Amid concerns about the ability of DOD's acquisition process to keep pace with evolving threats, Congress included numerous reforms in recent National Defense Authorization Acts that could help to streamline acquisition oversight and field capabilities faster. GAO was asked to examine DOD's efforts to implement these reforms. This report addresses (1) the progress DOD has made implementing selected oversight reforms related to major defense acquisition programs; (2) how DOD has used middle-tier acquisition pathways; and (3) challenges DOD faces related to reform implementation. GAO reviewed five reforms: milestone decision authority designation; cost, fielding, and performance goals; independent technical risk assessments; restructuring of acquisition oversight offices; and middle-tier acquisition. GAO analyzed applicable statutes and implementing guidance, collected information from DOD about the number and types of middle-tier acquisition programs, reviewed relevant documentation, and interviewed DOD officials. The Department of Defense (DOD) has made progress in implementing reforms to restructure the oversight of major defense acquisition programs. As a result of one of these reforms, decision-making authority for many programs shifted from the Office of the Secretary of Defense to the military departments (see figure). Questions remain about how some reforms GAO reviewed will be carried out. For example, no programs have been required to have cost and fielding goals set under DOD's new process yet, and DOD has formed a working group to determine when to delegate risk assessments to the military departments. DOD also began using new pathways referred to as middle-tier acquisition to rapidly prototype and field new weapon systems. Middle-tier programs are expected to field capabilities within 2 to 5 years. As of March 2019, military departments were using this authority for 35 unclassified programs (see table). Source: GAO analysis of Department of Defense data. | GAO-19-439 DOD has yet to fully determine how it will oversee middle-tier acquisition programs, including what information should be required to ensure informed decisions about program selection and how to measure program performance. Without consistent oversight, DOD is not well positioned to ensure that these programs—some of which are multibillion dollar acquisitions—are likely to meet expectations for delivering prototypes or capability to the warfighter quickly. DOD also continues to face implementation challenges, including one related to disagreements about oversight roles and responsibilities between the Office of the Secretary of Defense and the military departments. Senior DOD leadership has not fully addressed these disagreements. As a result, DOD is at risk of not achieving an effective balance between oversight and accountability and efficient program management.


NMB was established under the Railway Labor Act to facilitate labor relations for airline and railway carriers by mediating and arbitrating labor disputes and overseeing union elections. The FAA Modernization and Reform Act of 2012 included a provision for GAO to evaluate NMB programs and activities every 2 years. GAO's previous reports, issued in December 2013, February 2016, and March 2018, included 13 recommendations for NMB based on assessments of policies and processes in several management and program areas. NMB had implemented six of those recommendations previously, leaving seven for our review. This fourth report examines the (1) extent to which NMB has taken actions to fully implement GAO's remaining recommendations, and (2) other challenges NMB faces in key management areas and in overseeing its operations. GAO reviewed relevant federal laws, regulations, and NMB documents, such as its travel and telework policies; examined arbitration caseload data and the results of NMB's 2019 Organizational Climate Assessment; and interviewed NMB officials. The National Mediation Board (NMB), which facilitates labor relations for airline and railway carriers, has implemented one of GAO's seven recommendations remaining from past reports (see table). Specifically, NMB has developed a policy to prevent violations of ethics rules regarding outside employment and monitors compliance with that policy. NMB has not yet fully implemented the other six recommendations. For example, NMB has developed some strategies to reduce its arbitration case backlog, but lacks a plan with goals and time frames to complete that work. Similarly, NMB has completed an organizational climate assessment, but still must take additional actions to address employee concerns. By not fully implementing these and other recommendations, NMB remains at risk of not fulfilling its mission in several key areas, including information security and organizational climate. In this review, GAO found that, in addition to the six unimplemented recommendations, NMB lacks internal controls to effectively manage and oversee its appropriations and consistently follow its audit policies. NMB officials said the agency needed its full funding to address various agency priorities, such as hiring information technology specialists, but NMB did not use all of its funding for fiscal years 2016 through 2019, leaving a total of more than $4 million unobligated from those years; those funds are not available to NMB for new obligations. Officials said that hiring challenges and uncertainty concerning the agency's final appropriations made managing its budget resources difficult. NMB has a new process to monitor its budget resources, but has not documented that process. Without documenting that process, NMB may not be certain it uses its funding effectively to achieve its hiring and other goals. Additionally, NMB has not consistently followed its audit policy to address deficiencies identified in financial and other audits. For example, NMB did not create specific corrective action plans to address findings from financial or GAO audits. The NMB Board said it relied on senior managers to follow procedures, but the Board is ultimately responsible for ensuring that its managers implement the internal control system. Without a process to effectively oversee and evaluate its adherence to internal controls and its own audit policies, NMB may miss opportunities to achieve objectives, address audit deficiencies, and improve management oversight.


NNSA has long faced challenges in determining and comparing the costs of its programs, which are principally performed by M&O contractors across eight sites. Congress needs this information to provide effective oversight and make budgetary decisions. The National Defense Authorization Act for Fiscal Year 2017 required NNSA to implement a common financial reporting system, to the extent practicable, across all sites by December 2020. NNSA's efforts began in 2016 and are ongoing. The Senate report accompanying a bill for the National Defense Authorization Act for Fiscal Year 2018 includes a provision for GAO to periodically review NNSA's implementation of common financial reporting. This is GAO's second report on this issue. This report examines (1) the steps NNSA has taken to implement common financial reporting since GAO's January 2019 report, and (2) the extent to which NNSA's approach to data collection aligns with the purpose of common financial reporting, including collecting accurate and consistent data from its M&O contractors. GAO reviewed NNSA documents about implementing common financial reporting, including policy and briefing documents, and interviewed NNSA officials and M&O contractor representatives. The National Nuclear Security Administration (NNSA)—a separately organized agency within the Department of Energy (DOE)—is required to implement common financial reporting, to the extent practicable, across its sites to better understand the total costs of its programs. NNSA has taken additional steps to implement such reporting since January 2019 but faces challenges in fully implementing the effort (see table). For example, for fiscal years 2018 and 2019, NNSA used separate work breakdown structures—a method of dividing a project into successive levels of detail—to collect data for some offices. Without a common work breakdown structure, NNSA cannot ensure that it can collect reliable financial data across its sites. NNSA plans to assess the feasibility of implementing a common work breakdown structure, in response to GAO's January 2019 recommendation. In fiscal years 2018 and 2019, NNSA also faced challenges in collecting financial data from management and operating (M&O) contractors, including collecting complete data for all program offices. NNSA is working to resolve these issues. NNSA's approach to data collection provides limited assurance that the data collected for common financial reporting are accurate and consistent across the M&O contractors. At most sites, the M&O contractors track their financial data in a way that does not align with how NNSA requests the contractors report the data. M&O contractors use professional judgment to crosswalk, or map, the financial data from their business systems to the NNSA structures to report the data. NNSA's data quality checks on the M&O contractors' financial data focus on data formatting and ensuring the data match the agency's accounting system. NNSA does not have a process to verify whether the contractors accurately crosswalk their financial data. Under NNSA's financial integration policy, the program director for financial integration is to, among other things, execute a plan to improve cost analysis, comparability, and reporting consistency among programs and M&O contractors. By developing an internal process for NNSA to verify how the M&O contractors crosswalk their financial data to the work breakdown structures, NNSA will have better assurance that it is collecting accurate financial data that are comparable across the M&O contractors, that satisfy the needs of Congress and other stakeholders, and that address long-term issues with its ability to report the total costs of its programs.


NNSA is responsible for the management and security of the U.S. nuclear stockpile. NNSA has ongoing and planned efforts to modernize nearly all of the weapons in the stockpile, which require new explosive components. The production of some key explosives ceased in the early 1990s, and much of the infrastructure supporting this work is aging, making it expensive and difficult to maintain. The Senate Report accompanying a bill for the National Defense Authorization Act for Fiscal Year 2018 included a provision for GAO to review NNSA's high explosive capabilities specific to nuclear weapons. This report examines (1) explosives activities that NNSA and its sites conduct and how NNSA manages them; (2) challenges NNSA officials and contractor representatives identified in conducting these activities and the extent to which NNSA has taken actions to address them; and (3) the extent to which NNSA's strategic plan for explosives activities describes further actions, if any, to address the challenges identified and follows leading practices for strategic planning. GAO reviewed NNSA documents related to explosives activities, including its strategic plan; compared the plan with leading practices; and interviewed NNSA officials and site representatives. Five National Nuclear Security Administration (NNSA) contractor-operated sites conduct activities to design and produce explosive materials. There are about 100 different nuclear weapon components that contain explosive materials (see figure). Each site assumes primary responsibility for certain activities, but most activities require collaboration by multiple sites, according to NNSA officials and contractor representatives. In 2018, NNSA began adopting a centralized approach to managing these activities and coordinating them across its sites. NNSA officials and contractor representatives identified several challenges related to explosives activities, such as the agency's dwindling supply of explosive materials, aging and deteriorating infrastructure, and difficulty recruiting and training qualified staff. For example, only a single container of one specialized material remains. NNSA officials and contractor representatives indicated that the agency is taking some actions to address these challenges, such as working to replenish the supply of dwindling, highly specialized materials. NNSA's strategic plan for explosives activities addresses some of the challenges agency officials and contractor representatives have identified, and NNSA followed several key leading practices in developing its strategic plan. However, some of the plan's elements have not been fully developed consistent with selected leading practices. For instance, the plan does not include a fully developed mission statement, and some performance goals are not quantifiable. NNSA officials stated that they are aware of the strategic plan's limitations and that they released it quickly to ensure that the explosives community could use it as soon as possible. NNSA officials said that they intend to revise the strategic plan in the next year or so. As NNSA revises its strategic plan, by including fully developed elements of an effective strategic plan, NNSA would help make the strategic plan more useful in measuring goal achievement and assessing accountability.


NNSA is simultaneously modernizing the nation's nuclear weapon stockpile and the infrastructure on which weapon programs depend. In a 2019 report, NNSA stated that this is the busiest time for the nuclear security enterprise since the Cold War era. GAO's April 2017 review of NNSA nuclear modernization programs concluded that NNSA made optimistic assumptions about future costs. DOD and DOE estimate that nuclear modernization will cost hundreds of billions of dollars over the next decade. This statement is based on 18 GAO reports issued from July 2003 to February 2020 and selected updates. It discusses (1) NNSA's ongoing and planned programs and projects to modernize weapons and related infrastructure and challenges they present; (2) NNSA's improvements in managing these programs and projects, and additional steps NNSA could take to make further improvements; and (3) GAO's prior recommendation to NNSA on assessing the affordability of its portfolio of modernization programs. To conduct the updates, GAO reviewed DOE planning and budget documents. The Department of Energy's (DOE) National Nuclear Security Administration (NNSA) is conducting four programs to modernize nuclear weapons, and the Department of Defense's (DOD) 2018 Nuclear Posture Review calls for NNSA to consider additional programs to refurbish or build new weapons over the next 2 decades. NNSA is also managing numerous, multi-billion-dollar construction projects to modernize the infrastructure it uses to produce components and materials needed for its weapon programs. GAO has reported on challenges NNSA faces in managing these efforts. For example, GAO's February 2020 report on the W87-1 warhead program found that NNSA's past challenges in managing plutonium activities cast doubt on NNSA's ability to produce the required number of plutonium weapon cores on schedule. GAO also found in June 2019 that future weapon programs will require newly produced explosives, including some that NNSA has not produced at scale since 1993. NNSA has improved its management of weapon programs and related projects in some respects. For example, NNSA has established requirements for independent cost estimates in weapon programs and has made progress in revising plans for the Uranium Processing Facility project. However, GAO has identified additional actions that could further improve NNSA's management of weapon programs and projects. For example, in September 2017, GAO reported that NNSA had not developed a complete scope of work, a life-cycle cost estimate, or an integrated master schedule for its overall uranium program. GAO recommended that NNSA set a time frame for developing these plans. GAO expects to issue a report on NNSA's uranium program plans in March 2020. GAO concluded in April 2017 that NNSA had not addressed a potential mismatch between funding needs and funding availability. GAO recommended that NNSA assess its portfolio of modernization programs—for example, by presenting options to align programs to potential future budgets, such as potentially deferring the start of or cancelling specific programs. NNSA did not explicitly agree or disagree with GAO's recommendation. NNSA included an affordability analysis in July 2019 planning documents, but the analysis does not fully respond to GAO's recommendation because it does not state how potential misalignment between program costs and budget projections may be addressed. GAO continues to believe that presenting options to align its portfolio of programs to potential future budgets could help Congress and NNSA better understand NNSA's priorities and trade-offs that may need to be undertaken in the future.


NNSA relies on M&O contracts to manage and operate its eight laboratory and production sites. In 2013, NNSA awarded a consolidated M&O contract to CNS for the Y-12 and Pantex sites to reduce costs. In the contract, NNSA required that CNS create a Cost Savings Program. CNS proposed it would save about $2.9 billion over the contract's potential 10-year term. The Senate committee report accompanying a bill for the National Defense Authorization Act for Fiscal Year 2019 includes a provision for GAO to review the cost savings achieved from the competition and award of the CNS contract. GAO's report examines the extent to which (1) CNS achieved proposed cost savings from fiscal year 2014 through fiscal year 2018 and (2) NNSA identified benefits associated with the Cost Savings Program and used that information to improve its M&O contracts. GAO reviewed documentation and data on the Cost Savings Program from NNSA and CNS, interviewed NNSA headquarters and field office officials as well as representatives from M&O contractors, and toured the Y-12 site to understand examples of cost savings initiatives. The National Nuclear Security Administration (NNSA) verified about $515 million in cumulative cost savings claimed by Consolidated Nuclear Security, LLC, (CNS) from fiscal year 2014 through fiscal year 2018 (see figure). CNS was awarded the management and operating (M&O) contract for both the Y-12 National Security Complex (Y-12) in Tennessee and the Pantex Plant (Pantex) in Texas. Those savings represented about 80 percent of the approximately $640 million CNS proposed it would save through the end of fiscal year 2018. CNS achieved most of the savings through labor savings—for example, by reducing positions. While CNS's and NNSA's methods for calculating and verifying savings evolved in the early years of the contract, GAO concluded the $515 million in reported cumulative savings represents a reasonable estimate. However, due to differences between proposed and achieved savings through fiscal year 2018, and annual savings projections that are lower for the remaining years of the contract, it may be difficult for the contractor to achieve its total proposed $2.9 billion in savings over the potential 10-year contract that would end in 2024. NNSA officials identified three key benefits of the Cost Savings Program—achieving savings, reinvesting in site infrastructure, and increasing financial transparency—but has not determined whether the program could be implemented at other sites to improve its M&O contracts. For example, NNSA officials said achieving cost savings at other sites could be useful, and most M&O contracts include a clause under which sites could implement a Cost Savings Program with some attributes of the program at Y-12 and Pantex. However, NNSA is not planning to implement the Cost Savings Program—or a variation of it—at other sites. NNSA officials and contractor representatives were uncertain about whether the Cost Savings Program could be exported to other existing or future contracts because NNSA has not gathered information on nor documented its analysis of the Cost Savings Program. GAO has previously found that leading organizations gather and analyze data to identify opportunities to reduce costs, among other reasons. By performing such an analysis, NNSA officials and contractors' representatives could make better-informed decisions about whether to implement aspects of the Cost Savings Program under existing contracts or as part of future M&O contracts to achieve additional savings in the future.


NRC is responsible for regulating the security of radioactive material in the U.S. Failure to secure this material could result in an RDD causing socioeconomic damage. The Consolidated and Further Continuing Appropriations Act, 2015 (Public Law 113-235) includes a provision for GAO to review NRC's security requirements for high-risk radioactive material. This report examines, among other things, (1) the extent to which radioactive security experts agreed that NRC's assessment of risk includes all relevant criteria, and (2) NRC's 2016 evaluation of its security requirements for high-risk radioactive material. GAO reviewed NRC policies and procedures, worked with the National Academies of Sciences to convene a meeting with 18 experts in radioactive security, and reviewed 3 recent Sandia studies. GAO used the views of security experts to define high risk, and they generally agreed that high risk includes both larger and some smaller quantities of radioactive materials. The 18 experts at a meeting GAO convened with the National Academies of Sciences generally agreed that the Nuclear Regulatory Commission (NRC) assessment of risks of radioactive material does not include all relevant criteria. NRC limits its criteria to prompt fatalities and deterministic health effects from radiation, which, according to the experts and recent studies, are unlikely to result from a radiological dispersal device (RDD). Two studies from Sandia National Laboratories (Sandia) measuring consequences of RDDs, released in 2017 and 2018, found that there would be no immediate fatalities from radiation. The experts at the meeting generally agreed that socioeconomic effects (e.g., relocations and clean-up costs) and fatalities that could result from evacuations are the most relevant criteria for evaluating the risks of radioactive material. The two Sandia studies found that a large RDD could cause about $30 billion in damage and 1,500 fatalities from the evacuation, and a considerably smaller RDD could cause $24 billion in damage and 800 fatalities from the evacuation. By considering socioeconomic impacts and fatalities resulting from evacuations in its criteria, NRC would have better assurance it was considering the more likely and more significant consequences of an RDD. NRC's 2016 report evaluating its security requirements for high-risk radioactive material, required by Public Law 113-235, considered only the security of larger quantities of such material and not smaller quantities. Experts who attended GAO's meeting stated, and two 2018 Sandia studies agree, that if smaller quantities of certain radioactive material were used in an RDD, the impacts would be comparable to an RDD with a considerably larger amount of such material. For example, a 2018 study from Sandia found that malicious use of certain radioactive materials in smaller quantities could cause significant socioeconomic consequences. By requiring additional security measures for these smaller quantities of high-risk material, NRC can have better assurance that its security requirements are sufficient to secure all high-risk radioactive material from theft and use in an RDD. Example of a Radiological Dispersal Device (RDD)


NRC regulates the commercial nuclear industry. In that role, the agency provides services for regulated entities that hold licenses—that is, licensees. NRC recovers the majority of costs for these services by setting fee rates and using those rates to bill licensees. In 2017 and 2018, GAO recommended actions to improve NRC's fee-setting, billing, and budgeting processes, and NRC OIG and internal agency initiatives recommended additional actions. However, industry stakeholders continue to identify challenges with these processes. GAO was asked to review NRC's (1) fee-setting, (2) billing, and (3) budgeting processes. This report examines NRC's progress since 2017 implementing changes to those processes in response to GAO, NRC OIG, and internal agency findings and recommendations. GAO identified relevant GAO, NRC OIG, and internal agency recommendations and evaluated NRC's progress implementing those using evidence such as NRC's fee rules and budget documentation. GAO also spoke with NRC officials and interviewed a non-generalizable sample of NRC licensees, who were selected based on the amount of fees NRC charged them from fiscal years 2014 through 2018. Since 2017, the Nuclear Regulatory Commission (NRC) has implemented changes to its fee-setting, billing, and budgeting processes in response to GAO, the NRC Office of Inspector General (OIG), and internal agency findings and recommendations: Fee-Setting . NRC has improved the clarity, consistency, and transparency of its fee-setting process by, among other things, defining key terms used in the calculation of its hourly-fee rate and by developing and meeting performance measures for the transparency and timeliness of the fee-setting process. Second, NRC did not clearly define what costs are included across all its public cost estimates for common regulatory actions. NRC created the estimates as a transparency measure to assist stakeholders—including licensees and potential applicants—with planning for the costs of future NRC oversight activities. However, NRC did not specify what costs are included across these cost estimates, such as those related to project management. According to GAO's analysis of NRC documents, such costs for some NRC actions can account for about two thirds of total hours billed. By clearly defining the costs in its public cost estimates, NRC could enhance transparency and increase the value of the estimates as a budgeting and planning tool for stakeholders, in accordance with NRC's Principles of Good Regulation . Budgeting . NRC has made some changes to its budgeting process to better enable stakeholders to determine how it spent its appropriation. For example, starting in fiscal year 2018, NRC began presenting actual obligation data and more detailed information on the status of funds it carried over from prior fiscal years in its annual budget justification.


NSF supports the design, construction, and operations of major facilities projects–science and engineering research infrastructure such as telescopes and research vessels that typically have construction costs of at least $70 million and may take many years to design and construct. The agency oversees the performance of each project against an authorized total project cost and schedule. NSF currently has four projects under construction at a combined authorized cost of $1.6 billion and two additional projects in design. Prior GAO reports reviewed NSF's cost estimating and schedule policies, as well as project management expertise of its oversight workforce. Senate Report 114-239 and House Report 114-605 included provisions for GAO to review NSF's major facilities projects. Among other objectives, this report (1) describes the cost and schedule performance of NSF's ongoing major facilities projects and (2) assesses the extent to which NSF addressed prior GAO recommendations related to its management of major facilities. GAO analyzed NSF policies and documents for projects in design and construction, interviewed agency officials, and compared NSF's processes to best practices identified in prior GAO work. Since GAO's March 2019 report on the status of its major facilities projects, the National Science Foundation (NSF) had no increases to the authorized total project costs or schedules for its four projects under construction (see figure): The Daniel K. Inouye Solar Telescope was on track to be completed within its $344.1 million cost and June 2020 completion date. NSF was evaluating options for reducing the scope of the Vera C. Rubin Observatory (previously the Large Synoptic Survey Telescope), which it believed might be necessary to keep the project within its $473 million cost and October 2022 completion date. Construction of a second Regional Class Research Vessel began in September 2019 and was anticipated to begin on a third and final vessel in March 2020 at a combined cost of $365 million. The Antarctic Infrastructure Modernization for Science entered the construction phase in February 2019 at a cost of $410.4 million. NSF fully implemented two of the six prior GAO recommendations including revising policies for estimating the costs of major facilities projects and revising the Vera C. Rubin Observatory's schedule to better meet best practices. NSF took steps to address but has not fully implemented the remaining four recommendations on the agency's oversight of major facilities.


Nationwide, about 1.4 million elderly or disabled individuals receive care in more than 15,500 nursing homes. CMS, an agency within the Department of Health and Human Services (HHS), defines standards nursing homes must meet to participate in the Medicare and Medicaid programs. Nursing home residents often have physical or cognitive limitations that can leave them particularly vulnerable to abuse. Abuse of nursing home residents can occur in many forms—including physical, mental, verbal, and sexual—and can be committed by staff, residents, or others in the nursing home. Any incident of abuse is a serious occurrence and can result in potentially devastating consequences for residents, including lasting mental anguish, serious injury, or death. This statement summarizes GAO's June 2019 report, GAO-19-433 . Specifically, it describes: (1) the trends and types of abuse in recent years, and (2) CMS's oversight intended to ensure residents are free from abuse. It also includes a brief summary of findings and recommendations from this June 2019 report and prior GAO reports that examined the health and welfare of the elderly in multiple settings, and the status, as of November 2019, of HHS's efforts to implement the recommendations GAO made. The Centers for Medicare & Medicaid Services (CMS) is responsible for ensuring nursing homes meet federal quality standards, including that residents are free from abuse. CMS enters into agreements with state survey agencies to conduct surveys of the state's homes and to investigate complaints and incidents. GAO's June 2019 report found that, while abuse deficiencies cited in nursing homes were relatively rare from 2013 through 2017, they more than doubled during that time, increasing from 430 in 2013 to 875 in 2017, with the largest increase in severe cases. In light of the increased number and severity of abuse deficiencies, it is imperative that CMS have strong nursing home oversight in place to protect residents from abuse. However, GAO found oversight gaps that may limit the agency's ability to do so. Specifically, GAO found: (1) Information on abuse and perpetrator types is not readily available. CMS's data do not allow for the type of abuse or perpetrator to be readily identified by the agency. Specifically, CMS does not require the state survey agencies to record abuse and perpetrator type and, when this information is recorded, it cannot be easily analyzed by CMS. GAO made a recommendation that CMS require state survey agencies to submit data on abuse and perpetrator type and HHS concurred. As of November 2019, HHS had not implemented the recommendation. (2) Facility-reported incidents lack key information. Despite federal law requiring nursing homes to self-report allegations of abuse and covered individuals to report reasonable suspicions of crimes against residents, CMS has not provided guidance to nursing homes on what information they should include in facility-reported incidents, contributing to a lack of information for state survey agencies and delays in their investigations. GAO made a recommendation that CMS develop guidance on what abuse information nursing homes should self-report and HHS concurred. As of November 2019, HHS had not implemented the recommendation. (3) Gaps exist in the CMS process for state survey agency referrals to law enforcement. GAO found gaps in CMS's process for referring incidents of abuse to law enforcement. These gaps may limit CMS's ability to ensure that nursing homes meet federal requirements for residents to be free from abuse. Specifically, GAO identified issues related to (1) referring abuse to law enforcement in a timely manner, (2) tracking abuse referrals, (3) defining what it means to substantiate an allegation of abuse—that is, the determination by the state survey agency that evidence supports the abuse allegation, and (4) sharing information with law enforcement. GAO made four recommendations to address these gaps and HHS concurred. As of November 2019, HHS had not implemented these recommendations.


Nearly 165,000 licensed health care providers, such as physicians and nurses, provide care in VHA's VA medical centers and outpatient facilities. Medical center staff must determine whether to hire and retain health care providers by reviewing and verifying information about their qualifications and practice history. The NPDB is a key source of information about a provider's clinical practice history. Medical center staff must also investigate any concerns that arise about the clinical care their providers deliver. Depending on the findings from these reviews, medical centers may take an adverse privileging action against a provider. VA medical centers are required to report providers to the NPDB and state licensing boards under certain circumstances. Failing to adhere to these requirements can negatively affect patient safety. This testimony is primarily based on GAO's 2019 and 2017 reports on VHA processes for reviewing and reporting quality and safety concerns about VA providers. It addresses VA medical centers' implementation and VHA's oversight of (1) reviews of adverse information about providers in the NPDB; (2) reviews of providers' clinical care after concerns are raised; and (3) reporting of providers to the NPDB and state licensing boards. For the 2019 report, GAO reviewed a nongeneralizable sample of 57 VA providers who had an NPDB report. For the 2017 report, GAO reviewed providers whose clinical care was reviewed after a concern was raised about that care at a nongeneralizable selection of five VA medical centers. The Department of Veterans Affairs (VA) needs to take action to ensure its health care providers have the appropriate qualifications and clinical abilities to deliver high quality, safe care to veterans, as GAO recommended in its February 2019 and November 2017 reports. Specifically, GAO found the following: VA medical centers took action against some providers who did not meet VA licensure requirements, but overlooked others . In its 2019 report, GAO found that some VA medical centers took administrative or disciplinary actions against these providers, such as removing them from employment, after becoming aware of disqualifying information in the National Practitioner Data Bank (NPDB). The NPDB is an electronic repository that contains information on providers who have been disciplined by a state licensing board, among other information. However, in some cases VA medical centers overlooked or were unaware of disqualifying information in the NPDB. For example, officials told GAO they inadvertently overlooked a disqualifying adverse action and hired a provider whose license had been revoked for patient neglect. GAO found three reasons for this inconsistency: lack of mandatory training for key staff, gaps in Veterans Health Administration (VHA) policies, and inadequate oversight. Selected VA medical centers' reviews of providers' clinical care were not always documented . The five selected VA medical centers that GAO included in its 2017 report were required to review 148 providers' clinical care after concerns were raised about their care from October 2013 through March 2017. However, officials at these medical centers could not provide documentation to show that almost half of these reviews had been conducted. GAO found two reasons for inadequate documentation of these reviews: gaps in VHA policies and inadequate oversight of the reviews. Selected VA medical centers did not report providers to the NPDB or to state licensing boards as required . The five selected VA medical centers that GAO included in its 2017 report had reported one of nine providers to the NPDB that they were required to report from October 2013 through March 2017. None of these providers were reported to state licensing boards, as required by VHA policy. These nine providers either had adverse privileging actions taken against them—actions that limit the care providers can deliver at a facility or prevent the providers from delivering care altogether—or resigned or retired while under investigation before such an action could be taken. GAO found two reasons providers were not reported: lack of awareness or understanding of VHA policies and inadequate oversight of this reporting. GAO made 11 recommendations in its 2019 and 2017 reports to address the deficiencies identified. VA implemented two of these 11 recommendations, and provided action plans to address the other nine recommendations.


Amtrakâofficially the National Railroad Passenger Corporationâhas been the national intercity passenger railroad since 1971, and currently serves over 500 stations on a network approximately 22,000 miles long. In some markets, such as the busy Northeast Corridor (NEC) connecting Washington, New York, and Boston, it has captured a greater share of intercity passengers than domestic airlines. In other, more rural markets, some see it as a vital link to the national transportation system despite low levels of ridership. Though Amtrak is legally a private for-profit corporation, the federal government controls the company's operations. A five-year authorization of federal funding for Amtrak was included in the Fixing America's Surface Transportation (FAST) Act of 2015 ( P.L. 114-94 ), which expires at the end of FY2020. Since its inception, Amtrak has depended on annual appropriations from the federal government to cover its capital (infrastructure, vehicles) and operating (train crews, maintenance) costs. Amtrak's financial health has improved in recent years. In 2018, according to the railroad, revenue covered 79% of its expenses, the highest ratio it has ever reported. Amtrak's preferred metric for financial performance, its adjusted operating loss, declined to $168 million, but this figure does not take its capital needs into account. Increased contributions from commuter railroads that use the NEC have played an important role in reducing the need for federal support. Amtrak's ridership continues to increase, as does its relative share of passenger miles traveled, though both remain small on a national scale when compared to road and air traffic. Despite these improvements, a large backlog of capital projects remains unfunded, and Amtrak remains under pressure to further reduce its need for operating subsidies. Capacity constraints will make further ridership increases difficult to achieve without capital expenditures for additional equipment and track improvements. The Amtrak system is divided into two subsets for funding purposes, the NEC and the National Network (everything else), each facing its own set of challenges. Congress may want to explore opportunities to further differentiate these systems in terms of how they are funded and managed. Comparatively high revenues on the NEC compared to operating costs have prompted occasional proposals to either partially or fully privatize the existing service, while its large capital backlog and lack of a long-term dedicated funding source have raised questions about whether a new NEC-only funding mechanism is needed. The National Network, meanwhile, encompasses both short-distance corridors supported by state governments and long-distance routes that require the largest federal subsidies in the Amtrak system. Amtrak is under pressure to accomplish two goals that at times seem to work against one another: to serve as the national passenger railroad, including through the operation of long-distance routes, and to reduce or eliminate the need for federal subsidies. While Congress has repeatedly taken steps to preserve long-distance passenger trains, both the Trump Administration and Amtrak have voiced support for shifting focus away from long-distance trains and toward serving a larger number of shorter corridors. Any such rebalancing, however, would be contingent on state support that is far from certain. Apart from funding, other issues facing Amtrak have been on the congressional agenda for years. On-time performance has seen only sporadic improvement since the enactment of a 2008 law designed to enforce the preferential treatment, codified in statute since the 1970s, of Amtrak trains running on freight tracks. Onboard food and beverage service, long seen by critics as a contributor to financial losses but by supporters as integral to the rail travel experience, has mirrored Amtrak as a whole in improving its financial performance while still falling short of goals set by Congress. Installation of a key safety technology mandated in 2008 is continuing according to federally approved schedules, but Amtrak routes that operate on track owned by freight or commuter railroads face the additional hurdle of demonstrating interoperability with those railroads' safety systems, putting the timeline to full implementation at risk.


Nearly a million individuals relied on organizational payees to manage their Social Security benefits in 2018. Due to an aging population more beneficiaries may need organizational payees in the future. These beneficiaries are among the most vulnerable because, in addition to being deemed incapable of managing their own benefits, they lack family or another responsible party to assume this responsibility. SSA reports that misuse of benefits by payees is rare, but its Office of Inspector General has identified cases of misuse that have harmed vulnerable beneficiaries. GAO was asked to review SSA's organizational payee program. This review examines, among other things SSA's process for approving payees and its monitoring efforts. GAO reviewed relevant federal laws, regulations, policies, and guidance; analyzed SSA data from fiscal year 2018; analyzed the predictive statistical model SSA uses to select low-volume payees for on-site reviews; and interviewed SSA central office staff and regional, area, and field office staff in four regions selected for geographic diversity. The Social Security Administration (SSA) approves organizational payees—such as nursing homes or non-profits that manage the Social Security benefits of individuals unable to do so on their own—by assessing a range of suitability factors, such as whether the organizations have adequate staff to manage benefits for multiple individuals. However, GAO found that SSA's policy does not specify how to assess more complex suitability factors, such as whether an organization demonstrates sound financial management. Without clearer guidance, unqualified or ill-prepared organizational payees could be approved to manage benefits. Also, SSA does not currently require background checks for key employees of an organizational payee. In contrast, SSA requires background checks for individual payees—such as a relative or friend of the beneficiary. A comprehensive evaluation could help SSA determine whether and how to expand their use of background checks to organizational payees. To ensure organizational payees are managing funds appropriately, SSA uses several monitoring tools, including resource-intensive onsite reviews. Certain organizational payees, such as those that charge fees for their services or have 50 or more beneficiaries (high-volume), receive onsite reviews every 3 to 4-years. In contrast, payees that serve fewer than 50 beneficiaries (low-volume)—the vast majority—are selected for review based on their estimated likelihood of misusing beneficiary funds, and a relatively low percent of them receive onsite reviews (see figure). SSA uses a predictive statistical model to identify higher risk low-volume payees, but the model's effectiveness cannot be fully assessed by GAO or others due to missing documentation on how it was designed. SSA officials said they will update the model in the future, but do not have a time frame for doing so. Establishing such a time frame and documenting design decisions are key steps toward assessing the model's effectiveness. Another way SSA oversees organizational payees is by reviewing their annual accounting forms, but shortcomings exist in SSA's review of the form and in the form's content and design. For example, SSA lacks timeframes for following up on missing or problematic forms. Also, the accounting form does not capture complete information on whether payees co-mingle beneficiaries' funds in collective accounts, which can limit SSA's ability to monitor those risk-prone accounts. Establishing timeframes and revising the form could enhance the effectiveness of the annual accounting form as an oversight tool.


Net metering is a policy that allows electricity customers with their own generation capacity to be financially compensated for the energy they produce. Net metering is widely regarded as having an important role in deployment of distributed generation (DG), especially solar energy. State and local governments have authority to establish net metering policies, and some have done so for many years. Congress took action to encourage net metering in the Energy Policy Act of 2005 (EPACT05), and the policy now exists, in some form, in 45 states. Recent state net metering policy modifications, and potential effects on solar energy deployment, may be relevant to congressional discussions regarding the role of renewable energy sources in the nation's electricity system. Solar photovoltaic panels (e.g., rooftop solar) accounted for 97% of the generation capacity participating in net metering programs in 2018. Net metering participation roughly quadrupled from 2013 to 2018, according to data from the U.S. Energy Information Administration. Hawaii has the highest participation rate of any state, with 15% of electricity customers participating in net metering in 2018. In a majority of states, however, net metering customers account for less than 1% of total electricity customers. States differ in the way net metering customers are compensated. A common method is the retail rate, under which energy from net metering capacity offsets energy consumed from the grid in a one-to-one fashion. This method is often described as the "meter running backward." Retail rate compensation was initially adopted, in large part, for its administrative simplicity. Some stakeholders continue to prefer it for the relatively high payments it gives to net metering customers. Other stakeholders criticize retail rate compensation as overcompensating net metering customers for the electricity they produce. Part of this criticism comes from the fact that electricity retail rates reflect not just costs associated with generating electricity, but also costs associated with building, maintaining, and operating the transmission and distribution systems ("the grid"). Electricity rates are typically designed so that utilities can recover their total costs associated with providing electricity. If a sufficiently large number of customers participate in net metering, costs might increase for non-net metering customers in order to pay for the grid benefits. This possibility is known as a cross-subsidy, or sometimes a cost shift. In addition to these concerns about fairness, some critics of retail rate compensation raise concerns about equity, because historically most net metering customers have had above-average incomes. Empirical evidence of the cost increases for non-net metering customers is mixed, partly because studies make different assumptions about costs and benefits associated with DG. Some projections in different states have quantified a potential cross-subsidy, but projections in other states have concluded that the value of cross-subsidies are approximately zero. States have considered, and in some cases adopted, alternative compensation approaches to address concerns over cross-subsidies. One type of approach adds a fixed charge to net metering customers' bills to reflect the costs of maintaining the grid. Another type of approach provides an alternative compensation rate (i.e., not the retail rate) that net metering customers receive for the energy they deliver to the grid. Options for alternative compensation rates are avoided cost rates, which reflect primarily the utility's cost of producing electricity, and value of solar (VOS) rates, which additionally consider societal benefits such as reduced air emissions. Generally, rates that consider more benefits (and avoided costs) associated with DG have a higher monetary value and might promote greater levels of DG penetration. States have included different costs and benefits in analyses conducted to estimate alternative compensation rates, resulting in different monetary values for alternative rates. Even if states opted to include the same types of costs and benefits, they might derive different values for rates, since the relative costs and benefits of DG can vary based on local circumstances. Relevant local circumstances include overall penetration of DG, average and marginal electricity costs, congestion in transmission and distribution systems, and potentially other factors. Other state net metering policy provisions can affect deployment of DG. They relate to whether to adopt program caps, thereby limiting the number of participants; which technology type and what size generator are eligible; how long customers can "carry over" credits associated with surplus electricity generation; and what types of system ownership arrangements may participate in net metering. A related consideration is whether third parties, such as solar leasing firms, may develop DG in the state. Some Members of Congress have expressed interest in various aspects of net metering policy since passage of EPACT05. Legislation has sought to limit revisions that states can make to net metering policies; expand access to net metering for different types of electricity generation; and estimate costs and benefits associated with net metering, among other topics.


New technologies in the financial services sector can create challenges for the various federal agencies responsible for financial regulation in the United States. As these regulators address the potential benefits and risks of innovation, policymakers have demonstrated significant interest in understanding the types of technologies that may benefit consumers and financial markets while identifying the risks that new financial services may present. As Congress considers the potential tradeoffs of financial technology or fintech , it can be useful to understand how the financial system regulators are approaching these issues. The financial system regulators can be grouped into three general categories: (1) depository institution regulators, (2) consumer protection agencies, and (3) securities regulators. Each type of regulator has the authority to write rules, publish guidance, supervise institutions, and enforce compliance with the laws they implement. Further, there are similarities and differences among each regulator's mandate, which shed light on the approaches the regulators tend to take when considering new fintech. The banking regulators generally are responsible for banks and credit unions, particularly focusing on the safety and soundness of these institutions. They have limited authority to write rules for, supervise the operations of, or enforce actions against firms outside their jurisdiction. Some banking regulators are responsible for granting licenses, or charters, to financial institutions so they can operate as banks and credit unions. Fintech firms typically are not licensed banks or credit unions; however, banks and credit unions often form partnerships with fintech firms, and banking regulators have legal authority to examine these types of relationships. This third-party partnership supervision allows the regulators to supervise depository institutions' interactions with new fintech firms. Banks and credit unions also have an important role in the payments system. Banking regulators have used some of their rulemaking authorities to influence technological advances in the payments system as consumers continue to shift toward electronic payment tools, such as debit and credit cards. The consumer protection agencies generally are responsible for protecting consumers from unfair and deceptive business activities while maintaining a fair, competitive marketplace. Similar to banking regulators, consumer protection agencies have rulemaking, supervision, and enforcement authorities to implement and ensure industry compliance with consumer protection and competition laws, but consumer protection agencies have broader jurisdiction than banking regulators. For example, often they can directly regulate fintech companies and use their enforcement authorities to interact with fintech. In addition, they have promulgated rules pertaining to aspects of fintech. Consumer protection agencies generally balance the potential benefits of new technologies that could improve consumer outcomes with the potential risks to consumers posed by new, untested products entering the marketplace. This mandate allows consumer protection agencies to take enforcement actions to protect consumers and create safeguards from enforcement actions to protect companies offering financial services that benefit consumers or the market. Securities regulators generally are concerned with protecting investors, maintaining fair and efficient markets, and facilitating capital formation. These regulators generally have limited concern for safety and soundness of the firms in their jurisdiction, focusing on disclosure requirements and contracts to promote investor protection and efficiency in the marketplace. Similar to the other regulators, they promulgate and enforce rules, but their mandate positions them somewhat differently than banking regulators and consumer protection agencies with respect to fintech. Securities regulators may endeavor to determine whether a new type of fintech product from a company counts as a security and how fintech is changing the way securities are offered. To this end, securities regulators tend to rely on their enforcement authority to ensure that new technologies do not violate securities laws.


Nuclear power contributes roughly 20% of the electrical generation in the United States. Uranium is the fundamental element in fuel used for nuclear power production. The nuclear fuel cycle is the cradle-to-grave life cycle from extracting uranium ore from the earth through power production in a nuclear reactor to permanent disposal of the resulting spent nuclear fuel. The front-end of the nuclear fuel cycle considers the portion of the nuclear fuel cycle leading up to electrical power production in a nuclear reactor. The front-end of the nuclear fuel cycle has four stages: mining and milling, conversion, enrichment, and fabrication. Mining and milling is the process of removing uranium ore from the earth, and physically and chemically processing the ore to develop "yellow-cake" uranium concentrate. Uranium conversion produces uranium hexafluoride, a gaseous form of uranium, from uranium concentrate. Uranium enrichment physically separates and concentrates the fissile isotope U-235. The enriched uranium used in nuclear power reactors is approximately 3%-5% U-235, while weapons-grade enriched uranium is greater than 90% U-235. Nuclear fuel fabrication involves manufacturing enriched uranium fuel rods and assemblies highly specific to a nuclear power reactor. Historically, the Atomic Energy Commission (AEC), a predecessor federal agency to the Department of Energy (DOE) and the Nuclear Regulatory Commission (NRC), promoted uranium production through federal procurement contracts between 1947 and 1971. Since the late 1980s, U.S. nuclear utilities and reactor operators have purchased increasingly more foreign-origin uranium for reactor fuel than domestically produced uranium. In 1987, about half of uranium used in domestic nuclear reactors was foreign origin. By 2018, however, 93% of uranium used in U.S. nuclear reactors was foreign origin. No uranium conversion facilities currently operate in the United States. There is one operational U.S. commercial uranium enrichment facility, which has the capacity to enrich approximately one-third of the country's annual reactor requirements. In addition to newly mined uranium, U.S. nuclear power reactors also rely on secondary sources of uranium materials. These sources include federal and commercial stockpiles, reenrichment of depleted uranium, excess feed from underfeeding during commercial enrichment, and downblending of higher enriched uranium. The global uranium market operates with multiple industries exchanging uranium products and services through separate, nondirect, and interrelated markets. Producers, suppliers, and utilities buy, sell, store, and transfer uranium materials. Nuclear utilities and reactor operators diversify fuel sources among primary and secondary supply, and may acquire uranium from multiple domestic and foreign suppliers and servicers. For example, a nuclear power utility in the United States may purchase uranium concentrate that has been mined and milled in Australia, converted in France, enriched in Germany, and fabricated into fuel in the United States. On January 16, 2018, two domestic uranium producersârepresentatives from the uranium mining/milling industryâpetitioned the U.S. Department of Commerce to conduct a Section 232 investigation pursuant to the Trade Expansion Act of 1962 (19 U.S.C. Â§1862) to examine whether U.S. uranium imports pose a threat to national security. The department found that uranium imports into the United States posed a threat to national security as defined under Section 232. In a July 12, 2019, memorandum, President Trump announced he did not concur with the Department of Commerce's "finding that uranium imports threaten to impair the national security of the United States as defined under section 232 of the Act." The Section 232 uranium investigation into uranium imports has increased the discussion about the nuclear fuel supply chain and potential future U.S. uranium needs. Included in the July 12, 2019, memorandum, the Trump Administration established a Nuclear Fuel Working Group, to assess the challenges facing the domestic uranium industry and to consider options to "revive and expand the nuclear energy sector." Given uncertainties regarding the long-term viability of the domestic uranium production and commercial nuclear power sectors, continued issues associated with the front-end of the nuclear fuel cycle may persist.


Nuclear terrorism remains a significant threat to the security of the United States and its allies and partners. U.S. efforts to prevent nuclear terrorism include working with IAEA, an autonomous international agency affiliated with the United Nations. The Department of State coordinates the United States' policy with and financial contributions to IAEA. IAEA's nuclear security program aims to assist countries in enhancing the physical protection, control, and accounting of their nuclear and radiological material and nuclear facilities. GAO was asked to review IAEA's nuclear security program. This report examines (1) the structure and range of nuclear security work that IAEA conducts, (2) how IAEA plans and prioritizes its nuclear security work and measures performance, and (3) the challenges that IAEA's nuclear security program faces. GAO analyzed key IAEA documents and interviewed IAEA officials, U.S. and foreign government officials, and nuclear security experts. The International Atomic Energy Agency (IAEA) carries out its nuclear security program under its Division of Nuclear Security through four subprograms. IAEA activities under these subprograms include developing guidance, providing training, and assisting countries in enhancing nuclear and radiological material security. IAEA plans its nuclear security work through several key documents, including a Nuclear Security Plan, which calls for activities to be prioritized. However, IAEA's planning documents do not include guidelines for prioritization. Instead, IAEA officials said they respond to member states' requests as they arrive and to the extent resources are available. By developing guidelines for prioritizing its nuclear security activities, IAEA could help ensure that it is allocating its resources to the areas of greatest need. IAEA has developed performance measures for its nuclear security program, but these measures do not have baselines or targets. This limits IAEA's ability to demonstrate the results of its nuclear security program. IAEA member states disagree over the agency's role in nuclear security, and according to U.S. and other member-state officials and experts GAO interviewed, these disagreements create challenges for the agency, such as funding its nuclear security efforts. Officials added that states that do not support the agency's nuclear security role resist efforts to substantially raise the agency's regular budget for nuclear security, contributing to the program's heavy reliance on voluntary, or extra-budgetary, contributions from member states. GAO previously reported that extra-budgetary funding is unreliable. Reliance on such funding affects nuclear security program planning, human resources, and sustainability. Experts and U.S. agency officials have suggested options to stabilize nuclear security program funding, but IAEA has not analyzed such options. By working with the United States and other member states to analyze options to stabilize nuclear security program funding, IAEA could ensure that it has sufficient, reliable resources to implement the Nuclear Security Plan.


Numerous U.S. universities and colleges have partnered with Chinese entities to establish (1) Confucius Institutes in the United States and (2) degree-granting institutions in China. Confucius Institutes are partnerships between Chinese entities and schools in other countries, arranged and funded in part by Hanban, which seek to promote Chinese language and culture. There were 96 institutes located at colleges and universities in the United States as of January 2019. U.S. universities have also partnered with Chinese universities to establish degree-granting institutions in China approved by the Chinese government. School officials have noted these types of partnerships provide valuable educational, cultural, and other benefits. Some researchers, government officials, and others, however, have raised concerns about them, including about the contents of written agreements and the role of the Chinese government, which, according to the Department of State, has made efforts to restrict academic freedom and impose censorship at Chinese universities and other institutions. Some have expressed concern that U.S. universities partnering with the Chinese government may face similar restrictions. This testimony discusses funding, agreements, and operations of (1) Confucius Institutes in the United States and (2) U.S. universities in China. This testimony is based on GAO's February 2019 report on Confucius Institutes in the United States and GAO's August 2016 report on U.S. universities in China. GAO reviewed 90 agreements establishing Confucius Institutes and spoke to officials about benefits and concerns related to the institutes. Agreements between Hanban—an affiliate of the Chinese Ministry of Education—and U.S. colleges and universities generally describe similar activities, funding, and management, though institute operations vary in practice. Confucius Institutes receive funding from Hanban and U.S. schools, and do not receive direct federal funding. While 42 of 90 agreements contained language about the document being confidential, some were available online or upon request, and one-third of the 90 agreements explicitly addressed how U.S. school policies apply to the institutes. Officials GAO interviewed at 10 case study schools noted U.S. school policies apply to institutes at their schools. GAO also interviewed some researchers and others who expressed concern that the presence of Confucius Institutes could constrain campus activities and classroom content. For example, several suggested schools with institutes might avoid hosting events on topics that could include criticism of China, such as Taiwan or Tibet, so as to not offend Chinese partners. School officials offered examples to illustrate that these concerns did not apply to their institute, noting institutes had sponsored events on such topics. Nonetheless, school officials and others suggested ways schools could improve institute management, such as renegotiating agreements to clarify U.S. schools' authority and making agreements publicly available. In August 2016, GAO reported that U.S. universities that have partnered with Chinese universities to establish degree-granting institutions in China emphasize academic freedom, but face internet censorship and other challenges. The 12 U.S. universities GAO reviewed generally reported receiving support for their institutions in China from Chinese government entities and universities, and 5 reported receiving U.S. government funding, mostly federal financial aid to U.S. students. Universities' agreements with Chinese partners or other policies GAO reviewed generally included language protecting academic freedom or indicating their institution in China would adhere to U.S. standards. University members generally indicated that they experienced academic freedom, but also stated that internet censorship, self-censorship, and other factors presented constraints. At several universities that lacked uncensored internet access, faculty and students noted that, as a result, they faced challenges teaching, conducting research, and completing coursework at that time.


Nursing homes provide care to about 1.4 million nursing home residents—a vulnerable population of elderly and disabled individuals. CMS, an agency within the Department of Health and Human Services (HHS), defines standards nursing homes must meet to participate in the Medicare and Medicaid programs. GAO was asked to review abuse of residents in nursing homes. Among other objectives, this report: (1) determines the trends and types of abuse in recent years, and (2) evaluates CMS oversight intended to ensure residents are free from abuse. GAO reviewed CMS's policies, analyzed CMS data on abuse deficiencies from 2013 through 2017, the most recent data at the time of our review, and interviewed officials from CMS and state survey agencies in five states, as well as other key stakeholders in those states such as ombudsmen and law enforcement officials. The states were selected for variation in factors such as number of nursing homes and role of other state agencies in abuse investigations. The Centers for Medicare & Medicaid Services (CMS) is responsible for ensuring nursing homes meet federal quality standards, including that residents are free from abuse. CMS enters into agreements with state survey agencies to conduct surveys of the state's homes and to investigate complaints and incidents. GAO analysis of CMS data found that, while relatively rare, abuse deficiencies cited in nursing homes more than doubled, increasing from 430 in 2013 to 875 in 2017, with the largest increase in severe cases. GAO also reviewed a representative sample of abuse deficiency narratives from 2016 through 2017. Physical and mental/verbal abuse occurred most often in nursing homes, followed by sexual abuse, and staff were more often the perpetrators of the abuse deficiencies cited. CMS cannot readily access information on abuse or perpetrator type in its data and, therefore, lacks key information critical to taking appropriate actions. GAO also found gaps in CMS oversight, including: Gaps in CMS processes that can result in delayed and missed referrals. Federal law requires nursing home staff to immediately report to law enforcement and the state survey agency reasonable suspicions of a crime that results in serious bodily injury to a resident. However, there is no equivalent requirement that the state survey agency make a timely referral for complaints it receives directly or through surveys it conducts. CMS also does not conduct oversight to ensure that state survey agencies are correctly referring abuse cases to law enforcement. Insufficient information collected on facility-reported incidents. CMS has not issued guidance on what nursing homes should include when they self-report abuse incidents to the state survey agencies. Officials from all of the state survey agencies in GAO's review said the facility-reported incidents can lack information needed to prioritize investigations and may result in state survey agencies not responding as quickly as needed.


OCWR is an independent, non-partisan office that administers and enforces various provisions related to fair employment and occupational safety and health within the legislative branch. Responding to concerns about sexual harassment in the workplace, Congress passed the Reform Act in 2018, which expanded worker protections and overhauled the process for resolving workplace claims, including claims relating to discrimination and harassment. The act also required OCWR to create a secure, electronic claims system and appoint a confidential advisor to assist claimants, among other requirements. The Reform Act includes a provision for GAO to review OCWR's management practices. This report examines (1) the status of OCWR's efforts to address new requirements in the Reform Act; (2) how OCWR is incorporating key management practices to implement the new requirements; and (3) the extent to which OCWR implemented recommendations from a related 2004 GAO report. GAO reviewed documentation on OCWR's processes, interviewed officials from OCWR and selected legislative branch offices, and assessed how OCWR's actions aligned with key organizational change management practices that GAO identified and key project management practices from the Project Management Institute. The Office of Congressional Workplace Rights' (OCWR) mission is to effectively implement and enforce the Congressional Accountability Act of 1995 (CAA), as amended in 2018 by the Congressional Accountability Act of 1995 Reform Act (Reform Act). OCWR has implemented three of the four Reform Act requirements that generally became effective June 19, 2019, as shown below. Three other Reform Act requirements—track and report data and assessments, conduct a workplace climate survey, and educate and assist legislative branch offices—are in progress. OCWR has incorporated some key management practices when implementing requirements, such as managing risks associated with appointing a confidential advisor. However, opportunities exist to further incorporate key management practices in OCWR's work. For example: Addressing risks . OCWR has not yet developed policies and procedures to address the risks associated with permanently retaining sensitive records, such as ensuring they remain confidential when stored in multiple locations. Measuring performance . OCWR has not established measurable performance targets and milestones or related performance measures. Doing so would allow OCWR to determine if it is making progress toward its long-term goals and better communicate with congressional and other stakeholders about its progress. Monitoring effectiveness . OCWR routinely conducts educational activities, such as holding brown bag events and online training, and performs a variety of outreach activities. OCWR has new opportunities every 2 years to collect data through the workplace climate survey on the extent to which legislative branch employees are aware of OCWR's services and their rights under the CAA. GAO found that OCWR implemented most recommendations from a 2004 GAO report examining OCWR's management controls. GAO also found that OCWR later stopped implementing a recommendation related to information technology (IT) planning, including ensuring that it obtained necessary IT skills. Without IT strategic planning, including recruiting and retaining staff with mission-critical IT skills, OCWR may be less able to carry out its strategic initiatives.


OCWR is an independent, nonpartisan office that administers and enforces various provisions related to fair employment, and occupational safety and health within the legislative branch. To meet its mission, OCWR relies extensively on external parties, such as the Library of Congress, for IT support. In December 2018, Congress passed the Congressional Accountability Act of 1995 Reform Act (Reform Act) which, among other things, required OCWR to create a secure, online system to receive and keep track of claims related to employee rights and protections, such as sexual harassment and discrimination. To meet this requirement, OCWR initiated the SOCRATES project to upgrade its legacy claims management system. The Reform Act included a provision for GAO to review OCWR's cybersecurity practices. This report examines the extent to which OCWR (1) incorporated key cybersecurity management activities into project planning for its claims management system upgrade, (2) performed oversight of security controls and mitigated risks for selected systems operated by external parties on its behalf and, (3) established an effective approach for managing organization-wide cybersecurity risk. To address these objectives, GAO compared OCWR IT policies, procedures, strategic plans, and documentation for two selected systems to leading IT project planning, system oversight, and cybersecurity management practices. The Office of Congressional Workplace Rights (OCWR) did not incorporate key cybersecurity management practices into the planning for its Secure Online Claims Reporting and Tracking E-filing System (SOCRATES) project. While OCWR drafted a SOCRATES project schedule, the office did not finalize and use this schedule to manage cybersecurity activities, such as the time frames for conducting information technology (IT) system security assessments. In addition, the office did not document project cybersecurity risks, such as the office's reliance on external parties to implement responsibilities on its behalf. These weaknesses were due, in part, to a lack of policies and procedures for IT project planning. Until OCWR establishes and implements such policies and procedures, it will continue to have a limited ability to effectively manage and monitor the completion of cybersecurity activities for its IT projects. OCWR did not fully implement important oversight activities for two selected systems—SOCRATES and the system used to document occupational safety and health violations known as the Facility Management Assistant (FMA)—operated by external entities (see table). These shortfalls contributed to concerns with the deployment of SOCRATES in June 2019. For example, important security controls needed to ensure the confidentiality, integrity, and availability of the system were not fully tested before the system was deployed. In addition, penetration testing—where evaluators mimic real-world attacks in an attempt to identify ways to circumvent the security features of the system—was not fully completed before deployment. GAO plans to issue a separate report with limited distribution on its assessment of security controls intended to, among other things, prevent successful attacks. Although OCWR's strategic plan includes a goal of developing cybersecurity policies and procedures, the office had not fully established an effective approach for managing organization-wide cybersecurity risk. For example, OCWR designated an executive to oversee risk, but had not established the responsibilities of the official in the office's policies. Until OCWR improves its appoach to managing cybersecurity risks, its ability to make operational decisions that adequately address security risks will be hindered.


OJJDP administers grant programs to improve positive outcomes for juveniles in the justice system. In fiscal year 2018, OJJDP made 295 awards across 16 programs totaling over $290 million. The Juvenile Justice Reform Act of 2018 included a provision for GAO to review OJJDP performance and internal controls intended to prevent fraud, waste, and abuse of grant funds. This report examines the extent to which (1) OJJDP has goals and measures to assess the performance of its programs, and (2) DOJ has considered fraud risks for OJJDP grant programs. GAO reviewed DOJ documentation, such as OJJDP's Performance Measures Manual and OJP's risk management policy. GAO also reviewed performance data from selected OJJDP programs from October 2015 through December 2018, and interviewed DOJ officials. The Department of Justice's (DOJ) Office of Juvenile Justice and Delinquency Prevention (OJJDP) has goal statements and performance measures for each of its programs, but has not established corresponding program-level targets (specific numeric goals). Rather, OJJDP has established several office-level targets to help assess progress across OJJDP grant programs collectively. For example, OJJDP has a target for the percent of youth who offend and reoffend across all applicable grant programs. Such office-level targets, while useful, might obscure the results of individual programs. Setting program-level targets would help OJJDP assess the progress of each program and reach its goal of increasing accountability for achieving results in individual programs. DOJ's Office of Justice Programs (OJP) and DOJ's Justice Management Division (JMD) have taken steps to consider fraud risk affecting OJJDP programs. Specifically, OJP—the grant-making component in which OJJDP resides—has tools it uses to monitor grantee performance and compliance with award terms and conditions. According to OJP, these tools—such as checklists used during desk reviews and site visit audits—provide insight into grant fraud risks. Additionally, JMD—the component that manages fraud risk assessment across all components within DOJ—has taken steps to assess fraud risks affecting OJJDP grant programs. Specifically, JMD conducted department-wide fraud risk assessments in fiscal years 2017, 2018, and 2019. These assessments addressed all DOJ grants, including OJJDP's. DOJ's 2017 assessment identified fraud risk scenarios and assessed their likelihood and impact—leading practices in GAO's Fraud Risk Framework. Building on the 2017 assessment, the 2018 assessment identified key fraud risk management activities, and the 2019 assessment resulted in a fraud risk profile. However, these assessments did not determine a fraud risk tolerance—i.e. managers' willingness to accept a specific level of risk—as it relates to OJJDP grant programs. JMD officials said they view this as the next step in the maturation of DOJ's fraud risk assessment processes, but did not have details or documentation of plans to do so. Determining a fraud risk tolerance—and assessing fraud risks against that tolerance to prioritize them—would help OJP calibrate resources to address grant fraud risk for OJJDP programs, helping ensure that resources are not under- or over-allocated.


An adequate, well-trained health care provider workforce is essential to ensure Americans have access to quality health care services. However, studies have shown the United States faces a shortage of physicians, making it increasingly difficult for people to access needed health care. Experts have identified ways to address this shortage, such as through strategies that increase the number of other types of non-physician providers, including NPs and PAs. For example, members of Congress and others have questioned whether expanding the scope of the Medicare GME program to include NPs and PAs could help mitigate the effects of a physician shortage. A Senate Committee on Appropriations report included a provision for GAO to examine the potential of making GME payments under the Medicare program for NPs and PAs. This report describes: (1) stakeholder views on the potential benefits and challenges of expanding the Medicare GME program to include NP and PA graduate training; and (2) available information on the estimated costs of NP and PA graduate training. GAO reviewed literature and interviewed officials from nine professional associations with knowledge of NP, PA, and physician graduate training; and agency officials. Based on these interviews, GAO identified sources of information on estimated costs and reviewed those sources. The federal government funds many education programs for health care providers, but the vast majority of this funding—more than $10.3 billion in 2015—supports physician residency training through the Department of Health and Human Services's (HHS) Medicare graduate medical education (GME) program. This program does not fund graduate training for nurse practitioners (NP) and physician assistants (PA) who deliver many of the same services as physicians, such as diagnosing patients and performing certain procedures. Instead, a smaller portion of federal funding—approximately $136 million in fiscal year 2019—is available to train them. Stakeholders GAO interviewed said that one benefit of expanding Medicare GME is that Medicare GME funding would provide more stable funding for NP and PA training, compared to existing programs. Stakeholders said one challenge of such an expansion is that clinical training requirements for NPs and PAs are different than physicians; therefore, any change to Medicare GME to include NPs and PAs would need to consider how to allocate GME funding in light of these differences. GAO identified two estimates of costs for completing an NP or PA graduate school program; while the estimates provide some information about these costs, they are limited and incomplete. The Centers for Medicare & Medicaid Services' (CMS) evaluation of its Graduate Nurse Education Demonstration estimated the total costs over the 2012-2018 demonstration period to be about $47,000 per NP student. While clinical and classroom training are required for NP students, CMS's demonstration only provided funding for clinical training, as specified by statute, and the estimate is not generalizable beyond the participating schools. The Physician Assistant Education Association estimated the total costs to be about $45,000 per PA student. The estimate is based on self-reported data from a 2018 survey of member PA programs and excludes in-kind contributions for clinical training. GAO received technical comments on this report from HHS and the professional associations interviewed and incorporated them as appropriate.


OMB Circular No. A-123 requires agencies to provide an annual assurance statement that represents the agency head's informed judgment as to the overall adequacy and effectiveness of internal controls related to operations, reporting, and compliance objectives. Although the Air Force is required annually to assess and report on its control effectiveness and to correct known deficiencies, it has been unable to demonstrate basic internal control, as identified in previous audits, that would allow it to report, with reasonable assurance, the reliability of internal controls, including those designed to account for mission-critical assets. This report, developed in connection with fulfilling GAO's mandate to audit the U.S. government's consolidated financial statements, examines the extent to which the Air Force has incorporated ERM into its management practices and designed a process for assessing internal control, including processes related to mission-critical assets. GAO reviewed Air Force policies and procedures and interviewed Air Force officials on their process for fulfilling ERM and internal control assessments. The Air Force's efforts to implement Enterprise Risk Management (ERM) are in the early stages, and accordingly, it has not fully incorporated ERM into its management practices as outlined in Office of Management and Budget (OMB) Circular No. A-123. As a result, the Air Force is not fully managing its challenges and opportunities from an enterprise-wide view. Until it fully incorporates ERM—planned for some time after 2023—the Air Force will continue to leverage its current governance and reporting structures as well as its existing internal control reviews. The Air Force has not designed a comprehensive process for assessing internal control, including processes related to mission-critical assets. GAO found that existing policies and procedures that Air Force staff follow to perform internal control assessments do not accurately capture the requirements of OMB Circular No. A-123. For example, the Air Force does not require (1) an assessment of each internal control element; (2) test plans that specify the nature, scope, and timing of procedures to conduct; and (3) validation that the results of internal control tests are sufficiently clear and complete to explain how units tested control procedures, what results they achieved, and how they derived conclusions from those results. Also, Air Force guidance and training was not adequate for conducting internal control assessments. In addition, GAO found that the Air Force did not design its assessment of internal control to evaluate all key areas that are critical to meeting its mission objectives as part of its annual Statement of Assurance process. Furthermore, GAO found that procedures the Air Force used to review mission-critical assets did not (1) evaluate whether the control design would serve to achieve objectives or address risks; (2) test operating effectiveness after first determining if controls were adequately designed; (3) use process cycle memorandums that accurately reflected the current business process; and (4) evaluate controls it put in place to achieve operational, internal reporting, and compliance objectives. GAO also found that the results of reviews of mission-critical assets are not formally considered in the Air Force's assessment of internal control. Without performing internal control reviews in accordance with requirements, the Air Force increases the risk that its assessment of internal control and related Statement of Assurance may not appropriately represent the effectiveness of internal control, particularly over processes related to its mission-critical assets.


Obesity has been associated with an increased risk of developing conditions such as heart disease, stroke, diabetes, and certain types of cancer. Treatment options for individuals with obesity include lifestyle therapy, such as diet, exercise, and behavioral counseling; obesity drugs; surgery; or a combination of these efforts. The Bipartisan Budget Act of 2018 (P.L. 115-123) included a provision for GAO to review the prevalence of obesity and the use and insurance coverage of obesity drugs. This report examines the prevalence of obesity in the United States, and what is known about the use and health insurance coverage of obesity drugs, among other objectives. GAO examined data from agencies within the Department of Health and Human Services (HHS) on the prevalence of obesity (using estimates for 2013 through 2016) and the use, spending, and coverage of obesity drugs; conducted a literature review of relevant studies published from January 2012 through January 2019 in peer-reviewed and other publications; reviewed drug formularies for selected health plans; and reviewed documents and interviewed officials from federal agencies and stakeholder organizations (including medical associations, advocacy groups, pharmacy benefit managers, and insurers). HHS provided technical comments on a draft of this report, which were incorporated as appropriate. The prevalence of obesity—that is, body weight higher than what is considered a healthy weight for a given height—was about 38 percent among all U.S. adults, according to the latest available national estimates at the time of GAO's analysis. This prevalence was similar for adults with different types of health insurance. Treatment for adults with obesity may include one or more of nine prescription drugs that the Food and Drug Administration has approved for weight management (i.e., obesity drugs), though relatively few adults have used these drugs. Of an estimated 71.6 million U.S. adults with obesity, an estimated 660,000 per year, on average, used an obesity drug from 2012 through 2016, according to national estimates. Among adults who reported trying to lose weight, about 3 percent reported that they took prescription medication for weight loss from 2013 through 2016, according to national estimates. Coverage of obesity drugs varied across different types of health insurance, including Medicare and Medicaid. Plans cited factors such as low consumer demand and strong evidence supporting other treatments in their coverage decisions. GAO's analysis of Centers for Medicare & Medicaid Services' data indicates that some Medicare prescription drug plans and state Medicaid programs reimbursed for some obesity drugs in 2016 and 2017. Coverage for private health insurance plans also varied, and plans may require the patient to obtain prior authorization for the drugs to be covered, according to officials from insurers and pharmacy benefit managers GAO interviewed. For example, officials from one insurer said that some of their plans only cover obesity drugs after a patient has tried other treatment options such as behavioral counseling.


Occupying almost half of South America, Brazil is the fifth-largest and fifth-most-populous country in the world. Given its size and tremendous natural resources, Brazil has long had the potential to become a world power and periodically has been the focal point of U.S. policy in Latin America. Brazil's rise to prominence has been hindered, however, by uneven economic performance and political instability. After a period of strong economic growth and increased international influence during the first decade of the 21 st century, Brazil has struggled with a series of domestic crises in recent years. Since 2014, the country has experienced a deep recession, record-high homicide rate, and massive corruption scandal. Those combined crises contributed to the controversial impeachment and removal from office of President Dilma Rousseff (2011-2016). They also discredited much of Brazil's political class, paving the way for right-wing populist Jair Bolsonaro to win the presidency in October 2018. Since taking office in January 2019, President Bolsonaro has maintained the support of his political base by taking socially conservative stands on cultural issues and proposing hard-line security policies intended to reduce crime and violence. He also has begun implementing economic and regulatory reforms favored by international investors and Brazilian businesses. Bolsonaro's confrontational approach to governance has alienated many potential congressional allies, however, slowing the enactment of his policy agenda. Brazilian civil society groups also have pushed back against Bolsonaro and raised concerns about environmental destruction and the erosion of democratic institutions, human rights, and the rule of law in Brazil. In international affairs, the Bolsonaro Administration has moved away from Brazil's traditional commitment to autonomy and toward alignment with the United States. Bolsonaro has coordinated closely with the Trump Administration on challenges such as the crisis in Venezuela. On other matters, such as commercial ties with China, Bolsonaro has adopted a pragmatic approach intended to ensure continued access to Brazil's major export markets. The Trump Administration has welcomed Bolsonaro's rapprochement and sought to strengthen U.S.-Brazilian relations. In 2019, the Trump Administration took steps to bolster bilateral cooperation on counternarcotics and counterterrorism efforts and designated Brazil as a m ajor n on-NATO a lly . The United States and Brazil also agreed to several measures intended to facilitate trade and investment. Nevertheless, some Brazilians have questioned the benefits of partnership with the United States, as the Trump Administration has maintained certain import restrictions and threatened to impose tariffs on other key Brazilian products. The 116 th Congress has expressed renewed interest in Brazil and U.S.-Brazilian relations. Environmental conservation has been a major focus, with Congress appropriating $15 million for foreign assistance programs in the Brazilian Amazon, including $5 million to address fires in the region, in the Further Consolidated Appropriations Act, 2020 ( P.L. 116-94 ). Likewise, Members introduced legislative proposals that would express support for Amazon conservation efforts ( S.Res. 337 ) and restrict U.S. defense and trade relations with Brazil in response to deforestation ( H.R. 4263 ). Congress also has expressed concerns about the state of democracy and human rights in Brazil. A provision of the National Defense Authorization Act for FY2020 ( P.L. 116-92 ) directs the Secretary of Defense, in coordination with the Secretary of State, to submit a report to Congress regarding Brazil's human rights climate and U.S.-Brazilian security cooperation. Another resolution ( H.Res. 594 ) would express concerns about threats to human rights, the rule of law, democracy, and the environment in Brazil.


On April 23, 2020, Congress passed its fourth measure including supplemental appropriations to respond to the COVID-19 pandemic. The Paycheck Protection Program and Health Care Enhancement Act (the act; P.L. 116-139 ) includes enhancements for the Small Business Administration's Paycheck Protection Program (PPP), Economic Injury Disaster Loans (EIDL), and Emergency EIDL grants, and emergency supplemental appropriations for the Department of Health and Human Services (HHS) and Small Business Administration (SBA). The President signed the bill into law on April 24, 2020. The Congressional Budget Office estimates that the act will result in $321.3 billion in additional direct spending for the PPP, and $162.1 billion in additional discretionary spending, including $50 billion for EIDL and $10 billion for Emergency EIDL grants. This report provides a brief overview of that measure.


On April 6, 2018, the Attorney General issued a memorandum on criminal prosecutions of immigration offenses. According to HHS officials, this resulted in a considerable increase in the number of minor children whom DHS separated from their parents after attempting to cross the U.S. border illegally. On June 20, 2018, the President issued an executive order directing that alien families generally be detained together, and on June 26, 2018, a federal judge ordered the government to reunify separated families. DHS is responsible for the apprehension and transfer of UAC to HHS. HHS is responsible for coordinating UAC placement and care. This testimony discusses DHS and HHS (1) planning efforts related to the Attorney General's April 2018 memo, (2) systems for indicating children were separated from parents, and (3) actions to reunify families in response to the June 2018 court order. It is based on a report GAO issued in October 2018. This testimony also includes updated data reported by the government on the number children separated from their parents subject to the court's reunification order and the number of those children in ORR custody as of December 11, 2018. Department of Homeland Security (DHS) and Department of Health and Human Services (HHS) officials GAO interviewed said the agencies did not plan for the potential increase in the number of children separated from their parent or legal guardian as a result of the Attorney General's April 2018 “zero tolerance” memo because they were unaware of the memo in advance of its public release. The memo directed Department of Justice prosecutors to accept for criminal prosecution all referrals from DHS of offenses related to improper entry into the United States, to the extent practicable. As a result, parents were placed in criminal detention, and their children were placed in the custody of HHS's Office of Refugee Resettlement (ORR). DHS and ORR treated separated children as unaccompanied alien children (UAC)—those under 18 years old with no lawful immigration status and no parent or legal guardian in the United States available to provide care and physical custody. Prior to April 2018, DHS and HHS did not have a consistent way to indicate in their data systems children and parents separated at the border. In April and July 2018, U.S. Customs and Border Protection's Border Patrol and ORR updated their data systems to allow them to indicate whether a child was separated. However, it is too soon to know the extent to which these changes, if fully implemented, will consistently indicate when children have been separated from their parents, or will help reunify families, if appropriate. In response to a June 26, 2018 court order to quickly reunify children separated from their parents, HHS determined how many children in its care were subject to the order and developed procedures for reunifying these families. As of September 2018, the government identified 2,654 children in ORR custody who potentially met reunification criteria, which does not include separated children released to sponsors prior to the June 2018 court order. On July 10, 2018, the court approved reunification procedures for the parents covered by the June 2018 court order. This July 10, 2018 order noted that ORR's standard procedures used to release UAC from its care to sponsors were not meant to apply in this circumstance, in which parents and children who were apprehended together were separated by government officials. Since GAO's October 2018 report, the government identified additional children separated from parents subject to the court's reunification order and released additional children from its custody (see figure).