United States General Accounting Office

GAO Briefing Report to Congressional

Requesters

August 1997 FEDERAL

PERSONNEL

Public Health Service

Commissioned Corps

Officers’ Health Care

for Native Americans

GAO/GGD-97-111BR

GAO United States

General Accounting Office

Washington, D.C. 20548

General Government Division

B-272103 

August 27, 1997

The Honorable Ben Nighthorse Campbell

Chairman, Committee on Indian Affairs

United States Senate

The Honorable John McCain

United States Senate

This briefing report responds to your request that we provide information

on Public Health Service (PHS) Commissioned Corps officers and others

who are involved in providing Native American health care through the

Indian Health Service (IHS) or tribal associations. As agreed with your

offices, this document provides information on (1) Corps officers’

historical involvement in providing health care to Native Americans;

(2) the extent of nationwide participation in Native American health care

by Corps officers and non-Corps providers in fiscal year 1996; (3) how

health-care provider vacancies were filled in selected geographic

areas—sections of Alaska, Arizona, New Mexico, and Oklahoma—and the

number of such vacancies filled by Corps officers; (4) how tribal

representatives, IHS officials, and medical facility staff in the locations we

visited perceived Corps and non-Corps providers and their perceptions of

the potential effects that converting Corps officers to civil service status

might have on Native American health care; and (5) changes in the Native

American health care system that might affect those providing health care

to Native Americans, whether Corps or non-Corps personnel.

This report summarizes the substance of our August 18, 1997, briefing.

Background IHS is an operating division within the Department of Health and Human

Services (HHS). Its mission is to provide a comprehensive health-services

delivery system for Native Americans and Alaska Natives (collectively

referred to as “Native Americans”). Until 1988, when it became a separate

agency, IHS was a component of PHS. IHS employs both PHS Commissioned

Corps officers and federal civil service health care personnel. In fiscal year

1996, IHS employed 14,613 nationwide, including about 6,300 health care

providers. A total of 2,237, or about 35 percent, of these health care

providers were Corps officers, and the remaining 65 percent were civil

service employees working as counterparts of the Corps’ professional

categories. IHS’ total fiscal year 1996 budget was $2.2 billion.

Page 1 GAO/GGD-97-111BR PHS Commissioned Corps Officers
B-272103 

The PHS Commissioned Corps is a uniformed personnel system. Corps

officers are health professionals whose pay and allowances are equivalent

to those of the armed forces, as authorized by title 37 of the U.S. Code.

Although health care professionals hired under this system perform

functions that are essentially the same as those of civil service employees,

they are given rank and compensation equivalent to those of U.S. Navy

officers. Corps officers’ military-like compensation is based on the Corps’

temporary service with the armed forces during World Wars I and II. Corps

officers are entitled to wear uniforms similar to those of naval officers,

with PHS insignia, but they do not belong to the military. When they are

detailed to the Coast Guard or the Department of Defense (DOD), they are

subject to the Uniform Code of Military Justice, which governs the

conduct and discipline of armed forces members.1

The Native American health care system consists of 533 health care

facilities funded through IHS; 150 of the facilities are operated by IHS, and

383 facilities are operated by tribes or associations of Alaska Native

villages under various contract agreements. IHS facilities are staffed by

Corps officers and civil service personnel. Tribal facilities are staffed by

Corps officers and civil service staff detailed from IHS and other nonfederal

personnel hired by the tribe. Staffing decisions at tribally operated

facilities are made by the tribes.

Results in Brief The Bureau of Indian Affairs (BIA), in the Department of the Interior, was

responsible for Native American health care until 1955. In 1954, Congress

gave the Surgeon General, then operating head of the PHS, responsibility

for Native American health care. In 1955, PHS established a Division of

Indian Health, which became IHS in 1968. Commissioned Corps officers

were detailed to BIA to provide Native American health care from 1926

until 1955 and have been part of IHS since its creation. From 1978 through

1996, they constituted, on average, about 17 percent of the total IHS

workforce.

Our analysis of fiscal year 1996 IHS and tribal data for 6,260 health care

providers nationwide in 6 professions—physician, registered nurse,

dentist, pharmacist, engineer, and sanitarian—in the Native American

health care system showed that about 46 percent were federal civil service

employees, and about 31 percent were Corps officers. The remaining

1

Under a 1902 statute, the President can incorporate the Corps into the armed forces in the event of

war or national emergency. Since all military members are subject to the Uniform Code of Military

Justice, Corps officers, after being incorporated into the military, would be subject to the code. This

situation has not occurred since 1952.

Page 2 GAO/GGD-97-111BR PHS Commissioned Corps Officers
B-272103 

providers were nonfederal employees directly hired by tribes or Alaska

Native health care associations. While most physicians and registered

nurses were civil service employees, most dentists, pharmacists,

sanitarians, and engineers were Corps officers. Tribally hired employees

were not the largest part of the workforce in any of the six categories, but

they represented from about 20 to 30 percent of physicians, pharmacists,

dentists, and registered nurses.

To fill 139 health-provider positions between July 1, 1995, and June 30,

1996, in the areas we visited, IHS and tribal governments generally used a

competitive selection process. None of these filled positions, nor 100

unfilled positions we reviewed in these areas, were reserved exclusively

for Corps officers. Corps officers filled 36 of the 139 recently filled

vacancies (26 percent); of the 36 vacancies, only Corps officers applied for

17 of them.

Interviewees’ perceptions of health care providers varied. Many

interviewees expressed no opinion on the skills and dedication of Corps

and non-Corps health care providers. Of those expressing an opinion, most

said they saw no difference between the skills of Corps officers and others

providing health care to Native Americans; but most interviewees

perceived Corps officers as being more dedicated than non-Corps

providers. Further, most IHS officials, medical facility staffs, and tribal

representatives said that converting Corps officers to the civil service

personnel system might have negative effects in terms of costs and health

care in their areas or facilities. Most based their predictions on the

premise that some Corps officers would not make the conversion. Fewer

interviewees predicted no negative impact resulting from the Corps’

conversion to another personnel system, while others said any impact

would depend on the extent to which Corps officers make the transition to

a non-Corps system.

About one-half of the interviewees preferred Corps over non-Corps health

care providers. Many said that having Corps officers provide health care

was less costly to them than using civil service or direct-hire providers and

that civil service employees caused an administrative burden. More

interviewees cited advantages than disadvantages in having Corps officers

provide health care, and cost was cited most frequently as an advantage.

Large-scale changes are occurring in the Native American health care

system. Tribes are moving toward administering their own health care

facilities and resources. IHS has projected that by 1999, tribes may control

Page 3 GAO/GGD-97-111BR PHS Commissioned Corps Officers
B-272103 

as much as 57 percent of the IHS budget, as opposed to 32 percent in 1994.

Further, in response to recommendations by an Indian-health design team,

IHS officials said the agency is decentralizing its operations, with

managerial and resource allocation decisions to be made at the health

facility level. While these changes may reduce the need for Corps and civil

service health care providers, they may not eliminate the perceived need

entirely. Although some tribes are planning to replace Corps or civil

service providers with tribally hired medical personnel, others said they

anticipate a continuing need for the Corps.

Scope and

Methodology

To gather information on Corps officers’ historical involvement in

providing health care to Native Americans, we obtained and reviewed PHS

and IHS documents and historical material.

To gather information on the extent of participation in Native American

health care by Corps officers and non-Corps providers in fiscal year 1996,

we obtained and reviewed nationwide data on the number of employees in

health care professions working in IHS or directly hired by the tribes. For

IHS employees, we obtained information from IHS’ personnel database as of

September 30, 1996, that included records for Corps officers and civil

service health care professionals. Because IHS does not maintain data on

the number of health care providers directly hired by tribes, we obtained

this information by using a data-collection instrument that we sent to IHS

area offices nationwide, requesting data as of June 30, 1996, on health care

providers directly hired by tribes and Alaska Native health associations.

We focused on collecting information on the following six

professions—physician, registered nurse, dentist, pharmacist, engineer,

and sanitarian—because these professions were comparable between IHS

and tribal direct-hire personnel and were substantially represented in the

Native American health care system.

To determine how selected health-provider vacancies were filled in the

areas we visited and whether any of these vacancies were reserved for

Corps officers, at each facility we visited, we requested information

concerning current and recently filled vacancies in the six professions. We

selected a number of tribes and medical facilities to visit in these states,

based upon tribal populations, patient workloads, and geographic

locations. We also reviewed records on 139 vacancies that had been filled

during the period July 1, 1995, to June 30, 1996, and 100 vacancies that had

not been filled at the time of our visits (from August through

November 1996).

Page 4 GAO/GGD-97-111BR PHS Commissioned Corps Officers
B-272103 

In 40 interview sessions, we interviewed tribal leaders, Alaska Native

health association officials, IHS area office officials, tribal medical facility

representatives, and IHS facility representatives to gather information on

their perceptions of (1) Corps and non-Corps health care providers and

(2) the potential effects that converting Corps officers to civil service

status might have on Native American health care. We also interviewed

senior IHS headquarters officials regarding changes in the Native American

health care system that might affect Corps and non-Corps health care

providers. As requested, we simply gathered and presented interviewees’

perceptions of those providing health care to Native Americans. We did

not attempt to corroborate what we were told in our interviews.

It should also be noted that more than 1 person participated in 25 of the 40

interview sessions. Ten of the 40 sessions consisted of both tribal and

medical facility representatives or representatives from more than one

medical facility; in these sessions, we received viewpoints from more than

1 representative. In 6 of the 25 sessions, tribal representatives were

present, together with IHS staff—either Corps officers or civil service

employees or both. We do not know what effect, if any, group composition

had on the views expressed in the interview sessions. (For more details

about the methodology we used to meet our reporting objectives, see app.

I.)

We obtained information on changes in the Native American health care

system that might affect Corps and non-Corps providers by reviewing IHS

documents and interviewing officials from IHS and the National Indian

Health Board. We also reviewed reports of an Indian-health design team.

We did our audit work between May 1996 and July 1997, in accordance

with generally accepted government auditing standards. A complete list of

the locations in which we did our audit work appears in appendix III.

We requested comments on a draft of this report from the Secretary of HHS.

HHS’ comments are discussed in the following section.

Agency Comments

and Our Evaluation

HHS, in a letter dated July 29, 1997, provided written general and technical

comments on a draft of this briefing report. These comments and our

responses to certain of the technical comments are contained in appendix

II.

Page 5 GAO/GGD-97-111BR PHS Commissioned Corps Officers
B-272103 

Although HHS generally agreed with the information we presented, in some

cases its characterization of our presentation was not accurate. For

example, it referred in several places to findings and conclusions. In

neither the draft nor this final briefing report did we, as indicated by HHS,

reach conclusions on the substance of the role played by Corps officers in

the Native American health care system. The scope of our field work was

limited, by agreement with the requester, to four states, thus by definition

excluding many facilities and tribal representatives. Our statements in the

report concerning perceptions of Corps providers by tribal representatives

do not constitute findings; they are simply a compilation of views

expressed by those whom we interviewed. Further, as previously

indicated, we did not attempt to corroborate any of the statements

interviewees made to us; and we therefore cannot say whether or to what

extent the statements reflect actual conditions.

Similarly, contrary to HHS’ characterization, we did not find that the skills,

dedication, and professionalism of Corps officers led to a general tribal

preference or choice for using Corps officers on detail when positions

cannot be filled with local tribal hires. Although advantages of using Corps

officers were cited primarily from the standpoints of cost and personnel

administration, many of our interviewees expressed no opinion on the

skills and dedication2

 of Corps and other health care providers. Of those

interviewees who did express an opinion, most saw no difference in their

relative skills but did perceive Corps providers as more dedicated than

non-Corps providers.

In discussing future changes in the Native American health care system,

we made no finding as to the role Corps officers may have in the system as

it moves toward more tribal self-determination. We took note that

representatives of Alaska Native health associations saw a continuing

need for Corps providers, while a representative of the Navajo Nation did

not see such a need.

We are sending copies of this briefing report to the Ranking Minority

Member, Senate Committee on Indian Affairs; the Secretary of HHS; HHS’

Assistant Secretary for Health; the Director of IHS; and other interested

parties. Copies will be made available to others upon request.

2

We did not seek views on the professionalism of health care providers.

Page 6 GAO/GGD-97-111BR PHS Commissioned Corps Officers
B-272103 

Major contributors to this report are listed in appendix IV. If you have

questions about this report, please call me on (202) 512-8676.

L. Nye Stevens

Director

Federal Management and

 Workforce Issues

Page 7 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Contents

Letter 1

Briefing Section I 

IHS, the

Commissioned Corps,

and the Native

American Health Care

System

10

Briefing Objectives 10

Scope and Methodology 12

Background: PHS Commissioned Corps 14

Background: IHS Today 16

Background: Native American Health Care System 18

Briefing Section II 

Makeup of Workforce

in the Native

American Health Care

System

22

History: Origins of IHS and History of Corps Officers in IHS 22

Workforce: Health Care Providers in Native American Health

Care System

24

Briefing Section III 

Health Care Vacancies

and the

Commissioned Corps

28

Vacancies: Health Care Positions at IHS and Tribal Facilities,

1995-1996

28

Briefing Section IV 

Perceptions of Corps

and Non-Corps

Providers

30

Perceptions: Skills and Dedication of Corps and Non-Corps

Providers

30

Perceptions: Effect of Corps Officers’ Conversion to Civil Service 32

Perceptions: Preferences for Corps or Non-Corps Health Care

Providers

34

Perceptions: Views on Corps’ Advantages and Disadvantages 36

Perceptions: Views on Civil Service Advantages and

Disadvantages

38

Perceptions: Views on Tribal Direct-Hire Advantages and

Disadvantages

40

Page 8 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Contents

Briefing Section V 

Changes in the Native

American Health Care

System

42

Changes in the Native American Health Care System 42

Appendix I 

Objectives, Scope,

and Methodology

44

Appendix II 

Comments From the

Department of Health

and Human Services

48

Appendix III 

Audit Work Locations

57

Appendix IV 

Major Contributors to

This Briefing Report

59

Abbreviations

BIA Bureau of Indian Affairs

DOD Department of Defense

HHS Department of Health and Human Services

IHS Indian Health Service

PHS Public Health Service

SEARHC Southeast Alaska Regional Health Consortium

Page 9 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section I 

IHS, the Commissioned Corps, and the

Native American Health Care System

GAO Briefing Objectives

Provide information on

History of Corps officers' involvement in 

Native American health care

Corps and non-Corps' nationwide 

participation in Native American health

care system

How health care vacancies are filled

Perception of Corps and non-Corps providers

Changes in Native American health care 

that might affect health care providers

Page 10 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section I 

IHS, the Commissioned Corps, and the

Native American Health Care System

Briefing Objectives The objectives of this briefing report are to provide information on

• Corps officers’ historical involvement in providing health care to Native

Americans;

• the extent of nationwide participation in Native American health care by

Corps officers and non-Corps providers in fiscal year 1996;

• how health care provider vacancies were filled in selected geographic

areas—sections of Alaska, Arizona, New Mexico, and Oklahoma—and the

number of such vacancies filled by Corps officers;

• how tribal representatives, IHS officials, and medical facility staff in the

locations we visited perceived Corps and non-Corps providers and their

perceptions of the potential effects that converting Corps officers to civil

service status might have on Native American health care;

• changes in the Native American health care system that might affect those

providing health care to Native Americans, whether Corps or non-Corps

personnel.

Page 11 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section I 

IHS, the Commissioned Corps, and the

Native American Health Care System

GAO Scope and Methodology

Reviewed IHS documents 

Collected nationwide data on health care 

providers 

Fieldwork in AK, AZ, NM, and OK:

reviewed current and recently filled 

vacancies and

interviewed medical facility staff, tribal 

representatives, and IHS officials

Page 12 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section I 

IHS, the Commissioned Corps, and the

Native American Health Care System

Scope and Methodology We obtained and reviewed PHS and IHS documents concerning the

representation of Corps officers over time as well as the present and

future structure of health care for Native Americans.

We obtained and reviewed nationwide data on the IHS workforce from IHS’

personnel database. Since IHS does not keep data on health care providers

hired directly by tribes, we obtained this information from the tribes by

means of a data-collection instrument distributed nationwide to the IHS

area offices.

As agreed, we did our fieldwork in the states of Alaska, Arizona, New

Mexico, and Oklahoma. We selected a number of tribes and medical

facilities to visit, based upon populations served. At each facility, we

obtained data on current and recently filled vacancies, reviewed records

on selected vacancies, and interviewed medical facility staff and

representatives of the tribes served by the facilities to obtain their

perceptions on various aspects of providing health care to Native

Americans. We did not attempt to corroborate what we were told in our

interviews. Instead, as requested, we have simply gathered and presented

interviewees’ perceptions.

Appendix I contains a detailed discussion of our objectives, scope, and

methodology.

Page 13 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section I 

IHS, the Commissioned Corps, and the

Native American Health Care System

GAO Background: PHS Commissioned 

Corps

Uniformed personnel system for health 

care professionals 

Corps officers assigned to 11 

professional categories, each having a 

civil service counterpart 

Corps officers receive military rank (Navy 

equivalent) and compensation, but do 

not belong to military

Background: PHS

Commissioned Corps

Unlike the Marine Corps or the Peace Corps, the Commissioned Corps is

not a separate organization with a unique function, but a uniformed

personnel system. The Surgeon General’s office in HHS makes overall

policy for the system, which is administered by an operating division of

HHS. Corps members are supervised by officials of the agency to which

they are assigned. As of September 30, 1996, the Corps had 6,124 officers:

2,237 working in IHS, 2,762 in other HHS agencies, and the remainder

detailed to agencies outside HHS. Officers are assigned to one of the

following 11 professional categories: physician, registered nurse, dentist,

Page 14 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section I 

IHS, the Commissioned Corps, and the

Native American Health Care System

pharmacist, sanitarian, engineer, scientist, dietician, physical therapist,

veterinarian, and health service officer (a category covering professions

ranging from biologist to social worker to hospital administrator). Corps

professional categories have civil service counterparts, and civil service

staff and Corps officers in the same profession often work in the same

facilities.1

Corps officers have ranks equivalent to those of Navy officers and are

entitled to wear uniforms similar to those worn by Navy officers. Corps

officers also receive the same pay and allowances as military members,

under title 37 of the U.S. Code. However, they do not belong to the

military; and they are not subject to the Uniform Code of Military Justice

(which governs the conduct and discipline of armed forces members),

except for the small number detailed to DOD or the Coast Guard. Under a

1902 statute, Corps officers can be transferred to the military by the

President in the event of a national emergency; this has not happened

since 1952. Corps officers’ entitlement to naval rank and military

compensation originated in their incorporation into the military during the

world wars. However, as we opined in May 1996, Corps officers did not

meet the criteria set forth in a DOD report as justification for military

compensation.2 HHS did not agree with our opinion.

1

While the Corps requires all of its officers to have at least a baccalaureate degree in order to be

commissioned, civil service entry-level nurses and sanitarians need not have a college degree.

2

Federal Personnel: Issues on the Need for the Public Health Service’s Commissioned Corps

(GAO/GGD-96-55, May 7, 1996); The Fifth Quadrennial Review of Military Compensation, DOD,

Washington, D.C., Jan. 1984.

Page 15 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section I 

IHS, the Commissioned Corps, and the

Native American Health Care System

GAO Background: IHS Today

Fiscal Year 1996: IHS employed 14,613 

nationwide, with total budget of $2.2 

billion

IHS headquarters in Rockville, MD

12 area offices, mostly in Midwest or 

West

Source: IHS.

Page 16 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section I 

IHS, the Commissioned Corps, and the

Native American Health Care System

Background: IHS Today IHS is an operating division within HHS. Its mission is to provide a

comprehensive health-services delivery system for Native Americans and

Alaska Natives. As of the end of fiscal year 1996, IHS had 14,613 employees,

including 6,306 health care providers (physicians, registered nurses,

dentists, pharmacists, sanitarians, engineers, dieticians, physical

therapists, scientists, and health service officers). A total of 2,237 of these

providers were Corps officers; the remainder were civil service employees

working as counterparts of the Corps’ professional categories. IHS’ total

budget for fiscal year 1996 was $2.2 billion.

IHS headquarters is located in Rockville, MD. IHS also has 12 area offices

located in Aberdeen, SD; Anchorage, AK; Albuquerque, NM; Bemidji, MN;

Billings, MT; Sacramento, CA; Nashville, TN; Navajo Reservation (Window

Rock, AZ); Oklahoma City, OK; Phoenix, AZ; Portland, OR; and Tucson,

AZ. Each IHS area office has oversight of Native American health care in

one or more entire states (except for the Navajo Reservation office, which

covers portions of northeast Arizona, northwest New Mexico and

southeast Utah; and the Tucson office, which covers one-eighth of the

state of Arizona). Area offices provide resources and support for

comprehensive health programs, including medical facilities run by IHS or

by tribal governments and Alaska Native associations. The area offices

also provide administrative support and internal controls to the IHS service

units, which are the local offices of IHS that administer IHS facilities and

public health programs and provide support to tribal facilities.

Page 17 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section I 

IHS, the Commissioned Corps, and the

Native American Health Care System

GAO Background: Native American Health 

Care System

Facility IHS operated Tribally operated

Hospitals 38 11

Health centers 65 132

Health stations 47 73

Alaska village clinics 0 167

Total 150 383

Type of personnel Corps officers and 

civil service

Direct tribal hire, 

plus Corps officers 

and civil service 

detailed from IHS

Note: Data are as of October 1, 1995, the most recent date for which complete data were available.

Source: IHS.

Page 18 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section I 

IHS, the Commissioned Corps, and the

Native American Health Care System

Background: Native

American Health Care

System

The Native American health care system consists of 533 health care

facilities, 150 operated by IHS and 383 operated by tribes, or Alaska Native

health associations formed by a number of Native villages, under various

contract agreements.

Personnel in IHS-run facilities are either Commissioned Corps officers or in

other federal personnel systems (General Schedule or Wage Grade). Tribal

governments or Alaska associations can directly hire their own personnel,

who are employees of the tribe rather than of the federal government.

Tribes can also obtain the services of Corps officers or civil service

employees on detail from IHS, provided IHS is able to make such employees

available.

Page 19 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section I 

IHS, the Commissioned Corps, and the

Native American Health Care System

GAO Background: Native American Health 

Care System (cont.)

Legislation allows tribes to operate (or 

contract for) their own health programs, 

including medical facilities, with federal 

funds

IHS estimates about 1.4 million Native 

Americans are eligible for federally 

provided health care in 1997 

About 91,000 admissions and 6.3 million 

outpatient visits at IHS and tribal facilities 

in fiscal year 1994

Source: IHS data.

Page 20 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section I 

IHS, the Commissioned Corps, and the

Native American Health Care System

Background: Native

American Health Care

System (cont.)

Under the Indian Self-Determination and Education Act of 1975 and

subsequent legislation, tribes and Alaska Native associations can operate

their own health programs, including medical facilities, or contract with a

third party to do so, using federal funds obtained from IHS. Tribes can

assume control by means of a self-determination contract under title I of

the act, or by a self-governing compact under title III, which gives the tribe

or association more autonomy and latitude in administering IHS-provided

resources than does a self-determination contract. Although tribes must

adhere to federal regulations, contracting or compacting tribes can

operate with flexibility in designing their health care systems.

IHS estimated that 1.43 million Native Americans living on or near

reservations, plus Native Americans living in urban areas,3

 are eligible for

health care in fiscal year 1997. This eligibility estimate does not necessarily

mean that this number of tribal members seeks medical treatment from IHS

or tribal facilities In fiscal year 1994, the last year for which complete data

were available, IHS and tribal hospitals had about 91,000 admissions, and

IHS and tribal medical facilities had 6.3 million outpatient visits.

3

IHS is not certain how many Native Americans there are living in urban areas who would be eligible

for health care in facilities other than those on or near reservations.

Page 21 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section II 

Makeup of Workforce in the Native

American Health Care System

GAO History: Origins of IHS and History of 

Corps Officers in IHS 

Legislation transferred Native American 

health care from Bureau of Indian Affairs 

to PHS in 1955

Corps officers first detailed to BIA in 

1926, continued to work in BIA until July 

1955

Corps officers averaged 17 percent of 

IHS workforce, 1978-1996

Source: IHS.

Page 22 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section II 

Makeup of Workforce in the Native

American Health Care System

History: Origins of IHS and

History of Corps Officers

in IHS

The Bureau of Indian Affairs (BIA), a component of the Department of the

Interior, was responsible for providing health care for Native Americans

until 1955. In 1954, Congress, in response to widely held views in the

public health community that Native American health care should be the

responsibility of an agency dedicated to health matters, enacted the

Transfer Act, which assigned responsibility for Native American health

care to the Surgeon General, operating through PHS.

4 PHS created a Division

of Indian Health in 1955 to administer Native American health care; this

division became IHS in October 1968. Between that time and 1988, IHS was a

component of various other PHS organizations—Health Services and

Mental Health Administration, Health Services Administration, and the

Health Resources and Services Administration. In 1988, IHS became a

separate agency. On October 1, 1995, IHS became an operating division of

HHS.

Involvement of the PHS Commissioned Corps in Native American health

care began in 1926, when two senior Corps physicians were detailed to BIA

to assume supervisory medical positions. Corps officers continued to

serve on detail to BIA until the PHS Division of Indian Health came into

existence in July 1955.

Continuous data on Corps officers in IHS was available only from 1978

onward. These data show that on average, about 17 percent of the IHS

workforce were Corps officers during the period from 1978 through 1996.

The percentage ranged from 15.2 percent in 1978 to 18.5 percent in 1986.

4

At the time the Transfer Act was enacted in 1954, and until 1966, the Surgeon General was operating

head of PHS.

Page 23 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section II 

Makeup of Workforce in the Native

American Health Care System

GAO Workforce: Health Care Providers in 

Native American Health Care System

Comparison of Corps, civil service, and tribal hire providers

31%

46%

23%

N = 6260

Tribal hire (1,412)

Civil service (2,905)

Corps (1,943)

Note: Chart includes health care providers in the six professions on which we focused—physician,

registered nurse, dentist, pharmacist, engineer, and sanitarian.

Sources: IHS database and tribal data.

Page 24 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section II 

Makeup of Workforce in the Native

American Health Care System

Workforce: Health Care

Providers in Native

American Health Care

System

We received nationwide data from both IHS and tribes/Alaska Native

associations on 6,260 providers in 6 professions, including physician,

registered nurse, dentist, pharmacist, engineer, and sanitarian. (We

requested data from tribes and Alaska associations for only these

professions, because these professions were comparable between IHS and

tribal personnel and were substantially represented in Native American

health care.) Of the health care providers working in the Native American

health care system in the 6 professions, about 46 percent (2,905) were civil

service (as of October 1996), about 31 percent (1,943) were Corps officers

(as of October 1996), and about 23 percent (1,412) were nonfederal

employees hired directly by tribes and Alaska associations (as of

July 1996).

Page 25 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section II 

Makeup of Workforce in the Native

American Health Care System

GAO Workforce: Providers in Native 

American Health Care System (cont.)

Percent of workforce

0

20

40

60

80

100

Physicians Dentists Registered 

Nurses

Pharmacists Engineers Sanitarians

Corps

Civil Service

Tribal hires

45.7

23.5

30.8

1.4

29.8

68.9

64.9

12.5

22.7

6.8

21.9

71.4

74.3

22

3.7

17.5

13

69.1

Note: Percentages may not add to 100 due to rounding.

Sources: IHS database and tribal data.

Page 26 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section II 

Makeup of Workforce in the Native

American Health Care System

Workforce: Providers in

Native American Health

Care System (cont.)

The six health care provider professions we reviewed had varying

proportions of Corps, civil service, and tribal direct-hire personnel. Civil

service workers predominated among registered nurses, while Corps

officers constituted the largest share of dentists, pharmacists, sanitarians,

and engineers. Almost one-half of the physicians were civil service

employees, while almost one-third were Corps, and the remainder were

tribal direct-hire employees. Tribally hired employees were not the largest

part of the workforce in any professional category, but they represented

from about 20 to 30 percent of pharmacists, dentists, and registered nurses

as well as physicians. Very few tribal-hire employees were sanitarians or

engineers.

Page 27 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section III 

Health Care Vacancies and the

Commissioned Corps

GAO Vacancies: Health Care Positions at 

IHS and Tribal Facilities, 1995-1996

Active recruiting efforts

Competitive selection process with no 

positions reserved for Corps officers

Corps officers filled 26 percent of 

vacancies reviewed

Source: IHS and tribal facilities.

Page 28 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section III 

Health Care Vacancies and the

Commissioned Corps

Vacancies: Health Care

Positions at IHS and Tribal

Facilities, 1995-1996

At the IHS and tribal medical facilities we visited, we discussed with staff

the vacancies—physician, dentist, registered nurse, pharmacist, engineer,

and sanitarian—filled during the period July 1, 1995, through June 30,

1996, and positions that were vacant at the time of our visit. We found that

active recruiting efforts were made to seek out candidates for health care

provider vacancies. Recruiting for positions in the IHS facilities was done

by the facilities, by IHS area offices, and by IHS headquarters, which carries

out a nationwide search for health care providers. Tribes or Alaska Native

associations can obtain IHS assistance to fill tribal facility positions,

including having IHS staff, if available, detailed to the facilities. Recruiters

visited college campuses and job fairs, and advertised in newspapers and

in professional journals.

IHS and the tribes we visited generally used a competitive selection process

to fill medical facility vacancies. According to information from facility

officials concerning vacancies at the facilities we visited, there was a

competitive selection process for 135 of 139 recently filled vacancies and

for 93 of 100 unfilled vacancies. (Competitive selection was not used in

some cases for reasons such as a prior employee returning to the job or a

vacancy being filled by reassigning a current employee.) No positions were

reserved exclusively for Corps officers. Corps officers filled 36 of the 139

recently filled vacancies (26 percent); only Corps officers applied for 17 of

these vacancies.

Page 29 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section IV 

Perceptions of Corps and Non-Corps

Providers

GAO

Many interviewees expressed no opinion 

on skills or dedication

Of those expressing an opinion,

most saw no difference in skills 

between Corps and non-Corps 

providers, a few said that Corps 

providers were more skilled than 

non-Corps providers, and most said 

Corps providers were more dedicated 

than non-Corps providers

Perceptions: Skills and Dedication of 

Corps and Non-Corps Providers

Page 30 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section IV 

Perceptions of Corps and Non-Corps

Providers

Perceptions: Skills and

Dedication of Corps and

Non-Corps Providers

We asked the 51 tribal representatives, IHS area office officials, and

medical facility staff for a comparison between Corps and non-Corps

health care providers in the six professions, including differences in their

skills and dedication. Many expressed no opinion.

Most interviewees who expressed an opinion on skills saw no difference

between Corps and non-Corps providers. For example, 28 interviewees

saw no difference in skills between Corps and non-Corps physicians, 16

saw no difference between Corps and non-Corps dentists, 19 saw no

difference for pharmacists, and 28 saw no difference for registered nurses.

Four interviewees said Corps physicians were more skilled than

non-Corps physicians. Further, three interviewees said Corps engineers

and sanitarians were more skilled than non-Corps providers in these

professions; seven said Corps dentists were more skilled, while six said

the same for Corps pharmacists and five said Corps registered nurses were

more skilled.

In contrast, most interviewees who expressed an opinion saw a difference

in dedication between Corps and non-Corps providers. Eighteen

interviewees saw Corps physicians as being more dedicated, while eight

saw no difference in dedication. Fourteen interviewees saw Corps

dentists, physicians, and registered nurses as being more dedicated than

non-Corps counterparts; 2 interviewees saw no difference for dentists, 4

for pharmacists, and 10 for registered nurses. Ten interviewees perceived

Corps engineers as being more dedicated than non-Corps, and 8 believed

the same about Corps sanitarians; 4 interviewees believed there was no

difference in dedication for engineers, and 2 expressed the same opinion

about sanitarians.

No interviewee said non-Corps providers in any category were more

skilled or dedicated than Corps providers.

Page 31 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section IV 

Perceptions of Corps and Non-Corps

Providers

GAO Perceptions: Effect of Corps Officers' 

Conversion to Civil Service

0

5

10

15

20

10

4

17

1 1

5

3

0

5

4

1

0

Number of interviewees

Tribal representatives

N = 18

IHS area office officials

N = 6

Medical facility staff

N = 27

N = Total number of interviewees

Negative effect on health care

Would depend on time and circumstances of conversion

No effect on health care

Don't know/No opinion

Source: GAO interviews.

Page 32 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section IV 

Perceptions of Corps and Non-Corps

Providers

Perceptions: Effect of

Corps Officers’ Conversion

to Civil Service

When questioned about potential effects in the event of an initiative to

eliminate the Corps as a health care provider (i.e., provide Corps officers

the opportunity to convert to civil service), tribal representatives, IHS area

office officials, and medical facility staff raised some concerns.

Thirty-one of the 51 interviewees (10 of 18 tribal representatives, 4 of 6 IHS

area office officials, and 17 of 27 medical facility staff), said there would

be increased costs or reduced care in their facilities if Corps officers were

converted. Most of the 31 who predicted negative impacts based their

predictions on the premise that some Corps officers would not make the

conversion. Interviewees who said there would be a negative effect

included Corps and civil service staff representing the W. W. Hastings

Indian Hospital in Tahlequah, OK, who predicted that increased costs in

the form of overtime pay and salaries for civil service employees would

result in cuts to medical programs and services. Also, the head of the Zuni

Pueblo tribal council and other tribal members, and the director of the

local IHS hospital, a civil service employee, forecast deteriorating health

care from the loss of Corps officers in their New Mexico location, which,

according to those interviewed, has historically proven unattractive to

medical professionals because of its remoteness and poor housing.

Of the 51 interviewees, 20 did not predict a negative effect. Of these 20

interviewees, 7 said that the effect on their facility would depend on the

circumstances of the conversion. For example, the Corps officer managing

the Wilma P. Mankiller Health Center, a tribal medical facility serving the

Cherokee Nation of Oklahoma, expressed the opinion that Corps officers

“hold the system together,” and said that the effect of conversion on

medical care would depend on the extent to which these officers make the

transition to a non-Corps system. Of the 20 interviewees who did not

predict a negative impact, 8 said there would be no effect, and 5 had no

opinion.

Page 33 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section IV 

Perceptions of Corps and Non-Corps

Providers

GAO Perceptions: Preferences for Corps or 

Non-Corps Health Care Providers

Number of interviewees

0

5

10

15

20

7

3

16

5

0

7

3

1

4

3

2

0

Tribal representatives

N = 18

IHS area office officials

N = 6

Medical facility staff

N = 27

Preferred Non-Corps

Preferred Corps

No preference

No opinion

Source: GAO interviews.

Perceptions: Preferences

for Corps or Non-Corps

Health Care Providers

We asked tribal representatives, IHS area office officials, and medical

facility staff whether it would make a difference to them if health care

providers were Corps or non-Corps if sufficient resources were available

to obtain quality medical personnel from any source. Twenty-six of 51

interviewees (including 7 of 18 tribal representatives, 3 of 6 IHS area office

officials, and 16 of 27 medical facility staff) said that they would prefer to

Page 34 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section IV 

Perceptions of Corps and Non-Corps

Providers

have Corps providers. It should be noted that some were unable to

exclude cost as a factor in stating their preference. Interviewees preferring

the Corps included the President of New Mexico’s Jicarilla Apache tribe,

and the director of the IHS-run local health center, a Corps officer, who

cited work schedule flexibility and not having to compensate officers for

overtime work5

 as reasons for their preference. Also, the Vice President,

Operations, of the Southeast Alaska Regional Health Consortium (SEARHC)

(a tribal direct-hire) and other medical staff, speaking for the Consortium’s

Mt. Edgecumbe Hospital, said the Corps attracts individuals who are

willing to make sacrifices in personal income and lifestyle to deliver

quality health care.

Twelve of the 51 interviewees preferred non-Corps providers. These 12

interviewees included the tribal direct-hire Director of Medical Services

for the Cherokee Nation of Oklahoma, speaking for the tribally run

Nowata Indian Health Clinic, who said tribal direct-hire staff can be

offered benefits and incentives that are tied to performance, which serve

to increase productivity. Also, the director and medical staff of an IHS

hospital in New Mexico (civil service employees) said that civil service

employees tend to be more willing to work with hospital management to

meet hospital needs than are Corps officers because civil service

employees are more likely to be local residents who wish to remain in the

community.

Eight interviewees had no preference for either Corps or non-Corps

providers, and five had no opinion.

5

Corps officers do not receive extra pay when they work outside the regular 40-hour workweek, while

most non-Corps employees are eligible to receive compensation for working more than 40 hours a

week.

Page 35 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section IV 

Perceptions of Corps and Non-Corps

Providers

GAO Perceptions: Views on Corps' 

Advantages and Disadvantages

More interviewees cited advantages than 

disadvantages

Advantages: majority of advantages 

focused on lower personnel costs, 

Corps professionalism, training, and 

commitment

Disadvantages: centered on officers' 

medical availability (rotations, 

assignments to nonclinical positions)

Perceptions: Views on

Corps’ Advantages and

Disadvantages

We asked tribal representatives, IHS area office officials and medical

facility staff for their perceptions of the advantages and disadvantages of

having Corps officers as health care providers. Advantages were cited by

47 of 51 interviewees, including 14 of the 18 tribal representatives.

Interviewees most commonly cited as an advantage reduced costs to the

facilities, such as not having to pay overtime for Corps officers.6

Interviewees also cited Corps officers’ professionalism, training, and

6

Interviewees were not asked about costs to the government. Our May 1996 report elaborated on such

costs.

Page 36 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section IV 

Perceptions of Corps and Non-Corps

Providers

commitment as an advantage. For example, a group of civil service staff

and Corps officers representing the IHS hospital and clinic in Sells and

Santa Rosa, Arizona cited Corps officers’ professionalism and savings in

overtime pay. The Chairman of the Tohono O’odham Nation in Arizona

cited officers’ professionalism and commitment to service on the

reservation. In New Mexico, the president of a Navajo tribal chapter and

the directors (civil service employees) and several Corps staff from the IHS

medical center and clinic mentioned overtime savings and said that Corps

officers serve where they are needed and possess higher levels of

expertise than non-Corps staff (e.g., a Corps registered nurse must have a

bachelor of science degree in nursing).

Thirty-seven of the 51 interviewees, including 14 tribal representatives,

cited disadvantages of Corps officers as health care providers. The

disadvantages included limited availability due to shortages and rotations

of Corps officers and using officers in positions other than direct medical

care. For example, a Corps officer detailed as the Executive Director,

Division of Health of the Navajo Nation and the Governor of Santo

Domingo Pueblo in New Mexico both said that sometimes rotation of

Corps officers disrupts continuity of patient care. Also, leaders of the

Acoma Pueblo, Laguna Pueblo, and the Canoncito Navajo tribe in New

Mexico expressed the opinion that too many officers are being used in IHS

area office management positions rather than being assigned to fill direct

health care needs.

Page 37 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section IV 

Perceptions of Corps and Non-Corps

Providers

GAO Perceptions: Views on Civil Service 

Advantages and Disadvantages

More cited disadvantages than 

advantages

Advantage: good source for recruiting 

medical personnel 

Disadvantages: difficult personnel 

system to manage, cost of overtime 

compensation

Page 38 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section IV 

Perceptions of Corps and Non-Corps

Providers

Perceptions: Views on Civil

Service Advantages and

Disadvantages

Asked about their perception of civil service employees as health care

providers, more interviewees—tribal representatives, medical facility staff,

and IHS area office officials—cited disadvantages than cited advantages.

Twenty-eight of the 51 interviewees cited a variety of advantages of the

civil service personnel system, including its value as a potential source of

medical staff. For example, the Principal Chief of the Creek Nation in

Oklahoma said the civil service is regarded as a promising recruiting

ground, especially for registered nurses.

Thirty-eight of the 51 interviewees cited disadvantages, including difficulty

in administering the civil service personnel system and the costs incurred

by compensating employees for overtime work. For example, in Alaska,

officials of the Yukon-Kuskokwim Health Corporation said paying

overtime was a disadvantage; representatives of the Maniilaq Association

cited personnel system complexity and overtime as negatives; and

spokespersons for SEARHC said the system was administratively complex

and would not be considered for filling vacancies.

Page 39 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section IV 

Perceptions of Corps and Non-Corps

Providers

GAO Perceptions: Views on Tribal DirectHire Advantages and Disadvantages

Many interviewees had no experience 

with tribal direct-hire

Principal advantage: tribal ability to 

manage personnel independent of IHS

Disadvantages: high personnel costs 

and lower quality personnel

Page 40 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section IV 

Perceptions of Corps and Non-Corps

Providers

Perceptions: Views on

Tribal Direct-Hire

Advantages and

Disadvantages

Many interviewees were generally unfamiliar with tribal direct-hiring.

(About 40 percent of the 51 tribal representatives, medical facility staff,

and IHS area officials were not knowledgeable about tribal direct-hiring

and the advantages or disadvantages of this personnel system.)

Twenty-six interviewees cited advantages of tribal direct-hire, primarily

the independence and flexibility it gives tribes in managing personnel,

independent of IHS. For example, officials of the Choctaw Nation in

Oklahoma said that hiring directly enables a tribe to be flexible and

competitive in salary negotiations. Officials of the Southeast Alaska

Regional Health Consortium (direct-hire personnel and a Corps officer)

said that work schedules for direct-hire employees can be adjusted to

meet individual needs and salaries can be adjusted to offer incentives in

high cost areas.

Twenty-two interviewees cited disadvantages to tribal direct-hire; 15 cited

high personnel costs and 10 cited lower quality of personnel. Specifically,

the Choctaw Nation officials said that directly hired providers came with

high salary and relocation costs and were relatively lacking in medical

experience and dedication to Native American health care. Officials at the

Maniilaq Association in Alaska, who themselves were tribal direct-hire

employees, told us they prefer to directly hire medical personnel; however,

getting such personnel was sometimes difficult and costly due to the

remote location of the medical facility.

Page 41 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section V 

Changes in the Native American Health Care

System

GAO Changes in the Native American 

Health Care System

Tribes moving toward administering their 

own health care facilities and resources

IHS decentralizing resource 

management

Proposed Indian Health Network to 

produce more sharing of resources

Changes to system may not completely 

eliminate perceived need for the Corps

Changes in the Native

American Health Care

System

The Native American health care system is undergoing large-scale change.

Tribal governments are increasingly moving toward assuming control of

health care facilities and resources. In 1994, 32 percent of the total IHS

budget was under the control of tribal governments or Alaska Native

health care associations. IHS projects that by 1999, the tribally controlled

part of the budget may be as high as 57 percent.

IHS itself plans significant structural change in the near future. An

Indian-health design team, appointed by IHS’ Director and composed

Page 42 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Briefing Section V 

Changes in the Native American Health Care

System

mostly of tribal representatives, recommended in November 1995 and

February 1997 reports that IHS functions be decentralized, with managerial

and resource allocation decisions being made at the facility level. The

report also recommended the establishment of an Indian Health Network,

which would interconnect medical facilities using advanced

communication technology, thus enabling tribes and IHS facilities to share

health care resources. Senior IHS officials said that these recommendations

have been accepted and are in the process of being implemented.

While these changes in the system may reduce the need for Corps and civil

service health care providers, they may not eliminate the perceived need

entirely. Some tribes in the Albuquerque and Oklahoma IHS areas that have

assumed control of tribal health care or plan to do so want to hire

providers directly rather than use Corps officers or IHS civilian personnel.

An official of the Navajo Nation, which plans to take over control of health

care in the next several years, said that as Corps or civil service providers

leave, they will be replaced by directly hired personnel. On the other hand,

officials of Alaska Native associations, which have been managing Native

health care for some years, told us they continue to need Corps officers for

some difficult-to-fill health care positions.

Page 43 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix I 

Objectives, Scope, and Methodology

In March 1996, the Chairman, Senate Committee on Indian Affairs asked

us to review the role of the Public Health Service (PHS) Commissioned

Corps in the Indian Health Service (IHS). As agreed with the Committee, we

did our field work in the states of Alaska, Arizona, New Mexico, and

Oklahoma. Our objectives were to provide information on

• Corps officers’ historical involvement in providing health care to Native

Americans;

• the extent of nationwide participation in Native American health care by

Corps officers and non-Corps providers in fiscal year 1996;

• how health care provider vacancies were filled in the locations we

visited—sections of Alaska, Arizona, New Mexico, and Oklahoma—and

the number of such vacancies filled by Corps officers;

• how tribal representatives, IHS officials, and medical facility staff in the

locations we visited perceived Corps and non-Corps providers and their

perceptions of the potential effects that converting Corps officers to civil

service status might have on Native American health care;

• changes in the Native American health care system that might affect those

providing health care to Native Americans, whether Corps or non-Corps

personnel.

To gather information on the history of PHS Corps officers’ involvement in

providing health care to Native Americans, we obtained and reviewed PHS

and IHS documents and historical material.

To provide information on the extent of participation of Corps and

non-Corps providers in Native American health care in fiscal year 1996, we

obtained and reviewed nationwide data on the number of employees in

health care professions working in the IHS or directly hired by tribes. The

professions we focused on were physician, registered nurse, dentist,

pharmacist, engineer, and sanitarian, because these professions were

comparable between IHS and tribal direct-hire personnel and were

substantially represented in the Native American health care system. Using

IHS’ personnel database as of September 30, 1996, we identified the number

of Corps officers working in IHS. Using the database and a table of

equivalent civil service job series given us by the Office of the Surgeon

General in our previous work on the PHS Commissioned Corps,1

 we

determined the number of civil service personnel in IHS working in the

same professions as Corps officers. The information provided in this

report includes both full-time and part-time employees. Further, we did

1

Federal Personnel: Issues on the Need for the Public Health Service’s Commissioned Corps

(GAO/GGD-96-55, May 7, 1996).

Page 44 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix I 

Objectives, Scope, and Methodology

not differentiate between experience or levels of responsibility within the

selected professions. For example, the information in this report includes

both supervisory and nonsupervisory personnel in each profession.

Because IHS does not maintain data on the number of health professionals

that are hired directly by the tribes, we supplemented the IHS data by

sending a data-collection instrument nationwide to IHS area offices,

requesting data as of June 30, 1996, on health care providers directly hired

by tribes and Alaska Native health associations. We received the returned

instruments from all IHS area offices between July 1996 and February 1997.

We did not verify the accuracy of IHS’ personnel database, the civil service

equivalency tables, or the responses to our data collection instrument.

To determine the tribes and medical facilities to visit in the requested

states, we obtained and reviewed information on tribal populations,

patient workloads, and geographic locations. Using this information and

logistical considerations, we judgmentally selected for review a sample of

tribes and medical facilities that offered variety in size and geographic

location. Our selection included 18 tribes and Alaska Native associations

and 27 medical facilities.

To determine how selected health-provider vacancies were filled in the

areas we visited and whether any of these vacancies were reserved for

Corps officers, we requested, at each facility we visited, information

concerning current and recently filled vacancies for physicians, dentists,

registered nurses, pharmacists, sanitarians, and engineers. We received

information from 20 facilities on 239 vacancies in these 6 professions, 139

of which were filled during the period July 1, 1995, to June 30, 1996, and

100 of which remained unfilled at the time of our visits (from August

through November 1996).

We obtained interviewees’ perceptions on the use of Corps and non-Corps

health care providers and on the potential effects of converting Corps

officers to civil service status by interviewing representatives of tribes

served by the medical facilities we visited, IHS officials at the IHS regional

area offices for the four states in our review, and staff of the medical

facilities. We interviewed representatives of 15 tribes and 3 Alaska Native

health associations. (App. III identifies the tribes and associations we

visited.) For each of the tribes and associations we visited, we attempted

to speak with the official leader of the tribe or the association (i.e., the

governor, president, or chief) or the tribal or association official

responsible for health care and, if possible, with both. For 14 tribes, we

Page 45 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix I 

Objectives, Scope, and Methodology

met with a tribal official (i.e., the governor, president, or chief). The

spokesperson for the other tribe was a Corps officer. For the three Alaska

Native associations, we met with the president, vice president, or

executive director.

In most of our meetings with tribal representatives, medical facility

representatives, or IHS regional area office officials, other associates or

staff were also present to assist the representative in answering our

questions. In all, we held 40 interview sessions, 25 of which were attended

by more than one person. In 10 of the 25 sessions, we met with both tribal

and medical facility representatives or representatives from more than 1

medical facility; in these sessions, we received viewpoints from more than

1 representative. In 6 of the 25 sessions, tribal representatives were

present with IHS staff—either Corps officers or civil service employees, or

both. We do not know what effect, if any, group composition had on the

views expressed in the interview sessions. Although the 40 sessions

contained more than 51 attendees, we considered 51 as the number of

interviewees because they were the spokespersons during the interviews,

and thus our key interviewees for purposes of counting responses—18

tribal representatives, 6 IHS area office officials, and 27 medical facility

representatives.

We then reviewed and summarized responses to interview questions. For

some items, we were able to develop a set of categories for characterizing

interviewees’ responses. In those instances in which we classified answers

into response categories, all classifications were reviewed to ensure the

appropriateness and completeness of the categorizations. As requested,

we gathered interviewees’ perceptions of those providing health care to

Native Americans. We did not attempt to corroborate information we were

given in our interviews.

We obtained information on changes in the Native American health care

system that might affect Corps and non-Corps health care providers by

interviewing senior IHS officials at IHS headquarters in Rockville, MD, and

reviewing IHS documents. We also interviewed the Chair and Executive

Director of the National Indian Health Board, which is a Native American

advisory committee to IHS, and reviewed the reports of an Indian-health

design team, a group of tribal leaders and IHS officials formed to prepare a

plan for the restructuring of Native American health care.

Page 46 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix I 

Objectives, Scope, and Methodology

We provided a draft of this briefing report to the Secretary of HHS for

review and comment. HHS’ written comments are summarized and

evaluated on pages 5 and 6 and are presented in full in appendix II.

We did our audit work between May 1996 and July 1997, in accordance

with generally accepted government auditing standards. A list of the sites

at which we did audit work appears in appendix III.

Page 47 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix II 

Comments From the Department of Health

and Human Services

Page 48 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix II 

Comments From the Department of Health

and Human Services

Page 49 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix II 

Comments From the Department of Health

and Human Services

Text modified.

See p. 1.

See comment 1.

See comment 2.

Page 50 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix II 

Comments From the Department of Health

and Human Services

Text modified.

See p. 2.

See also comment 3.

Text modified.

See p. 2.

Page 51 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix II 

Comments From the Department of Health

and Human Services

Now on p. 2, para. 3.

See comment 4.

Now on p. 2, para. 4.

See comment 5.

Text modified.

See p. 15, footnote 1.

Now on p. 15.

See comment 6.

Page 52 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix II 

Comments From the Department of Health

and Human Services

Text modified.

See p. 17.

Text modified.

See p. 20.

Text modified.

See p. 21.

Text modified.

See p. 23.

Chart modified.

See p. 26.

Page 53 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix II 

Comments From the Department of Health

and Human Services

Text modified.

See p. 27.

Now on p. 29.

See comment 7.

Text modified.

See p. 35, footnote 5.

Page 54 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix II 

Comments From the Department of Health

and Human Services

GAO Comments 1. We believe our analysis appropriately compares Corps officers in six

key health care professions with their counterparts among federal civil

service employees. We based our analysis on an equivalency table supplied

by PHS for civil service employees, which we modified based on

discussions with IHS to exclude two job series which did not include health

care providers. Based on this modification, we reduced the number of civil

service sanitarians in our workforce data, which in turn reduced the total

number of IHS health providers from 6,664 to 6,306.

2. Although Corps officers have a rank structure comparable to Navy

officers, we do not agree that the Corps’ mobility requirements are

comparable to the armed forces. According to PHS officials whom we

spoke to in our 1996 review of the PHS Corps, Corps officers have a degree

of control over whether or when they will relocate, since many positions

in PHS are filled by taking applications and interviewing applicants. Corps

officers can therefore choose whether or not to apply for a position. In

addition, we were told by a PHS official that Corps officers in most PHS

agencies do not relocate regularly and that many officers stay at one

geographic location throughout all or most of their careers. We therefore

do not believe it would be accurate to say that the PHS Commissioned

Corps has mobility requirements comparable to the officer components of

the armed forces.

3. We modified our report language concerning title 37 of the U.S. Code

along the lines suggested by HHS. However, we disagree with HHS’

background information concerning the history of the PHS Corps’ rank

structure. It is true that the PHS Corps had a rank structure prior to World

War I. However, at that time the only ranks used were nonmilitary and

medically related (i.e., Surgeon General, Assistant Surgeon General,

surgeon, assistant surgeon, etc.). PHS ranks were explicitly made

equivalent to military ranks by the Joint Service Pay Act of 1920. The

legislative history of this act indicates that this action was taken because

of Corps officers’ service in the military during World War I.

4. We could not calculate the percentage of Corps officers among health

care providers from 1978 to 1996, as suggested by HHS, because data was

not readily available on tribal direct-hire providers during that same

period. Thus, as in our draft report, we were only able to include the

percentage of Corps officers among total health care providers during

1996, using data provided directly by the tribes and associations at our

request.

Page 55 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix II 

Comments From the Department of Health

and Human Services

5. After discussions with IHS officials, we revised the letter and section II of

the briefing document to reflect a lower number of civil service

sanitarians. We used revised data as of fiscal year 1996, however, in order

to portray all six professions as of the same date.

6. We modified page 15 of our report to indicate that it was our opinion

that the Corps did not meet the criteria for military compensation as set

forth in the DOD report and that HHS disagrees. However, we did not fully

incorporate HHS’ suggested language because its essence was already

contained in this report.

7. In our draft report, we stated that the nonuse of competitive selection in

filling some vacancies was in part due to Indian Preference. HHS suggested

that we clarify our definition of Indian Preference. We reviewed our

vacancies data after receiving the comments and found that only one filled

vacancy involved a candidate with Indian Preference; while this candidate

was the only one considered, a competitive selection process was in fact

used for this vacancy. We have accordingly revised our report to indicate

that one additional vacancy was filled using competitive selection, and we

have removed the textual references to Indian Preference and the

explanatory footnote.

Page 56 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix III 

Audit Work Locations

Alaska Alaska Area IHS Office, Anchorage

Maniilaq Medical Center, Kotzebue

Maniilaq Association, Kotzebue

SouthEast Alaska Regional Health Consortium (SEARHC), Juneau

SEARHC Health Center, Ketchikan

SEARHC Mt. Edgecumbe Hospital, Sitka

Yukon-Kuskokwim Health Corporation, Bethel

Yukon-Kuskokwim Hospital, Bethel

Arizona Bylas Health Center, San Carlos

Gila River Health Care Corporation, Sacaton

Hu Hu Kam Memorial Hospital, Sacaton

Navajo Area IHS Office, Window Rock

The Navajo Nation, Window Rock

Navajo Nation Council, Health & Social Services Committee, Window Rock

Phoenix Area IHS Office, Phoenix

San Carlos Apache Tribe, San Carlos

San Carlos PHS Indian Hospital, San Carlos

Santa Rosa PHS Indian Health Center, Sells

Sells PHS Indian Hospital, Sells

Tohono O’odham Nation, Sells

Tucson Area IHS Office, Tucson

Winslow PHS Indian Health Center, Winslow

Washington, D.C. National Indian Health Board1

Maryland IHS Headquarters, Rockville

New Mexico Acomita Canoncito Laguna PHS Indian Hospital, San Fidel

Albuquerque Area IHS Office, Albuquerque

Albuquerque Area Indian Health Board, Inc., Albuquerque

Canoncito Navajo Chapter, Canoncito

Dulce PHS Indian Health Center, Dulce

Dzilth-Na-O-Dith-Hle PHS Indian Health Center, Bloomfield

Huerfano Navajo Chapter, Bloomfield

Jicarilla Apache Tribe, Dulce

New Sunrise Regional Treatment Center, San Fidel

1

Officials of the National Indian Health Board were interviewed in Washington, D.C.; the offices of the

Board are located in Denver, CO.

Page 57 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix III 

Audit Work Locations

Northern Navajo Medical Center, Shiprock

Pueblo of Acoma, Pueblo of Acoma

Pueblo of Jemez, Jemez Pueblo

Pueblo of Laguna, Laguna

Pueblo of Sandia, Bernalillo

Pueblo of Zuni, Zuni

Ramah Navajo School Board, Inc., Pine Hill

Santa Fe PHS Indian Hospital, Santa Fe

Santo Domingo Pueblo, Santo Domingo

Taos ~ Picuris Indian Health Center, Taos

Taos Pueblo, Taos

Zuni PHS Indian Hospital, Zuni

Oklahoma Broken Bow Health Clinic, Broken Bow

Cherokee Nation of Oklahoma, Tahlequah

Chickasaw Nation of Oklahoma, Ada

Choctaw Nation Health Services Authority, Talihina

Choctaw Nation of Oklahoma, Durant

Claremore Indian Hospital, Claremore

Creek Nation Community Hospital, Okemah

Creek Nation of Oklahoma, Okmulgee

Eufaula Health Center, Eufaula

Nowata Primary Health Care Clinic, Nowata

Oklahoma City Area IHS Office, Oklahoma City

Sapulpa Health Center, Sapulpa

Wilma P. Mankiller Health Center, Stilwell

W.W. Hastings Indian Hospital, Tahlequah

Page 58 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Appendix IV 

Major Contributors to This Briefing Report

General Government

Division, Washington,

D.C.

Larry H. Endy, Assistant Director, Federal Management and Workforce

Issues

Nancy A. Patterson, Assignment Manager

Steven J. Berke, Evaluator-in-Charge

Thomas Beall, Technical Advisor

Katharine M. Wheeler, Publishing Advisor

Hazel J. Bailey, Communications Analyst

Lessie M. Burke, Writer-Editor

Dallas Regional Office Linda J. Libician, Regional Management Representative

Reid H. Jones, Senior Evaluator

Christina M. Nicoloff, Senior Evaluator

James W. Turkett, Technical Advisor

Enemencio Sanchez, Evaluator

(410036) Page 59 GAO/GGD-97-111BR PHS Commissioned Corps Officers
Ordering Information

The first copy of each GAO report and testimony is free.

Additional copies are $2 each. Orders should be sent to the

following address, accompanied by a check or money order

made out to the Superintendent of Documents, when

necessary. VISA and MasterCard credit cards are accepted, also.

Orders for 100 or more copies to be mailed to a single address

are discounted 25 percent.

Orders by mail:

U.S. General Accounting Office

P.O. Box 37050

Washington, DC 20013

or visit:

Room 1100

700 4th St. NW (corner of 4th and G Sts. NW)

U.S. General Accounting Office

Washington, DC

Orders may also be placed by calling (202) 512-6000 

or by using fax number (202) 512-6061, or TDD (202) 512-2537.

Each day, GAO issues a list of newly available reports and

testimony. To receive facsimile copies of the daily list or any

list from the past 30 days, please call (202) 512-6000 using a

touchtone phone. A recorded menu will provide information on

how to obtain these lists.

For information on how to access GAO reports on the INTERNET,

send an e-mail message with "info" in the body to:

info@www.gao.gov

or visit GAO’s World Wide Web Home Page at:

http://www.gao.gov

PRINTED ON RECYCLED PAPER
United States

General Accounting Office

Washington, D.C. 20548-0001

Official Business

Penalty for Private Use $300

Address Correction Requested

Bulk Rate

Postage & Fees Paid

GAO

Permit No. G100