for projects in this area, as well.

The Committee encourages IHS to pursue pilot projects in Alaska to develop and test innovative individual drinking water storage systems, technological improvements in the operation of composting toilets, and modification of "honey-bucket" haul system components should be pursued. Test results and information from reviews of current operating procedures should be evaluated thoroughly before implementing full-scale projects. Appropriate projects using the results of these pilot efforts should be included on the area sanitation deficiencies priority list for future funding.

The Committee is concerned about the urgent need to improve the sanitary conditions in former Bennett freeze homes by bringing water and sanitation services into these communities. To expedite the provision of water and sanitary services to this area, the Committee urges the Indian Health Service to consider the use of the cistern system in combination with community water servicing points, where feasible, and in combination with an intensive health education program to bring water to homes that have no access to running water or a domestic water source.

The Committee expects the Indian Health Service to work with the Havasupai Tribe to identify and develop a domestic water source and system at the Hilltop location of the reservation. Priority attention should be given to this project due to the urgent need to protect tribal members against routine flooding which occurs multiple times a year and to improve access to critical health care for kidney dialysis and other patients. The unique and emergency circumstances should be taken into account in determining the Hilltop project funding priority, if identified by the tribe within the existing system.

Environmental health and support.-The Committee recommends an increase of $7,029,000, which includes $5,977,000 to raise service units to a level of 60 percent level of need funded, $52,000 to fund maintenance support at the expanded Wagner facility at the 85-percent level, and $1,000,000, as recommended by the House, for operations and maintenance training for sanitation facilities. Since these facilities are turned over to the tribes for operations and maintenance upon completion of construction, it is important that the capital investment be protected through adequate attention to proper operation and preventative maintenance. This will help to ensure the longevity of these systems, while contributing to the improvement of services for the tribes.

Other. The Committee has recommended an increase of $458,000 which reflects a transfer from the "Health services" account to "Facilities" to correct a discrepancy between the President's budget and the IHS budget justification.

As recommended by the House, the Committee encourages the IHS to explore, in consultation with the tribes, the development of standardized designs for its health facilities. These standardized designs should capitalize on lessons learned from past construction projects and could result in considerable savings of time and money required to construct individual projects. If additional funds are needed to pursue this effort, IHS should propose a reprogramming, to the extent that additional funds are available from completed projects or due to lower than expected construction contract awards.

The Committee recommends an appropriation of $83,405,000, which is a decrease of $601,000 from the budget request and a decrease of $95,000 below the House allowance. The fiscal year 1994 recommendation represents an increase of $2,822,000 over the fiscal year 1993 enacted level.

The following table represents the distribution of funds for the Department of Education's portion of Indian education funding: Subpart 1, grants to LEA's and Indian-controlled schools

$60,304,000