By: Thamys Gaertner
The United States Government Office Accountability Office (GAO) issued a report in February 2016 analyzing the disturbing costs and problems of the current on-site and off-site medical care in immigration detention facilities across the United States. U.S. Gov’t Accountability Office, GAO-16-231, Immigration Detention: Additional Actions Needed to Strengthen Management and Oversight of Detainee Medical Care (2016).
During 2015, ICE held about 28,000 detainees per day in over 165 facilities. Id. at 6. In line with what has previously been reported on crimmigration.com, each immigration detention facility has its own contract with its own applicable set of standards for inspection. This means that facilities of the same type may be inspected using different sets of standards with different requirements. These inspection standards are used to manage the conditions of confinement, including the provision of on-site and off-site medical care by the ICE Health Service Corps (IHSC), the organization responsible for providing direct care to nineteen facilities designed to house people for more than seventy-two hours and supervising care at the remaining 146 facilities. Id.
To provide some measure of uniformity to this hodgepodge detention network, the GAO report focuses on three overarching questions about DHS’ oversight of medical care in immigration detention centers.
Issues and Findings
First, the GAO examined DHS’ processes for administering detainee medical care and maintaining cost information for care. Id. at 12. As required by federal law and detention inspection standards, all facilities that house detainees for over 72 hours, regardless of detainee population, must provide an on-site medical clinic. Id.
According to the Federal Financial Management System accounting system, the total cost for medical care at only the nineteen IHSC-staffed facilities in 2015 was $206 million. Id. at 15. At the remaining 146 facilities, the costs are covered by a set fee per day per detainee paid by ICE. Id. Determined in contracts with individual detention center operators, these fees vary from facility to facility, complicating ICE’s attempts to determine medical costs across facilities. Id. In 2014, ICE promised to develop appropriate internal controls for tracking and managing detention facility cost, but as of January 2016 it had not. Id.
Regardless where they are held, detainees frequently request medical care provided off-site ranging from dental visits to surgical procedures. There are big discrepancies between requests for off-site medical care and payouts for off-site medical care that result from DHS’ failure to adopt a straightforward method of deciding which claims to approve and then paying them. IHSC uses an electronic system, the Medical Payment Authorization (MedPAR) protocol, to approve or deny off-site care requests for detainees Id. at 16. Meanwhile, ICE uses the Veterans Affairs Financial Services Center (VAFSC) to actually pay out claims to off-site medical providers. Id. at 19. These separate systems seriously limit ICE’s ability to determine where to allocate appropriate resources for outside medical care. Id. at 18. For example, from 2012-2014 ICE claims that it paid out $24 million per year for off-site medical care. Id. at 19. Yet the number of claims paid through VAFSC did not match the number of request approvals through MedPAR. Id. There were 144,000 more claims paid than actual requests received in MedPAR. Id. Another example shows that 326 MedPAR requests were approved in 2012 and 9,675 claims were paid in VAFSC. Id. The GAO describes this discrepancy as a serious issue and acknowledges that many times one individual MedPAR request may be associated with multiple claims to be paid. Id. Also, the GAO noted that some billing providers pay claims in a different fiscal year than when the actual approval was issued. Id. These do not entirely explain the large amount of discrepancies; thus, the GAO recommends a more inter-related analysis of the off-site care to help ensure that off-site requests are approved or denied consistently across facilities. This is crucial because the adjudication of requests is done by simple professional judgment and there are no formal guidelines for these determinations. Id. at 18.
Second, the GAO examined how DHS monitors and assesses compliance with medical care standards across immigration detention facilities. Primarily through contractors employed by its Custody Management Division (CMD), ICE periodically inspects facilities to measure their compliance with the National Detention Standards (NDS) issued in 2000, Performance Based National Detention Standards (PBNDS) issued in 2008 and updated in 2011, or Family Residential Standards, whichever standards apply to the particular facility. Id. at 21. In 2015, ninety-nine percent of the average daily population (ADP) of detainees was covered by one of these standards for inspections. Id.
Despite gathering data about detention center compliance with medical care standards, the GAO reported that ICE does not use this data in a way that would facilitate decision-making across all immigration detention facilities. Id. at 26. Field Medical Coordinator programs conduct site visits every sixth months to assess the quality of on-site medical care at facilities. Id. at 23. An FMC official stated that FMC programs are limited in resources and that, “FMCs are more focused on resolving local, facility-specific medical care issues than looking at issues across facilities.” Id. at 27. FMC officials acknowledge the value in conducting analyses across facilities, but stated that their priority was to resolve issues within individual facilities rather than examine data across all facilities. Id. ICE’s Office of Detention Oversight (ODO) and IHSC conduct their own independent analyses, but again these do not address systemic issues across all immigration facilities. Id. at 26.
ICE further reduces the usefulness of inspections by doing next to nothing with data that it gathers from facilities housing, on average, ten detainees or less per day. These facilities complete an annual Operational Review Self-Assessment (ORSA). Id. at 23. ORSA forms are scanned and stored electronically, but CMD officials stated that they do not currently track any repeat findings noted on ORSA forms. Id. Indeed, ICE has not analyzed or conducted an evaluation of any received ORSAs since 2012. Id. at 27. ICE management cannot assess the medical care performance across time or contract type. This oversight limitation hampers ICE’s ability to plan and manage overarching changes to detainee medical care. Id. at 28.
Third, the GAO examined DHS’ processes to obtain and address complaints about detainee medical care. Id. Although DHS has established various avenues for immigration detainees to file medical complaints, DHS does not have any tool that can analyze the overall volume of complaints it receives, their status, or outcome. Id. at 36. An immigration detainee can file a medical care complaint through multiple formal or informal means. Id. ICE detention standards require all facilities to maintain grievance logs to document all complaints filed and their dispositions. Id. at 29. Problems arise from the immensely complex process for investigating, distributing, and addressing complaints once submitted by a detainee. In 2014, the five DHS entities that received complaints via phone, e-mail, mail, and fax tallied a total of 1,350 medical complaints. Id. at 31. Most of those medical care complaints are forwarded to IHSC which is responsible for addressing and investigating complaints. Id. at 34. IHSC manages medical care complaints through a very casual process of e-mail folders and Excel spreadsheets. Id. IHSC is unable to create a complaint count that determines what the source for each complaint is without going through each complaint’s text. Id. IHSC stated that they plan to develop and launch a new complaint tasking management system in 2016, but it is yet to be finalized. Id. at 36.
GAO directs DHS and ICE to the following three recommendations in order to make better business decisions.
- Develop and implement a mechanism to identify and assess trends in off-site medical care procedures across types of procedures and facilities;
- Develop and implement a mechanism to ensure that payments for off-site care are supported by the appropriate authorizations; and
- Track inspection results and conduct analyses of oversight data over time, by standards, and by facility type. Id. at 37-38.
This GAO report has exposed how DHS has allowed for medical care to become inconsistent, uninspected, and below standards across hundreds of immigration detention facilities. Immigration detainees need to have their concerns heard, addressed, and communicated regardless of what facility they are in. Therefore, it is only a matter of time that will show whether DHS is truly dedicated to improving detention medical conditions across the country or whether it will simply keep pushing these problems along until there will be no fix. In the meantime, thousands of immigrant detainees sit and wait with no guarantee that when a medical emergency strikes, they will be helped.
Thamys Gaertner is a second-year law student at the University of Denver Sturm College of Law. Thamys is currently completing an externship with the Rocky Mountain Immigrant Advocacy Network. She is passionate about immigration law and will dedicate her career to immigration law.
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