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entitled 'Department of Homeland Security: Organizational Structure, 
Spending, and Staffing for the Health Care Provided to Immigration 
Detainees' which was released on March 3, 2009.

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Before the Subcommittee on Homeland Security, Committee on 
Appropriations, House of Representatives: 

United States Government Accountability Office: 

For Release on Delivery: 
Expected at 10:00 a.m. EST:
Tuesday, March 3, 2009: 

Department of Homeland Security: 

Organizational Structure, Spending, and Staffing for the Health Care 
Provided to Immigration Detainees: 

Statement of Alicia Puente Cackley, Director: 
Health Care: 


Mr. Chairman and Members of the Subcommittee: 

I am pleased to be here today as you examine issues related to the 
health care provided to detainees held by U.S. Immigration and Customs 
Enforcement (ICE), a component of the Department of Homeland Security 
(DHS).[Footnote 1] For fiscal year 2004 through fiscal year 2007, ICE 
reported that 69 detainees died while in ICE custody, and during 2008, 
national news organizations investigated and published reports of the 
circumstances surrounding several detainee deaths. Other reports have 
also outlined concerns about the health care provided to detainees. For 
example, in 2007, the DHS Office of the Inspector General found 
problems with adherence to ICE's medical standards at two ICE 
facilities it reviewed where detainee deaths had occurred.[Footnote 2] 
Additionally, members of the Congress, the media, and advocacy groups 
have raised questions about the health care provided to detainees in 
ICE custody. An explanatory statement accompanying the fiscal year 2009 
DHS appropriations act directed ICE to fund an independent, 
comprehensive review of the medical care provided to persons detained 
by DHS and identified $2 million for that purpose.[Footnote 3] My 
remarks today are based on our report, released at this hearing, 
entitled DHS: Organizational Structure and Resources for Providing 
Health Care to Immigration Detainees.[Footnote 4] 

ICE was created in March 2003 as part of DHS.[Footnote 5] From fiscal 
year 2003 through fiscal year 2007, the average daily population of 
detainees in ICE custody increased by about 40 percent, with the most 
growth occurring since fiscal year 2005.[Footnote 6] In fiscal year 
2007, ICE held over 311,000 detainees at more than 500 detention 
facilities. Most of these were Intergovernmental Service Agreement 
(IGSA) facilities--state and local jails under contract with ICE to 
hold detainees. Some ICE detainees received health care services from 
IGSA staff, IGSA contractors, or community medical providers, and other 
ICE detainees received health care provided or arranged by the Division 
of Immigration Health Services (DIHS). DIHS is mainly composed of 
contract employees and officers from the U.S. Public Health Service 
(PHS) Commissioned Corps--a uniformed service of public health 
professionals who are part of the Department of Health and Human 
Services (HHS) and who provide services in different settings, 
including ICE detention facilities. 

In light of questions about the health care provided to detainees in 
ICE custody, you requested information about ICE's organizational 
structure and its health care resources for detainees. Our report 
provides (1) a description of ICE's organizational structure for 
providing health care services to detainees, which includes our review 
of the relevant agreements between DHS and HHS regarding DIHS; (2) 
information about ICE's annual spending and staffing resources devoted 
to the provision of health care for detainees, and the number of 
services provided; and (3) an assessment of whether ICE's mortality 
rate can be compared with the mortality rates of the Federal Bureau of 
Prisons (BOP) and the U.S. Marshals Service (USMS)--two entities that 
are responsible for holding certain persons, such as criminals. To 
address these issues, we reviewed pertinent government reports and 
interagency agreements regarding DIHS; interviewed agency officials; 
examined ICE's fiscal year 2003 through fiscal year 2007 data on health 
care spending, staffing, and services;[Footnote 7] and obtained 
information on ICE's mortality rate and the health care goals, 
services, and populations for ICE, BOP, and USMS.[Footnote 8] 

In summary, we found that ICE's organizational structure for providing 
health care to detainees is not uniform across facilities. In fiscal 
year 2007, 21 DIHS-staffed facilities provided or arranged for health 
care for about 53 percent of the average daily population of detainees, 
while 508 IGSA facilities provided or arranged for health care for the 
remaining detainees--about 47 percent of the population. Before October 
1, 2007, DHS and HHS maintained annual interagency agreements through 
which DIHS--a component of HHS's Health Resources and Services 
Administration (HRSA)--provided health care for ICE detainees. As of 
that date, the last annual interagency agreement was terminated, and 
DIHS no longer is a component of HRSA. DHS officials told us that this 
termination--along with a 2007 Memorandum of Agreement between HHS and 
DHS that placed PHS officers on detail to DHS on an open-ended basis 
and that allowed for additional PHS officers to be detailed to DHS in 
the future--affected 565 direct health care providers and 
administrative staff. According to DHS officials, ICE now has a 
component known as DIHS which provides health care services to 

We also found that although ICE's health care data are not complete, 
the available data on health care spending, staffing, and services 
provided generally showed growth in all three areas. For instance, from 
fiscal year 2003 through fiscal year 2007, reported expenditures for 
medical claims and program operations increased by 47 percent, while 
the average daily population of detainees increased by about 40 
percent. However, ICE facilities do not use standardized record 
keeping, and are not required to routinely report data to DHS on the 
health care services provided to detainees. Furthermore, data were not 
available on the detainee health expenditures that are incurred by 

In addition, we determined that ICE's mortality rate cannot be directly 
compared with BOP's or USMS's mortality rate. This is due to 
differences in the three agencies' health care goals and scopes of 
services, as well as to demographic differences among the ICE, BOP, and 
USMS detainee populations. 

Based on our work, we have identified a number of issues that may merit 
further assessment in the $2 million external study that ICE was 
directed to fund. These include: 

* ICE's ability to access detainee population data that measure unique 
individuals in ICE custody, rather than the average number of beds 

* Reporting relationships between DIHS and ICE; 

* IGSA reporting requirements--including the frequency of reporting on 
health care services provided to detainees and the format in which 
health records are maintained; 

* ICE's ability to routinely ensure the transfer of medical records 
when detainees are transferred between facilities; 

* ICE's ability to identify and report the detainee health care costs 
incurred by IGSAs; and: 

* ICE's ability to identify and report medical claims expenditures by 
facility type--such as for all IGSAs. 

After reviewing the draft report, DHS provided general comments and 
both DHS and HHS provided technical comments. DHS did not comment as to 
whether the issues we identified as meriting further assessment would 
be addressed in the $2 million external study. However, DHS disagreed 
with the way we presented some information. Specifically, the agency 
commented that we mischaracterized DIHS's relationship with HHS and DHS 
and that our report could lead to the incorrect conclusion that DIHS 
was transferred from HHS to DHS. DHS also stated that we 
mischaracterized the degree of control ICE has over detainee health 
care providers, ICE's ability to track the cost of health care services 
for detainees held at IGSAs, and other issues. After considering the 
agency's comments and our evidence, we maintain that the report 
appropriately describes ICE's organization, management structure, and 
ability to monitor health care spending. A complete discussion of DHS's 
comments and our evaluation are provided in the report. 

Mr. Chairman, this concludes my prepared remarks. I would be happy to 
answer any questions that you or other members of the subcommittee may 

For future contacts regarding this statement, please contact Alicia 
Puente Cackley at (202) 512-7114 or at Contact points 
for our Offices of Congressional Relations and Public Affairs may be 
found on the last page of this statement. Rosamond Katz, Assistant 
Director; Joy L. Kraybill; and Kevin Milne also made key contributions 
to this statement. 

[End of section] 


[1] Under the Immigration and Nationality Act, ICE is authorized to 
arrest, detain, and remove certain individuals from the United States. 
8 U.S.C. §§ 1226, 1227, 1229, 1229a, 1231, and 1357. We refer to these 
individuals as "detainees." 

[2] Department of Homeland Security, Office of the Inspector General, 
ICE Policies Related to Detainee Deaths and the Oversight of 
Immigration Detention Facilities (Washington, D.C., June 2008). 

[3] See Comm. Print of the Comm. on Approp., U.S. House of Rep., 
Explanatory Statement related to the Consolidated Security, Disaster 
Assistance, and Continuing Appropriations Act, 2009, Pub. L. No. 110- 
329, Div. D., p. 636 (Oct. 2008). Section 4 of Pub. L. No. 110-329 
provides that the Explanatory Statement shall have the same effect with 
respect to the allocation of funds and the implementation of the act as 
if it were a joint explanatory statement of a committee of conference. 

[4] [hyperlink,] (Washington, 
D.C.: Feb. 23, 2009). 

[5] Responsibility for detainees was transferred from the Department of 
Justice's Immigration and Naturalization Service to DHS's ICE. 

[6] The scope of our work was primarily limited to detainees who were 
in ICE custody because of immigration violations and who were held at 
facilities that serve adults. Some of these facilities are owned and 
operated by ICE, some operate under contracts with ICE, and some 
operate through service agreements with ICE. 

[7] We assessed the data DHS provided and we worked with DHS to address 
discrepancies. Subsequently, we determined that the data we used were 
sufficiently reliable for our purposes. Throughout our work, we used 
data on the average daily population--the number of beds ICE used for 
detainees on an average day during a fiscal year--because ICE was not 
able to provide reliable data on the number of unique individuals 
detained per fiscal year. 

[8] We conducted our work from July 2008 to February 2009 in accordance 
with all sections of GAO's Quality Assurance framework that are 
relevant to our objectives. The framework requires that we plan and 
perform the engagement to obtain sufficient, appropriate evidence to 
meet our stated objectives and to discuss any limitations in our work. 
We believe that the information and data obtained and the analysis 
conducted provide a reasonable basis for any findings and conclusions. 

[End of section] 

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