Improving Federal Programs that Serve Tribes and Their Members - High Risk Issue
Concerns about ineffective federal administration of Indian education and healthcare programs and federal mismanagement of energy resources held in trust for tribes and their members has resulted in the designation of federal management of these programs as high risk in 2017.
Federal agencies conduct a number of programs to fulfill their responsibilities to Indian tribes and Indians.
- The Bureau of Indian Education (BIE) administers education programs to approximately 41,000 Indian students at 185 schools around the country. Other offices under the Department of the Interior's Office of the Assistant Secretary-Indian Affairs (Indian Affairs), including Bureau of Indian Affairs (BIA) offices, provide administrative support to BIE schools.
- BIA also manages energy development on the 55 million surface acres (and 57 million subsurface acres) held in trust or restricted status for tribes and their members.
- The Indian Health Service (IHS) administers health care programs to approximately 2.2 million tribal members.
However, each of these agencies has had issues with oversight, collaborating with stakeholders, workforce planning, equipment and infrastructure, and data use. Consequently, federal management of programs that serve tribes was placed on our High Risk List in 2017.
- IHS provides limited and inconsistent oversight of the quality of care provided in its federally operated facilities. As a result, the agency cannot ensure that its patients are receiving quality health care.
- The amount of time it takes BIA to review and respond to proposals for energy development projects on Indian land has hindered the development of these energy resources. On September 30, 2018, BIA completed system updates that allow it to capture key dates in the agency review and approval process for mineral leases. BIA needs to continue its system enhancements to track the review timeframes in its processes so it can determine if its process is timely, transparent, and efficient.
- IHS does not require its area offices to inform headquarters if they distribute program funds to local Purchase Referred Care (PRC) programs using different criteria than headquarters recommends. These programs pay for patient services provided by external providers when services are not accessible or available at an IHS or tribal facility. As a result, IHS may be unaware of additional variation in the allocation of resources for patient services across areas.
- BIA has taken steps to form an Indian Energy Service Center to help expedite the permitting process for Indian energy projects. However, BIA did not coordinate with key regulatory agencies, such as the U.S. Fish and Wildlife Service or the Environmental Protection Agency, when doing so. As a result, this Center is not the central point for collaborating with all federal agencies involved in energy development, nor does it serve as a single point of contact for permitting requirements—as it was intended to be.
- About half of all BIE positions have not been filled, including positions in the field offices responsible for providing guidance and assistance to schools. Furthermore, BIE has not completed a workforce plan to address staffing and training gaps—which is critical to helping BIE and other Indian Affairs offices better understand and support the needs of BIE schools.
- An insufficient workforce has been the biggest impediment to ensuring patients can access timely primary care through the Indian health care system. There are over 1,550 vacancies for health care professionals throughout the IHS health care system—including for physicians, dentists, nurses, pharmacists, physician assistants, and nurse practitioners. As of November 2017, the overall vacancy rate for providers at IHS averaged 25 percent.
- BIA has not conducted key workforce planning activities, such as identifying key workforce skills, even though it has high vacancy rates at some of its offices.
Equipment and infrastructure
- Aging BIE school facilities and equipment contribute to degraded and unsafe conditions for students and staff. For example, seven boilers failed inspection at one school due to safety hazards like elevated levels of carbon monoxide and a natural gas leak. Four of the boilers were located in a student dormitory, three were located in classroom buildings, and all but one of the boilers were about 50 years old. Most of these boilers were not repaired until 8 months after failing inspection.
Source: GAO. | GAO-16-313
- Access to timely primary care at some health care facilities serving Indian communities is hindered by outdated medical and telecommunications equipment.
- Indian Affairs has not ensured that the data its inspectors collect on the safety of BIE school facilities are complete and accurate. For example, inspectors assigned incorrect or inconsistent risk assessment codes in 11 school safety reports (which identify the risk level associated with specific safety hazards and the associated timeframes for addressing them). In addition, 18 reports prepared by 10 inspectors indicated they had not inspected all school buildings. Incomplete or inaccurate school inspection data could misinform school officials about safety hazards, lead to delays in repairs, and potentially put the health and safety of students at risk.
- IHS does not have reliable estimates of unmet needs in the PRC program. For example, the agency has not provided adequate oversight to ensure that the annual reports it receives from each area office (and uses to estimate unmet need) include all necessary data.
GAO-18-580: Published: Aug 15, 2018. Publicly Released: Aug 15, 2018.
Indian Health Service clinics don’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-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 causes—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 that—when developed—can improve tribal well-being and long-term economic success. However, a number of factors—including a complex federal regulatory framework that involves multiple agencies—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 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...