HEALTH CARE 

ACCESS

Improved Oversight, 

Accountability, and 

Prioritization Can 

Improve Access for 

Native American 

Veterans

Report to Congressional Requesters

June 2014

GAO-14-489

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-489, a report to 

congressional requesters

June 2014

HEALTH CARE ACCESS

Improved Oversight, Accountability, and Prioritization 

Can Improve Access for Native American Veterans

Why GAO Did This Study

Native Americans who have served in 

the military may be eligible for health 

care services from both VA and IHS, 

but according to reports some have 

had problems accessing care. In 2010 

these two agencies expanded upon an 

MOU designed to improve Native 

American veterans’ access to care at 

their facilities. GAO was asked to 

examine how the MOU has increased 

access to care.

This report examines: (1) the actions 

that VA and IHS have taken to 

implement the provisions in the 2010 

MOU related to access to care for 

Native American veterans, and 

(2) what is known about how access to 

care for Native American veterans has 

improved. To conduct this work, GAO 

reviewed agency documents and VA 

and IHS reimbursement data and 

interviewed VA and IHS officials. GAO 

also visited three sites selected to 

reflect geographic variation to learn 

about access to care locally through 

interviews with regional VA and IHS 

officials, health facility officials, and 

Native American veterans and their 

tribal representatives. GAO also 

contacted other individuals who help 

Native American veterans seek 

enrollment in the VA to obtain their 

insights about improvements in access 

to care.

What GAO Recommends

GAO recommends that VA and IHS 

establish written policy or guidance 

designating specific roles and 

responsibilities for agency staff to hold 

leadership accountable and improve

implementation and oversight of the 

MOU. VA and IHS agreed with GAO’s

recommendation.

What GAO Found

The Department of Veterans Affairs (VA) and the Indian Health Service (IHS) 

have taken a variety of actions to improve access to care for Native American

veterans under their 2010 memorandum of understanding (MOU); however 

according to stakeholders, these agencies face substantial implementation 

challenges. VA and IHS have taken actions to (1) strengthen outreach and 

enrollment through information sharing and training; (2) expand services through 

national and local projects; (3) increase training about cultural competency for 

staff at VA and IHS facilities; and (4) establish reimbursement agreements that 

allow VA to reimburse IHS facilities for services provided to veterans. However, 

in each of these areas challenges remain, such as insufficient data to identify 

Native American veterans for outreach, obstacles to reaching those who live in 

very remote areas, and technological challenges such as lack of Internet 

connectivity or phone lines.

While VA and IHS have taken actions to increase access, the oversight, 

accountability, and prioritization of MOU implementation are lacking. Specifically:

• Oversight is inconsistent: In 2013, the officials tasked with oversight of the 

implementation of the MOU did not meet and did not systematically evaluate 

the progress of MOU implementation.

• Written policies and guidance are lacking: According to officials, the only 

documentation outlining the procedures to report VA and IHS progress on 

implementation efforts is contained in a set of training slides used in a 

December 2012 training session, and these slides have not been formalized 

in written policy or guidance.

• Prioritization of MOU implementation is lacking: Leadership of VA and IHS 

have not made MOU implementation a priority, which threatens the ability of 

the two agencies to move forward in implementing the MOU. Key officials 

attributed this, in part, to their perception that their non-MOU related 

responsibilities had a higher priority.

Without consistent oversight, formal policy or guidance on responsibilities for 

MOU implementation, and the prioritization of MOU implementation, VA and IHS 

leadership do not have reasonable assurance that the objectives of the MOU 

related to access to care are being addressed.

Native American veterans and their representatives that GAO contacted reported 

mixed views on whether access to care has improved over the past 3 years. 

Although a majority reported that access to care had improved, others either said 

that that they did not think it had improved or were unsure. For example, 53 of 

102 Native American veterans representatives GAO contacted reported that in 

the last 3 years there had been an increase in the number of Native American 

veterans accessing health care at VA or IHS-funded facilities; however, 12 felt 

there had been no change, and 36 said they did not know.

View GAO-14-489. For more information, 

contact Randall Williamson at (202) 512-7114 

or williamsonr@gao.gov.
Page i GAO-14-489 Native American Veteran Access to Care

Letter 1 

Background 5

Actions VA and IHS Have Taken to Improve Access to Care for 

Native American Veterans Face Implementation Challenges, 

and Oversight and Accountability Are Lacking 9

Native American Veterans and Their Representatives Reported 

Mixed Views on Whether Access to Care Has Improved 24

Conclusions 26

Recommendation for Executive Action 27

Agency Comments 27

Appendix I Comments from the Department of Veterans Affairs 30

Appendix II Comments from the Department of Health and Human Services 33

Appendix III GAO Contact and Staff Acknowledgments 36

Related GAO Products 37

Figure

Figure 1: Procedures Outlined in 2012 Training Slides for Tracking 

and Overseeing Actions Taken to Achieve the Goals of 

the Memorandum of Understanding between the 

Department of Veterans Affairs (VA) and the Indian 

Health Service (IHS) 22

Contents
Page ii GAO-14-489 Native American Veteran Access to Care

Abbreviations

HHS Department of Health and Human Services

IHS Indian Health Service

MOU memorandum of understanding

ORH Office of Rural Health

OTGR Office of Tribal Government Relations

PTSD post-traumatic stress disorder

THP Tribal Health Program

TVR Tribal Veterans Representative

VA Department of Veterans Affairs

VISN Veterans Integrated Service Network

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

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Page 1 GAO-14-489 Native American Veteran Access to Care

441 G St. N.W.

Washington, DC 20548

June 10, 2014

Congressional Requesters

Native Americans historically have served in the military at a higher rate 

than any other ethnic group, according to the Department of Defense.1

According to Congressional testimony and media reports, Native 

American veterans have had problems accessing care in both VA and 

IHS. For example, some Native American veterans report being turned 

away from both VA and IHS-funded facilities because of confusion among 

facility staff over eligibility requirements.

Once separated from the military, some Native American veterans are 

eligible to receive health care services from both the Department of 

Veterans Affairs (VA) and the Indian Health Service (IHS), an agency 

within the Department of Health and Human Services (HHS). 

2

 

1

For the purposes of our report, the term Native American includes both American Indians 

and Alaska Natives.

Native American veterans have 

also reported that a lack of cultural competency regarding tribal practices 

and the needs of veterans can affect their access to care at VA and IHSfunded facilities. For example, it has been reported that a lack of 

understanding of traditional healing practices or the varied needs of each 

tribe can be a barrier to accessing care at VA, and a lack of clinical 

expertise on certain veterans’ care issues—such as expertise on how to 

treat post-traumatic stress disorder (PTSD)—can make it difficult for 

According to the U.S. Census Bureau, in 2012 approximately 162,000 individuals 

identified themselves as Native American veterans. This includes only individuals who 

identified as American Indian or Alaska Native alone and not in combination with another 

racial group. Therefore, it underestimates the number of Native American veterans.

2

IHS-funded facilities include both facilities that are operated by the IHS and tribal health 

program (THP) facilities that are funded by IHS, but operated by the tribes.

Hearing on VA and Indian Health Service Cooperation: Hearing Before the Committee on 

Veterans’ Affairs, United States Senate, 111th Cong (November 5, 2009).
 

Page 2 GAO-14-489 Native American Veteran Access to Care

veterans to access certain types of care at IHS-funded facilities.3 Further, 

it has been reported that many Native American veterans live in very rural 

areas and have difficulty obtaining transportation to both VA and IHSfunded facilities, or face very long travel times to facilities, which can 

make it difficult to access care at either type of facility.4

In 2010, VA and IHS expanded upon a 2003 memorandum of 

understanding (MOU), which included provisions to improve Native 

American veterans’ access to VA and IHS facilities and the agencies’ 

coordination of efforts related to the MOU.5 The 2010 MOU, which aimed 

to more fully address the core access problems for Native American 

veterans, includes goals to increase access to health care services for 

Native American veterans. It also describes strategies intended to 

achieve this goal. For example, the 2010 MOU includes provisions for 

expanding outreach through the Tribal Veterans Representative Program, 

expanding telehealth services, developing payment and reimbursement 

policies and mechanisms to support care delivered to Native American 

veterans eligible for care in both systems, and providing training to VA 

and IHS staff on the agencies’ eligibility requirements.6

 

3

For the purposes of this report, we define cultural competency in terms of health care 

services as the respect and response to the health beliefs, practices, and cultural and 

linguistic needs of diverse patients. It refers to Native American traditions, beliefs and 

practices, but also to clinical care needs of veterans.

Hearing on VA and Indian Health Service Cooperation: Hearing Before the Committee on 

Veterans’ Affairs, United States Senate, 111th Cong. (November 5, 2009).

4

See Broken Promises: Evaluating the Native American Health Care System, U.S. 

Commission on Civil Rights (September 2004): 77-80; and Frequently Asked Questions

about the Native Domain, Veterans Health Administration: Office of Rural Health, 

http://www.ruralhealth.va.gov/native/faqs.asp, accessed June 2, 2014. 

5

The MOU indicates that improvements in access to care may be achieved through an 

increase in the amount and types of services available to Native American veterans and 

the use of more geographically accessible services (e.g., mobile services, telehealth, and 

sharing of staff.) In some cases, enrollment in the VA may give Native American veterans 

access to services not readily available at certain IHS or Tribal Health Program (THP) 

facilities.

6

Telehealth includes telemedicine, which is the use of medical information exchanged 

from one site to another via electronic communications (such as video or e-mail) to 

improve a patient’s clinical health status through, for example, provision of health care 

services or clinical monitoring. Telehealth can include telemental health—the provision of 

mental health services to patients living in remote locations or otherwise underserved 

areas.
 

Page 3 GAO-14-489 Native American Veteran Access to Care

We previously reported on the agencies’ coordination of efforts related to 

the MOU.7

We were asked to report on the extent to which the MOU has increased 

access to care for Native American veterans. This report examines: 

(1) the actions that VA and IHS have taken to implement the provisions in 

the 2010 MOU related to access to care for Native American veterans; 

and (2) what is known about how access to care for Native American 

veterans has improved.

We examined the extent to which the agencies established 

mechanisms for MOU implementation and monitoring, the key challenges 

the agencies faced in implementing the MOU, such as the challenge of 

coordinating with a large number of unique tribes, and the progress made 

in overcoming those challenges.

To examine the actions that VA and IHS have taken to implement 

provisions in the 2010 MOU related to access to care for Native American 

veterans, we collected information from a variety of sources. We reviewed

a broad range of documents related to MOU activities, such as quarterly 

reports that describe MOU-related activities and progress by VA and IHS. 

We reviewed information and data related to reimbursement by VA to 

IHS-funded facilities for services provided to Native American veterans. 

We interviewed agency officials, including leaders of 5 of the 12 work 

groups that were established to implement the MOU, about actions they 

have taken to increase access to care, monitor progress, and assess 

outcomes in improving access. Finally, we conducted site visits to three 

regions of the country—the Upper Peninsula of Michigan, Northern 

Arizona, and Alaska—to learn about actions taken by VA and IHS to 

improve access to care at the local level. The regions were selected to 

reflect geographic variation, variation in the types of VA and IHS-funded 

facilities available, and the presence or absence of reimbursement 

agreements between the VA and IHS-funded facilities. We conducted 

interviews with: VA and IHS regional officials; VA, IHS, and tribal health 

facility staff such as administrators, enrollment coordinators, and business 

office managers; and representatives of tribes. Information obtained 

through these site visits cannot be generalized to the nationwide Native 

American veteran population.

 

7

See GAO, VA and IHS: Further Action Needed to Collaborate on Providing Health Care 

to Native American Veterans, GAO-13-354 (Washington, D.C.: Apr. 26, 2013).
 

Page 4 GAO-14-489 Native American Veteran Access to Care

To examine what is known about how access to care for Native American 

veterans has improved, we interviewed Native American veterans and 

their representatives—such as Tribal Veterans Representatives (TVR)—

in 12 interviews during our three site visits.8 We analyzed this information 

to determine the extent to which there were positive or negative 

comments related to changes in access to care for Native American 

veterans—such as whether interviewees thought that the number of 

Native American veterans obtaining care at VA or IHS facilities had 

increased or decreased. We used the following convention to state 

whether comments were made at most, many, some, or few of these 

interviews: most—at least one comment in 9 to 11 interviews; many—at 

least one comment in 5 to 8 interviews; some—at least one comment in 3 

to 4 interviews; and few—at least one comment made in 1 to 2 interviews. 

We also obtained views from an additional 102 representatives of Native 

American veterans through a Web-based questionnaire.9

We conducted this performance audit from June 2013 to June 2014 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

This 

questionnaire included questions about the extent to which access to care 

for Native American veterans had changed during the past 3 years. The 

responses to this questionnaire are not generalizable to the entire 

population of representatives of Native Americans.

 

8

TVRs conduct outreach to educate Native American veterans about the availability of 

veterans’ benefits and the process for enrolling for these benefits. They are often 

volunteers and may receive training from VA. In addition to TVRs, other staff who assist 

Native American veterans are Tribal Outreach Workers, Veterans Service Officers, and 

Tribal Veterans Service Officers. In this report we will refer to all such types of individuals 

as representatives of Native American veterans.

9

We obtained contact information for these individuals from a variety of sources including 

VA, national veterans service organizations, and state offices of veterans’ affairs.
 

Page 5 GAO-14-489 Native American Veteran Access to Care

While Native American veterans are geographically dispersed throughout 

the United States, the West and South regions contain the majority of the 

Native American veteran population, according to Census data. Some 

Native American veterans are members of the 566 federally recognized 

tribes that are distinct, independent, political communities that possess 

certain powers of self-government.10

VA is charged with providing health care services to the nation’s eligible 

veterans, and served 6.5 million individual patients in fiscal year 2013. In 

fiscal year 2013, VA had $56 billion in appropriations available for medical 

care. VA’s health care system includes 21 regional networks—Veterans 

Integrated Service Networks (VISN)—to which each of VA’s 151 medical 

centers are assigned.11 The VA medical centers offer a variety of inpatient 

and outpatient services, ranging from routine examinations to complex 

surgical procedures. VA’s health care system also includes facilities such 

as community-based outpatient clinics. Eligibility for VA health care is 

based on several factors, including the veteran’s period of active service, 

discharge status, the presence of service connected disabilities or 

exposures, income, and other factors such as status as a former prisoner 

of war. In addition, VA categorizes eligible veterans into eight priority 

groups, and some veterans may be responsible for co-payments.12

 

10Federally recognized tribes have government-to-government relationships with the 

United States, and are eligible for certain funding and services provided by the United 

States because of their status as Indians.

In addition, some Native American veterans are members of the more than 400 Native 

American groups that are not recognized by the federal government. Veterans who are 

members of these Native American groups may be eligible for VA benefits, but are not 

generally eligible for IHS benefits. For more information on federal funding for nonfederally recognized tribes, see GAO, Indian Issues: Federal Funding for Non-Federally 

Recognized Tribes, GAO-12-348, (Washington, D.C.: Apr. 12, 2012).

11Each VA medical center is assigned to a single VISN.

12See 38 U.S.C. § 1705; 38 C.F.R. § 17.36(b). To manage its provision of health care 

services for eligible veterans, VA operates a system of annual patient enrollment in 

accordance with eight priorities listed in statute. VA may change which priority groups and 

sub-groups of veterans are eligible for enrollment by amending the applicable regulation. 

See 38 C.F.R. § 17.36(c).

Background

Native American Veterans

VA and IHS Structure and 

Benefits
 

Page 6 GAO-14-489 Native American Veteran Access to Care

IHS was established for the purpose of providing, or arranging for, health 

care to the approximately 2.2 million eligible Native Americans. IHS’s 

fiscal year 2013 budget was approximately $4.1 billion. While IHS’s 

headquarters is based in the Washington, D.C., area, overall the agency 

is organized into 12 federally designated geographic service areas that 

cover all or part of 35 states.13 IHS provides health care services directly 

through a system of about 120 facilities that are operated by IHS—

including hospitals, health clinics, and health stations. In addition to IHSoperated facilities, some federally recognized tribes choose to operate 

their own health care facilities—tribal health programs (THPs)—that 

receive IHS funding. THPs operate the majority of facilities funded by 

IHS, including 500 facilities, such as hospitals, clinics and health stations. 

IHS also provides funding to nonprofit, urban Native American 

organizations through the Urban Indian Health program to provide health 

care services to Native Americans living in urban areas. To be eligible for 

IHS health care services, an individual must be a person of Indian 

descent belonging to the Indian community, as evidenced by such factors 

as membership, enrollment, residence on tax-exempt land, ownership of 

restricted property, active participation in tribal affairs, or other relevant 

factors.14 In instances where a Native American veteran is eligible for a 

particular health care service from both VA and IHS, VA is the primary 

payer.

In 2003, VA and IHS signed an MOU to facilitate collaborative efforts in 

serving Native American veterans eligible for health care in both systems. 

In 2010, VA and IHS replaced the MOU with an updated MOU, which 

outlines specific goals and strategies related to increasing access to care 

for Native American veterans, such as goals to improve outreach and 

cultural competency, expand services including through telehealth, and 

develop payment and reimbursement policies. Specifically, the MOU 

included the following provisions related to access to care:

• providing training for IHS and tribal staff on VA and IHS eligibility 

requirements to assist them with appropriate referrals for services;

 

13The 12 IHS service areas are Alaska, Albuquerque, Bemidji, Billings, California, Great 

Plains, Nashville, Navajo, Oklahoma City, Phoenix, Portland, and Tucson.

14See 42 C.F.R. § 136.12.

Memorandum of 

Understanding
 

Page 7 GAO-14-489 Native American Veteran Access to Care

• expanding the TVR program, which uses Native American liaisons to 

conduct outreach to tribes to assist with veterans’ eligibility questions;

• increasing cultural awareness and culturally competent care;

• developing and implementing telehealth services such as 

telepsychiatry and telepharmacy; and

• increasing the availability of services by developing payment and 

reimbursement policies and mechanisms.

The MOU provides for a broad range of collaboration between VA and 

IHS. One goal of the MOU is to bring together strengths and expertise 

from each agency to improve both the care and services provided by 

each organization.

VA and IHS designated certain staff to implement the MOU. The two key 

offices within VA that have been involved in implementing the MOU are 

the Office of Rural Health (ORH) and the Office of Tribal Government 

Relations (OTGR). VA created ORH in 2007 to focus on better serving 

the needs of veterans residing in geographically remote areas through a 

combination of community-based clinic expansions, increased 

partnerships with non-VA providers, and increased use of telehealth 

services.15

To accomplish the goals set forth in the MOU, VA and IHS created 

interagency work groups, tasked with implementing and developing 

strategies to address the goals of the MOU, such as developing payment 

and reimbursement policies and mechanisms, and developing and 

implementing new models of care through new technology, including 

telehealth services.

VA established OTGR in 2011 to work to strengthen and 

enhance partnerships that enhance access to services and benefits for 

Native American veterans. Within IHS, MOU responsibilities have been 

delegated to the Chief Medical Officer and staff.

16

 

15ORH is located in the Office of the Assistant Deputy Undersecretary for Policy and 

Planning of the Veterans Health Administration.

Each work group includes staff from VA and IHS, 

and, in some cases, tribal representatives. In many cases, work group 

16The work groups are: Services and Benefits; Coordination of Care; Health Information 

Technology; New Technologies; System Level; Payment and Reimbursement; Sharing of 

Care Process, Programs and Services; Cultural Competency and Awareness; Training 

and Recruitment; Emergency and Disaster Preparedness; Alaska; and Leadership. 
 

Page 8 GAO-14-489 Native American Veteran Access to Care

members volunteered to serve on the work groups. The goals established 

by each work group align with MOU goals.

One of the work groups, referred to as either the Leadership work group 

or the Joint Implementation Task Force, is responsible for the oversight 

and the overall implementation of the MOU, and charged with identifying 

strategies and plans for accomplishing the goals of the MOU. It includes 

officials from both agencies, including from the Office of the Secretary of 

Veterans Affairs, the IHS Chief Medical Officer, and the director of OTGR, 

and also includes the co-chairs of certain MOU work groups. The 

agencies defined responsibilities for the Joint Implementation Task Force. 

Specifically, it is charged with developing implementation plans and 

procedures for policy-related issues identified by the work groups, 

creating performance metrics and timelines, collecting quarterly progress 

reports from the work groups and from other sources such as VA VISN 

Native American Inventory reports, evaluating progress, identifying 

priority action items for work groups, and providing an annual report on 

progress in MOU implementation.17 According to the MOU 2012 Annual 

Report, the Joint Implementation Task Force is expected to meet 

quarterly.

 

17Work group reports are submitted on a quarterly basis. They are intended to collect 

project and program data on MOU interagency collaborations. The Native American 

Inventory Reports are submitted by VISNs to VA on a quarterly basis. They are intended 

to provide information about projects and activities conducted by VA and IHS staff in each 

VISN area to support Native American veterans.
 

Page 9 GAO-14-489 Native American Veteran Access to Care

VA and IHS staff have taken actions to improve access to care, including 

strengthening outreach and enrollment efforts, expanding services 

offered, increasing efforts to improve cultural competency, and 

implementing reimbursement agreements. However, according to various 

stakeholders, these efforts face a variety of implementation challenges, 

such as a lack of data identifying which Native Americans are veterans, 

difficulty reaching Native American veterans who live in remote locations, 

and staff turnover at IHS and THP facilities. In addition, although VA and 

IHS have identified procedures for collecting information on the various 

actions taken by VA and IHS facilities to address the goals of the MOU, 

the agencies lack a defined approach to effectively track and oversee 

implementation of the MOU.

In four main areas, VA and IHS have taken actions to improve access to 

care for Native American veterans: (1) outreach and enrollment, 

(2) expanded services including telehealth, (3) training and improvement 

in cultural competency, and (4) reimbursement agreements. However, in 

each of these areas, unresolved challenges prevent these actions from 

being fully or effectively implemented.

Both agencies have taken actions to improve outreach to Native 

American veterans and to provide information about enrollment into the 

VA health system. Specifically, IHS and VA have developed various ways 

to share information about eligibility and enrollment and VA has 

conducted a variety of training programs about these topics.

• Information sharing: IHS and VA have supported information 

sharing in a variety of ways with tribes, IHS and THP facilities, and 

Native American veterans. For example, OTGR published a monthly 

newsletter focusing on resources available to tribes to promote 

enrollment in the VA health system. In addition, IHS officials in two of 

our three site visit areas reported that they organized introductions of 

VA staff to tribal officials and IHS and THP facility staff, and the VA 

medical centers in all of these site visit areas reported that they 

shared information in a variety of ways such as health benefit fairs 

held at tribal locations, regular conference calls with tribal health 

officials, and meetings with Native American veterans’ organizations. 

In the Native American Inventory quarterly reports, 20 of 21 VISNs 

reported one or more information sharing activities, such as making 

Actions VA and IHS 

Have Taken to 

Improve Access to 

Care for Native 

American Veterans 

Face Implementation 

Challenges, and 

Oversight and 

Accountability Are 

Lacking

VA and IHS Have Taken 

Actions to Improve Access 

to Care, but 

Implementation 

Challenges Limit Their 

Effectiveness

Information Sharing, Training, 

and Outreach about Enrollment

Have Improved, but Sufficient 

Information to Identify Native 

Americans and Resources to 

Help Them Are Lacking
 

Page 10 GAO-14-489 Native American Veteran Access to Care

presentations to tribal elders and providing information at tribal health 

fairs.

• Training: VA and IHS conducted a variety of training activities about 

eligibility and enrollment. VA holds monthly on-line training about the 

enrollment process that is available for staff at IHS and THP facilities 

and for representatives of Native American veterans. In partnership 

with IHS, VA funded multiple regional training events designed to 

increase knowledge of VA benefits, eligibility criteria, and the 

enrollment process. Participants in these events included tribal health 

officials, IHS and THP facility staff, TVRs, and members of Native 

American veteran military organizations. Facilities in two of our three 

site visit locations also reported conducting training activities. For 

example, at one of the sites we visited, IHS provided training to staff 

at its facilities about VA health benefits and services. In another site 

visit area, VA officials reported that they recruited and trained over 

190 TVRs from 2010 through 2013.

Although VA and IHS have undertaken a variety of outreach efforts, 

officials from VA, IHS, and THP facilities identified two main ongoing 

challenges to implementing effective outreach to Native American 

veterans—the lack of available data to identify eligible Native American 

veterans and insufficient agency resources to effectively conduct 

outreach in rural areas.

• Lack of available data: VA and IHS headquarters officials, as well as 

local facility officials in all three of our site visit areas, reported that it is 

difficult to conduct outreach to Native American veterans because 

there is limited data identifying who they are. While officials reported 

that IHS health registration forms include a question about whether 

the patient is a veteran, officials indicated that patients are not 

required to report this information. While officials at some IHS and 

THP facilities with whom we met said they have taken actions to 

identify veterans in their tribes, others lack such data. An official at 

one THP facility, for example, said that veteran status data had not 

been collected from their patients; officials at another THP reported 

that without a list identifying who is a veteran, it is difficult to conduct 

outreach and enroll veterans in the VA. Similarly, while VA registration 

forms include a question about race/ethnicity, VA officials reported 

that VA facilities have not required veterans to report whether they are 
 

Page 11 GAO-14-489 Native American Veteran Access to Care

Native American, and this limits VA’s ability to conduct outreach to 

Native American veterans.18

• Insufficient resources for effective outreach to very rural areas: 

VA, IHS and THP officials, and TVRs reported that there are 

insufficient resources—such as outreach volunteers and funding for 

travel—for effective outreach to the remote areas where many Native 

American veterans live. For example, officials at one THP that serves 

an area of approximately 75,000 square miles, including terrain that 

requires travel by boat or plane, reported that they were not aware of 

any TVRs serving their region. Officials at another THP said that there 

was a lack of funding for TVRs to travel to conduct outreach.

Actions taken by VA and IHS to expand health care services for Native 

American veterans include funding for service expansion, a national effort 

to increase telehealth connections between VA and IHS, and local efforts 

to expand health services through satellite and mobile services and 

through telehealth.

• Funding for service expansion: Since the MOU was signed, both 

agencies have sponsored funding to support the expansion of health 

services. Specifically, ORH awarded about $1.8 million in funding 

from 2012 through 2014 for five telemental health projects for eligible 

veterans in Native American communities, including the development 

and operation of programs in certain areas of Alaska, Michigan, and 

Oklahoma; and IHS provided financial support to enable the 

expansion of three THP clinics in Alaska, Mississippi, and Oklahoma 

in 2011.

• National effort to expand telehealth consultation between VA and 

IHS: Officials from the MOU work group that promotes new 

technology reported that VA and IHS are in the process of completing 

activities designed to improve the connectivity between VA and IHS 

required for live telehealth consultation. VA officials reported that as of 

April 2014, the testing phase was nearing completion. According to 

VA officials, the next step is the development of business plans by 

 

18A VA official told us that historically, VA has not required the reporting of race and 

ethnicity data in part because it has been accused of using race and ethnicity to bias the 

disability claim/adjudication process. As a result, Native American veterans may choose 

not to report their ethnicity because they believe that it will bias how they are treated. 

Race/ethnicity data may be recorded in the VA medical record as little as 50 percent of the 

time.

More Health Services Are Now 

Available to Native American 

Veterans, but Further Progress 

Has Been Slowed by Technical 

Issues and Delays in Finalizing 

Service Expansion 

Agreements
 

Page 12 GAO-14-489 Native American Veteran Access to Care

individual IHS facilities to establish collaborative telehealth programs 

with VA. This work group has also identified opportunities for 

collaboration between the two agencies, specifically on teleretinal 

services for diabetes care.19

• Local efforts to expand services and telehealth: Data gathered 

from our site visits and our review of the quarterly VISN reports for 

2013 identified a number of local efforts to expand the availability of 

health care services. For example, in one area, officials reported that 

the local VA medical center expanded services to Native American 

veterans in one location by renting space from a THP to provide 

onsite health services to eligible Native American veterans; further, it 

was seeking agreements with two THPs to establish VA-provided 

telehealth services. According to VA and IHS officials at another site 

we visited, the local VA medical center and an IHS facility 

collaborated to establish a VA primary care presence at the IHS 

facility. This VA medical center also initiated similar plans to partner 

with another IHS facility and two THP facilities, established a mobile 

clinic that serves eligible veterans on Native American reservations, 

and added telehealth services to its community based outpatient 

clinics that serve Native American veterans.20

Agency officials and staff at VA, IHS, and THP facilities described three 

main challenges that need to be addressed to better ensure the 

successful implementation of expansion efforts: (1) the lack of 

interoperability between VA and THP computer systems; (2) a lack of 

technical resources; and (3) delays in finalizing service expansion 

agreements.

In the quarterly Native 

American Inventory reports submitted to VA by VISNs, 14 of 21 VISNs 

listed one or more efforts to expand telehealth services for Native 

American veterans in their region.

 

19Diabetes is the leading cause of adult vision loss in the United States. Digital retinal 

imaging with remote image interpretation (teleretinal imaging) assists in providing eye care 

to patients with diabetes.

20The degree to which there is a need to expand VA services to IHS and THP facilities 

may vary by region depending on the number, size, and geographic distribution of local 

tribes, and also by the range of services already available at the area’s IHS and THP 

facilities.
 

Page 13 GAO-14-489 Native American Veteran Access to Care

• Incompatible systems: Agency officials said that while VA and IHS 

facilities have been working on connectivity between their VA and IHS 

platforms for telehealth, THPs may use different computer systems 

than IHS; therefore, connectivity between VA and THPs has to be 

tested and explored on a case-by-case basis. This can slow 

collaboration on telehealth services, and tribes that do not use the IHS 

or VA platform would need to obtain the necessary technology. For 

example, in one site visit area, integration of THP and VA telehealth 

has been challenged by differences in technical connectivity and 

information security policies. Since a majority of IHS-funded facilities 

are operated by THPs, the potential for collaboration on telehealth 

services may be limited by the interest and resources available from 

tribes for this purpose.

• Insufficient technical resources: According to facility officials in all 

three site visit areas, the lack of technical resources in some rural 

locations has hampered the expansion of telehealth or other services 

such as home-based health. For example, in one area, tribal health 

officials said that there was no infrastructure to support telehealth 

services. Also in this area, VA medical center officials said that they 

explored expanding virtual care through the use of veterans’ home 

computers but found that some veterans lack phone lines or adequate 

Internet connectivity. In another area, THP facility officials said that 

there was poor Internet “bandwidth” in their area that reduced the 

quality of transmission for telehealth

• Delays in finalizing agreements to expand services: Agency and 

facility officials from two of our three site visit areas reported that it 

can take years to finalize service expansion agreements between VA 

and IHS or THP facilities, which could limit incentives to pursue such 

agreements. There were several examples cited in which it took 3 

years to finalize service expansion agreements. In one case an official 

reported that it took 3 years to process an agreement to allow a VA

medical center to use a small area in an IHS facility for 2 days per 

week, in part due to lengthy legal and contracting reviews by VA and 

IHS. An official in another area reported that it took 3 years and many 

layers of approval to establish an agreement between the local VA 

medical center and THP provider to expand optometry services to 

Native American veterans.
 

Page 14 GAO-14-489 Native American Veteran Access to Care

VA and IHS have distributed informational resources among agency staff 

and some VA and IHS facilities have provided training to provider staff 

locally aimed at improving cultural competency. In some cases, the 

information and training have been targeted at informing VA staff about 

Native American culture, while in others it has been targeted at informing 

IHS and THP staff about veterans’ issues.21

• Training VA staff about Native American culture: VA and IHS 

agency officials said they had promoted informational resources 

among some agency and health facility staff and conducted training, 

both of which were designed to improve cultural competency. For 

example, they have publicized certain informational resources 

available to VA and IHS staff with respect to Native Americans, 

including a webinar on Native American behavioral health issues and 

A Guide to Build Cultural Awareness publication.22

• Training IHS staff about veterans’ issues: VA and IHS agency 

officials reported that there are a number of training aides to inform 

IHS staff about veterans’ issues, including (1) a video training 

program for IHS facility officials about PTSD; (2) a webinar distributed 

by a IHS facility to its staff about PTSD and sexual assault issues in 

Moreover, at all of 

our site visit areas, officials reported that staff training and other 

activities were conducted to improve the cultural competency of care 

provided to Native American veterans. An official at one VA medical 

center, for example, reported that they provide a 1-week training 

program covering Native American culture for providers who work with 

predominantly Native American patients; this training is followed by 

tribe-specific educational programs coordinated with a local tribe. 

Also, IHS-employed, traditional Native healers provided cultural 

orientations to VA staff. In fiscal year 2013 Native American Inventory 

quarterly reports submitted by VISNs to VA, 19 of 21 VISNs listed one 

or more activities related to improving cultural competency related to 

Native American culture.

 

21Cultural competency training may address the spiritual beliefs and traditional healing 

practices of Native Americans, including those related to beliefs about warfare as well as 

the nature of disease and appropriate ways to communicate about disease. Cultural 

competency training may also address the special issues faced by some veterans, such 

as PTSD, domestic violence, and combat-related poisoning.

22Department of Health and Human Services, Substance Abuse and Mental Health 

Services Administration, CultureCard: A Guide to Build Cultural Awareness – American 

Indian and Alaska Native, SMA 08-4354 (January 2009).

VA and IHS Have Provided 

Information and Training to 

Improve Cultural Competency, 

but Cultural Variation among 

Tribes and Staff Turnover Limit 

Its Effectiveness
 

Page 15 GAO-14-489 Native American Veteran Access to Care

the military; and (3) presentations by VA to THP facility staff about 

PTSD and traumatic brain injury.

The effectiveness of cultural competency training has been limited by 

cultural variation across some tribes and by the challenges of high staff 

turnover in some VA and IHS facilities.

• Cultural variation: IHS officials explained that customs and beliefs 

may vary in important ways across different tribes, and this presents a 

challenge for providing training that adequately addresses these 

variations, particularly in cases where VA and IHS facilities serve 

Native American veterans from multiple tribes. For example, in one 

site visit area, IHS officials at a facility that primarily served one tribe 

reported that their native healing practices were different than those of 

other nearby tribes with regard to the selection of a traditional healer 

to participate in healing ceremonies. Native American veterans from 

the tribe reported that if VA and IHS providers did not understand 

these differences it would make it difficult for their tribal members to 

obtain culturally competent health care treatment.

• High staff turnover: Native American veterans with whom we spoke 

during our site visits identified high staff turnover as an issue affecting 

cultural competency. Native American veterans said that the use of 

temporary staff and the high degree of provider turnover limit the 

effectiveness of any training in cultural competency, which in turn can 

diminish the quality of care provided. Without training in cultural 

competency, provider staff may not be aware of important issues, 

such as how to effectively communicate with Native American 

veterans about their health or how to diagnose certain symptoms 

unique to veterans.

IHS and VA collaborated at the national and local levels to establish a 

VA-IHS reimbursement agreement that applies to all IHS facilities and to 

encourage THPs to develop reimbursement agreements with VA. Under 

such agreements, VA pays IHS and THP facilities for eligible services that 

they provide to eligible Native American veterans. VA, IHS, and THP 

officials said that reimbursement agreements may improve access to care 

because the presence of the agreements may encourage IHS and THP 

facilities to be more active in outreach and encouraging of enrollment of 

Native American veterans into VA. This could provide more opportunities 

for Native American veterans to obtain health care at any type of facility, 

as well as obtain services they would not otherwise have access to, 

including services targeted at veterans, such as PTSD counseling and 

treatment, as well as specialty services unavailable at the IHS or THP 

Reimbursement Agreements 

Are in Place in Many

Locations, but Site-Specific 

Factors and Circumstances 

Have Limited Establishing 

Such Agreements in Other 

Locations
 

Page 16 GAO-14-489 Native American Veteran Access to Care

facility. The actions taken by the agencies include the development of a 

national reimbursement agreement between VA and IHS facilities and the 

development of individual reimbursement agreements between VA and 

some THPs.

• National reimbursement agreement covering IHS: VA and IHS 

officials explained that together the agencies developed a national 

reimbursement agreement as well as procedures and systems 

through which VA payments may be made to IHS facilities. In 

addition, VA and IHS agency staff worked at the local level to 

complete implementation plans with each IHS facility and its area VA 

medical center. Officials reported that all 81 local implementation 

plans were in place as of July 2013. According to these officials, 

implementation planning at the local level involved: (1) “get to know 

you” sessions, in which local VA and IHS officials shared information 

about what services were provided by their respective facilities; 

(2) training of IHS staff about VA’s eligibility, billing, and enrollment 

processes; (3) registration of the IHS facility into VA’s payment 

system; and (4) setting up the IHS facility site for billing to VA. Data 

provided by VA indicates that as of April 8, 2014, VA had paid a total 

of $3.28 million for services provided to 2,047 Native American 

veterans at IHS facilities. 

• Reimbursement agreements with THPs: In addition to a national 

agreement, VA officials said that VA had established 53

reimbursement agreements with THPs as of May 16, 2014, and 

conducted additional outreach through tribal letters and events to 

educate other THPs about the option of establishing these 

agreements.23

Challenges cited by officials at VA, IHS, and THP facilities included 

delays in activating established reimbursement agreements and 

obstacles to establishing agreements with additional THPs.

Data provided by VA indicate that as of April 8, 2014, 

VA had paid a total of $1.99 million for services provided to 307 

Native American veterans at THP facilities.

 

23The earliest THP reimbursement agreements were completed in Alaska where, as of 

August 2012 there were 26 agreements that collectively covered nearly all THPs in that 

state. Unlike agreements in other parts of the United States, these reimbursement 

agreements also provide Alaska THPs with payment for eligible services for eligible 

veterans who are not Native American. This arrangement is meant to address the fact that 

VA has a limited number of health facilities in the state.
 

Page 17 GAO-14-489 Native American Veteran Access to Care

• Delays in starting reimbursement under established agreements: 

Not all IHS and THP facilities that are covered under reimbursement 

agreements have received reimbursement. While there are currently 

over 130 facilities covered under such agreements, as of April 8, 2014 

only 86 had received reimbursement for services provided in fiscal 

year 2014. According to agency officials, although many agreements 

are in place, it may take some time before reimbursement will begin at 

some IHS and THP facilities. Before reimbursement can begin, 

eligible Native American veterans must be identified as such. 

However, the previously mentioned challenges of a lack of data that 

identifies veterans as Native Americans and high staff turnover among 

IHS facilities have hindered efforts to identify these eligible individuals, 

according to officials. VA officials said that it takes time to firmly 

establish the procedures for providing and transmitting complete 

claims information. For example, some THP facilities do not have the 

ability to file electronic claims and therefore the process for submitting 

claims needs to be worked out at each THP, sometimes using paper 

filing. Officials also said that in some cases the time required to 

establish reimbursement procedures is extended as a result of staff 

turnover at THPs. In one case it took a year before the THP’s staff 

consistently provided the necessary information on submitted claims 

forms.

• Obstacles to establishing agreements with additional THPs: 

Factors such as the time it may take to establish a reimbursement 

agreement as well as the perceived lack of need for agreements may 

discourage some THPs from pursuing such agreements. Officials said 

that while the reimbursement agreement between VA and IHS applies 

to all IHS facilities, VA’s agreements with THPs need to be negotiated 

individually and are based on each tribal facility’s specific 

circumstances, such as whether it has the accreditation status 

required by VA to provide care for veterans, and assessment of these 

unique situations will require time and resources.24

 

24Under the Indian Self-Determination and Education Assistance Act, as amended, 

federally recognized Indian tribes can enter into self-determination contracts or selfgovernance compacts with the Secretary of Health and Human Services to take over 

the administration of certain IHS programs for Indians. In such cases the VA must work 

with each tribe individually regarding its specific program. See 25 U.S.C. §§ 450f(a), 

458aaa-3.

VA and IHS 

officials said that some THPs may choose not to invest the time and 

resources needed to establish agreements for a variety of reasons. 

For example, the THP may be located near a VA facility and not 
 

Page 18 GAO-14-489 Native American Veteran Access to Care

believe it is necessary to establish such an arrangement. One THP 

official we interviewed noted that it can take a long time to develop a 

reimbursement agreement with VA. THP officials cited a range of 

issues that need to be worked out in these agreements, such as the 

reimbursement rate, requirements for provider credentialing and 

privileging, and whether electronic health records would be 

exchanged. VA has created a template for agreements with THPs 

which addresses these issues and may expedite the process of 

finalizing agreements. However, VA officials noted that THPs may 

propose changes to the template language, and each agreement 

requires a legal review and a contracting officer’s review and 

signature. VA may have disincentives to sign such agreements as 

well. For example, VA officials at one facility reported the concern that 

pursuing a reimbursement agreement with area THPs could divert 

funds from VA facilities if Native American veterans shifted from using 

VA services to using THP services.

VA and IHS lack a defined approach for effectively implementing and 

overseeing the MOU, and we identified three main contributing factors. 

First, oversight of the MOU’s implementation is inconsistent and, in 2013, 

the officials tasked with this oversight did not meet and did not 

systematically evaluate the progress of MOU implementation. Second, 

according to agency officials, no formal policies or guidance have been 

developed that outline the procedures to implement the MOU, which limits 

the agencies’ ability to hold individuals accountable for its implementation. 

Third, leadership in VA and IHS have not made MOU implementation a 

priority, which threatens the ability of the two agencies to move forward in 

implementing the MOU. Without consistent oversight, formal guidance on 

responsibilities for MOU implementation, and the prioritization of MOU 

implementation, leadership in VA and IHS do not have reasonable 

assurance that the objectives of the MOU related to access to care are 

being addressed.

Standards for Internal Control in the Federal Government require that the 

agency’s organizational structure define key areas of authority and 

responsibility, and also that appropriate and clear internal reporting 

relationships be established.25

 

25GAO, Standards for Internal Control in the Federal Government, 

The standards further require top-level 

GAO/AIMD-00-21.3.1

(Washington, D.C.: Nov. 1999). Internal controls are components of an organization’s 

management that provide reasonable assurance that certain objectives are being met.

VA and IHS Lack a 

Defined Approach for 

Effectively Implementing 

and Overseeing the MOU

Implementation and Oversight 

Are Inconsistent
 

Page 19 GAO-14-489 Native American Veteran Access to Care

reviews of actual performance to track achievements and compare goals 

and objectives, as well as the assessment of the quality of performance 

over time to ensure that actions are promptly taken in response to 

findings or recommendations. They also specify that it is important not 

only to establish, but also to review, performance measures to ensure 

they are working as intended. Furthermore, our prior work on interagency 

collaborations found that collaborating agencies should work together to 

define and agree on respective roles and responsibilities, including how 

the efforts will be led.26 This work also found that federal agencies 

working together need to create the means to monitor and evaluate 

efforts to identify areas for improvement.27

In implementing the MOU, VA and IHS have not complied with these 

standards or good practices. For example,

• While the Joint Implementation Task Force held meetings in 2011 and 

2012, the full Joint Implementation Task Force has not met since 

2012 according to several agency officials, and it was the 

understanding of one agency official that this group was on a hiatus. 

Another official with a key role on the Joint Implementation Task 

Force reported being unaware of who actually led this task force. 

Another official with a key role on the Joint Implementation Task 

Force reported that while some of its members met in 2013 to work on 

implementing the national VA/IHS reimbursement agreement, these 

meetings did not focus on MOU oversight.

• As of April 2014, officials responsible for leading the Joint 

Implementation Task Force told us that they had not systematically 

reviewed or analyzed information in the work group or Native 

American Inventory quarterly reports for fiscal year 2013, although 

officials in VA said they had reviewed selected reports for specific 

purposes, such as learning what types of training were being provided 

by VISNs. However, the leaders of the Joint Implementation Task 

Force did not comprehensively track the information provided and 

therefore did not provide oversight to identify priority action items for 

 

26GAO, Results-Oriented Government: Practices That Can Help Enhance and Sustain 

Collaboration among Federal Agencies, GAO-06-15 (Washington, D.C.: Oct. 21, 2005).

27GAO-06-15. 
 

Page 20 GAO-14-489 Native American Veteran Access to Care

work groups or possible obstacles to achieving the goals of the 

MOU.28

• As of fiscal year 2013, the Joint Implementation Task Force has not 

systematically identified strategies and plans for accomplishing tasks 

related to the MOU moving forward or addressed challenges or 

implemented best practices.

• Furthermore, although work groups were tasked with reporting MOUrelated activities each quarter, only 28 of the 44 work group quarterly 

reports due for fiscal year 2013 (64 percent) were submitted. 

Members of one of the five work groups with whom we spoke reported 

that they no longer held work group meetings regularly.

Based on our assessment, these problems occurred in 2013 because VA 

and IHS leaders were not holding themselves or others accountable for 

their role in implementing the MOU. Without reviewing the quarterly work 

group reports, and ensuring that all required reports are submitted, VA 

and IHS leaders do not have reasonable assurance that the objectives of 

the MOU related to access to care are being addressed. In addition, they 

may be unaware of challenges and obstacles that VISNs, IHS and THP 

facilities, and work groups are encountering.

While VA and IHS have informal procedures to track and oversee actions 

taken under the MOU, the agencies have not developed written policies 

and guidelines governing implementation of the MOU. Our prior work on 

interagency collaborations found that agencies that articulate 

agreements—in areas such as leadership, roles and responsibilities and 

accountability—in formal documents can strengthen their commitment to 

working collaboratively.29 According to VA and IHS agency officials, the 

only documentation outlining the procedures to report VA and IHS 

progress in implementing the MOU is contained in a set of training slides 

used in a December 2012 staff training session. Based on the information 

presented in the slides, the procedures are generally consistent with 

Standards for Internal Control in the Federal Government.

30

 

28VA officials told us that they do have plans to review the quarterly reports for the first 

quarter of 2014.

(See figure 1 

29GAO-06-15. 

30GAO/AIMD-00-21.3.1.

Written Policies and Guidance 

Are Lacking
 

Page 21 GAO-14-489 Native American Veteran Access to Care

for a diagram of our interpretation of the procedures outlined in the 

training slides).

For example: 

• The slides include an organizational chart and other information that 

establish clear reporting relationships and assign key roles and 

responsibilities to agency staff. 

• Each MOU work group is required to collect information and develop a 

quarterly report detailing the types of activities it has conducted 

related to MOU objectives, including the objectives aimed at taking 

actions to improve access to care.

31

• The MOU coordinators are responsible for providing assistance and 

training to work groups, aggregating information from the work group 

reports and other sources such as VA’s Native American Inventory 

Reports, and submitting a quarterly report for review by the Joint 

Implementation Task Force.

32

• The Joint Implementation Task Force, made up of officials from VA 

and IHS including leaders from certain work groups, is responsible for 

oversight, including reviewing quarterly reports that are submitted by 

the MOU coordinators, and identifying plans for accomplishing MOU 

goals going forward.33

 

31The slides stipulate that work groups should upload the reports to a centralized, internal 

VA website. VA developed a quarterly reporting template for the work group reports 

aligned according to MOU goals. In addition to describing activities conducted, these 

reports may also note accomplishments or barriers to activities conducted.

These slides stipulate that the Joint 

Implementation Task Force should hold regular meetings to review 

progress and set priorities.

32The Native American Inventory Reports submitted by VISNs are aligned according to 

MOU goals. At the same time, VA officials told us that these reports are intended to serve 

other purposes within VA, in addition to those of the MOU.

33The Joint Implementation Task Force is also referred to as the leadership work group, 

which was established by the 2010 MOU.
 

Page 22 GAO-14-489 Native American Veteran Access to Care

Figure 1: Procedures Outlined in 2012 Training Slides for Tracking and Overseeing 

Actions Taken to Achieve the Goals of the Memorandum of Understanding between 

the Department of Veterans Affairs (VA) and the Indian Health Service (IHS)

However, VA and IHS officials said that these training slides are not 

binding because they have not been formalized in written policy or 

guidance, including establishing clearly defined roles and responsibilities. 

Without formal written policy or guidance to govern the implementation of 

the MOU, VA and IHS have little basis to hold those responsible for 

implementing the MOU accountable for effectively managing the 

implementation process.

VA and IHS leaders have not made MOU implementation a priority, which 

threatens the ability of the two agencies to move forward in implementing 

the MOU as it relates to access to care. This is demonstrated in a number 

of ways. First, according to officials, the Joint Implementation Task Force 

has not created any written policy or guidance that specifically defines 

Prioritization of MOU 

Implementation Is Lacking
 

Page 23 GAO-14-489 Native American Veteran Access to Care

roles and responsibilities for agency staff under the MOU. Moreover, key 

members of the Joint Implementation Task Force attributed their lack of 

tracking and oversight of the MOU activities in part to their perception that 

other work-related responsibilities had a higher priority than some of their 

MOU related responsibilities. The leaders of the Joint Implementation 

Task Force from both agencies reported that MOU responsibilities were 

not their top priority, and that resource constraints have affected their 

ability to focus attention on oversight of MOU implementation. For 

example, officials from ORH reported that, while it is the lead office within 

VA responsible for MOU-related activities, it is also responsible for many 

other initiatives. The office experienced staff turnover in 2012 and 2013, 

replacing 4 of its 11 staff members, including members of the leadership 

team. As a result, current leadership and some staff have only been in 

their current positions since April 2013 or later and have not had time to 

fully focus on MOU implementation and oversight. Similarly, an IHS 

official stated that IHS has limited resources, that agency staff are 

stretched in order to complete their primary responsibilities, and that 

activities related to the MOU are a part of their additional 

responsibilities.34

VA and IHS officials reported that they have plans to examine efforts to 

implement the MOU by looking at the effectiveness of the work group 

structure.35

 

34The 2013 and 2014 individual performance plans for two key leaders in VA and IHS who 

are involved with the MOU indicate general expectations relating to the MOU, for example 

“provide leadership to MOU implementation and report on MOU progress.” 

Specifically, VA and IHS have entered into an agreement to 

have VA’s National Center for Organization Development undertake an 

assessment of the views of work group members about their experience 

and about whether they think the goals of the MOU are being met. The 

assessment is scheduled to be completed by May 2014 and, according to 

officials, will be used to identify best practices for improved efficiency and 

effectiveness, or the need for adjustments to organizational structure or 

processes. It is unclear at this point, however, whether this study will fully 

address the implementation and oversight shortcomings we have noted 

and whether it will spur greater focus on the leadership required to 

effectively implement the MOU.

35This is consistent with our past work on practices that can enhance and sustain 

collaboration by revisiting and refreshing interagency groups. See GAO, Managing for 

Results: Implementation Approaches Used to Enhance Collaboration in Interagency 

Groups, GAO-14-220 (Washington, D.C.: Feb. 14, 2014).
 

Page 24 GAO-14-489 Native American Veteran Access to Care

Although the majority of Native American veterans and their 

representatives we contacted reported that they thought access to care 

for Native American veterans had improved over the past 3 years, a 

number of others said either that they did not believe that access to care 

had improved during that time or they did not know whether it had. In 

addition, there were mixed perceptions about the degree to which VA and 

IHS-funded facilities had made improvements in providing care that was 

culturally competent with regard to the needs of Native Americans or 

veterans.

Most Native American veteran representatives that we contacted via 

questionnaire perceived that there had been improvements in access to 

care, such as increases in the number of Native American veterans being 

enrolled in the VA health system and getting health care services. 

However, others did not see that any gains had been made or did not 

know. For example, Native American veteran representatives that we 

contacted provided the following responses to our web-based 

questionnaire when asked about whether there has been a change in the 

number of Native American veterans enrolled in the VA:36

• Of the 102 representatives, 63 said they thought enrollment had 

increased, 11 said enrollment had remained the same, 5 said that 

enrollment had declined, and 23 said they did not know whether 

enrollment had changed.

• Of the 102 representatives, 53 reported that in the last 3 years there 

had been an increase in the number of Native American veterans 

accessing health care at a VA, IHS, or THP facility. However, 12 felt 

that there had been no change and 36 reported that they didn’t know. 

Of the 53 respondents who reported that there had been an increase 

in access, 41 reported that access had improved at VA facilities, 

25 reported that access had improved at IHS-run facilities, and 

24 reported that access had improved at THPs.37

 

36The responses to this questionnaire are not generalizable to the entire population of 

representatives of Native Americans; however, they provide insights about improvements 

in access to care.

37Respondents could report increases at more than one type of facility. Also, the type of 

facilities available in a respondent’s service area may vary. For example, there may be 

only THP or IHS-run facilities in a service area but not both.

Native American 

Veterans and Their 

Representatives 

Reported Mixed 

Views on Whether 

Access to Care Has 

Improved
 

Page 25 GAO-14-489 Native American Veteran Access to Care

Native American veterans and their representatives we interviewed 

reported similar opinions about whether there had been improvements to 

access to care. Specifically, most of the 12 interviews we conducted with 

veterans or their representatives included one or more comments 

indicating that access to health care had improved.38

There were also mixed views about the extent to which VA and IHS 

facilities had made improvements in providing care that was culturally 

competent with regard to the needs of Native Americans or veterans. For 

example, Native American veteran representatives who responded to our 

web-based questionnaire reported the following when asked whether they 

thought there had been changes in culturally competent care for Native 

American veterans at different types of facilities:

Examples of 

comments indicating that access had improved included the statements 

“the area VA liaison had played a big part in increasing [health care] use 

and enrollment,” and “as a result of the assistance provided by TVRs to 

Native [American] veterans, they have better access to more health care 

services.” However, all of the interviews included one or more comments 

specifying challenges to access, such as the lack of awareness on the 

part of Native American veterans about VA benefits and what services 

are available to them, lack of transportation, long waiting times, and the 

lack of enough providers in certain areas such as behavioral health and 

substance abuse. In addition, some of the interviews included one or 

more comments by Native American veterans and their representatives 

that indicated that they thought that access had not improved.

• Of 102 representatives, 38 said care at VA facilities had generally 

improved with respect to its cultural competency, 28 said there had 

been no change, 9 said it had declined, and 26 said they did not know 

if there had been improvements;

• Of 102 representatives, 36 said care at IHS-run facilities had generally 

improved with respect to its cultural competency, 25 said there had 

been no change, 9 said it had declined, and 32 said they did not 

know; and for THPs, 37 said care at THPs had generally improved 

with respect to its cultural competency, 25 said there had been no 

change, 8 said it had declined, and 32 said they did not know.

 

38We used the following convention to state whether specific types of comments were 

made at most, some, or few of these interviews: most—at least one comment in 9 to 

11 interviews; many—at least one comment in 5 to 8 interviews; some—at least one 

comment in 3 to 4 interviews; and few—at least one comment made in 1 to 2 interviews.
 

Page 26 GAO-14-489 Native American Veteran Access to Care

In many of the 12 site visit interviews we conducted, Native American 

veterans made one or more comments that care was not culturally 

competent. For example, in one interview a Native American veteran said 

that the local VA providers did not understand the cultural needs of his 

tribe. In another interview, Native American veterans and their 

representatives said that veterans have significant issues around PTSD 

and domestic and sexual violence, but that the local IHS health facility 

was not addressing these issues. At the same time, many of the 12 site 

visit interviews we conducted also included one or more positive 

comments about cultural competency. One noted that there had been an 

increase in the provision of culturally competent care provided by VA 

because VA had hired a Native American to help with outreach, and 

another noted that care from their tribal clinic was culturally competent 

with respect to veterans’ needs in part because the facility had a 

specialist providing wound care who had experience working with 

veterans.

Native American veterans have historically faced many issues in 

accessing health care and to their credit, both VA and IHS have taken 

actions under the 2010 memorandum of understanding to improve access 

to care for Native American veterans. However, significant unresolved 

challenges still remain that the agencies need to address. Moreover, 

many Native American veterans and their representatives we contacted 

believed that the agencies need to build upon actions already taken to 

improve access for Native American veterans. Addressing access 

challenges and further improving the overall access to care for Native 

American veterans is hampered by ineffective oversight and the lack of 

accountability and prioritization of MOU-related responsibilities among 

those tasked with implementing the MOU. Written policies, procedures, 

and guidelines have not been developed to lay out roles and 

responsibilities, methods for collecting and disseminating information 

about MOU implementation activities, oversight mechanisms, and the 

process for assessing progress and developing strategies going forward. 

Absent clear, binding policies and guidance, oversight and accountability 

have waned and staff have not assessed progress, addressed barriers, or 

set priorities for how to accomplish the MOU goals going forward. The 

lack of oversight also makes it difficult for VA and IHS to know how well 

MOU activities are being carried out, to identify potential best practices for 

nationwide implementation, or to address existing or future challenges 

and strategies. Ultimately, access to VA and IHS facilities could be 

negatively affected and further progress in improving access 

compromised.

Conclusions
 

Page 27 GAO-14-489 Native American Veteran Access to Care

To improve access to care for Native American veterans through MOU 

implementation, we recommend that the Acting Secretary of Veterans 

Affairs and the Secretary of Health and Human Services take the 

following action:

Establish written policy or guidance designating specific roles and 

responsibilities for agency staff to hold leadership accountable and 

improve implementation and oversight of the MOU. In developing written 

policies and guidelines, strong consideration should be given to the 

guidance embodied in the training slides from December 2012, including 

the following:

• Develop an organizational chart clearly outlining the VA and IHS MOU 

structure and detailing agency staff roles and responsibilities.

• Require that regularly scheduled meetings be held by the Joint 

Implementation Task Force or other groups charged with the 

oversight of MOU implementation.

• Ensure that VISNs and the MOU work groups submit reports to VA 

and IHS quarterly, as well as ensure that the groups charged with the 

oversight of MOU implementation complete reviews and analyses of 

the information collected to assess MOU progress and address any 

deficiencies.

• Ensure that the Joint Implementation Task Force, or other groups 

charged with oversight of MOU implementation, identifies strategies 

and plans for accomplishing tasks related to the MOU to implement 

best practices and address challenges.

We provided draft copies of this report to VA and HHS for review. Both 

agencies concurred with our recommendation and in their comments on 

the draft described the plans for implementing the recommendation. Most 

noteworthy, they reported that the agencies will develop an organizational 

chart outlining VA and IHS MOU structure and agency roles and 

responsibilities, hold quarterly leadership meetings to provide oversight 

and guide the direction of MOU implementation efforts, and adopt and 

disseminate a Standard Operating Procedure outlining data reporting and 

submission requirements for work groups responsible for MOU 

implementation. We have reprinted the comments from VA in appendix I 

and the comments from HHS in appendix II. VA also provided technical 

comments, which were incorporated in the draft as appropriate.

Recommendation for 

Executive Action

Agency Comments
 

Page 28 GAO-14-489 Native American Veteran Access to Care

We are sending copies of this report to appropriate congressional 

committees, the Acting Secretary of Veterans Affairs, and the Secretary 

of Health and Human Services. The report is also available at no charge 

on the GAO website at http://www.gao.gov. 

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or williamsonr@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs are on the last page 

of this report. GAO staff who made major contributions to this report are 

listed in appendix III.

Randall B. Williamson

Director, Health Care
Page 29 GAO-14-489 Native American Veteran Access to Care

List of Requesters

The Honorable Patty Murray

Chairman

Committee on the Budget

United States Senate

The Honorable Jon Tester

Chairman

Committee on Indian Affairs

United States Senate

The Honorable Bernard Sanders

Chairman

Committee on Veterans’ Affairs

United States Senate

The Honorable Mark Begich

United States Senate

The Honorable Mazie Hirono

United States Senate
Appendix I: Comments from the Department of 

Veterans Affairs

Page 30 GAO-14-489 Native American Veteran Access to Care

Appendix I: Comments from the Department 

of Veterans Affairs
Appendix I: Comments from the Department of 

Veterans Affairs

Page 31 GAO-14-489 Native American Veteran Access to Care
Appendix I: Comments from the Department of 

Veterans Affairs

Page 32 GAO-14-489 Native American Veteran Access to Care
Appendix II: Comments from the Department 

of Health and Human Services

Page 33 GAO-14-489 Native American Veteran Access to Care

Appendix II: Comments from the Department 

of Health and Human Services
Appendix II: Comments from the Department 

of Health and Human Services

Page 34 GAO-14-489 Native American Veteran Access to Care
Appendix II: Comments from the Department 

of Health and Human Services

Page 35 GAO-14-489 Native American Veteran Access to Care
Appendix III: GAO Contact and Staff 

Acknowledgments

Page 36 GAO-14-489 Native American Veteran Access to Care

Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov

In addition to the contact named above, Gerardine Brennan, Assistant 

Director, Ashley Dixon, Carolyn Fitzgerald, Lori Fritz, Mary Giffin, 

Laurie Pachter, and Jeanette Soares made key contributions to this 

report.

Appendix III: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments
Related GAO Products

Page 37 GAO-14-489 Native American Veteran Access to Care

The following is a list of related products.

VA and IHS: Further Action Needed to Collaborate on Providing Health 

Care to Native American Veterans. GAO-13-354. Washington, D.C.: 

April 26, 2013

Native American Veterans: DOL Needs a Clear Plan to Improve 

Employment and Training Services on Tribal Lands. GAO-13-664. 

Washington, D.C.: September 26, 2013.

Related GAO Products

(291139)
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