Department of Homeland Security
Organizational Structure, Spending, and Staffing for the Health Care Provided to Immigration Detainees
Gao ID: GAO-09-401T March 3, 2009
Immigration and Customs Enforcement (ICE) was created in March 2003 as part of the Department of Homeland Security (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 composed 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. Our 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.
In summary, we found that 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. Before October 1, 2007, DHS and HHS maintained annual interagency agreements through which DIHS--a component of HHS's Health Resources and Services Administration (HRSA)--provided health care for ICE detainees. As of that date, the last annual interagency agreement was terminated, and DIHS no longer is a component of HRSA. DHS officials told us that this termination--along with a 2007 Memorandum of Agreement between HHS and DHS that placed PHS officers on detail to DHS on an open-ended basis and that allowed for additional PHS officers to be detailed to DHS in the future--affected 565 direct health care providers and administrative staff. According to DHS officials, ICE now has a component known as DIHS which provides health care services to detainees. We also found that 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. However, ICE facilities do not use standardized record keeping, and are not required to routinely report data to DHS on the health care services provided to detainees. Furthermore, data were not available on the detainee health expenditures that are incurred by IGSAs. In addition, we determined that 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 include: (1) ICE's ability to access detainee population data that measure unique individuals in ICE custody, rather than the average number of beds used; (2) Reporting relationships between DIHS and ICE; (3) IGSA reporting requirements--including the frequency of reporting on health care services provided to detainees and the format in which health records are maintained; (4) ICE's ability to routinely ensure the transfer of medical records when detainees are transferred between facilities; (5) ICE's ability to identify and report the detainee health care costs incurred by IGSAs; and (6) ICE's ability to identify and report medical claims expenditures by facility type--such as for all IGSAs.
GAO-09-401T, Department of Homeland Security: Organizational Structure, Spending, and Staffing for the Health Care Provided to Immigration Detainees
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Spending, and Staffing for the Health Care Provided to Immigration
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Testimony:
Before the Subcommittee on Homeland Security, Committee on
Appropriations, House of Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery:
Expected at 10:00 a.m. EST:
Tuesday, March 3, 2009:
Department of Homeland Security:
Organizational Structure, Spending, and Staffing for the Health Care
Provided to Immigration Detainees:
Statement of Alicia Puente Cackley, Director:
Health Care:
GAO-09-401T:
Mr. Chairman and Members of the Subcommittee:
I am pleased to be here today as you examine issues related 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 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 the 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] My
remarks today are based on our report, released at this hearing,
entitled DHS: Organizational Structure and Resources for Providing
Health Care to Immigration Detainees.[Footnote 4]
ICE was created in March 2003 as part of DHS.[Footnote 5] 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 6] 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 composed 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. Our 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. To
address these issues, we reviewed pertinent government reports and
interagency agreements regarding DIHS; interviewed agency officials;
examined ICE's fiscal year 2003 through fiscal year 2007 data on health
care spending, staffing, and services;[Footnote 7] and obtained
information on ICE's mortality rate and the health care goals,
services, and populations for ICE, BOP, and USMS.[Footnote 8]
In summary, we found that 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. Before October
1, 2007, DHS and HHS maintained annual interagency agreements through
which DIHS--a component of HHS's Health Resources and Services
Administration (HRSA)--provided health care for ICE detainees. As of
that date, the last annual interagency agreement was terminated, and
DIHS no longer is a component of HRSA. DHS officials told us that this
termination--along with a 2007 Memorandum of Agreement between HHS and
DHS that placed PHS officers on detail to DHS on an open-ended basis
and that allowed for additional PHS officers to be detailed to DHS in
the future--affected 565 direct health care providers and
administrative staff. According to DHS officials, ICE now has a
component known as DIHS which provides health care services to
detainees.
We also found that 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. However, ICE facilities do not use standardized record
keeping, and are not required to routinely report data to DHS on the
health care services provided to detainees. Furthermore, data were not
available on the detainee health expenditures that are incurred by
IGSAs.
In addition, we determined that 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 include:
* 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; and:
* ICE's ability to identify and report medical claims expenditures by
facility type--such as for all IGSAs.
After reviewing the draft report, DHS provided general comments and
both DHS and HHS provided technical comments. DHS did not comment as to
whether the issues we identified as meriting further assessment would
be addressed in the $2 million external study. However, DHS disagreed
with the way we presented some information. Specifically, the agency
commented that we mischaracterized DIHS's relationship with HHS and DHS
and that our report could lead to the incorrect conclusion that DIHS
was transferred from HHS to DHS. DHS also stated that we
mischaracterized the degree of control ICE has over detainee health
care providers, ICE's ability to track the cost of health care services
for detainees held at IGSAs, and other issues. After considering the
agency's comments and our evidence, we maintain that the report
appropriately describes ICE's organization, management structure, and
ability to monitor health care spending. A complete discussion of DHS's
comments and our evaluation are provided in the report.
Mr. Chairman, this concludes my prepared remarks. I would be happy to
answer any questions that you or other members of the subcommittee may
have.
For future contacts regarding this statement, please contact Alicia
Puente Cackley at (202) 512-7114 or at cackleya@gao.gov. Contact points
for our Offices of Congressional Relations and Public Affairs may be
found on the last page of this statement. Rosamond Katz, Assistant
Director; Joy L. Kraybill; and Kevin Milne also made key contributions
to this statement.
[End of section]
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] [hyperlink, http://www.gao.gov/products/GAO-09-308R] (Washington,
D.C.: Feb. 23, 2009).
[5] Responsibility for detainees was transferred from the Department of
Justice's Immigration and Naturalization Service to DHS's ICE.
[6] The scope of our work was primarily limited to detainees who were
in ICE custody because of 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.
[7] 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.
[8] 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.
[End of section]
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