Department of Homeland Security:

Organizational Structure, Spending, and Staffing for the Health Care Provided to Immigration Detainees

GAO-09-401T: Published: Mar 3, 2009. Publicly Released: Mar 3, 2009.

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Alicia P. Cackley
(202) 512-7022


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Immigration and Customs Enforcement (ICE) was created in March 2003 as part of the Department of Homeland Security (DHS). From fiscal year 2003 through fiscal year 2007, the average daily population of detainees in ICE custody increased by about 40 percent, with the most growth occurring since fiscal year 2005. In fiscal year 2007, ICE held over 311,000 detainees at more than 500 detention facilities. Most of these were Intergovernmental Service Agreement (IGSA) facilities--state and local jails under contract with ICE to hold detainees. Some ICE detainees received health care services from IGSA staff, IGSA contractors, or community medical providers, and other ICE detainees received health care provided or arranged by the Division of Immigration Health Services (DIHS). DIHS is mainly composed of contract employees and officers from the U.S. Public Health Service (PHS) Commissioned Corps--a uniformed service of public health professionals who are part of the Department of Health and Human Services (HHS) and who provide services in different settings, including ICE detention facilities. In light of questions about the health care provided to detainees in ICE custody, Congress requested information about ICE's organizational structure and its health care resources for detainees. Our report provides (1) a description of ICE's organizational structure for providing health care services to detainees, which includes our review of the relevant agreements between DHS and HHS regarding DIHS; (2) information about ICE's annual spending and staffing resources devoted to the provision of health care for detainees, and the number of services provided; and (3) an assessment of whether ICE's mortality rate can be compared with the mortality rates of the Federal Bureau of Prisons (BOP) and the U.S. Marshals Service (USMS)--two entities that are responsible for holding certain persons, such as criminals.

In summary, we found that ICE's organizational structure for providing health care to detainees is not uniform across facilities. In fiscal year 2007, 21 DIHS-staffed facilities provided or arranged for health care for about 53 percent of the average daily population of detainees, while 508 IGSA facilities provided or arranged for health care for the remaining detainees--about 47 percent of the population. Before October 1, 2007, DHS and HHS maintained annual interagency agreements through which DIHS--a component of HHS's Health Resources and Services Administration (HRSA)--provided health care for ICE detainees. As of that date, the last annual interagency agreement was terminated, and DIHS no longer is a component of HRSA. DHS officials told us that this termination--along with a 2007 Memorandum of Agreement between HHS and DHS that placed PHS officers on detail to DHS on an open-ended basis and that allowed for additional PHS officers to be detailed to DHS in the future--affected 565 direct health care providers and administrative staff. According to DHS officials, ICE now has a component known as DIHS which provides health care services to detainees. We also found that although ICE's health care data are not complete, the available data on health care spending, staffing, and services provided generally showed growth in all three areas. For instance, from fiscal year 2003 through fiscal year 2007, reported expenditures for medical claims and program operations increased by 47 percent, while the average daily population of detainees increased by about 40 percent. However, ICE facilities do not use standardized record keeping, and are not required to routinely report data to DHS on the health care services provided to detainees. Furthermore, data were not available on the detainee health expenditures that are incurred by IGSAs. In addition, we determined that ICE's mortality rate cannot be directly compared with BOP's or USMS's mortality rate. This is due to differences in the three agencies' health care goals and scopes of services, as well as to demographic differences among the ICE, BOP, and USMS detainee populations. Based on our work, we have identified a number of issues that may merit further assessment in the $2 million external study that ICE was directed to fund. These include: (1) ICE's ability to access detainee population data that measure unique individuals in ICE custody, rather than the average number of beds used; (2) Reporting relationships between DIHS and ICE; (3) IGSA reporting requirements--including the frequency of reporting on health care services provided to detainees and the format in which health records are maintained; (4) ICE's ability to routinely ensure the transfer of medical records when detainees are transferred between facilities; (5) ICE's ability to identify and report the detainee health care costs incurred by IGSAs; and (6) ICE's ability to identify and report medical claims expenditures by facility type--such as for all IGSAs.

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