Indian Self-Determination Contracting: Effects of Individual Community
Contracting for Health Services in Alaska (Letter Report, 06/01/98,
GAO/HEHS-98-134).
Pursuant to a legislative requirement, GAO reviewed the impact of
individual Indian Health Service (IHS) contracts, focusing on the: (1)
extent to which Alaska Native communities contract directly with IHS to
manage their own health care services; and (2) effects these contracts
are having on costs and the availability of services.
GAO noted that: (1) relatively few Alaska Native communities have
contracted directly with IHS, and those that have done so generally
contracted for a limited range of health services and thus continue to
receive many services through a regional health organization (RHO); (2)
fifteen percent of the 227 Alaska Native communities have some form of
direct contract with IHS; (3) the dollar amount of these direct
contracts represents about 6.5 percent of all IHS contracts in Alaska
under the Indian Self-Determination Act; (4) GAO found that communities
with their own contracts have higher administrative costs than RHOs; (5)
IHS works with each contractor to determine the amount of administrative
costs needed to manage the contracts; (6) indirect costs--the major
component of the administrative costs--include such expenses as
financial and personnel management, utilities and housekeeping, and
insurance and legal services; (7) community contracts need about twice
the amount of indirect costs that a RHO would need to manage the same
programs; (8) when a community chooses the contract directly with IHS
for services previously provided by a RHO, it also has a need for
one-time start-up costs that increase the administrative cost
differences between community contracts and RHOs; (9) determining the
effects of individual community contracts on service availability proved
difficult because contracts involving a switch from RHOs to local
communities are relatively few in number, cover few services, and some
have been in effect for a short time; (10) the limited comparisons that
can be made show that service levels have not been greatly affected by
the switches thus far; (11) however, under current IHS funding
limitations, new contractors are receiving only part of their funding
needs for administrative costs and may have to wait several years to
receive full funding; (12) if communities decide to contract for service
programs but do not receive full funding for administrative costs and do
not have other resources from which to pay for these costs, they face
the risk of having to divert funds from services to cover their unfunded
administrative costs; (13) while funding shortfalls have not yet
resulted in widespread adverse effects on health services availability
in Alaska, the long-term picture raises cause for concern; and (14) in
choosing to operate their health services without waiting for sufficient
administrative funding, Alaska Native communities may have little option
but to accept a potential for reduced services as a trade-off for
managing elements of their health care systems.
--------------------------- Indexing Terms -----------------------------
REPORTNUM: HEHS-98-134
TITLE: Indian Self-Determination Contracting: Effects of
Individual Community Contracting for Health Services in
Alaska
DATE: 06/01/98
SUBJECT: Health care services
Native Americans
Service contracts
Administrative costs
Health services administration
Comparative analysis
Health care programs
IDENTIFIER: Alaska
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Cover
================================================================ COVER
Report to Congressional Committees
June 1998
INDIAN SELF-DETERMINATION
CONTRACTING - EFFECTS OF
INDIVIDUAL COMMUNITY CONTRACTING
FOR HEALTH SERVICES IN ALASKA
GAO/HEHS-98-134
Alaska Native Community Contracting
(108352)
Abbreviations
=============================================================== ABBREV
ANCSA - Alaska Native Claims Settlement Act
BIA - Bureau of Indian Affairs
CATG - Council of Athabascan Tribal Governments
CSC - contract support cost
FTE - full-time equivalent
IHS - Indian Health Service
KIC - Ketchikan Indian Corporation
RHO - regional health organization
SEARHC - Southeast Alaska Regional Health Consortium
Letter
=============================================================== LETTER
B-279160
June 1, 1998
The Honorable Ted Stevens, Chairman
The Honorable Robert C. Byrd
Ranking Minority Member
Committee on Appropriations
United States Senate
The Honorable Bob Livingston, Chairman
The Honorable David R. Obey
Ranking Minority Member
Committee on Appropriations
House of Representatives
In Alaska, the Indian Health Service (IHS) funds health services for
more than 100,000 Alaska Natives--Eskimos, Aleuts, Athabascans, and
American Indians--most of whom live in small, isolated communities.
Under provisions of the Indian Self-Determination Act, nearly all of
the health care programs traditionally administered by IHS have been
transferred to 13 Alaska Native regional health organizations (RHO)
with which IHS contracts to manage the programs for the Native
communities.\1 In recent years, however, some Native communities have
chosen to contract directly with IHS rather than go through an RHO to
manage their health care programs.
Some of these individual community contracts have generated
controversy. Critics contend that such contracts carry extra
administrative costs that can shift dollars out of health care and
into overhead. But supporters view the contracts as essential to
maintaining the sovereignty of Native communities and achieving the
Indian Self-Determination Act's goal of maximizing Native
participation in federal health care services. The fiscal year 1998
appropriations act for the Department of the Interior placed a
moratorium on IHS' further contracting with Native communities in
Alaska in order to review these issues more closely.
The appropriations act requires us to study the impact of these
individual contracts. As agreed with the staffs of your offices, we
set the following objectives for our review:
-- Determine the extent to which Alaska Native communities contract
directly with IHS to manage their own health care services.
-- Identify the effects these contracts are having on costs.
-- Identify the effects these contracts are having on the
availability of services.
Our review encompassed all IHS contracts currently in effect in
Alaska under the provisions of the Indian Self-Determination Act,
whether these contracts are with RHOs or with communities. We
analyzed programs and services covered by each contract and compared
costs and service availability. We conducted work on site at the IHS
Alaska area office and the Alaska Native Health Board office in
Anchorage and at IHS headquarters in Rockville, Maryland. To gain a
better understanding of circumstances surrounding a recent IHS award
of a large individual community contract in Ketchikan, we also
conducted work there. We supplemented this information through
interviews with officials from RHOs and Native communities. Our work
was conducted from December 1997 through April 1998 in accordance
with generally accepted government auditing standards.
--------------------
\1 The RHOs are nonprofit organizations designated by the Native
communities to contract with IHS in managing and delivering health
services for Native residents.
RESULTS IN BRIEF
------------------------------------------------------------ Letter :1
Relatively few Alaska Native communities have contracted directly
with IHS, and those that have done so generally contracted for a
limited range of health services and thus continue to receive many
services through an RHO. Fifteen percent of the 227 Alaska Native
communities--which represents about 10 percent of the Alaska Native
population--have some form of direct contract with IHS.\2 Most
communities participating in such contracts are small, and the scope
of the contracts are limited. The services they have most often
decided to manage on their own have included alcohol abuse and mental
health services; primary care services delivered by community health
aides and other nonphysician providers; and health education,
transportation, and other services provided by community health
representatives. A notable exception to the limited scope of these
contracts is in Ketchikan, where a Native community recently assumed
management and operation of a comprehensive primary care health
center staffed with physicians and dentists. The dollar amount of
these direct contracts represents about 6.5 percent of all IHS
contracts in Alaska under the Indian Self-Determination Act; the
contract with the Native community in Ketchikan accounts for about
one quarter of the 6.5 percent.
We found that communities with their own contracts have higher
administrative costs than RHOs. IHS works with each contractor to
determine the amount of administrative costs needed to manage the
contracts. Indirect costs--the major component of the administrative
costs--include such expenses as financial and personnel management,
utilities and housekeeping, and insurance and legal services.
Community contracts need about twice the amount of indirect costs
that an RHO would need to manage the same programs. When a community
chooses to contract directly with IHS for services previously
provided by an RHO, it also has a need for one-time start-up costs
that increase the administrative cost differences between community
contracts and RHOs.
Determining the effects of individual community contracts on service
availability proved difficult because contracts involving a switch
from RHOs to local communities are relatively few in number, cover
few services, and some have been in effect for a short time. The
limited comparisons that can be made show that service levels have
not been greatly affected by the switches thus far. However, under
current IHS funding limitations, new contractors are receiving only
part of their funding needs for administrative costs and may have to
wait several years to receive full funding. If communities decide to
contract for service programs but do not receive full funding for
administrative costs and do not have other resources from which to
pay for these costs, they face the risk of having to divert funds
from services to cover their unfunded administrative costs. While
funding shortfalls have not yet resulted in widespread adverse
effects on health services availability in Alaska, the long-term
picture raises cause for concern. In choosing to operate their
health services without waiting for sufficient administrative
funding, Alaska Native communities may have little option but to
accept a potential for reduced services as a trade-off for managing
elements of their health care systems.
--------------------
\2 Of the 227 Alaska Native communities, 224 are federally recognized
entities as determined by the Bureau of Indian Affairs. The three
exceptions are Native communities recognized in Alaska for
self-determination contracting purposes: Cook Inlet Region Natives,
Valdez Native Tribe, and Qutekcak (Seward area) Native Tribe.
BACKGROUND
------------------------------------------------------------ Letter :2
IHS, an agency within the Department of Health and Human Services, is
responsible for providing federal health services to an estimated 1.5
million American Indians and Alaska Natives. In fiscal year 1998,
IHS received appropriations of about $1.8 billion to provide these
services, with about $291 million of this amount for Alaska. To
provide care to Alaska's estimated 104,305 Natives, most of whom live
in small and isolated villages, a three-tiered health care delivery
system of local clinics, regional hospitals, and a comprehensive
medical center was developed. (See table 1.)
Table 1
Overview of Health Care Delivery System
for Alaska Natives
Service Source of care
------------------ --------------------------------------
Routine health Care is usually provided by community
maintenance and health aides in 178 village clinics
emergency first throughout the state. The community
aid health aide is usually a village
resident selected and trained to
deliver routine health services under
the long-distance telephone
supervision of a physician. In some
larger cities and towns, 17 health
centers and clinics provide care (8
staffed with a physician and 9 with a
midlevel provider, such as a physician
assistant or nurse practitioner).
Routine hospital Care is usually provided in one of six
admissions regional hospitals or, when
authorized, in a local private
hospital.
Treatment of Care is generally provided by referral
serious illnesses to the Alaska Native Medical Center in
and injuries Anchorage, which is available to all
of Alaska's Natives. In some cases,
care is authorized to be provided by
private hospitals in Alaska or
elsewhere in the United States.
----------------------------------------------------------
IHS' mission is to provide a comprehensive health services system,
while at the same time providing opportunity for maximum tribal
involvement in developing and managing programs to meet their needs.
The Indian Self-Determination Act gives Alaska Native communities, as
well as Indian tribes throughout the United States, the option of
replacing IHS as the manager and provider of health care services.
To cover the costs of operating such systems on their own, the act
authorizes IHS to contract with any of the recognized Alaska Native
communities or other tribal organizations, such as regional or
village corporations.\3
In Alaska, IHS has established an order of precedence for recognizing
various Native entities for purposes of self-determination
contracting.\4 In this order of precedence, an individual Native
community has priority over an RHO in obtaining contract awards from
IHS. If a contract is awarded to an organization that performs
services benefiting more than one community, the approval of each
community's governing body (a resolution of support) is a
prerequisite.
--------------------
\3 The Indian Self-Determination Act as amended in 1992 also
authorizes IHS to negotiate self-governance compacts with Indian
tribes that allow them greater flexibility in the operation of health
programs. For purposes of this report, both self-determination
contracts and self-governance compacts are referred to as
"contracts."
\4 In establishing the order of precedence, IHS' Alaska Area Circular
No. 82-10 states that Alaska Native villages, as the smallest tribal
units under the Alaska Native Claims Settlement Act (ANCSA), must
approve contracts that will benefit their members. IHS will
recognize as the village governing body the following entities in
order of precedence: (1) Indian Reorganization Act Councils, which
provide governmental functions for the village; (2) traditional
village councils; (3) village for-profit Native corporations; and (4)
regional for-profit Native corporations. This order of precedence
has withstood several court challenges.
RELATIVELY FEW ALASKA NATIVE
COMMUNITIES CONTRACT DIRECTLY
WITH IHS TO MANAGE HEALTH
SERVICES
------------------------------------------------------------ Letter :3
Alaska Native communities that contract directly with IHS manage a
relatively small share of health care services in Alaska.
Thirty-four of Alaska's 227 Native communities (15 percent)--which
represents about 10 percent of the total Alaska Native
population--have obtained funding in direct contracts from IHS to
provide some of the health services they receive. (See table 2.)
These 34 communities comprise two main groups--25 communities that
decided at some point to separate from their RHO to obtain certain
services, and 9 communities, mostly in the Cook Inlet area near
Anchorage, that generally have not participated in an RHO. Because
some communities have banded together for contracting purposes, the
34 communities are involved in a total of 21 contracts, which account
for 6.5 percent of IHS' total contract funding in Alaska under the
Indian Self-Determination Act.
Table 2
Indian Self-Determination Act
Contracting in Alaska, Fiscal Year 1998
Communities served People served Contract funding
------------------ ------------------ --------------------
Number
Type of entity of
contracting with contract Percent Percent Amount (in Percent
IHS s Number of total Number of total millions) of total
---------------- -------- -------- -------- -------- -------- ---------- --------
RHO 13 193\a 85% 94,326\a 90.4% $185.0 93.5%
Native communities
----------------------------------------------------------------------------------------
Community 12 25 11 6,974 6.7 8.7 4.4
contractors
that separated
from an RHO
Community 9 9 4 3,005 2.9 4.1 2.1
contractors
that did not
participate in
an RHO
========================================================================================
Total 34 227 100% 104,305 100% $197.8 100%
----------------------------------------------------------------------------------------
Note: Number and percent of people served are estimates for fiscal
year 1998 prepared by IHS on the basis of 1990 U.S. Census Bureau
data.
\a This figure does not include the communities or people served by
community contractors, although in many cases, RHOs continue to
provide some services to residents in these communities and are
funded by IHS to do so.
RHOS DELIVER MOST HEALTH
SERVICES TO ALASKA NATIVES
---------------------------------------------------------- Letter :3.1
Of those entities contracting with IHS, the 13 RHOs have the greatest
capacity to deliver comprehensive inpatient and outpatient services.
The RHOs vary considerably in size. The largest serves more than
20,000 Natives and has a budget of nearly $40 million; the four
smallest serve fewer than 2,000 Natives each and have budgets of $2
million to $4 million. (See app. I for details on the 13 RHOs.) Six
of the RHOs operate regional hospitals, and all 13 provide community
health services to some outlying communities in their areas.
Community health services usually include training and placement of
community health aides, long-distance physician supervision for the
village-based community health aides, itinerant physician and dental
coverage, mental health and alcohol abuse programs, and a wide range
of other health and social services.
SOME COMMUNITIES CONTRACT
DIRECTLY TO MANAGE SERVICES
FORMERLY OBTAINED THROUGH
RHOS
---------------------------------------------------------- Letter :3.2
Historically, IHS has contracted with RHOs in Alaska because the RHOs
were well established when the Indian Self-Determination Act became
law in 1975\5 and because they were able to obtain resolutions of
support from the Native communities they represented. However, a
Native community has the option of withdrawing its resolution from an
RHO and contracting directly with IHS to manage all or part of the
health services that previously were provided by the RHO.
Communities have pursued this option for a variety of reasons,
including the belief that local control will improve the delivery of
health services and help them attain self-determination goals. Under
the Self-Determination Act, IHS' authority to decline such community
contract proposals is very limited.\6
Twenty-five communities have decided to stop obtaining some services
through RHOs and to contract directly with IHS. In total, there are
12 contractors that separated from RHOs because some contracts cover
more than one community. These contracts are generally for a limited
number of services--most often alcohol and mental health services,
community health aides, community health representatives, and other
community-based services. Ten of the contracts, for example, involve
management of village community health aide clinics, often in
conjunction with alcohol education, prevention, and counseling
activities. The Native populations served by the 12 contracts range
in size from fewer than 30 people to nearly 2,000, and contract
awards range from about $100,000 to more than $3 million. (See app.
II.)
Although these communities, through direct contracting, manage some
of their own health services, they most often remain part of the RHO
network for other services, such as community health aide supervision
and training, physician and dentist services, inpatient care, and
management of referrals for specialty services obtained from private
providers (known as contract health care).
One contractor that separated from an RHO--Ketchikan Indian
Corporation (KIC)--has assumed the management of a much broader scope
of services. KIC is the largest Native community contractor, serving
a Native population of nearly 2,000 and with nearly $3.4 million in
fiscal year 1998 funding--one quarter of the 6.5 percent share of
Alaska self-determination contract funding received by community
contractors. KIC manages a comprehensive primary care health center
with a permanent staff of physicians, dentists, nurses, and a wide
range of ancillary services, such as laboratory, X-ray, and pharmacy.
KIC officials told us that the community decided to manage the health
center itself because it was dissatisfied that the RHO did not
provide information that it had agreed to provide, such as quarterly
financial statements; did not attend KIC tribal council meetings; and
had planned to replace the existing health center with a new one in
the neighboring village of Saxman rather than on KIC property in
Ketchikan. Nonetheless, Ketchikan continues to participate in the
RHO and use the RHO's hospital in Sitka for some inpatient care.
--------------------
\5 Between 1930 and 1960, Alaska Natives established local
organizations in many parts of the state to assist Native communities
and advocate on their behalf. When ANCSA was passed in 1971, these
organizations were in place and became the designated nonprofit
service corporations to work with the for-profit ANCSA corporations
in managing programs for Native residents. Thus, the majority of
today's RHOs were in existence before 1975.
\6 IHS can only decline a contract proposal on the basis of one or
more of the five specific reasons listed in the Indian
Self-Determination Act: (1) the service to be rendered or function
to be contracted will not be provided in a satisfactory manner; (2)
adequate protection of trust resources is not ensured; (3) the
proposed project or function cannot be properly completed or
maintained by the proposed contract; (4) the amount of funds proposed
is in excess of the applicable funding level for the contract; and
(5) the program, function, service, or activity proposed is beyond
the scope covered under the act. In cases where IHS cannot approve a
contract proposal fully, it is required to approve any severable
portion of it and to provide technical assistance to help tribes
overcome other obstacles to successful contracting. In addition, the
burden of proof for declination rests with IHS.
SOME COMMUNITIES HAVE NOT
BEEN PART OF A REGIONAL
NETWORK
---------------------------------------------------------- Letter :3.3
Nine of the communities that contract directly with IHS present a
somewhat different picture than the 25 communities that separated
from an RHO in that they did not previously obtain the contracted
services from an RHO. Most of these communities are located in the
Cook Inlet (Anchorage) area, where they have access to the extensive
resources of the Alaska Native Medical Center.\7
Eight of these nine contractors serve one small Native community
each, with populations ranging from 11 to 392. (See app. III.) The
ninth contractor, Kenaitze, is exceptionally large, serving a
resident population of more than 1,400 Alaska Natives on the Kenai
Peninsula south of Anchorage. Kenaitze has administered a health
services contract since 1983; its current contract--which is over
$1.1 million--provides for a midlevel practitioner clinic with a
dentist, a community health representative, and alcohol and mental
health services. In addition to the Kenaitze clinic, two other
contractors manage clinics with midlevel practitioners, and two
manage community health aide clinics with some additional services.
Two of the contracts, which were initiated in 1997, are especially
limited: Chickaloon Village, which serves 11 Natives with $46,327 in
fiscal year 1998 contract funding, and Knik Tribal Council, which
serves 39 Natives with $53,079 in fiscal year 1998 contract funding.
The Chickaloon and Knik contracts illustrate the extent to which IHS
is bound to support village self-determination decisions. When IHS
identified funding to open a new midlevel clinic in the
Matanuska-Susitna Valley northeast of Anchorage, three Native
organizations in that area submitted proposals to manage the clinic:
Southcentral Foundation (an RHO), Chickaloon, and Knik. IHS approved
Southcentral's proposal to manage the clinic; in addition, IHS--under
rules requiring IHS to approve any severable portion of a
self-determination proposal--negotiated with Chickaloon and Knik
regarding what services they could provide with their limited
per-capita-based shares of the clinic funding. IHS and the villages
agreed on transportation for village residents who need services in
Anchorage, plus management of contract health care for Knik.
--------------------
\7 For self-determination contracting purposes, the Southcentral
Foundation is viewed as a "one-tribe" RHO representing the Cook Inlet
area. According to an IHS official, however, under IHS policy,
Southcentral Foundation represents only those Natives who reside in
geographic locations in the Cook Inlet area that are not represented
by a tribal government. A number of tribal governments in the area
have chosen not to give resolutions of support to Southcentral
Foundation to act as their RHO.
INDIVIDUAL COMMUNITY CONTRACTS
HAVE HIGHER ADMINISTRATIVE
COSTS
------------------------------------------------------------ Letter :4
Administrative costs are higher under individual community contracts
than under contracts with RHOs. Under either contracting
arrangement, the Native organization receives the same amount of
funding for direct program costs, but IHS has determined that
individual communities need more funding for administrative
expenses--both to start up the contract and to administer it on an
ongoing basis. The higher administrative costs generally reflect
lost economies of scale that result from the smaller scope of most
individual contracts.
IHS DETERMINES FUNDING NEEDS
WITH NATIVE ORGANIZATIONS
---------------------------------------------------------- Letter :4.1
Under the Indian Self-Determination Act, an Indian tribe or Alaska
Native community that chooses to contract with IHS is entitled to
funding for both direct program costs and contract support costs
(CSC) to cover administrative functions. In Alaska, these provisions
apply both to contracts between IHS and RHOs and to contracts between
IHS and individual Native communities. Direct program funding is the
amount that IHS would have spent to operate the programs that were
transferred to the contractors. CSC funding generally is an
additional amount, not normally spent by IHS, that is needed to cover
reasonable costs incurred by Native organizations to ensure
compliance with the terms of the contracts and prudent management of
the programs. Direct program costs are the same regardless of who
manages the contracts--communities or RHOs. In contrast, CSC amounts
may differ considerably.
Determination of CSC needs is based on three cost categories:
start-up costs, indirect costs, and direct costs. (See table 3.) The
largest cost category is indirect costs, which include most ongoing
overhead expenses. For most contracts, indirect costs account for
over 80 percent of the recurring CSC funding needs.
Table 3
Categories and Types of Contract Support
Costs
CSC category Description
------------ --------------------------------------------
Start-up One-time costs incurred in planning and
costs assuming management of the programs.
Examples include buying computers and
training staff.
Indirect Ongoing overhead expenses, which are often
costs divided into three groups--management and
administration, facilities and equipment,
and general services and expenses.
Management and administration includes
financial and personnel management,
procurement, property and records
management, data processing, and office
services. Facility and equipment includes
building, utilities, housekeeping, repair
and maintenance, and equipment. General
services includes insurance and legal
services, audit, general expenses, interest,
and depreciation.
Direct costs This category covers such costs as
unemployment taxes and workers' compensation
insurance for direct program salaries.
----------------------------------------------------------
Our analysis of cost differences between RHO contracts and individual
community contracts focused on the first two types of contract
support costs--start-up and indirect costs.\8 To provide a consistent
comparison, we examined the fiscal year 1998 funding needs of each
contractor for these costs as determined by IHS.
--------------------
\8 We excluded direct costs from the analysis because it is a small
component of contract support costs and because, unlike the two other
cost categories, it consists mainly of costs that tend not to be
affected by who is doing the contracting.
START-UP COSTS
-------------------------------------------------------- Letter :4.1.1
New and expanded contracts are eligible for start-up CSC funding. If
an individual Native community decides to contract separately for
services formerly obtained through an RHO, its funding needs for
start-up costs represent an increased, one-time cost for the program.
IHS records show that the 12 community contracts involving services
formerly provided by RHOs received IHS approval for at least $452,000
in start-up CSC needs--ranging from about $22,500 to $140,000 per
contract--which were generally based on program size.\9
--------------------
\9 IHS has data on start-up costs for only 9 of the 12 community
contracts that cover services formerly obtained through an RHO.
INDIRECT COSTS
-------------------------------------------------------- Letter :4.1.2
On average, individual community contractors have considerably higher
indirect costs than RHOs would have to manage the same programs. For
fiscal year 1998, IHS determined indirect cost needs of slightly more
than $3 million for the 12 individual community contracts that
separated from RHOs.\10 The IHS official responsible for negotiating
these contracts told us that to estimate what the indirect costs
would have been if the services provided under the 12 contracts had
instead been provided through RHOs, he would use the indirect cost
rates in place for the RHOs during fiscal year 1998. Using these
rates that he provided, we determined the indirect costs for the RHOs
to be about $1.3 million--or less than half of the indirect costs for
the community contractors. (See app. IV for a contract-by-contract
comparison of indirect cost needs of the Native communities and
RHOs.)
IHS officials said the main reason individual community contracts had
higher indirect costs was that the small size of these contracts
resulted in the loss of administrative economies of scale. Because
RHOs have an administrative structure in place to support other
contracts and services, they can spread the overhead expenses among
their programs. Small communities, however, generally have to build
the administrative structure for these services alone.
We did not compare the indirect costs of the other nine community
contracts with those of RHOs because the programs managed by these
contracts were not formerly a part of an RHO. However, we found that
indirect costs as a proportion of total funding needs that IHS
determined for these contracts were similar to those of the 12
community contracts that cover services formerly obtained through an
RHO. This would indicate that these contracts also are likely to
have higher indirect costs than RHOs.
--------------------
\10 IHS determines CSC funding needs with each contractor on an
annual basis. For large Native organizations that have negotiated
their indirect cost rates with another federal agency--such as the
Bureau of Indian Affairs (BIA)--for other contracts, IHS will apply
those rates to the program costs to determine the amount of indirect
costs. For organizations without an existing rate, IHS negotiates
the amount of indirect costs by identifying and calculating overhead
cost items.
AVAILABILITY OF SERVICES NOT
GREATLY AFFECTED, BUT RISK FOR
ADVERSE EFFECTS EXISTS
------------------------------------------------------------ Letter :5
To date, IHS contracting with Native communities rather than RHOs
does not appear to have had a significant impact on the level of
services available to Alaska Natives, although we did identify a few
temporary service disruptions. The small number of these contracts;
their generally restricted scope; and in some cases, their recent
implementation have likely been key factors in limiting the effects
on Native communities or RHOs. However, a shortfall in available CSC
funding may jeopardize the continuation of this level of service.
Native communities that are not in a financial position to absorb
unfunded contract support costs may face the risk of having to divert
funds from health services to cover their unfunded contract support
needs. We found one instance, in Fort Yukon, where this may already
have occurred.
TO DATE, SERVICE
AVAILABILITY HAS NOT BEEN
GREATLY AFFECTED
---------------------------------------------------------- Letter :5.1
When individual Alaska Native communities have contracted directly
with IHS to provide some of their own health services, they generally
have assumed management responsibility for existing, defined service
programs being operated by IHS or an RHO. Because these contracts
essentially enable program transfers, the types of services provided
do not change initially. In addition, the community contractors
generally continue to employ the same staff and use the same
facilities.
Generally, we did not find that a community's takeover of services
from an RHO in itself had a substantial effect on the types of
services provided or service utilization. The service disruptions
that we did find in some communities, such as in Ketchikan, and in
some clinics staffed by community health aides tended to be
transitory in nature.
-- In Ketchikan, when KIC took over the contract from the RHO in
October 1997, the health center's resources, staff, and patient
population were split and two separate facilities were
established. KIC's health center initially had a gap in dental
services because the RHO retained both dentists when staffing
was split. This gap has been partly remedied, and we observed
no other gaps in services at the time of our review. However,
due to uncertainty surrounding the future of this contract, the
staffing situation at both the KIC and RHO clinics was not
stable.\11
-- A review of clinics staffed by community health aides that now
are managed by community contractors revealed sharp variations
in some communities over past years in the numbers of patient
encounters provided. However, these variations did not appear
to be related to community contracting because they occurred
whether a community or an RHO was managing the services. The
variations most likely reflect temporary losses of staff because
in small, remote Alaska communities, it takes time and training
to replace community health aides.
--------------------
\11 Because of concerns about cost inefficiencies in this case, the
Congress enacted P.L. 105-143 in December 1997, which requires IHS
to make only one contract award in the Ketchikan area beginning in
fiscal year 1999. As of April 1998, IHS had not decided whether KIC
or the RHO would receive the renewal contract award.
SHORTFALL IN CSC FUNDING
POSES RISKS TO SERVICE
AVAILABILITY
---------------------------------------------------------- Letter :5.2
The 1988 and 1994 amendments to the Indian Self-Determination Act
clarified that CSC funding should be made available to provide Indian
tribes and Alaska Native communities with additional resources to
develop the capability and expertise to manage services on their own.
The Senate report accompanying the 1994 amendments expressed concern
that without this additional support, Indian tribes would be
compelled to divert funds from health services to contract support
costs.
IHS has established two separate pools of CSC funding--one for the
recurring CSC needs of ongoing contracts and the other for additional
CSC needs of new or expanded contracts. IHS-wide, CSC funding for
ongoing contracts has increased from about $100.6 million in fiscal
year 1993 to $168.7 million in fiscal year 1998; and since 1994, the
Congress has appropriated $7.5 million per year specifically for the
CSC needs of new or expanded contracts. However, the demand for CSC
funding has greatly exceeded these appropriations. As a result,
while IHS has agreed with each contractor on the amount of their CSC
funding needs, it has not been able to fully fund those needs. The
contractors have the option of delaying or going ahead without full
CSC funding, and most of them have chosen to begin implementing their
contracts without full funding. Since 1995, IHS has reported a
shortfall in CSC funding each year, largely because of the rapid
increase in tribal assumption of IHS programs nationwide. For fiscal
year 1997, the shortfall totaled $82 million nationwide, over $12
million of it in Alaska.\12
As a mechanism for allocating available CSC funds among contractors,
IHS maintains a waiting list for new contractors that have chosen to
operate without full CSC funding. Available funding is allocated on
a first-come, first-served basis, and a new contractor's waiting time
for full CSC funding may be at least several years. For example,
contractors that entered into contracts in 1994 are now at the top of
the waiting list and expect to be funded in fiscal year 1998, a 3- to
4-year wait.\13
IHS reports that a continued lack of sufficient CSC funds could, by
necessity, result in tribes funding administrative functions with
moneys that otherwise would have been used to provide direct health
care services.\14 This condition could occur if tribes are unable to
realize efficiency gains or do not have other resources to help
offset their CSC funding shortfalls.
This risk is present in Alaska. Fourteen of the 21 direct community
contractors were operating with CSC shortfalls in fiscal year 1998,
and 7 of these shortfalls represented between 30 to 74 percent of the
contract's total recurring CSC funding needs. (See app. V for
details on the CSC shortfalls by contractor.) Shortfalls of this
magnitude could make it difficult for tribes to continue to maintain
the same level of health services. The risk is less for RHOs, which
also may have CSC shortfalls but generally are in a better financial
position than community contractors to manage these shortfalls
because they manage large multimillion-dollar operations that can
benefit from economies of scale and have multiple sources of revenue
that can generate positive cash flow. The varying effects of
substantial CSC shortfalls on communities that contract directly with
IHS can be seen in Ketchikan and Fort Yukon--which are served by the
two largest direct community contractors.
--------------------
\12 Based on IHS' fiscal year 1997 report to the Congress, about $33
million of this shortfall was for ongoing contracts and $49 million
was for new or expanded awards. IHS maintains a waiting list for the
CSC funding needed for new or expanded contracts. When a contract on
the waiting list receives CSC funding, that amount is treated as
recurring costs and is funded from ongoing CSC funding in subsequent
years.
\13 The wait could be significantly longer or shorter for contractors
at the bottom of the waiting list, depending on the amount of CSC
funding appropriated in future years.
\14 The Indian Self-Determination Act allows tribes the flexibility
to rebudget funds between program and administrative functions as
needed to perform the contract.
IN KETCHIKAN, OTHER
RESOURCES WERE INITIALLY
AVAILABLE TO MANAGE THE CSC
SHORTFALL
---------------------------------------------------------- Letter :5.3
In Ketchikan, the large CSC shortfall of over $500,000 a year has not
had a negative impact on overall services to the communities involved
because both the community contractor, KIC, and the RHO, Southeast
Alaska Regional Health Consortium (SEARHC), were able--at least
temporarily--to provide additional resources to make up for the
funding gap.
Prior to October 1997, SEARHC was managing the Ketchikan Indian
health center to serve six Native communities--Ketchikan, Saxman, and
four outlying communities on Prince of Wales Island. When the health
center contract was split, KIC received 58 percent of the funding to
serve Ketchikan Natives and SEARHC retained the remainder to serve
Saxman and the other communities. Loss of economies of scale
occurred in two ways. First, additional clinic space was leased to
operate two separate clinics. Second, additional staff were needed
to deliver the same level of services in two facilities. For
example, the total number of clinical and administrative staff for
the clinic before the split was 59.5 full time equivalents (FTE).
After the split, the two clinics had a combined total of 68 FTEs.
Most of the increase was for duplicated administrative functions,
such as the need to have two clinic directors, two business office
directors, and two computer programmers. Both SEARHC and KIC had the
additional resources to initially absorb the additional costs.
-- SEARHC is a large RHO that manages many federal and state health
programs and services for the benefit of Alaska Natives in
Southeast Alaska. At the end of fiscal year 1996, its annual
budget was over $50 million and it had over $23 million in net
assets. Although the Ketchikan clinic had 2 years remaining on
its lease, SEARHC decided to lease a new facility nearby for its
own clinic to serve Saxman and the outlying communities,
asserting that it was not practical to share the original
building with KIC. SEARHC spent almost an additional $1 million
of its own resources on this new clinic. With the new clinic
and additional staff, clinic waiting times for the Saxman Native
community were reduced.
-- KIC assumed management of the original clinic with a contract
award of nearly $3.4 million and a CSC shortfall of over
$500,000. Although it is too soon to determine the long-term
impact of this shortfall, KIC has been able to use its tribal
government resources--especially management staff from other
programs--to reduce the additional administrative need. A large
tribe by Alaska standards, Ketchikan has a well-established
tribal government with a staff of more than 70 that administers
BIA and other federal and state-funded programs totaling at
least $2.5 million in addition to the IHS contract.
IN FORT YUKON, OTHER
RESOURCES WERE NOT AVAILABLE
TO MANAGE THE CSC SHORTFALL
---------------------------------------------------------- Letter :5.4
CSC shortfalls have created significant difficulties for the Council
of Athabascan Tribal Governments (CATG) in managing the small Fort
Yukon clinic and community health aide services in the Yukon Flats
area northeast of Fairbanks. CATG, which is a consortium of eight
small Native communities, has been operating its $1.8 million
contract with an annual CSC shortfall of about $500,000. This
shortfall represents almost 53 percent of CATG's total recurring CSC
funding needs. According to its most recent audit report, CATG did
not have any additional resources to compensate for a shortfall of
this size. The official responsible for CATG operations told us that
because CATG did not have resources to cover the CSC funding gap, it
had no option but to use some program funds to support administrative
functions.
There were some indications that CATG's financial strain may have
contributed to other operational problems. In 1997, for example,
there was considerable turnover in the Fort Yukon clinic's physician
assistant staff, resulting in vacancies that were not immediately
filled. Although the number of outpatient visits at the clinic did
not decline substantially, the Native Village of Fort Yukon was so
dissatisfied with CATG's failure to fill the clinic vacancies and
with other matters that the village considered asking IHS or the RHO
to resume management of the clinic or contracting directly with IHS.
In the end, however, no action was taken; and as of April 1998, the
Native Village of Fort Yukon remained a member of CATG and was
receiving health services through its contract.
CONCLUSIONS
------------------------------------------------------------ Letter :6
Through the Indian Self-Determination Act, the Congress has clearly
expressed support for Alaska Native communities to exercise their
preferences for managing health care resources, such as through an
RHO or on their own. Many Native communities view the option to
contract directly with IHS as fundamental to their ability to achieve
self-determination and self-governance objectives, and about 15
percent of Native communities in Alaska have chosen to do so.
However, funds have been available to only partially support the
additional administrative costs created by lost economies of scale
when Native communities contract directly with IHS. These funding
shortfalls appear not to have greatly affected the availability of
health services in Alaska at this time, but maintaining the
availability of services in the future could pose challenges to some
Native community contractors. To the extent that Native communities
assume management of a greater portion of their health services in a
time of increasing CSC funding shortfalls, the risk for adverse
impacts on health services delivery also increases.
AGENCY COMMENTS
------------------------------------------------------------ Letter :7
We provided a draft of this report to IHS officials, who concurred
with the report's findings. In addition, they provided some
technical comments, which we incorporated as appropriate. Appendix
VI contains the full text of IHS' comments.
---------------------------------------------------------- Letter :7.1
We are sending copies of this report to the Secretary of Health and
Human Services, the Director of Indian Health Service, the Director
of the Office of Management and Budget, and other interested parties.
We will also make copies available to others upon request.
The information contained in this report was developed by Frank
Pasquier, Assistant Director; Sophia Ku; and Ellen M. Smith. Please
contact me at (202) 512-6543 or Frank Pasquier at (206) 287-4861 if
you or your staff have any questions.
Bernice Steinhardt
Director, Health Services Quality
and Public Health Issues
ALASKA NATIVE RHO CONTRACTORS
=========================================================== Appendix I
This appendix presents data to describe the 13 Alaska Native RHOs in
terms of the amount of their fiscal year 1998 contract awards,
numbers of Alaska Natives and Native communities served in 1998, and
types of facilities operated. Six of the RHOs operate regional
hospitals, and all 13 use the Alaska Native Medical Center in
Anchorage for treatment of serious illnesses and injuries.
Outpatient medical care is provided at three types of facilities:
(1) health centers staffed with physicians and dentists; (2) midlevel
clinics staffed with physician assistants or nurse practitioners; and
(3) village-based clinics that rely on community health aides--who
usually are village residents with special training--to provide first
aid in emergencies, primary care, and preventive health services
under telephone supervision by physicians.
Table I.1
Key Characteristics of Alaska Native RHO
Contractors
Number of
Alaska
Native
FY 1998 1998 Census communitie
RHO award amount population\a s\b Facilities
------------ ------------ ------------ ---------- -----------------------------------
Aleutian/ $2,336,138 1,189 7 St. Paul midlevel clinic
Pribilof
Islands
Association
, Inc.
Arctic Slope 4,764,444 4,216 7 Samuel Simmonds Hospital, Barrow
Native
Association
Bristol Bay 19,018,994 6,069 32 Kanakanak Hospital, Dillingham;
Area Health midlevel clinics at Chignik and
Corporation Togiak
Chugachmiut 3,722,339 1,769 7 Seward midlevel clinic
Copper River 2,013,338 669 8 Community health aide clinics only
Native
Association
Kodiak Area 5,633,895 2,465 9 Kodiak physician and dentist health
Native center
Association
Maniilaq 21,763,548 7,017 12 Maniilaq Hospital, Kotzebue
Association
Metlakatla 2,310,839 1,398 1 Metlakatla physician and dentist
Indian health center
Community
Norton Sound 18,501,941 7,386 20 Norton Sound Hospital, Nome
Health
Corporation
Southcentral 9,264,759 21,374 1 Patient Care Center, Anchorage;
Foundation physician and dentist health
center
Southeast 32,800,865 13,693 17 Mt. Edgecumbe Hospital, Sitka;
Alaska physician and dentist health
Regional centers at Juneau, Ketchikan, and
Health Klawock
Consortium
Tanana 23,299,626 11,993 34 Fairbanks physician and dentist
Chiefs health center; McGrath midlevel
Conference, clinic
Inc.
Yukon- 39,521,229 21,364 58 Yukon-Kuskokwim Hospital, Bethel;
Kuskokwim Aniak midlevel clinic
Health
Corporation
Other\c 3,703 14
=========================================================================================
Total $184,951,955 104,305 227
-----------------------------------------------------------------------------------------
Note: We included as RHOs those specified in section 325 of the
Department of the Interior's appropriations act for fiscal year 1998.
\a These are Census-based population estimates for 1998 developed by
IHS. Populations include Alaska Natives served by community
contractors within the RHOs' areas because the RHOs generally
continue to provide some services, such as inpatient care, to
contractor populations. Alaska Natives living in "unspecified" areas
or in other communities in RHO or contractor areas are included in
counts for those areas.
\b Numbers of Alaska Native communities include federally recognized
tribes and villages as determined by BIA, with the following
exceptions that are recognized for self-determination contracting
purposes: Cook Inlet Region Natives represented by Southcentral
Foundation, Valdez Native Tribe, and Qutekcak (Seward area) Native
Tribe.
\c Includes communities in the Anchorage and Cook Inlet areas that do
not participate in Southcentral Foundation.
ALASKA NATIVE COMMUNITY
CONTRACTORS THAT SEPARATED FROM AN
RHO
========================================================== Appendix II
This appendix describes the 12 community contractors that separated
from an RHO, listing the facilities operated and some of the services
provided under each contract. Some of the services are somewhat
unique to Alaska, and they may vary from one contractor to another,
but they generally can be considered as follows:
-- Community health aides usually are village residents trained to
give first aid in emergencies, examine the ill, report symptoms
by telephone to a supervising physician, and carry out
recommended treatments, including dispensing prescription drugs.
They also provide preventive health services, such as fluoride
treatments, and health education.
-- Community health representatives differ from community health
aides by focusing more on social and support services than on
health care, although there may be overlap in some areas.
Community health representatives may provide general health
care, including home health care visits to the elderly and new
mothers, along with health education and outreach.
-- Midlevel clinics most often are staffed by nurse practitioners
and physician assistants.
-- Contract health care programs purchase services for Alaska
Natives from private providers when the services are not
available from IHS or tribally operated programs.
-- Alcohol, substance abuse, and mental health programs at the
village level often are provided by local residents trained as
behavioral counselors, supported by regional professionals.
Many program elements are intended to prevent alcoholism,
especially in youth, including Alcoholics Anonymous meetings,
activities to promote sobriety, and home visits.
-- Emergency medical services at the community level generally
focus on safety training and injury prevention, such as swimming
and bicycle safety and first aid and CPR (cardiopulmonary
resuscitation) training. Some programs provide and monitor fire
extinguishers and smoke alarms in the homes.
-- Patient transportation programs generally help coordinate
patient travel for necessary health services with local and
outside health providers.
Table II.1
Key Characteristics of Alaska Native
Community Contractors That Separated
From an RHO
Number of
Alaska
Native
FY 1998 1998 Census communitie
Contractor award amount population\a s\b Facilities and services
------------ ------------ ------------ ---------- -----------------------------------
Akiachak $287,560 562 1 1 community health aide clinic;
Native community health representatives;
Community alcohol and mental health services
Chitina 206,709 26 1 1 community health aide clinic;
Traditional patient transportation services
Village
Council
Council of 1,777,668 1,271 8 Midlevel clinic; dentist; 6
Athabascan community health aide clinics;
Tribal community health representatives;
Governments alcohol and mental health services
Native 109,691 201 1 1 community health aide clinic;
Village of alcohol and mental health services
Diomede
Eastern 1,240,785 1,160 6 5 community health aide clinics;
Aleutian community health representatives;
Tribes alcohol and mental health and
emergency medical services
Hoonah 248,845 649 1 1 community health aide clinic
Indian (with a state-funded midlevel
Association provider); community health
representatives; alcohol and
mental health services
Karluk 165,043 75 1 1 community health aide clinic;
Tribal community health representatives;
Council alcohol and mental health services
Ketchikan 3,368,612 1,915 1 Health center with physicians;
Indian dentists; ancillary services;
Corporation contract health care program;
alcohol and mental health services
Native 327,933 578 1 1 community health aide clinic;
Village of alcohol and mental health services
Kwinhagak
Mt. Sanford 666,118 125 2 2 community health aide clinics;
Tribal community health representatives;
Consortium contract health care program;
alcohol and mental health,
emergency medical, and patient
transportation services
St. George 153,188 145 1 1 community health aide clinic
Traditional
Council
Valdez 157,463 267 1 Community health representatives;
Native contract health care program
Tribe
=========================================================================================
Total $8,709,615 6,974 25
-----------------------------------------------------------------------------------------
\a These are Census-based population estimates for 1998 developed by
IHS. Alaska Natives living in "unspecified" areas and other
communities in contractor areas are included in these counts.
\b Numbers of Alaska Native communities include federally recognized
tribes and villages as determined by BIA, with the exception of
Valdez Native Tribe, which is recognized for self-determination
contracting purposes.
OTHER COMMUNITY CONTRACTORS
========================================================= Appendix III
This appendix describes the nine community contractors that did not
separate services from an RHO. (See app. II for definitions of the
types of services and facilities these contractors operate.)
Table III.1
Key Characteristics of Other Community
Contractors
Number of
Alaska
Native
FY 1998 1998 Census communitie
Contractor award amount population\a s\b Facilities and services
------------ ------------ ------------ ---------- -----------------------------------
Chickaloon $46,327 11 1 Patient transportation services
Village
Native 135,611 63 1 Community health representatives;
Village of alcohol and mental health and
Eklutna emergency medical services
Kenaitze 1,142,154 1,428 1 Midlevel clinic; dentist; community
Indian health representatives; contract
Tribe health care program; alcohol and
mental health services
Knik Tribal 53,079 39 1 Contract health care program;
Council patient transportation services
Ninilchik 558,411 266 1 1 community health aide clinic;
Traditional contract health care program;
Council alcohol and mental health and
emergency medical services
Seldovia 807,305 392 1 Community health representatives;
Village contract health care program;
Tribe alcohol and mental health and
emergency medical services
Tanana 861,622 297 1 Midlevel clinic; alcohol and mental
Tribal health and emergency medical
Council services
Native 214,648 185 1 1 community health aide clinic;
Village of community health representatives;
Tyonek contract health care program;
alcohol and mental health and
emergency medical services
Yakutat 276,704 324 1 1 community health aide clinic
Tlingit (with a city-funded midlevel
Tribe provider); community health
representatives
=========================================================================================
Total $4,095,861 3,005 9
-----------------------------------------------------------------------------------------
\a These are Census-based population estimates for 1998 developed by
IHS. Alaska Natives living in "unspecified" areas and other
communities in the contractor areas are included in these counts.
\b Numbers of Alaska Native communities include federally recognized
tribes and villages as determined by BIA.
COMPARISON OF IHS-DETERMINED
FUNDING NEEDS FOR COMMUNITY AND
RHO CONTRACTORS
========================================================== Appendix IV
This appendix compares the recurring funding needs of the 12
community contractors that separated from RHOs with the funding needs
of the RHOs for managing the same programs. The total funding needs
include direct program costs and direct and indirect contract support
costs. A comparison of indirect cost needs is also provided since
this is the major cost category that can vary depending on who
manages the contract. The indirect cost need for each affiliated RHO
is estimated by applying the RHO's indirect cost rates to the
community contractor's program costs; it represents what the indirect
costs would have been if the services provided by the community
contractor had instead been managed by the RHO.
Table IV.1
IHS-Determined Funding Needs for
Community and RHO Contractors, Fiscal
Year 1998
Indirect costs as
percentage of total
Total funding needs Indirect cost needs funding needs
-------------------- -------------------- --------------------
Community Affiliated
contractor RHO Community RHO Community RHO Community RHO
---------- ----------- ---------- -------- ---------- -------- ---------- --------
Akiachak Yukon- $289,504 $284,274 $62,085 $56,855 21% 20%
Native Kuskokwim
Community Health
Corporatio
n
Chitina Copper 218,891 159,310 92,471 32,890 42 21
Tradition River
al Native
Village Associatio
Council n
Council of Tanana 2,290,874 1,436,40 974,280 119,810 43 8
Athabascan Chiefs 4
Tribal Conference
Governmen , Inc.
ts
Native Norton 165,831 119,198 63,780 17,147 38 14
Village Sound
of Health
Diomede Corporatio
n
Eastern Aleutian/ 1,482,830 1,344,58 381,729 243,481 26 18
Aleutian Pribilof 2
Tribes Islands
Associatio
n, Inc.
Hoonah Southeast 334,630 279,956 97,000 42,326 29 15
Indian Alaska
Associati Regional
on Health
Consortium
Karluk Kodiak Area 165,043 112,950 68,600 16,507 42 15
Tribal Native
Council Associatio
n
Ketchikan Southeast 3,879,901 3,446,89 955,878 522,870 25 15
Indian Alaska 3
Corporati Regional
on Health
Consortium
Native Yukon- 327,933 265,639 114,026 51,732 35 19
Village Kuskokwim
of Health
Kwinhagak Corporatio
n
Mt. Copper 682,175 617,344 198,363 133,532 29 22
Sanford River
Tribal Native
Consortiu Associatio
m n
St. George Aleutian/ 153,188 151,478 28,778 27,068 19 18
Tradition Pribilof
al Islands
Council Associatio
n, Inc.
Valdez Chugachmiut 148,521 122,236 50,810 24,525 34 20
Native
Tribe
=========================================================================================
Total $10,139,32 $8,340,2 $3,087,800 $1,288,7 30% 15%
1 64 43
-----------------------------------------------------------------------------------------
COMMUNITY CONTRACTORS' CONTRACT
SUPPORT COST SHORTFALLS
=========================================================== Appendix V
This appendix details the amount and the magnitude of CSC shortfalls
for each of the 21 community contractors. The amount of CSC
shortfall is computed by subtracting each contract's CSC funding from
its recurring CSC needs. The magnitude of each contractor's CSC
shortfall is shown by the percent of its recurring CSC needs that is
represented by the shortfall.
Table V.1
CSC Shortfalls of Community Contractors,
Fiscal Year 1998
Shortfall
as
percentage
Total Direct Recurring CSC of
funding program CSC funding CSC recurring
Contractor needs funding needs\a received shortfalls CSC needs
----------------- ---------- ---------- ---------- ---------- ---------- ----------
Akiachak Native $289,504 $227,419 $62,085 $60,141 $1,944 3%
Community
Chitina 218,891 119,167 99,724 87,542 12,182 12
Traditional
Village Council
Council of 2,290,874 1,316,594 974,280 461,074 513,206 53
Athabascan
Tribal
Governments
Native Village of 165,831 90,248 75,583 19,443 56,140 74
Diomede
Eastern Aleutian 1,482,830 1,031,701 451,129 209,084 242,045 54
Tribes
Hoonah Indian 334,630 207,480 127,150 41,365 85,785 67
Association
Karluk Tribal 165,043 88,748 76,295 76,295 0 0
Council
Ketchikan Indian 3,879,901 2,563,087 1,316,814 805,525 511,289 39
Corporation
Native Village of 327,933 206,929 121,004 121,004 0 0
Kwinhagak
Mt. Sanford 682,175 483,812 198,363 182,306 16,057 8
Tribal
Consortium
St. George 153,188 114,694 38,494 38,494 0 0
Traditional
Council
Valdez Native 148,521 97,711 50,810 59,752 0\b 0
Tribe
Chickaloon 46,327 30,727 15,600 15,600 0 0
Village
Native Village of 162,008 111,517 50,491 24,094 26,397 52
Eklutna
Kenaitze Indian 1,142,243 929,636 212,607 212,518 89 0
Tribe
Knik Tribal 53,079 36,122 16,957 16,957 0 0
Council
Ninilchik 582,673 301,325 281,348 257,086 24,262 9
Traditional
Council
Seldovia Village 893,911 606,061 287,850 201,244 86,606 30
Tribe
Tanana Tribal 898,816 679,648 219,168 181,974 37,194 17
Council
Native Village of 214,648 159,911 54,737 54,737 0 0
Tyonek
Yakutat Tlingit 282,562 186,817 95,745 89,887 5,858 6
Tribe
=========================================================================================
Total $14,415,58 $9,589,354 $4,826,234 $3,216,122 $1,610,112 33%
8 \b
-----------------------------------------------------------------------------------------
\a Recurring CSC funding needs do not include start-up costs.
\b Valdez Native Tribe had a CSC surplus of $8,942, which reduced the
total CSC shortfall from $1,619,054 to $1,610,112.
(See figure in printed edition.)Appendix VI
COMMENTS FROM THE INDIAN HEALTH
SERVICE
=========================================================== Appendix V
(See figure in printed edition.)
*** End of document. ***