United States Government Accountability Office

Washington, DC 20548 

February 23, 2009 

The Honorable Robert C. Byrd 

Chairman 

Subcommittee on Homeland Security 

Committee on Appropriations 

United States Senate 

The Honorable David Price 

Chairman 

Subcommittee on Homeland Security 

Committee on Appropriations 

House of Representatives 

Subject: DHS: Organizational Structure and Resources for Providing Health Care to

Immigration Detainees

Recent events have drawn attention to the health care provided to detainees held by U.S. 

Immigration and Customs Enforcement (ICE), a component of the Department of Homeland 

Security (DHS).1

 For fiscal year 2004 through fiscal year 2007, ICE reported that 69 detainees 

died while in ICE custody, and during 2008, national news organizations investigated and 

published reports of the circumstances surrounding several detainee deaths. Other reports 

have also outlined concerns about the health care provided to detainees. For example, in 

2007, the DHS Office of the Inspector General (OIG) found problems with adherence to ICE’s 

medical standards at two ICE facilities it reviewed where detainee deaths had occurred.2

Additionally, members of Congress, the media, and advocacy groups have raised questions 

about the health care provided to detainees in ICE custody. An explanatory statement 

accompanying the fiscal year 2009 DHS appropriations act directed ICE to fund an 

independent, comprehensive review of the medical care provided to persons detained by 

DHS and identified $2 million for that purpose.3

 1

Under the Immigration and Nationality Act, ICE is authorized to arrest, detain, and remove certain individuals

from the United States. 8 U.S.C. §§ 1226, 1227, 1229, 1229a, 1231, and 1357. We refer to these individuals as

“detainees.” 

2

Department of Homeland Security, Office of the Inspector General, ICE Policies Related to Detainee Deaths and

the Oversight of Immigration Detention Facilities (Washington, D.C.: June 2008). 

3

See Comm. Print of the Comm. on Approp., U.S. House of Rep., Explanatory Statement related to the

Consolidated Security, Disaster Assistance, and Continuing Appropriations Act, 2009, Pub. L. No. 110-329, Div. D., 

p. 636 (Oct. 2008). Section 4 of Pub. L. No. 110-329 provides that the Explanatory Statement shall have the same 

effect with respect to the allocation of funds and the implementation of the act as if it were a joint explanatory 

statement of a committee of conference. 

 GAO-09-308R DHS Resources for ICE Detainee Health Care 
ICE was created in March 2003 as part of DHS.4

 From fiscal year 2003 through fiscal year 

2007, the average daily population of detainees in ICE custody increased by about 40 percent, 

with the most growth occurring since fiscal year 2005.

5

 In fiscal year 2007, ICE held over 

311,000 detainees at more than 500 detention facilities. Most of these were Intergovernmental 

Service Agreement (IGSA) facilities—state and local jails under contract with ICE to hold 

detainees. Some ICE detainees received health care services from IGSA staff, IGSA 

contractors, or community medical providers, and other ICE detainees received health care 

provided or arranged by the Division of Immigration Health Services (DIHS). DIHS is mainly 

comprised of contract employees and officers from the U.S. Public Health Service (PHS) 

Commissioned Corps—a uniformed service of public health professionals who are part of the 

Department of Health and Human Services (HHS) and who provide services in different 

settings, including ICE detention facilities. 

In light of questions about the health care provided to detainees in ICE custody, you 

requested information about ICE’s organizational structure and its health care resources for 

detainees. This report provides (1) a description of ICE’s organizational structure for 

providing health care services to detainees, which includes our review of the relevant 

agreements between DHS and HHS regarding DIHS; (2) information about ICE’s annual 

spending and staffing resources devoted to the provision of health care for detainees, and the 

number of services provided; and (3) an assessment of whether ICE’s mortality rate can be 

compared with the mortality rates of the Federal Bureau of Prisons (BOP) and the U.S. 

Marshals Service (USMS)—two entities that are responsible for holding certain persons, such 

as criminals. 

We took the following steps to develop our findings. To describe ICE’s organizational 

structure for providing health care services to detainees, including interagency agreements, 

we reviewed pertinent reports issued by government agencies and interagency agreements 

regarding DIHS, and we also interviewed agency officials.6

 To determine the annual health 

care spending, staffing, and services provided to ICE detainees, we examined ICE’s fiscal 

year 2003 through fiscal year 2007 data for these three areas. To determine whether ICE’s 

mortality rate could be directly compared with the mortality rate for BOP or USMS, we 

examined ICE mortality data and information about the health care goals, services, and 

populations for ICE, BOP, and USMS. 

We assessed the data DHS provided and we worked with DHS to address discrepancies. 

Subsequently, we determined that the data we used were sufficiently reliable for our 

purposes. Throughout our work, we used data on the average daily population—the number 

of beds ICE used for detainees on an average day during a fiscal year—because ICE was not 

able to provide reliable data on the number of unique individuals detained per fiscal year. We

conducted our work from July 2008 to February 2009 in accordance with all sections of 

 4

Responsibility for detainees was transferred from the Department of Justice’s Immigration and Naturalization 

Service (INS) to DHS’s ICE. 

5

The scope of our work was primarily limited to detainees who were in ICE custody due to immigration violations

and who were held at facilities that serve adults. Some of these facilities are owned and operated by ICE, some 

operate under contracts with ICE, and some operate through service agreements with ICE. We did not include 

detainees held by the Bureau of Prisons (BOP) for committing a criminal offense. 

6

The government reports we reviewed were issued by GAO, the DHS OIG, and the Congressional Research 

Service. We interviewed agency officials from DHS, ICE, HHS, DIHS, BOP, and USMS. 

2 GAO-09-308R DHS Resources for ICE Detainee Health Care
GAO’s Quality Assurance framework that are relevant to our objectives. The framework 

requires that we plan and perform the engagement to obtain sufficient, appropriate evidence 

to meet our stated objectives and to discuss any limitations in our work. We believe that the 

information and data obtained and the analysis conducted provide a reasonable basis for any 

findings and conclusions. 

On December 18, 2008, we briefed your staff on the results of this work. The briefing slides, 

included as enclosure I, have been updated to include more current information. This report 

formally conveys the information presented during that briefing and officially transmits our 

work to the Secretary of DHS and the Acting Secretary of HHS. 

In summary, we reported the following findings: 

• ICE’s organizational structure for providing health care to detainees is not uniform across 

facilities. In fiscal year 2007, 21 DIHS-staffed facilities provided or arranged for health

care for about 53 percent of the average daily population of detainees, while 508 IGSA 

facilities provided or arranged for health care for the remaining detainees—about 

47 percent of the population. In addition, recent agreements with HHS reassigned medical 

personnel to DHS. DHS officials told us that a total of 565 direct health care providers and 

administrative staff were affected by these agreements. 

• Although ICE’s health care data are not complete, the available data on health care 

spending, staffing, and services provided generally showed growth in all three areas. For 

instance, from fiscal year 2003 through fiscal year 2007, reported expenditures for medical 

claims and program operations increased by 47 percent, while the average daily 

population of detainees increased by about 40 percent. 

• ICE’s mortality rate cannot be directly compared with BOP’s or USMS’s mortality rate. 

This is due to differences in the three agencies’ health care goals and scopes of services, 

as well as to demographic differences among the ICE, BOP, and USMS detainee 

populations.

Based on our work, we have identified a number of issues that may merit further assessment 

in the $2 million external study that ICE was directed to fund. These are shown in enclosure I 

and relate to data availability and some aspects of program oversight. 

Agency Comments and Our Evaluation 

We provided HHS and DHS with drafts of this report for their review and comment. HHS had 

no general comments but made a technical comment, which we addressed. DHS provided 

written comments (reprinted in enclosure II) and technical comments that we incorporated 

as appropriate. 

DHS disagreed with the way we presented some of the information in our briefing report. 

First, the agency pointed out that we did not clearly differentiate between the HHS entity 

named DIHS and the identically-named ICE program, and that our report could lead to the 

incorrect conclusion that the HHS entity or its public health personnel were transferred to 

ICE. Noting that DIHS was not transferred from HHS, DHS explained that ICE established its 

own organization that it also named DIHS, to preclude confusion among field offices. In our 

report, we state that, prior to October 1, 2007, DIHS was a component of HHS’s Health 

Resources and Services Administration (HRSA). As we also state in our work, DHS officials 

3 GAO-09-308R DHS Resources for ICE Detainee Health Care
told us that ICE now has a component known as DIHS that provides health care services to 

detainees. We did not determine whether DIHS was transferred from HHS to DHS. Although 

DHS was unable to provide an official organizational chart that shows the placement of

DIHS, we understand that the two DIHS entities shared the same name, and that the entity 

bearing that name now exists only in DHS’s ICE. 

Second, DHS stated that we erroneously asserted that health care providers within what DHS 

referred to as HHS’s DIHS report to ICE’s Office of Detention and Removal Operations. The 

agency stated that ICE does not impinge on the autonomy of HHS’s health care professionals 

who provide services to detainees. As our work indicates, HHS informed us that its DIHS 

ceased to exist as a component of HHS as of October 1, 2007. However, PHS officers are 

detailed to ICE’s DIHS under the Memorandum of Agreement between HHS and DHS. DHS 

officials previously informed us that DHS does exercise some control over DIHS general 

policy development as well as other administrative matters. We also clearly stated in our 

work, however, that DHS officials told us that their agency does not have supervisory control 

over clinical decisions made by DIHS personnel. 

Third, DHS wrote that we erroneously implied that ICE lacks basic information about the 

cost of health care services provided to detainees held at IGSAs. The agency noted that the 

cost for basic health care services provided to detainees is built into the per diem payment 

IGSAs receive. Although the estimated cost of basic services is covered under the per diem 

rate for housing detainees, DHS officials cautioned us during the course of our work that 

such payment does not represent actual expenses incurred. Therefore, IGSA expenditures for 

providing basic health care cannot be separately identified under the current payment

method. As a result, ICE may not have the information needed to determine whether the 

IGSA per diem rate is adequate or excessive for the delivery of basic health care services. 

Fourth, DHS commented that ICE uses the Treatment Authorization Request (TAR) system 

as a tool for authorizing payment for services provided to ICE detainees and that the TAR can 

identify health-related procedures and visits. This seems to imply that the TAR routinely 

provides ICE with additional cost information. However, the description of the TAR system 

shown in the agency’s “DIHS Medical Dental Detainee Covered Services Package,”7

 as well as 

our interviews with senior ICE program staff, do not support this position. Rather, the TAR 

system is used to obtain approval that authorizes payment for off-site, nonroutine health care 

services. As such, it is not designed to track health care spending and is not used to routinely 

report information on health care expenditures by facility type. 

Finally, DHS commented that we did not provide context on ICE’s transfer practices. The 

agency noted that its operational needs for transferring detainees can relate to access to 

medical treatment, access to the courts, or efficiently completing their removal. We recognize 

that ICE transfer practices can have an impact on the health care provided to detainees—

such as the need to rescreen a detainee after a transfer or the need to ensure that a 

transferred detainee’s medical information can be accessed by the new facility. However, 

determining the appropriateness of ICE transfer policy or the rationale behind transfer 

decisions was beyond the scope of our work. The DHS OIG is currently conducting work on 

ICE transfers, which may help to inform the issues DHS noted. 

 7

Division of Immigration Health Services, DIHS Medical Dental Detainee Covered Services Package, 

http://www.icehealth.org/managedcare/providers.shtm (accessed Feb. 13, 2009). 

4 GAO-09-308R DHS Resources for ICE Detainee Health Care
– – – – – 

As agreed with your office, unless you publicly announce its contents earlier, we plan no 

further distribution of this report for 30 days. At that time, we will send copies of this report 

to the Secretary of DHS and the Acting Secretary of HHS. In addition, the report is available 

at no charge on the GAO Web site at http://www.gao.gov. 

If you or your staff have any questions or need additional information, please contact me at 

(202) 512-7114, or CackleyA@gao.gov. Contact points for our Offices of Congressional 

Relations and Public Affairs may be found on the last page of this report. Major contributors 

to this report were Rosamond Katz, Assistant Director; Eleanor M. Cambridge; Joy L. 

Alicia Puente Cackley 

Kraybill; Drew Long; Kevin Milne; and Katherine Wunderink.

Director, Health Care 

Enclosures—2 

5 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

DHS: Organizational Structure and Resources for 

Providing Health Care to Immigration Detainees

Briefing for the staffs of

The Honorable Robert C. Byrd 

Chairman, Subcommittee on Homeland Security 

Committee on Appropriations, United States Senate

The Honorable David Price

Chairman, Subcommittee on Homeland Security

Committee on Appropriations, House of Representatives

Updated

6 GAO-09-308R DHS Resources for ICE Detainee Health Care 
Enclosure I 

Overview

• Introduction

• Objectives 

• Scope and Methodology

• Background

• Results

• Issues for Further Assessment

• Appendix I

7 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

Introduction

1 ICE was created in March 2003 as part of DHS. Responsibility for detainees was transferred from the Department of Justice’s

Immigration and Naturalization Service (INS) to DHS’s ICE. Under the Immigration and Nationality Act, ICE is authorized to arrest,

detain, and remove certain individuals from the United States. 8 U.S.C. §§ 1226, 1227, 1229, 1229a, 1231, and 1357. 2 The scope of our work was primarily limited to detainees who were in ICE custody due to immigration violations and who were housed 

at facilities that serve adults. Some of these facilities are owned and operated by ICE, some operate under contracts with ICE, and 

some operate through service agreements with ICE. We did not include detainees held by the Bureau of Prisons (BOP) for committing a 

criminal offense.

• In fiscal year (FY) 2007, the Department of Homeland Security’s (DHS) U.S.

Immigration and Customs Enforcement (ICE) detained over 311,000 individuals at

more than 500 detention facilities.1 We refer to these individuals as “detainees.”2

• Questions have been raised by members of Congress, the media, and advocacy 

groups about the health care provided to detainees in ICE custody. From FY 2004

through FY 2007, ICE reported that 69 detainees had died in ICE custody. 

• An explanatory statement accompanying the FY 2009 DHS appropriations act 

directed ICE to fund an independent study on the health care services ICE provides

to detainees and identified $2 million for this purpose.

8 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

Introduction (cont.)

• Multiple federal entities have some responsibility for 

providing housing or health care services to people in 

detention.

• DHS is the agency charged with the security of the country. Within DHS, ICE

holds and removes certain detainees from the U.S.—including those held for

immigration violations.

• The Department of Health and Human Services (HHS) is the principal agency 

tasked with protecting the health of Americans. The U.S. Public Health Service

(PHS) Commissioned Corps, within HHS, is a uniformed service of public health

professionals that provide services in different settings, including detention 

facilities.

• The Division of Immigration Health Services (DIHS) is an entity that provides

health care services to detainees held in ICE custody.

• The Federal Bureau of Prisons (BOP) is an entity within the Department of

Justice (DOJ) that holds inmates serving sentences for criminal offenses and 

provides essential medical care while inmates are in the agency’s custody.

• The U.S. Marshals Service (USMS) is a DOJ entity that holds certain

detainees—such as federal fugitives and some criminals.

9 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

Objectives

• We were requested to examine issues pertaining to the 

provision of health care to detainees. In this briefing, we

1. describe ICE’s organizational structure for providing health

care services to detainees, including a review of the relevant

agreements between DHS and HHS regarding DIHS,

2. determine the annual health care spending, staffing, and 

services provided to ICE detainees, and

3. determine whether ICE’s mortality rate can be compared 

with BOP’s or USMS’s mortality rate.

10 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

Scope and Methodology3

3 We conducted our work from July 2008 to February 2009 in accordance with all sections of GAO’s Quality Assurance framework that

are relevant to our objectives. The framework requires that we plan and perform the engagement to obtain sufficient, appropriate

evidence to meet our stated objectives and to discuss any limitations in our work. We believe that the information and data obtained and

the analysis conducted provide a reasonable basis for any findings and conclusions. 4 FY 2007 was generally the most recent year of data available. Unless otherwise indicated, the data we present reflect the detainees

held at three types of facilities: Service Processing Centers (SPC), Contract Detention Facilities (CDF), and Intergovernmental Service

Agreement (IGSA) facilities.

• We reviewed pertinent reports issued by GAO, the DHS Office of the Inspector General, and the

Congressional Research Service. These reports pertained to ICE’s organizational structure and 

the health care services provided to ICE detainees.

• We reviewed agreements in place between DHS and HHS regarding DIHS.

• We interviewed officials from DHS, ICE, DIHS, HHS, BOP, and USMS.

• We examined data on ICE’s FY 2003 through FY 2007 health care expenditures, staffing, and 

services provided. We also examined mortality data for ICE detainees and information about the 

health care goals, services, and populations for ICE, BOP, and USMS.

4

• We assessed the data DHS provided and we worked with DHS to address discrepancies.

Subsequently, we determined that the data were sufficiently reliable for our purposes.

11 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

Background 

Reported average daily population of detainees in ICE custody,

FY 2003–FY 2007

• The average daily population of

detainees in ICE custody

increased by about 40 percent

from FY 2003 through FY 2007,

with the most growth occurring 

since FY 2005.

• The average daily population of

detainees is the most reliable and

readily available population 

measure DHS was able to

provide. It indicates the number of

detainee beds ICE used on an

average day during a fiscal year. 

ICE computes the average daily 

population by dividing the annual 

number of bed days used by 365.

0

5,000

10,000

15,000

20,000

25,000

30,000

2003 2004 2005 2006 2007

Fiscal year

Average daily

population

Source: GAO analysis of DHS data.

12 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

Background (cont.)

Gender and age of ICE’s reported average daily population, FY 2007

88%

12%

Male Female

5%

61%

28%

6%

0-18 19-35 36-50 51 and up

Source: GAO analysis of DHS data on total average

daily population.

Source: GAO analysis of DHS data on total average

daily population.

13 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

Background (cont.)

Number and type of detention facilities used by ICE, FY 2007

• Most ICE detainees are housed in 

three types of detention facilities:

• Service Processing Centers (SPC):

8 federal facilities operated by ICE to 

hold detainees

• Contract Detention Facilities (CDF):

7 facilities operated by private

contractors specifically to hold 

detainees

• Intergovernmental Service 

Agreement (IGSA) facilities: 

514 state and local jails under

contract with ICE to hold detainees5

514

7 8

IGSA CDF SPC

Source: DHS.

5 DHS officials stated that the 514 IGSA facilities include over 300 facilities that each generally report a total of more than 60 days of

detainee bed use per year. The other IGSA facilities report less activity—some report a total of only one or two nights of detainee bed 

use per year. 

14 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

Background (cont.)

ICE’s reported average daily population by facility type,

FY 2003–FY 2007

• IGSAs house the majority of 

the detainee population. In 

FY 2007, almost 65 percent 

of the average daily 

population was housed at an 

IGSA. 

• From FY 2003 through FY 

2007, the average daily 

population at IGSAs grew by 

about 31 percent.

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

2003 2004 2005 2006 2007

Fiscal year

SPC CDF IGSA

Source: DHS.

Average daily 

population

15 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

Background (cont.)

Reported length of stay in ICE custody, FY 2003–FY 2007

• From FY 2003 through FY 

2007, the median length of 

stay for detainees increased 

from 12 days to 18 days. 

• At ICE’s discretion, detainees can be transferred 

between facilities, sometimes 

more than once. The agency 

estimated that the average 

detainee is booked into 

about 2 facilities while in ICE 

custody.

Source: DHS data on total average daily population.

12 12

14 14

18

0

2

4

6

8

10

12

14

16

18

20

2003 2004 2005 2006 2007

Fiscal year

Days 

Reported median length of stay, in days, for ICE detainees

16 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

Background (cont.)

ICE detention standards and medical care standards

• ICE developed detention standards designed to ensure 

facilities provide services that will protect detainees’ lives and 

dignity. These detention standards are comprised of 41 

standards that pertain to specific areas—such as medical 

care, food service, and environmental safety. 

• ICE’s medical care detention standards aim to ensure “that 

detainees have access to emergent, urgent, or non-emergent 

medical, dental, and mental health care that are within the 

scope of services provided by the DIHS, so that their health 

care needs are met in a timely and efficient manner.”6

6 ICE/DRO Detention Standard: Medical Care, http://www.ice.gov/doclib/PBNDS/pdf/medical_care.pdf (accessed Dec. 1, 2008). The 

medical care standard was revised by ICE during 2008.

17 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

Background (cont.)

ICE medical care standards

• ICE medical care standards include

• an intake screening, including a tuberculosis screening, is to be performed for each

detainee within 12 hours of their arrival at a new facility. 

• a physical examination is to be performed for each detainee within 14 days of arrival at 

a different facility. If a physical has been performed for the detainee within the last 90

days, a health care provider may determine that a new physical examination is not 

necessary.

• when a facility is unable to provide certain need-based medical care, detainees can

receive care from community medical providers.

• if a detainee is transferred to another facility, the transferring facility must compose a 

“transfer summary” that includes the detainee’s medical issues, any treatment provided

by the facility, tuberculosis screening results, and at a minimum, a 7-day supply of any 

needed prescription medications.

18 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

Results

1. ICE’s organizational structure for providing health care to

detainees is not uniform across facilities; recent agreements 

with HHS reassigned medical personnel to DHS.

2. Although ICE’s health care data are not complete, available 

data on health care spending, staffing, and services provided 

generally showed growth in all three areas.

3. ICE’s mortality rate cannot be directly compared with BOP’s or 

USMS’s mortality rate due to differences in the agencies’ health

care goals, scopes of services, and population demographics.

19 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

1: ICE’s organizational structure for providing health care to

detainees is not uniform across facilities; recent agreements 

with HHS reassigned medical personnel to DHS

• ICE uses DIHS staff to provide or arrange for health care for 

some detainees, and uses IGSA staff to provide or arrange for 

health care for other detainees.

• In FY 2007, DIHS staff provided care to detainees at 21 facilities—including 

8 SPCs, 7 CDFs, and 6 IGSAs.7 In some instances, this care can be

supplemented by services from community medical providers.

• In FY 2007, at the approximately 508 remaining IGSA facilities, detainee 

health care was provided or arranged for by the respective IGSA. DHS 

officials indicated that each IGSA may determine whether health care

services for detainees will be provided by IGSA staff, contractors, or

community medical providers.

7 In FY 2007, these 6 IGSAs accounted for about 27 percent of the total average daily population for all IGSAs.

20 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

1: ICE’s organization

DIHS providers differ from IGSA providers

• DIHS staff include PHS officers, contract employees, and 

civil servants. In FY 2007, about 46 percent of DIHS staff 

were PHS officers detailed to DHS, about 52 percent were 

contract employees, and about 2 percent were civil 

servants.8

• IGSA staff may include on-site clinicians, employed by a 

county public health service or under contract with the facility

itself. Some IGSAs have no health care staff on-site and rely 

solely on community medical providers to deliver care. 

8 A “detail” is the assignment of a PHS officer or employee by HHS to another federal agency, to perform duties in support of that 

agency or the PHS. 42 U.S.C. § 215.

21 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

1: ICE’s organization

DIHS provided or arranged for health care for about half of the detainee 

population in FY 2007

• In FY 2007, DIHS-staffed facilities provided or arranged 

for health care for about 53 percent of the average daily 

population of detainees. 

• The proportion of the average daily population served by

DIHS-staffed facilities grew from about 35 percent in 

FY 2003 to about 53 percent in FY 2007. 

• In FY 2007, the remaining 508 IGSA facilities provided or 

arranged for health care for about 47 percent of the 

average daily population of detainees.

22 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

1: ICE’s organization

In 2007 DIHS was removed from HHS’s organizational chart; DIHS now 

reports to an ICE component

• Before October 1, 2007, DHS and HHS maintained annual interagency agreements

through which DIHS provided detainee health care services for ICE. DIHS was a

component of HHS’s Health Resources and Services Administration (HRSA).

• The last interagency agreement was terminated as of October 1, 2007, and DIHS is

no longer a component of HRSA. According to DHS officials, ICE has a component

known as DIHS which provides health care services to detainees in support of ICE's

overall mission.

• Some of the civilian staff formerly employed at HRSA’s DIHS became employees of

DHS during 2007.

• A 2007 Memorandum of Agreement between DHS and HHS placed PHS officers on

detail to DHS on an open-ended basis, and allowed for additional PHS officers to be

detailed in the future.

• DHS officials said that the termination of the interagency agreement and the 

development of the Memorandum of Agreement affected 565 direct health care 

providers and administrative staff—253 PHS officers, 301 contract employees, and 11

civil servants.

23 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

• DHS officials stated that the agency has some supervisory 

responsibilities over the movement and assignment of DIHS 

staff, as well as general DIHS policy development. According to

DHS officials, DHS does not have supervisory responsibility 

over DIHS’s clinical decision making.

• DHS officials indicated that DIHS reports to the Detention

Management Division, which is located in ICE’s Office of 

Detention and Removal Operations.

• DHS officials could not provide an official organizational chart to 

show DIHS’s placement in DHS.

1: ICE’s organization

DIHS reports to DHS on administrative matters

24 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

1: ICE’s organization

Facilities do not use standardized record keeping or reporting to

monitor health care services provided to detainees

• DIHS officials told us that they collect data on the health care services 

provided at the DIHS-staffed facilities. 

• At the 21 facilities that DIHS staffed in FY 2007, 9 recorded information 

electronically and 12 used paper records.

• DIHS compiles a monthly report that incorporates data from the facilities it 

staffs, but officials told us that DIHS is not required to report data to DHS 

routinely.

• DHS officials confirmed that ICE does not routinely collect data on the 

health care services provided at the IGSAs that are not staffed by 

DIHS. 

• Officials stated that they do not know whether these IGSAs record health

care information electronically or on paper. 

• Officials can obtain data from these IGSAs, but they need to request paper 

copies of individual detainee health records to compile any needed data, 

because IGSAs are not required to report data to DHS routinely.

25 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

1: ICE’s organization

Facilities are responsible for transferring detainee medical 

information when detainees are transferred

• According to DHS officials, in FY 2007, ICE conducted 

about 261,000 transfers of detainees among facilities.

• DHS officials confirmed that ICE does not have a uniform 

method for routinely monitoring facilities’ completion of 

medical transfer summaries at the time detainees are 

transferred, as required by ICE detention standards.

26 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

2: Although ICE’s health care data are not complete, available 

data on health care spending, staffing, and services provided 

generally showed growth in all three areas

• Complete ICE health care expenditure data fall into three categories:

• Program operations

• salaries for DIHS staff—including PHS officers

• transportation costs for DIHS staff

• rent and information technology systems

• Medical claims

• medical claims submitted by community medical providers

• pharmacy expenses, dental expenses, psychological care

• Health care component of IGSA contract costs

• any salaries for IGSA health care staff or costs for the health care services they

provide—both of which are paid to IGSAs as part of their contract payments for 

housing detainees

• Data are not available on IGSA’s health care costs, but data are available for

program operations and medical claims.

27 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

2: Health care spending, staffing, and services

ICE’s health care expenditure data only permit high-level analysis

• DHS officials confirmed that no itemized medical claims exist

for health care services provided by DIHS staff. These costs 

are paid through DIHS staff salaries, which are included in 

program operations expenditure data.

• DHS officials confirmed that no data are available on the cost

of health care services provided by IGSA staff. Payments for 

these items are included as part of the contracts IGSAs have 

with ICE. DHS officials confirmed that IGSA contract payments 

reimburse each IGSA’s overall costs for housing detainees—

precise costs cannot be identified.

28 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

0

10

20

30

40

50

60

70

80

90

100

2003-2004 average 2005 2006 2007

Fiscal year

Dollars in millions

0

5,000

10,000

15,000

20,000

25,000

30,000

Average daily

population

Reported program operations and medical

claims expenditures Average daily population

2: Health care spending, staffing, and services

ICE’s reported program operations and medical claims expenditures for detainees increased by 

47 percent and average daily population increased by about 40 percent, FY 2003–FY 2007

Note: Reported health care expenditures represent program operations and

medical claims expenditures. These data exclude the value of services provided 

by IGSA staff and the value of any IGSA staff salaries—both of which are 

included in IGSAs’ contract rates. FY 2003 and FY 2004 data were averaged to

address a delay in medical claims payments that occurred when DHS changed 

its claims processing contractor. 

Source: GAO analysis of DHS data. 

29 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

$0

$5

$10

$15

$20

$25

$30

$35

$40

$45

$50

$55

$60

$65

2003 2004 2005 2006 2007

Fiscal year

Program operations expenditures for DIHS

2: Health care spending, staffing, and services

Reported program operations expenditures for DIHS increased, 

FY 2003–FY 2007

Dollars in millions

Note: Program operations expenditures include DIHS salaries, 

transportation, and related costs. These data exclude the value of 

IGSA staff salaries, transportation, and any other IGSA costs.

Source: DHS. 

• From FY 2003 through 

FY 2007, spending for DIHS 

staff salaries and other program 

operations expenditures more

than doubled. 

• ICE officials primarily attributed

this increase in spending to

growth in the number of DIHS 

staff to support ICE detention 

operations.

30 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

$0

$5

$10

$15

$20

$25

$30

$35

$40

2003-2004

average

2005 2006 2007

Fiscal years

Medical claims expenditures

2: Health care spending, staffing, and services

Reported medical claims expenditures showed moderate fluctuation, 

FY 2003–FY 2007

Dollars in millions

Notes: Medical claims expenditures include claims from community

medical providers. DIHS providers do not submit claims. 

Reimbursement for IGSA staff providers’ services is paid through the

IGSAs’ contract rates. FY 2003 and FY 2004 data were averaged to 

address a delay in medical claims payments that occurred when 

DHS changed its claims processing contractor. 

Source: GAO analysis of DHS data. 

• Medical claims expenditures 

ranged between $21.2 million and 

$30.7 million per year from 

FY 2003 through FY 2007. 

• Claims for health care services

provided by community medical 

providers are submitted to ICE’s

claims processing contractor, and

these costs are included in the 

medical claims expenditure data.

Care from community medical

providers may supplement 

services provided by any of the

IGSAs or by the 21 DIHS-staffed 

facilities. 

31 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

2: Health care spending, staffing, and services

DIHS staff increased, FY 2003–FY 2007

0

100

200

300

400

500

600

2003 2004 2005 2006 2007

Fiscal year

DIHS FTEs

Direct health care providers Administrative staff

Note: These FTE data reflect staff at DIHS-staffed facilities, 

and do not include any staff at approximately 508 IGSAs.

Source: DHS.

• From FY 2003 through FY 2007, the 

number of DIHS direct health care 

providers more than doubled—

growing from 208 to 460 full-time 

equivalent staff (FTE).

• The number of DIHS administrative

FTEs nearly doubled, from 57 in 

FY 2003 to 105 in FY 2007. In 

FY 2007, each administrative staff 

person supported roughly 4.4 direct

health care providers.

• DIHS officials told us that they

intend to increase their total staff to 

900 FTEs by FY 2010.

32 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

2: Health care spending, staffing, and services

Total reported number of health care services DIHS provided to 

detainees increased, FY 2003–FY 2007

• The total number of health 

care services provided by 

DIHS more than doubled 

from FY 2003 through FY

2007. 

• These data do not include 

health care services 

provided at approximately 

508 IGSAs, because ICE 

does not routinely collect 

data on services provided at 

the facilities DIHS does not 

staff.

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

2003 2004 2005 2006 2007

Fiscal year

Number of

services

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

Services provided by DIHS staff

Average daily population at DIHS-staffed facilities

Note: These data reflect services provided at DIHS-staffed facilities and the 

average daily population at DIHS-staffed facilities. A “health care service”

represents one encounter with a medical official or specially-trained

detention officer.

Source: GAO analysis of DHS data. 

Average daily 

population

33 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

2: Health care spending, staffing, and services

DIHS reported increasing numbers of mandatory services, 

FY 2003–FY 2007

0

25,000

50,000

75,000

100,000

125,000

150,000

175,000

200,000

2003 2004 2005 2006 2007

Fiscal year

Number of

services

0

3,000

6,000

9,000

12,000

15,000

Average daily

population

Intake screenings, mandatory

Physical exams, mandatory within 14 days

Average daily population at DIHS-staffed facilities

Notes: These data reflect mandatory services provided at DIHS-staffed facilities and 

the average daily population at DIHS-staffed facilities. ICE medical care standards

require that a physical exam should be performed each time a detainee is transferred

to a new facility. If a physical has been performed for the detainee within the last 

90 days, a health care provider may determine that a new physical examination is not 

necessary. If a detainee is transferred out of a facility within 14 days of arrival, the

detainee may not receive a physical exam. 

Source: GAO analysis of DHS data.

34 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

2: Health care spending, staffing, and services

Reported number of need-based health care services provided by 

DIHS increased 148 percent, FY 2003–FY 2007

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

2003 2004 2005 2006 2007

Fiscal year

Number of

services

Need-based health care services provided at DIHSstaffed facilities

Notes: These data reflect services provided at DIHS-staffed facilities

only. Need-based health care includes any services provided beyond

mandatory intake screenings and physical exams. The specific types of

need-based services that DIHS provides are shown in appendix I.

Source: GAO analysis of DHS data. 

35 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

3: ICE’s mortality rate cannot be directly compared with BOP’s or 

USMS’s mortality rate due to differences in the agencies’ health care 

goals, scopes of services, and population demographics

• The agencies’ health care goals and the health care services 

each agency provides to their detainees differ. Also, lengths of

stay and demographic data vary among ICE, BOP, and USMS 

detainee populations. 

• Because of these differences, direct, meaningful comparisons 

between the three agencies’ mortality rates cannot be made.

36 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

3: Agency comparisons

Average lengths of stay, health care goals, and health care services 

of ICE, BOP, and USMS differ

Medically necessary, 

including some chronic

and some preventive

Access to health care

within ICE’s scope of

service

FY 2007 reported 

average length of stay: 

37.1 days

ICE

Medically necessary, 

including chronic and 

preventive

Health maintenance 

throughout imprisonment

Average sentence length

as of July 1, 2007: 

10.3 years

BOP

Medically necessary,

including some chronic

Health care

services

provided

Health care No health care goal

goals

Average Not recorded

length of

stay

USMS

Source: DHS, BOP, and USMS. 

37 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

3: Agency comparisons

Mortality rates for ICE, BOP, and USMS cannot be compared

• Limited availability of ICE data prevents meaningful 

mortality analyses. • According to DHS officials, some relevant information is unknown—such as

detainees’ comprehensive health histories.

• Some relevant information within each detainee’s file is not consistently 

recorded in standardized medical terms—such as detainees’ causes of 

death. 

• Differences among the ICE, BOP, and USMS populations 

prevent meaningful mortality comparisons.

• The three populations exhibit different lengths of stay, average age, and 

other demographic information that would be needed to reliably compare 

the respective mortality rates.

• The number of deaths in custody from FY 2004 through FY 2007 is low 

relative to the overall average daily population for the same time period.

38 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

Issues for Further Assessment

• The following issues may merit further assessment in the 

$2 million external study that ICE was directed to fund:

• ICE’s ability to access detainee population data that measure unique 

individuals in ICE custody, rather than the average number of beds used

• Reporting relationships between DIHS and ICE

• IGSA reporting requirements—including the frequency of reporting on 

health care services provided to detainees, and the format in which health 

records are maintained

• ICE’s ability to routinely ensure the transfer of medical records when

detainees are transferred between facilities

• ICE’s ability to identify and report the detainee health care costs incurred by

IGSAs

• ICE’s ability to identify and report medical claims expenditures by facility 

type—such as for all IGSAs

39 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure I 

Appendix I: 

DIHS health care services included in our analysis

• Mandatory services: 

• Intake screenings

• Physical exams

• Need-based care service categories:

• Sick call visits—scheduled visits for non-emergency health care requests

• Urgent care visits—unscheduled visits for detainees who require a medical 

response 

• Dental health visits

• Mental health visits

• Chronic disease visits

• Short stay unit visits—observation unit stays for detainees who have been 

determined to require close monitoring, but do not require a hospital stay

• Pill line distributions—single distributions of prescription or over-the-counter

medications

40 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure II 

Comments from the Department of Homeland Security 

41 GAO-09-308R DHS Resources for ICE Detainee Health Care 
Enclosure II 

42 GAO-09-308R DHS Resources for ICE Detainee Health Care
Enclosure II 

(290755) 

43 GAO-09-308R DHS Resources for ICE Detainee Health Care
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