Health Care Access:

Improved Oversight, Accountability, and Prioritization Can Improve Access for Native American Veterans

GAO-14-489: Published: Jun 10, 2014. Publicly Released: Jun 10, 2014.

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What GAO Found

The Department of Veterans Affairs (VA) and the Indian Health Service (IHS) have taken a variety of actions to improve access to care for Native American veterans under their 2010 memorandum of understanding (MOU); however according to stakeholders, these agencies face substantial implementation challenges. VA and IHS have taken actions to (1) strengthen outreach and enrollment through information sharing and training; (2) expand services through national and local projects; (3) increase training about cultural competency for staff at VA and IHS facilities; and (4) establish reimbursement agreements that allow VA to reimburse IHS facilities for services provided to veterans. However, in each of these areas challenges remain, such as insufficient data to identify Native American veterans for outreach, obstacles to reaching those who live in very remote areas, and technological challenges such as lack of Internet connectivity or phone lines.

While VA and IHS have taken actions to increase access, the oversight, accountability, and prioritization of MOU implementation are lacking. Specifically:

Oversight is inconsistent: In 2013, the officials tasked with oversight of the implementation of the MOU did not meet and did not systematically evaluate the progress of MOU implementation.

Written policies and guidance are lacking: According to officials, the only documentation outlining the procedures to report VA and IHS progress on implementation efforts is contained in a set of training slides used in a December 2012 training session, and these slides have not been formalized in written policy or guidance.

Prioritization of MOU implementation is lacking: Leadership of VA and IHS have not made MOU implementation a priority, which threatens the ability of the two agencies to move forward in implementing the MOU. Key officials attributed this, in part, to their perception that their non-MOU related responsibilities had a higher priority.

Without consistent oversight, formal policy or guidance on responsibilities for MOU implementation, and the prioritization of MOU implementation, VA and IHS leadership do not have reasonable assurance that the objectives of the MOU related to access to care are being addressed.

Native American veterans and their representatives that GAO contacted reported mixed views on whether access to care has improved over the past 3 years. Although a majority reported that access to care had improved, others either said that that they did not think it had improved or were unsure. For example, 53 of 102 Native American veterans representatives GAO contacted reported that in the last 3 years there had been an increase in the number of Native American veterans accessing health care at VA or IHS-funded facilities; however, 12 felt there had been no change, and 36 said they did not know.

Why GAO Did This Study

Native Americans who have served in the military may be eligible for health care services from both VA and IHS, but according to reports some have had problems accessing care. In 2010 these two agencies expanded upon an MOU designed to improve Native American veterans' access to care at their facilities. GAO was asked to examine how the MOU has increased access to care.

This report examines: (1) the actions that VA and IHS have taken to implement the provisions in the 2010 MOU related to access to care for Native American veterans, and (2) what is known about how access to care for Native American veterans has improved. To conduct this work, GAO reviewed agency documents and VA and IHS reimbursement data and interviewed VA and IHS officials. GAO also visited three sites selected to reflect geographic variation to learn about access to care locally through interviews with regional VA and IHS officials, health facility officials, and Native American veterans and their tribal representatives. GAO also contacted other individuals who help Native American veterans seek enrollment in the VA to obtain their insights about improvements in access to care.

What GAO Recommends

GAO recommends that VA and IHS establish written policy or guidance designating specific roles and responsibilities for agency staff to hold leadership accountable and improve implementation and oversight of the MOU. VA and IHS agreed with GAO's recommendation.

For more information, contact Randall Williamson at (202) 512-7114 or williamsonr@gao.gov.

Recommendations for Executive Action

  1. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: To improve access to care for Native American veterans through MOU implementation, the Acting Secretary of Veterans Affairs and the Secretary of Health and Human Services should establish written policy or guidance designating specific roles and responsibilities for agency staff to hold leadership accountable and improve implementation and oversight of the MOU. In developing written policies and guidelines, strong consideration should be given to the guidance embodied in the training slides from December 2012, including the following: (1) Develop an organizational chart clearly outlining the VA and IHS MOU structure and detailing agency staff roles and responsibilities. (2) Require that regularly scheduled meetings be held by the Joint Implementation Task Force or other groups charged with the oversight of MOU implementation. (3) Ensure that VISNs and the MOU work groups submit reports to VA and IHS quarterly, as well as ensure that the groups charged with the oversight of MOU implementation complete reviews and analyses of the information collected to assess MOU progress and address any deficiencies. (4) Ensure that the Joint Implementation Task Force, or other groups charged with oversight of MOU implementation, identifies strategies and plans for accomplishing tasks related to the MOU to implement best practices and address challenges.

    Agency Affected: Department of Health and Human Services

  2. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: To improve access to care for Native American veterans through MOU implementation, the Acting Secretary of Veterans Affairs and the Secretary of Health and Human Services should establish written policy or guidance designating specific roles and responsibilities for agency staff to hold leadership accountable and improve implementation and oversight of the MOU. In developing written policies and guidelines, strong consideration should be given to the guidance embodied in the training slides from December 2012, including the following: (1) Develop an organizational chart clearly outlining the VA and IHS MOU structure and detailing agency staff roles and responsibilities. (2) Require that regularly scheduled meetings be held by the Joint Implementation Task Force or other groups charged with the oversight of MOU implementation. (3) Ensure that VISNs and the MOU work groups submit reports to VA and IHS quarterly, as well as ensure that the groups charged with the oversight of MOU implementation complete reviews and analyses of the information collected to assess MOU progress and address any deficiencies. (4) Ensure that the Joint Implementation Task Force, or other groups charged with oversight of MOU implementation, identifies strategies and plans for accomplishing tasks related to the MOU to implement best practices and address challenges.

    Agency Affected: Department of Veterans Affairs

 

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