DHS: Organizational Structure and Resources for Providing Health Care to Immigration Detainees.

GAO-09-308R February 23, 2009

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). For fiscal year 2004 through fiscal year 2007, ICE reported that 69 detainees died while in ICE custody, and during 2008, national news organizations investigated and published reports of the circumstances surrounding several detainee deaths. Other reports have also outlined concerns about the health care provided to detainees. For example, in 2007, the DHS Office of the Inspector General (OIG) found problems with adherence to ICE's medical standards at two ICE facilities it reviewed where detainee deaths had occurred. Additionally, members of Congress, the media, and advocacy groups have raised questions about the health care provided to detainees in ICE custody. An explanatory statement accompanying the fiscal year 2009 DHS appropriations act directed ICE to fund an independent, comprehensive review of the medical care provided to persons detained by DHS and identified $2 million for that purpose. ICE was created in March 2003 as part of DHS. From fiscal year 2003 through fiscal year 2007, the average daily population of detainees in ICE custody increased by about 40 percent, with the most growth occurring since fiscal year 2005. In fiscal year 2007, ICE held over 311,000 detainees at more than 500 detention facilities. Most of these were Intergovernmental Service Agreement (IGSA) facilities--state and local jails under contract with ICE to hold detainees. Some ICE detainees received health care services from IGSA staff, IGSA contractors, or community medical providers, and other ICE detainees received health care provided or arranged by the Division of Immigration Health Services (DIHS). DIHS is mainly comprised of contract employees and officers from the U.S. Public Health Service (PHS) Commissioned Corps--a uniformed service of public health professionals who are part of the Department of Health and Human Services (HHS) and who provide services in different settings, including ICE detention facilities. In light of questions about the health care provided to detainees in ICE custody, Congress requested information about ICE's organizational structure and its health care resources for detainees. This report provides (1) a description of ICE's organizational structure for providing health care services to detainees, which includes our review of the relevant agreements between DHS and HHS regarding DIHS; (2) information about ICE's annual spending and staffing resources devoted to the provision of health care for detainees, and the number of services provided; and (3) an assessment of whether ICE's mortality rate can be compared with the mortality rates of the Federal Bureau of Prisons (BOP) and the U.S. Marshals Service (USMS)--two entities that are responsible for holding certain persons, such as criminals.

ICE's organizational structure for providing health care to detainees is not uniform across facilities. In fiscal year 2007, 21 DIHS-staffed facilities provided or arranged for health care for about 53 percent of the average daily population of detainees, while 508 IGSA facilities provided or arranged for health care for the remaining detainees--about 47 percent of the population. In addition, recent agreements with HHS reassigned medical personnel to DHS. DHS officials told us that a total of 565 direct health care providers and administrative staff were affected by these agreements. Although ICE's health care data are not complete, the available data on health care spending, staffing, and services provided generally showed growth in all three areas. For instance, from fiscal year 2003 through fiscal year 2007, reported expenditures for medical claims and program operations increased by 47 percent, while the average daily population of detainees increased by about 40 percent. ICE's mortality rate cannot be directly compared with BOP's or USMS's mortality rate. This is due to differences in the three agencies' health care goals and scopes of services, as well as to demographic differences among the ICE, BOP, and USMS detainee populations.