Improving Federal Management of Programs that Serve Tribes and Their Members
Because our work has shown federal agencies have ineffectively administered Indian education and health care programs, and inefficiently met their responsibility for managing the development of Indian energy resources, we added this area to our High-Risk List in 2017. It includes three components across agencies in two departments, including BIE and BIA under Interiorâ€™s Office of the Assistant-Secretary of Indian Affairs (Indian Affairs), and IHS in Health and Human Services.
Education. BIE challenges included poor conditions at BIE school facilities that endangered students and the agencyâ€™s weak oversight of school spending.
Health care. HHSâ€™s inadequate oversight has hindered IHSâ€™s ability to ensure that Indian communities have timely access to quality health care.
Energy. BIA mismanagement of Indian energy resources held in trust limited opportunities for tribes and their members to use those resources to create economic benefits and improve the well-being of their communities.
We added this area to our High-Risk List in 2017 and are assessing all three segments against our high-risk criteria for the first time. Overall, the three agencies have partially met the leadership commitment, capacity, action plan, monitoring, and demonstrated progress criteria for the education, health care, and energy areas.
Since we added this area to our High-Risk List in 2017, we have testified at seven congressional hearings. We believe that it is vital for Congress to maintain its focus on improving the effectiveness with which federal agencies meet their responsibilities to serve tribes and their members in these areas.
When we added this area to our High-Risk List in February 2017, there were 39 open recommendations. Since then, we added 13 recommendations. As of December 2018, 32 recommendations remain open.
The education segment has partially met all five criteria for addressing high-risk issues.
Leadership commitment: partially met. Indian Affairs leaders have shown commitment to addressing key weaknesses in the management of BIE schools. For example, the BIE Director formed an internal working group, convened meetings with other senior leaders within Indian Affairs, and publicly stated that his agency is committed to implementing our recommendations. We also met with the new Assistant Secretary-Indian Affairs, who expressed her commitment to supporting the agencyâ€™s efforts to address weaknesses in the management of BIE schools. However, frequent turnover in key leadership positions in recent years has hampered Indian Affairsâ€™ efforts to make improvements to Indian education.
Capacity: partially met. BIE and other Indian Affairs offices that support BIE schools have made some progress in increasing their capacity to address risks to Indian education. For example, BIE officials hired a full-time program analyst to coordinate the agencyâ€™s working group and help oversee the implementation of our recommendations. However, about 50 percent of all BIE positions have not been filled and the bureau has not completed a workforce plan to address staffing and training gaps, as we previously recommended. BIE officials told us they are developing a workforce plan, which they plan to complete by the end of 2018.
Action plan: partially met. Among other actions, BIE implemented a new action plan, including written procedures and risk criteria for overseeing BIE school expenditures, which fully addressed two priority recommendations. However, Indian Affairs has not provided documentation that it has developed and put in place action plans on other important issues, such as a comprehensive, long-term capital asset plan to inform its allocation of school facility funds, which we recommended.
Monitoring: partially met. Indian Affairs, in consultation with Department of Interiorâ€™s Office of Occupational Safety and Health, has taken actions to monitor corrective measures that address weaknesses with the agencyâ€™s safety programâ€”which covers safety at BIE schools. However, the agency has not yet demonstrated that it is monitoring several other areas, such as whether relevant employees are being held to the agencyâ€™s required performance standards for safety inspections.
Demonstrated progress: partially met. Since our 2017 High-Risk report, Indian Affairs has fully addressed 11 of our 23 outstanding recommendations on Indian education. Overall, this represents a substantial increase in implementing our recommendations on Indian education since we identified the area as high-risk. Significant work, however, remains to address our outstanding recommendations in several key areas, such as workforce planning and accountability for BIE school safety and school construction projects.
IHS has partially met all five criteria to address the health care high-risk segment.
Leadership commitment: partially met. IHS officials have demonstrated leadership commitment by regularly meeting with us to discuss the agencyâ€™s progress in addressing our recommendations. In addition, IHS has chartered a policy advisory council that will focus on issues related to strategic direction, recommended policy, and organizational adjustments. According to IHS, this advisory council will, among other things, serve as a liaison among IHS leadership for issues involving strategic direction and policy, as well as monitor and facilitate related policy workgroups. However, IHS still does not have permanent leadershipâ€”including a Director of IHS.
Capacity: partially met. Among other actions, IHS officials stated that the agency is expanding the role of internal audit staff within its enterprise risk management program to augment internal audits and complement both the Department of Health and Human Services Inspector General and our audits. In addition, IHS has developed a new Office of Quality, which is expected to develop and monitor agency-wide quality of care standards. However, according to IHS, there are still vacancies in several key positions.
Action plan: partially met. IHS is in the final stages of developing a strategic plan and a related work plan to address certain root causes of management challenges and define solutions and corrective measures for the agency. The draft strategic plan divides these challenges into three categories: (1) access to care, (2) quality of care, and (3) program management and operations. We will examine the final strategic plan and related work plan to determine whether they contain the needed elements of an action plan once issued.
Monitoring: partially met. IHS has taken some steps toward monitoring the agencyâ€™s progress in addressing the root causes of their management weaknesses. In addition to developing its new Office of Quality, IHS has taken steps to develop a patient experience of care survey, as well as standards for tracking patient wait times. These efforts should be reflected in the agencyâ€™s corrective plan, as part of an overall framework for monitoring progress that includes goals and performance measures to track their efforts and ultimately verify the effectiveness of their efforts.
Demonstrated progress: partially met. IHS has made progress in implementing corrective actions related to the management of health care programs. Specifically, since our 2017 High-Risk report, IHS implemented four of our 13 open recommendations. For example, in response to our April 2013 recommendation, to ensure that IHSâ€™s payment rates for contracted services do not impede patient access to physician and other nonhospital care, IHS developed an online tool that enables the agency to track providers that do not accept IHSâ€™s payment rates. In addition, IHS officials told us that they plan to complete the implementation of additional recommendations in 2019.
BIA has partially met all five criteria to address the energy high-risk segment.
Leadership commitment: partially met. In June 2018, a permanent Assistant Secretary for Indian Affairs was confirmed. This action provided an opportunity to improve Indian Affairsâ€™ oversight of federal actions associated with energy development. However, BIA does not have a permanent Director, and BIAâ€™s Office of Trust Servicesâ€”which has significant responsibility over Indian energy activitiesâ€”does not have a permanent Director or Deputy Director.
Capacity: partially met. In November 2016, we recommended that BIA establish a documented process for assessing the workforce at its agency offices. BIA conducted a survey to identify workforce needs related to energy development to support staffing decisions at the new Indian Energy Service Center. However, BIA officials said the agency does not have the staff or resources to implement a comprehensive workforce planning system to ensure it has staff in place at its agency offices to meet its organization needs.
Action plan: partially met. BIA officials met with us several times in fiscal year 2018 to discuss actions and plans for implementing our recommendations related to Indian energy resources. BIA officials told us that they proposed several modifications to the bureauâ€™s land records data management system that will enable increased tracking and monitoring of key documents that BIA must review prior to the development of Indian energy resources. However, the agency does not have a comprehensive plan in place to identify causes of long-standing management weaknesses or an action plan to address the problems.
Monitoring: partially met. BIA has taken steps to improve monitoring by holding frequent meetings assessing its progress in implementing our recommendations. However, BIA has not taken steps to monitor its progress addressing the root causes of management weaknesses.
Demonstrated progress: partially met. BIA has shown significant progress developing data collection instruments and processes needed to track and review response times for a number of different actions associated with energy development. However, more needs to be done to close open recommendations, as discussed below.
Continued progress will depend on sustained direction and support of top management in Indian Affairs and BIE. In addition, to increase its capacity to support functions related to administering and overseeing BIE schools, BIE needs to conduct strategic workforce planning and determine how best to align its human capital program with its mission and programmatic goals, as we have recommended. As of December 2018, 12 recommendations related to this high-risk area remain open and Indian Affairs concurred with all 12 recommendations.
We have identified several priority actions for IHS in its role of providing accessible health care services to Indian tribes.
- IHS needs to ensure stable, permanent leadership that can assign the tasks needed to address weaknesses and hold individuals accountable for progress.
- IHS needs to continue to develop a corrective action plan that defines root causes, identifies solutions, and provides for substantially completing corrective measures.
- IHS needs to set up goals and performance measures to monitor the outcomes from its action plan.
- IHS needs to continue to address our open recommendations in this area, including (1) ensuring that agency-wide standards for the quality of care are developed, that facility performance in meeting these standards is systematically monitored over time, and that enhancements are made to its adverse event reporting system, and (2) monitoring patient wait times and ensuring corrective actions are taken when standards are not met.
As of December 2018, 7 out of the 13 recommendations in our 2017 High-Risk report remain open, and we have added one additional recommendationâ€”for a total of 8 open recommendations related to this high-risk area. IHS fully concurred with these 8 recommendations.
Congressional Actions Needed
We have an open matter for Congress to consider requiring IHS to develop and use a new method to more equitably allocate Purchased/Referred Care program fundsâ€”which allow patients to receive care from external providersâ€”across areas.
BIA needs to (1) provide decision makers with key information on resources needed to assess the composition of its workforce and implement a comprehensive workforce planning system, and (2) continue to identify causes of weaknesses with the management of Indian energy and mineral resources, and develop a plan to address these problems with clear milestones, well-defined performance measures, and a monitoring approach. As of December 2018, 12 of the 14 recommendations in our 2017 High-Risk report remain open. BIA fully concurred with all 12 recommendations.
GAO-18-580: Published: Aug 15, 2018. Publicly Released: Aug 15, 2018.
Indian Health Service clinics donâ€™t have enough doctors or nurses to provide quality and timely health care to American Indian and Alaska Native people. IHS data show an average vacancy rate for physicians, nurses, and other care providers of 25%. IHS uses multiple strategies to recruit and retain providers, including offering financial incentives and housing. However, IHS has trouble matching...
GAO-18-616T: Published: Jun 13, 2018. Publicly Released: Jun 13, 2018.
We added the federal management of programs that serve Indian tribes and their members to our High Risk List in February 2017. We found numerous weaknesses in how the Interior Department's Bureaus of Indian Education and Indian Affairs managed education, how the Bureau of Indian Affairs managed energy resources, and how the Department of Health and Human Services' Indian Health Services managed he...
GAO-17-790T: Published: Sep 13, 2017. Publicly Released: Sep 13, 2017.
As discussed in the 2017 High Risk report, GAO has identified numerous weaknesses in how the Department of the Interior (Interior) and the Department of Health and Human Services (HHS) manage programs serving Indian tribes. Specifically, these weaknesses were related to Interior's Bureau of Indian Education (BIE) and Bureau of Indian Affairs (BIA)â€”under the Office of the Assistant Secretary-Indi...
GAO-17-421: Published: May 24, 2017. Publicly Released: May 24, 2017.
The Department of the Interior (Interior) and its Office of the Assistant Secretary-Indian Affairs (Indian Affairs) have not taken actions to address identified weaknesses in the Bureau of Indian Affairs' (BIA) safety program, despite internal evaluations that have consistently found it to be failing. Specifically, Interior's internal evaluations conducted since 2011 identified major deficiencies...
GAO-17-447: Published: May 24, 2017. Publicly Released: May 24, 2017.
The Department of the Interior's (Interior) Office of the Assistant Secretary-Indian Affairs (Indian Affairs) does not have a comprehensive capital asset plan to guide the allocation of funding for school construction projects across its 185 Bureau of Indian Education (BIE) schools. Indian Affairs is in the process of replacing 3 schools and plans to replace 10 additional schools from a list of 54...
GAO-17-181: Published: Jan 9, 2017. Publicly Released: Jan 9, 2017.
American Indians and Alaska Natives die at higher rates than other Americans from preventable causesâ€”such as diabetes and influenza. The Indian Health Service is charged with providing health care to these populations, but we found it had limited, inconsistent oversight over the quality of care at its facilities. Among other things, a lack of agency-wide performance standards and significant le...
GAO-17-43: Published: Nov 10, 2016. Publicly Released: Nov 17, 2016.
Tribal nations hold considerable energy resources thatâ€”when developedâ€”can improve tribal well-being and long-term economic success. However, a number of factorsâ€”including a complex federal regulatory framework that involves multiple agenciesâ€”have hampered development. A collaborative federal approach to helping tribes achieve their energy goals is important. But we found that federal init...
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 timesâ€”including both how long it should take to schedule...