Since 1990, generally every 2 years at the start of a new Congress, we call attention to agencies and program areas that are high risk due to their vulnerability to mismanagement or that are most in need of transformation. Our high-risk program is intended to help inform the congressional oversight agenda and to improve government performance. Since 1990, a total of 62 different areas have appeared on the High-Risk List. Of these, 26 areas have been removed, and 2 areas have been consolidated. On average, the high-risk areas that were removed from the list had been on it for 9 years after they were initially added. Our experience with the High-Risk List over the past 29 years has shown that the key elements needed to make progress in high-risk areas are top-level attention by the administration and agency leaders grounded in the five criteria for removing high-risk designations, which we reported on in November 2000. When legislative and agency actions, including those in response to our recommendations, result in our finding significant progress toward resolving a high-risk problem, we will remove the high- risk designation. However, implementing our recommendations alone will not result in the removal of the designation, because the condition that led to the recommendations is symptomatic of systemic management weaknesses. In cases in which we remove the high-risk designation, we continue to closely monitor the areas. If significant problems again arise, we will consider reapplying the high-risk designation. The five criteria for removing high-risk designations are as follows: Leadership commitment. Demonstrated strong commitment and top leadership support to address the risks. Capacity. Agency has the capacity (i.e., people and other resources) to resolve the risk(s). Action plan. A corrective action plan that defines the root causes, identifies solutions, and provides for substantially completing corrective measures in the near term, including steps necessary to implement solutions we recommended. Monitoring. A program has been instituted to monitor and independently validate the effectiveness and sustainability of corrective measures. Demonstrated progress. Ability to demonstrate progress in implementing corrective measures and in resolving the high-risk area. These five criteria form a road map for efforts to improve and ultimately address high-risk issues. Addressing some of the criteria leads to progress, and satisfying all of the criteria is central to removal from the list. Figure 1 shows the five criteria for removal for a designated high-risk area and examples of agency actions leading to progress toward removal. Importantly, the actions listed are not “stand alone” efforts taken in isolation of other actions to address high-risk issues. That is, actions taken under one criterion may be important to meeting other criteria as well. For example, top leadership can demonstrate its commitment by establishing a corrective action plan, including long-term priorities and goals to address the high-risk issue and by using data to gauge progress—actions that are also vital to addressing the action plan and monitoring criteria. When an agency meets all five of these criteria, we can remove the agency from the High-Risk List. We rate agency progress on the criteria using the following definitions: Met. Actions have been taken that meet the criterion. There are no significant actions that need to be taken to further address this criterion. Partially met. Some, but not all, actions necessary to meet the criterion have been taken. Not met. Few, if any, actions toward meeting the criterion have been taken. Officials from Indian Affairs, BIE, BIA, and IHS expressed their commitment to addressing the issues that led to the high-risk designation for federal management of programs that serve tribes and their members. Since we last testified before this committee on June 13, 2018, we met with agency leaders and worked with each agency to identify actions the agencies took or plan to take to address the concerns that contributed to the designation. We determined that Indian Affairs, BIE, BIA, and IHS demonstrated some progress to partially meet each of the criteria for removing a high-risk designation. However, additional progress is needed for the agencies to fully address the criteria and related management weaknesses. As we reported in the March 2019 high-risk report, when we applied the five criteria for High-Risk List removal to each of the three segments— education, energy, and health care—we determined that Indian Affairs, BIE, BIA, and IHS have each demonstrated some progress. Overall, the agencies have partially met the leadership commitment, capacity, action plan, monitoring, and demonstrated progress criteria for the education, health care, and energy areas. However, the agencies continue to face challenges, particularly in retaining permanent leadership and a sufficient workforce. The following is a summary of the progress that Indian Affairs, BIE, BIA, and IHS have made in addressing the five criteria for removal from the High-Risk List. To meet the leadership commitment criterion for removal of a high-risk designation, an agency needs to have demonstrated strong commitment and top leadership support to address management weaknesses. The following examples show actions Indian Affairs, BIE, BIA, and IHS took to partially meet the leadership commitment criterion. Education. Indian Affairs’ leaders have demonstrated commitment to addressing key weaknesses in the management of BIE schools in several ways. For example, the BIE Director formed an internal working group, convened meetings with other senior leaders within Indian Affairs, and publicly stated that his agency is committed to ensuring implementation of our recommendations on Indian education. In addition, the BIE Director and other Indian Affairs leaders and senior managers have met with us frequently to discuss outstanding recommendations, actions they have taken to address these recommendations, and additional actions they could take. We also met with the new Assistant Secretary-Indian Affairs, who expressed her commitment to supporting the agency’s efforts to address weaknesses in the management of BIE schools. However, it is important that Indian Affairs leaders be able to sustain this level of commitment to solving problems in Indian education. Since 2012, there have been seven Assistant-Secretaries of Indian Affairs and five BIE Directors. There has also been leadership turnover in other key offices responsible for implementing our recommendations on Indian education. We have previously reported that leadership turnover hampered Indian Affairs’ efforts to make improvements to Indian education. We believe that ensuring stable leadership and a sustained focus on needed changes is vital to the successful management of BIE schools. Energy. BIA officials demonstrated leadership commitment by, among other things, meeting with us to discuss the agency’s progress in addressing our recommendations. In June 2018, a permanent Assistant Secretary for Indian Affairs was confirmed. This action provided an opportunity to improve Indian Affair’s oversight of federal actions associated with energy development. According to the BIA Acting Director and the Acting Director for Trust Services, BIA held a number of meetings with the Assistant Secretary to discuss agency action plans for our recommendations. However, BIA does not have a permanent Director, and BIA’s Office of Trust Service—which has significant responsibility over Indian energy activities—does not have a permanent Director or Deputy Director. We have seen turnover in these leadership positions as officials have been brought in to temporarily fill these roles. As officials are brought in temporarily, previously identified plans and time frames for completing some activities have changed, and BIA has found itself starting over on the process to identify or implement corrective actions. Health Care. IHS officials demonstrated leadership commitment by regularly meeting with us to discuss the agency’s progress in addressing our recommendations. In addition, IHS has chartered a policy advisory council that will focus on issues related to strategic direction, recommended policy, and organizational adjustments. According to IHS, this advisory council will, among other things, serve as a liaison among IHS leadership for issues involving strategic direction and policy, as well as monitor and facilitate related policy workgroups. However, IHS still does not have permanent leadership—including a Director of IHS—which is necessary for the agency to demonstrate its commitment to improvement. Additionally, since 2012, there have been five IHS Acting Directors, and there has been leadership turnover in other key positions, such as area directors. To fully meet the leadership commitment criterion, all agencies will need, among other things, stable, permanent leadership that has assigned the tasks needed to address weaknesses and that holds those assigned accountable for progress. For a timeline of senior leadership turnover in Indian Affairs, BIE, BIA, and IHS from 2012 through March 2019, see Figure 3. To meet the capacity criterion, an agency needs to demonstrate that it has the capacity (i.e., people and other resources) to resolve its management weaknesses. Indian Affairs, BIE, BIA, and IHS each made some progress in identifying capacity and resources to implement some of our recommendations, but BIE and IHS continue to face significant workforce challenges. The following examples show actions Indian Affairs, BIE, BIA, and IHS took to partially meet the capacity criterion. Education. BIE and other Indian Affairs offices that support BIE schools have made some progress in demonstrating capacity to address risks to Indian education. For example, BIE hired a full-time program analyst to coordinate its working group and help oversee the implementation of our recommendations on Indian education. This official has played a key role in coordinating the agency’s implementation efforts and has provided us with regular updates on the status of these efforts. BIE has also conducted hiring in various offices in recent years as part of a 2014 Secretarial Order to reorganize the bureau. For example, it has hired school safety officers and personnel in offices supporting the oversight of school spending. However, about 50 percent of all BIE positions have not been filled, including new positions that have been added as a result of the agency’s restructuring, according to recent BIE documentation. Moreover, the agency reported that it has not filled the position of Chief Academic Officer, a top-level BIE manager responsible for providing leadership and direction to BIE’s academic programs. Furthermore, BIE has not completed a strategic workforce plan to address staffing and training gaps with key staff, which we previously recommended. Such a plan is important to allow BIE and other Indian Affairs offices to better understand workforce needs and leverage resources to meet them. In February 2019, BIE drafted a strategic workforce plan and reported it is currently gathering feedback on the plan from internal stakeholders. BIE officials indicated they are planning to finalize and implement the plan in 2019. Energy. In November 2016, we recommended that BIA establish a documented process for assessing the workforce at its agency offices. BIA has taken a number of actions, such as conducting an internal survey to identify general workforce needs related to oil and gas development. This survey information supported staffing decisions for the recently created Indian Energy Service Center. In February 2019, BIA officials told us they have drafted a long-range workforce plan to ensure BIA has staff in place to meet its organizational needs. We will review the plan to determine if the planned actions will help BIA identify critical skills and competencies related to energy development and identify potential gaps. Health Care. IHS has made some progress in demonstrating it has the capacity and resources necessary to address the program risks we identified in our reports. For example, among other actions, IHS officials stated that the agency is expanding the role of internal audit staff within its enterprise risk management program to augment internal audits and complement audits by the HHS Inspector General and GAO. In addition, IHS has developed a new Office of Quality, which is expected to develop and monitor agency-wide quality of care standards. However, IHS officials told us there are still vacancies in several key positions, including the Director of the Office of Resource Access and Partnerships, and the Office of Finance and Accounting. Additionally, our August 2018 report found that IHS’s overall vacancy rate for clinical care providers was 25 percent. To fully meet the capacity criterion, all of the agencies need to assess tradeoffs between these and other administration priorities in terms of people and resources, and the agencies should provide to decision makers key information on resources needed to address management weaknesses. To meet the action plan criterion, an agency needs to have a corrective action plan that defines the root causes, identifies solutions, and provides for substantially completing corrective measures in the near term, including steps necessary to implement the solutions we recommended. The following examples show actions Indian Affairs, BIE, BIA, and IHS took to partially meet the action plan criterion. Education. Among other actions, BIE implemented a new action plan for overseeing BIE school spending, including written procedures and risk criteria, which fully addressed two priority recommendations. Also, BIE completed a strategic plan in August 2018, which we recommended in September 2013. The plan provides the agency with goals and strategies for improving its management and oversight of Indian education, and establishes detailed actions and milestones for the implementation. However, Indian Affairs has not provided documentation that it has completed action plans on other important issues, such as a comprehensive, long-term capital asset plan to inform its allocation of school facility funds, which we recommended in May 2017. Energy. In meetings, BIA officials identified actions they have taken towards implementing our recommendations. For instance, BIA officials told us they have recently completed modifications to BIA’s database for recording and maintaining historical and current data on ownership and leasing of Indian land and mineral resources—the Trust Asset and Accounting Management System (TAAMS). The officials said that the modifications incorporate the key identifiers and data fields needed to track and monitor review and response times for oil and gas leases and agreements. BIA officials we met with have demonstrated an understanding that addressing long-standing management weaknesses is not accomplished through a single action but through comprehensive planning and continued movement toward a goal. However, the agency does not have a comprehensive action plan to identify the root causes of all identified management weaknesses and address the problems. Health Care. In February 2019, IHS finalized its strategic plan for fiscal years 2019 through 2023, and is developing a related work plan to address certain root causes of management challenges and define solutions and corrective measures for the agency. The strategic plan divides these challenges into three categories: (1) access to care, (2) quality of care, and (3) program management and operations. We will examine the strategic plan and IHS’s work plan, once issued, to determine whether they contain the needed elements of an action plan. To fully meet the action plan criterion, a comprehensive plan that identifies actions to address the root causes of its management shortcomings would have to come from top leadership with a commitment to provide sufficient capacity and resources to take the necessary actions to address management shortcomings and risks. To meet the monitoring criterion, an agency needs to demonstrate that a program has been instituted to monitor and independently validate the effectiveness and sustainability of corrective measures. We have been working with the agencies to help clarify the need to establish a framework for monitoring progress that includes goals and performance measures to track their efforts and ultimately verify the effectiveness of their efforts. The following examples show actions Indian Affairs, BIE, BIA, and IHS took to partially meet the monitoring criterion. Education. Indian Affairs, in consultation with Department of Interior’s Office of Occupational Safety and Health, has taken actions to monitor corrective measures that address weaknesses with the agency’s safety program—which covers safety at BIE schools. However, the agency has not yet demonstrated that it is monitoring several other areas, such as whether relevant employees are being held to the agency’s required performance standards for safety inspections. Energy. BIA has taken steps to improve monitoring by holding frequent meetings to assess its progress in implementing our recommendations. However, BIA has not yet taken needed steps to monitor its progress in addressing the root causes of management weaknesses. Health Care. IHS has taken some steps toward monitoring the agency’s progress in addressing the root causes of their management weaknesses. In addition to developing its new Office of Quality, IHS has taken steps to develop a patient experience of care survey, as well as standards for tracking patient wait times. These efforts should be reflected in the agency’s corrective plan, as part of an overall framework for monitoring progress that includes goals and performance measures to track their efforts and ultimately verify the effectiveness of their efforts. To fully meet the monitoring criterion, the agencies need to establish goals and performance measures as they develop action plans and take further actions to monitor the effectiveness of actions to address root causes of identified management shortcomings. To meet the demonstrated progress criterion, an agency needs to demonstrate progress in implementing corrective measures and in resolving the high-risk area. The following examples show actions Indian Affairs, BIA, and IHS took to partially meet the demonstrated progress criterion. Education. As of February 2019, Indian Affairs had addressed 11 of the 23 outstanding education recommendations we identified in our September 2017 testimony. Three of these recommendations were closed after the June 2018 hearing, including a recommendation from our 2013 report for BIE to develop a strategic plan and two recommendations from our 2017 report on improving the oversight and accountability for BIE school safety inspections. Overall, Indian Affairs’ efforts since we issued our High-Risk List update in February 2017 represent a significant increase in activity implementing our recommendations. Substantial work, however, remains to address our outstanding recommendations in several key areas, such as in accountability for BIE school safety and school construction projects. For example, Indian Affairs has not provided documentation that the inspection information its personnel collect on the safety of BIE schools is complete and accurate. As of late February 2019, 12 recommendations related to this high-risk area remain open and Indian Affairs concurred with all 12 recommendations. For a full description of the status of these open recommendations, see in table 1 in appendix I. Energy. BIA has shown significant progress developing data collection instruments and processes needed to track and review response times for a number of different actions associated with energy development. For example, in our June 2015 report, we recommended that BIA take steps to improve its geographic information system (GIS) capabilities to ensure it can verify ownership in a timely manner. We closed this recommendation as BIA has made significant progress in enhancing its GIS capabilities by integrating map-viewing technology and capabilities into its land management data system. In addition, we recommended that BIA take steps to identify cadastral survey needs. BIA’s enhanced map- viewing technology allows the bureau to identify land boundary discrepancies, which can then be researched and corrected. To address the recommendation, BIA identified unmet survey needs that were contained within the defunct cadastral request system. BIA developed a new mechanism for its regions and agency offices to make survey requests and a new database to maintain survey requests. In fall 2018, BIA completed enhancements to TAAMS that will allow the agency to track time frames and status of oil and gas revenue-sharing agreements-called communitization agreements (CA) through the review process. BIA held training on the enhancements in November 2018 and requested staff input information on any newly submitted CAs in the system. In a meeting on February 25, 2019, the Acting Director of BIA said that BIA had also completed efforts to modify TAAMS, incorporating the key identifiers and data fields needed to track and monitor review and response times for oil and gas leases and agreements. We believe these actions show significant progress in addressing management weaknesses associated with outdated technology and data limitations for tracking and monitoring the review and approval of energy related documents. However, BIA needs to collect data from its updated system, develop time frames, and monitor agency performance to close open recommendations. For a full description of the status of the agency’s open recommendations, see in table 2 in appendix II. Health Care. IHS has made progress in implementing corrective actions related to the management of health care programs. Specifically, since our 2017 High-Risk Report, IHS implemented four of our 13 open recommendations. For example, in response to our April 2013 recommendation, to ensure that IHS’s payment rates for contracted services do not impede patient access to physician and other nonhospital care, IHS developed an online tool that enables the agency to track providers that do not accept IHS’s payment rates. As of March 2019, six out of the 13 recommendations in our 2017 High- Risk Report remain open, and we have added one additional recommendation—for a total of seven open recommendations related to this high-risk area. IHS officials told us that they plan to complete the implementation of additional recommendations in 2019. For a full description of the status of the agency’s open recommendations, see in table 3 in appendix III. To fully meet the demonstrating progress criterion, agencies need to continue taking actions to ensure sustained progress and show that management shortcomings are being effectively managed and root causes are being addressed. In conclusion, we see some progress in meeting all of the criteria, at all agencies, especially related to education programs. However, permanent leadership that provides continuing oversight and accountability is needed. We also see varying levels of progress at all of the agencies in understanding what they need to do to be removed from the High-Risk List, and identifying steps that can be incorporated into corrective action plans. We look forward to working with the agencies to track their progress in implementing a framework for monitoring and validating the effectiveness of planned corrective actions. Among the greatest continuing challenges for the agencies is developing sufficient capacity, including demonstrating that they have the people and other resources required to address the deficiencies in their programs and activities. This challenge cannot be overcome by the agencies without a commitment from their leadership and the administration to prioritize fixing management weaknesses in programs and activities that serve tribes and their members. Sustained congressional attention to these issues will help ensure that the agencies continue to achieve progress in these areas. Chairman Hoeven, Vice Chairman Udall, and Members of the Committee, this completes my prepared statement. I would be pleased to respond to any questions that you may have. If you or your staff have any questions about health care issues in this testimony or the related reports, please contact Jessica Farb at (202) 512-7114 or farbj@gao.gov. For questions about education, please contact Melissa Emrey-Arras at (617) 788-0534 or emreyarrasm@gao.gov. For questions about energy resource development, please contact Frank Rusco at (202) 512-3841 or ruscof@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement. Key contributors to this statement include Kelly DeMots, (Assistant Director), Christina Ritchie (Analyst-in-Charge), Edward Bodine, Christine Kehr, Elizabeth Sirois, and Leigh White. As of late February 2019, 12 of the 23 recommendations to the Department of the Interior on Indian education we identified in our September 13, 2017, testimony remain open. As of February 2019, 12 of the 14 recommendations to the Department of Interior’s Bureau of Indian Affairs cited in our 2017 High-Risk Report remain open. As of March 2019, six out of the 13 recommendations in our 2017 High- Risk Report remain open, and we have added one additional recommendation—for a total of seven open recommendations related to this high-risk area.

Summary: GAO's High-Risk List identifies federal program areas that are high risk due to their vulnerability to mismanagement, among other things. GAO added the federal management of programs that serve Indian tribes and their members to its February 2017 biennial update of high-risk areas in response to management weaknesses at Interior and HHS. GAO's recommendations identified in this high-risk area are neither reflective of the performance of programs administered by tribes nor directed at any tribally operated programs and activities. This testimony, which is based on GAO's March 2019 High Risk report, provides examples of actions taken and progress made by these agencies to address the five criteria GAO uses for determining whether to remove a high-risk designation. For this statement, GAO also drew on findings from its reports issued from September 2011 through August 2018 and updated that work by reviewing agency documentation and interviewing agency officials. GAO designated the federal management of programs that serve tribes and their members as high risk in 2017. Officials from the Department of the Interior's Office of the Assistant Secretary-Indian Affairs (Indian Affairs), the Bureau of Indian Education (BIE), the Bureau of Indian Affairs (BIA), and the Department of Health and Human Services' (HHS) Indian Health Service (IHS) have expressed their commitment to addressing the issues that led to the designation. Since GAO last testified before this committee on June 13, 2018, Indian Affairs, BIE, BIA, and IHS have demonstrated progress to partially meet each of the five criteria for removing a high-risk designation (leadership commitment, capacity, action plan, monitoring, and demonstrated progress). However, additional progress is needed to fully address management weaknesses—particularly in the areas of retaining permanent leadership and a sufficient workforce. For example, to meet the capacity criterion, an agency needs to demonstrate that it has the capacity (i.e., people and other resources) to resolve its management weaknesses. While Indian Affairs, BIE, BIA, and IHS each made progress identifying capacity and resources to partially meet this criterion, BIE and IHS continue to face significant workforce challenges. Specifically, although BIE has conducted hiring in recent years as part of an effort to reorganize the bureau, about 50 percent of all BIE positions have not been filled according to recent BIE documentation. IHS also faces workforce challenges—GAO's August 2018 report found that IHS's overall vacancy rate for clinical care providers was 25 percent. GAO has identified varying levels of progress at the agencies in understanding what they need to do to be removed from the list and will continue to closely monitor their progress. GAO has made more than 50 recommendations related to this high-risk area to improve management weaknesses at some Interior and HHS agencies—specifically BIE, BIA, and IHS—of which 31 recommendations are still open. Sustained focus by Interior and HHS in fully implementing these recommendations and continued oversight by Congress are essential to achieving progress in these areas.