S.1790 - Indian Health Care Improvement Reauthorization and Extension Act of 2009111th Congress (2009-2010)
|Sponsor:||Sen. Dorgan, Byron L. [D-ND] (Introduced 10/15/2009)|
|Committees:||Senate - Indian Affairs|
|Latest Action:||12/16/2009 Placed on Senate Legislative Calendar under General Orders. Calendar No. 233. (All Actions)|
|Notes:||The bill as reported by the Senate Committee on Indian Affairs was enacted into law by reference, and with minor changes, by section 10221 of H.R.3590 (the Patient Protection and Affordable Care Act).|
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Summary: S.1790 — 111th Congress (2009-2010)All Information (Except Text)
Reported to Senate with amendment(s) (12/16/2009)
Indian Health Care Improvement Reauthorization and Extension Act of 2009 - Title I: Indian Health Care Improvement Act Reauthorization and Amendments - (Sec. 101) Amends the Indian Health Care Improvement Act to authorize appropriations to carry out the Act.
Directs the Secretary of Health and Human Services (HHS) to maintain model diabetes projects in existence on October 29, 1992, and located in specified places.
(Sec. 103) Replaces the Act's declaration of health objectives with a declaration of national Indian health policy.
Subtitle A: Indian Health Manpower - (Sec. 111) Requires development and operation of a Community Health Aide Program in the state of Alaska. Allows establishment, through the Indian Health Service (Service), of a national Community Health Aide Program in accordance with the Alaskan program. Excludes dental health aide therapist services from the national program.
(Sec. 112) Authorizes funding of demonstration programs for Indian health programs to address chronic shortages of health professionals.
Subtitle B: Health Services - (Sec. 121) Revises provisions concerning the Indian Health Care Improvement Fund.
(Sec. 122) Establishes an Indian Catastrophic Health Emergency Fund (CHEF) to meet the extraordinary medical costs associated with the treatment of victims of disasters or catastrophic illnesses who are within the responsibility of the Service.
(Sec. 123) Directs the Secretary to: (1) determine the incidence of, and the types of complications resulting from, diabetes among Indians and the measures each Service unit should take to reduce the incidence of, and prevent, treat, and control the complications resulting from, diabetes among Indian tribes; and (2) screen, when medically indicated and with informed consent, each Indian who receives services from the Service for diabetes and for conditions which indicate a high diabetes risk and establish a cost-effective monitoring approach.
Authorizes the Secretary to: (1) provide dialysis programs, including the purchase of dialysis equipment and the provision of necessary staffing; and (2) establish and maintain in each area office a position of diabetes control officer.
(Sec. 124) Authorizes funding for hospice care and for assisted living, long-term care, home- and community-based, and convenient care services.
Authorizes providing long-term care in a facility to Indians either directly or through contracts or compacts with Indian Tribes or Tribal Organizations.
(Sec. 125) Gives tribes and tribal organizations (and in some circumstances, the United States) the right to recover from any responsible or liable third party (including, with limitation, a political subdivision of a state) the reasonable charges billed by the Secretary, a tribe, or a tribal organization in providing health services through the Service, a 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 damages, reimbursement, or indemnification for such charges or expenses if the services had been provided by a nongovernmental provider and the individual had been required to pay, and did pay, the charges or expenses.
Prohibits state laws, contracts, or any health care plan or program entered into or renewed after enactment of the Indian Health Care Amendments of 1988 from hindering the right of recovery.
(Sec. 126) Revises provisions concerning crediting of reimbursements.
(Sec. 127) Directs the HHS Secretary and the Secretary of the Interior to study and compile a list of the types of staff positions in elementary and secondary education, social services and family and child welfare, law enforcement and judicial services, and alcohol and substance abuse whose qualifications include, or should include, training in the identification, prevention, education, referral, or treatment of mental illness, or dysfunctional and self destructive behavior. Directs those Secretaries to provide training criteria and training appropriate to each such position.
Requires the Service to develop and implement, on request, or assist in the development and implementation of, a program of community education on mental illness.
Directs the HHS Secretary to develop a plan to increase the health care staff providing behavioral health services by at least 500 positions within five years after enactment, with at least 200 of those positions devoted to child, adolescent, and family services.
(Sec. 129) Authorizes the Secretary to provide funds for certain transportation costs for patients and their escorts.
(Sec. 130) Directs the Secretary to establish an epidemiology center in each Service area to carry out specified duties, including to: (1) the collect data relating to, and monitor progress made toward meeting, each of the health status objectives of the Service, the Indian tribes, tribal organizations, and urban Indian organizations in the Service area; (2) evaluate existing systems that impact Indian health improvement; (3) assist tribes, tribal organizations, and urban Indian organizations in identifying highest-priority health status objectives; (4) make recommendations for service targeting and to improve health care delivery systems; (6) provide disease surveillance and requested technical assistance.
Authorizes the Secretary to make grants to Indian tribes, tribal organizations, Indian organizations, and eligible intertribal consortia to conduct epidemiological studies of Indian communities.
(Sec. 132) Requires the Secretary to make grants of not more than $300,000 to each of nine colleges and universities (under current law, grants are authorized for at least three 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.
Directs the Secretary to provide a grant 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." Requires such program, to the maximum extent feasible, to coordinate with the Quentin N. Burdick Indian health programs authorized under the Quentin N. Burdick American Indians Into Nursing Program and existing university research and communications networks.
Sets forth requirements for receiving a grant and an active duty service requirement for graduates who received stipends under the grant program.
(Sec. 133) Expands the current program for the prevention, control, and elimination of tuberculosis to authorize the Secretary, after consultation with the Centers for Disease Control and Prevention (CDC), to make grants available to Indian tribes and tribal organizations for the following: (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, training, and clinical skills improvement activities in the prevention, control, and elimination of 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).
(Sec. 134) Exempts licensed health professionals employed by a tribal health program, if licensed in any state, from the licensing requirements of the state in which the tribal health program performs the services described in the contract or compact of the tribal health program under the Indian Self-Determination and Education Assistance Act.
Authorizes the Secretary to: (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; and (2) provide programs or allowances to health professionals employed in an Indian health program to enable those professionals to take leave for professional consultation, management, leadership, and refresher training courses.
(Sec. 136) Revises current provisions concerning the Office of Indian Women's Health Care to provide, in addition to such Office, for an Office of Indian Men's Health.
(Sec. 137) Requires the Comptroller General of the United States (GAO) to submit to the Secretary, to Congress, and to make available to each Indian tribe, a report describing the results of the study of the Comptroller General regarding the funding of the contract health service program and the administration of the contract health service program. Requires the Secretary to consult with Indian tribes regarding the contract health service program, including the distribution of funds pursuant to the program.
Subtitle C: Health Facilities - (Sec. 141) Requires the Secretary, acting through the Service, to maintain a health care facility priority system which: (1) shall be developed in consultation with Indian tribes and tribal organizations; (2) shall give Indian tribes' needs the highest priority; (3) may include a health care facilities list, must include the methodology adopted by the Service in establishing priorities under its health care facility priority system, and may include such health care facilities, and such renovation or expansion needs of any health care facility, as the Service may identify; (4) 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 three years, or more frequently as the Secretary determines to be appropriate.
(Sec. 142) Prohibits the priority of any project established under the construction priority system in effect on the date of enactment from being affected by any change in the construction priority system taking place after that date for certain projects.
(Sec. 143) Authorizes the Secretary, acting through the Service, to carry out, or to enter into contracts or compacts under the Indian Self-Determination and Education Assistance Act with Indian tribes or tribal organizations to carry out, health care delivery demonstration projects that test alternative means of delivering health care and services to Indians through facilities. Permits the use of funds for, among other things, contracts for the construction and renovation of hospitals, health centers, health stations, and other facilities to deliver health care services. Gives priority to projects located in any of the following Service units: (1) Cass Lake, Minnesota; (2) Mescalero, New Mexico; (3) Owyhee and Elko, Nevada; (4) Schurz, Nevada; and (5) Ft. Yuma, California. Sets forth project approval criteria.
(Sec. 144) Permits a tribal health program that operates a hospital or other health facility and the federally owned quarters associated with such a facility pursuant to a contract or compact under the Indian Self-Determination and Education Assistance Act to establish the rental rates charged to the occupants of those quarters, on providing notice to the Secretary.
(Sec. 145) Authorizes the head of any federal agency to which funds, equipment, or other supplies are made available for the planning, design, construction, or operation of a health care or sanitation facility to transfer the funds, equipment, or supplies to the Secretary for the planning, design, construction, or operation of a health care or sanitation facility to achieve: (1) the purposes of the Indian Health Care Improvement Act; and (2) the purposes for which the funds, equipment, or supplies were made available to the federal agency.
(Sec. 146) Directs the Secretary, acting through the Service, to establish a demonstration program under which the Secretary shall award no less than three grants for purchase, installation and maintenance of modular component health care facilities in Indian communities for provision of health care services.
(Sec. 147) Directs the Secretary, acting through the Service, to establish a demonstration program under which the Secretary shall provide at least three mobile health station projects.
Subtitle D: Access to Health Services - (Sec. 151) Prohibits any payments received by an Indian health program or by an urban Indian organization under title XVIII (Medicare), XIX (Medicaid), or XXI (CHIP) of the Social Security Act for services provided to Indians eligible for benefits under such respective titles from being considered in determining appropriations for the provision of health care and services to Indians. Sets froth provisions concerning use of funds and direct billing.
(Sec. 152) Permits Indian tribes, tribal organizations, and urban Indian organizations to use amounts made available for health benefits to purchase health benefits coverage 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; (4) a self-insured plan; or (5) a high deductible or health savings account plan.
(Sec. 153) Directs the Secretary, acting through the Service, to 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, including programs to provide outreach and enrollment through video, electronic delivery methods, or telecommunication devices that allow real-time or time-delayed communication between individual Indians and the benefit program, 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. Sets forth grant conditions.
(Sec. 154) Authorizes the Secretary to 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 (VA) and the Department of Defense (DOD).
(Sec. 155) Reaffirms, as specified, the goals stated in the document entitled "Memorandum of Understanding Between the VA/Veterans Health Administration And HHS/Indian Health Service" and dated February 25, 2003 (relating to cooperation and resource sharing between the Veterans Health Administration and Service).
(Sec. 156) Requires a federal health care program to accept an entity 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.
(Sec. 157) Entitles an Indian tribe or tribal organization carrying out programs under the Indian Self-Determination and Education Assistance Act or an urban Indian organization carrying out programs under title V of this Act to purchase coverage, rights, and benefits for the employees of such Indian tribe or tribal organization, or urban Indian organization, under the federal employees health benefit plan and life insurance program if necessary employee deductions and agency contributions in payment for the coverage, rights, and benefits for the period of employment with such Indian tribe or tribal organization, or urban Indian organization, are currently deposited in the applicable employee's fund.
(Sec. 159) Directs the Secretary to conduct a study to determine the feasibility of treating the Navajo Nation as a state for Medicaid purposes 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 Medicaid state plan.
Subtitle E: Health Services for Urban Indians - (Sec. 161) Permits making funds available for the construction or expansion of facilities for urban Indians under the Indian Health Care Improvement Act.
(Sec. 162) Makes the Tulsa Clinic and Oklahoma City Clinic demonstration projects permanent within the Service's direct care program, continues treating them as Service units and operating units in the allocation of resources and coordination of care and as meeting the requirements and definitions of an urban Indian organization under the Indian Health Care Improvement Act.
(Sec. 163) Requires the Secretary to ensure that the Service confers, to the maximum extent practicable, with urban Indian organizations in carrying out the Indian Health Care Improvement Act.
Requires the Secretary, acting through the Service, to enter into contracts with, or make grants to, urban Indian organizations to assist the urban Indian organizations in the establishment and administration, within urban centers, of approved programs.
(Sec. 164) Authorizes the Secretary, acting through the Service, to establish programs, including programs for awarding grants, for urban Indian organizations that are identical to other Indian organizations' programs for: (1) the prevention, control, and elimination of communicable and infectious diseases; (2) behavioral health and treatment; and (3) the multidrug abuse program for Indian youth.
(Sec. 165) Authorizes the Secretary, acting through the Service, to 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 Representative Program in the provision of health care, health promotion, and disease prevention services to urban Indians.
(Sec. 166) Authorizes the Secretary to permit an urban Indian organization that has entered into a contract or received an urban Indian grant, in carrying out the contract or grant, to use, in accordance with such terms and conditions for use and maintenance as are agreed on by the Secretary and the urban Indian organizations: (1) any existing facility under the jurisdiction of the Secretary; (2) all equipment contained in or pertaining to such an existing facility; and (3) any other personal property of the federal Government under the jurisdiction of the Secretary.
Authorizes the Secretary, acting through the Service, to make grants to urban Indian organizations for the development, adoption, and implementation of health information technology, telemedicine services development, and related infrastructure.
Subtitle F: Organizational Improvements - (Sec. 171) Rewrites provisions establishing the Indian Health Service and expands the duties of the Director.
(Sec. 172) Establishes within the Service an office, to be known as the "Office of Direct Service Tribes" which shall be located in the Office of the Director.
Makes the Office responsible for: (1) providing Service-wide leadership, guidance and support for direct service tribes to include strategic planning and program evaluation; (2) ensuring maximum flexibility to tribal health and related support systems for Indian beneficiaries; (3) serving as the focal point for consultation and participation between direct service tribes and organizations and the Service in the development of Service policy; (4) holding no less than biannual consultations with direct service tribes in appropriate locations to gather information and aid in the development of health policy; and (5) directing a national program and providing leadership and advocacy in the development of health policy, program management, budget formulation, resource allocation, and delegation support for direct service tribes.
(Sec. 173) Directs the Secretary to submit to Congress a plan describing the manner and schedule by which an area office, separate and distinct from the Phoenix Area Office of the Service, can be established in the State of Nevada.
Subtitle G: Behavioral Health Programs - (Sec. 181) Rewrites the current title VII (Substance Abuse Programs) of the Indian Health Care Improvement Act and entitles the new title VII "Behavioral Health Programs."
Sets forth the purposes of title VII, including: (1) authorizing and directing the Secretary, acting through the Service, Indian tribes, and tribal 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; and (2) ensuring 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.
Directs the Secretary, acting through the Service, Indian tribes, and tribal organizations, to 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 which shall include specified components.
Requires the Secretary, acting through the Service, to provide, to the extent feasible and if funding is available, specified programs of comprehensive care, child care, adult care, family care, and elder care.
Permits the governing body of any Indian tribe, tribal organization, or urban Indian organization to adopt a resolution for the establishment of a community behavioral health plan providing for the identification and coordination of available resources and programs.
Directs the Secretary, acting through the Service, and the Secretary of the Interior to develop and enter into a memoranda of agreement, or review and update any existing memoranda of agreement, as required by the Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986.
Directs the Secretary, acting through the Service, to provide a program of comprehensive behavioral health, prevention, treatment, and aftercare.
Directs the Secretary to establish and maintain a mental health technician program within the Service.
Requires 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 to be licensed as a psychologist, social worker, or marriage and family therapist, respectively.
Directs the Secretary, acting through the Service, to develop and implement a program for acute detoxification and treatment for Indian youths, including behavioral health services. Requires the program to include regional treatment centers designed to include detoxification and rehabilitation for both sexes on a referral basis and programs developed and implemented by Indian tribes or tribal organizations at the local level under the Indian Self-Determination and Education Assistance Act.
Authorizes the Secretary, acting through the Service, to provide, in each area of the Service, not less than one inpatient mental health care facility, or the equivalent, for Indians with behavioral health problems.
Directs the Secretary, in cooperation with the Secretary of the Interior, to develop and implement or assist Indian tribes and tribal organizations to develop and implement, within each 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.
Directs the Secretary, acting through the Service, to plan, develop, implement, and carry out programs to deliver innovative community-based behavioral health services to Indians. Authorizes grants.
Authorizes the Secretary, acting through the Service, Indian Tribes, and Tribal Organizations, to establish and operate fetal alcohol spectrum disorders programs.
Directs the Secretary, acting through the Service, to establish, in every Service area, programs involving treatment for: (1) victims of sexual abuse who are Indian children or children in an Indian household; and (2) other members of the household or family of the victims.
Authorizes the Secretary to establish in each Service area programs involving the prevention and treatment of: (1) Indian victims of domestic violence or sexual abuse; and (2) other members of the household or family of the victims.
Directs the Secretary, in consultation with appropriate federal agencies, 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 served by the Service, Indian tribes, or tribal organizations and among Indians in urban areas.
Authorizes the Secretary, acting through the Service, to carry out a demonstration project to award up to five grants for the provision of telemental health services to Indian youth who: (1) have expressed suicidal ideas; (2) have attempted suicide; or (3) have behavioral health conditions that increase or could increase the risk of suicide. Permits an Indian tribe or tribal organization to use and promote the traditional health care practices of the Indian tribes of the youth to be served. Sets forth reporting requirements.
Directs the Secretary, acting through the Administration, to carry out such measures as the Secretary determines to be necessary to maximize the time and workload efficiency of the process by which Indian tribes and tribal organizations apply for grants under any program administered by the Administration, including by providing methods other than electronic methods of submitting applications for those grants, if necessary. Sets forth provisions concerning priorities for making grants and requirements for states.
Directs the Secretary to carry out such activities as the Secretary determines to be necessary to encourage Indian tribes, tribal organizations, and other mental health care providers to obtain the services of predoctoral psychology and psychiatry interns.
Authorizes the Secretary, acting through the Administration, to establish and carry out a demonstration grant program under which the Secretary shall: (1) identify a culturally compatible, school-based, life skills curriculum for the prevention of Indian and Alaska Native adolescent suicide; (2) identify the Indian tribes that are at greatest risk for adolescent suicide; (3) invite those Indian tribes to participate in the demonstration program; and (4) provide grants to the identified Indian tribes and eligible entities to implement the curriculum. Sets forth reporting requirements.
Subtitle H: Miscellaneous - (Sec. 191) Provides for the confidentiality of medical records, subject to exceptions.
(Sec. 192) Designates the state of Arizona as a contract health service delivery area by the Service for the purpose of providing contract health care services to members of Indian tribes in the State of Arizona.
Designates the States of North Dakota and South Dakota as a contract health service delivery area by the Service for the purpose of providing contract health care services to members of Indian tribes in the States of North Dakota and South Dakota.
Makes the following California Indians eligible for health services provided by the Service: (1) any member of a federally recognized Indian tribe; (2) any descendant of an Indian who was residing in California on June 1, 1852, if such descendant is a member of the Indian community served by a local program of the Service and is regarded as an Indian by the community in which such descendant lives; (3) any Indian who holds trust interests in public domain, national forest, or reservation allotments in California; and (4) any Indian of California who is listed on the plans for distribution of the assets of rancherias and reservations located within the State of California under the Act of August 18, 1958, and any descendant of such an Indian.
(Sec. 193) 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 a member, unless the Secretary, acting through the Service, has ensured that the Indians receiving services from the member will experience no reduction in services.
Permits, at the request of an Indian health program, limiting the services of a member of the National Health Service Corps assigned to the Indian health program to the individuals who are eligible for services from that Indian health program.
(Sec. 194) Revises provisions concerning health services for ineligible persons.
(Sec. 195) Requires, effective beginning with the submission of the annual budget request to Congress for FY2011, the President to include, in the amount requested and the budget justification, amounts that reflect any changes in: (1) the cost of health care services, as indexed for United States dollar inflation; and (2) the size of the population served by the Service.
(Sec. 196) Directs the Secretary, in coordination with the Secretary of the Interior and the Attorney General, to establish a prescription drug monitoring program, to be carried out at health care facilities of the Service, tribal health care facilities, and urban Indian health care facilities. Sets forth reporting requirements.
(Sec. 197) Prohibits anything in this Act from limiting the ability of a tribal health program funded, in whole or part, by the Service through, or provided for in, a compact with the Service pursuant to provisions of the Indian Self-Determination and Education Assistance Act to charge an Indian for services provided by the tribal health program.
Prohibits authorizing the Service: (1) to charge an Indian for services; or (2) to require any tribal health program to charge an Indian for services.
(Sec. 198) Directs the Secretary to submit to Congress a report describing: (1) all disease and injury prevention activities conducted by the Service, independently or in conjunction with other federal departments and agencies and Indian tribes; and (2) the effectiveness of those activities, including the reductions of injury or disease conditions achieved by the activities.
(Sec. 199) Requires the The Comptroller General to conduct a study, and evaluate the effectiveness, of coordination of health care services provided to Indians: (1) through Medicare, Medicaid, or CHIP; (2) by the Service; or (3) using funds provided by either state or local governments or Indian tribes. Requires a report to Congress.
Requires the Comptroller General to conduct a study, and to report on, the use of health care furnished by health care providers under the contract health services program funded by the Service and operated by the Service, an Indian tribe, or a tribal organization.
(Sec. 199A) States that, 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, the United States is not liable for any provision of traditional health care practices that results in damage, injury, or death to a patient.
(Sec. 199B) Directs the Secretary, acting through the Service, to establish within the Service the position of the Director of HIV/AIDS Prevention and Treatment. Sets forth the Director's duties and requires a recurring report to Congress.
Title II: Amendments to Other Acts - (Sec. 201) Amends Medicare provisions concerning Indian health service facilities to state that payments made pursuant to such provisions shall not be reduced as a result of any beneficiary deductible, coinsurance, or other charge.
(Sec. 202) Amends the Native Hawaiian Health Care Act of 1988 to reauthorize appropriation through FY2019.
Permits identified private educational organization to continue to offer educational programs and services to Native Hawaiians first, and to others, only after the need for such programs and services by Native Hawaiians has been met.