Improving Federal Management of Programs that Serve Tribes and Their Members
For nearly a decade, we, along with inspectors general, special commissions, and others, have reported that federal agencies have ineffectively administered Indian education and health care programs and inefficiently fulfilled their responsibilities for managing the development of Indian energy resources. In particular, we have found numerous challenges facing the Department of the Interior's (Interior) Bureau of Indian Education (BIE) and Bureau of Indian Affairs (BIA)—both under the Office of the Assistant Secretary for Indian Affairs (Indian Affairs)—and the Department of Health and Human Services' (HHS) Indian Health Service (IHS), in administering education and health care services, which put the health and safety of American Indians served by these programs at risk. These challenges included poor conditions at BIE school facilities that endangered students and inadequate oversight of health care that hindered IHS's ability to ensure quality care to Indian communities. In addition, we have reported that BIA mismanages Indian energy resources held in trust and thereby limits opportunities for tribes and their members to use those resources to create economic benefits and improve the well-being of their communities.
Congress recently noted, "through treaties, statutes, and historical relations with Indian tribes, the United States has undertaken a unique trust responsibility to protect and support Indian tribes and Indians."1 In light of this unique trust responsibility and concerns about the federal government ineffectively administering Indian education and health care programs and mismanaging Indian energy resources, we are adding these programs as a high-risk issue because they uniquely affect tribal nations and their members.
Federal agencies have ineffectively administered and implemented Indian education and health care programs and mismanaged Indian energy resources in the following broad areas: (1) oversight of federal activities; (2) collaboration and communication; (3) federal workforce planning; (4) equipment, technology, and infrastructure; and (5) federal agencies’ data. Although federal agencies have taken some actions to address the 41 recommendations we made related to Indian programs, there are currently 39 that have yet to be fully resolved.
We plan to continue monitoring federal efforts to address the 39 recommendations that have yet to be fully resolved. To this end, we have ongoing work focusing on accountability for safe schools and school construction and tribal control of energy delivery, management, and resource development.
In the past 3 years, we issued 3 reports on challenges with Indian Affairs' management of BIE schools in which we made 13 recommendations. Eleven recommendations below remain open.
- To help ensure that BIE schools provide safe and healthy facilities for students and staff, we made 4 recommendations which remain open, including that Indian Affairs ensure the inspection information it collects on BIE schools is complete and accurate; develop a plan to build schools' capacity to promptly address safety and health deficiencies; and consistently monitor whether BIE schools have established required safety committees.
- To help ensure that BIE conducts more effective oversight of school spending, we made 4 recommendations which remain open, including that Indian Affairs develop a workforce plan to ensure that BIE has the staff to effectively oversee school spending; put in place written procedures and a risk-based approach to guide BIE in overseeing school spending; and improve information sharing to support the oversight of BIE school spending.
- To help ensure that Indian Affairs improves how it manages Indian education, we made 5 recommendations. Three recommendations remain open, including that Indian Affairs develop a strategic plan for BIE that includes goals and performance measures for how its offices are fulfilling their responsibilities to provide BIE with support; revise Indian Affairs' strategic workforce plan to ensure that BIA regional offices have an appropriate number of staff with the right skills to support BIE schools in their regions; and develop and implement decision-making procedures for BIE to improve accountability for BIE schools.
In the past 6 years, we have made 14 recommendations related to Indian health care that remain open. Although IHS has taken several actions in response to our recommendations, such as improving the data collected for the Purchased/Referred Care (PRC) program and adopting Medicare-like rates for non-hospital services, much needs to be done.
- To help ensure that Indian people receive quality health care, the Secretary of HHS should direct the Director of IHS to take the following two actions: (1) as part of implementing IHS's quality framework, ensure that agency-wide standards for the quality of care provided in its federally operated facilities are developed and systematically monitor facility performance in meeting these standards over time; and (2) develop contingency and succession plans for replacing key personnel, including area directors.
To help ensure that timely primary care is available and accessible to Indians, IHS should: (1) develop and communicate specific agency-wide standards for wait times in federally-operated facilities, and (2) monitor patient wait times in federally-operated facilities and ensure that corrective actions are taken when standards are not met.
- To help ensure that IHS has meaningful information on the timeliness with which it issues purchase orders authorizing payment under the PRC program, and to improve the timeliness of payments to providers, we recommend that IHS: (1) modify IHS's claims payment system to separately track IHS referrals and self-referrals, revise the Government Performance and Results Act measures for the PRC program so that it distinguishes between these two types of referrals, and establish separate timeframe targets for these referral types; and (2) better align PRC staffing levels and workloads by revising its current practices, where available, used to pay for PRC program staff. In addition, as HHS and IHS monitor the effect that new coverage options available to IHS beneficiaries through the Patient Protection and Affordable Care Act (PPACA) have on PRC funds, we recommend that IHS concurrently develop potential options to streamline requirements for program eligibility.
- To help ensure successful outreach efforts regarding PPACA coverage expansions, we recommend that IHS realign current resources and personnel to increase capacity to deal with enrollment in Medicaid and the exchanges and prepare for increased billing to these payers.
- If payments for physician and other nonhospital services are capped, we recommend that IHS monitor patient access to these services.
- To help ensure a more equitable allocation of funds per capita across areas, we recommended that Congress consider requiring IHS to develop and use a new method for allocating PRC funds. To make IHS's allocation of PRC program funds more equitable, we recommended that IHS develop (1) written policies and procedures to require area offices to notify IHS when changes are made to the allocation of funds to PRC programs; (2) use actual counts of PRC users in any formula allocating PRC funds that relies on the number of active users; and (3) use variations in levels of available hospital services, rather than just the existence of a qualifying hospital, in any formula for allocating PRC funds that contain a hospital access component.
- To develop more accurate data for estimating the funds needed for the PRC program and improve IHS oversight, we recommended that IHS develop a written policy documenting how it evaluates need for the PRC program, and disseminate it to area offices so they understand how unfunded services data are used to estimate overall program needs. We also recommend that IHS develop written guidance for PRC programs outlining a process to use when funds are depleted but recipients continue to need services.
In the past 2 years, we issued 3 reports on developing Indian energy resources in which we made 14 recommendations to BIA. All recommendations remain open.
- To help ensure BIA can verify ownership in a timely manner and identify resources available for development, we made 2 recommendations, including that Interior take steps to improve its geographic information system mapping capabilities.
- To help ensure BIA's review process is efficient and transparent, we made 2 recommendations, including that Interior take steps to develop a documented process to track review and response times for energy-related documents that must be approved before tribes can develop energy resources.
- To help improve clarity of tribal energy resource agreement regulations, we recommended BIA provide additional guidance to tribes on provisions that tribes have identified to Interior as unclear.
- To help ensure that BIA's effort to streamline the review and approval process for revenue-sharing agreements achieves its objectives, we made 3 recommendations, including that Interior establish time frames for the review and approval of Indian revenue-sharing agreements for oil and gas, and establish a system for tracking and monitoring the review and approval process to determine whether time frames are met.
- To help improve efficiencies in the federal regulatory process, we made 4 recommendations, including that BIA take steps to coordinate with other regulatory agencies so the Indian Energy Service Center can serve as a single point of contact or lead agency to navigate the regulatory process.
- To help ensure that it has a workforce with the right skills, appropriately aligned to meet the agency's goals and tribal priorities, we made 2 recommendations, including that BIA establish a documented process for assessing BIA's workforce composition at agency offices.
Congressional Actions Needed
It is critical that Congress maintain its focus on improving the effectiveness with which federal agencies meet their responsibilities to serve tribes and their members. Since 2013, we testified at 6 hearings to address significant weaknesses we found in the federal management of programs that serve tribes and their members. Sustained congressional attention to these issues will highlight the challenges discussed here and could facilitate federal actions to improve Indian education and health care programs and the development of Indian energy resources.
GAO-17-181: Published: Jan 9, 2017. Publicly Released: Jan 9, 2017.
The Indian Health Service's (IHS) oversight of the quality of care provided in its federally operated facilities has been limited and inconsistent. While some oversight functions are performed at the headquarters level, the agency has delegated primary responsibility for the oversight of care to nine area offices. Area officials stated that the oversight they provide has included, for example, hol...
GAO-17-43: Published: Nov 10, 2016. Publicly Released: Nov 17, 2016.
Two key federal initiatives led by the Department of the Interior (Interior)—the interagency White House Council on Native American Affairs’ Energy Subgroup (Energy Subgroup) and Interior’s Indian Energy Service Center (Service Center)—were implemented to help improve collaboration and the effectiveness of federal efforts to fulfill management responsibilities for Indian lands, assist trib...
GAO-16-553: Published: Jun 13, 2016. Publicly Released: Jun 14, 2016.
The Department of the Interior (Interior) recently issued guidance intended to streamline the review process and reduce the approval times of oil and gas revenue-sharing agreements—called a communitization agreement (CA)—that include Indian resources. Under the revised guidance, for example, oil and gas operators are to provide simplified, less detailed information in their CA applications. In...
GAO-16-333: Published: Mar 29, 2016. Publicly Released: Apr 28, 2016.
The Indian Health Service (IHS) has not conducted any systematic, agency-wide oversight of the timeliness of primary care provided in its federally operated facilities. IHS has delegated primary responsibility for the oversight of care provided in its facilities to its area offices and has not set any agency-wide standards for patient wait times—including both how long it should take to schedule...
GAO-16-313: Published: Mar 10, 2016. Publicly Released: Mar 10, 2016.
The Department of the Interior's (Interior) Office of the Assistant Secretary-Indian Affairs (Indian Affairs) lacks sound information on safety and health conditions of all Bureau of Indian Education (BIE) school facilities. Specifically, GAO found that Indian Affairs' national information on safety and health deficiencies at schools is not complete and accurate because of key weaknesses in its in...
GAO-15-502: Published: Jun 8, 2015. Publicly Released: Jun 15, 2015.
Bureau of Indian Affairs' (BIA) management shortcomings and other factors—such as a complex regulatory framework, tribes' limited capital and infrastructure, and varied tribal capacity—have hindered Indian energy development. Specifically, BIA does not have the data it needs to verify ownership of some Indian oil and gas resources, easily identify resources available for lease, or identify whe...
GAO-15-389T: Published: Feb 27, 2015. Publicly Released: Feb 27, 2015.
Information on the physical condition of Bureau of Education (BIE) schools is not complete or accurate as a result of longstanding issues with the quality of data collected by the Department of the Interior's (Interior) Office of the Assistant Secretary-Indian Affairs (Indian Affairs). GAO's preliminary results indicate that issues with the quality of data on school conditions—such as inconsiste...
GAO-15-121: Published: Nov 13, 2014. Publicly Released: Nov 13, 2014.
Unlike public schools, Bureau of Indian Education (BIE) schools receive almost all of their funding from federal sources. BIE directly operates about a third of its schools, and tribes operate two-thirds. According to BIE data, all of the BIE schools received a total of about $830 million in fiscal year 2014: about 75 percent from the Department of the Interior (Interior), 24 percent from the Depa...
GAO-14-57: Published: Dec 11, 2013. Publicly Released: Dec 11, 2013.
For Indian Health Service (IHS) contract health services (CHS) delivered in fiscal year 2011, a majority of claims were paid within 6 months of the service delivery date, but some took much longer. Specifically, about 73 percent of claims were paid within 6 months of service delivery, while about 8 percent took more than 1 year. The CHS payment process consists of three main steps: (1) the local C...
GAO-13-774: Published: Sep 24, 2013. Publicly Released: Sep 24, 2013.
Students in Bureau of Indian Education (BIE) schools perform consistently below Indian students in public schools on national and state assessments. For example, based on estimates from a 2011 study using national assessment data, in 4th grade, BIE students on average scored 22 points lower for reading and 14 points lower for math than Indian students attending public schools. The gap in scores is...
GAO-13-553: Published: Sep 5, 2013. Publicly Released: Sep 5, 2013.
GAO estimates, on the basis of recent U.S. Census Bureau data, that most American Indians and Alaska Natives will be potentially eligible for either expanded or new coverage options created by the Patient Protection and Affordable Care Act (PPACA). These options include expanded eligibility for Medicaid--the federal-state program for certain low-income individuals--and eligibility for the Health I...
GAO-13-272: Published: Apr 11, 2013. Publicly Released: Apr 11, 2013.
The Indian Health Service's (IHS) federal contract health services (CHS) programs primarily paid physicians at their billed charges, which were significantly higher than what Medicare and private insurers would have paid for the same services. IHS's policy states that federal CHS programs should purchase services from contracted providers at negotiated, reduced rates. However, of the almost $63 mi...
GAO-12-446: Published: Jun 15, 2012. Publicly Released: Jun 15, 2012.
The Indian Health Services (IHS) allocation of contract health services (CHS) funds varied widely across the 12 IHS geographic areas. In fiscal year 2010, CHS funding ranged from nearly $17 million in one area to more than $95 million in another area. Per capita CHS funding for fiscal year 2010 also varied widely, ranging across the areas from $299 to $801 and was sometimes not related to th...
GAO-11-767: Published: Sep 23, 2011. Publicly Released: Sep 23, 2011.
The Indian Health Service (IHS), an agency in the Department of Health and Human Services (HHS), provides health care to American Indians and Alaska Natives. When care at an IHS-funded facility is unavailable, IHS's contract health services (CHS) program pays for care from external providers if the patient meets certain requirements and funding is available. The Patient Protection and Affordable C...