TRAHANT REPORTS— Federal Indian programs, like Bureau of Indian Education and Indian Health Service, have been added to the “high-risk” category by the Government Accountability Office. That designation could not come at a worse time.
The details. This is how the GAO defines its high risk identification: “The federal government is one of the world’s largest and most complex entities: about $3.9 trillion in outlays in fiscal year 2016 funded a broad array of programs and operations. GAO’s high-risk program identifies government operations with greater vulnerabilities to fraud, waste, abuse, and mismanagement or the need for transformation to address economy, efficiency, or effectiveness challenges.”
The GAO said it added federal Indian programs to its high risk category because “we have found numerous challenges facing Interior’s Bureau of Indian Education and Bureau of Indian Affairs and the Department of Health and Human Services’ Indian Health Service in administering education and health care services, which put the health and safety of American Indians served by these programs at risk. These challenges included poor conditions at BIE school facilities that endangered students, and inadequate oversight of health care that hindered IHS’s ability to ensure quality care to Indian communities. In addition, we have reported that BIA mismanages Indian energy resources held in trust and thereby limits opportunities for tribes and their members to use those resources to create economic benefits and improve the well-being of their communities.”
More from the GAO: “Congress recently noted, ‘through treaties, statutes, and historical relations with Indian tribes, the United States has undertaken a unique trust responsibility to protect and support Indian tribes and Indians.’ In light of this unique trust responsibility and concerns about the federal government ineffectively administering Indian education and health care programs and mismanaging Indian energy resources, we are adding these programs as a high-risk issue because they uniquely affect tribal nations and their members.”
The three agencies are lumped together as one in this report, yet the causes of what makes the agencies high risk are considerably different, requiring solutions that go well beyond what the agencies themselves can accomplish.
So let’s break it down.
First: GAO complains that the BIA has a problem quickly approving energy projects. This is Congress’ favorite problem. Congress can’t wait to solve this one by making the approval process faster than filling your car with a tank of gas. But the solutions ahead will also have unintended consequences for the very notion of trust lands, tribal control of energy projects, and the challenge of global warming. What happens when a tribe says, “hell no!” to say, the Keystone XL pipeline? That is a policy question that this Congress has all but answered.
Next the GAO says the Bureau of Indian Education “improves how it manages Indian education … including that Indian Affairs develop a strategic plan for BIE that includes goals and performance measures for how its offices are fulfilling their responsibilities to provide BIE with support; revise Indian Affairs’ strategic workforce plan to ensure that BIA regional offices have an appropriate number of staff with the right skills to support BIE schools in their regions; and develop and implement decision-making procedures for BIE to improve accountability for BIE schools.” My translation: Measure what works. Make better hires (with the right skills). And improve the decision-making process. Easy, right? Only hiring for BIE schools is easier said than done and the decision-making process is complicated by community priorities.
There is another problem at play: Conservative think-tanks have targeted BIE as operating “failing schools” and would replace them with a whacky scheme to create Education Savings Accounts. (Previous: Day One. Dramatic restructuring of government.) This whole notion is written by people who have no understanding of the geography of Indian country or the makeup of the Native students. The BIE has unique challenges and there are many, many improvements that could be made. So adding to this discourse a GAO high-risk warning is, well, not helpful.
The third high-risk agency identified by the GAO is the Indian Health Service. The report says: “To help ensure that Indian people receive quality health care, the Secretary of HHS should direct the Director of IHS to take the following two actions: as part of implementing IHS’s quality framework, ensure that agency-wide standards for the quality of care provided in its federally operated facilities are developed and systematically monitor facility performance in meeting these standards over time; and develop contingency and succession plans for replacing key personnel, including area directors.” My translation: Measure what works. Make better hires (with the right skills). And improve the decision-making process. Easy, right? Again, it’s not as if the Indian Health Service is not trying to hire people. The problem is funding and a hiring process that is both cumbersome and required by law.
What I don’t get is why the GAO doesn’t see that the Indian Health Service mission has changed dramatically. One part of the agency is a funding mechanism, directing resources to tribal, non-profit, and urban health care facilities. The report alludes to that fact with this recommendation: “To help ensure that timely primary care is available and accessible to Indians, IHS should: develop and communicate specific agency-wide standards for wait times in federally-operated facilities, and monitor patient wait times in federally-operated facilities and ensure that corrective actions are taken when standards are not met.” The key phrase here is “federally-operated” because many of the tribal and nonprofit centers have solved this problem. GAO should have said this and focused on what works and why.
Another GAO recommendation about Indian Health Service might be the most tone deaf. It says, “we recommend that IHS realign current resources and personnel to increase capacity to deal with enrollment in Medicaid and the exchanges and prepare for increased billing to these payers.”
Clearing my throat here. Umm. Congress is going in exactly the opposite direction. The serious questions – the ones that Congress ought to be answering – are how much will it cost Indian Health Service when Medicaid is turned into a block grant? What replaces Medicaid expansion funding at the local unit level? And, will states even fund a federal health care delivery system?
The GAO report makes a big deal about Indian Health Service developing a fair method for how it spends money on purchased and referral care. What the report should have said is that Congress is to blame. The problem is not the architecture; it’s the funding. No federal agency. No state agency. Hell, no private medical system spends less than the Indian health system. The real problem here is that it’s impossible to defy gravity.
Mark Trahant is the Charles R. Johnson Endowed Professor of Journalism at the University of North Dakota. He is an independent journalist and a member of The Shoshone-Bannock Tribes. On Twitter @TrahantReports