In 1990, GAO began a program to report on government operations that we identified as “high risk.” Since then, generally coinciding with the start of each new Congress, we have reported on the status of progress addressing previously identified high-risk areas and have updated the High-Risk List to add new high-risk areas. Our most recent high-risk update in February 2017 identified 34 high-risk areas. Overall, our high-risk program has served to identify and help resolve serious weaknesses in areas that involve substantial resources and provide critical services to the public. Since the program began, the federal government has taken high-risk problems seriously and has made long-needed progress toward correcting them. In a number of cases, progress has been sufficient for us to remove the high-risk designation. To determine which federal government programs and functions should be designated high risk, we use our guidance document, Determining Performance and Accountability Challenges and High Risks. In making this determination, we consider whether the program or function is of national significance or is key to the performance and accountability of the federal government, among other things. Our experience has shown that the key elements needed to make progress in high-risk areas are top-level attention by the administration and agency leaders grounded in the five criteria for removal from the High-Risk List, as well as any needed congressional action. The five criteria for removal that we identified in November 2000 are listed in table 1 below. In each of our high-risk updates, we have assessed agencies’ progress to address the five criteria for removing a high-risk area from the list 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 towards meeting the criterion have been taken. Figure 1, which is based on a general example, shows a visual representation of varying degrees of progress in each of the five criteria for a high-risk area. We use this system to assess and track the progress of all agencies with areas on our High Risk list. When we rate Interior and HHS’s progress on Improving Federal Management of Programs that Serve Tribes and Their Members for the first time in our 2019 High Risk report, we will provide similar information. As we have previously reported, the Office of the Assistant Secretary- Indian Affairs (Indian Affairs), through BIE, is responsible for providing quality education opportunities to Indian students and oversees 185 elementary and secondary schools that serve approximately 41,000 students on or near Indian reservations in 23 states, often in rural areas and small towns. About two-thirds of BIE schools are operated by tribes, primarily through federal grants, and about one-third are operated directly by BIE. BIE’s Indian education programs originate from the federal government’s trust responsibility to Indian tribes. It is the policy of the United States to fulfill this trust responsibility for educating Indian children by working with tribes to ensure that education programs are of the highest quality and, in accordance with this policy, Interior is responsible for providing children a safe and healthy environment in which to learn. All BIE schools—both tribally- and BIE-operated—receive almost all of their operational funding from federal sources—namely, Interior and the Department of Education (Education)—totaling about $1.2 billion in 2016. Indian Affairs considers many BIE schools to be in poor condition. BIE is primarily responsible for its schools’ educational functions, while their administrative functions—such as safety, facilities, and property management—are divided mainly between two other Indian Affairs’ offices: BIA and the Office of the Deputy Assistant Secretary of Management. As discussed below, we have made 23 recommendations to Interior on Indian education—including recommendations cited in GAO’s 2017 High Risk report and included in two late May reports. Interior generally agreed with our recommendations. However, none have been fully implemented. In our 2017 High Risk report, we cited 3 recommendations from a 2013 report on management challenges facing Indian Affairs, with which Interior agreed, and these recommendations remain unimplemented as of late August 2017. These recommendations were based on our findings of Indian Affairs’ poor management and lack of accountability for BIE schools. In particular, we found that BIE did not have procedures in place specifying who should be involved in making key decisions, resulting in inaccurate guidance provided to some BIE schools about the appropriate academic assessments required by federal law. We also found that Indian Affairs had not developed a strategic plan with specific goals and measures for itself or BIE or conducted workforce analysis to ensure it has the right people in place with the right skills to effectively meet the needs of BIE schools. Further, we found that fragmented administrative services for BIE schools and a lack of clear roles for BIE and Indian Affairs’ Office of the Deputy Assistant Secretary for Management contributed to delays in BIE schools acquiring needed materials, such as textbooks. As a result, we recommended that Indian Affairs develop decision-making procedures and a strategic plan for BIE and revise its workforce plan, among other areas. Of the 3 unimplemented recommendations we made to Interior on Indian Affairs’ management and accountability for BIE schools, agency officials reported that they have taken several actions to address them, including drafting written procedures for BIE decision-making; starting to develop a strategic plan for BIE; and conducting workforce planning. Indian Affairs’ actions to implement our recommendations to develop decision-making procedures and a strategic plan for BIE had not been completed as of late August. Indian Affairs officials told us they believed they had fully implemented our recommendation on strategic workforce planning. However, in reviewing their supporting documentation, we determined that their actions did not address our recommendation to ensure that the staff who are responsible for providing administrative support to BIE schools have the requisite skills and knowledge and are placed in the appropriate offices. For a full description of the agency’s actions and our evaluation of these actions, see recommendations in table 2 in appendix I. We made 4 recommendations in a 2014 report on BIE’s oversight of school spending, none of which have been implemented. These recommendations were based on our findings of key weaknesses in Indian Affairs’ oversight of BIE school spending. In particular, we found that BIE lacked sufficient staff with expertise to oversee school expenditures, and as a result, these staff told us they lacked the knowledge and skills to understand the audits they needed to review. We also found that some staff did not have access to some of these audits. In addition, we found that BIE lacked written procedures and a risk-based approach to overseeing school spending—both integral to federal internal control standards—which resulted in schools’ misuse of federal funds. For example, external auditors identified $13.8 million in unallowable spending at 24 schools. Auditors also found that one school lost about $1.7 million in federal funds that were improperly transferred to off-shore accounts. As a result, we recommended that Indian Affairs take several actions to address these oversight weaknesses, including developing written procedures and a risk-based approach to monitor school spending and a process to share relevant information, such as audit reports, with all BIE staff responsible for overseeing BIE school spending, among other areas. Of the 4 unimplemented recommendations we made to Interior on the oversight of BIE school spending, agency officials reported taking several actions, including providing their auditors with needed access to schools’ audit reports. Officials also said they would put in place written procedures and a risk-based approach to improve the financial monitoring of BIE schools. As of late August 2017, officials had not provided us with documentation of any steps they have taken to improve oversight of school spending. For a full description of the agency’s actions and our evaluation of these actions, see recommendations in table 2 in appendix I. We made 4 recommendations in a 2016 report on the safety and health of BIE school facilities, none of which have been implemented. These recommendations were based on our findings that Indian Affairs was not annually inspecting all BIE schools, as required by Indian Affairs’ policy. We also found that the agency did not have a plan to monitor safety inspections across its regions to ensure that inspection practices were consistent and supported the collection of complete and accurate inspection information. Further, we found the agency had not taken steps to assist BIE schools to build their capacity to address identified safety deficiencies. Some school officials we spoke to reported lacking staff with the knowledge and skills necessary to understand and address safety issues. Further, at one school we visited, we found seven boilers that failed inspection because of multiple high-risk safety deficiencies, including elevated levels of carbon monoxide and a natural gas leak. Four of the boilers were located in a student dormitory, and three were located in classroom buildings. All but one of the boilers were about 50 years old. Although the poor condition of the boilers posed an imminent danger to the safety of students and staff, most of them were not repaired until about 8 months after failing their inspection, prolonging safety risks to students and staff. As a result of these findings, we recommended that Indian Affairs take several actions, including developing a plan to build BIE schools’ capacity to address safety hazards identified by BIA inspectors, among other areas. Of the 4 unimplemented recommendations we made to Interior on ensuring safety and health at BIE schools, Indian Affairs completed safety inspections at all BIE schools in 2016, among other actions. However, based on our review of the agency’s actions, we determined that several steps remain for these recommendations to be fully implemented. For example, as of late August 2017 the agency had not provided us with documentation that it has developed a plan for monitoring safety inspections across its regions to ensure that inspection practices are consistent. Further, Indian Affairs did not provide documentation that it had taken any actions to develop a plan to build BIE schools’ capacity to address safety and health problems identified with their facilities. For a full description of the agency’s actions and our evaluation of these actions, see recommendations in table 2 in appendix I. We also made 6 recommendations in a May 2017 report on oversight and accountability for BIE school safety inspections, none of which have been implemented. These recommendations were based on our findings of key weaknesses in Indian Affairs’ oversight of school safety inspections. In particular, we found that Interior and Indian Affairs had not taken actions to address identified weaknesses in BIA’s safety program, despite internal evaluations since 2011 that consistently found it to be failing. For example, no Indian Affairs office routinely monitored the quality or timeliness of inspection reports, and BIA employees were not held accountable for late reports despite a new employee performance standard on timely report submission. We found that 28 of 50 inspection reports we reviewed were incomplete, inaccurate, or unclear, including reports in which inspectors did not include all school facilities or incorrectly gave schools a year to fix broken fire alarms instead of the required 24 hours. We concluded that unless steps are taken to address safety program weaknesses, the safety and health of BIE students and staff may be at risk. As a result, we recommended that Indian Affairs take steps to address weaknesses in BIA’s safety program, including establishing processes to monitor the quality and timeliness of BIE school inspection reports, among other areas. Of these 6 unimplemented recommendations we made to Interior to improve its oversight of school safety inspections, Indian Affairs reported taking several actions. In particular, Indian Affairs reported that its safety office had established a procedure to monitor the timeliness of inspection report submissions to schools, and that BIA is currently developing a corrective action plan to address findings and recommendations from a 2016 Interior review of BIA’s safety program. However, as of late August 2017, Indian Affairs had not provided us with any documentation on these two actions. For a full description of the agency’s actions and our evaluation of these actions, see recommendations in table 2 in appendix I. We made 6 recommendations in a May 2017 report on school construction projects, none of which have been implemented. These recommendations were based on our findings of key weaknesses in Indian Affairs’ oversight of school construction projects. In particular, we found that Indian Affairs did not have a comprehensive capital asset plan to guide the allocation of funding for school construction projects. We concluded that until Indian Affairs develops such a plan, it risks using federal funds inefficiently and not prioritizing funds to schools with the most pressing needs. Additionally, we found that Indian Affairs has not consistently used accountability measures or conducted sufficient oversight to ensure that BIE school construction projects are completed on time, within budget, and meet schools’ needs. For instance, Indian Affairs has not always used accountability measures, such as warranties, to have builders replace defective parts or repair poor workmanship, and project managers do not always understand how to use accountability measures because Indian Affairs had not provided them guidance. We concluded that until Indian Affairs develops and implements guidance to ensure accountability throughout the school construction process and improves its oversight of construction projects, it will have little assurance they are completed satisfactorily and meet the needs of students and staff. As a result, we recommended that Indian Affairs take several actions, including developing a comprehensive capital asset plan and guidance on the effective use of accountability measures for managing BIE school construction projects, among other areas. Of these 6 unimplemented recommendations that we made to Interior to improve its oversight of BIE school construction projects, Indian Affairs reported taking several actions. For example, Indian Affairs reported that to support the effective use of accountability measures, it established new oversight mechanisms, hired staff with expertise in construction contracting, and administered training for contracting staff. As of late August 2017, however, Indian Affairs had not provided us any documentation of these steps, so we cannot verify that the actions were responsive to our recommendations. Further, Indian Affairs did not report taking any actions to develop guidance on the effective use of accountability measures, which our recommendation specifies. Indian Affairs also reported that it is currently in the process of establishing a new work group to focus on asset management and will continue working to develop a capital asset management plan. Finally, the agency reported it was planning to take several other actions to address our recommendations. For a full description of the agency’s actions and our evaluation of these actions, see recommendations in table 2 in appendix I. As we have previously reported, some tribes and their members hold abundant energy resources and have decided to develop these resources to meet the needs of their community, in part because energy development provides opportunities to improve poor living conditions, decrease high levels of poverty, and fund public services for tribal members. While tribes and their members determine how to use their energy resources, if the resources are held in trust or restricted status, BIA—through its 12 regional offices, 85 agency offices, and other supporting offices—generally must review and approve leases, permits, and other documents required for the development of these resources. In the past 2 years, we have reported that BIA has mismanaged Indian energy resources held in trust, thereby limiting opportunities for tribes and their members to use those resources to create economic benefits and improve the well-being of their communities. Specifically, we issued 3 reports that identified concerns associated with BIA management of energy resources and categorized those concerns into the following four areas: (1) BIA’s data and technology; (2) oversight of BIA activities; (3) collaboration and communication; and (4) BIA’s workforce planning. As discussed below, we made 14 recommendations to BIA to help address BIA management weaknesses that were cited in our 2017 High Risk report. BIA generally agreed with these recommendations. However, none have been fully implemented. We made 2 recommendations related to data and technology for which BIA has taken some actions and made some progress to implement. However, neither of these recommendations has been fully implemented. We made these recommendations based on our June 2015 findings that BIA did not have the necessary geographic information systems (GIS) mapping data and that BIA’s federal cadastral surveys cannot be found or are outdated. According to Interior guidance, GIS mapping technology allows managers to easily identify resources available for lease and where leases are in effect. However, we found that BIA did not have the necessary GIS mapping data for identifying who owns and uses resources, such as existing leases. We also found that BIA could not verify who owned some Indian resources or identify where leases were in effect in a timely manner because, in part, federal cadastral surveys could not be found or were outdated. In addition, we found the extent of this deficiency was unknown because BIA did not maintain an inventory of Indian cadastral survey needs, as called for in Interior guidance. Of the 2 unimplemented recommendations to help ensure that BIA can verify ownership in a timely manner and identify resources available for development, BIA has taken several actions. Regarding GIS data, BIA officials told us that the agency has integrated and deployed data viewing and map creation capabilities into its 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)—on August 31, 2017. We will work with BIA to obtain the documentation needed to determine if the deployed GIS capability has the functionality for us to consider this recommendation as fully implemented. Regarding cadastral surveys, according to a BIA official, the agency requested that each of its 12 regions review and identify historic survey requests from a data system that has not been fully maintained or consistently used since 2011 to determine if the requests are still valid. BIA officials told us the next step is to create a new database that will track cadastral survey needs and a reporting mechanism for each BIA region to use when making new survey requests. According to BIA officials, the agency anticipates the new database and reporting mechanism will be deployed by September 30, 2017. For a full description of the agency’s actions and our evaluation of these actions, see table 3 in appendix II. We made 5 recommendations to BIA related to its review process for energy development, none of which have been fully implemented. In June 2015 and June 2016, we found that BIA did not have a documented process or the data needed to track its review and response times throughout the development process, including the approval of leases, rights-of-way (ROW) agreements, and communitization agreements (CA). The ability to track and monitor the review of permits and applications is a best practice to improve the federal review process. Of the 5 unimplemented recommendations we made to help ensure that BIA fulfills its responsibilities concerning the review and approval of documents related to energy development in an efficient and transparent manner, BIA has taken some actions and identified other actions it plans to take. For example, on May 17, 2017, the Acting Assistant Secretary- Indian Affairs testified before this committee that a group of BIA subject matter experts have been working 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. The Acting Assistant Secretary also stated that BIA is in the process of evaluating and reviewing the current realty tracking system and TAAMS to improve efficiencies and timeliness in processing workloads. BIA identified actions to track and monitor review and response times for oil and gas leases and agreements; however, BIA did not indicate whether it intends to track and monitor its review of other energy-related documents, such as ROW agreements, that must be approved before tribes can develop resources. In another example, on May 17, 2017, the Acting Assistant Secretary- Indian Affairs testified before this committee that a National Policy Memorandum has been developed that establishes time frames for review and approval of Indian CAs. The Acting Assistant Secretary also stated that such time frames will also be incorporated into the BIA Fluid Mineral Estate Procedural Handbook and the Onshore Energy and Mineral Lease Management Interagency Standard Operating Procedures. However, in our review of the National Policy Memorandum we did not find that it establishes time frames for review and approval of Indian CAs. In response to our request for clarification, a BIA official told us the agency is in the process of drafting suggested time frames. For a full description of the agency’s actions and our evaluation of these actions, see table 3 in appendix II. We made 5 recommendations related to collaboration and communication in our June 2015 and November 2016 reports. BIA has taken some actions, but the actions are generally limited in scope and none of these recommendations have been fully implemented. We found in our November 2016 report that BIA has taken steps to form an Indian Energy Service Center that is intended to, among other things, help expedite the permitting process associated with Indian energy development. However, we found several weaknesses in BIA’s collaboration processes and structure. For example, in November 2016, we reported that BIA did not coordinate with other key regulatory agencies that can have a role in the development of Indian energy resources, including Interior’s Fish and Wildlife Service (FWS), the Army Corps of Engineers (Corps), and the Environmental Protection Agency (EPA). As a result, the Service Center was neither established as the central point for collaborating with all federal regulatory partners generally involved in energy development, nor did it serve as a single point of contact for permitting requirements. In addition, BIA did not include the Department of Energy (DOE) in a participatory, advisory, or oversight role in the development of the Service Center. Further, although Interior’s Office of Indian Energy and Economic Development (IEED) developed the initial concept and proposal for the Service Center and has special expertise regarding the development of Indian energy resources, BIA did not include IEED in the memorandum of understanding (MOU) establishing the Service Center. BIA also did not document the rationale for key management decisions or the alternatives considered in forming the Service Center—a leading practice for effective organizational change. In addition, several tribal leaders and tribal organizations made suggestions that were not currently reflected in BIA’s Service Center. Without documentation on alternatives considered, it was unclear whether these requests were appropriately considered. Of the 5 unimplemented recommendations to help improve efficiencies in the federal regulatory process, BIA reported that it has taken some actions. For example: According to a BIA official, the agency has initiated discussions with FWS, EPA, and the Corps in an effort to establish formal agreements. BIA has a target of December 31, 2017, to establish these agreements. However, in its current structure, the Service Center is not serving as a lead agency or single point of contact to coordinate and navigate the regulatory process. Without additional information, it is unclear if the formal agreements alone will allow the Service Center to serve this role. We will continue to work with BIA officials to understand how the formal agreements with other regulatory agencies will help to transform the Service Center into a central point of contact for Indian energy development. According to a BIA official, the agency developed and is currently reviewing an addendum to expand an existing MOU between DOE and IEED to include the Service Center. However, the existing MOU between DOE and IEED does not identify the role for these agencies as related to the Service Center. As such, the addendum, as currently described to us by a BIA official, will not fully implement our recommendation. On May 17, 2017, the Acting Assistant Secretary- Indian Affairs testified before this committee that Interior considers this recommendation implemented because (1) the development of the Service Center was the result of a concept paper produced by a multi- agency team and (2) a multi-agency team held a tribal listening session, received written comments, and conducted conference calls in an effort to gather input from relevant stakeholders. We do not agree that these actions meet the intent of the recommendation. BIA’s actions have not resulted in documentation on the alternatives considered, whether tribal input and requests were considered, and the rationale for not incorporating key suggestions. In addition, in 2005, Congress provided an option for tribes to enter into a tribal energy resource agreement (TERA) with the Secretary of the Interior that allows the tribe, at its discretion, to enter into leases, business agreements, and rights-of-way agreements for energy resource development on tribal lands without review and approval by the Secretary. However, in a June 2015 report, we found that uncertainties about Interior’s regulations for implementing this option have contributed to deter tribes from pursuing agreements. We recommended that Interior provide clarifying guidance. On May 17, 2017, the Acting Assistant Secretary- Indian Affairs testified before this committee that Interior is working to provide additional energy development-specific guidance on provisions of TERA regulations that tribes have identified to the department as unclear. As part of this effort, the Acting Assistant Secretary reported that IEED continues to perform training and technical assistance on the TERA regulations, and plans to issue guidance on those provisions of TERA that have been identified as unclear. As of September 6, 2017, Interior has not issued additional guidance and several Interior officials told us it is unlikely any new guidance will clarify “inherently federal functions”—one provision of Interior’s regulations tribes have identified as unclear. For a full description of the agency’s actions and our evaluation of these actions, see table 3 in appendix II. We made 2 recommendations on workforce planning to BIA in November 2016, neither of which has been fully implemented. In our November 2016 report we found BIA had high vacancy rates at some agency offices and that the agency had not conducted key workforce planning activities consistent with Office of Personnel Management standards and leading practices identified in our prior work. Of the 2 unimplemented recommendations to help ensure that it has a workforce with the right skills, appropriately aligned to meet the agency’s goals and tribal priorities, BIA has reported several actions it plans to take. On May 17, 2017, the Acting Assistant Secretary- Indian Affairs testified before this committee that BIA is in the process of identifying and implementing a workforce plan regarding positions associated with the development of Indian energy and minerals. Specifically, the Acting Assistant Secretary stated that the Service Center will collect data directly from BIA, Bureau of Land Management (BLM), the Office of Natural Resources Revenue (ONRR), and the Office of Special Trustee (OST) employees in an effort to identify workload and necessary technical competencies. Then, the Service Center will work with partner bureaus to assess skills and competencies needed for energy and mineral workforce standards. BIA’s target for completion of the activities is the end of 2017. BIA stated it is taking steps to identify workload and technical competencies, but without additional information, it is unclear if these actions will identify potential gaps in its workforce or result in the establishment of a documented process for assessing BIA’s workforce composition at agency offices. For a full description of the agency’s actions and our evaluation of these actions, see table 3 in appendix II. As we have previously reported, the Indian Health Service (IHS), an agency within the Department of Health and Human Services (HHS), is charged with providing health care to approximately 2.2 million Indians. IHS oversees its health care facilities through a decentralized system of area offices, which are led by area directors and located in 12 geographic areas. In fiscal year 2016, IHS allocated about $1.9 billion for health services provided by federally and tribally operated hospitals, health centers, and health stations. Federally operated facilities—including 26 hospitals, 56 health centers, and 32 health stations—provide mostly primary and emergency care, in addition to some ancillary or specialty services. When services are not available at federally operated or tribally operated facilities, IHS may, in some cases, pay for services provided through external providers through its Purchased/Referred Care (PRC) program— previously referred to as the Contract Health Services program. The PRC program is funded through annual appropriations and must operate within the limits of available appropriated funds. To be eligible for PRC services, recipients must generally meet several criteria, including being a member or descendant of a federally recognized tribe or having close social and economic ties with the tribe, and living within a designated PRC area. Although funding available for the PRC program has recently increased, we have reported that the program is unable to pay for all eligible services, and that these gaps in services sometimes delay diagnoses and treatments, which can exacerbate the severity of a patient’s condition and necessitate more intensive treatment. As discussed below, we made 13 recommendations to IHS that were unimplemented when we issued our 2017 High Risk report, with which HHS generally agreed. One has been fully implemented. In our February 2017 High Risk report, we cited 2 recommendations from a 2011 report on the accuracy of data used for estimating PRC needs, with which HHS agreed. These recommendations remain unimplemented as of late August 2017. We based these recommendations on our finding that IHS’s estimates of the extent to which unmet needs exist in the PRC program were not reliable because of deficiencies in the agency’s oversight of the collection of data on deferred and denied PRC program services. As a result, we made several recommendations for IHS to develop more accurate data for making these estimates and improving agency oversight. Of the 2 recommendations not yet fully implemented that we made to IHS on estimating PRC program needs, HHS officials reported that updated policy and procedural guidance will be issued to all IHS sites by September 30, 2017. We will evaluate the policy and procedural guidance when it is issued. For a full description of the agency’s actions and our evaluation for these unimplemented recommendations, see table 4 in appendix III. We made 3 recommendations to IHS to help make its allocation of PRC program funds more equitable, none of which have been implemented. We also raised a matter for Congress to consider requiring IHS to develop and use a new PRC funding allocation methodology. These recommendations and matter for Congress to consider were based on our findings of wide variations in PRC funding across the 12 IHS areas, that these variations were largely maintained by IHS’s long-standing use of its base funding methodology, that variation in PRC funding was sometimes not related to the availability of IHS-funded hospitals, that IHS’s estimate of PRC service users was imprecise, and that IHS allowed area offices to distribute program increase funds to local PRC programs using different criteria than the PRC allocation formula without informing IHS. As a result, we suggested that Congress consider requiring IHS to develop and use a new method to allocate all PRC program funds to account for variations across areas, and recommended that IHS use actual counts of PRC users and variations in levels of available hospital services in allocation formulas, and develop written policies and procedures to require area offices to notify IHS when changes are made to the allocations of funds to PRC programs. In response to our matter for Congress to consider, a bill that would have addressed this matter was introduced in the House and reported out of committee in 2016, but the bill did not become law. In response to our recommendations, HHS officials told us that a tribal/federal workgroup is currently discussing the PRC fund allocation issues. In July 2017, we requested additional information about the workgroup and any discussion that has occurred or decisions that have been made about PRC funding allocation since we made the recommendation 5 years ago, but as of late August 2017, we have not received any information. As the workgroup continues to discuss the PRC fund allocation issues, we will evaluate any decisions that are made to determine if they address this recommendation. For a full description of the agency’s actions and our evaluation for these recommendations, see table 4 in appendix III. We made 1 recommendation to IHS in a 2013 report on IHS payment rates for nonhospital services through the PRC program, which has not been fully implemented, as well as a matter for Congress to consider. The recommendation and matter for Congress to consider were based on our finding that IHS primarily paid nonhospital providers, including physicians, at their billed charges, despite an IHS policy—in place since 1986—that stated that area offices should attempt to negotiate with providers at rates that are no higher than Medicare rates. As a result, we suggested that Congress consider imposing a cap on payments for physician and other nonhospital services made through IHS’s PRC program that is consistent with the rates paid by other federal agencies. We also recommended that IHS monitor PRC program patient access to physician and other nonhospital care in order to assess how any new payment rates may benefit or impede the availability of care. In response to our recommendation, HHS officials told us that the agency has developed an online PRC rates provider tracking tool that enables PRC programs to document providers that refuse to contract for their most favored customer rate or accept the Medicare-like rate. We have requested documentation of this provider tracking tool, but as of late August 2017, we have not yet received information sufficient to consider the recommendation implemented. For a full description of the agency’s actions and our evaluation for these recommendations, see table 4 in appendix III. In our February 2017 High Risk report, we cited 1 recommendation from a 2013 report on the eligibility and enrollment of American Indians in expanded health care programs, with which HHS neither agreed nor disagreed. This recommendation remains unimplemented as of late August 2017. We reported that the expansion of Medicaid and new coverage options under the Patient Protection and Affordable Care Act (PPACA) may allow many American Indians to obtain additional health care benefits for which they were not previously eligible, resulting in IHS facilities receiving increased reimbursements from third-party payers and an increased workload for IHS facility staff responsible for processing these payments. We also found that IHS did not have an effective plan in place to ensure that a sufficient number of facility staff were prepared to assist with enrollment and to process increased third-party payments. As a result, we recommended that IHS realign its resources and personnel to increase its capacity to assist with increased enrollment and third-party billing. IHS has not reported taking any new action to implement the remaining recommendation. In response to our request for an update, IHS again provided a copy of a planning template it developed for facility Chief Executive Officers (CEO) that encourages them to assess the need for staffing changes in light of new and expanded coverage options available under PPACA. IHS previously explained, during the course of our review, that its planning template is a document that facility CEOs have been directed to use. We agree that developing a template to aid facilities in their planning for PPACA implementation is a good step. However, considering the large, system-wide growth in eligibility for new and expanded coverage options described in our report, we expect to see a system-wide response. Under its current approach, preparing for increased eligibility is dependent on the discretion of facility CEOs. IHS has not provided any evidence that this approach has resulted in the realignment of personnel needed to address an increased need for application assistance and third party billing. For a full description of the agency’s actions and our evaluation for these recommendations, see table 4 in appendix III. We made 2 recommendations in a 2013 report on opportunities for IHS to improve the PRC program, neither of which has been fully implemented. Our recommendations were based on our finding that determining eligibility for PRC funding—including the need to ascertain each time a referral is received whether the patient met residency requirements and the service met medical priorities—is inherently complex. As a result, we recommended that IHS take steps to improve the PRC program, including separately tracking IHS referrals and self-referrals, and revising its practices to allow available funds to be used to pay for PRC program staff. HHS agreed with our recommendation to separately track IHS referrals and self-referrals, but not to revise its practices to allow available funds to be used to pay for PRC program staff. HHS agreed to our recommendation to proactively develop potential options to streamline program eligibility requirements. IHS has not yet fully implemented these recommendations. HHS officials told us that IHS is developing 2 new measures that will track and measure PRC authorized referrals and self- referrals to time of payment for each type of referral. We will review the proposed changes when they are available. For a full description of the agency’s actions and our evaluation for these recommendations, see table 4 in appendix III. We made 2 recommendations in a 2016 report on IHS oversight of patient wait times, one of which was implemented in August 2017. These recommendations were based on our finding that IHS had not set any agency-wide standards for patient wait times at IHS federally operated facilities. We found that, while individual facilities had taken steps to help improve patient wait times, IHS had not monitored the timeliness of patient care on an agency-wide scale. As a result, we recommended that IHS 1) develop specific agency-wide standards for patient wait times, and 2) monitor patient wait times in its federally operated facilities and ensure corrective actions are taken when standards are not met. In response to our first recommendation, IHS developed specific standards for patient wait times and published them to the IHS Indian Health Manual website in August 2017. As a result of this action, we consider this recommendation to be fully implemented. In response to our second recommendation, in early September 2017 HHS officials told us that data collection tools for monitoring are under development. We will review IHS’s monitoring of facility performance, as well as any corrective actions, when these steps have been completed. For a full description of the agency’s actions on the unimplemented recommendation and our evaluation, see table 4 in appendix III. We made 2 recommendations in a 2017 report on IHS’s oversight of quality of care in its federally operated facilities, neither of which has been fully implemented. These recommendations were based on our finding that IHS’s oversight of the quality of care provided in its federally operated facilities has been limited and inconsistent, due in part to a lack of agency-wide quality of care standards. We found that these inconsistencies were exacerbated by significant turnover in area leadership and that the agency had not defined contingency or succession plans for the replacement of key personnel, including area directors. As a result, we recommended that IHS develop agency-wide standards for quality of care, systematically monitor facility performance in meeting these standards, enhance its adverse event reporting system, and develop contingency and succession plans for the replacement of key personnel. HHS agreed with our recommendations, and officials reported that the development of agency-wide measures, goals, and benchmarks are nearing completion. According to HHS, it is also developing a system- wide dashboard of performance accountability metrics for use at the enterprise, area, and facility levels. HHS officials told us that the enhancements to their adverse event reporting system are delayed because key personnel on the project became unavailable due to deployment. Finally, HHS officials told us that all IHS headquarters offices and area offices established a succession plan that identified staff and development needs to prepare for future leadership opportunities. We requested documentation of these succession plans, but as of late August 2017, we have not received any. For a full description of the agency’s actions and our evaluation for these recommendations, see table 4 in appendix III. In conclusion, although Interior and HHS have taken some actions to address our recommendations related to federal programs serving Indian tribes, 49 recommendations discussed in this testimony have not yet been fully implemented. We plan to continue monitoring the agencies’ efforts to address these unimplemented recommendations. In order for the Federal Management of Programs that Serve Tribes and Their Members to be removed from our High-Risk List, Interior and HHS need to show improvement on the five key elements described earlier: leadership commitment, capacity, action plan, monitoring, and demonstrated progress. These five criteria form a road map for agencies’ efforts to improve and ultimately address high-risk issues. We look forward to continuing our work with this committee in overseeing Interior and IHS to ensure that they are operating programs for tribes in the most effective and efficient manner, consistent with the federal government’s trust responsibilities, and working toward improving services for tribes and their members. Chairman Hoeven, Vice Chairman Udall, and Members of the Committee, this completes my prepared statement. My colleagues and I would be pleased to respond to any questions that you may have. If you or your staff have any questions about education issues in this testimony or the related reports, please contact Melissa Emrey-Arras at (617) 788-0534 or emreyarrasm@gao.gov. For questions about energy resource development, please contact Frank Rusco at (202) 512-3841 or ruscof@gao.gov. For questions about health care, please contact Kathleen King at (202) 512-7114 or kingk@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement. Key contributors to this statement include Elizabeth Sirois (Assistant Director), Edward Bodine (Analyst-in- Charge), James Bennett, Richard Burkard, Kelly DeMots, Christine Kehr, Liam O’Laughlin, William Reinsberg, James Rebbe, Jay Spaan, Ann Tynan, and Emily Wilson. Appendix III: Status of Unimplemented Recommendations to the DHHS on the Indian Health Service 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 copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.

Summary: GAO's High-Risk Series identifies federal program areas needing attention from Congress and the executive branch. GAO added federal management of programs that serve Indian tribes and their members to its February 2017 biennial update of high-risk areas in response to serious problems with management and oversight by Interior and HHS. This testimony identifies GAO's recommendations to Interior and HHS from prior GAO reports on the federal management and oversight of Indian education, energy resources, and health care that remain unimplemented. It also examines agencies' recent actions to address the recommendations and the extent to which these actions address GAO's recommendations. To conduct this work, GAO reviewed and analyzed agency documentation on actions taken to implement the recommendations and conducted interviews with agency officials. As discussed in the 2017 High Risk report, GAO has identified numerous weaknesses in how the Department of the Interior (Interior) and the Department of Health and Human Services (HHS) manage programs serving Indian tribes. Specifically, these weaknesses were related to Interior's Bureau of Indian Education (BIE) and Bureau of Indian Affairs (BIA)—under the Office of the Assistant Secretary-Indian Affairs (Indian Affairs)—in overseeing education services and managing Indian energy resources, and HHS's Indian Health Service (IHS) in administering health care services. GAO cited nearly 40 recommendations in its 2017 High Risk report that were not implemented, and has since made an additional 12 recommendations in two new reports on BIE school safety and construction published in late May of this year. Interior and HHS have taken some steps to address these recommendations but only one has been fully implemented. Education. GAO has found serious weaknesses in Indian Affairs' oversight of Indian education. For example, in 2016, GAO found that the agency's lack of oversight of BIE school safety contributed to deteriorating facilities and equipment in school facilities. At one school, GAO found seven boilers that failed inspection because of safety hazards, such as elevated levels of carbon monoxide and a natural gas leak. In 2017, GAO found key weaknesses in the way Indian Affairs oversees personnel responsible for inspecting BIE school facilities for safety and manages BIE school construction projects. Of GAO's 23 recommendations on Indian education—including recommendations cited in GAO's 2017 High Risk report and in two late May reports—none have been fully implemented. Energy resource management. In three prior reports on Indian energy, GAO found that BIA inefficiently managed Indian energy resources and the development process, thereby limiting opportunities for tribes and their members to use those resources to create economic benefits and improve the well-being of their communities. GAO categorized concerns associated with BIA management of energy resources and the development process into four broad areas, including oversight of BIA activities, collaboration, and BIA workforce planning. GAO made 14 recommendations to BIA to address its management weaknesses, which were cited in the 2017 High Risk report. However, none have been fully implemented. Health care. GAO has found that IHS provides inadequate oversight of its federally operated health care facilities and of its Purchased/Referred Care program. For example, in 2016 and 2017, GAO found that IHS provided limited and inconsistent oversight of the timeliness and quality of care provided in its facilities and that inconsistencies in quality oversight were exacerbated by significant turnover in area leadership. GAO also found that IHS did not equitably allocate funds to meet the health care needs of Indians. Of GAO's 13 recommendations on Indian health care cited in GAO's 2017 High Risk report, one has been fully implemented. GAO cited nearly 40 unimplemented recommendations in its February 2017 High Risk report on federal programs for Indian tribes in education, energy development, and health care, and added 12 recommendations in two new reports on BIE school safety and construction in late May of this year. Sustained focus by Interior and HHS in fully implementing these recommendations and continued oversight by Congress are essential to achieving progress in these areas.