Indian Health Service: Actions Needed to Improve Oversight of Federal Facilities’ Decision-Making About the Use of Funds

What GAO Found

The Indian Health Service’s (IHS) oversight of federally operated health care facilities’ decision-making process about the use of funds has been limited and inconsistent. Funds include those from appropriations, as well as payments from federal programs, such as Medicaid and from private insurance, for care provided by IHS to American Indians and Alaska Natives (AI/AN). While some oversight functions are performed at IHS headquarters, the agency has delegated primary responsibility for the oversight of health care facilities’ decision-making about the use of funds to its area offices. Area office officials said the oversight they provide has generally included (1) reviewing facilities’ scope of services, and (2) reviewing facilities’ proposed expenditures. However, GAO’s review found that this oversight was limited and inconsistent across IHS area offices, in part, due to a lack of consistent agency-wide processes.

  • While IHS officials from all nine area offices GAO interviewed said they reviewed facilities’ scope of services and coordinated with tribes when doing so, none reported systematically reviewing the extent to which their facilities’ services were meeting local health needs, such as by incorporating the results of community health assessments. Such assessments can involve the collection and assessment of data, as well as the input of local community members and leaders to identify and prioritize community needs. These assessments can be used by facilities to assess their resources and identify priorities for facility investment. While IHS has identified such assessments as a priority, the agency does not require federally operated facilities to conduct such assessments or require the area offices to use them as they review facilities’ scope of services.
  • To ensure that facilities are effectively managing their resources, IHS has a process to guide its review of facilities’ proposed construction projects that cost at least $25,000. However, IHS does not have a similar process to guide its oversight of other key proposed expenditures, such as those involving the purchase of major medical equipment, the hiring of providers, or the expansion of services. Specifically, GAO found limitations and inconsistencies with respect to requiring a documented justification for proposed expenditures; documenting the review and approval of decisions; and conducting an impact assessment on patient access, cost, and quality of care.

The limitations and inconsistencies that GAO found in IHS’s oversight are driven by the lack of consistent oversight processes across the area offices. Without establishing a systematic oversight process to compare federally operated facilities’ current services to population needs, and to guide the review of facilities’ proposed expenditures, IHS cannot ensure that its facilities are identifying and investing in projects to meet the greatest community needs, and therefore that federal resources are being maximized to best serve the AI/AN population.

Why GAO Did This Study

IHS, an agency of the Department of Health and Human Services, provides care to AI/AN populations through a system of federally operated and tribally operated health care facilities. AI/AN have experienced long standing problems accessing needed health care services. GAO has previously reported that IHS has not been able to pay for all eligible health care services; however, the resources available to federally operated facilities have recently grown.

This report assesses IHS oversight of federal health care facilities’ decision-making about the use of funds. GAO reviewed IHS policies and documents; and interviewed IHS officials from headquarters, nine area offices, and three federally operated facilities (two hospitals and one health clinic).

What GAO Recommends

GAO recommends that IHS develop processes to guide area offices in (1) systematically assessing how federally operated facilities will effectively meet the needs of their patient populations, and (2) reviewing federal facilities’ spending proposals. HHS concurred with these recommendations.

For more information, contact Jessica Farb at (202) 512-7114 or farbj@gao.gov.

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    Local education officials in natural disaster-affected areas told us the Coronavirus Disease 2019 (COVID-19) pandemic has exacerbated mental health issues and contributed to lost instructional time, staff burnout, delays in recovery projects, and financial strain in their communities. These officials explained that after the natural disaster, restoring students' mental health was a top priority. Many local education officials said that the services needed to treat trauma and other disaster-related mental health issues were not readily available in their areas, and some noted that providing mental health services has been especially difficult during the pandemic. For example, one official said that because half of her students live in poverty, they usually access mental health services through the school, and were cut off from those services during the pandemic. Some local education officials said they were also particularly worried about the effects of the pandemic on their low-income and other at-risk students, noting that these students are especially vulnerable to learning loss. The COVID-19 pandemic has also affected districts by slowing progress on some disaster recovery projects. For example, an official in a district affected by wildfire said that an effort to restore running water to damaged school buildings was delayed due the pandemic. The U.S. Department of Education (Education) supported school recovery efforts by awarding nearly $1.4 billion to assist schools in over 30 states and U.S. territories with recovery from presidentially-declared major disasters occurring between 2017 and 2019, although some local education officials reported difficulty in using these grant funds during the pandemic. Education provided this funding through the Immediate Aid to Restart School Operations (Restart) and the Project School Emergency Response to Violence grant programs, among others. Local education officials from several districts and counties said that they are using or planning to use Education disaster grants to provide mental health services to students and cover other costs associated with re-opening, such as additional transportation services, but that during the pandemic this was sometimes challenging. For example, officials in two counties said that timeframes for using Restart funds, which expire after 2 years, were too short for long-term recovery needs such as mental health services, particularly with the compounding effects of the pandemic. Education officials said that grantees may request waivers to extend the end dates of these grants and that as of October 2020, no Restart grantees who experienced a 2018 disaster had done so. With regard to oversight, Education officials said they paused on-site monitoring efforts for recent disaster grants as a result of the pandemic, but have continued to hold quarterly phone calls with Restart grantees. These grantees have noted some challenges related to the grant program but have not discussed specific technical assistance needs, according to Education officials. More than 260 presidentially-declared major disasters have occurred since 2017, affecting every state and several U.S. territories, according to the Federal Emergency Management Agency (FEMA). Many of these natural disasters have had devastating effects, including rendering K-12 school facilities unusable for lengthy periods of time. These schools are now experiencing the compounding challenge of recovering from natural disasters while managing effects of the COVID-19 pandemic. Social distancing practices and building closures are meant to keep staff and students safe, but may also complicate recovery efforts for disaster-affected districts. The Additional Supplemental Appropriations for Disaster Relief Act of 2019 provided funds for GAO to audit issues related to presidentially-declared major disasters that occurred in 2018. We reviewed (1) how the COVID-19 pandemic has affected schools recovering from recent natural disasters; and (2) support Education has provided to help school recover from recent natural disasters and how the COVID-19 pandemic has affected schools' use of these resources. We interviewed 29 local education officials representing over 50 school districts in California, Commonwealth of the Northern Mariana Islands, Florida, and Hawaii, which were selected because they were affected by a diverse set of major natural disasters in 2018 that occurred in a mix of populated and less-populated areas. In addition, through a national school superintendents association, we convened a discussion group of superintendents who have experienced natural disasters and mentor other affected districts. Finally, we reviewed federal guidance and interviewed Education officials. For more information, contact Jacqueline M. Nowicki at (617) 788-0580 or nowickij@gao.gov.
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  • Justice Department Applauds Passage of the Criminal Antitrust Anti-Retaliation Act
    In Crime News
    On Dec. 23, 2020, President Donald J. Trump signed into law the Criminal Antitrust Anti-Retaliation Act (the “Act”), which prohibits employers from retaliating against certain individuals who report criminal antitrust violations. The Act was sponsored by Senator Chuck Grassley, passed the Senate on Oct. 17, 2019, and passed the House of Representatives on Dec. 8, 2020.
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  • Military Spouse Employment: DOD Should Continue Assessing State Licensing Practices and Increase Awareness of Resources
    In U.S GAO News
    According to estimates from Department of Defense (DOD) survey data, roughly one-quarter of military spouses who were in the workforce and in career fields that required credentials (state licenses or certifications) were unemployed in 2017. In that same year, about one-quarter of spouses who were employed in credentialed career fields were working outside their area of expertise, and about one in seven were working part-time due to a lack of full-time opportunities—two potential indicators of underemployment. Employment outcomes for military spouses may also vary due to other factors, including their partner's rank and frequent moves, according to DOD survey data and GAO's literature review. In February 2020, the Defense State Liaison Office, which works on key issues affecting military families, assessed states' use of best practices that help military spouses transfer occupational licenses. For example, the Liaison Office found that 34 states could increase their use of interstate compacts, which allow spouses in certain career fields, such as nursing, to work in multiple states without relicensing (see figure). However, the Liaison Office does not plan to continue these assessments, or assess whether states' efforts are improving spouses' experiences with transferring licenses. As a result, DOD may not have up-to-date information on states' actions that help spouses transfer their licenses and maintain employment. Assessment by the Defense State Liaison Office of Number of States Using Interstate Compacts to Improve Military Spouse Employment DOD and the military services use a range of virtual and in-person outreach to promote awareness of employment resources among military spouses. For example, officials GAO interviewed at installations said they promoted resources through social media and at orientation briefings. Nonetheless, GAO found that inconsistent information sharing across DOD and with external stakeholders who help spouses with employment hindered the effectiveness of outreach. For instance, officials from two services said they do not have methods to regularly exchange outreach best practices or challenges, while officials from another service said they have quarterly staff calls to share lessons learned. Without strategies for sharing information among internal and external stakeholders, DOD may miss opportunities to increase spouses' awareness of available resources, and improve their employment opportunities. There were over 605,000 spouses of active duty servicemembers in the U.S. military as of 2018. These spouses may face conditions associated with the military lifestyle that make it challenging to start or maintain a career, including frequent moves and difficulties transferring occupational licenses. House Armed Services Committee Report 116-120 accompanying the National Defense Authorization Act for Fiscal Year 2020 included a provision for GAO to review several matters related to military spouse employment. This report examines (1) selected employment outcomes for military spouses, (2) DOD's efforts to evaluate states' licensing policies for spouses, and (3) DOD's outreach efforts to promote awareness of employment resources. GAO reviewed DOD documentation and 2017 survey data (most recent available), relevant literature, and federal laws; interviewed DOD and military services officials and relevant stakeholders; and spoke with staff at six military installations selected based on the numbers of servicemembers, among other factors. GAO is making two recommendations to DOD to continue assessing and reporting on states' efforts to help military spouses transfer occupational licenses, and to establish information sharing strategies on outreach to military spouses about employment resources. DOD concurred with both recommendations. For more information, contact Elizabeth Curda at (202) 512-7215 or curdae@gao.gov.
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    In Travel
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  • Researcher Pleaded Guilty to Conspiring to Steal Scientific Trade Secrets from Ohio Children’s Hospital to Sell in China
    In Crime News
    Former Ohio woman Li Chen, 46, pleaded guilty today via video conference in U.S. District Court today to conspiring to steal scientific trade secrets and conspiring to commit wire fraud concerning the research, identification and treatment of a range of pediatric medical conditions.
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  • Secretary Blinken’s Call with Special Envoy for the UN Secretary-General on Yemen Griffiths
    In Crime Control and Security News
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  • Secretary Antony J. Blinken With Martha Raddatz of ABC’s This Week with George Stephanopoulos
    In Crime Control and Security News
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    In Crime Control and Security News
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  • Statement by Attorney General Merrick B. Garland on Earth Day
    In Crime News
    On April 22, 1970, millions of people across America came together and sparked a movement that led to the enactment of many of our nation’s foundational environmental laws, including the Clean Air Act, the Endangered Species Act, the Clean Water Act, and the Safe Drinking Water Act.
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  • Justice Department Sues Yale University for Illegal Discrimination Practices in Undergraduate Admissions
    In Crime News
    The Justice Department today filed suit against Yale University for race and national origin discrimination. The complaint alleges that Yale discriminated against applicants to Yale College on the grounds of race and national origin, and that Yale’s discrimination imposes undue and unlawful penalties on racially-disfavored applicants, including in particular most Asian and White applicants.
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  • The Departments of Justice and Homeland Security Publish Final Rule on Procedures for Asylum and Withholding of Removal
    In Crime News
    Today, the Department of Justice and the Department of Homeland Security (collectively, the Departments) announced the forthcoming publication of a Final Rule that will streamline and enhance procedures for the adjudication of claims for asylum, withholding of removal, and protection under the Convention Against Torture (CAT) regulations. 
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  • Justice Department Announces Civil Investigation into Louisiana’s Prisoner Release Practices
    In Crime News
    The Justice Department announced today that it has opened a statewide civil investigation into Louisiana’s prisoner release practices.
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