I. Purpose of Study
The focus of this study is to prepare for an evaluation of the impact of Tribal Self-Governance on the delivery and costs of health and social services to Indians. The study is intended to inform policy officials regarding the utility of proceeding to evaluation design and implementation and advise them concerning the nature and quality of information that is both currently available or that would be need to be obtained in order to conduct such evaluation.
Executive orders and legislative changes beginning in 1970 have gradually permitted Indian (American Indian/Alaska Native) Tribes to take over more management ownership of Federal health and social services programs whose benefits are aimed either exclusively at Indians or for which Indians are among the intended beneficiaries. Congress continues to express interest and support for expanding such “self-determination” contracts and “self-governance” compacts (SDC/SGCs) to include additional Tribes and additional Federal programs. Tribes engaged in these administrative arrangements express their preference for them over having services administered by others. Anecdotal reports, qualitative studies, and some limited program assessments suggest that SDC/SGCs are effective in providing equivalent health care services. However, the evidence is incomplete.
How do the levels and quality of services and the costs incurred by Tribes that operate as Self-Governance compacts compare to one another and to the costs and services provided by other Federal, State, or private organizations administering the same programs? Do Indians served by IHS directly receive more or better services than those served by Self-Government Tribes? Are there measurable differences in the services and costs incurred by Tribes operating as Self-Governance compacts and those merely contracting to operate the same services?
This study is intended to determine the feasibility of evaluating the cost effectiveness, quality and levels of health care and social services provided by American Indian/Alaska Native (AI/AN) Tribes operating under Tribal Self-Governance compacts compared with the costs and services provided by (a) Tribes managing these same programs but operating under Self-Determination contracts, (b) directly by the Department of Health and Human Services, or (c) through other State, local, or private organizations under a grant or contract. The study is also needed to prepare for conducting an evaluation of a possible Congressionally-mandated Self-Governance project involving non-IHS programs of the Department. All stakeholders (Federal, State, Tribal, and NGO) questioned agreed that a comprehensive evaluation of such a project would be needed to assess its results.
What the fundamental research topics an evaluation of Tribal Self-Governance could address cannot yet be identified because it is unclear what information is available, in what form, and how accessible and comparably formatted for gathering and analysis. Before we could begin designing either a research effort or an evaluation of the effectiveness of Tribal Self-Governance, we must answer preliminary topics. The scope, thoroughness, availability and reliability of data with which to assess process outcomes, cost effectiveness, services levels, and quality of services has yet to be systematically investigated, analyzed, and reported. Because of this current state of the art, it is deemed appropirate, as a first step that could lead eventually to a meaningful evaluation of Tribal Self-Governence, to conduct a feasibility study to determine whether appropriate data are available, the nature and scope of the data, and its availability for future analysis. This first, proposed step, would involve discussions with Tribal representatives and Area office and headquarters staff, assistance of a diverse Technical Work Group advising the Contractor, and close work between the ASPE Task Order Monitors and the Contractor in order to lead to a report on the current conditions of information and identification of information that would be needed before evaluation design and implementation could proceed.
While the number of Tribally managed programs has increased substantially in recent years, over half of funds administered by the Department for services to American Indians and Alaska Natives are currently administered by the Department directly or by the States rather than through either contracts or compacts with the Tribes. The 569 Federally-recognized American Indian/Alaskan Native (AI/AN) Tribes of the United States are an immensely diverse mosaic of membership sizes, cultures, languages, histories, political aspirations, administrative sophistication, geography, tribal economics, and religious and social practices. As part of this diversity, the challenges Tribes face and the needs they perceive as most pressing also vary widely and the ideal responses and solutions to these challenges and problems will, of necessity, need to vary considerably. Tribes have asserted that Self-Governance has been one effective method of responding to local needs in more diverse and adaptive ways. This diversity presents interesting dilemmas to attempts to systematically evaluate self-governance. This is another reason why, it is necessary, before proceeding to evaluation design, to conduct a feasibility study.
In studying the feasibility of an evaluation of the processes, effectiveness, and impacts of Tribal contracting and compacting for management of health and social service systems, possible areas the contractor will need to assess include:
- the availability, comparability, and completeness of data, from some of several DHHS programs currently or anticipated to be operated in the future under a Self-Governance compacts (including IHS and some of the 12 programs identified below, in ACF, SAMHSA, and AoA the Tribes are interested in operating under Self-Governance compacting arrangements), the Tribes, States, and any other pertinent sources, for measuring financial performance, accessibility of services, use of services, and, as relevant for the evaluation, health and social outcomes;
- the availability of data to categorize Tribally-managed and DHHS or State-managed health and social services systems to establish valid comparisons, controlling for differences in socio-economic, educational, government-to-government relationships, and geography; and
- the availability of data and data systems of Tribes and Federal and State social services programs (for ACF, SAMHSA, and AoA) to establish baselines for future comparisons of effectiveness and cost in anticipation of a possible Congressionally-mandated Self-Governance compacting project involving non-IHS programs.
However, refinement of these areas will need to be part of the tasks addressed by the Contractor for this study. Both IHS and non-IHS programs are important to this study. The IHS component is essential because there is the longest history of Self-Governance in the IHS area and therefore greatest likelihood of being able to accurately measure the impact of Self-Governance performance for these programs and to provide insights regarding the needs and issues that Tribes and IHS will have to address in order to make further Self-Governance gains in IHS programs. The inclusion of the social service programs is essential in order to prepare the basis for an effective evaluation for the anticipated Congressional project mandate in this area.
Feasibility Study Areas:
The feasibility study should examine whether information is available or how it could be obtained to enable a subsequent evaluation to address questions including:
- Level of Services - How does Self-Governance affect the level of services, e.g., number of people served, level and quality of services provided, change in health and social service outcomes?
- Accessibility - What are the effects on access/waiting times for services for AI/ANs who are residing on Tribal lands but are members of other federally recognized Tribes?
- Service Quality - How is the quality of services affected by the changes in management of services? How is patient satisfaction affected? Do the kinds of services provided by Self-governance versus direct-service programs differ?
- Service Expenditures - How do expenditures of self-managing tribes compare to Federal/State-managed services? Is there a difference in other funds leveraged for the Tribe? How do costs compare over time? How do such cost/expenditure changes correspond to changing service levels? What are the sources of other funds leveraged by the Tribes?
- Management Factors - How can relative effectiveness of management of health and social services programs by Tribes be characterized?
- Staff Retention Rates - Does the type of management system operating for the provision of services to the Tribe correlate with the levels of staffing and staff retention rates in health care and social services?
- Willingness to Self-Govern - What are the reasons that account for the differences among Tribes which account for their levels of interest/willingness to contract/compact for Tribal management of services? Are there correlations between Tribal size, economic circumstances, and other factors with whether a Tribe operates Self-governing services?
- Technical Assistance and Support - What program or financial support and technical assistance would facilitate Tribal management of their health and social service systems?
- Applicability - What observations can be made regarding the extent to which the data, financial, and service management of Tribes self-managing their health care services would carry over to other, social services programs? How can Tribes be assisted in transitioning to self-governance for other non-IHS social service programs?
II. Project Management
The contractor will need to secure the services of an individual or management team to direct and carry out the day-to-day activity of the contract who has/have the following qualifications:
- Proven significant experience and expertise as principle investigator responsible for designing and conducting evaluations of health care and social service delivery systems;
- Documented experience identifying the needs or accounting for the unique cultural distinctions with regard to research involving minority, disadvantaged, or other special populations;
- Extensive background in and experience with Indian issues in general and Tribal Self-Governance activities in particular;
- Extensive knowledge of U.S. health care and social services delivery systems in general and issues regarding the Indian Health Service operations in particular; and
- Knowledge and familiarity with the IHS health Care Resource and Patient Management System (RPMS).
III. Background on Self-Governance
Conditions on Many Reservations
American Indians and Alaskan Natives, especially those living on reservation lands, have among the worst health morbidity/mortality and social welfare measures of any population groups in the United States. For several indices (diabetes, alcoholism, suicide, etc.), Indians have morbidity and mortality statistics at least five times as great as for the American population at large. As part of their efforts to address these health and social problems of their Tribal members, during the past 25 years, Tribes have sought new relationships to Federal and State agencies previously responsible for providing care to Tribal members.
Legislative and Programmatic History
The Indian Self-Determination and Education Assistance Act (the Act), enacted in 1975 allowed Tribes to manage (under contract) programs that previously had been managed on their behalf by the Departments of Interior (DOI) and Health, Education and Welfare (HEW). In 1988, enactment of Title III of the Act created the first Tribal Self-Governance Demonstration Act in DOI. This Title permitted the Tribes to "compact" for greater management discretion over programs than they had when contracting or under the direct service model where services were provided by the Federal government. In 1994, the Congress created a permanent self-governance authority in BIA. In 1996, the Act was again amended to allow tribes to take over control and management of programs in the DOI outside the BIA. In the meantime, 1992 amendments to the Indian Health Care Improvement Act extended the Title III self-governance demonstration to the IHS and its programs.
Most recently, this latter program was made permanent in the Tribal Self-Governance Act Amendments of 2000. Both the Department of Interior's Bureau of Indian Affairs, and the Department of Health and Human Services' Indian Health Service, have been engaged with Tribes in a process of gradually transferring the management responsibility for programs serving Indians from the Federal government to Tribes during this time. The Tribal Self-Governance Amendments of 2000 also required the Department of Health and Human Services (DHHS) to study the feasibility of conducting a Tribal Self-Governance demonstration project for other, non-IHS, programs of the Department. As part of that study, a literature search was carried out by the Department to identify any relevant reports and evaluations of the effectiveness of self-determination contracting and self-governance compacting activities of DOI and DHHS. While extant studies of the impact of direct Tribal management of Federal programs conclude that Tribal assumption of program operations generally has had a positive effect on program beneficiaries, the studies are primarily qualitative in nature, based on discussions with Tribal officials, and do not provide quantitative data on either service outcomes, such as changes in the number of clients served and beneficiary health and well-being, or health outcomes. Also, the number of studies that have looked at the impact of Tribal assumption of program operations on beneficiaries is limited and the study samples not broadly representative.
Approximately half the country's 569 Tribes have been managing health programs, under compacting arrangements with the Indian Health Service, for up to ten years. Other Tribes also provide their own health services, but under a Self-Determination contract with the IHS. The remaining tribes receive their health services directly from providers managed directly by the Indian Health Service. The Amendments of 2000 provide for up to 50 new Tribal Self-Government operated health care programs under IHS each year; this provision offers the opportunity for additional tribes to choose to directly manage health care services on their own behalf.
Under various legislative authorities, growing number of Tribes also manage one or more of a dozen social service grant programs, including Head Start and Tribal TANF, that are included in the draft demonstration feasibility report, cited earlier. Non-Self-Governing Tribes, Congressional and Administration policy makers, program managers, other State, public, and private stake-holders and beneficiary representative groups, are increasingly interested in obtaining objective evidence regarding the fiscal, service level, and quality impact of this transfer of management from Federal, State and private agencies to Tribally-run organizations.
Although there is much anecdotal evidence that has been collected, some, such as the report of the National Indian Health Board, quite systematically, there has yet been no comprehensive, independent evaluation conducted of the effectiveness, costs and services of Tribal Self-Governance. Self-Governing Tribes believe strongly in the virtues of self-governance. They express the opinion that regardless of the cost and service impacts, self-governance is itself a value to the Tribe and to its individual members because it provides the opportunity for direct control by the Tribe of some of the resources and services that benefit the Tribe.
In practice, self-governance has two basic parts: 1) the transfer of the responsibility for managing Federal programs (and funds) that serve Indians from existing service providers to the tribes, and 2) providing tribes with the broad authority to redesign federal programs and reallocate federal resources to more effectively and efficiently meet the needs of tribal communities. Tribal leaders from those Tribes most active in Self-Governance believe that the Self-Governance model of Federal-Tribal relations is preferable to previous contractual or benefactor-beneficiary relationships. Self-Governance Tribes believe that they have meaningfully greater autonomy and are able to make and implement program and service delivery decisions that benefit their Tribal membership. Meantime, however, there remains a significant block of Tribes which express open scepticism regarding the advantages of taking on health and social service programs themselves. Their choice not to enter into Self-Governing compacts appear to stem from several sources: a concern that Federal funding, especially for administrative expenses, is inadequate and will stretch limited Tribal resources even further; a belief that Federal agencies may use transfer of programs under Self-Governance as a pretext for withdrawing from their "trust" obligations to the Tribes; and practical uncertainty about the nature of the services they would be able to offer.
As defined in the Self-Government Act of 2000, the goal of self-governance, as it currently applies to IHS programs, is to permit an orderly transition from Federal domination of programs and services to provide Indian Tribes with meaningful authority, control, funding, and discretion to plan, conduct, redesign, and administer programs, services, functions, and activities that meet the needs of the individual Tribal communities. For IHS programs operated by Tribes, the law permits the transfer of responsibility for managing Federal programs to the Tribes and provides Tribes with broad authority to redesign Federal programs and reallocate Federal resources to more effectively and efficiently meet the needs of Tribal communities. Tribes may request either self-determination contracts or self-governance compacts with the Indian Health Service; as mentioned above, the IHS is now required, under law, to support up to 50 new Tribal Self-Governance compacts each year.
In 1994, the Congress created a permanent self-governance authority in BIA. In 1996, the Act was again amended to allow tribes to take over control and management of programs in the DOI outside the BIA. In the meantime, 1992 amendments to the Indian Health Care Improvement Act extended the Title III self-governance demonstration to the IHS and its programs.
The amendments of 2000 also added Title VI to the Act, requiring that the Secretary of HHS "conduct a study to determine the feasibility of a tribal self-governance demonstration project for appropriate programs, services, functions, and activities (or portions thereof ) of the agency [HHS]." This Title applies to non-IHS programs administered by the Department. Title VI also delineates what the Secretary must consider in conducting the study and requires a joint federal/tribal stakeholder consultation process.
It is anticipated that the next Congress will take up legislation calling for establishment of a Self-Governance program within DHHS to demonstrate that Tribes can successfully operate non-IHS programs as effectively as can Federal, State, local, and private organization managers of those programs currently. The June, 2002 draft of the Congressionally-mandated DHHS report, "Tribal Self-Governance Feasibility Study," identifies 12 possible programs that the Congress might include in a mandatory demonstration project: Grants for Native Americans, Tribal Temporary Assistance for Needy Families (TTANF), Low Income Home Energy Assistance (LIHEAP), Community Services Block Grant (CSBG), Child Care and Development Fund (CCDF), Native Employment Works (NEW), Head Start, Child Welfare Services, Promoting Safe and Stable Families, Family Violence Prevention Grants for Battered Women's Shelters, Mental Health Block Grant, and Substance Abuse Block Grant. Most of these programs are already managed under contract or grant arrangements by one or more Tribes (for instance, there are over 100 Tribally-run Head Start grantees and separate legislative authority has already provided for expanding the number of Tribally-run TANF projects).
Findings and Limits of Previous Studies
Most studies of the impact of direct tribal management of federal programs conclude that tribal assumption of program operations generally has had a positive effect on program beneficiaries. However, the extant studies are primarily qualitative in nature, based on discussions with tribal officials, and do not provide quantitative data on service outcomes, such as the number of clients served or beneficiary health and well-being. Also, the number of studies that have looked at the impact of tribal assumption of program operations on beneficiaries is limited and the study samples are not nationally representative. A summary of what is known about the effects of self-governance on beneficiaries follows:
- A report by the National Indian Health Board (NIHB) looked at the impact of self-governance on beneficiaries by comparing compacting, contracting and IHS direct-service experiences over several years. The information was based on questionnaires submitted by tribal leaders and health care directors. Study results for the study period showed that tribally-operated health care systems substantially improved access to services: 50% of tribally-operated systems reported a net increase in community-based programs; 100% added at least one new clinical service; 34% had more auxiliary services; and 100% had at least one new prevention program, with 68% having more than one additional prevention program. In addition, the contracting and compacting tribes in the study added a net total of 37 facilities - about 44% of the contracting and compacting tribes in the study. The survey also found that some 93-95% of compact and contract tribal leaders and health directors felt quality of care (waiting time, types of services, number of people served and overall health care system) had improved during the period of study. This is compared to 62% for IHS direct-service tribes. (Tribal Perspectives on Indian Self-Determination and Self-Governance in Health Care Management, NIHB,1998)
- A General Accounting Office (GAO) study of individual tribal community health contracts in Alaska concluded that service levels were not greatly affected by the switch from IHS Regional Health Organizations to community-run programs, although existing problems with the inadequate reimbursement of indirect costs have the potential to affect service levels if tribes begin to move program funds to cover shortfalls in indirect costs. (GAO/HEHS-98-134)
- A review of tribal Child Care Development Fund (CCDF) grants by the HHS Office of the Inspector General found that such grants increased access to child care in their service areas. This was done in several ways. For example, a number of tribes chose to administer certificate programs that maximize the number of children served by paying lower rates to providers. Tribes also chose to extend services to tribal members not eligible for the State programs, rather than supplanting the State services. This was done by expanding eligibility criteria beyond that set by States and by setting copayments below State levels to make services affordable to those who could not afford State copayments. Tribal programs were found to be more culturally sensitive than State-run programs. (OEI-05-98-00010)
- Based on discussions and available tribal records, an independent evaluation of the first year of the BIA self-governance demonstration project (1991) showed evidence of increased program and service availability. However, little information was available to compare client experiences before and after tribal assumption of services. (Independent Assessment Report on the Self-Governance Demonstration Project, The Center for the Study of American Indian Law and Policy, University of Oklahoma and The Center for Tribal Studies, Northeastern State University at Tahlequah Oklahoma, unpublished)
- Reflecting its earlier warning, a subsequent GAO study (GAO/HEHS-98-134), based on discussions with tribal and federal staff, concluded that tribes had begun to use either program funds or other tribal resources to support shortfalls in indirect costs. The effect had been either to reduce services to tribal members, if program funds were used as an offset, or to preclude the use of tribal resources to supplement program funds or support other activities to help tribal members. Examples given included: reductions in staff salaries; the inability to offer salaries sufficient to attract qualified personnel, filling positions with unqualified or under qualified personnel; and unfilled positions - all of which could have an eroding effect on access and quality of services to beneficiaries. (GAO/RCED-99-150)
Additional Research Activities Anticipated in the Future:
- An evaluation contractor to the IHS is currently completing work toward a report, in January 2003, concerning the success of a five year diabetes reductions effort. The early indications are that positive results are being identified. The study distinguishes programs that are IHS-direct versus those where the Tribe operates the health effort. This may yield useful information regarding the relative effectiveness of Tribally-operated, Self-Governance projects.
- The Agency for Healthcare Research and Quality, AHRQ, is currently pilot testing an extension of CAHPs beneficiary satisfaction survey in an AI/AN community in Oklahoma. If successful, the survey will be applied more broadly to the Indian population and should yield valuable insights regarding Indians' satisfaction with health care services.