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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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