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Three federal agencies that run essential programs for American Indian and Native Alaskan tribes have been flagged by the Government Accountability Office for mismanaging resources.

For the first time, GAO included the Department of Interior’s Bureau of Indian Affairs and Bureau of Indian Education, along with the Indian Health Service, in its “High Risk” report documenting inefficiencies at the federal government.

Together, the agencies are responsible for critical services: Delivering healthcare and education, and managing energy resources on tribe-owned land.

The performance “put the health and safety of American Indians served by these programs at risk,” according to the report, which urged Congress to study and improve these offices.

The Indian Health Service (IHS) operates 114 clinics and hospitals nationwide, many of which are in rural areas. But the agency is underfunded and understaffed, the report noted.

In dire need of attention was the Purchased Referred Care program, the mechanism that directs patients to other clinics when the nearest IHS facility does not offer the services they need. In some locations IHS locations lack even basic services like cancer screenings or colonoscopies.

The report noted that the program is understaffed, and does not have a uniform mechanism for selecting patients into the program. The formula used to allocate funds to the program is outdated, according to the report, and “cannot equitably allocate funds to meet the health care needs of Indians.” Because the IHS does not have complete data on this program, it makes it even harder to fix, the report noted.

Hearings in Congress and recent lawsuits suggest that poorest and most rural tribes are hit hardest by these shortfalls. Last year, when Rosebud Sioux Tribe of South Dakota sued the federal government for services at the IHS-run hospital on its reservation, the tribe cited some of the same problems mentioned in the GAO report.

Like the IHS, the Bureau of Indian Education (BIE), which runs 185 schools in 23 states, is also under-resourced.

In January, members of the Havasupai Nation, represented by civil rights groups including the ACLU, sued the Bureau of Indian Affairs for failing to provide a general education in BIA schools, or accommodate the needs of students with special needs.

According to the GAO report, the BIE skips safety inspections for a third of school campuses. At one school, faulty boilers that leaked gas and carbon monoxide into dormitories and classrooms were not fixed for eight months.

The agency was also faulted for inconsistently tracking funds, citing one instance when $1.7 million from a school’s budget was “improperly transferred to an offshore account.”

The Bureau of Indian Affairs is the federal custodian of tribal lands, but like other agencies, struggles to respond quickly to requests from tribes, the GAO reported.

One tribe told the GAO inspectors that it lost $95 million in revenue because the BIA took eight years to process documents related to leasing.

Like sister agencies, the BIA is beset by a lack of data. The report noted that the BIA cannot verify the original owners of sections of land or the owners of energy leases that the agency oversees as caretaker.

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