Introduction

Purpose

Background

Study Requirements

Methodology

Findings

A Self-Governance Demonstration Project is Feasible

Costs Will Likely Outweigh Potential Savings Under a Demonstration

Recommendations

Programs

Demonstration Design

Methods to Assure Quality and Accountability

Appendix A

Appendix B

Appendix C

Appendix D

Appendix E

Appendix F

Appendix G

PURPOSE
To determine the feasibility of a tribal self-governance demonstration project for appropriate programs, services, functions, and activities (or portions thereof) of the Department of Health and Human Services (HHS).

BACKGROUND

History of Tribal Self-Governance Legislation
In 1970, President Nixon, in a "Special Message to Congress on Indian Affairs," laid the foundation of a new federal policy to promote tribal self-determination. Since that time, the policy of the federal government has been to promote tribal self-determination. As a major first step, the Indian Self-Determination and Education Assistance Act (the Act) was passed in 1975 to allow tribal management of programs that previously had been managed on their behalf by the Departments of the Interior (DOI) and Health, Education, and Welfare. Specifically, Title I of the Act authorized tribes to assume management of programs in the Bureau of Indian Affairs (BIA) and Indian Health Service (IHS) through contractual agreements with the two agencies. For the IHS, programs that could be contracted included hospitals, clinics, dental services and prevention and health promotion services. Under theses contracts, tribes assumed full responsibility for planning, conducting, and administering the contracted programs, including hiring personnel, delivering services, record keeping, and other administrative functions.

Subsequent amendments to the Act extended the scope of tribal control over BIA and IHS programs. A 1988 amendment to the Act (Title III) created the first "Tribal Self-Governance Demonstration Project" in the DOI. Under the demonstration, tribes were authorized to consolidate multiple contracts and grants into a single funding agreement and assume control over decision-making and management of BIA programs, services, functions, and activities previously managed by the agency. Most significantly, the demonstration provided tribes with broad flexibility to use the resources under the agreement, including the flexibility to consolidate and redesign programs to better meet tribal needs. In 1994, the success of the demonstration was recognized and Congress amended the Act to create a permanent self-governance authority in BIA. In 1996, the Act was again amended to allow tribes to take over control and management of programs in the DOI outside the BIA.

In the meantime, 1992 amendments to the Indian Health Care Improvement Act extended the Title III self-governance demonstration to the IHS and its programs. The Tribal Self-Governance Amendments of 2000 (P.L. 106-260) confirmed the success of the self-governance demonstration in the IHS by the passage of Title V of the Act, making tribal self-governance permanent within the IHS.

The amendments of 2000 also added Title VI (Appendix A) to the Act, requiring that the Secretary of HHS "conduct a study to determine the feasibility of a tribal self-governance demonstration project for appropriate programs, services, functions, and activities (or portions thereof ) of the agency [HHS]." This Title applies to non-IHS programs administered by the Department. Title VI also delineates what the Secretary must consider in conducting the study and requires a joint federal/tribal stakeholder consultation process. This report addresses the Title VI study and report requirements.

Self-Governance Goals
Tribal self-governance is an expansion of self-determination with notable changes in how federal funding is received and expended by tribes. Tribes have described tribal self-governance as a "new partnership" between the federal government and tribes. As defined by Congress in P.L. 106-260, the goal of self-governance is "to permit an orderly transition from Federal domination of programs and services to provide Indian tribes with meaningful authority, control, funding, and discretion to plan, conduct, redesign, and administer programs, services, functions, and activities (or portions thereof) that meet the needs of the individual tribal communities." In practice, self-governance has two basic parts: 1) the transfer of the responsibility for managing Federal programs (and funds) that serve Indians from existing service providers to the tribes, and 2) providing tribes with the broad authority to redesign federal programs and reallocate federal resources to more effectively and efficiently meet the needs of tribal communities.

Department Programs
Title VI requires an assessment of the feasibility of expanding self-governance to HHS programs and activities beyond those in the IHS. Currently, HHS comprises 10 major agencies and a number of staff offices. These agencies have jurisdiction over more than 300 different programs, ranging from highly specialized medical research to the provision of health and social service benefits to individuals. As a prelude to the study, an inventory of all non-IHS programs was compiled. Throughout the study, the inventory provided a baseline of programs to assess the feasibility for self-governance.

STUDY REQUIREMENTS

To determine the feasibility of a self-governance demonstration project for appropriate programs, services, functions, and activities (or portions thereof) of the Department of Health and Human Services, Title VI requires that the Secretary consider the following: 1) the probable effects on specific programs and program beneficiaries of such a demonstration project; 2) statutory, regulatory, or other impediments to the implementation of such a demonstration project; 3) strategies for implementing such a demonstration project; 4) probable costs or savings associated with such a demonstration project; 5) methods to assure quality and accountability in such a demonstration project; and 6) other issues determined by the Secretary or in consultation with Indian tribes.

The study report must include the results of the feasibility assessment and a list of the HHS programs, services, functions, and activities (or portions thereof) that would be feasible to include in a self-governance demonstration project. The list must indicate which programs would be feasible to include both with and without amending statutes or waiving regulations that the Secretary may not waive. In the case of those programs and other functions that could be included only with amending statutes or waiving regulations that the Secretary may not waive, the study must identify legislative actions required to include those programs.

In conducting the study, the Secretary is required to consult with tribes, States, counties, municipalities, program beneficiaries, and interested public interest groups. Consultations are jointly conducted by the Secretary and tribes. At the conclusion of the study, the legislation allows for separate and direct recommendations from the tribes and other entities with respect to the conclusions of the Secretary regarding a self-governance demonstration project.

METHODOLOGY

Program Feasibility
The study must identify HHS programs, services, functions, and activities (or portions thereof) that are feasible for inclusion in a self-governance demonstration project. The study recommends eleven existing HHS programs for inclusion in a demonstration. The recommendation is based on a number of considerations. First, except in the area of substance abuse and mental health programs, transfer of the programs to tribal authority has already taken place. In this respect, the primary issue of self-governance for a demonstration is not the transfer of program authority, but the issue of flexibility, control over priorities, and administrative simplification. Tribes have a demonstrated record in managing these programs and no studies or other evidence exists to suggest that tribes are not managing these programs satisfactorily. Second, there are no insurmountable legal barriers that were identified that would preclude inclusion of these programs in a demonstration under the recommended design, although it will be necessary to make certain provisions in the existing program statutes and regulations inapplicable to the tribes participating in a demonstration in order to implement the recommended design (see Appendix E). A cited provision in a program statute or regulation can be made inapplicable to the tribes participating in a demonstration project through either a provision in the legislation authorizing the project or amendment of the statute authorizing the program or programs in question. Third, based on consultation with the tribes, the tribes feel these programs address significant needs facing their communities. Fourth, most of these programs have well-established processes for arriving at tribal funding amounts, thereby avoiding the IHS and BIA difficulties in determining funding levels. Finally, consideration was given to the number of programs that were successfully managed under the BIA and IHS demonstrations. The number was small in each case, less than 10 programs. Using the BIA and IHS demonstrations as a proxy, it appears that a demonstration within that range of programs is feasible. The manageability of a larger demonstration, in terms of programs, is unknown and could impose more risk.

Impact on Programs and Beneficiaries
The Secretary is required to consider the probable effects of a demonstration on specific programs and program beneficiaries in determining the feasibility of a demonstration project. To determine probable effects, information was mined from a number of federally and privately sponsored studies and reports that examined the self-governance experience in the BIA and IHS and tribal management of non-IHS programs in HHS. These are summarized in the impact section of this report and a comprehensive list of the studies and reports that were consulted is provided at Appendix B.

While most of the existing studies focus on BIA and IHS self-governance programs, the studies are used as a proxy to assess the ability of tribes to manage programs, assure program quality and accountability, and serve beneficiaries under a self-governance demonstration for non-IHS programs. For the most part, the studies are qualitative, based on personal accounts of staff and clients of self-governance programs. No quantitative assessment of client outcomes, program quality or access to services under self-governance currently exists. One recommendation of this study is for Congress to require a comprehensive evaluation of a demonstration project as part of any legislation authorizing a demonstration.

Costs and Savings
The study requires an assessment of the probable costs and savings of the project. Again, much of the information for this assessment is derived from the BIA and IHS experience with self-governance. Costs and savings have been quantified to the extent that data is available. Some elements of costs and savings were not quantifiable due to lack of reliable data. The specific methodology used to arrive at a cost or savings projection is incorporated in the discussion of the cost or savings element.

Consultation
Congress provided a significant role for stakeholder consultations in the development of the study findings. In light of this, stakeholders were consulted on key study issues such as what HHS programs should be included in a demonstration, the potential impact of a demonstration on beneficiaries, and the design of a demonstration. The consultation process included a variety of stakeholders such as tribes, state government organizations and program managers within HHS. The process was used not only to solicit opinions on particular issues of design and programs, but to try to reach a consensus, to the extent possible, on the recommendations that are in this report. Therefore, the consultation process and the opinions and recommendations of the stakeholders played a significant role in reaching the conclusions of the study.

Consultations were carried out jointly by a tribal advisory group and HHS staff. An initial consultation protocol (Appendix C) was jointly developed by HHS staff and the tribal advisory group. The protocol served as the basis for the consultation process. The leader of the tribal advisory group, Merle Boyd, and the HHS study leader, Dr. Delores Parron, served as joint chairpersons of the consultation process.

Initially, four regional tribal consultation meetings were held, followed by a consultation meeting with representatives of state and local government organizations. A meeting with non-governmental organizations representing health and human service professional associations and beneficiaries was also held. Finally, a national wrap-up session for all interested stakeholders was held in Washington, D.C. Written invitations to the tribal sessions were extended to more than 950 tribes and tribal organizations. Some 20 organizations representing state and local governments were invited to the state and local government session. Over 180 non- governmental organizations were invited to that session. All stakeholder organizations were invited to the national wrap-up session. Transcripts of each session are available at the study website (http://aspe.hhs.gov/SelfGovernance) and Appendix D provides additional information and details regarding each session. Written comments were also solicited from all stakeholder organizations at various stages of the study, including during initial consultations and on a formal draft of the report.

Throughout the study, a study website (see above) was maintained. It included background information on the study, information on meetings and meeting transcripts, as well as drafts of study issue papers. Stakeholders were provided the website address and were encouraged to regularly visit the site for up-to-date developments and information.

Study results indicate that a self-governance demonstration project for non-IHS programs, services, functions, and activities (or portions thereof) of HHS is feasible, provided that the statutory changes listed in Appendix E are made. To arrive at that conclusion, a number of factors were considered. The probable effects of a self-governance demonstration on beneficiaries weighed considerably in the conclusion. The opinions and recommendations of potential stakeholders also were important. A determination that a number of HHS programs could reasonably be part of a demonstration was critical to the conclusion. While it is recognized that these factors are qualitative to a great extent, Congress placed considerable weight on these factors, especially the consultation process, when authorizing the study. Findings relevant to each of these factors are discussed below in detail.

A Demonstration Would Likely Have a Positive Effect on Programs and Program Beneficiaries, Although Some Problems May Exist.

Most extant studies of the impact of direct tribal management of federal programs conclude that tribal assumption of program operations generally has had a positive effect on program beneficiaries. This conclusion must, however, be qualified. The extant studies are primarily qualitative in nature, based on interviews with tribal officials, and do not provide quantitative data on service outcomes, such as the number of clients served or beneficiary health and well-being. Also, the number of studies that have looked at the impact of tribal assumption of program operations on beneficiaries is limited and the study samples are not nationally representative.

With this caveat, a summary of what is known about the probable effect of a self-governance demonstration project on beneficiaries follows. As mentioned earlier, a bibliographical reference to these reviewed studies is provided in Appendix B.

• A General Accounting Office (GAO) study of individual tribal community health contracts in Alaska concluded that service levels were not greatly affected by the switch from IHS Regional Health Organizations to community-run programs, although existing problems with the inadequate reimbursement of indirect costs have the potential to affect service levels if tribes begin to move program funds to cover shortfalls in indirect costs. (GAO/HEHS-98-134)
• A review of the tribal Child Care Development Fund (CCDF) grants by the HHS Office of the Inspector General found that such grants increased access to child care in their service areas. This was done in several ways. For example, a number of tribes chose to administer certificate programs that maximize the number of children served by paying lower rates to providers. Tribes also chose to extend services to tribal members not eligible for the State programs, rather than supplanting the State services. This was done by expanding eligibility criteria beyond those that are set by the States and by setting copayments below State levels to make services affordable to those who could not afford State copayments. Tribal programs were found to be more culturally sensitive than State-run programs. (OEI-05-98-00010)
• A report by the National Indian Health Board (NIHB) looked at the impact of self-governance on beneficiaries by comparing compacting, contracting and IHS direct-service experiences over several years. The information was based on questionnaires submitted by tribal leaders and health care directors. Study results for the study period showed that tribally-operated health care systems substantially improved access to services: 50% of tribally-operated systems reported a net increase in community-based programs; 100% added at least one new clinical service; 34% had more auxiliary services; and 100% had at least one new prevention program, with 68% having more than one additional prevention program. In addition, the contracting and compacting tribes in the study added a net total of 37 facilities - about 44% of the contracting and compacting tribes in the study. The survey also found that some 93-95% of compact and contract tribal leaders and health directors felt quality of care (waiting time, types of services, number of people served and overall health care system) had improved during the term of study. This is compared to 62% for IHS direct-service tribes. (Tribal Perspectives on Indian Self-Determination and Self-Governance in Health Care Management, NIHB,1998)
• Based on interviews and available tribal records, an independent evaluation of the first year of the BIA self-governance demonstration project (1991) showed evidence of increased program and service availability. However, little information was available to compare client experiences before and after tribal assumption of services. (Independent Assessment Report on the Self-Governance Demonstration Project, The Center for the Study of American Indian Law and Policy, University of Oklahoma and The Center for Tribal Studies, Northeastern State University at Tahlequah Oklahoma, unpublished)
• Reflecting its earlier warning, a subsequent GAO study (GAO/HEHS-98-134), based on interviews with tribal and federal staff, concluded that tribes had begun to use either program funds or other tribal resources to support shortfalls in indirect costs. The effect had been either to reduce services to tribal members, if program funds were used as an offset, or to preclude the use of tribal resources to supplement program funds or support other activities to help tribal members. Examples given included: reductions in staff salaries; the inability to offer salaries sufficient to attract qualified personnel, filling positions with unqualified or under qualified personnel; and unfilled positions - all of which could have an eroding effect on access and quality of services to beneficiaries. (GAO/RCED-99-150)
• In the course of conducting the current feasibility study, BIA and IHS employees were interviewed and asked for their assessment of how self-governance had affected program beneficiaries. Most indicated that, although they lacked empirical data to support their conclusions, they believed self-governance overall had been positive.

A final note with respect to the potential impact of a demonstration is necessary. Many of the cited studies also mention the positive benefit that self-governance has on the roles and capabilities of tribal governments. While this may not relate directly to service levels, it is an important benefit that should not go unmentioned.

Stakeholders Do Not Oppose a Tribal Self-governance Demonstration if Concerns Are Addressed.

In the course of consultations on the feasibility of a demonstration, stakeholders did not disagree that a demonstration is feasible (transcripts of the sessions are available on the website cited earlier). While this was the case, stakeholders also raised a number of issues regarding the need to design a demonstration that would address concerns about program impact, quality and identity. For example, State and local government stakeholder organizations were especially concerned about dual eligibility and program accountability. These and other stakeholder concerns were considered and are addressed in the study recommendations.

Statutory Changes Would Be Needed to Include a Number of HHS Programs in a Demonstration.

While specific programs are identified and listed as feasible for inclusion in a self-governance demonstration project, it is important to note that their inclusion is recommended in conjunction with specific demonstration design recommendations that will provide important protections for program identity and quality. Further, specific statutory changes in virtually all of the programs will be needed before they can be included in a demonstration with the recommended design. Appendix E lists the necessary statutory changes. In general, the changes appear to be ones that can be addressed.

COSTS WILL LIKELY OUTWEIGH POTENTIAL SAVINGS UNDER A DEMONSTRATION

The BIA and IHS demonstration experiences are used as a proxy to approximate what may happen to costs under a demonstration. Both demonstrations reasonably resemble the size and scope of the recommendations in this study and their use as a proxy is intended to illustrate a general range of what might happen. The actual scope of a demonstration that is authorized would determine costs more precisely. In this respect, both the BIA and IHS self-governance experiences indicate the likelihood that a self-governance demonstration project will require funding above current levels in several cost categories. It is also probable that the cost of a demonstration will exceed any realized savings from self-governance, at least in the short term (savings, if they occur, would more likely be long term). Since none of the targeted programs include direct Federal delivery of services, but rather are components of a Federal/State/Tribal partnership, there also will be no apparent immediate savings in Federal administrative costs (see pp. 13-14).

Costs
Possible costs of a demonstration project fall into five cost categories: startup, including tribal planning and negotiation costs; project management; direct; indirect; and matching costs.

• Startup

  Before entering a demonstration project, tribes will need to assess their capacity to enter into a self-governance agreement. This includes identifying tribal law or tribal organization changes that may be needed, management systems improvements that must be made, or other changes necessary prior to the assumption of program responsibility. Tribes also will need to prepare and submit self-governance proposals, negotiate self-governance agreements with HHS, and implement identified management changes and improvements after startup. All of this will require tribes to incur startup costs for which they are unlikely to have sufficient tribal resources.

  Because of the limited resources of many tribes, both BIA and IHS have made small, one-time grants available to tribes to cover startup costs. In IHS, $50,000 planning grants were offered to tribes to defer the costs of assessing capacity, developing proposals and identifying and implementing management changes. An additional $20,000 grant is available for covering the cost of negotiating initial self-governance agreements with HHS. During consultations with the tribes on design issues, the availability of similar grants was identified as essential by the tribes for a demonstration project. If authorized, $3.5 million would be needed to provide a planning and negotiation grant to each of the 50 tribes or tribal consortia participating in a demonstration based on the IHS model. If a demonstration was later made permanent, a much larger number of tribes would probably choose to participate, increasing the cost proportionally.

• Project Management

  Design recommendations for a demonstration (see the recommendations section of the study) include a single point of contact in HHS for project management. During stakeholder consultations, tribes were especially vocal about the need for this structure. Under this design, a single office in HHS would be assigned the responsibility for management of a demonstration project, including policy development, leading negotiations, technical assistance, financial management, and project oversight.

  Currently, both BIA and IHS have offices dedicated to the management of their self-governance programs. Both offices have workloads similar to what might be anticipated under a demonstration and are almost identical in size. Therefore, the cost of these offices is assumed to be a good proxy for the cost of a project management office for a demonstration. Based on this assumption, the annual cost of supporting a project office would be about $1.2 million annually.

  Not included in the office estimate are additional project costs for travel to sites for negotiation of initial and annual agreements. Assuming an average of 50 negotiations annually, teams of five federal negotiators (similar to the IHS experience), and an average per person cost of $1,500, annual travel costs to the project would average about $375,000. Also, not included in the office estimate are legal support costs. The cost of legal staff to review agreements and waiver requests, assist with negotiations, and address other legal issues that are likely to arise during the course of a demonstration is estimated at $1,000,000 annually (the equivalent of six full-time staff based on the IHS experience).

  Finally, the cost of an evaluation of a demonstration project (see the recommendations section of the study) is likely to be about $1,000,000 annually, including costs to help tribes meet data collection requirements of the evaluation. All stakeholders agreed that a comprehensive evaluation is needed to assess the results of a demonstration. Tribes were especially concerned that additional resources be available if data collection requirements were significant.

  The cost to tribes of data collection and reporting related to performance measurement requirements (see recommendations section) is not included as a cost, since existing program funds can be used for data collection and reporting related to program outcomes.

  In total, annual project management costs are estimated to be about $3.575 million annually during the period of a demonstration. One time costs of up to $3.5 million would be needed for tribal planning grants.

• Direct Costs

  Of the programs recommended for inclusion in a demonstration project (see recommendations section), tribes currently are eligible for and receive funding under all eleven of the programs. In all but one, funds are already set aside for tribal grantees.

• Indirect Costs

  A number of recent studies have documented the problems tribes encountered during the BIA and IHS self-governance experience in receiving full reimbursement for indirect costs (see GAO/HEHS-98-134, GAO/RCED-99-150 and GAO-01-249). The studies also highlight the potential impact of shortfalls in indirect costs. Either program or tribal funds may be diverted to cover shortfalls, resulting in a diminution of services or other development opportunities for tribal members.

  Full reimbursement of indirect costs is an issue for a tribal self-governance demonstration project. Eight of the programs identified as feasible to include in a demonstration currently have statutory or regulatory limits on administrative costs (see Appendix F) which may affect the ability of tribes to fully recover their indirect costs. Administrative costs can make up a substantial portion of a Tribe's total indirect costs. The magnitude of the potential problem caused by the limitation on administrative costs can be seen from a projection of the shortfall of indirect costs under tribal programs. Using an aggregate negotiated indirect cost rate of 25% for tribes by the DOI between 1989 and 1996 (the aggregate or average rate was cited by the GAO in a study of tribal indirect cost rates - GAO/RCED-99-150), and assuming that administrative costs sometimes comprise all of the indirect costs incurred by a tribal grantee, shortfalls in indirect costs could range from 0% to 20% for the eight programs that impose reimbursement limits. Tribes having indirect rates above the average rate of 25% would have significantly greater shortfalls.

  Three options are available to Congress to address the indirect cost issue. First, caps on administrative costs can be maintained, although the impact of caps may discourage participation in a demonstration by tribes with insufficient resources to offset shortfalls or force tribes to use tribal resources that otherwise could be used for services or other development purposes. Second, caps can be waived. This has the potential for diverting funds from program services to cover administrative costs. Third, caps can be waived, but additional funds provided to offset a potential shift of funds from services to indirect cost categories.

  If the last option is considered by Congress, the cost of a demonstration would be considerable. For example, administrative costs and development costs are limited to 15% of the Head Start program. Using the aggregate negotiated rate of 25%, an average shortfall in indirect costs for a grantee whose administrative and development costs comprise all of their indirect costs would be 10% of the grant award. For the Head Start program, 160 tribal grantees received a total of $171 million in FY 2001 grants, an average of a little more than $1.0 million per grantee. Applying the average indirect cost differential to the Head Start program and assuming 50 tribes or tribal consortia in a demonstration, the shortfall in indirect costs for one year would be about $5 million. While this is one example, there are seven other programs where similar costs would be incurred. If a demonstration were later made permanent, the cost of raising the allowable administrative and development cost rate from 15% to 25% for all 160 tribal Head Start Grantees could be as high as $16 million.

  Of the three options, the Department's recommendation is to maintain the status quo; i.e, administrative cost caps should be maintained. As stated, the two other options would have considerable consequences. The cost of a demonstration would rise significantly; or funds would be directed away from program services. These options would also mean that participating tribes would be treated differently than other recipients under the programs, including those tribes not participating in a demonstration project. What is recommended, to help balance the potential tribal need for indirect costs, is to allow tribes to consolidate indirect costs funds up to the total allowable from all programs and use those funds to cover any allowable indirect costs.

• Matching

  Four of the programs determined feasible for inclusion in a self-governance demonstration require that grantee funds match federal funds. These requirements currently apply to tribal as well as State grantees. Matching requirements range from 0% to 25%. For tribes with limited resources, matching requirements make participation in a demonstration project problematic, although several programs permit and do waive all or part of the matching requirement. Congress may want to consider this impact if a demonstration is authorized. Appendix F outlines current matching requirements for targeted programs.

Savings
In trying to assess probable savings that might accrue under a tribal self-governance demonstration project, potential savings from the transfer of program management to the tribes and program consolidation were examined. In doing so, the development of numerical estimates of savings was found to be impractical due to a lack of quantitative data on which to base estimates. However, from an analytical viewpoint, it does not appear that any substantial amount of savings is likely to accrue to offset the projected costs of a demonstration. An analysis follows.

• Program Efficiencies

  Much of the literature on self-government concludes that savings in management costs will accrue as tribes consolidate or simplify accounting, reporting, and other management structures under self-government agreements. For example, when tribes consolidated multiple contracts with IHS into single, self-governance compact agreements, savings in overhead expenses associated with the management of the separate contracts were believed to accrue. There is no clear evidence, however, to support that conclusion. While extant studies mention that possibility and some cite case examples, none provide quantitative evidence to that effect.

• Devolution of Federal Responsibility

  It is generally assumed that the transfer of program responsibility to tribes under self-governance will reduce the need for federal staff and other expenses and that the attendant savings can be transferred to the tribes for program use. This was the case as tribes exercised self-governance options in IHS. Technically, no actual savings accrue in this situation, nor were savings intended to accrue. Federal funds simply move from one provider (the federal government or other non-tribal entity) to another (the tribe). The process involves an offset and transfer of funds. A further discussion of this process is warranted to explain what tribes may or may not expect in the way of funds available for transfer under a demonstration.

  Fundamentally, there is a difference between the IHS experience and what can be expected under self-governance for non-IHS programs. The IHS is a direct service delivery program. IHS personnel directly provide health services to tribal members. As tribes take over service delivery from IHS, IHS personnel are no longer needed and attendant savings or personnel are transferred to the tribes.

  However, for the HHS programs recommended for inclusion in a demonstration project, federal personnel do not deliver services directly. Rather, these programs are carried out as either financial assistance (grant) programs or through contracts. Under these instruments, grantee or contract personnel deliver services. Therefore, under a self-governance demonstration, there would not be a corresponding reduction in federal staff as tribes assume responsibility for programs under a demonstration.

  On the other hand, it is probable that some grantees or contractors (State agencies for example) may experience savings if tribes begin to deliver services heretofore delivered by grantee or contract staff. However, it is not possible to provide an estimate of what savings might accrue for a particular program for a variety of reasons. Data to estimate the amount of funds currently spent by grantees or contractors serving tribal clients are not available. Also, most of the programs recommended for inclusion in a demonstration project already authorize tribes to receive grants or contracts to deliver services to tribal members and many tribes already are doing so. In these cases, no savings would accrue if the transfer of a program to tribal control takes place prior to the initiation of a demonstration project. Furthermore, it is not known which tribes would qualify under a demonstration and what programs they would want to include in a self-governance agreement. This uncertainty makes it impossible at this time to estimate the extent to which specific programs might devolve from existing grantees or contractors to a tribe and what attendant savings might be available for transfer to the tribe.

  With respect to the transfer of program responsibility and funds from existing grantees to tribes, it also should be noted that tribes may actually receive less funding in some cases. Specifically, in programs such as the Low Income Home Energy Assistance Program (LIHEAP) and Temporary Assistance to Needy Families (TANF), some States regularly supplement the statutory minimum that tribes are due under statutory formulas or provide additional funds if tribes run out of funds. States could withdraw these supplements if tribes elect to participate in a demonstration and receive funding directly, rather than receiving funding through the State. Continuation of supplemental agreements between tribes and States would not, however, be precluded because of a demonstration. Inclusion of LIHEAP and TANF by a tribe in a demonstration project, would be a tribal choice and based on what the tribe determines is in its best interest and negotiations between the tribe and State.

  While federal funds are largely transferred to grantees or contractors, federal personnel will be involved in project management activities related to the grants or contracts. These activities include policy development, award and oversight, financial management, and legal duties. There is no likelihood, however, that a self-governance demonstration will lead to savings related to these federal functions since most staff performing these functions are not solely, or even significantly, dedicated to tribal work. Most have broad portfolios that encompass all types of grantees or contractors and tribal work will be a very small percentage of the total time and effort. In those few cases where federal staff may be working exclusively on tribal programs, the functions are those typically needed for award, audit, and other federal responsibilities, not direct program administration or service delivery.

Recommendation 1: Eleven existing HHS programs have been identified as feasible for inclusion in a tribal self-governance demonstration project.

The study requires identification of HHS programs, programs, services, functions, and activities (or portions thereof) that are feasible to include in a tribal self-governance demonstration project. Based on the factors discussed in the study section on methodology, the following programs are identified.

Administration on Aging
Grants for Native Americans

Administration for Children and Families
Tribal Temporary Assistance for Needy Families
Low Income Home Energy Assistance
Community Services Block Grant
Child Care and Development Fund
Native Employment Works
Head Start
Child Welfare Services
Promoting Safe and Stable Families
Family Violence Prevention: Grants for Battered Women’s Shelters

Substance Abuse and Mental Health Services Administration
Target Capacity Expansion

All of these programs already have statutory authority that provides for grant awards directly to tribes and tribal responsibility for program management. In this sense, the tenet of self-governance relating to tribal assumption of program administration is already realized and implemented under these programs. However, tribes must administer each program separately under current program rules and are not allowed to redesign or consolidate programs to meet tribally-defined needs to the extent contemplated under the other important tenet of self-governance.

Recommendation 2: The Secretary should be authorized to add up to six additional programs during the course of the demonstration project.

While specific programs would be authorized at the outset of the demonstration, tribal needs are not necessarily limited to those programs that are initially included. To allow flexibility and meet additional tribal needs as the demonstration progresses, it is desirable to provide some ability to expand the demonstration beyond the initial programs. Therefore, it is recommended that the Secretary have the authority to place up to six additional programs in the demonstration.

Recommendation 3: Programs targeted for a demonstration project should be specifically designated in authorizing legislation.

Eleven existing programs are recommended for inclusion in a demonstration project. Authorizing legislation should clarify this point. No additional programs are recommended at this time, and stability is important to the ultimate evaluation of a demonstration.

Statutory/Regulatory Changes
Title VI requires that all statutory and non-waivable regulatory changes needed to include recommended programs in a self-governance demonstration project be listed in the report. Such changes, for the eleven existing programs, have been identified and are presented in Appendix E. Specifically, the changes identified in Appendix E are needed to make existing program or administrative statutes and regulations compatible with the demonstration design recommendations outlined in the design section that follows. The need for similar changes may limit the Secretary's ability to add additional programs during the course of a demonstration.

DEMONSTRATION DESIGN

While Title V of the Act contains the basic elements that define self-governance in the view of tribes and the Congress, there are significant differences between the IHS model and a demonstration that includes non-IHS programs that will vary significantly in objectives, services, beneficiaries, and administrative requirements. These differences argue for modifying the Title V model. For example, most of the programs recommended for inclusion in a demonstration have statutorily derived formulas for awarding funds, making it impractical to adopt the Title V approach to negotiating funding agreements. The need to address program identity and accountability issues raised by stakeholders also argues for something other than the Title V model.

Therefore, rather than relying on Title V, a specific set of demonstration design recommendations (not to be confused with specific recommendations that follow on the ability of tribes to redesign programs during the course of a demonstration) have been developed and are recommended as the basis for a demonstration. If Congress chooses to create a self-governance demonstration, these design elements should be included in the authorizing legislation.

Definition- Indian Tribe
Recommendation: For the purpose of a demonstration project, it is recommended that the definition of an Indian tribe include federally-recognized Indian tribes or, where authorized by an Indian tribe, an inter-tribal consortium or a tribal organization acting on its behalf.

Selection of Participating Tribes
Recommendation: A demonstration should be limited to up to 50 projects composed of tribes or inter-tribal consortia that either have established compact and funding agreements under Title V of the Act or tribes or consortia that have successfully carried out a planning grant (or in lieu of a planning grant completed a pre-award survey) and meet specified financial stability requirements.

A demonstration project should be open to tribes or tribal consortia that have established compact and funding agreements under the terms of Title V of the Act. These tribes or consortia have already demonstrated program and financial management capacity. For those tribes or consortia not meeting this threshold, eligibility should be established by successful completion of a planning grant (or in lieu of a planning grant completed a pre-award survey) and demonstration of 3 fiscal years of financial stability and management as evidenced by having no uncorrected significant and material audit exceptions under Federal grants or contracts.

In addition, a demonstration should be limited to 50 projects to maintain costs and the manageability of a demonstration and attendant evaluation. The Secretary should be authorized to establish criteria for the selection of participating tribes or consortia in the event that more than 50 tribes or consortia apply for a demonstration. It should be noted that a demonstration will not affect the ability of non-participating tribes or consortia to apply for and operate HHS programs, including the programs under a demonstration.

Planning and Negotiation Grants
Recommendation: Planning grants should be authorized to assist tribes in preparing self-governance proposals. Grants should be limited to tribes with a demonstrated need.

As discussed in the cost section of the study, most tribes do not have sufficient resources to prepare and negotiate self-governance agreements. Prior models have allowed one-time grants for that purpose. Similarly, it is recommended that planning and negotiation grants (at $70,000) be authorized for up to 50 tribes or tribal consortia that want to participate in a self-governance demonstration project. Since some tribes may already administer programs and have experience with self-governance, grants should be limited to those tribes demonstrating a need for planning technical assistance.

Application Process
Recommendation: The Secretary should be authorized to consolidate existing program application requirements into a single application that tribes would submit for proposing participation in a demonstration project.

Currently, programs recommended for inclusion under a demonstration project have separate and often extensive application requirements. While administrative simplification is integral to self-governance and a single application should be part of a demonstration project, implementation of the single application approach will require abolishing separate application processes and information requirements that now exist in the targeted programs. While some of these processes and requirements may not be critical or overlap, others will remain essential to defining the scope of the programs, services, functions, or activities to be carried out under a demonstration; e.g., information related to definitions of service areas, client eligibility, programs objectives and assurances required in program legislation. Therefore, it is important that the Secretary be given specific authority to develop a consolidated process and format for submission of compacts, including the ability to require continued use of critical elements of the existing application process and information requirements from the targeted programs.

Compacts
Recommendation: The Secretary should be authorized to negotiate, to the extent permitted under current law, and enter into a written compact with each Indian tribe participating in a demonstration.

The compact should set forth the terms of the agreement that apply while the agreement is in effect and modifications made only by mutual agreement of the parties.

Funding Agreements
Recommendation: The Secretary should be authorized to negotiate, to the extent permitted under current law, and enter into a written funding agreement with each participating Indian tribe.

With the exception of Head Start, the Older Americans Act, and the SAMHSA Targeted Capacity Expansion program, the programs targeted for a demonstration have statutorily mandated formulas for calculating award amounts, including provisions for indirect costs. In the case of Head Start, awards are based on a negotiated amount. In the case of the Older Americans Act, the Administration on Aging uses a population-based formula (although, as stated, not statutorily mandated). Therefore, it will be important for legislation authorizing a demonstration to recognize that award amounts under funding agreements will largely be based on formulas or other statutory requirements of the authorizing legislation of the programs and will not be subject to negotiation or change unless Congress revises existing formulas. Specific legislative authority will also be needed to allow tribes to move funds between programs included in their demonstrations. With these caveats regarding award amounts, the overall recommendations is that agreements should be mutually negotiated between the Secretary and the tribe.

Indirect Costs/Matching
Recommendation: Current statutory requirements relating to indirect cost should be maintained.

The issue of indirect cost is discussed in detail under the "findings" section of the study. Removing statutory caps on administrative cost that affect recovery of indirect cost would significantly increase the cost of a demonstration project (or potentially result in a reduction of services) and create a situation where State programs would be treated differently than tribes. It is also possible that administrative efficiencies of a demonstration will allow tribes to realize cost savings that will reduce or eliminate any burden caps impose. For these reasons, the recommendation is to maintain current indirect cost caps where applicable, while allowing the consolidation of total allowable indirect costs from each program into a single indirect cost pool to cover administrative costs of the compact and funding agreement.

For similar reasons, a change in current law with respect to program matching requirements also is not recommended, although some of the target programs allow the Secretary to waive matching requirements.

Redesign and Consolidation
Recommendation: Tribes should be provided the authority to redesign and consolidate programs during the course of the demonstration project, subject to limits imposed by non-waivable statutory or regulatory provisions of the individual programs.

Redesign and consolidation authority is a principal tenet and inseparable from the definition of self-government. In practice, this authority provides tribes with the flexibility to change programs and reallocate funds among programs to meet specific tribal needs under a self-government agreement within the boundaries of controlling program legislation.

Also, it should be noted that, since a demonstration largely will be administered within existing legal requirements, redesign and consolidation opportunities will be limited by the authority to waive statutory requirements.

Waivers
Recommendation 1: Program waivers, to the extent provided by statute and regulation, should be available to tribes throughout the demonstration project.

The ability to redesign and consolidate programs and activities depends, in part, on the use of regulatory waiver authority. The Secretary's authority to grant waivers is spelled out in current law and regulations applicable to the targeted programs. Current authority is seen as sufficient and no additional waiver authority is requested for a demonstration.

Recommendation 2: Waiver requests should be limited to the term of a demonstration and subject to withdrawal if the Secretary determines compliance with the waived provision is essential to program integrity. If withdrawal is contemplated, tribes should be provided due process that would include timely notification and the ability to propose a corrective action plan.

Since waivers may have a substantial impact on program beneficiaries, the ability of the Secretary to monitor the use of waivers and to withdraw waivers is an important element under a demonstration project when there is clear evidence that continuation of a waiver will result in substantial harm to the beneficiaries. Tribes should have administrative appeal rights with the tribe bearing the burden of proof and the standard of review being whether the decision withdrawing the waiver was arbitrary or capricious.

Withdrawal and Termination
Recommendation: A demonstration should defer to current law regarding withdrawal and termination for the targeted programs.

Withdrawal occurs when a tribe decides not to receive funding and the Federal government funds another grantee in its place to conduct the program. Termination occurs when the Federal government terminates tribal control of programs for cause. Current statutory and regulatory provisions address withdrawal and termination and should be maintained for the demonstration. It is important to note that States or other entities would assume services should withdrawal and termination occur, since these programs are not delivered directly by HHS.

Final Offers - Appeals
Recommendation: While tribes should have the ability to appeal rejections of final offers for compacts and funding agreements, these appeals should be limited in scope.

To evaluate a time-limited demonstration, it is important that the project and agreements be in place quickly and stability of the program be established. This will not be the case if appeals delay the start of one or more components of a demonstration, such as putting in place funding agreements or reporting systems. Therefore, it is recommended that a demonstration project provide for a limited appeals process in cases where the department and tribes are unable to reach agreement on the terms of self-governance agreements. The legal framework for the process should include the issuance by the Department of a written statement giving the reasons for disapproval of a final tribal offer and the right of a tribe to appeal the decision to the Intra-Departmental Council on Native American Affairs, a body of senior department officials responsible for advising the Secretary on tribal matters in the Department. The burden of proof on appeal would be borne by the tribe. An "arbitrary or capricious" standard would be used. The decision of the Council should be final and not subject to judicial review.

Conflict of Interest
Recommendation: A conflict of interest prohibition should be established for tribes participating in a demonstration project.

Tribes should be required to have internal measures in place to prevent conflict of interest in the administration of the programs under a demonstration project.

Cost Principles
Recommendation: Cost principles found in applicable Office of Management and Budget (OMB) circulars and made applicable to recipients of financial assistance by various Federal regulations must be made applicable to tribes under a demonstration project.

Audit Exceptions
Recommendation: Current audit procedures under OMB Circular A-133 regarding resolution of audit exceptions must be made applicable to a demonstration project.

Record Keeping
Recommendation: Current Federal recording keeping requirements applicable to grantees should apply to tribes participating in a demonstration.

Savings
Recommendation: To the extent that compacts and funding agreements reduce the administrative or other responsibilities of the Secretary through program consolidation with respect to the operation of programs under a demonstration project, the savings should be made available to the tribes.

While it is not expected that savings to HHS will accrue because of a demonstration, any savings that can be identified should be available to the tribes.

Transfer of Funds
Recommendation: To facilitate coordination of programs under a demonstration, the Secretary should be authorized to establish a common funding cycle for programs under a demonstration project.

Currently, some of the programs targeted for a demonstration have different award and funding cycles. Manageability of a demonstration would be greatly improved by allowing all programs under a demonstration to begin on the same cycle. This would also enhance coordination of program reporting and evaluation of a demonstration project.

Prompt Payment Act
Recommendation: Chapter 39 of title 31, United States Code must be made applicable to the transfer of funds due under a compact or funding agreement in a demonstration project.

This would ensure that the interest penalty and other provisions of the Prompt Payment Act would apply to the transfer of funds under a funding agreement in a demonstration project.

Carryover of Funds
Recommendation: All funds awarded under a funding agreement should remain available until expended.

Current law requires federal approval for tribes to carry over funds from one fiscal year to the next. Again, a core element of self-governance is tribal discretion and control over the management of funds. This recommendation will devolve federal control over this level of decision making while enhancing tribal flexibility.

Construction
Recommendation: The provisions of Title V, Sections 509 and 510 relating to construction should be made applicable to a demonstration, subject to retention of a federal interest in the property.

This recommendation will ease the administrative burden on tribes, consolidating current construction rules that vary from program to program into a single, uniform set of construction rules that tribes currently use under the IHS self-governance program. This promotes the goal of administrative simplification. This recommendation also would allow tribes, under the consolidation and redesign authority to consolidate and use funds from the programs under a compact or funding agreement for construction purposes to the extent that the use of funds for construction is allowable under the authorizing legislation of the programs included in the demonstration project. In this respect, it should be noted that several of the programs currently prohibit the use of funds for construction and would require changes to the legislation authorizing the programs (see Appendix E), if funds from these programs were to be available for construction. The legislation authorizing a demonstration project should specify that there is a federal interest in facilities constructed using funds provided under a demonstration project in order to avoid future controversy on the matter.

Changes in Funding
Recommendation: Changes in tribal funding for any program or activity under a demonstration should be in accordance with existing statutory authority and nothing in a demonstration should be construed to change that authority.

Clearly, nothing in a demonstration should affect the level of funding a tribe should otherwise receive under the statutes and regulations governing the programs in a demonstration. It is recommended that the authorization for a demonstration include language stating that participation in a demonstration will not change the amount of funding a tribe would receive for any program compared to the amount it would receive from that program outside of a demonstration.

Length of Demonstration
Recommendation: A demonstration should be authorized for five years.

A five-year demonstration should provide adequate time to implement and evaluate a demonstration project.

Project Administration
Recommendation: A single program office in HHS should manage a demonstration project.

Given the number and complexity of programs and tribes that could participate in a demonstration, a single point of contact and coordination of demonstration project operations is essential to success. Specific legislative authority would be needed for a single office to be able to provide consolidated awards, which are currently made by the separate HHS programs recommended for inclusion in the demonstration, to tribes participating in a demonstration. Therefore, the Secretary should be authorized to establish a single point of contact for management of a demonstration project. The Secretary should also have the authority to establish policy, negotiate and make awards, and evaluate a demonstration.

METHODS TO ASSURE QUALITY AND ACCOUNTABILITY

Congress requested that the Secretary advise on methods to assure quality and accountability in a self-governance demonstration. The following recommendations address this requirement.

Financial
Recommendation: The Single Audit Act, as amended and including its implementation guidance, must be made applicable to a self-governance demonstration.

The Single Audit Act is the government-wide mechanism for assuring financial accountability and is already applied to self-governance projects under Title V of the Act.

Program
Recommendation 1: Program accountability and quality should be monitored through specific performance measures and performance reports, established through negotiations with the tribes prior to the establishment of self-governance agreements.

The flexibility to redesign and consolidate programs and activities and waive certain existing program requirements in a demonstration raises concerns about maintaining program identity and assuring that eligible beneficiaries continue to receive quality services. These concerns can be addressed through program performance measures and reporting. This parallels the Government Performance and Results Act and is the current paradigm for program accountability. In the case of a demonstration, the Secretary would negotiate a single set of performance measures and performance report that would be standard for all tribes throughout a demonstration. The measurement system would incorporate key measures and data requirements that currently exist for each program under a demonstration into a single system, eliminating redundancy. A tribe would report on only those measures applicable to the programs under their particular self-governance agreement.

Recommendation 2: A maintenance of effort provision should be part of a demonstration with the option for tribes to reprogram up to 20 percent of funds of the individual programs.

To further address the concern that the redesign and consolidation authority, by allowing tribes to move funds between programs, would result in the erosion of program services, a maintenance of effort requirement is recommended. Such a provision could require tribes to maintain a baseline level of services and expenditures for each program under a demonstration. To provide flexibility to redesign and consolidate programs and activities, tribes should be allowed to reprogram up to 20 percent of the funds of a program. This change will require amendments to existing legislation authorizing the programs selected to participate in the demonstration project, or to the statute establishing the project.

Recommendation 3: An overall evaluation of a demonstration should also be authorized.

In order to evaluate the success of a demonstration as a basis for deciding future extensions of self-governance, a process and outcome evaluation of a demonstration should be authorized. This should incorporate such items as an evaluation of the use of waivers and limitations of a demonstration model for future self-governance authorizations.

Recommendation 4: Authorization should be given to use compact funds to comply with performance data collection and reporting requirements.

Tribes should be authorized to use compact funds to fully cover any data collections and reporting requirements.

Program Duplication - State Concerns
Recommendation: Participating tribes should be required to demonstrate efforts to coordinate information on dually eligible clients with States.

One prominent issue raised by State government organizations during the consultation process was the issue of dually eligible clients - clients who can elect to be served through either State systems or the tribe. In these cases (e.g., child care subsidies) the potential for duplicate benefits exists, as well as for a negative impact on States. For example, a tribe might receive funds to provide child care subsidies to qualified tribal members while the State does not. However, because the tribal member is eligible under current law for subsidies both from the tribe and the State, the tribal member can elect to receive subsidies from the State. Since the tribe, not the state, receives funds for services to tribal members, this creates an unfunded liability for the State. Short of changing eligibility rules, a system of information sharing might help this problem. Therefore, a recommendation is made to have tribes demonstrate efforts to coordinate client information with States. For example, tribes might identify dually eligible tribal members to the States and indicate when they have elected to receive services from the tribe.

Section 5.

The Indian Self-Determination and Education Assistance Act is amended by adding at the end the following:

TITLE VI--TRIBAL SELF-GOVERNANCE-DEPARTMENT OF HEALTH AND HUMAN SERVICES

SEC. 601. DEFINITIONS.

1. In General.--In this title, the Secretary may apply the definitions contained in title V.
2. Other Definitions.--In this title:
   1. Agency.--The term `agency' means any agency or other organizational unit of the Department of Health and Human Services, other than the Indian Health Service.
   2. Secretary.--The term `Secretary' means the Secretary of Health and Human Services.

SEC. 602. DEMONSTRATION PROJECT FEASIBILITY.

1. Study.--The Secretary shall conduct a study to determine the feasibility of a tribal self-governance demonstration project for appropriate programs, services, functions, and activities (or portions thereof ) of the agency.
2. Considerations.--In conducting the study, the Secretary shall consider--
   1. the probable effects on specific programs and program beneficiaries of such a demonstration project;
   2. statutory, regulatory, or other impediments to implementation of such a demonstration project;
   3. strategies for implementing such a demonstration project;
   4. probable costs or savings associated with such a demonstration project;
   5. methods to assure quality and accountability in such a demonstration project; and
   6. such other issues that may be determined by the Secretary or developed through consultation pursuant to section 603.
3. Report.--Not later than 18 months after the date of the enactment of this title, the Secretary shall submit a report to the Committee on Indian Affairs of the Senate and the Committee on Resources of the House of Representatives. The report shall contain-
   1. the results of the study under this section;
   2. a list of programs, services, functions, and activities (or portions thereof ) within each agency with respect to which it would be feasible to include in a tribal self-governance demonstration project;
   3. a list of programs, services, functions, and activities (or portions thereof ) included in the list provided pursuant to paragraph (2) that could be included in a tribal self-governance demonstration project without amending statutes, or waiving regulations that the Secretary may not waive;
   4. a list of legislative actions required in order to include those programs, services, functions, and activities (or portions thereof ) included in the list provided pursuant to paragraph (2) but not included in the list provided pursuant to paragraph (3) in a tribal self-governance demonstration project; and
   5. any separate views of tribes and other entities consulted pursuant to section 603 related to the information provided pursuant to paragraphs (1) through (4).

SEC. 603. CONSULTATION.

1. Study Protocol.--
   1. Consultation with Indian tribes.--The Secretary shall consult with Indian tribes to determine a protocol for consultation under subsection (b) prior to consultation under such subsection with the other entities described in such subsection.
   2. Requirements for protocol.--The protocol shall require, at a minimum, that--
      1. the government-to-government relationship with Indian tribes forms the basis for the consultation process;
      2. the Indian tribes and the Secretary jointly conduct the consultations required by this section; and
      3. the consultation process allows for separate and direct recommendations from the Indian tribes and other entities described in subsection (b).
2. Conducting Study.--In conducting the study under this title, the Secretary shall consult with Indian tribes, States, counties, municipalities, program beneficiaries, and interested public interest groups, and may consult with other entities as appropriate.

SEC. 604. AUTHORIZATION OF APPROPRIATIONS.

There are authorized to be appropriated such sums as may be necessary to carry out this title, Such sums shall remain available until expended.

Alaska Native Health Board, O&M Project Yearbook, Your Guide to ideas, tips, and solutions for water and sewer system management, operation and maintenance in rural Alaska, October 2000.

Alaska Native Health Board, Rural Sanitation Facilities Operation and Management Demonstration Project, Final Project Report, October 2000.

Dean, S. Bobo and Joseph H. Webster, 2000 Native American Law Symposium: Contract Support Funding and the Federal Policy of Indian Tribal Self-Determination, 36 Tulsa L.J. 349, Winter 2000.

Department of Health and Human Services Inspector General, Tribal Child Care, October 1998.

Indian and Native American Employment and Training Coalition, 477 Equals Jobs and Opportunities: A Progress Report to the National Congress of American Indians, October 23, 1996.

Institute of Social and Economic Research, University of Alaska Anchorage, Evaluation of the Alaska Health Board's Sanitation Facility Operation and Maintenance Program: Final Report on Phase III Projects and Phase II Extended Projects, Volume II. Community Reports, September 2000.

Institute of Social and Economic Research, University of Alaska Anchorage, Evaluation of the Alaska Health Board's Sanitation Facility Operation and Maintenance Program: Final Report on Phase III Projects and the Program Overall, Volume I. Summary and Analysis, September 2000.

Johnson, Tadd M. and James Hamilton, Symposium Rules of the Game: Sovereignty and the Native American Nation: Self-Governance for Indian Tribes: from Paternalism to Empowerment, 27 Conn. L. Rev. 1251, Summer 1995.

National Congress of American Indian, National Policy Work Group on Contract Support Costs, Final Report, July 1999.

National Indian Health Board, Tribal Perspectives on Indian Self-Determination and Self-Governance in Health Care Management, Volume 1-Executive Summary, 1998.

National Indian Health Board, Tribal Perspectives on Indian Self-Determination and Self-Governance in Health Care Management, Volume 2-Narrative Report, 1998.

National Indian Health Board, Tribal Perspectives on Indian Self-Determination and Self-Governance in Health Care Management, Volume 3-Background Data, 1998.

The Center for the Study of American Indian Law and Policy, University of Oklahoma, Norman, OK and The Center for Tribal Studies, Northeastern State University, Tahlequah, OK, Trying a New Way, Independent Assessment Report on the Self-Governance Demonstration Project, Title III, P.L. 100-472, Final Report, undated.

Self-Governance Communication and Education, National Tribal Self-Governance Advocacy Plan for the Bush Administration and 107^th Congress, January 31, 2001.

Sizemore C.P.A., James M., Determining the True Cost of Contracting Federal Programs for Indian Tribes, Second Ed., 1997.

United States General Accounting Office, Report to the Chairman, Committee on Indian Affairs, U.S. Senate: Federal Tort Claims Act, Issues Affecting Coverage for Tribal Self-Determination Contracts, (GAO/RCED-00-169), July 2000.

United States General Accounting Office, Report to the Chairman, Subcommittee on Oversight of Government Management, Restructuring and the District of Columbia, U.S. Senate: Early Education and Care, Overlap Indicates Need to Assess Crosscutting Programs, April 2000.

United States General Accounting Office, Report to Congressional Requesters: Indian Programs, Tribal Priority Allocations Do Not Target the Neediest Tribes, July 1998.

United States General Accounting Office, Report to Congressional Committees: Indian Self-Determination Contracting, Effects of Individual Community Contracting for Health Services in Alaska, June 1998.

United States General Accounting Office, Report to Congressional Committees, Indian Self-Determination Act, Shortfalls in Indian Contract Support Costs Need to be Addressed, June 1999.

United States General Accounting Office, Performance and Accountability Series, Major Management Challenges and Program Risks, Department of Interior, January 2001.

The "Tribal Self-Governance Amendments of 2000" requires the Department of Health and Human Services to conduct a study to determine the feasibility of a tribal self-governance demonstration for appropriate programs, services, functions, and activities

(or portions thereof) of the agency (other than the Indian Health Service). In conducting the study, the Department is to consult with Indian tribes, States, counties, municipalities, program beneficiaries, and interested public interest groups. Additionally, before undertaking the consultation, the Department must develop a consultation protocol in consultation with the Indian tribes. At a minimum, the protocol is to provide that: (a) the protocol be based on a government-to- government relationship between Indian Tribes and HHS; (b) Tribes and the Secretary jointly conduct the consultations; and (c) the consultation process allows for separate and direct recommendations from the Indian tribes and other entities.

This document sets forth the consultation protocol for the study. Consultation will be carried out in terms of the principles and processes set forth in this document.

PRINCIPLES

The United States recognizes a special government-to-government relationship with Indian Tribes, including the right of Indian Tribes to self-governance.

Although progress has been made, Congress has found that centralized rules and regulations of the Federal bureaucracy erodes tribal self-governance and dominates tribal affairs.

Tribal self-governance has been demonstrated to improve and perpetuate the government-to- government relationship and strengthen tribal control over Federal funding and program management.

To the maximum extent possible, the goal of the feasibility study is to identify ways to reduce and eliminate barriers that prevent Tribes and Tribal organizations from assuming responsibility for Department of Health and Social Services programs.

The Feasibility Study shall be conducted consistent with the government-to-government relationship and the principles of self-governance.

Tribal consultation required through the Feasibility Study shall be carried out consistent with the Executive Order 13175 regarding Consultation and Coordination with Indian Tribal Governments.

CONSULTATION - GENERAL

Formal consultations with designated entities will take place at three important junctures of the study: 1) at the outset of the study; 2) following the development of a draft report; and 3) following the development of a final report before transmittal to Congress. Details on the consultation process follow.

As required by Section 603(a)(2)(B) of the Tribal Self-Governance Amendments of 2000, consultations will be jointly conducted by the Department and the Indian tribes. With respect to this requirement, the Title VI Feasibility Study Team of the HHS Tribal Self-Governance Advisory Committee and the Deputy Assistant Secretary for Planning and Evaluation (Special Policy Initiatives and Planning) are jointly responsible for the management of the study consultation process.

CONSULTATION - PROCESS

Consultation with statutorily designated entities will take place in four phases.

Phase One: Consultation with tribal entities wi