DHS
Organizational Structure and Resources for Providing Health Care to Immigration Detainees Gao ID: GAO-09-308R February 23, 2009Recent events have drawn attention to the health care provided to detainees held by U.S. Immigration and Customs Enforcement (ICE), a component of the Department of Homeland Security (DHS). For fiscal year 2004 through fiscal year 2007, ICE reported that 69 detainees died while in ICE custody, and during 2008, national news organizations investigated and published reports of the circumstances surrounding several detainee deaths. Other reports have also outlined concerns about the health care provided to detainees. For example, in 2007, the DHS Office of the Inspector General (OIG) found problems with adherence to ICE's medical standards at two ICE facilities it reviewed where detainee deaths had occurred. Additionally, members of Congress, the media, and advocacy groups have raised questions about the health care provided to detainees in ICE custody. An explanatory statement accompanying the fiscal year 2009 DHS appropriations act directed ICE to fund an independent, comprehensive review of the medical care provided to persons detained by DHS and identified $2 million for that purpose. ICE was created in March 2003 as part of DHS. From fiscal year 2003 through fiscal year 2007, the average daily population of detainees in ICE custody increased by about 40 percent, with the most growth occurring since fiscal year 2005. In fiscal year 2007, ICE held over 311,000 detainees at more than 500 detention facilities. Most of these were Intergovernmental Service Agreement (IGSA) facilities--state and local jails under contract with ICE to hold detainees. Some ICE detainees received health care services from IGSA staff, IGSA contractors, or community medical providers, and other ICE detainees received health care provided or arranged by the Division of Immigration Health Services (DIHS). DIHS is mainly comprised of contract employees and officers from the U.S. Public Health Service (PHS) Commissioned Corps--a uniformed service of public health professionals who are part of the Department of Health and Human Services (HHS) and who provide services in different settings, including ICE detention facilities. In light of questions about the health care provided to detainees in ICE custody, Congress requested information about ICE's organizational structure and its health care resources for detainees. This report provides (1) a description of ICE's organizational structure for providing health care services to detainees, which includes our review of the relevant agreements between DHS and HHS regarding DIHS; (2) information about ICE's annual spending and staffing resources devoted to the provision of health care for detainees, and the number of services provided; and (3) an assessment of whether ICE's mortality rate can be compared with the mortality rates of the Federal Bureau of Prisons (BOP) and the U.S. Marshals Service (USMS)--two entities that are responsible for holding certain persons, such as criminals.
ICE's organizational structure for providing health care to detainees is not uniform across facilities. In fiscal year 2007, 21 DIHS-staffed facilities provided or arranged for health care for about 53 percent of the average daily population of detainees, while 508 IGSA facilities provided or arranged for health care for the remaining detainees--about 47 percent of the population. In addition, recent agreements with HHS reassigned medical personnel to DHS. DHS officials told us that a total of 565 direct health care providers and administrative staff were affected by these agreements. Although ICE's health care data are not complete, the available data on health care spending, staffing, and services provided generally showed growth in all three areas. For instance, from fiscal year 2003 through fiscal year 2007, reported expenditures for medical claims and program operations increased by 47 percent, while the average daily population of detainees increased by about 40 percent. ICE's mortality rate cannot be directly compared with BOP's or USMS's mortality rate. This is due to differences in the three agencies' health care goals and scopes of services, as well as to demographic differences among the ICE, BOP, and USMS detainee populations.
GAO-09-308R, DHS: Organizational Structure and Resources for Providing Health Care to Immigration Detainees
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GAO-09-308R:
United States Government Accountability Office:
Washington, DC 20548:
February 23, 2009:
The Honorable Robert C. Byrd:
Chairman:
Subcommittee on Homeland Security:
Committee on Appropriations:
United States Senate:
The Honorable David Price:
Chairman:
Subcommittee on Homeland Security:
Committee on Appropriations:
House of Representatives:
Subject: DHS: Organizational Structure and Resources for Providing
Health Care to Immigration Detainees:
Recent events have drawn attention to the health care provided to
detainees held by U.S. Immigration and Customs Enforcement (ICE), a
component of the Department of Homeland Security (DHS).[Footnote 1] For
fiscal year 2004 through fiscal year 2007, ICE reported that 69
detainees died while in ICE custody, and during 2008, national news
organizations investigated and published reports of the circumstances
surrounding several detainee deaths. Other reports have also outlined
concerns about the health care provided to detainees. For example, in
2007, the DHS Office of the Inspector General (OIG) found problems with
adherence to ICE's medical standards at two ICE facilities it reviewed
where detainee deaths had occurred.[Footnote 2] Additionally, members
of Congress, the media, and advocacy groups have raised questions about
the health care provided to detainees in ICE custody. An explanatory
statement accompanying the fiscal year 2009 DHS appropriations act
directed ICE to fund an independent, comprehensive review of the
medical care provided to persons detained by DHS and identified $2
million for that purpose.[Footnote 3]
ICE was created in March 2003 as part of DHS.[Footnote 4] From fiscal
year 2003 through fiscal year 2007, the average daily population of
detainees in ICE custody increased by about 40 percent, with the most
growth occurring since fiscal year 2005.[Footnote 5] In fiscal year
2007, ICE held over 311,000 detainees at more than 500 detention
facilities. Most of these were Intergovernmental Service Agreement
(IGSA) facilities--state and local jails under contract with ICE to
hold detainees. Some ICE detainees received health care services from
IGSA staff, IGSA contractors, or community medical providers, and other
ICE detainees received health care provided or arranged by the Division
of Immigration Health Services (DIHS). DIHS is mainly comprised of
contract employees and officers from the U.S. Public Health Service
(PHS) Commissioned Corps--a uniformed service of public health
professionals who are part of the Department of Health and Human
Services (HHS) and who provide services in different settings,
including ICE detention facilities.
In light of questions about the health care provided to detainees in
ICE custody, you requested information about ICE's organizational
structure and its health care resources for detainees. This report
provides (1) a description of ICE's organizational structure for
providing health care services to detainees, which includes our review
of the relevant agreements between DHS and HHS regarding DIHS; (2)
information about ICE's annual spending and staffing resources devoted
to the provision of health care for detainees, and the number of
services provided; and (3) an assessment of whether ICE's mortality
rate can be compared with the mortality rates of the Federal Bureau of
Prisons (BOP) and the U.S. Marshals Service (USMS)--two entities that
are responsible for holding certain persons, such as criminals.
We took the following steps to develop our findings. To describe ICE's
organizational structure for providing health care services to
detainees, including interagency agreements, we reviewed pertinent
reports issued by government agencies and interagency agreements
regarding DIHS, and we also interviewed agency officials.[Footnote 6]
To determine the annual health care spending, staffing, and services
provided to ICE detainees, we examined ICE's fiscal year 2003 through
fiscal year 2007 data for these three areas. To determine whether ICE's
mortality rate could be directly compared with the mortality rate for
BOP or USMS, we examined ICE mortality data and information about the
health care goals, services, and populations for ICE, BOP, and USMS.
We assessed the data DHS provided and we worked with DHS to address
discrepancies. Subsequently, we determined that the data we used were
sufficiently reliable for our purposes. Throughout our work, we used
data on the average daily population--the number of beds ICE used for
detainees on an average day during a fiscal year--because ICE was not
able to provide reliable data on the number of unique individuals
detained per fiscal year. We conducted our work from July 2008 to
February 2009 in accordance with all sections of GAO's Quality
Assurance framework that are relevant to our objectives. The framework
requires that we plan and perform the engagement to obtain sufficient,
appropriate evidence to meet our stated objectives and to discuss any
limitations in our work. We believe that the information and data
obtained and the analysis conducted provide a reasonable basis for any
findings and conclusions.
On December 18, 2008, we briefed your staff on the results of this
work. The briefing slides, included as enclosure I, have been updated
to include more current information. This report formally conveys the
information presented during that briefing and officially transmits our
work to the Secretary of DHS and the Acting Secretary of HHS.
In summary, we reported the following findings:
* ICE's organizational structure for providing health care to detainees
is not uniform across facilities. In fiscal year 2007, 21 DIHS-staffed
facilities provided or arranged for health care for about 53 percent of
the average daily population of detainees, while 508 IGSA facilities
provided or arranged for health care for the remaining detainees--about
47 percent of the population. In addition, recent agreements with HHS
reassigned medical personnel to DHS. DHS officials told us that a total
of 565 direct health care providers and administrative staff were
affected by these agreements.
* Although ICE's health care data are not complete, the available data
on health care spending, staffing, and services provided generally
showed growth in all three areas. For instance, from fiscal year 2003
through fiscal year 2007, reported expenditures for medical claims and
program operations increased by 47 percent, while the average daily
population of detainees increased by about 40 percent.
* ICE's mortality rate cannot be directly compared with BOP's or USMS's
mortality rate. This is due to differences in the three agencies'
health care goals and scopes of services, as well as to demographic
differences among the ICE, BOP, and USMS detainee populations.
Based on our work, we have identified a number of issues that may merit
further assessment in the $2 million external study that ICE was
directed to fund. These are shown in enclosure I and relate to data
availability and some aspects of program oversight.
Agency Comments and Our Evaluation:
We provided HHS and DHS with drafts of this report for their review and
comment. HHS had no general comments but made a technical comment,
which we addressed. DHS provided written comments (reprinted in
enclosure II) and technical comments that we incorporated as
appropriate.
DHS disagreed with the way we presented some of the information in our
briefing report. First, the agency pointed out that we did not clearly
differentiate between the HHS entity named DIHS and the identically-
named ICE program, and that our report could lead to the incorrect
conclusion that the HHS entity or its public health personnel were
transferred to ICE. Noting that DIHS was not transferred from HHS, DHS
explained that ICE established its own organization that it also named
DIHS, to preclude confusion among field offices. In our report, we
state that, prior to October 1, 2007, DIHS was a component of HHS's
Health Resources and Services Administration (HRSA). As we also state
in our work, DHS officials told us that ICE now has a component known
as DIHS that provides health care services to detainees. We did not
determine whether DIHS was transferred from HHS to DHS. Although DHS
was unable to provide an official organizational chart that shows the
placement of DIHS, we understand that the two DIHS entities shared the
same name, and that the entity bearing that name now exists only in
DHS's ICE.
Second, DHS stated that we erroneously asserted that health care
providers within what DHS referred to as HHS's DIHS report to ICE's
Office of Detention and Removal Operations. The agency stated that ICE
does not impinge on the autonomy of HHS's health care professionals who
provide services to detainees. As our work indicates, HHS informed us
that its DIHS ceased to exist as a component of HHS as of October 1,
2007. However, PHS officers are detailed to ICE's DIHS under the
Memorandum of Agreement between HHS and DHS. DHS officials previously
informed us that DHS does exercise some control over DIHS general
policy development as well as other administrative matters. We also
clearly stated in our work, however, that DHS officials told us that
their agency does not have supervisory control over clinical decisions
made by DIHS personnel.
Third, DHS wrote that we erroneously implied that ICE lacks basic
information about the cost of health care services provided to
detainees held at IGSAs. The agency noted that the cost for basic
health care services provided to detainees is built into the per diem
payment IGSAs receive. Although the estimated cost of basic services is
covered under the per diem rate for housing detainees, DHS officials
cautioned us during the course of our work that such payment does not
represent actual expenses incurred. Therefore, IGSA expenditures for
providing basic health care cannot be separately identified under the
current payment method. As a result, ICE may not have the information
needed to determine whether the IGSA per diem rate is adequate or
excessive for the delivery of basic health care services.
Fourth, DHS commented that ICE uses the Treatment Authorization Request
(TAR) system as a tool for authorizing payment for services provided to
ICE detainees and that the TAR can identify health-related procedures
and visits. This seems to imply that the TAR routinely provides ICE
with additional cost information. However, the description of the TAR
system shown in the agency's "DIHS Medical Dental Detainee Covered
Services Package,"[Footnote 7] as well as our interviews with senior
ICE program staff, do not support this position. Rather, the TAR system
is used to obtain approval that authorizes payment for off-site,
nonroutine health care services. As such, it is not designed to track
health care spending and is not used to routinely report information on
health care expenditures by facility type.
Finally, DHS commented that we did not provide context on ICE's
transfer practices. The agency noted that its operational needs for
transferring detainees can relate to access to medical treatment,
access to the courts, or efficiently completing their removal. We
recognize that ICE transfer practices can have an impact on the health
care provided to detainees--such as the need to rescreen a detainee
after a transfer or the need to ensure that a transferred detainee's
medical information can be accessed by the new facility. However,
determining the appropriateness of ICE transfer policy or the rationale
behind transfer decisions was beyond the scope of our work. The DHS OIG
is currently conducting work on ICE transfers, which may help to inform
the issues DHS noted.
As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report for 30 days. At
that time, we will send copies of this report to the Secretary of DHS
and the Acting Secretary of HHS. In addition, the report is available
at no charge on the GAO Web site at [hyperlink, http://www.gao.gov].
If you or your staff have any questions or need additional information,
please contact me at (202) 512-7114, or CackleyA@gao.gov. Contact
points for our Offices of Congressional Relations and Public Affairs
may be found on the last page of this report. Major contributors to
this report were Rosamond Katz, Assistant Director; Eleanor M.
Cambridge; Joy L. Kraybill; Drew Long; Kevin Milne; and Katherine
Wunderink.
Signed by:
Alicia Puente Cackley:
Director, Health Care:
Enclosures--2:
[End of section]
Enclosure I: Slide Presentation:
DHS: Organizational Structure and Resources for Providing Health Care
to Immigration Detainees:
Briefing for the staffs of:
The Honorable Robert C. Byrd:
Chairman, Subcommittee on Homeland Security:
Committee on Appropriations, United States Senate:
The Honorable David Price:
Chairman, Subcommittee on Homeland Security:
Committee on Appropriations, House of Representatives:
Updated:
Overview:
* Introduction;
* Objectives;
* Scope and Methodology;
* Background;
* Results;
* Issues for Further Assessment;
* Appendix I.
Introduction:
In fiscal year (FY) 2007, the Department of Homeland Security‘s (DHS)
U.S. Immigration and Customs Enforcement (ICE) detained over 311,000
individuals at more than 500 detention facilities.[Footnote 8] We refer
to these individuals as ’detainees.“[Footnote 9]
Questions have been raised by members of Congress, the media, and
advocacy groups about the health care provided to detainees in ICE
custody. From FY 2004 through FY 2007, ICE reported that 69 detainees
had died in ICE custody.
An explanatory statement accompanying the FY 2009 DHS appropriations act
directed ICE to fund an independent study on the health care services
ICE provides to detainees and identified $2 million for this purpose.
Multiple federal entities have some responsibility for providing
housing or health care services to people in detention.
* DHS is the agency charged with the security of the country. Within
DHS, ICE holds and removes certain detainees from the U.S.”including
those held for immigration violations.
* The Department of Health and Human Services (HHS) is the principal
agency tasked with protecting the health of Americans. The U.S. Public
Health Service (PHS) Commissioned Corps, within HHS, is a uniformed
service of public health professionals that provide services in
different settings, including detention facilities.
* The Division of Immigration Health Services (DIHS) is an entity that
provides health care services to detainees held in ICE custody.
* The Federal Bureau of Prisons (BOP) is an entity within the
Department of Justice (DOJ) that holds inmates serving sentences for
criminal offenses and provides essential medical care while inmates are
in the agency‘s custody.
* The U.S. Marshals Service (USMS) is a DOJ entity that holds certain
detainees”such as federal fugitives and some criminals.
Objectives:
We were requested to examine issues pertaining to the provision of
health care to detainees. In this briefing, we:
1. describe ICE‘s organizational structure for providing health care
services to detainees, including a review of the relevant agreements
between DHS and HHS regarding DIHS,
2. determine the annual health care spending, staffing, and services
provided to ICE detainees, and,
3. determine whether ICE‘s mortality rate can be compared with BOP‘s or
USMS‘s mortality rate.
Scope and Methodology[Footnote 10]:
We reviewed pertinent reports issued by GAO, the DHS Office of the
Inspector General, and the Congressional Research Service. These
reports pertained to ICE‘s organizational structure and the health care
services provided to ICE detainees.
We reviewed agreements in place between DHS and HHS regarding DIHS.
We interviewed officials from DHS, ICE, DIHS, HHS, BOP, and USMS.
We examined data on ICE‘s FY 2003 through FY 2007 health care
expenditures, staffing, and services provided. We also examined
mortality data for ICE detainees and information about the health care
goals, services, and populations for ICE, BOP, and USMS.[Footnote 11]
We assessed the data DHS provided and we worked with DHS to address
discrepancies. Subsequently, we determined that the data were
sufficiently reliable for our purposes.
Background:
Reported average daily population of detainees in ICE custody, FY
2003–FY 2007:
The average daily population of detainees in ICE custody increased by
about 40 percent from FY 2003 through FY 2007, with the most growth
occurring since FY 2005.
The average daily population of detainees is the most reliable and
readily available population measure DHS was able to provide. It
indicates the number of detainee beds ICE used on an average day during
a fiscal year. ICE computes the average daily population by dividing
the annual number of bed days used by 365.
Figure: Average daily population:
[Refer to PDF for image: line graph]
Fiscal year: 2003;
Detainee population: 19,087.
Fiscal year: 2004;
Detainee population: 19,638.
Fiscal year: 2005;
Detainee population: 17,535.
Fiscal year: 2006;
Detainee population: 19,405.
Fiscal year: 2007;
Detainee population: 26,934.
Source: GAO analysis of DHS data.
[End of figure]
Figure: Gender and age of ICE‘s reported average daily population, FY
2007:
[Refer to PDF for image: 2 pie-charts]
Gender:
Male: 88%;
Female: 12%.
Age:
0-10: 5%;
19-35: 61%;
36-50: 28%;
51 and up: 6%.
Source: GAO analysis of DHS data on total average daily population.
[End of figure]
Number and type of detention facilities used by ICE, FY 2007:
Most ICE detainees are housed in three types of detention facilities:
* Service Processing Centers (SPC): 8 federal facilities operated by
ICE to hold detainees;
* Contract Detention Facilities (CDF): 7 facilities operated by private
contractors specifically to hold detainees;
* Intergovernmental Service Agreement (IGSA) facilities: 514 state and
local jails under contract with ICE to hold detainees[Footnote 12]
Figure: Number and type of detention facilities used by ICE, FY 2007:
[Refer to PDF for image: pie-chart]
IGSA: 514;
SPC: 8;
CDF: 7.
Source: DHS.
[End of figure]
ICE‘s reported average daily population by facility type, FY 2003–FY
2007:
IGSAs house the majority of the detainee population. In FY 2007, almost
65 percent of the average daily population was housed at an IGSA.
From FY 2003 through FY 2007, the average daily population at IGSAs
grew by about 31 percent.
Figure: ICE‘s reported average daily population by facility type, FY
2003–FY 2007:
[Refer to PDF for image: vertical bar graph]
Fiscal year: 2003;
SPC: 3,644;
CDF: 2,116;
IGSA: 13,327.
Fiscal year: 2004;
SPC: 3,585;
CDF: 2,305;
IGSA: 13,748.
Fiscal year: 2005;
SPC: 3,425;
CDF: 2,933;
IGSA: 11,177.
Fiscal year: 2006;
SPC: 3,413;
CDF: 4,381;
IGSA: 11,611.
Fiscal year: 2007;
SPC: 4,143;
CDF: 5,293;
IGSA: 17,498.
Source: DHS.
[End of figure]
Reported length of stay in ICE custody, FY 2003–FY 2007:
From FY 2003 through FY 2007, the median length of stay for detainees
increased from 12 days to 18 days.
At ICE‘s discretion, detainees can be transferred between facilities,
sometimes more than once. The agency estimated that the average
detainee is booked into about 2 facilities while in ICE custody.
Figure: Reported length of stay in ICE custody, FY 2003–FY 2007:
[Refer to PDF for image: vertical bar graph]
Fiscal year: 2003;
Length of stay: 12 days.
Fiscal year: 2004;
Length of stay: 12 days.
Fiscal year: 2005;
Length of stay: 14 days.
Fiscal year: 2006;
Length of stay: 14 days.
Fiscal year: 2007;
Length of stay: 18 days.
Source: DHS data on total average daily population.
[End of figure]
ICE detention standards and medical care standards:
ICE developed detention standards designed to ensure facilities provide
services that will protect detainees‘ lives and dignity. These
detention standards are comprised of 41 standards that pertain to
specific areas”such as medical care, food service, and environmental
safety.
ICE‘s medical care detention standards aim to ensure ’that detainees
have access to emergent, urgent, or non-emergent medical, dental, and
mental health care that are within the scope of services provided by
the DIHS, so that their health care needs are met in a timely and
efficient manner.“[Footnote 13]
ICE medical care standards:
ICE medical care standards include:
* an intake screening, including a tuberculosis screening, is to be
performed for each detainee within 12 hours of their arrival at a new
facility.
* a physical examination is to be performed for each detainee within 14
days of arrival at a different facility. If a physical has been
performed for the detainee within the last 90 days, a health care
provider may determine that a new physical examination is not
necessary.
* when a facility is unable to provide certain need-based medical care,
detainees can receive care from community medical providers.
* if a detainee is transferred to another facility, the transferring
facility must compose a ’transfer summary“ that includes the detainee‘s
medical issues, any treatment provided by the facility, tuberculosis
screening results, and at a minimum, a 7-day supply of any needed
prescription medications.
Results:
1. ICE‘s organizational structure for providing health care to
detainees is not uniform across facilities; recent agreements with HHS
reassigned medical personnel to DHS.
2. Although ICE‘s health care data are not complete, available data on
health care spending, staffing, and services provided generally showed
growth in all three areas.
3. ICE‘s mortality rate cannot be directly compared with BOP‘s or
USMS‘s mortality rate due to differences in the agencies‘ health care
goals, scopes of services, and population demographics.
1: ICE‘s organizational structure for providing health care to
detainees is not uniform across facilities; recent agreements with HHS
reassigned medical personnel to DHS:
ICE uses DIHS staff to provide or arrange for health care for some
detainees, and uses IGSA staff to provide or arrange for health care
for other detainees.
* In FY 2007, DIHS staff provided care to detainees at 21
facilities”including 8 SPCs, 7 CDFs, and 6 IGSAs.[Footnote 14] In some
instances, this care can be supplemented by services from community
medical providers.
* In FY 2007, at the approximately 508 remaining IGSA facilities,
detainee health care was provided or arranged for by the respective
IGSA. DHS officials indicated that each IGSA may determine whether
health care services for detainees will be provided by IGSA staff,
contractors, or community medical providers.
1: ICE‘s organization: DIHS providers differ from IGSA providers:
DIHS staff include PHS officers, contract employees, and civil
servants. In FY 2007, about 46 percent of DIHS staff were PHS officers
detailed to DHS, about 52 percent were contract employees, and about 2
percent were civil servants.[Footnote 15]
IGSA staff may include on-site clinicians, employed by a county public
health service or under contract with the facility itself. Some IGSAs
have no health care staff on-site and rely solely on community medical
providers to deliver care.
1: ICE‘s organization: DIHS provided or arranged for health care for
about half of the detainee population in FY 2007:
In FY 2007, DIHS-staffed facilities provided or arranged for health
care for about 53 percent of the average daily population of detainees.
The proportion of the average daily population served by DIHS-staffed
facilities grew from about 35 percent in FY 2003 to about 53 percent in
FY 2007.
In FY 2007, the remaining 508 IGSA facilities provided or arranged for
health care for about 47 percent of the average daily population of
detainees.
1: ICE‘s organization: In 2007 DIHS was removed from HHS‘s
organizational chart; DIHS now reports to an ICE component:
Before October 1, 2007, DHS and HHS maintained annual interagency
agreements through which DIHS provided detainee health care services
for ICE. DIHS was a component of HHS‘s Health Resources and Services
Administration (HRSA).
The last interagency agreement was terminated as of October 1, 2007,
and DIHS is no longer a component of HRSA. According to DHS officials,
ICE has a component known as DIHS which provides health care services
to detainees in support of ICE's overall mission.
Some of the civilian staff formerly employed at HRSA‘s DIHS became
employees of DHS during 2007.
A 2007 Memorandum of Agreement between DHS and HHS placed PHS officers
on detail to DHS on an open-ended basis, and allowed for additional PHS
officers to be detailed in the future.
DHS officials said that the termination of the interagency agreement
and the development of the Memorandum of Agreement affected 565 direct
health care providers and administrative staff”253 PHS officers, 301
contract employees, and 11 civil servants.
1: ICE‘s organization: DIHS reports to DHS on administrative matters:
DHS officials stated that the agency has some supervisory
responsibilities over the movement and assignment of DIHS staff, as
well as general DIHS policy development. According to DHS officials,
DHS does not have supervisory responsibility over DIHS‘s clinical
decision making.
DHS officials indicated that DIHS reports to the Detention Management
Division, which is located in ICE‘s Office of Detention and Removal
Operations.
DHS officials could not provide an official organizational chart to
show DIHS‘s placement in DHS.
1: ICE‘s organization: Facilities do not use standardized record
keeping or reporting to monitor health care services provided to
detainees:
DIHS officials told us that they collect data on the health care
services provided at the DIHS-staffed facilities.
* At the 21 facilities that DIHS staffed in FY 2007, 9 recorded
information electronically and 12 used paper records.
* DIHS compiles a monthly report that incorporates data from the
facilities it staffs, but officials told us that DIHS is not required
to report data to DHS routinely.
DHS officials confirmed that ICE does not routinely collect data on the
health care services provided at the IGSAs that are not staffed by
DIHS.
* Officials stated that they do not know whether these IGSAs record
health care information electronically or on paper.
* Officials can obtain data from these IGSAs, but they need to request
paper copies of individual detainee health records to compile any
needed data, because IGSAs are not required to report data to DHS
routinely.
1: ICE‘s organization: Facilities are responsible for transferring
detainee medical information when detainees are transferred:
According to DHS officials, in FY 2007, ICE conducted about 261,000
transfers of detainees among facilities.
DHS officials confirmed that ICE does not have a uniform method for
routinely monitoring facilities‘ completion of medical transfer
summaries at the time detainees are transferred, as required by ICE
detention standards.
2: Although ICE‘s health care data are not complete, available data on
health care spending, staffing, and services provided generally showed
growth in all three areas:
Complete ICE health care expenditure data fall into three categories:
* Program operations:
- salaries for DIHS staff”including PHS officers;
- transportation costs for DIHS staff;
- rent and information technology systems;
* Medical claims:
- medical claims submitted by community medical providers;
- pharmacy expenses, dental expenses, psychological care;
* Health care component of IGSA contract costs:
- any salaries for IGSA health care staff or costs for the health care
services they provide”both of which are paid to IGSAs as part of their
contract payments for housing detainees.
Data are not available on IGSA‘s health care costs, but data are
available for program operations and medical claims.
2: Health care spending, staffing, and services: ICE‘s health care
expenditure data only permit high-level analysis:
DHS officials confirmed that no itemized medical claims exist for
health care services provided by DIHS staff. These costs are paid
through DIHS staff salaries, which are included in program operations
expenditure data.
DHS officials confirmed that no data are available on the cost of
health care services provided by IGSA staff. Payments for these items
are included as part of the contracts IGSAs have with ICE. DHS
officials confirmed that IGSA contract payments reimburse each IGSA‘s
overall costs for housing detainees”precise costs cannot be identified.
2: Health care spending, staffing, and services: ICE‘s reported program
operations and medical claims expenditures for detainees increased by
47 percent and average daily population increased by about 40 percent,
FY 2003–FY 2007:
Figure: Health care spending, staffing, and services:
[Refer to PDF for image: combined vertical bar and line graph]
Fiscal year: 2003-2004 average;
Reported program operations and medical claims expenditures: $62.2
million;
Average daily population: 19,363.
Fiscal year: 2005;
Reported program operations and medical claims expenditures: $61
million;
Average daily population: 17,535.
Fiscal year: 2006;
Reported program operations and medical claims expenditures: $73.6
million;
Average daily population: 19,405.
Fiscal year: 2007;
Reported program operations and medical claims expenditures: $91.6
million;
Average daily population: 26,934.
Note: Reported health care expenditures represent program operations and
medical claims expenditures. These data exclude the value of services
provided by IGSA staff and the value of any IGSA staff salaries”both of
which are included in IGSAs‘ contract rates. FY 2003 and FY 2004 data
were averaged to address a delay in medical claims payments that
occurred when DHS changed its claims processing contractor.
Source: GAO analysis of DHS data.
[End of figure]
2: Health care spending, staffing, and services: Reported program
operations expenditures for DIHS increased, FY 2003–FY 2007:
From FY 2003 through FY 2007, spending for DIHS staff salaries and
other program operations expenditures more than doubled.
ICE officials primarily attributed this increase in spending to growth
in the number of DIHS staff to support ICE detention operations.
Figure: Health care spending, staffing, and services:
[Refer to PDF for image: vertical bar graph]
Fiscal year: 2003
Program operations expenditures for DIHS: $30.07 million.
Fiscal year: 2004
Program operations expenditures for DIHS: $33.85 million.
Fiscal year: 2005
Program operations expenditures for DIHS: $39.78 million.
Fiscal year: 2006
Program operations expenditures for DIHS: $43.31 million.
Fiscal year: 2007
Program operations expenditures for DIHS: $60.9 million.
Note: Program operations expenditures include DIHS salaries,
transportation, and related costs. These data exclude the value of
IGSA staff salaries, transportation, and any other IGSA costs.
Source: DHS.
[End of figure]
2: Health care spending, staffing, and services: Reported medical
claims expenditures showed moderate fluctuation, FY 2003–FY 2007:
Medical claims expenditures ranged between $21.2 million and $30.7
million per year from FY 2003 through FY 2007.
Claims for health care services provided by community medical providers
are submitted to ICE‘s claims processing contractor, and these costs
are included in the medical claims expenditure data. Care from
community medical providers may supplement services provided by any of
the IGSAs or by the 21 DIHS-staffed facilities.
Figure: Health care spending, staffing, and services: Reported medical
claims expenditures showed moderate fluctuation, FY 2003–FY 2007:
[Refer to PDF for image: vertical bar graph]
Fiscal year: 2003-2004 average;
Medical claims expenditures: $30.2 million.
Fiscal year: 2005
Medical claims expenditures: $21.2 million.
Fiscal year: 2006
Medical claims expenditures: $30.3 million.
Fiscal year: 2007
Medical claims expenditures: $30.7 million.
Notes: Medical claims expenditures include claims from community
medical providers. DIHS providers do not submit claims. Reimbursement
for IGSA staff providers‘ services is paid through the IGSAs‘ contract
rates. FY 2003 and FY 2004 data were averaged to address a delay in
medical claims payments that occurred when DHS changed its claims
processing contractor.
Source: GAO analysis of DHS data.
[End of figure]
2: Health care spending, staffing, and services: DIHS staff increased,
FY 2003–FY 2007:
From FY 2003 through FY 2007, the number of DIHS direct health care
providers more than doubled”growing from 208 to 460 full-time
equivalent staff (FTE).
The number of DIHS administrative FTEs nearly doubled, from 57 in FY
2003 to 105 in FY 2007. In FY 2007, each administrative staff person
supported roughly 4.4 direct health care providers.
DIHS officials told us that they intend to increase their total staff to
900 FTEs by FY 2010.
Figure: Health care spending, staffing, and services: DIHS staff
increased, FY 2003–FY 2007:
[Refer to PDF for image: stacked vertical bar graph]
Fiscal year: 2003
DIHS FTEs, Direct health care providers: 208;
DIHS FTEs, Administrative staff: 57.
Fiscal year: 2004
DIHS FTEs, Direct health care providers: 254;
DIHS FTEs, Administrative staff: 59.
Fiscal year: 2005
DIHS FTEs, Direct health care providers: 278;
DIHS FTEs, Administrative staff: 65.
Fiscal year: 2006
DIHS FTEs, Direct health care providers: 398;
DIHS FTEs, Administrative staff: 68.
Fiscal year: 2007
DIHS FTEs, Direct health care providers: 460;
DIHS FTEs, Administrative staff: 105.
Note: These FTE data reflect staff at DIHS-staffed facilities, and do
not include any staff at approximately 508 IGSAs.
Source: DHS.
[End of table]
2: Health care spending, staffing, and services: Total reported number
of health care services DIHS provided to detainees increased, FY
2003–FY 2007:
The total number of health care services provided by DIHS more than
doubled from FY 2003 through FY 2007.
These data do not include health care services provided at approximately
508 IGSAs, because ICE does not routinely collect data on services
provided at the facilities DIHS does not staff.
Figure: Health care spending, staffing, and services: Total reported
number of health care services DIHS provided to detainees increased, FY
2003–FY 2007:
[Refer to PDF for image: combined vertical bar and line graph]
Fiscal year: 2003
Services provided by DIHS staff: 551,356;
Average daily population at DIHS-staffed facilities: 6,718.
Fiscal year: 2004
Services provided by DIHS staff: 718,834;
Average daily population at DIHS-staffed facilities: 6,955.
Fiscal year: 2005
Services provided by DIHS staff: 823,459;
Average daily population at DIHS-staffed facilities: 7,370.
Fiscal year: 2006
Services provided by DIHS staff: 787,010;
Average daily population at DIHS-staffed facilities: 9,140.
Fiscal year: 2007
Services provided by DIHS staff: 1,388,848;
Average daily population at DIHS-staffed facilities: 14,147.
Note: These data reflect services provided at DIHS-staffed facilities
and the average daily population at DIHS-staffed facilities. A ’health
care service“ represents one encounter with a medical official or
specially-trained detention officer.
Source: GAO analysis of DHS data.
[End of figure]
Figure: 2: Health care spending, staffing, and services: DIHS reported
increasing numbers of mandatory services, FY 2003–FY 2007:
[Refer to PDF for image: combined vertical bar and line graph]
Fiscal year: 2003;
Intake screenings, mandatory: 69,536;
Physical exams, mandatory within 14 days: 31,534;
Average daily population at DIHS-staffed facilities: 6,718.
Fiscal year: 2004;
Intake screenings, mandatory: 82,162;
Physical exams, mandatory within 14 days: 29,642;
Average daily population at DIHS-staffed facilities: 6,955.
Fiscal year: 2005;
Intake screenings, mandatory: 95,456;
Physical exams, mandatory within 14 days: 41,699;
Average daily population at DIHS-staffed facilities: 7,370.
Fiscal year: 2006;
Intake screenings, mandatory: 114,646;
Physical exams, mandatory within 14 days: 54,485;
Average daily population at DIHS-staffed facilities: 9,140.
Fiscal year: 2007;
Intake screenings, mandatory: 184,448;
Physical exams, mandatory within 14 days: 87,017;
Average daily population at DIHS-staffed facilities: 14,147.
Notes: These data reflect mandatory services provided at DIHS-staffed
facilities and the average daily population at DIHS-staffed facilities.
ICE medical care standards require that a physical exam should be
performed each time a detainee is transferred to a new facility. If a
physical has been performed for the detainee within the last 90 days, a
health care provider may determine that a new physical examination is
not necessary. If a detainee is transferred out of a facility within 14
days of arrival, the detainee may not receive a physical exam.
Source: GAO analysis of DHS data.
[End of figure]
Figure: 2: Health care spending, staffing, and services Reported number
of need-based health care services provided by DIHS increased 148
percent, FY 2003–FY 2007:
[Refer to PDF for image: vertical bar graph]
Fiscal year: 2003;
Need-based health care services provided at DIHS-staffed facilities:
450,286.
Fiscal year: 2004;
Need-based health care services provided at DIHS-staffed facilities:
607,030.
Fiscal year: 2005;
Need-based health care services provided at DIHS-staffed facilities:
686,304.
Fiscal year: 2006;
Need-based health care services provided at DIHS-staffed facilities:
617,879.
Fiscal year: 2007;
Need-based health care services provided at DIHS-staffed facilities:
1,117,383.
Notes: These data reflect services provided at DIHS-staffed facilities
only. Need-based health care includes any services provided beyond
mandatory intake screenings and physical exams. The specific types of
need-based services that DIHS provides are shown in appendix I.
Source: GAO analysis of DHS data.
[End of figure]
3: ICE‘s mortality rate cannot be directly compared with BOP‘s or
USMS‘s mortality rate due to differences in the agencies‘ health care
goals, scopes of services, and population demographics:
The agencies‘ health care goals and the health care services each
agency provides to their detainees differ. Also, lengths of stay and
demographic data vary among ICE, BOP, and USMS detainee populations.
Because of these differences, direct, meaningful comparisons between
the three agencies‘ mortality rates cannot be made.
3: Agency comparisons: Average lengths of stay, health care goals, and
health care services of ICE, BOP, and USMS differ:
Table:
Average length of stay:
ICE: FY 2007 reported average length of stay: 37.1 days;
BOP: Average sentence length as of July 1, 2007: 10.3 years;
USMS: Not recorded.
Health care goals:
ICE: Access to health care within ICE‘s scope of service;
BOP: Health maintenance throughout imprisonment;
USMS: No health care goal.
Health care services provided:
ICE: Medically necessary, including some chronic and some preventive;
BOP: Medically necessary, including chronic and preventive;
USMS: Medically necessary, including some chronic.
Source: DHS, BOP, and USMS.
[End of table]
3: Agency comparisons: Mortality rates for ICE, BOP, and USMS cannot be
compared:
Limited availability of ICE data prevents meaningful mortality
analyses.
According to DHS officials, some relevant information is unknown”such as
detainees‘ comprehensive health histories.
Some relevant information within each detainee‘s file is not
consistently recorded in standardized medical terms”such as detainees‘
causes of death.
Differences among the ICE, BOP, and USMS populations prevent meaningful
mortality comparisons.
The three populations exhibit different lengths of stay, average age,
and other demographic information that would be needed to reliably
compare the respective mortality rates.
The number of deaths in custody from FY 2004 through FY 2007 is low
relative to the overall average daily population for the same time
period.
Issues for Further Assessment:
The following issues may merit further assessment in the $2 million
external study that ICE was directed to fund:
* ICE‘s ability to access detainee population data that measure unique
individuals in ICE custody, rather than the average number of beds
used;
* Reporting relationships between DIHS and ICE;
* IGSA reporting requirements”including the frequency of reporting on
health care services provided to detainees, and the format in which
health records are maintained;
* ICE‘s ability to routinely ensure the transfer of medical records when
detainees are transferred between facilities;
* ICE‘s ability to identify and report the detainee health care costs
incurred by IGSAs;
* ICE‘s ability to identify and report medical claims expenditures by
facility type”such as for all IGSAs.
Appendix I: DIHS health care services included in our analysis:
Mandatory services:
* Intake screenings;
* Physical exams.
Need-based care service categories:
* Sick call visits”scheduled visits for non-emergency health care
requests;
* Urgent care visits”unscheduled visits for detainees who require a
medical response;
* Dental health visits;
* Mental health visits;
* Chronic disease visits;
* Short stay unit visits”observation unit stays for detainees who have
been determined to require close monitoring, but do not require a
hospital stay;
* Pill line distributions”single distributions of prescription or over-
the-counter medications.
[End of enclosure]
Enclosure II: Comments from the Department of Homeland Security:
U.S. Department of Homeland Security:
Washington, DC 20528:
[hyperlink, http://www.dhs.gov]
February 11, 2009:
Ms. Alicia Puente Cackley:
Acting Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Cackley:
RE: Draft Report GAO-09-308R, DHS: Organizational Structure and
Resources for Providing Health Care to Immigration Detainees (GAO Job
Codes 290755 and 290727):
The Department of Homeland Security (DHS) appreciates the opportunity
to review and comment on the presentation slides that were used in the
U.S. Government Accountability Office's (GAO's) briefing of
Congressional staff members and the GAO draft report based on those
slides. The draft report and updated briefing slides included as an
enclosure have no recommendations.
GAO's draft report presented information about three topics: (1) an
assessment of whether the mortality rates of detainees held in U.S.
Immigration and Customs Enforcement (ICE) custody can be compared with
the mortality rates of prisoners held by the U.S. Marshals Service or
incarcerated with the Federal Bureau of Prisons; (2) information about
ICE's annual spending and staff resources devoted to providing health
care for detainees, and the number of services provided; and (3) the
ICE organizational structure for providing health care to detainees
[Footnote 16]
GAO found that "the number of deaths in [ICE] custody from FY 2004
through FY 2007 is low relative to the overall average daily [detainee]
population for the same time period." GAO also found that ICE
substantially increased its funding and staffing for detainee health
care in the FY 2003 - FY 2007 period examined. Indeed, GAO likely
underreported ICS's actual spending on detainee health since "no data
[is] available on the cost of health care services provided by IGSA
[intergovernmental service agreement] staff"[Footnote 17] These
findings are notable, given that many detainees have received no or
minimal health care in their lives prior to the initial medical
screening the detainee receives in ICE custody.
ICE provided GAO significant documentary evidence and testimonial
information about its organizational structure for providing health
care to detainees but believes the GAO presentation needs further
clarification.
The GAO draft report and slides pertaining to DIHS do not clearly
differentiate between the HHS entity with that name and the similarly-
named ICE program. For example, GAO's assertion that "according to DHS
officials, DIHS is now located within ICE" could lead to the incorrect
conclusion that the HHS entity or its public health personnel were
transferred to ICE, which has not occurred. Instead, ICE established
its own organization, that it also named DINS, to preclude confusion in
the field. While this helps field personnel, it is understandable that
GAO could misunderstand.
This confusion between the HHS and ICE entities bearing the same name
is further reflected in GAO's erroneous assertion that the professional
health providers within the HHS DIHS "report" to ICE's Office of
Detention and Removal Operations (DRO). The implications of this
confusion are profound, so it is important to state that ICE does not
impinge on the professional autonomy of the health care providers
providing services to detainees, and any contrary impression is
inaccurate. The providers remain HHS employees.
Other information in the GAO briefing slides would also benefit from
additional context, and ICE representatives welcome the opportunity to
provide further clarification to members of Congress and their staffs
at the upcoming hearing on detainee health care by the House
Appropriations Committee, Subcommittee on Homeland Security that is
currently scheduled for March 3, 2009.
For example, the GAO updated briefing slides imply that ICE lacks basic
information about the cost of health care services provided to
detainees housed at IGSA contract facilities. However, a cost for basic
health care services is built into the daily rate of reimbursement for
IGSAs, and a standard model is applied as it pertains to population
volume. In addition, ICE uses the Treatment Authorization Request (TAR)
system as a tool for authorizing payment for services provided to ICE
detainees. TAR can identify health-related medical procedures,
consultations, off-site specialist visits, hospitalizations and
emergency room visits. The TAR captures services detainees need beyond
routine medical care. This information can be obtained for both DIHS
staffed facilities and IGSAs.
Similarly, GAO reports that "the average detainee is booked into about
2 facilities while in ICE custody," but provides no context about ICE's
operational needs in any given decision to transfer a detainee,
including the efficient carrying out of a removal, affording the
detainee access to the courts, or even providing access to medical
treatment.
Technical comments have been provided under separate cover.
Sincerely,
Signed by:
Jerald E. Levine:
Director:
Departmental GAO/OIG Liaison Office:
[End of enclosure]
Footnotes:
[1] Under the Immigration and Nationality Act, ICE is authorized to
arrest, detain, and remove certain individuals from the United States.
8 U.S.C. §§ 1226, 1227, 1229, 1229a, 1231, and 1357. We refer to these
individuals as "detainees."
[2] Department of Homeland Security, Office of the Inspector General,
ICE Policies Related to Detainee Deaths and the Oversight of
Immigration Detention Facilities (Washington, D.C.: June 2008).
[3] See Comm. Print of the Comm. on Approp., U.S. House of Rep.,
Explanatory Statement related to the Consolidated Security, Disaster
Assistance, and Continuing Appropriations Act, 2009, Pub. L. No. 110-
329, Div. D., p. 636 (Oct. 2008). Section 4 of Pub. L. No. 110-329
provides that the Explanatory Statement shall have the same effect with
respect to the allocation of funds and the implementation of the act as
if it were a joint explanatory statement of a committee of conference.
[4] Responsibility for detainees was transferred from the Department of
Justice's Immigration and Naturalization Service (INS) to DHS's ICE.
[5] The scope of our work was primarily limited to detainees who were
in ICE custody due to immigration violations and who were held at
facilities that serve adults. Some of these facilities are owned and
operated by ICE, some operate under contracts with ICE, and some
operate through service agreements with ICE. We did not include
detainees held by the Bureau of Prisons (BOP) for committing a criminal
offense.
[6] The government reports we reviewed were issued by GAO, the DHS OIG,
and the Congressional Research Service. We interviewed agency officials
from DHS, ICE, HHS, DIHS, BOP, and USMS.
[7] Division of Immigration Health Services, DIHS Medical Dental
Detainee Covered Services Package, [hyperlink,
http://www.icehealth.org/managedcare/providers.shtm] (accessed Feb. 13,
2009).
[8] ICE was created in March 2003 as part of DHS. Responsibility for
detainees was transferred from the Department of Justice‘s
Immigration and Naturalization Service (INS) to DHS‘s ICE. Under the
Immigration and Nationality Act, ICE is authorized to arrest,
detain, and remove certain individuals from the United States. 8 U.S.C.
§§ 1226, 1227, 1229, 1229a, 1231, and 1357.
[9] The scope of our work was primarily limited to detainees who were
in ICE custody due to immigration violations and who were housed
at facilities that serve adults. Some of these facilities are owned and
operated by ICE, some operate under contracts with ICE, and
some operate through service agreements with ICE. We did not include
detainees held by the Bureau of Prisons (BOP) for committing a
criminal offense.
[10] We conducted our work from July 2008 to February 2009 in
accordance with all sections of GAO‘s Quality Assurance framework that
are relevant to our objectives. The framework requires that we plan and
perform the engagement to obtain sufficient, appropriate evidence to
meet our stated objectives and to discuss any limitations in our work.
We believe that the information and data obtained and the analysis
conducted provide a reasonable basis for any findings and conclusions.
[11] FY 2007 was generally the most recent year of data available.
Unless otherwise indicated, the data we present reflect the detainees
held at three types of facilities: Service Processing Centers (SPC),
Contract Detention Facilities (CDF), and Intergovernmental Service
Agreement (IGSA) facilities.
[12] DHS officials stated that the 514 IGSA facilities include over 300
facilities that each generally report a total of more than 60 days of
detainee bed use per year. The other IGSA facilities report less
activity”some report a total of only one or two nights of detainee bed
use per year.
[13] ICE/DRO Detention Standard: Medical Care, [hyperlink,
http://www.ice.gov/doclib/PBNDS/pdf/medical_care.pdf] (accessed Dec. 1,
2008). The medical care standard was revised by ICE during 2008.
[14] In FY 2007, these 6 IGSAs accounted for about 27 percent of the
total average daily population for all IGSAs.
[15] A ’detail“ is the assignment of a PHS officer or employee by HHS
to another federal agency, to perform duties in support of that
agency or the PHS. 42 U.S.C. § 215.
[16] Included in the information about ICE's structure, GAO also
reviewed and reported on "the relevant agreements between DHS and HHS
[the Department of Health and Human Services] regarding DIHS [the HHS
Division of Immigration Health Services]. As the report notes, ICE
contracts with HHS personnel within the U.S. Public Health Service to
provide certain health care services to detainees.
[17] ICE houses detainees in a mix of Federally owned and administered
service processing centers and contract detention facilities that are
not owned by the Federal government and for which ICE executes an
intergovernmental service agreement (IGSA) with the state and local
government or private sector owner.
[End of section]
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