HIGH RISK

Actions Needed to 

Address Serious 

Weaknesses in Federal 

Management of Programs 

Serving Indian Tribes

Statement of Melissa Emrey-Arras, Director, 

Education, Workforce, and Income Security

Frank Rusco, Director, Natural Resources and 

Environment

Kathleen M. King, Director, Health Care

Accessible Version

Testimony 

Before the Subcommittee on Interior, 

Environment, and Related Agencies,

Committee on Appropriations, House of 

Representatives

For Release on Delivery 

Expected at 2:00 p.m. ET

Wednesday, May 24, 2017

GAO-17-589T

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-17-589T, a testimony

before the Subcommittee on Interior, 

Environment, and Related Agencies, 

Committee on Appropriations, House of 

Representatives

May 24, 2017

HIGH RISK

Actions Needed to Address Serious Weaknesses in 

Federal Management of Programs Serving Indian 

Tribes

What GAO Found

As discussed in GAO’s 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) in overseeing education 

services and managing Indian energy resources, and HHS’ Indian Health 

Service (IHS) in administering health care services.

· Education. GAO found serious weaknesses in BIE’s oversight of school 

spending and identified unsafe school conditions. For example, in 2014 GAO 

reported that BIE did not have written procedures and risk criteria to ensure 

that schools use federal funds to educate students. Further, GAO found that 

BIE staff lacked expertise and training to effectively oversee school 

spending. As a result, GAO found several instances of misused funds, 

including $1.7 million for one school that was improperly transferred to offshore accounts. In 2016, GAO also reported that deteriorating facilities and 

equipment contributed to unsafe conditions at BIE schools. At one school, 

GAO found seven boilers that failed inspection because of safety hazards, 

such as elevated levels of carbon monoxide and a natural gas leak. Though 

they endangered student safety, most of the boilers were not repaired until 8 

months after inspection.

· Energy resource management. GAO found that BIA had inefficiently 

managed Indian energy resources and the energy development process. For 

example, in June 2015 GAO reported that although BIA’s review and 

approval are required before Indian energy resources can be developed, BIA 

does not have a process or the data needed to track its review and response 

times. According to a tribal official, BIA’s review of some energy-related 

documents took as long as 8 years, and during that time the tribe estimates it 

lost more than $95 million in revenues. GAO recommended, among other 

things, that BIA develop a process to track its review and response times of 

energy-related documents. Interior stated that it will develop such a process 

by September 30, 2018. 

· Health care. GAO has found that IHS provides inadequate oversight of its 

federally operated health care facilities and of its Purchase Referred Care 

program (PRC). For example, in 2016 and 2017, GAO reported that IHS 

provided limited and inconsistent oversight of the timeliness and quality of 

care provided in its federally operated facilities, and as a result, could not 

ensure that patients received timely, quality care. GAO reported that, 

according to IHS officials, access to timely primary care at some facilities 

was hindered by outdated medical and telecommunications equipment, as 

well as an insufficient workforce. GAO also found that IHS had taken few 

steps to evaluate variations in the level of funds it allocated for the PRC 

program and concluded that IHS could not equitably allocate funds to meet 

the health care needs of Indians.

Why GAO Did This Study

GAO’s High-Risk Series identifies 

federal program areas needing 

attention from Congress and the 

executive branch. GAO added federal 

management of programs that serve 

Indian tribes and their members to its 

2017 biennial update of high-risk areas 

in response to serious problems in 

management and oversight by Interior 

and HHS.

This testimony primarily summarizes

the findings and recommendations 

from GAO’s prior reports on the federal 

management and oversight of Indian 

education, energy resources, and 

health care, which are discussed in 

GAO’s February 2017 High-Risk 

report. To conduct this work, GAO 

reviewed relevant federal laws, 

regulations, and policies; reviewed and 

analyzed federal data; and interviewed 

tribal, federal, and industry officials, 

among others. 

GAO uses five criteria to assess an 

agency’s progress in addressing highrisk areas: (1) leadership commitment, 

(2) agency capacity, (3) an action plan, 

(4) monitoring efforts, and (5) 

demonstrated progress. 

What GAO Recommends

As discussed in the February 2017 

High-Risk Report, Interior and HHS 

have not implemented nearly 40 of 

GAO’s recommendations on 

management and oversight of federal 

programs for Indian tribes on 

education, energy, and health care. 

Sustained focus by Interior and HHS in 

implementing GAO’s recommendations 

and continued oversight by Congress 

are essential to achieving progress in 

these areas. 

View GAO-17-589T. For more information, 

contact Melissa Emrey-Arras at (617) 788-

0534 or emreyarrasm@gao.gov; Frank Rusco 

at (202) 512-3841 or ruscof@gao.gov; or 

Kathleen King at (202) 512-7114 or 

kingk@gao.gov.
Letter

Page 1 GAO-17-589T 

Letter

Chairman Calvert, Ranking Member McCollum, and Members of the 

Subcommittee:

We are pleased to be here today to discuss a new area we added to our 

High Risk List this year—Improving Federal Management of Programs 

that Serve Tribes and Their Members.

We added this high-risk area in February 2017 in response to serious 

problems in federal management and oversight of Indian education, 

health care programs, and energy resources, which were highlighted in 

several of our prior reports, along with reports and testimony from 

Inspectors General, tribal nations, special commissions, and others. In 

particular, we have found numerous weaknesses in how the Department 

of the Interior’s (Interior) Bureau of Indian Education (BIE) and Bureau of 

Indian Affairs (BIA)—under the Office of the Assistant Secretary for Indian 

Affairs (Indian Affairs)—and the Department of Health and Human 

Services’ (HHS) Indian Health Service (IHS) have administered education 

and health care services, which has put the health and safety of American 

Indians served by these programs at risk. These weaknesses included 

poor conditions at BIE school facilities that endangered students, and 

inadequate oversight of health care that hindered IHS’s ability to ensure 

quality care to Indian communities. In addition, we have reported that BIA 

has mismanaged Indian energy resources held in trust and thereby 

limited opportunities for tribes and their members to use those resources 

to create economic benefits and improve the well-being of their 

communities.

In 2016, Congress found in the Indian Trust Asset Reform Act that 

“through treaties, statutes, and historical relations with Indian tribes, the 

United States has undertaken a unique trust responsibility to protect and 

support Indian tribes and Indians.”1 As further stated in that act, the 

fiduciary responsibilities of the United States to Indians arise in part from 

commitments made in treaties and agreements, in exchange for which 

Indians surrendered claims to vast tracts of land, and this history of 

federal-tribal relations and understandings has benefitted the people of 

the United States and established “enduring and enforceable [f]ederal 

obligations to which the national honor has been committed.” Through 

improvements to federal management of programs that serve tribes and 

their members, agencies can improve the efficiency of federal programs 

 

1Pub. L. No. 114-178, § 101 (2016)(codified at 25 U.S.C. § 5601). 
Letter

under which services are provided to tribes and their members. This 

would be consistent with the expressed view of Congress as to the 

federal government’s trust responsibilities, and strengthen confidence in 

the performance and accountability of our federal government. In light of 

this unique trust responsibility and concerns about the federal 

government ineffectively administering Indian education and health care 

programs and mismanaging Indian energy resources, we added these 

programs as a high-risk area because they uniquely affect tribal nations 

and their members.

In this context, our testimony today will discuss the findings and 

recommendations from our prior reports on the federal management and 

oversight of Indian education, health care, and energy resource 

development, which are summarized in our February 2017 High-Risk 

report.

Page 2 GAO-17-589T 

2

In particular, we will highlight key actions that Interior and HHS 

can take to help overcome challenges associated with federal 

management and oversight of programs in these areas.

Our testimony draws on findings from multiple reports we have issued in 

recent years, as well as updates we have received from Interior and HHS 

on our prior recommendations. To conduct our prior issued work, we 

reviewed relevant federal laws, regulations, and policies; reviewed and 

analyzed federal data; and interviewed tribal, federal, and industry 

officials, among others. More detailed information on our scope and 

methodology can be found in each of the cited reports.3

Our remarks on Indian education also draw on findings from two reports 

being released today on oversight and accountability for BIE school 

safety and school construction projects.4 To conduct our work on BIE 

school safety, we reviewed Interior’s safety program evaluations; a 

nongeneralizable sample of 50 randomly selected fiscal year 2016 BIE 

school inspection reports; BIA regional documentation of employee 

appraisals; and performance management practices in four BIA regions 

 

2GAO, High-Risk Series: Progress on Many High-Risk Areas, While Substantial Efforts 

Needed on Others, GAO-17-317 (Washington, D.C.: Feb. 15, 2017). 

3For a list of related reports, see GAO-17-317.

4GAO, Indian Affairs: Further Actions Needed to Improve Oversight and Accountability for 

School Safety Inspections, GAO-17-421 (Washington, D.C.: May 24, 2017); GAO, Indian 

Affairs: Actions Needed to Better Manage Indian School Construction Projects, 

GAO-17-447 (Washington, D.C.: May 24, 2017).
Letter

selected for geographic diversity and a range of safety inspection results. 

To conduct our work on BIE school construction, we assessed agency 

data on the cost and timeliness of 49 school replacement projects 

completed from fiscal years 2003 to 2016 and reviewed contract and 

grant files for 10 recently completed or ongoing projects. We also 

assessed Indian Affairs’ practices against its policies, design standards, 

and federal laws and regulations.

We conducted the work on which this testimony is based in accordance 

with generally accepted government auditing standards. Those standards 

require that we plan and perform the audit to obtain sufficient, appropriate 

evidence to provide a reasonable basis for our findings and conclusions 

based on our audit objectives. We believe that the evidence obtained 

provides a reasonable basis for our findings and conclusions.

Background

Page 3 GAO-17-589T 

The High-Risk Program

In 1990, GAO began a program to report on government operations that 

we identified as “high risk.” Since then, generally coinciding with the start 

of each new Congress, we have reported on the status of progress 

addressing previously identified high-risk areas and have updated the 

High-Risk List to add new high-risk areas. Our most recent high-risk 

update in February 2017 identified 34 high-risk areas.5

Overall, our high-risk program has served to identify and help resolve 

serious weaknesses in areas that involve substantial resources and 

provide critical services to the public. Since the program began, the 

federal government has taken high-risk problems seriously and has made 

long-needed progress toward correcting them. In a number of cases, 

progress has been sufficient for us to remove the high-risk designation.

To determine which federal government programs and functions should 

be designated high risk, we use our guidance document, Determining 

Performance and Accountability Challenges and High Risks.

6

In making 

 

5GAO-17-317. 

6GAO, Determining Performance and Accountability Challenges and High Risks, 

GAO-01-159SP (Washington, D.C.: November 2000). 
Letter

this determination, we consider whether the program or function is of 

national significance or is key to the performance and accountability of 

the federal government.

Further, we consider qualitative factors, such as whether the risk involves 

public health or safety, service delivery, national security, national 

defense, economic growth, privacy or citizens’ rights, or could result in 

significantly impaired service, program failure, injury or loss of life, or 

significantly reduced economy, efficiency, or effectiveness. In addition, we 

consider the exposure to loss in monetary or other quantitative terms, 

including financial risk in areas such as the value of major assets being 

impaired; revenue sources not being realized; major agency assets being 

lost, stolen, damaged, wasted, or underutilized; potential for, or evidence 

of improper payments; and the presence of contingencies or potential 

liabilities. Before making a high-risk designation, we also consider 

corrective measures planned or under way to resolve weaknesses and 

the status and effectiveness of these actions.

Our experience has shown that the key elements needed to make 

progress in high-risk areas are top-level attention by the administration 

and agency leaders grounded in the five criteria for removal from the 

High-Risk List, as well as any needed congressional action.

Page 4 GAO-17-589T 

7 The five 

criteria for removal that we identified in November 2000 are as follows:

· Leadership Commitment. Demonstrated strong commitment and top 

leadership support.

· Capacity. The agency has the capacity (i.e., people and resources) to 

resolve the risk(s).

· Action Plan. A corrective action plan exists that defines the root 

cause, solutions, and provides for substantially completing corrective 

measures, including steps necessary to implement solutions we 

recommended.

· Monitoring. A program has been instituted to monitor and 

independently validate the effectiveness and sustainability of 

corrective measures.

· Demonstrated Progress. Ability to demonstrate progress in 

implementing corrective measures and in resolving the high-risk area.

 

7GAO-01-159SP.
Letter

The five criteria form a road map for efforts to improve and ultimately 

address high-risk issues. Addressing some of the criteria leads to 

progress, while satisfying all of the criteria is central to removal from the 

list.

In each of our high-risk updates, for more than a decade, we have 

assessed progress to address the five criteria for removing a high-risk 

area from the list. In our 2015 update, we added clarity and specificity to 

our assessments by rating each high-risk area’s progress on the criteria 

and used the following definitions:

· Met. Actions have been taken that meet the criterion. There are no 

significant actions that need to be taken to further address this 

criterion.

· Partially Met. Some, but not all, actions necessary to meet the 

criterion have been taken.

· Not Met. Few, if any, actions toward meeting the criterion have been 

taken.

Figure 1 shows a visual representation of varying degrees of progress in 

each of the five criteria for a high-risk area.

Figure 1: High-Risk Progress Criteria Ratings

Page 5 GAO-17-589T 

Data for Figure 1: High-Risk Progress Criteria Ratings

High Risk Criteria Status

Action plan Partially met

Capacity Partially met

Demonstrated progress Not met (Declined since 2015)
Letter

Page 6 GAO-17-589T 

High Risk Criteria Status

Leadership commitment Partially met

Monitoring Partially met (Progressed since 2015)

Note: Each point of the star represents one of the five criteria for removal from the High-Risk List and 

each ring represents one of the three designations: not met, partially met, or met. An unshaded point 

at the innermost ring means that the criterion has not been met, a partially shaded point at the middle 

ring means that the criterion has been partially met, and a fully shaded point at the outermost ring 

means that the criterion has been met.

Indian Education

Indian Affairs, through BIE, is responsible for providing quality education 

opportunities to Indian students and oversees 185 elementary and 

secondary schools that serve approximately 41,000 students on or near 

Indian reservations in 23 states, often in rural areas and small towns (see 

fig. 2).
Letter

Figure 2: Bureau of Indian Education (BIE) Schools and Dormitories by Bureau of Indian Affairs Region

Page 7 GAO-17-589T 

About two-thirds of BIE schools are operated by tribes, primarily through 

federal grants, and about one-third are operated directly by BIE. BIE’s 

Indian education programs originate from the federal government’s trust 

responsibility to Indian tribes. It is the policy of the United States to fulfill 

this trust responsibility for educating Indian children by working with tribes 

to ensure that education programs are of the highest quality and that 

children are provided a safe and healthy environment in which to learn.

Students attending BIE schools generally must be members of federally 

recognized Indian tribes, or descendants of members of such tribes, and 

reside on or near federal Indian reservations. All BIE schools—both 

tribally- and BIE-operated—receive almost all of their operational funding 

from federal sources, namely, Interior and the Department of Education, 
Letter

totaling about $1.2 billion in 2016. Indian Affairs considers many BIE 

schools to be in poor condition.

BIE is primarily responsible for its schools’ educational functions, while 

their administrative functions—such as safety, facilities, and property 

management—are divided mainly between two other Indian Affairs’ 

offices: BIA and the Office of the Deputy Assistant Secretary of 

Management. However, we have identified long-standing personnel 

issues, such as frequent turnover of leadership in these offices that have 

hampered efforts to improve Indian education over the years. For 

example, in September 2013, we reported that from 2000 through 2013 

there were repeated changes in the tenure of acting and permanent 

assistant secretaries of Indian Affairs, with the tenure ranging from 16 

days to 3 years.

Page 8 GAO-17-589T 

8 During this period, there was also frequent turnover in 

acting and permanent directors of BIE. Since that time, leadership 

turnover has continued in these offices. For example, in March 2016 

Interior’s Inspector General found that the BIE director had violated 

federal hiring practices, and he was removed from his position.9

Indian Energy Resources

Considerable energy resources, including domestic mineral resources 

such as oil, gas, and coal, and resources with significant potential for 

renewable energy development, including wind, solar, hydroelectric 

power, geothermal, and biomass, exist throughout Indian country. Tribal 

nations may seek opportunities to use these resources as an option to 

create economic benefits that provide revenue for government operations 

and social service programs, create high-quality jobs, and offset power 

costs by increasing access to reliable and affordable energy for tribal 

buildings and individual homes. While tribes and their members 

determine how to use their energy resources, if the resources are held in 

trust or restricted status, BIA—through its 12 regional offices, 85 agency 

offices, and other supporting offices—generally must review and approve 

 

8GAO, Indian Affairs: Bureau of Indian Education Needs to Improve Oversight of School 

Spending, GAO-15-121 (Washington, D.C.: Nov. 13, 2014). 

9U.S. Department of the Interior, Office of Inspector General, Investigative Report of 

Improper Hiring at the Bureau of Indian Education, (Washington, D.C.: March 30, 2016). 
Letter

leases, permits, and other documents required for development (see 

fig. 3).

Page 9 GAO-17-589T 

10

Figure 3: Bureau of Indian Affairs (BIA) Regions and Number of Agency Offices

Data Table for Figure 3: Bureau of Indian Affairs (BIA) Regions and Number of 

Agency Offices

Region Number of agency offices

Alaska Region 2

Eastern Region 3

 

10Trust resources are held by the U.S. government for the beneficial interest of the tribe or 

a member, and restricted resources are owned by the tribe or a member but subject to 

restrictions on their sale or transfer. Trust and restricted resources generally cannot be 

leased without approval of the Secretary of the Interior, who has generally delegated this 

authority to BIA. 
Letter

Page 10 GAO-17-589T 

Region Number of agency offices

Eastern Oklahoma Region 5

Great Plains Region 12

Midwest Region 3

Navajo Region 5

Northwest Region 14

Pacific Region 4

Rocky Mountain Region 7

Southern Plains Region 4

Southwest Region 9

Western Region 13

BIA’s management of Indian energy resources and oversight of 

development is to be conducted pursuant to federal law, in a manner that 

is consistent with the federal government’s fiduciary trust responsibility to 

federally recognized Indian tribes and their members. In addition to BIA, 

the development of Indian energy resources can be a complex process 

involving a range of additional stakeholders, including federal, tribal, and 

state agencies. For example, the Bureau of Land Management issues 

drilling permits to operators developing Indian oil and gas resources after 

receiving BIA concurrence to approve the permits. The Environmental 

Protection Agency issues permits for air emissions that may be required 

for some oil and gas development. Interior’s Fish and Wildlife Service 

issues permits for incidental deaths of certain wildlife species, which may 

be affected by certain wind projects. If energy development affects 

navigable waters, the U.S. Army Corps of Engineers may need to issue a 

permit. The specific role of federal agencies can vary on the basis of 

multiple factors, such as the type of resource, location of development, 

scale of development, ownership of the resource, and Indian tribe 

involved. Figure 4 shows various roles federal agencies may have in the 

development of Indian energy resources.
Letter

Figure 4: Various Roles of Federal Agencies in the Development of Indian Energy Resources

Page 11 GAO-17-589T 

Data for Figure 4: Various Roles of Federal Agencies in the Development of Indian 

Energy Resources

Diagram shows agencies with roles in oversight and assistance.

Identify resource potential

· Department of Energy (DOE)

· Office of Indian Energy and Economic Development (IEED)

Provide technical assistance
Letter

· Bureau of Indian Affairs (BIA)

· Department of Energy (DOE)

· Office of Indian Energy and Economic Development (IEED)

· Western Area Power Administration (WAPA)

Regulate

· Bureau of Indian Affairs (BIA)

· Bureau of Land Management (BLM)

· U.S. Army Corps of Engineers

· Environmental Protection Agency (EPA)

· U.S. Fish and Wildlife Service

· U.S. Department of Agriculture (USDA)

Provide financial assistance

· Department of Energy (DOE)

· Economic Development Administration (EDA)

· U.S. Department of Housing and Urban Development (HUD)

· Office of Indian Energy and Economic Development (IEED)

· U.S. Department of the Treasury

· U.S. Department of Agriculture (USDA)

Provide transmission access assistance

· Western Area Power Administration (WAPA)

Purchase power

· Department of Defense (DOD)

· Department of Energy (DOE)

· General Services Administration (GSA)

Source: GAO analysis of federal documentation. | GAO-17-589T

In 2014, in response to tribal requests for increased coordination and 

efficient management of their resources from the numerous federal 

regulatory agencies involved with Indian energy development, Interior 

took initial steps to form a new office, the Indian Energy Service Center 

Page 12 GAO-17-589T 
Letter

(Service Center)—with BIA as the lead agency. According to Interior’s 

fiscal year 2016 budget justification, the Service Center is intended to, 

among other things, help expedite the leasing and permitting processes 

associated with Indian energy development.

Indian Health Care

Page 13 GAO-17-589T 

The Indian Health Service (IHS), an agency within HHS, is charged with 

providing health care to approximately 2.2 million Indians. IHS oversees 

its health care facilities through a decentralized system of area offices, 

which are led by area directors and located in 12 geographic areas. (See 

fig. 5 for a U.S. map showing the IHS patient population by area). Nine of 

these 12 IHS areas have federally operated IHS facilities—Albuquerque, 

Bemidji, Billings, Great Plains, Nashville, Navajo, Oklahoma City, 

Phoenix, and Portland.11

 

11The Alaska, California, and Tucson areas do not have any federally operated IHS 

facilities. 
Letter

Figure 5: Indian Health Service (IHS) Patient Population by Area, Calendar Year 2014

Page 14 GAO-17-589T 

Data Table for Figure 5: Indian Health Service (IHS) Patient Population by Area, 

Calendar Year 2014

Map of the continental United States delineates Indian Health Service 

regions

Region Population

Alaska 140,260

Albuquerque 118,763

Bemidji 135,768

Billings 77,042

California 197,918

Great Plains 138,022

Navajo 266,450

Nashville 118,763

Oklahoma City 411,263
Letter

Page 15 GAO-17-589T 

Region Population

Phoenix 229,334

Portland 228,215

Tucson 40,274

Source: Indian Health Service. | GAO-17-589T

Note: The Albuquerque, Nashville, and Oklahoma City area offices oversee facilities in Texas.

In fiscal year 2016, IHS allocated about $1.9 billion for health services 

provided by federally and tribally operated hospitals, health centers, and 

health stations. Federally operated facilities provide mostly primary and 

emergency care, in addition to some ancillary or specialty services. The 

federally operated system consists of 26 hospitals, 56 health centers, and 

32 health stations. IHS hospitals range in size from 4 to 133 beds.

According to IHS, the headquarters office is responsible for setting health 

care policy, ensuring the delivery of quality comprehensive health 

services, and advocating for the health needs and concerns of Indians. 

The IHS area offices are responsible for distributing funds to the facilities 

in their areas, monitoring their operation, and providing guidance and 

technical assistance. (See fig. 6).

Figure 6: Health Care Responsibilities of Indian Health Service (IHS) Headquarters, Area Offices, and Federally Operated 

Facilities

Data for Figure 6: Health Care Responsibilities of Indian Health Service (IHS) 

Headquarters, Area Offices, and Federally Operated Facilities

Indian Health Service (IHS) Headquarters
Letter

· Setting agency-wide health care policy

· Ensuring delivery of quality comprehensive services

· Advocating for health needs of Indians

Area offices

· Distributing funds to facilities

· Monitoring facility operations

· Providing guidance and technical assistance to facilities

Facilities

· Providing care to patients

· Providing other services, such as health and nutrition education 

and public health nursing

· Monitoring facility operations

Source: GAO. | GAO-17-589T

When services are not available at federally operated or tribally operated 

facilities, IHS may, in some cases, pay for services provided through 

external providers through its Purchased/Referred Care (PRC) program. 

IHS facilities and their associated PRC programs are located in 12 

geographic areas, each overseen by an IHS office led by an area director. 

The PRC program is funded through annual appropriations and must 

operate within the limits of available appropriated funds. To be eligible for 

PRC services, recipients must generally meet several criteria, including 

being a member or descendant of a federally recognized tribe or having 

close social and economic ties with the tribe, and living within a Tribal 

Contract Health Services Area. Although funding available for the PRC 

program has recently increased, we have reported that the program is 

unable to pay for all eligible services, and that these gaps in services 

sometimes delay diagnoses and treatments, which can exacerbate the 

severity of a patient’s condition and necessitate more intensive 

treatment.

Page 16 GAO-17-589T 

12

 

12GAO, Indian Health Service: Health Care Services Are Not Always Available to Native 

Americans, GAO-05-789 (Washington, D.C.: Aug. 31, 2005).
Letter

The Patient Protection and Affordable Care Act (PPACA) expanded or 

created new health care coverage options that may benefit Indians, 

including a state option to expand Medicaid eligibility to individuals with 

incomes at or below 138 percent of the federal poverty level (FPL), 

federal premium tax credits for individuals obtaining insurance through 

health insurance exchanges with incomes between 100 and 400 percent 

of the FPL, and cost sharing exemptions for Indians who are members of 

federally recognized tribes with incomes at or below 300 percent of the 

FPL who purchase insurance through the exchanges.

Page 17 GAO-17-589T 

13 In September 

2013, we estimated that PPACA’s new coverage options may allow 

hundreds of thousands of Indians to obtain health care benefits for which 

they were not previously eligible, assuming all states expanded their 

Medicaid programs.14 We reported that, if Indians enroll in one of these 

options and choose to receive care through IHS, increased revenue from 

third party payers such as Medicaid could free up IHS resources and help 

alleviate pressure on IHS’s budget.

Serious Weaknesses with Federal Agencies’ 

Management and Oversight of Programs 

Serving Tribes and Their Members

We have found that Interior and HHS have ineffectively administered and 

implemented Indian education and health care programs and 

mismanaged Indian energy resources in the following broad areas: (1) 

oversight of federal activities; (2) collaboration and communication; (3) 

federal workforce planning; (4) equipment, technology, and infrastructure; 

and (5) federal agencies’ data. Although the agencies have taken some 

actions to address the recommendations we have made related to Indian 

programs, as of our February 2017 High-Risk update, there were nearly

40 that have yet to be fully addressed.

 

13See Pub. L. No. 111-148, 124 Stat. 119 (Mar. 23, 2010), as amended by the Health 

Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (Mar. 

30, 2010).

14GAO, Indian Health Service: Most American Indians and Alaska Natives Potentially 

Eligible for Expanded Health Coverage, but Action Needed to Increase Enrollment, 

GAO-13-553 (Washington, D.C.: Sep. 5, 2013).
Letter

Indian Education

Page 18 GAO-17-589T 

Inadequate oversight of federal activities

We have identified weaknesses in how Indian Affairs oversees school 

safety and construction and in how it monitors the way schools use 

federal funds. In a March 2016 report, we found that Indian Affairs had 

not taken actions to ensure that its BIA regional offices annually inspect 

the safety and health of all BIE school campuses, as required, or that the 

information it collected through inspections was complete and accurate, 

and we recommended that it take such actions.15 Specifically, we found 

that Indian Affairs did not conduct annual inspections at about 1 in 3 BIE 

schools from fiscal years 2012 through 2015. Further, 4 out of 10 regions 

did not conduct any inspections during this period. We also found that 

Indian Affairs did not systematically evaluate the thoroughness of the 

school safety inspections it conducted or monitor the extent to which 

inspection procedures varied within and across regions. We concluded 

that it did not monitor whether safety inspectors in each of its regions are 

consistently following appropriate procedures and guidance and as a 

result inspections in different regions may continue to vary in 

completeness and miss important safety and health deficiencies at 

schools that could pose dangers to students and staff.

In response to our findings and recommendations in September 2016, 

Indian Affairs provided documentation that it had conducted fiscal year 

2016 annual safety inspections at all BIE schools. In 2016, agency 

officials also reported on changes they had made to managing the 

performance of personnel responsible for overseeing and conducting 

school safety inspections. However, as of April 2017, the agency had not 

provided documentation that the inspection information that its safety 

personnel collect and report to BIE schools is complete and accurate. In 

addition, our findings from one of the two reports on Indian education that 

are being released today point to continued problems with Indian Affairs’ 

oversight of safety inspections at BIE schools.16 In particular, we found 

that BIA employees responsible for providing safety inspection reports to 

schools were not held accountable for late reports despite the agency’s 

requirement and a new employee performance standard on submitting all 

 

15GAO, Indian Affairs: Key Actions Needed to Ensure Safety and Health at Indian School 

Facilities, GAO-16-313 (Washington, D.C.: Mar. 10, 2016).

16GAO-17-421.
Letter

reports within 30 days of an inspection. We found that some reports were 

submitted more than 4 months after an inspection. We will continue to 

monitor the agency’s efforts in this area.

In February 2015, we also testified that Indian Affairs did not consistently 

oversee some BIE school construction projects.

Page 19 GAO-17-589T 

17 For example, we found 

that at one BIE school Indian Affairs managed a $3.5 million project to 

replace roofs, but the new roofs had leaked continually since they were 

installed, causing mold and ceiling damage in classrooms, according to 

agency documents. At another school, Indian Affairs funded construction 

of a $1.5 million building for school bus maintenance and bus storage, but 

the size of the building did not allow a large school bus to fit on the lift 

when the exterior door was closed (see fig. 7).18

Figure 7: Exterior and Interior of Recently-Constructed School Bus Maintenance Building Where Door Does Not Close When a 

Large School Bus Is On Hydraulic Lift

Further, our findings from the second report on Indian education being 

released today indicate that Indian Affairs has not consistently used 

accountability measures or conducted sufficient oversight to ensure that 

BIE school construction projects were completed on time, within budget, 

 

17GAO, Indian Affairs: Preliminary Results Show Continued Challenges to the Oversight 

and Support of Education Facilities, GAO-15-389T (Washington, D.C.: Feb. 27, 2015).

18As a result, staff at the school were required to maintain or repair a large bus with the 

door open, which is not practical in the cold South Dakota winters.
Letter

and met schools’ needs.

Page 20 GAO-17-589T 

19 For instance, of the 49 school construction 

projects we reviewed that had been completed from fiscal years 2003 to 

2016, 16 were 3 or more years behind schedule and 1 was nearly 10 

years behind schedule (see fig. 8).

Figure 8: Timeliness of Indian Affairs’ School Replacement Projects Completed, 

Fiscal Years 2003 - 2016

Data table for Figure 8: Timeliness of Indian Affairs’ School Replacement Projects 

Completed, Fiscal Years 2003 - 2016

Timeliness criteria Number of projects

On time or early 10

Up to 3 years late 23

3 to 5 years late 11

More than 5 years late 5

Source: GAO analysis of Indian Affairs’ annual submissions to the President’s budget. | GAO-17-

589T

In a November 2014 report, we also identified serious weaknesses in 

Indian Affairs’ oversight of school expenditures.20 For example, we 

reported that BIE does not have written oversight procedures and risk 

criteria for ensuring schools use funds provided by Interior for their 

intended purpose of providing BIE students a quality education. As a 

result of Indian Affairs’ lack of oversight, we identified several instances of 

funds being misused, including $1.7 million for a school that were 

improperly transferred to off-shore accounts. Our report contained several 

recommendations that, if implemented, could help BIE accurately track 

and oversee BIE school expenditures to ensure that federal funds are 

being used for their intended purposes. Specifically, we recommended 

that Interior develop both written procedures and a risk-based approach 

to monitor school expenditures. In response to our recommendations in 

May 2016, Indian Affairs’ officials said they were in the process of 

establishing a new Office of Financial Accountability within BIE that, 

 

19GAO-17-447. 

20GAO-15-121.
Letter

among other duties, would oversee school expenditures. They noted they 

were planning to hire auditors and grants management specialists who 

would be responsible for developing written procedures to oversee school 

expenditures. In April 2017, agency officials also reported that they had 

filled the BIE Deputy Director for School Operations position. In addition, 

they noted that newly hired personnel were being trained in risk 

assessment and fraud prevention policy. However, the agency did not 

provide documentation that it had developed and implemented written 

procedures and risk criteria to ensure accountability of BIE school 

expenditures as we recommended. Further, it reported that the target 

date for fully implementing our recommendations was October 1, 2018. 

Therefore, we will continue to monitor the agency’s efforts to implement 

these recommendations.

Limited federal workforce planning

Page 21 GAO-17-589T 

We have found limited workforce planning in several key areas related to 

BIE schools. Specifically, in a February 2015 testimony, we noted that the 

capacity of Indian Affairs and BIE school staff to address school facility 

needs is limited due to gaps in expertise, steady declines in staffing 

levels, and limited institutional knowledge.21

In November 2014 we reported that the lack of financial expertise and 

training, among other things, hindered BIE administrators’ effectiveness in 

overseeing school expenditures.22 For example, although BIE line office 

administrators made key decisions about schools’ single audit report 

findings—such as whether funds are being spent appropriately—they 

were not auditors or accountants. Additionally, the administrators 

responsible for the three BIE offices we visited said they did not have the 

financial expertise to understand the content of single audits. We 

recommended that the agency develop a comprehensive workforce plan 

to ensure that BIE has an adequate number of staff with the requisite 

knowledge and skills to effectively oversee BIE school expenditures. 

Interior agreed to implement this recommendation, but as of April 2017, it 

had not provided documentation that it had done so.

In September 2013, we reported that Indian Affairs could not ensure that 

staffing levels at Indian Affairs’ regional offices were adjusted to meet the 

 

21GAO-15-389T.

22GAO-15-121.
Letter

needs of BIE schools in regions with varying numbers of schools—

ranging from 2 to 65—because it had not updated its strategic workforce 

plan.

Page 22 GAO-17-589T 

23 We recommended that Indian Affairs revise its strategic workforce 

plan to ensure that its employees who provide administrative support to 

BIE are placed in the appropriate offices to ensure that regions with a 

large number of schools have sufficient support. Indian Affairs agreed to 

implement this recommendation. In September 2016, Interior provided us 

with a revised workforce plan for Indian Affairs. However, this plan did not 

include information about the workforce needs of the Indian Affairs offices 

that provide administrative support to BIE and its schools and therefore 

did not address our recommendation. As of April 2017, we had not 

received any further updates from Indian Affairs. We will continue to 

monitor its efforts in this area.

Outdated and deteriorating equipment, technology, and 

infrastructure

Aging BIE school facilities and equipment have contributed to degraded 

and unsafe conditions for students and staff. In a March 2016 report, we 

found one school with 7 boilers that failed inspection because of multiple

high-risk safety deficiencies, including elevated levels of carbon monoxide 

and a natural gas leak (see fig. 9).

 

23GAO, Indian Affairs: Better Management and Accountability Needed to Improve Indian 

Education, GAO-13-774 (Washington, D.C.: Sept. 24, 2013).
Letter

Figure 9: Failed Boiler Inspection Tag in a Bureau of Indian Education (BIE) School 

Page 23 GAO-17-589T 

Classroom Building

Four of the boilers were located in a student dormitory, and three were 

located in classroom buildings. All but one of the boilers were about 50 

years old. Although the poor condition of the boilers posed an imminent 

danger to the safety of students and staff, most of the boilers were not 

repaired until about 8 months after failing their inspection, prolonging 

safety risks to students and staff.
Letter

In February 2015, we also testified that BIE schools faced a variety of 

challenges associated with their facilities, such as aging buildings and 

problems that result from years of deferred maintenance.

Page 24 GAO-17-589T 

24 For example, 

at one school built in 1959 we observed extensive cracks in concrete 

block walls and supports, which a BIA official said had resulted from a 

shifting foundation.

Incomplete and inaccurate data

A lack of internal controls and other weaknesses hinder Indian Affairs’ 

ability to collect complete and accurate information on the physical 

conditions of BIE schools. In addition to our March 2016 findings on 

Indian Affairs’ lack of sound safety inspection information on BIE school 

facilities, as discussed above, in February 2015 we also testified on 

problems with the quality of data on overall BIE school conditions. These 

issues included inconsistent data entry by schools and insufficient quality 

controls, which made it difficult to determine the actual number of schools 

in poor condition and undermined Indian Affairs’ ability to effectively track 

and address problems at school facilities.25

Open Recommendations on Indian Education

When we issued our February 2017 High-Risk update, we had made 13 

recommendations to Indian Affairs regarding improvements needed in the 

management of BIE schools, of which 11 recommendations remain 

unaddressed. Specifically,

· To help ensure that BIE schools provide safe and healthy facilities for 

students and staff, we made 4 recommendations, including that Indian 

Affairs ensure the inspection information it collects on BIE schools is 

complete and accurate; develop a plan to build schools’ capacity to 

promptly address safety and health deficiencies; and consistently 

monitor whether BIE schools have established required safety 

committees.

· To help ensure that BIE conducts more effective oversight of school 

spending, we made 4 recommendations, including that Indian Affairs 

develop a workforce plan to ensure that BIE has the staff to effectively 

oversee school spending; put in place written procedures and a risk-

 

24GAO-15-389T.

25GAO-15-389T.
Letter

based approach to guide BIE in overseeing school spending; and 

improve information sharing to support the oversight of BIE school 

spending.

· To help ensure that Indian Affairs improves how it manages Indian 

education, we made 5 recommendations of which 3 remain open, 

including that Indian Affairs develop a strategic plan for BIE that 

includes goals and performance measures for how its offices are 

fulfilling their responsibilities to provide BIE with support; revise Indian 

Affairs’ strategic workforce plan to ensure that BIA regional offices 

have an appropriate number of staff with the right skills to support BIE 

schools in their regions; and develop and implement decision-making 

procedures for BIE to improve accountability for BIE schools.

Indian Energy Resources

Page 25 GAO-17-589T 

Inadequate oversight of federal activities

We reported in June 2015 that BIA’s review and approval is required to

develop Indian energy resources, including the approval of leases, rightof-way (ROW) agreements, and appraisals.26 However, BIA does not 

have a documented process or the data needed to track its review and 

response times—such as data on the date documents are received, the 

date the review is considered complete by the agency, and the date 

documents are approved or denied.

Stakeholders we interviewed and literature we reviewed suggested that 

BIA’s review and approval can be a lengthy process and increase 

development costs and project development times, resulting in missed 

development opportunities, lost revenue, and jeopardized viability of 

projects.27 For example, in 2014, the Acting Chairman for the Southern 

Ute Indian Tribe reported that BIA’s review of some of its energy-related 

documents took as long as 8 years. Specifically, as of April 30, 2014, the 

 

26GAO, Indian Energy Development: Poor Management by BIA Has Hindered Energy 

Development on Indian Lands, GAO-15-502 (Washington, D.C.: June 8, 2015). 

27See, for example, Hearing on the Indian Tribal Energy and Self-Determination Act 

Amendments (S. 2132), 113th Cong. (April 30, 2014). Statement of the Honorable James 

M. Olguin, Acting Chairman, Southern Ute Indian Tribal Council on behalf of the Southern 

Ute Indian Tribe; and Prepared statement of Hon. Nathan Small, Chairman, Fort Hall 

Business Council, Shoshone-Bannock Tribes. Strengthening Self-Sufficiency: Overcoming 

Barriers to Economic Development in Native Communities, Field Hearing Before the 

Committee on Indian Affairs, United States Senate 112th Cong. 1st sess. (Aug. 17, 2011). 
Letter

tribe had been waiting for at least 5 years for BIA to review 81 pipeline 

ROW agreements—11 of these 81 ROW agreements had been under 

review for 8 years. According to the tribal official, had these ROW 

agreements been approved in a timely manner, the tribe would have 

received revenue through various sources, including tribal permitting fees, 

oil and gas severance taxes, and royalties. The tribal official noted that, 

during the period of delay, prices for natural gas rose to an historic high 

but had since declined. Therefore, the official reported that much of the 

estimated $95 million in lost revenue would never be recovered by the 

tribe.

In another example from our June 2015 report, one lease for a proposed 

utility-scale wind project took BIA more than 3 years to review and 

approve and according to a tribal official, the lease was only reviewed and 

approved after multiple calls and letters from the tribe to BIA 

headquarters. According to a tribal official, the long review time 

contributed to uncertainty about the continued viability of the project 

because data used to support the economic feasibility and environmental 

impact of the project became too old to accurately reflect current 

conditions.

In our June 2015 report, we recommended that Interior direct BIA to 

develop a documented process to track its review and response times. In 

response, Interior stated it has taken initial steps to develop a 

documented process to track its review and response times for oil and 

gas leases and estimates it will have a fully documented process by 

September 30, 2018. However, it did not indicate whether it intends to 

track and monitor the review of other energy-related documents that must 

be approved before development can occur. Without comprehensively 

tracking and monitoring its review process, BIA cannot ensure that 

documents are moving forward in a timely manner, and lengthy review 

times may continue to contribute to lost revenue and missed development 

opportunities for Indian tribes.

Moreover, in a June 2016 report, we found that BIA took steps to improve 

its process for reviewing revenue-sharing agreements, but it still had not 

established a systematic mechanism for monitoring or tracking.

Page 26 GAO-17-589T 

28 With 

respect to revenue sharing agreements, we recommended, among other 

 

28GAO, Indian Energy Development: Interior Could Do More to Improve Its Process for 

Approving Revenue-Sharing Agreement, GAO-16-553 (Washington, D.C.: June 13, 2016).
Letter

things, that BIA develop a systematic mechanism for tracking these 

agreements through the review and approval process. Interior concurred 

with this recommendation and stated that BIA will develop such a 

mechanism, however in the meantime it would use a centralized tracking 

spreadsheet.

Ineffective collaboration and limited communication

Page 27 GAO-17-589T 

In June 2015, we reported that the added complexity of the federal 

regulatory process, which can include multiple regulatory agencies, 

prevents many developers from pursuing Indian energy resources for 

development.29 Subsequently, in November 2016 we reported that Interior 

had recognized the need for collaboration in the regulatory process and 

described the creation of the Service Center as a center point of 

collaboration for permitting that will break down barriers between federal 

agencies.30 We found that BIA had taken steps to form a Service Center 

that was intended to, among other things, help expedite the permitting 

process associated with Indian energy development. We reported that the 

Service Center had the potential to increase collaboration between BIA 

and BLM on some permitting requirements associated with oil and gas 

development. However, we found that BIA did not coordinate with other 

key regulatory agencies, including Interior’s Fish and Wildlife Service, the 

U.S. Army Corps of Engineers, and the Environmental Protection Agency. 

As a result, the Service Center was neither functioning as the central 

point for collaborating with all federal regulatory partners generally 

involved in energy development, nor did it serve as a single point of 

contact for permitting requirements. Without serving in these capacities, 

we concluded that the Service Center was limited in its ability to improve 

efficiencies in the federal regulatory process. We also found that in 

forming the Service Center, BIA did not involve key stakeholders, such as 

the Department of Energy (DOE)—an agency with significant energy 

expertise—and BIA employees from agency offices. By not involving key 

stakeholders, BIA was missing an opportunity to incorporate their 

expertise into its efforts.

 

29GAO-15-502. 

30GAO, Indian Energy Development: Additional Actions by Federal Agencies Are Needed 

to Overcome Factors Hindering Development, GAO-17-43 (Washington, D.C.: Nov. 10, 

2016). 
Letter

In our November 2016 report, we recommended that BIA include other 

regulatory agencies in the Service Center so that it can act as a single 

point of contact or a lead agency to coordinate and navigate the 

regulatory process. We also recommended that BIA establish formal 

agreements with key stakeholders, such as DOE, that identify the role of 

each stakeholder, and establish a process for seeking and obtaining input 

from key stakeholders, such as BIA employees, on the Service Center’s 

activities. Interior agreed with our recommendations and stated it will 

implement Memoranda of Understanding to include the Corps, FWS, and 

EPA that defines roles and responsibilities of each agency by December 

31, 2017.

In 2005, Congress provided an option for tribes to enter into an 

agreement with the Secretary of the Interior that allows tribes, at their 

discretion, to enter into leases, business agreements, and rights-of-way 

agreements for energy resource development on tribal lands without 

review and approval by the Secretary. However, in a June 2015 report, 

we found that uncertainties about Interior’s regulations for implementing 

this option had contributed to deterring tribes from pursuing such 

agreements. We therefore recommended that Interior provide clarifying 

guidance.

Page 28 GAO-17-589T 

31 In response to our recommendation, Interior stated it will 

provide additional energy development-specific guidance on provisions of 

tribal energy resource agreement regulations tribes have identified as 

unclear by September 30, 2018.

Limited federal workforce planning

In our June 2015 report, we found that BIA’s long-standing workforce 

challenges, such as inadequate staff resources and staff at some offices 

without the skills needed to effectively review energy-related documents, 

were factors hindering Indian energy development.32 Further, in 

November 2016, we found BIA had high vacancy rates at some agency 

offices and that the agency had not conducted key workforce planning 

activities, such as identifying the key workforce skills needed to achieve 

agency goals and assessing any skill gaps.33 We concluded that these 

workforce issues contributed to BIA’s management shortcomings that 

 

31GAO-15-502. 

32GAO-15-502. 

33GAO-17-43. 
Letter

have hindered Indian energy development; and until BIA undertakes 

necessary workforce planning activities, it cannot ensure that it has a 

workforce with the right skills, appropriately aligned to meet the agency’s 

goals and tribal priorities. We recommended that BIA assess critical skills 

and competencies needed to fulfill its responsibilities related to energy 

development and identify potential gaps. We also recommended BIA 

establish a documented process for assessing BIA’s workforce 

composition at agency offices taking into account BIA’s mission, goals, 

and tribal priorities. Interior agreed with our recommendations and stated 

it is taking steps to implement them by September 30, 2017.

Outdated and deteriorating equipment, technology, and 

Page 29 GAO-17-589T 

infrastructure

In June 2015, we found that BIA does not have the necessary geographic 

information system (GIS) mapping data for identifying who owns and uses 

resources, such as existing leases. Interior guidance states that efficient

management of oil and gas resources relies, in part, on GIS mapping 

technology because it allows managers to easily identify resources 

available for lease and where leases are in effect.34 According to a BIA 

official, without GIS data, the process of identifying transactions, such as 

leases and access agreements for Indian land and resources, can take 

significant time and staff resources to search paper records stored in 

multiple locations. We recommended BIA should take steps to improve its 

GIS capabilities to ensure it can verify ownership in a timely manner. In 

response, Interior stated it will enhance mapping capabilities by 

developing a national dataset composed of all Indian land tracts and 

boundaries in the next 4 years.

Incomplete and inaccurate data

In June 2015, we found that BIA did not have the data it needs to verify 

who owns some Indian oil and gas resources or identify where leases are 

in effect.35 In some cases, BIA cannot verify ownership because federal 

cadastral surveys—the means by which land is defined, divided, traced, 

and recorded—cannot be found or are outdated. We concluded that the 

ability to account for Indian resources would assist BIA in fulfilling its 

federal trust responsibility, and determining ownership was a necessary 

 

34GAO-15-502. 

35GAO-15-502. 
Letter

step for BIA to approve leases and other energy-related documents. We 

recommended that Interior direct BIA to identify land survey needs. In 

response, Interior stated it will develop a data collection tool to identify the 

extent of its survey needs in fiscal year 2016. As of April 2017, Interior 

had not provided information on the status of its efforts to develop a data 

collection tool.

Open Recommendations on Indian Energy Development

Page 30 GAO-17-589T 

When we issued our February 2017 High-Risk update, we had made 14 

recommendations to BIA regarding actions needed to help develop Indian 

energy resources. All 14 recommendations remain open. Specifically,

· To help ensure BIA can verify ownership in a timely manner and 

identify resources available for development, we made 2 

recommendations, including that Interior take steps to improve its 

geographic information system mapping capabilities.

· To help ensure BIA’s review process is efficient and transparent, we 

made 2 recommendations, including that Interior take steps to 

develop a documented process to track review and response times for 

energy-related documents that must be approved before tribes can 

develop energy resources.

· To help improve clarity of tribal energy resource agreement 

regulations, we recommended BIA provide additional guidance to 

tribes on provisions that tribes have identified to Interior as unclear.

· To help ensure that BIA’s effort to streamline the review and approval 

process for revenue-sharing agreements achieves its objectives, we 

made 3 recommendations, including that Interior establish time 

frames for the review and approval of Indian revenue-sharing 

agreements for oil and gas, and establish a system for tracking and 

monitoring the review and approval process to determine whether 

time frames are met.

· To help improve efficiencies in the federal regulatory process, we 

made 4 recommendations, including that BIA take steps to coordinate 

with other regulatory agencies so the Indian Energy Service Center 

can serve as a single point of contact or lead agency to navigate the 

regulatory process.

· To help ensure that it has a workforce with the right skills that are 

appropriately aligned to meet the agency’s goals and tribal priorities, 

we made 2 recommendations, including that BIA establish a 
Letter

documented process for assessing BIA’s workforce composition at 

agency offices.

Indian Health Care

Page 31 GAO-17-589T 

Inadequate oversight of federal activities

IHS provides inadequate oversight of health care, both of its federally 

operated facilities and through the PRC program. In January 2017, we 

reported that IHS provided limited and inconsistent oversight of the quality 

of care provided in its federally operated facilities.36 As a result, the 

agency cannot ensure that patients receive quality care. IHS has recently 

finalized a quality framework designed to address these deficiencies and 

improve its oversight. We recommended that, as part of implementing the 

quality framework, IHS ensure that agency-wide standards for the quality 

of care provided in its federally operated facilities are developed, and that 

facility performance in meeting these standards is systematically 

monitored over time. HHS agreed with our recommendation and cited 

steps it already has underway to improve the quality of care in IHS’s 

federally-operated facilities. HHS described the development of the IHS 

Quality Framework and Implementation Plan released in November 2016. 

However, as of April 2017, IHS had not developed agency-wide 

standards for the quality of care provided in its federally operated 

facilities.

In March 2016, we reported that IHS had not set any agency-wide 

standards for patient wait times at IHS federally operated facilities, 

including how long it should take to schedule an appointment and 

complete an office visit.37 According to tribal representatives, patients 

reported difficulty scheduling primary care visits because of extended wait 

times. For example, one facility reported that new patients may wait 6 

weeks for an initial exam with a family medicine physician, and new 

patients in internal medicine may wait 3 to 4 months for an initial exam.

We found that IHS has delegated this responsibility to its area offices and 

has not conducted any systematic, agency-wide oversight of the 

 

36GAO, Indian Health Service: Actions Needed to Improve Oversight of Quality Care, 

GAO-17-181 (Washington, D.C.: Jan. 9, 2017).

37GAO, Indian Health Service: Actions Needed to Improve Oversight of Patient Wait 

Times, GAO-16-333 (Washington, D.C.: Mar. 29, 2016).
Letter

timeliness of primary care. We concluded that, without these standards, 

IHS cannot know whether it is providing sufficient primary care to meet 

the needs of its patients. We recommended that IHS develop and 

communicate specific agency-wide standards for patient wait times in 

federally operated facilities, monitor patient wait times, and take 

corrective actions when standards are not met. HHS stated that it agreed 

with the need to improve patient wait times at IHS federally-operated 

facilities to ensure that primary care is available and accessible to 

Indians. In response to our recommendation, HHS described its plan to 

establish an Office of Quality Health Care at IHS Headquarters to provide 

for national policy and oversight of critical quality improvement strategies 

and ensure their success and accountability. As of April 2017, IHS has 

not established the Office of Quality Health Care and has not developed 

agency-wide standards for patient wait times in federally operated 

facilities.

In June 2012, we found that IHS had taken few steps to evaluate 

variations in the funds it allocates for the Contract Health Services 

program (now called PRC), which varied from $299 to $801 per capita 

across the 12 IHS geographic areas in fiscal year 2010.

Page 32 GAO-17-589T 

38 IHS did not 

know the origin of the base funding formula, which, according to IHS 

officials, had existed since the 1930s and accounted for 82 percent of the 

funds allocated to the area offices in fiscal year 2010. Annual adjustments 

for population growth and inflation were made as a percentage of base 

funding and are the same across all areas. Additional program increases 

were not large enough to alter funding variations because these 

additional increases had been a relatively small proportion of PRC funds 

that area offices received. Because IHS continued to use this 

methodology, we concluded that it could not equitably allocate funds to 

meet the health care needs of Indians. In order to ensure IHS equitably 

allocates PRC funds, we recommended that Congress consider requiring 

IHS to develop and use a new method to allocate funds to account for 

variations across areas. Legislation introduced in the House and reported 

out of committee in 2016 would have addressed this issue by requiring 

the agency to establish regulations to develop and implement a revised 

PRC distribution formula taking into account certain factors that may vary 

across areas. Also, a House Report partially addressed this issue by 

directing the agency to allocate an increased funding increment resulting 

 

38GAO, Indian Health Service: Action Needed to Ensure Equitable Allocation of 

Resources for the Contract Health Services Program, GAO-12-446 (Washington, D.C.: 

June 15, 2012).
Letter

from Interior’s 2017 regular appropriation, H.R. 5538, pursuant to a 

specified allocation formula that may vary across areas. However, neither 

bill became law.

Ineffective collaboration and limited communication

Page 33 GAO-17-589T 

In a June 2012 report, we found that IHS does not require its area offices 

to inform IHS headquarters if they distribute program increase funds to 

local PRC programs using different criteria than the PRC allocation 

formula suggested by headquarters.39 As a result, we concluded that IHS 

may be unaware of additional funding variation across areas. We 

recommended that IHS develop written policies and procedures to require 

area offices to notify IHS when they diverge from the formula for 

allocating funds to PRC programs. HHS concurred with this 

recommendation and noted that guidance requiring area offices to report 

these changes to IHS headquarters would be added to the PRC manual, 

but it did not specify a date for doing so. As of April 2017, IHS had not 

added this guidance to the manual.

Limited federal workforce planning

In a March 2016 report, we reported that, according to IHS officials, an 

insufficient workforce was the biggest impediment to ensuring patients 

could access timely primary care.40 According to IHS’s 2016 budget 

justification, there were over 1,550 vacancies for health care 

professionals throughout IHS’s health care system including: physicians, 

dentists, nurses, pharmacists, physician assistants, and nurse 

practitioners. According to IHS officials, staffing vacancies had created 

obstacles for facilities working to provide primary care.

In January 2017, we found that inconsistencies in IHS’s oversight of 

quality of care provided in its federally operated facilities were 

exacerbated by significant turnover in area leadership. 41 Officials from 

four of the nine area offices in our review reported that they had at least 

three area directors in the past 5 years. (See fig. 10).

 

39GAO-12-446

40GAO-16-333

41GAO-17-181
Letter

Figure 10: Reported Indian Health Service (IHS) Area Director Turnover, January 2011 through July 2016

Page 34 GAO-17-589T 

Note: This figure reflects the number of positions held for a designated time period. One individual 

could be counted multiple times if that individual held both acting and permanent positions for 

different non-adjacent time periods. In four areas—Albuquerque, Great Plains, Nashville, and 

Portland—an acting director transitioned to a permanent position. In these situations, we counted this 

as one area director.

aArea officials reported information through July 2016.

In September 2013, we found that IHS did not have an effective plan to 

ensure that sufficient staff would be in place to assist with increased 
Letter

enrollment and third party billing under expanded Medicaid or the 

exchanges beginning in 2014 under PPACA.

Page 35 GAO-17-589T 

42 We concluded that without 

a plan, IHS may not be able to ensure that a sufficient number of staff 

were available to assist with enrollment and to process increased thirdparty payments. We recommended that IHS realign current resources 

and personnel to increase capacity to assist with these efforts. HHS 

neither agreed nor disagreed with our recommendation, and as of April 

2017, IHS had not implemented it.

In December 2013, we reported that, according to local PRC program 

officials, insufficient staffing for the PRC program affected their ability to 

issue timely purchase orders for health care services approved by the 

program.43 IHS’s staffing standards model established a staffing ratio 

based on the annual number of purchase orders authorized for health 

services at a facility, and some PRC program officials noted that their 

number of staff was below these standards, contributing to delays in 

determining eligibility for the program and processing payments to 

providers. We recommended that IHS use available PRC funds to pay for 

PRC program staff. HHS disagreed with this recommendation, stating its 

intent to use PRC funds to pay only for services, not staff, since PRC 

funding was not sufficient to pay for all needed services. We 

acknowledged the difficult challenges and choices faced by PRC 

programs when program funds are not available to pay for all needed 

services. However, we maintained that without using funds to pay for

staff, some PRC programs would continue to have staffing levels below 

IHS’s staffing standards model, which contributes to delays in 

administering the program. As of April 2017, IHS had not implemented 

this recommendation.

Outdated and deteriorating equipment, technology, and 

infrastructure

In March 2016, we reported that, according to IHS officials, access to 

timely primary care at some health care facilities serving Indian 

communities is hindered by outdated medical and telecommunications 

 

42GAO-13-553.

43GAO, Indian Health Service: Opportunities May Exist to Improve the Contract Health 

Services Program, GAO-14-57 (Washington, D.C.: Dec. 11, 2013).
Letter

equipment, such as analog mammography machines and telephones with 

an insufficient number of lines for scheduling patient appointments.

Page 36 GAO-17-589T 

44

Incomplete and inaccurate data

In a June 2012 report, we found that IHS officials do not believe that its 

PRC program data are complete or that areas collect these data in the 

same manner.45 We concluded that, without accurate data, IHS cannot 

know if the proportion of actual PRC users is consistent across areas. We 

made three recommendations to improve the accuracy of the PRC data 

for future allocations, including using actual counts of PRC users, using 

variation in levels of available hospital services in the funding formula, 

and, as mentioned above, requiring area offices to notify headquarters 

when they diverge from the formula for allocating funds to PRC programs. 

HHS did not concur with our recommendation to use actual counts of 

PRC users, rather than all IHS users, in any formula for allocating PRC 

funds that relies on the number of active users, stating that IHS’s 

combined count of all users is intended to reflect the health care needs of 

PRC users. HHS concurred with our recommendation that IHS use 

variations in levels of available hospital services to allocate PRC funds. 

As of April 2017, IHS had not implemented these recommendations.

In December 2013, we reported that one of the measures IHS uses to 

assess the time it takes to approve and process payments to providers in 

the PRC program did not provide a clear picture of timeliness because it 

combines data for two different types of PRC services.46 We 

recommended that IHS take steps to improve its ability to measure 

timeliness by modifying its claims data system to distinguish between two 

types of referrals and establish separate timeframe targets for each type. 

HHS concurred with this recommendation, but as April 2017, IHS had not 

implemented it.

Open Recommendations on Indian Health Care

When we issued our February 2017 High-Risk update, we had made over 

a dozen recommendations to HHS regarding improvements needed in the 

 

44GAO-16-333

45GAO-12-446

46GAO-14-57
Letter

management of IHS facilities, all of which remain unaddressed. Although 

IHS has taken several actions in response to our recommendations, such 

as improving the data collected for the PRC program and adopting 

Medicare-like rates for non-hospital services, additional steps are needed. 

Specifically,

· To help ensure that Indian people receive quality health care, we 

recommended that the Secretary of HHS direct the Director of IHS to 

take the following two actions: (1) as part of implementing IHS’s 

quality framework, ensure that agency-wide standards for the quality 

of care provided in its federally operated facilities are developed and 

systematically monitor facility performance in meeting these standards 

over time; and (2) develop contingency and succession plans for 

replacing key personnel, including area directors.

· To help ensure that timely primary care is available and accessible to 

Indians, we recommended that IHS: (1) develop and communicate 

specific agency-wide standards for wait times in federally-operated 

facilities, and (2) monitor patient wait times in federally-operated 

facilities and ensure that corrective actions are taken when standards 

are not met.

· To help ensure that IHS has meaningful information on the timeliness 

with which it issues purchase orders authorizing payment under the 

PRC program, and to improve the timeliness of payments to 

providers, we recommended that IHS: (1) modify its claims payment 

system to separately track IHS referrals and self-referrals, revise the 

Government Performance and Results Act measures for the PRC 

program so that it distinguishes between these two types of referrals, 

and establish separate timeframe targets for these referral types; and 

(2) better align PRC staffing levels and workloads by revising its 

current practices, where available, used to pay for PRC program staff. 

In addition, as HHS and IHS monitor the effect that new coverage 

options available under PPACA have on PRC funds, we 

recommended that IHS concurrently develop potential options to 

streamline requirements for program eligibility.

· To help ensure successful outreach efforts regarding PPACA 

coverage expansions, we recommended that IHS realign current 

resources and personnel to increase capacity to deal with enrollment 

in Medicaid and the exchanges and prepare for increased billing to 

these payers.

· If payments for physician and other nonhospital services are capped, 

we recommended that IHS monitor patient access to these services.

Page 37 GAO-17-589T 
Letter

· To help ensure a more equitable allocation of funds per capita across 

areas, we recommended that Congress consider requiring IHS to 

develop and use a new method for allocating PRC funds. To make 

IHS’s allocation of PRC program funds more equitable, we 

recommended that IHS (1) develop written policies and procedures to 

require area offices to notify IHS when changes are made to the 

allocation of funds to PRC programs; (2) use actual counts of PRC 

users in any formula allocating PRC funds that relies on the number of 

active users; and (3) use variations in levels of available hospital 

services, rather than just the existence of a qualifying hospital, in any 

formula for allocating PRC funds that contain a hospital access 

component.

· To develop more accurate data for estimating the funds needed for 

the PRC program and improve IHS oversight, we recommended that 

IHS develop a written policy documenting how it evaluates need for 

the PRC program, and disseminate it to area offices so they 

understand how unfunded services data are used to estimate overall 

program needs. We also recommended that IHS develop written 

guidance for PRC programs outlining a process to use when funds 

are depleted but recipients continue to need services.

In conclusion, although Interior and HHS have taken some actions to 

address the recommendations we have made related to Indian programs, 

as of our February 2017 High-Risk update, there were nearly 40

recommendations that have not been fully resolved. We plan to continue 

monitoring the agencies’ efforts to address these open recommendations. 

To this end, we have ongoing work focusing on accountability for safe 

schools and school construction and tribal control of energy delivery, 

management, and resource development.

In order for these areas to be removed from our High-Risk List, Interior 

and HHS need to show improvement on the 5 key elements described 

earlier: leadership commitment, capacity, action plan, monitoring, and 

demonstrated progress. These five criteria form a road map for agencies’ 

efforts to improve and ultimately address high-risk issues.

We also 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. We look forward to 

continuing our work with this committee in overseeing Indian Affairs, 

including BIA and BIE, and IHS to ensure that they are operating in the 

most effective and efficient manner, consistent with the federal 

Page 38 GAO-17-589T 
Letter

government’s trust responsibilities, and working toward improving 

services to tribes and their members.

Chairman Calvert, Ranking Member McCollum, and Members of the 

Subcommittee, this completes our prepared statement. We would be 

pleased to respond to any questions that you may have.

GAO Contacts and Staff Acknowledgments

Page 39 GAO-17-589T 

If you or your staff have any questions about education issues in this 

testimony or the related reports, please contact Melissa Emrey-Arras at 

(617) 788-0534 or emreyarrasm@gao.gov. For questions about energy 

resource development, please contact Frank Rusco at (202) 512-3841 or 

ruscof@gao.gov. For questions about health care, please contact 

Kathleen King at (202) 512-7114 or kingk@gao.gov. Contact points for 

our Offices of Congressional Relations and Public Affairs may be found 

on the last page of this statement. Key contributors to this statement and 

the related report include Elizabeth Sirois (Assistant Director), Edward 

Bodine (Analyst-in-Charge), James Bennett, Richard Burkard, David 

Chrisinger, Kelly DeMots, Jyoti Gupta, Christine Kehr, Lara Laufer, James 

Rebbe, William Reinsberg, Lisa Rogers, Jay Spaan, and Emily Wilson.

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