Chapter 1 Introduction Background On September 6, 1985, Chairman Mark Andrews of the Senate Select The Public Health Service is composed of the Office of the Assistant Secretary for Health and the following agencies—the Alcohol, Drug Abuse, and Mental Health Administration; the Centers for Disease Control; the Food and Drug Administration; the National Institutes of Health; and HRSA. One of the organizational components of HRSA is IHS. HRSA oversees the contracting activities of IHS. IHS is responsible for providing comprehensive health care to approximately 987,000 Indians and Alaska Natives through its system of 47 hospitals, 80 health centers, and more than 500 smaller health stations and satellite clinics. Also, IHS contracts with private and public health facilities to supplement its direct health care delivery system. In the field, the programs are administered through 12 field offices. With the passage of Public Law 93-638 on January 4, 1975, the Congress responded to the Indian people's desire for self-determination by assuring maximum Indian participation in deciding on the direction of educational and other federal services to Indian communities. The Congress declared its commitment to the Indians by establishing a policy that would permit an orderly transition from federal domination of programs and services for Indians to an effective and meaningful participation by the Indian people in the planning, conduct, and administration of those programs and services. The Congress further provided that the Secretary of Health, Education, and Welfare (now HHS), upon the request of any Indian tribe, is to enter into a contract or contracts with any tribal organization to carry out any or all of the Secretary's functions, authorities, and responsibilities under the act. While the Congress allowed Indian tribes and organizations to Introduction enter into contracts for the operation of all or part of the activities performed by the federal government, the federal government still retains responsibility for the quality of services provided to the Indians and for monitoring the activity of the tribes contracting under Public Law 93-638. Contracts under Public Law 93-638 range from providing a community health service representative for an Indian tribe to operating a hospital for Indian tribal members. If an Indian tribe wants to take over the operation of an IHS function, it does so by making a contract proposal to IHS. Acceptance of the proposal by IHS enables the Indian tribe to begin performing the service for IHS. The tribe receives funds for the operation based on the amounts IHS would normally allocate for the service in question. The services to be performed would be similar to those currently being performed by IHS. The Indian contractor provides the service by using his own people or hiring personnel for that function. If the tribe or organization cannot provide the service required under The objectives of this assignment were to determine whether: Indian tribes and organizations were experiencing problems in obtaining Indian tribes and organizations were having problems in administering a Indian tribes and organizations were experiencing difficulties with self- HRSA was interfering with IHS's approval of Public Law 93-638 contracts. We reviewed the involvement of 12 Indian contractors with four IHS Introduction Table 1.1: Contracting Activity by 12 By looking at 12 Indian contractors that were extensively involved with Public Law 93-638 contracts, we believed, we could obtain information that would be helpful in describing the difficulties, if any, that the contractors have had with this form of contracting. We chose Indian contractors that had received Public Law 93-638 contracts for different types of activities. For example, we chose contractors that had assumed control of an IHS health care operation, contractors that had contracts for the delivery of health services under a comprehensive health care program, a contractor that was building a hospital with a Public Law 93-638 contract, and contractors that had used Public Law 93-638 as a means of operating small health care activities, for example, a community health representative. We chose four IHS field offices that ranked high in the relationship The selection of Indian tribes and tribal organizations was done in consultation with the requester, but followed the same logic as the selection Introduction of IHS field offices. We chose Indian contractors that had experience con- Our review was done at the four field offices and 12 contractors listed in the table and at the IHS and HRSA headquarters in Rockville, Maryland. We reviewed pertinent laws, regulations, documents, and agency procedures as they related to Public Law 93-638 contracting. Our review was done from August 1985 to January 1986 in accordance with generally accepted government auditing standards. In addition to examining 12 contractors' experiences in contracting under the Self-Determination Act, we sent questionnaires to all tribes and tribal organizations, whether or not they were contracting under the act. Our objectives were the same as those for the 12 cases selected for review; however, we also wanted to know why tribes not contracting under Public Law 93-638 had not done so. To obtain a universe of American Indian and Native Alaska tribes and tribal organizations eligible to contract under the provisions of Public Law 93-638, we requested that the 12 IHS field offices provide us with a list of appropriate tribes and tribal organizations in each jurisdiction. Based on those lists, we sent questionnaires in November 1985 to the universe of 386 tribes and tribal organizations. Subsequently, we identified and removed from our universe six organizations not eligible to contract under the Indian Self-Determination Act because they were urban programs receiving their funding under the Indian Health Care Improvement Act. We received completed questionnaires from 63 percent of the tribes and tribal organizations. Table 1.3 shows the response rates from |