The study must identify HHS programs, services, functions, and activities (or portions thereof) that are feasible for inclusion in a self-governance demonstration project. The study recommends eleven existing HHS programs for inclusion in a demonstration. The recommendation is based on a number of considerations. First, except in the area of substance abuse and mental health programs, transfer of the programs to tribal authority has already taken place. In this respect, the primary issue of self-governance for a demonstration is not the transfer of program authority, but the issue of flexibility, control over priorities, and administrative simplification. Tribes have a demonstrated record in managing these programs and no studies or other evidence exists to suggest that tribes are not managing these programs satisfactorily. Second, there are no insurmountable legal barriers that were identified that would preclude inclusion of these programs in a demonstration under the recommended design, although it will be necessary to make certain provisions in the existing program statutes and regulations inapplicable to the tribes participating in a demonstration in order to implement the recommended design (see Appendix E). A cited provision in a program statute or regulation can be made inapplicable to the tribes participating in a demonstration project through either a provision in the legislation authorizing the project or amendment of the statute authorizing the program or programs in question. Third, based on consultation with the tribes, the tribes feel these programs address significant needs facing their communities. Fourth, most of these programs have well-established processes for arriving at tribal funding amounts, thereby avoiding the IHS and BIA difficulties in determining funding levels. Finally, consideration was given to the number of programs that were successfully managed under the BIA and IHS demonstrations. The number was small in each case, less than 10 programs. Using the BIA and IHS demonstrations as a proxy, it appears that a demonstration within that range of programs is feasible. The manageability of a larger demonstration, in terms of programs, is unknown and could impose more risk.
Impact on Programs and Beneficiaries
The Secretary is required to consider the probable effects of a demonstration on specific programs and program beneficiaries in determining the feasibility of a demonstration project. To determine probable effects, information was mined from a number of federally and privately sponsored studies and reports that examined the self-governance experience in the BIA and IHS and tribal management of non-IHS programs in HHS. These are summarized in the impact section of this report and a comprehensive list of the studies and reports that were consulted is provided at Appendix B.
While most of the existing studies focus on BIA and IHS self-governance programs, the studies are used as a proxy to assess the ability of tribes to manage programs, assure program quality and accountability, and serve beneficiaries under a self-governance demonstration for non-IHS programs. For the most part, the studies are qualitative, based on personal accounts of staff and clients of self-governance programs. No quantitative assessment of client outcomes, program quality or access to services under self-governance currently exists. One recommendation of this study is for Congress to require a comprehensive evaluation of a demonstration project as part of any legislation authorizing a demonstration.
Costs and Savings
The study requires an assessment of the probable costs and savings of the project. Again, much of the information for this assessment is derived from the BIA and IHS experience with self-governance. Costs and savings have been quantified to the extent that data is available. Some elements of costs and savings were not quantifiable due to lack of reliable data. The specific methodology used to arrive at a cost or savings projection is incorporated in the discussion of the cost or savings element.
Congress provided a significant role for stakeholder consultations in the development of the study findings. In light of this, stakeholders were consulted on key study issues such as what HHS programs should be included in a demonstration, the potential impact of a demonstration on beneficiaries, and the design of a demonstration. The consultation process included a variety of stakeholders such as tribes, state government organizations and program managers within HHS. The process was used not only to solicit opinions on particular issues of design and programs, but to try to reach a consensus, to the extent possible, on the recommendations that are in this report. Therefore, the consultation process and the opinions and recommendations of the stakeholders played a significant role in reaching the conclusions of the study.
Consultations were carried out jointly by a tribal advisory group and HHS staff. An initial consultation protocol (Appendix C) was jointly developed by HHS staff and the tribal advisory group. The protocol served as the basis for the consultation process. The leader of the tribal advisory group, Merle Boyd, and the HHS study leader, Dr. Delores Parron, served as joint chairpersons of the consultation process.
Initially, four regional tribal consultation meetings were held, followed by a consultation meeting with representatives of state and local government organizations. A meeting with non-governmental organizations representing health and human service professional associations and beneficiaries was also held. Finally, a national wrap-up session for all interested stakeholders was held in Washington, D.C. Written invitations to the tribal sessions were extended to more than 950 tribes and tribal organizations. Some 20 organizations representing state and local governments were invited to the state and local government session. Over 180 non- governmental organizations were invited to that session. All stakeholder organizations were invited to the national wrap-up session. Transcripts of each session are available at the study website (http://aspe.hhs.gov/SelfGovernance) and Appendix D provides additional information and details regarding each session. Written comments were also solicited from all stakeholder organizations at various stages of the study, including during initial consultations and on a formal draft of the report.
Throughout the study, a study website (see above) was maintained. It included background information on the study, information on meetings and meeting transcripts, as well as drafts of study issue papers. Stakeholders were provided the website address and were encouraged to regularly visit the site for up-to-date developments and information.