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aPercents do not equal 100 because some tribes and organizations (1) did not respond to our question about the delivery of a particular service or (2) received the service from a source other than IHS or through Public Law 93-638 (i.e., the tribe or organization's own funds or other non-Indian sources, such as state or local governments).

"The number of tribes and organizations that responded that they were receiving a health service through a particular source. For example, 64 respondents said they were participating in the delivery of inpatient care.

Lack of Funds Is
Predominant Reason
for Not Increasing
Contracting

Through our questionnaire, we attempted to determine the reasons why some tribes and tribal organizations currently contracting under the provisions of Public Law 93-638 were not interested in increasing their level of contracting. Table 3.4 indicates the prevalence of various reasons a tribe or tribal organization might choose not to increase its contracting responsibility. As indicated earlier, lack of IHS funds to expand projects is a major reason for not increasing Public Law 93-638 contracting.

Table 3.4: Reasons for Not Increasing
Contracting to Deliver Health Services
Under Public Law 93-638

Mixed Reasons for Not
Contracting

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We also attempted to obtain information concerning why certain tribes and tribal organizations eligible to contract under the provisions of the Indian Self-Determination Act chose not to do so. Based on the responses received, there is no predominant reason for not participating. Table 3.5 shows the prevalence of reasons given by tribes or tribal organizations for choosing not to contract.

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Agency Actions

As indicated in chapter 2, IHS and HRSA have taken several initiatives to improve the Public Law 93-638 contracting process. One proposed change suggested by IHS and HRSA is to allow the contractor more latitude to manage contract funds. Contractors will continue to be required to submit detailed cost budgets indicating the various categories of expenditures for their proposed contract under Public Law 93-638, and this budget will be used to arrive at the total contract figure. However, according to IHS, the detailed budget will not become part of the contract, only the total agreed-upon contract figure. Deleting the detailed cost budget from the contract is intended to eliminate the need for submitting justifications to IHS for moving funds between line items of the cost budget. According to IHS, this should increase the flexibility of the Indian contractors to manage their contract funds.

On April 22, 1986, the Director of IHS informed the IHS field offices of a pilot project to develop a more rational, equitable, and consistent policy for determining the level of funding for IHS and Public Law 93-638 tribal contractors. The purpose of the project is to identify indirect costs such as Indian contractor administration and executive director costs and to develop a process of allocation to Indian contractors that is more reflective of health needs at the tribal level.

Indian Self-Determination Under Public Law
93-638: What Are the Concerns?

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There is a difference in how some Indian tribes and IHS interpret the meaning of "self-determination" as it applies to Public Law 93-638. Some tribes view this term as giving them the authority to make decisions autonomously concerning the manner in which health care is to be delivered to them with minimal involvement or interference by IHS.

IHS, on the other hand, views the term somewhat differently and sees its role as requiring it to ensure that self-determination contracts specifically define what service is to be provided and how and by whom it will be delivered. Moreover, IHS sees its role as requiring it to ensure that tribes adhere to all applicable contracting rules and regulations. We agree with IHS that it has a responsibility under Public Law 93-638 to ensure that contracts are clearly written and administered in accordance with applicable contracting procedures.

In commenting on this report (see app. III), HHS officials indicated that the following changes are being initiated to streamline the contracting process:

Detailed cost budgets will be discontinued as part of the contract document, thus reducing the need to modify the contract for changes in the budget.

Contract modifications will no longer be issued for certain changes under the contract, for example rebudgeting and domestic travel estimates.

Contracts will be funded on an annual basis for the full estimated

amounts negotiated when the Appropriation Act becomes effective. Funding allocation will be based on a new allocation methodology reflecting need and providing for a rational and equitable distribution of funds.

The proposed changes, if properly implemented, should resolve some of the concerns raised by the Public Law 93-638 contractors. The improvements in the contracting process under Public Law 93-638 discussed above and on page 22 and the allocation of funds to tribal contractors in a manner more reflective of tribal need are steps in the right direction and should improve the working relationship between the Indian contractors and IHS.

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