Study results indicate that a self-governance demonstration project for non-IHS programs, services, functions, and activities (or portions thereof) of HHS is feasible, provided that the statutory changes listed in Appendix E are made. To arrive at that conclusion, a number of factors were considered. The probable effects of a self-governance demonstration on beneficiaries weighed considerably in the conclusion. The opinions and recommendations of potential stakeholders also were important. A determination that a number of HHS programs could reasonably be part of a demonstration was critical to the conclusion. While it is recognized that these factors are qualitative to a great extent, Congress placed considerable weight on these factors, especially the consultation process, when authorizing the study. Findings relevant to each of these factors are discussed below in detail.
A Demonstration Would Likely Have a Positive Effect on Programs and Program Beneficiaries, Although Some Problems May Exist.
Most 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. This conclusion must, however, be qualified. The extant studies are primarily qualitative in nature, based on interviews 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.
With this caveat, a summary of what is known about the probable effect of a self-governance demonstration project on beneficiaries follows. As mentioned earlier, a bibliographical reference to these reviewed studies is provided in Appendix B.
- 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 the 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 those that are set by the 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)
- 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 term 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)
- Based on interviews 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 interviews 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)
- In the course of conducting the current feasibility study, BIA and IHS employees were interviewed and asked for their assessment of how self-governance had affected program beneficiaries. Most indicated that, although they lacked empirical data to support their conclusions, they believed self-governance overall had been positive.
A final note with respect to the potential impact of a demonstration is necessary. Many of the cited studies also mention the positive benefit that self-governance has on the roles and capabilities of tribal governments. While this may not relate directly to service levels, it is an important benefit that should not go unmentioned.
Stakeholders Do Not Oppose a Tribal Self-governance Demonstration if Concerns Are Addressed.
In the course of consultations on the feasibility of a demonstration, stakeholders did not disagree that a demonstration is feasible (transcripts of the sessions are available on the website cited earlier). While this was the case, stakeholders also raised a number of issues regarding the need to design a demonstration that would address concerns about program impact, quality and identity. For example, State and local government stakeholder organizations were especially concerned about dual eligibility and program accountability. These and other stakeholder concerns were considered and are addressed in the study recommendations.
Statutory Changes Would Be Needed to Include a Number of HHS Programs in a Demonstration.
While specific programs are identified and listed as feasible for inclusion in a self-governance demonstration project, it is important to note that their inclusion is recommended in conjunction with specific demonstration design recommendations that will provide important protections for program identity and quality. Further, specific statutory changes in virtually all of the programs will be needed before they can be included in a demonstration with the recommended design. Appendix E lists the necessary statutory changes. In general, the changes appear to be ones that can be addressed.