In March 2017, the President issued an executive order to federal agencies intended to improve the efficiency, effectiveness, and accountability of the executive branch. The order required the Director of the Office of Management and Budget (OMB) to develop a plan to reorganize and streamline the government. In April 2017, OMB issued additional guidance to agencies on implementing the order. In response, USAID launched several efforts to reform its organizational structure, workforce, programs, and processes with the ultimate goal of ending the need for foreign assistance by helping partner countries become more self-reliant. GAO's prior work has shown that successful agency reforms depend on following key practices for organizational transformation, such as establishing goals and outcomes and involving key stakeholders. This report examines (1) the status of USAID's reform efforts and (2) the extent to which USAID has addressed key practices in planning and implementing those efforts. GAO reviewed USAID reform plans, proposals, and related documents and met with officials involved in its reform efforts. GAO also assessed USAID's planning and implementation of its reform efforts against 11 key practices identified in GAO's June 2018 report, Government Reorganization: Key Questions to Assess Agency Reform Efforts (GAO-18-427). The reform efforts of the U.S. Agency for International Development (USAID) consist of a total of 32 reform projects—31 projects being implemented by USAID's Transformation Task Team and an additional Human Resources Transformation project that predates the 31 projects. As of July 2019, USAID has completed 19 reform projects and is implementing 12 additional projects, which it intends to complete by mid-2021. The task team has one additional project in the planning phase. In planning and implementing these efforts, USAID has generally addressed nine of 11 key practices for organizational transformation and partially addressed two. For example, USAID generally addressed the key practice of involving employees and key stakeholders such as the Department of State and Congress through a variety of mechanisms, such as briefings and town halls. USAID also used data and evidence to guide its reform efforts by integrating employee and external input into its reform plans. Morever, USAID addressed fragmentation, overlap, and duplication by planning a restructuring effort to streamline operations and achieve efficiencies. Further, it generally addressed leadership focus and attention by designating a reform coordinator and establishing a dedicated team responsible for managing and planning USAID's reform efforts. However, while USAID established goals for its reform efforts, it established outcome-oriented performance measures for only four of its 32 projects. Establishing such measures would improve its ability to assess the results of the changes it is making. In addition, while USAID is developing a strategic workforce plan, it has yet to develop the tools needed to identify and meet staffing needs arising from the reforms in order to fully assess its workforce. Completing a strategic workforce plan with these tools could help USAID ensure it has the workforce needed to meet existing and emergent program demands. Addressing these gaps could help USAID make long-term improvements in its efficiency and effectiveness.


In March 2019, the White House directed NASA to accelerate its plans to return humans to the moon by 4 years, to 2024. To accomplish a lunar landing, NASA is developing programs including a small platform in lunar orbit, known as Gateway, and a lunar lander. NASA plans to use the Space Launch System and Orion crew capsule—two programs with a history of cost growth and schedule delays—to launch and transport crew to Gateway. The House Committee on Appropriations included a provision in its 2018 report for GAO to review NASA's proposed lunar-focused programs, including the Gateway program. GAO's report assesses (1) how NASA updated its lunar plans to support the accelerated 2024 landing timeline; (2) the extent to which NASA has made initial decisions about requirements, cost, and schedule for its lunar mission and programs; and (3) the extent to which NASA analyzed alternatives for its lunar plans, including the Gateway program. GAO analyzed NASA lunar mission and program documents, assessed NASA studies that informed NASA's lunar plans, and interviewed NASA officials. To support accelerated plans to land astronauts on the moon by 2024—four years earlier than planned—the National Aeronautics and Space Administration (NASA) quickly refocused its acquisition plans. In particular, NASA separated its lunar plans into two phases, with the first phase focused on the systems NASA identified to support the new timeline (see figure). One system, Gateway, includes three components—power and propulsion, habitation, and logistics—to form a small platform in lunar orbit. NASA has begun making decisions related to requirements, cost, and schedule for programs, but is behind in taking these steps for the whole lunar mission: NASA risks the discovery of integration challenges and needed changes late in the development process because it established some requirements for individual lunar programs before finalizing requirements for the overall lunar mission. NASA plans to take steps to mitigate this risk, such as by holding reviews to ensure that requirements align across programs, but has not yet defined these reviews or determined when they would occur. NASA has made some decisions that will increase visibility into the costs and schedules for individual lunar programs, but does not plan to develop a cost estimate for the first mission. Cost estimates provide management with critical cost-risk information to improve control of resources. Without a cost estimate for this mission, Congress will not have insight into affordability and NASA will not have insight into monitoring total mission costs. NASA conducted studies to inform its lunar plans, but did not fully assess a range of alternatives to these plans. GAO best practices state that analyzing alternatives provides a framework to help ensure that entities consistently and reliably select the alternative that best meets the mission need and justify agency decisions. Given NASA's schedule, conducting this analysis is no longer viable. Instead, NASA intends to create a summary of the studies that informed its lunar plans. However, it has not committed to a completion date. Without a documented rationale, NASA is ill-positioned to effectively communicate its decisions to stakeholders and facilitate a better understanding of its plans.


Air ambulances provide emergency services for critically ill patients. Relatively few patients receive such transports, but those who do typically have no control over the selection of the provider, which means privately-insured patients may be transported by out-of-network providers. The Joint Explanatory Statement accompanying the 2017 Consolidated Appropriations Act includes a provision for GAO to review air ambulance services. Among other objectives, this report describes (1) the extent of out-of-network transports and balance billing and (2) the approaches selected states have taken to limit potential balance billing. GAO analyzed a private health insurance data set for air ambulance transports with information on network status and prices charged in 2017 (the most recent data available). Although this was the most complete data identified, the data may not be representative of all private insurers. In addition, GAO interviewed officials in six states (Florida, Maryland, Montana, New Mexico, North Dakota, and Texas) selected in part for variation in approaches to limit balance billing and location. GAO also interviewed air ambulance providers, health insurers, and Centers for Medicare & Medicaid Services and Department of Transportation (DOT) officials. DOT provided technical comments on a draft of this report, which GAO incorporated as appropriate, and the Department of Health and Human Services had no comments. Privately-insured patients transported by air ambulance providers outside of their insurers' provider networks are at financial risk for balance bills—which, as the figure shows, are for the difference between prices charged by providers and payments by insurers. Any balance bills are in addition to copayments or other types of cost-sharing typically paid by patients under their insurance coverage. According to GAO's analysis of the most complete data identified for air ambulance transports of privately-insured patients, 69 percent of about 20,700 transports in the data set were out-of-network in 2017. This is higher than what research shows for ground ambulance transports (51 percent in 2014 according to one study) and other emergency services. Air ambulance providers that GAO spoke with reported entering into more network contracts recently, which could lower the extent of out-of-network transports in areas covered by the contracts. While out-of-network transports may result in balance billing, the data GAO analyzed do not indicate the extent to which patients received balance bills and, if so, the size of the bills. In addition, as GAO reported in 2017, there is a lack of national data on balance billing, but some states have attempted to collect information from patients. For example, GAO reviewed over 60 consumer complaints received by two of GAO's selected states—the only states able to provide information on the amount of individual balance bills—and all but one complaint was for a balance bill over $10,000. Patients may not end up paying the full amount if they reach agreements with air ambulance providers, insurers, or both. The amounts of potential balance bills are informed in part by the prices charged. GAO's analysis of the data set with transports for privately-insured patients found the median price charged by air ambulance providers was about $36,400 for a helicopter transport and $40,600 for a fixed-wing transport in 2017. The six states reviewed by GAO and others have attempted to limit balance billing. For example, the six states have taken actions to regulate insurers, generate public attention, or both. As required by recent federal law, the Secretary of Transportation has taken steps to form an advisory committee to, among other things, recommend options to prevent instances of balance billing.


In May 2018, GAO reported that the Trust Fund, which pays benefits to certain coal miners, faced financial challenges. The Trust Fund has borrowed from the U.S. Treasury's general fund almost every year since 1979 to make needed expenditures. GAO's June 2019 testimony included preliminary observations that coal operator bankruptcies were further straining Trust Fund finances because, in some cases, benefit responsibility was transferred to the Trust Fund. This report examines (1) how coal mine operator bankruptcies have affected the Trust Fund, and (2) how DOL managed coal mine operator insurance to limit financial risk to the Trust Fund. GAO identified coal operators that filed for bankruptcy from 2014 through 2016 using Bloomberg data. GAO selected these years, in part, because bankruptcies were more likely to be resolved so that their effects on the Trust Fund could be assessed. GAO analyzed information on commercially-insured and self-insured coal operators, and examined workers' compensation insurance practices in four of the nation's top five coal producing states. GAO also interviewed DOL officials, coal mine operators, and insurance company representatives, among others. Coal mine operator bankruptcies have led to the transfer of about $865 million in estimated benefit responsibility to the federal government's Black Lung Disability Trust Fund (Trust Fund), according to DOL estimates. The Trust Fund pays benefits when no responsible operator is identified, or when the liable operator does not pay. GAO previously testified in June 2019 that it had identified three bankrupt, self-insured operators for which benefit responsibility was transferred to the Trust Fund. Since that time, DOL's estimate of the transferred benefit responsibility has grown—from a prior range of $313 million to $325 million to the more recent $865 million estimate provided to GAO in January 2020. According to DOL, this escalation was due, in part, to recent increases in black lung benefit award rates and higher medical treatment costs, and to an underestimate of Patriot Coal's future benefit claims. DOL's limited oversight of coal mine operator insurance has exposed the Trust Fund to financial risk, though recent changes, if implemented effectively, can help address these risks. In overseeing self-insurance in the past, DOL did not estimate future benefit liability when setting the amount of collateral required to self-insure; regularly review operators to assess whether the required amount of collateral should change; or always take action to protect the Trust Fund by revoking an operator's ability to self-insure as appropriate. In July 2019, DOL began implementing a new self-insurance process that could help address past deficiencies in estimating collateral and regularly reviewing self-insured operators. However, DOL's new process still lacks procedures for its planned annual renewal of self-insured operators and for resolving coal operator appeals should operators dispute DOL collateral requirements. This could hinder DOL from revoking an operator's ability to self-insure should they not comply with DOL requirements. Further, for those operators that do not self-insure, DOL does not monitor them to ensure they maintain adequate and continuous commercial coverage as appropriate. As a result, the Trust Fund may in some instances assume responsibility for paying benefits that otherwise would have been paid by an insurer.


In May 2018, GAO reported that the Trust Fund, which pays disability benefits to certain coal miners, faced financial challenges. The Trust Fund has borrowed from the U.S. Treasury's general fund almost every year since 1979 to make needed expenditures. GAO's June 2019 testimony included preliminary observations that coal operator bankruptcies were further straining Trust Fund finances because, in some cases, benefit responsibility was transferred to the Trust Fund. This testimony is based on GAO's report being released today, and describes (1) how coal mine operator bankruptcies have affected the Trust Fund, and (2) how DOL managed coal mine operator insurance to limit financial risk to the Trust Fund. In producing this report, GAO identified coal operators that filed for bankruptcy from 2014 through 2016. GAO analyzed information on commercially-insured and self-insured coal operators, and examined workers' compensation insurance practices in four of the nation's top five coal producing states. GAO also interviewed DOL officials, coal mine operators, and insurance company representatives, among others. Coal mine operator bankruptcies have led to the transfer of about $865 million in estimated benefit responsibility to the federal government's Black Lung Disability Trust Fund (Trust Fund), according to DOL estimates. The Trust Fund pays benefits when no responsible operator is identified, or when the liable operator does not pay. GAO previously testified in June 2019 that it had identified three bankrupt, self-insured operators for which benefit responsibility was transferred to the Trust Fund. Since that time, DOL's estimate of the transferred benefit responsibility has grown—from a prior range of $313 million to $325 million to the more recent $865 million estimate provided to GAO in January 2020. According to DOL, this escalation was due, in part, to recent increases in black lung benefit award rates and higher medical treatment costs, and to an underestimate of one company's (Patriot Coal) future benefit claims. Trust Fund, Filed from 2014 through 2016 DOL's limited oversight of coal mine operator insurance has exposed the Trust Fund to financial risk, though recent changes, if implemented effectively, can help address these risks. In overseeing self-insurance in the past, DOL did not: estimate future benefit liability when setting the amount of collateral required to self-insure; regularly review operators to assess whether the required amount of collateral should change; or always take action to protect the Trust Fund by revoking an operators' ability to self-insure as appropriate. In July 2019, DOL began implementing a new self-insurance process that could help address past deficiencies in estimating collateral and regularly reviewing self-insured operators. However, DOL's new process still lacks procedures for its planned annual renewal of self-insured operators and for resolving coal operator appeals should operators dispute DOL collateral requirements. This could hinder DOL from revoking operators' ability to self-insure should they not comply with DOL requirements. Further, for those operators that do not self-insure, DOL does not monitor them to ensure they maintain adequate and continuous commercial coverage as appropriate. As a result, the Trust Fund may in some instances assume responsibility for paying benefits that otherwise would have been paid by insurers.


In November 2009, an Army officer killed or wounded 45 people at Fort Hood, Texas; 4 years later in September 2013, a Navy contractor killed or wounded 16 people at the Washington Navy Yard in Washington, D.C. Independent reviews conducted in the aftermath of these shootings identified physical access control weaknesses at DOD installations. The conference report accompanying the National Defense Authorization Act for Fiscal Year 2018 contained a provision for GAO to assess DOD's installation access control efforts. GAO (1) described actions DOD has taken to develop guidance on physical access to domestic installations and to field PACS at these installations, (2) evaluated the extent to which DOD has monitored the use of fielded PACS at these installations, and (3) evaluated the extent to which DOD has implemented an approach for addressing PACS technical issues and assessing associated performance. GAO analyzed DOD guidance on physical access control requirements, and visited installations to discuss with installation command and security force officials their experiences using PACS. This is a public version of a sensitive report that GAO issued in May 2019. Information that DOD deemed sensitive has been omitted. The Department of Defense (DOD) has issued guidance on accessing its domestic installations and strengthening physical access control systems (PACS)—used to scan credentials to authenticate the identity and authorize individuals to access DOD installations. Specifically, DOD has recently issued guidance directing the fielding of PACS and has fielded or plans to field such systems at domestic installations. The Defense Manpower Data Center (DMDC) developed the PACS used by the Air Force, the Navy, the Marine Corps, and the Defense Logistics Agency. The Army developed its own PACS. Both types of PACS electronically connect to DOD's Identity Matching Engine for Security and Analysis (IMESA). IMESA accesses authoritative government databases to determine an individual's fitness for access (i.e., whether an individual is likely a risk to an installation or its occupants), and continually vets this fitness for subsequent visits (see fig.). The Air Force and DLA have monitored their installations' use of PACS, but the Army, the Navy, and the Marine Corps have not. Army, Navy, and Marine Corps installation officials stated that they do not monitor PACS use at their installations because there is no requirement to do so. Because the Army, the Navy, and the Marine Corps do not monitor PACS use and DOD does not require that they do so, those military services do not have the data they need to evaluate the effectiveness of PACS and make informed risk-based decisions to safeguard personnel and mission-critical, high-value installation assets. DOD, Army, Navy, and Marine Corps officials agreed that monitoring installations' use of PACS would be beneficial and could be readily accomplished without significant cost using existing technology. The Army and DMDC have used a tiered approach and established helpdesks to address PACS technical issues. The Army has established performance measures and goals to assess its approach, which has improved the ability to resolve technical issues. DMDC, however, does not have performance measures and goals, and thus lacks the information needed to evaluate its PACS' performance and address issues negatively affecting operational availability.


In October 2015, the U.S cargo vessel EL FARO sank after encountering heavy seas and winds from Hurricane Joaquin, killing all 33 crew members. Subsequent investigations cited deficiencies in the vessel's SMS plans as a factor that may have contributed to the vessel's sinking. Some in Congress have raised questions about the effectiveness of vessel SMS plans and the Coast Guard's oversight of third parties responsible for ensuring vessels comply with international standards and federal regulations. The Hamm Alert Maritime Safety Act of 2018 included a provision for GAO to review Coast Guard oversight and enforcement of vessel SMS plans. Accordingly, this report addresses (1) how the Coast Guard (a) verifies domestic commercial vessels' SMS plans comply with federal regulations and (b) conducts oversight of ROs, and (2) the extent to which domestic vessels' SMS plans identify potential shipboard emergencies and include applicable response procedures. To address these objectives, GAO reviewed Coast Guard regulations and guidance, accompanied marine inspectors on vessel inspections and audits, and analyzed available data on identified vessel deficiencies. GAO also reviewed the format and content of a nongeneralizable sample of 12 SMS plans representing various types of vessels and interviewed relevant Coast Guard and RO officials. The Coast Guard verifies that domestic commercial vessels comply with safety management system (SMS) requirements through activities that include conducting annual inspections of applicable U.S.-flagged vessels. In practice, the Coast Guard delegates primary vessel SMS compliance activities to third party entities, called Recognized Organizations (ROs). Among their responsibilities, ROs coordinate with vessel operators to review SMS plans, issue applicable vessel certificates, and conduct SMS compliance audits at the company level and aboard each vessel. Because the Coast Guard relies on ROs to perform SMS certification services on its behalf, it has initiated a series of efforts to enhance its oversight of ROs since 2018. The efforts include: establishing a new group within the Coast Guard to monitor ROs, developing new SMS-related guidance and work instructions, increasing direct observations of ROs performing SMS audits, developing key performance indicators for assessing ROs, and requesting internal investigations for certain RO deficiencies. It is too soon to assess the effectiveness of these efforts; however, GAO believes these are positive steps toward enhancing the Coast Guard's oversight of ROs. Each of the 12 domestic vessel SMS plans GAO reviewed include potential shipboard emergencies and applicable response procedures to address them. None of the plans address all 21 potential shipboard emergencies included in 2018 Coast Guard guidance. However, these 21 potential emergencies are not required to be included in SMS plans; rather, they are suggested as part of the 2018 guidance. Further, GAO found that the SMS plans may not address all potential shipboard emergencies because not all emergency scenarios are applicable for each type of vessel or geographical operating area. Also, vessel operators may still be in the process of revising their SMS plans to include additional emergency scenarios and applicable response procedures.


In October 2019, the Army published a new modernization strategy aimed at transforming the Army in order to conduct Multi-Domain Operations (MDO) which are intended to address the current and future actions of near-peer competitors Russia and China. The Army's Modernization Strategy is part of a hierarchy of strategies designed, among other things, to inform the Service's respective modernization plans. These strategies include the National Security Strategy (NSS), the National Defense Strategy (NDS), the National Military Strategy (NMS), and the Army Strategy. The Army's Modernization Strategy establishes six material modernization priorities: Long Range Precision Fires. Next Generation of Combat Vehicles. Future Vertical Lift. Army Network. Air and Missile Defense. Soldier Lethality. Because the Army's Modernization Strategy covers the years from 2020 to 2035, the possibility exists for a variety of Army modernization hearings spanning a number of different Congresses. In this regard a common oversight architecture could potentially provide both an element of continuity and a means by which Congress might evaluate the progress of the Army's modernization efforts. Such a potential architecture might examine: Is the Army's Modernization Strategy appropriate given the current and projected national security environment? Is the Army's Modernization Strategy achievable given a number of related concerns? Is the Army's Modernization Strategy affordable given current and predicted future resource considerations? For FY2020, funding requested for programs related to the Army's six modernization priorities, $8.9 billion, accounted for less than a quarter (23%) of its overall acquisition budget. The service projected $57.3 billion in research, development, test, and evaluation (RDT&E) and procurement funding for programs related to its six modernization priorities over the Future Years Defense Program (FYDP) from FY2020 through FY2024. This amount, if authorized and appropriated by Congress, would reflect an increase of $33.1 billion from spending projections for the five-year period in the FY2019 budget request. Meanwhile, the Army projected a total of $187.5 billion for its acquisition accounts (in nominal dollars) over this period, including $128.8 billion for procurement and $58.7 billion for RDT&E. Thus, for the FY2020 FYDP, funding for programs related to the Army's six modernization priorities accounts for less than a third (31%) of its overall acquisition budget. This report provides a number of possible questions and observations related to a potential Army modernization oversight architecture which could serve to provide both an element of continuity for hearings and a standard by which Congress might evaluate the efficacy of Army Modernization.


In September 2016, GAO reported that annual combat aircrew training requirements delineated in the Air Force's Ready Aircrew Program might not address pilot training needs, and that the Air Force did not systematically evaluate the effectiveness of its training. As a result, Congress included a provision in Section 351 of the NDAA for Fiscal Year 2017 for the Air Force to commission an independent review of its Ready Aircrew Program, report on actions it planned to take in response to any recommendations, and provide an estimate of any resources required. Section 351 also included a provision for GAO to assess the Air Force report. This report examines whether (1) the independent review conducted by the RAND Corporation addressed statutory requirements to review and assess the Ready Aircrew Program, and (2) the Air Force has reported on completed or planned actions to implement the RAND report recommendations. To address these objectives, GAO reviewed the RAND and Air Force reports on the Ready Aircrew Program, assessed the study against generally accepted research standards, and interviewed officials at RAND, Air Force Headquarters, and the Air Combat Command. A July 2018 RAND report—commissioned by the Air Force—addressed the statutory requirements of the National Defense Authorization Act (NDAA) for Fiscal Year 2017 to review and assess the Air Force's Ready Aircrew Program and make recommendations for ways to improve it. The Ready Aircrew Program establishes minimum annual training requirements for combat aircrew. RAND's report, entitled Independent Review and Assessment of the Air Force Ready Aircrew Program , made nine recommendations to improve its management: 1. Leverage internal expertise to implement measures for proficiency. 2. Invest resources to design data collection and storage solutions that facilitate analysis and readiness reporting. 3. Document the Ready Aircrew Program Tasking Memorandum development process in Air Force instruction supplements and ensure that the process incorporates squadron-level input and feedback. 4. Establish a more explicit and formal link between proficiency and Ready Aircrew Program requirements. 5. Document training quality to support requests for training resources. 6. Identify the conditions under which Ready Aircrew Program requirements, including mission types, can be accomplished. 7. Consider changing how Ready Aircrew Program requirements affect the Flying Hour Program. 8. Invest in data systems to correct data collection and assess deficiencies. 9. Leverage the Air Force Research Laboratory's performance data work and invest in added analysis to produce enterprise-wide proficiency metrics. The nine RAND recommendations aligned with two GAO recommendations made in 2016 to comprehensively assess the assumptions underlying the annual aircrew training requirements and develop a process to collect data to assess the effectiveness of the training. The Air Force's August 2018 one-page report to Congress included three broad actions in response to RAND's recommendations. The Air Force planned to build training matrices to help commanders assess their units' effectiveness, establish common data architecture through the Air Force's Chief Data Officer–led effort, and evaluate aspects of the Ready Aircrew Program to increase lethality and improve readiness as the Air Force shifts to executing the mandates of the 2018 National Defense Strategy. The Air Force, however, did not explain how these three efforts would specifically address the nine recommendations. Air Force officials said that, though they generally agreed with RAND's recommendations, the Air Force lacked the resources to fully implement them beyond actions that were underway prior to the RAND report, and considers all recommendations as “closed.” In part due to its not fully implementing RAND's recommendations, the Air Force has not fully addressed GAO's two recommendations. Fully implementing GAO's recommendations would better position the Air Force to ensure its aircrews receive effective training to achieve a range of missions.


In September 2017, the Deputy Secretary of Defense issued a memorandum calling for the accelerated adoption of a Department of Defense (DOD) enterprise-wide cloud services solution as a fundamental component of ongoing DOD modernization efforts. As a component of this effort, DOD is seeking to acquire a cloud services solution accessible to the entirety of the Department that can support Unclassified, Secret, and Top Secret requirements, focusing on commercially available cloud service solutions, through the Joint Enterprise Defense Infrastructure (JEDI) Cloud acquisition program. DOD intends to conduct a full and open competition that is expected to result in a single award Indefinite Delivery/Indefinite Quantity firm-fixed price contract for commercial items. DOD has indicated that the minimum guaranteed award is $1 million, and that the initial period of performance is two years. The contract is expected to have a maximum ceiling of $10 billion across a potential 10-year period of performance. DOD is in the final stages of evaluating proposals, with Amazon Web Services and Microsoft remaining in contention for the contract. The Department originally expected to award the contract in August 2019. However, Secretary of Defense Dr. Mark T. Esper is reportedly currently reviewing the JEDI Cloud program, which may delay the award. Significant industry and congressional attention has been focused on DOD's intent to award the JEDI Cloud contract to a single company. Oracle America filed multiple pre-award bid protests with the Government Accountability Office, which were denied. Oracle America then filed a bid protest lawsuit with the U.S. Court of Federal Claims; the court ruled against Oracle in a July 12, 2019, decision. In filings associated with its bid protests, Oracle America alleged in part that the JEDI Cloud acquisition process was unfairly skewed in favor of Amazon Web Services through potential organizational conflicts of interest associated with three former DOD employees, each of whom was involved to greater or lesser degrees in the early development of the program. DOD investigations determined that Amazon Web Services had no conflicts of interest and established that the actions of the individuals identified by Oracle America did not negatively impact the procurement or grant Amazon Web Services an unfair competitive advantage. However, the investigations did identify individual violations of ethical standards established by the Federal Acquisition Regulation. Some industry observers contend that an initial single award appears to contradict broader federal cloud computing implementation guidance and industry best practices that stress the importance of multi-cloud solutions. Others point to the implementation approaches identified by DOD's 2019 Cloud Strategy as evidence that the Department expects the JEDI Cloud to serve certain enterprise-wide functions, performing as one component of a broader multi-cloud, multi-vendor system. Opponents of DOD's use of a single-award contract for the JEDI Cloud program have suggested that this tactic could restrict future competition for enterprise-wide DOD cloud services. Supporters of DOD's approach argue that the JEDI Cloud program's requirement for offerors to develop applications and data schema easily transferable to different platforms suggests that the Department may be equipped to migrate from any service environment developed under the JEDI Cloud contract to another such environment. Several Members of Congress have engaged the Administration to express their views regarding the JEDI Cloud acquisition program and pending contract award. The 116 th Congress is considering related authorization and appropriations legislation that could shape future implementation of the program ( H.R. 2740 , H.R. 2500 , and S. 1790 ).


In September 2017, two major hurricanes—Irma and Maria—struck Puerto Rico and the USVI, causing billions of dollars in damage to infrastructure, housing, and the economy. FEMA—a component of the Department of Homeland Security—is the lead federal agency responsible for assisting Puerto Rico and the USVI to recover from these natural disasters. Among other responsibilities, FEMA is administering the Public Assistance program in partnership with the governments of Puerto Rico and the USVI, providing them grant funding for response and recovery activities, including debris removal efforts, life-saving emergency protective measures, and the repair, replacement, or restoration of public infrastructure. This statement describes (1) the status of FEMA's Public Assistance grant funding in Puerto Rico and the USVI in response to the 2017 hurricanes as of April 2019, (2) the establishment of recovery offices in Puerto Rico and the USVI, and (3) challenges in implementing the Public Assistance program and actions FEMA has taken to address them. This statement is based on GAO reports issued in February, March, and June 2019, and includes preliminary observations from ongoing GAO reviews of FEMA operations. For ongoing work, GAO analyzed program documents and data on obligations and expenditures; interviewed agency officials; and visited disaster-damaged areas in Puerto Rico and the USVI, where GAO also interviewed FEMA and local officials. GAO's prior and ongoing work found that the Federal Emergency Management Agency (FEMA) obligated about $7.4 billion in Public Assistance grant funding to Puerto Rico and the U.S. Virgin Islands (USVI) as of April 2019, in response to the 2017 hurricanes. FEMA obligated about $6.2 billion in Public Assistance grants for emergency work—debris removal activities, power restoration, and other emergency measures—and about $965 million in Public Assistance grants for permanent work—including the repair or replacement of public infrastructure such as roads, electrical utilities, and damaged buildings. Further, FEMA is continuing to work with Puerto Rico and the USVI to develop additional permanent work projects to repair damaged public infrastructure, such as schools and hospitals (see figure). In 2017, Puerto Rico established the Central Office for Recovery, Reconstruction, and Resilience and in 2019 the USVI established the Office of Disaster Recovery to coordinate and oversee federal recovery efforts. Among other things, these recovery offices are responsible for monitoring and overseeing the Public Assistance program and developing internal controls to ensure it is implemented in accordance with applicable laws, regulations, and FEMA requirements. GAO's prior and ongoing work highlighted challenges with the Public Assistance program including concerns about the clarity of FEMA's guidance, and the time and resources needed to transition to a new Public Assistance delivery model in Puerto Rico. Further, Puerto Rico and USVI officials reported difficulties understanding FEMA's implementation of new flexibilities authorized by law as well as delays in jointly developing cost estimates for long-term recovery projects such as the repair or replacement of hospitals, buildings, and other public infrastructure. FEMA has taken some actions to help address these issues, including developing additional guidance and specific training. However, it is too soon to determine the effectiveness of FEMA's actions. GAO will continue to evaluate the Public Assistance program in the USVI and Puerto Rico and plans to report its findings in late 2019 and early 2020, respectively.


In September 2017, two major hurricanes—Irma and Maria—struck Puerto Rico, destroying roads and buildings among other things. Puerto Rico estimates that $132 billion will be needed to repair and reconstruct infrastructure and services through 2028. FEMA is the lead federal agency responsible for assisting Puerto Rico to recover from these disasters. FEMA administers the Public Assistance program in partnership with Puerto Rico to provide funds to rebuild damaged infrastructure and restore services. GAO was asked to review federal recovery efforts in Puerto Rico. In this report, GAO examines, among other things, (1) the status of FEMA Public Assistance program funding and any challenges in implementing the program, (2) the extent to which Public Assistance cost estimating guidance addresses conditions in Puerto Rico and aligns with best practices, and (3) the extent to which FEMA has developed policies and guidance for the program and any challenges with these policies and guidance. GAO reviewed FEMA's cost estimation guidance as well as documentation and data on the Public Assistance program through September 2019. GAO conducted site visits to Puerto Rico and interviewed FEMA and Puerto Rico government officials regarding the status of recovery efforts. As of September 30, 2019, the Federal Emeregency Management Agency (FEMA) had obligated nearly $6 billion in Public Assistance grants to Puerto Rico for 1,558 projects since the September 2017 hurricanes. Of this $6 billion, $5.1 billion was obligated for emergency work projects such as debris removal and temporary power restoration. However, FEMA and Puerto Rico faced challenges in developing long-term, permanent work projects under the Public Assistance program. The large number of damaged sites and delays in establishing cost estimation guidance specific to Puerto Rico have also presented challenges to developing projects, according to FEMA and Puerto Rico officials. Both parties must agree to fixed cost estimates for these projects before work can begin. FEMA and Puerto Rico had approved fixed cost estimates for 19 projects as of September 2019, out of 9,344 damaged sites in Puerto Rico, such as schools, hospitals, and roads. FEMA and Puerto Rico have recently taken actions, including extending the deadline for fixed cost estimates, to address these challenges. However, it is too soon to assess the impact of these actions. FEMA has adapted its Public Assistance cost estimating guidance to accurately reflect costs in Puerto Rico but could improve the guidance to further enhance its reliability. GAO found that FEMA's guidance substantially or fully met best practices for nine of 12 steps included in the GAO Cost Estimating and Assessment Guide , such as documenting and defining the purpose of the estimate. However, FEMA could improve the guidance in three areas, including analyzing risks and future uncertainties that could affect these estimates. FEMA has developed Public Assistance policies and guidance to respond to complex recovery conditions in Puerto Rico. However, Puerto Rico government officials GAO spoke with stated that they were not always certain about how to proceed in accordance with FEMA policy because they did not consistently understand what guidance was in effect. Further, FEMA does not maintain a repository of Public Assistance guidance available to all recovery partners that includes current applicable guidance. Without real time access to current applicable guidance, recovery partners risk using guidance that has been revised or replaced.


In September 2017, two major hurricanes—Irma and Maria—struck the USVI, causing billions of dollars in damage to its infrastructure, housing, and economy. FEMA—a component of the Department of Homeland Security—is the lead federal agency responsible for assisting the USVI as it recovers from these natural disasters. Among other responsibilities, FEMA administers the Public Assistance program in partnership with the USVI territorial government, providing the USVI grant funding for response and recovery activities, including debris removal efforts, life-saving emergency protective measures, and the repair, replacement, or restoration of public infrastructure. GAO was asked to review the federal government's response and recovery efforts related to the 2017 hurricanes. This report describes (1) the status of FEMA's Public Assistance program funding provided to the USVI in response to the 2017 hurricanes as of October 1, 2018, and (2) the USVI's transition to implementing the Public Assistance alternative procedures in the territory. GAO reviewed program documents and data on obligations and expenditures as of October 1, 2018, and interviewed officials from FEMA and the USVI regarding the Public Assistance program specifically and disaster recovery efforts more generally. GAO also conducted site visits to the USVI islands of St. Croix, St. Thomas, and St. John. GAO is not making any recommendations in this report, but will continue to monitor the progress of the USVI's recovery as part of its ongoing work. The Federal Emergency Management Agency (FEMA) obligated more than $1.4 billion in grant funding for Public Assistance projects in the U.S. Virgin Islands (USVI) as of October 1, 2018, in response to the 2017 hurricanes. FEMA obligated about $873.8 million for emergency work—debris removal activities and emergency measures to lessen the immediate threat to life, public health, and safety—and about $516.3 million for permanent work—including the repair or replacement of public infrastructure such as roads, electrical utilities, and schools. For example, FEMA obligated about $101 million for the purchase and installation of modular units to be used as temporary classrooms and other facilities while permanent school buildings are repaired or replaced. FEMA's obligations for permanent work also included funding for hazard mitigation measures to reduce the risk of damage during future storms—for example, by replacing wooden utility poles with composite fiberglass poles (see figure). FEMA and the USVI are transitioning from using the standard Public Assistance program in the territory to using the Public Assistance alternative procedures program. Unlike in the standard Public Assistance program where FEMA will fund the actual cost of a project, the alternative procedures allow awards to be made on the basis of fixed-cost estimates to provide financial incentives for the timely and cost-effective completion of permanent work projects. FEMA and USVI officials stated that the alternative procedures will give the USVI more flexibility in determining when and how to fund projects and provide an opportunity to repair and rebuild the USVI's critical services infrastructure—such as its education system and electrical grid—so it meets industry standards without regard to pre-disaster condition. As of November 2018, FEMA and USVI officials were discussing the process for developing projects under the Public Assistance alternative procedures. GAO will continue to monitor the USVI's plans for using the alternative procedures as part of its broader review assessing the USVI's disaster recovery efforts and will issue a follow-on report later this year.


All TCS programs are state programs. States develop program policies and requirements, including establishing the roles and responsibilities of SGOs and participating private schools. The President's fiscal year 2020 budget request included a proposal for federal tax credits for donations to state-authorized SGOs. GAO was asked to review key characteristics related to accountability in state TCS programs that can fund K-12 educational expenses. This report examines (1) key requirements state TCS programs have chosen to establish for SGOs, (2) key requirements for private schools participating in state TCS programs, and (3) how selected states implement TCS programs and assess whether SGOs and participating private schools are following key state requirements. GAO identified key requirements states may choose to establish related to accountability for SGOs and schools based on relevant research and prior work. GAO also reviewed program documents from all 22 TCS programs to identify whether they had these key requirements as of school year 2018-2019 and then verified this information with state program officials. GAO did not conduct an independent review of state laws and regulations. GAO visited Arizona, Florida, and Pennsylvania, which have the largest TCS programs. In each of these states, GAO reviewed program documents and interviewed officials at state agencies and staff at selected SGOs and private schools (selected to provide variation in size and other characteristics). State tax credit scholarship (TCS) programs—programs that offer state tax credits for donations that can fund scholarships for students to attend private elementary and secondary schools—have established various key requirements for the scholarship granting organizations (SGO) that collect donations and distribute awards. For example, all 22 TCS programs in operation as of January 2019 require SGOs to register with or be approved by the state and limit the percentage of donations they can use for non-scholarship expenses. In addition, almost all of these programs—which received over $1.1 billion in donations and awarded approximately 300,000 scholarships in 2017—also require SGOs to undergo annual financial audits or reviews (19 programs). Fewer programs have requirements about SGO fundraising practices (9 programs) or the qualifications of SGO leadership personnel (10 programs), such as restrictions on officials having previous bankruptcies. States also have various key requirements that apply to private schools that enroll students with TCS scholarships. For example, private schools in most of the 22 programs must follow certain academic guidelines related to curriculum content (18 programs) and instructional time (19 programs), and have staff undergo background checks (18 programs). Schools in fewer programs are required to conduct academic testing (11 programs), ensure their teachers have specified qualifications (12 programs), or undergo an annual audit or financial review (4 programs). The three states with the largest TCS programs—Arizona, Florida, and Pennsylvania—implement and oversee their programs in different ways. In all three states, state agencies administer the tax credits while SGOs are generally responsible for managing donations and awarding scholarships; the details of these processes varied based on the requirements of each program. For example, Arizona and Pennsylvania's programs allow donors to recommend that funds go to specific schools, which can affect how SGOs solicit donations and award scholarships. Florida does not permit recommendations. All three states require SGOs to report on operations and undergo annual financial audits or reviews, while the states differ in how participating private schools are overseen. Florida's TCS programs use multiple monitoring methods, while all Arizona programs and one of two Pennsylvania programs generally rely on SGOs to confirm that schools comply with program requirements.


In September 2017, two major hurricanes—Irma and Maria—struck the USVI, causing billions of dollars in damage. FEMA is the lead federal agency responsible for assisting the USVI to recover from natural disasters. FEMA administers the Public Assistance program and Hazard Mitigation Grant Program in partnership with the USVI government, providing grant funding for response and recovery activities, including life-saving emergency protective measures, the repair or replacement of public infrastructure, and measures to increase the territory's resilience during future disasters. GAO was asked to review the federal government's response and recovery efforts in the USVI. This report examines (1) the status of Public Assistance program and Hazard Mitigation Grant Program funding and challenges, if any, with implementation, (2) the STEP pilot program, and (3) the oversight of these programs. GAO reviewed documentation and data on the Public Assistance program and Hazard Mitigation Grant Program in the USVI as of June 30, 2019. GAO interviewed FEMA and USVI officials regarding the status of recovery efforts and associated challenges, and conducted site visits to the USVI islands of St. Croix, St. Thomas, and St. John. As of June 30, 2019, FEMA obligated more than $1.9 billion in grant funding for 640 projects in the U.S. Virgin Islands (USVI) through the Public Assistance program and Hazard Mitigation Grant Program in response to the 2017 hurricanes. However, the limited availability of local USVI personnel to staff key recovery positions and the territory's difficult fiscal situation presented challenges in implementing these programs. Further, FEMA and USVI officials stated they faced challenges with implementing the Public Assistance alternative procedures program, which provides the USVI with flexibility in determining when and how to fund projects. Specifically, these officials stated that developing accurate fixed-cost estimates and using new flexibilities authorized by law delayed longer-term recovery projects. USVI officials told GAO they plan to take a cautious approach when deciding whether to pursue projects using the alternative procedures. FEMA expanded its Sheltering and Temporary Essential Power (STEP) pilot program in the USVI to address the lack of other sheltering options for survivors, such as hotels. The program aimed to provide minimal, temporary repairs to damaged homes to quickly make them habitable. In May 2019, FEMA decided it would not use the STEP pilot program in the future since it did not provide assistance as rapidly as intended. Historically, the program was used to address survivors' emergency sheltering needs. However, since ending it, FEMA has not evaluated options for providing future emergency sheltering assistance. Doing so could help FEMA plan for when the next disaster inevitably strikes. The USVI and FEMA established structures for overseeing recovery efforts. For example, the USVI established a new office to oversee federal recovery programs and FEMA has processes in place to oversee recovery projects at the local, regional, and headquarters levels. However, GAO found that FEMA does not have a consolidated standard operating procedures document for monitoring Hazard Mitigation Grant Program projects. Assessing the need for a consolidated document would help FEMA determine whether its existing guidance should be strengthened.


In accordance with the authority conferred by the Chief Financial Officers Act of 1990, as amended, GAO annually audits IRS's financial statements to determine whether (1) the financial statements are fairly presented and (2) IRS management maintained effective internal control over financial reporting. GAO also tests IRS's compliance with selected provisions of applicable laws, regulations, contracts, and grant agreements. IRS's tax collection activities are significant to overall federal receipts, and the effectiveness of its financial management is of substantial interest to Congress and the nation's taxpayers. In GAO's opinion, the Internal Revenue Service's (IRS) fiscal years 2019 and 2018 financial statements are fairly presented in all material respects, and although controls could be improved, IRS maintained, in all material respects, effective internal control over financial reporting as of September 30, 2019. GAO's tests of IRS's compliance with selected provisions of applicable laws, regulations, contracts, and grant agreements detected no reportable instances of noncompliance in fiscal year 2019. Limitations in the financial systems IRS uses to account for federal taxes receivable and other unpaid assessment balances, as well as other control deficiencies that led to errors in taxpayer accounts, continued to exist during fiscal year 2019.These control deficiencies affect IRS's ability to produce reliable financial statements without using significant compensating procedures. In addition, unresolved information system control deficiencies from prior audits, along with application and general control deficiencies that GAO identified in IRS's information systems in fiscal year 2019, placed IRS systems and financial and taxpayer data at risk of inappropriate and undetected use, modification, or disclosure. IRS continues to take steps to improve internal controls in these areas. However, the remaining deficiencies are significant enough to merit the attention of those charged with governance of IRS and therefore represent continuing significant deficiencies in internal control over financial reporting related to (1) unpaid assessments and (2) financial reporting systems. Continued management attention is essential to fully addressing these significant deficiencies.


In addition to providing health care services, VA funds research on veterans' health conditions, including chronic conditions (such as diabetes) as well as illnesses and injuries resulting from military service (such as TBI). VA's ORD manages the agency's research program, including its intramural research. In fiscal year 2018, VA resources for its intramural research program included an appropriation of $722 million. GAO was asked to review aspects of VA's research program. In this report, which focuses on VA's intramural research, GAO describes 1) how VA sets priorities for funding research, 2) VA efforts to facilitate translation of research into clinical practice, and 3) coordination between VA's research program and other VA entities. To perform this work, GAO reviewed VA policies, reports, and other documents about VA research efforts. GAO also interviewed officials from ORD, three VA national clinical program offices, and two VA offices that focus on implementing evidence-based practices. In addition, GAO conducted site visits with four VA medical centers. GAO selected those locations because they house VA-funded research centers that focus on a range of topics and ORD programs that focus on disseminating and translating research. At each location, GAO interviewed medical center officials and VA researchers. GAO also reviewed VA summary data on research projects and funding for fiscal year 2018. VA provided technical comments on a draft of this report, which GAO incorporated as appropriate. The Department of Veterans Affairs (VA) uses stakeholder input and other information to set priorities for funding research projects. VA's Office of Research and Development (ORD) manages VA's intramural research program—that is, research funded by and conducted within VA, by VA researchers. To set priorities, ORD considers input from VA and non-VA stakeholders (such as agency leaders and a federal research advisory council, respectively) and data on veterans' health conditions. ORD encourages VA researchers to study—and collaborate with other VA researchers on—priority topics, such as post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). ORD's Quality Enhancement Research Initiative (QUERI) and other VA entities facilitate translating research findings into clinical practice to improve care for veterans. QUERI is VA's central point of focus for research translation and provides a link between ORD, VA program offices, and providers. For example, one QUERI program is studying delivery of an evidence-based treatment for PTSD using telemedicine, specifically, by providing psychotherapy via video to veterans in rural areas. Another program recently adopted a new research translation strategy by establishing a requirement that research proposals for large, multi-center clinical trials include an implementation plan. VA officials said the goal of the new requirement is to encourage researchers to think about research translation from the beginning of a study—and how their work might be translated into practice. VA officials from both ORD and the national program offices GAO spoke with described a variety of efforts coordinating on research. Such coordination can help inform research priorities and help program offices incorporate evidence-based practices in developing and rolling out national policies. For example, ORD officials said that VA researchers were serving as subject matter experts to the national program office developing a protocol and clinical guidelines for a new treatment for certain veterans with depression that is resistant to existing treatments.


In early August 2019, the Indian government announced that it would make major changes to the legal status of its Muslim-majority Jammu and Kashmir (J&K) state, specifically by repealing Article 370 of the Indian Constitution and Section 35A of its Annex, which provided the state "special" autonomous status, and by bifurcating the state into two successor "Union Territories" with more limited indigenous administrative powers. The changes were implemented on November 1, 2019. The former princely region's sovereignty has been unsettled since 1947 and its territory is divided by a military "Line of Control," with Pakistan controlling about one-third and disputing India's claim over most of the remainder as J&K (China also claims some of the region's land). The United Nations considers J&K to be disputed territory, but New Delhi, the status quo party, calls the recent legal changes an internal matter, and it generally opposes third-party involvement in the Kashmir issue. U.S. policy seeks to prevent conflict between India and Pakistan from escalating, and the U.S. Congress supports a U.S.-India strategic partnership that has been underway since 2005, while also maintaining attention on issues of human rights and religious freedom. India's August actions sparked international controversy as "unilateral" changes of J&K's status that could harm regional stability, eliciting U.S. and international concerns about further escalation between South Asia's two nuclear-armed powers, which nearly came to war after a February 2019 Kashmir crisis. Increased separatist militancy in Kashmir may also undermine ongoing Afghan peace negotiations, which the Pakistani government facilitates. New Delhi's process also raised serious constitutional questions andâgiven heavy-handed security measures in J&Kâelicited more intense criticisms of India on human rights grounds. The United Nations and independent watchdog groups fault New Delhi for excessive use of force and other abuses in J&K (Islamabad also comes under criticism for alleged human rights abuses in Pakistan-held Kashmir). India's secular traditions may suffer as India's Hindu nationalist governmentâwhich returned to power in May with a strong mandateâappears to pursue Hindu majoritarian policies at some cost to the country's religious minorities. The long-standing U.S. position on Kashmir is that the territory's status should be settled through negotiations between India and Pakistan while taking into consideration the wishes of the Kashmiri people. The Trump Administration has called for peace and respect for human rights in the region, but its criticisms have been relatively muted. With key U.S. diplomatic posts vacant, some observers worry that U.S. government capacity to address South Asian instability is thin, and the U.S. President's July offer to "mediate" on Kashmir may have contributed to the timing of New Delhi's moves. The United States seeks to balance pursuit of a broad U.S.-India partnership while upholding human rights protections, as well as maintaining cooperative relations with Pakistan. Following India's August 2019 actions, numerous Members of the U.S. Congress went on record in support of Kashmiri human rights. H.Res. 745 , introduced in December and currently with 40 cosponsors, urges the Indian government to end the restrictions on communications and mass detentions in J&K that continue to date. An October hearing on human rights in South Asia held by the House Subcommittee on Asia, the Pacific, and Nonproliferation included extensive discussion of developments in J&K. In November, the Tom Lantos Human Rights Commission held an event entitled "Jammu and Kashmir in Context." This report provides background on the Kashmir issue, reviews several key developments in 2019, and closes with a summary of U.S. policy and possible questions for Congress.


In fiscal year 2017, Medicare FFS had an estimated $23.2 billion in improper payments due to insufficient documentation, while Medicaid FFS had $4.3 billion—accounting for most of the programs' estimated FFS medical review improper payments. Medicare FFS coverage policies are generally national, and the program directly pays providers, while Medicaid provides states flexibility to design coverage policies, and the federal government and states share in program financing. Among other things, GAO examined: (1) Medicare and Medicaid documentation requirements and factors that contribute to improper payments due to insufficient documentation; and (2) the extent to which Medicaid reviews provide states with actionable information. GAO reviewed Medicare and Medicaid documentation requirements and improper payment data for fiscal years 2005 through 2017, and interviewed officials from CMS, CMS contractors, and six state Medicaid programs. GAO selected the states based on, among other criteria, variation in estimated state improper payment rates, and FFS spending and enrollment. The Centers for Medicare & Medicaid Services (CMS) uses estimates of improper payments to help identify the causes and extent of Medicare and Medicaid program risks and develop strategies to protect the integrity of the programs. CMS estimates Medicare and Medicaid fee-for-service (FFS) improper payments, in part, by conducting medical reviews—reviews of provider-submitted medical record documentation to determine whether the services were medically necessary and complied with coverage policies. Payments for services not sufficiently documented are considered improper payments. In recent years, CMS estimated substantially more improper payments in Medicare, relative to Medicaid, primarily due to insufficient documentation (see figure). For certain services, Medicare generally has more extensive documentation requirements than Medicaid. For example, Medicare requires additional documentation for services that involve physician referrals, while Medicaid requirements vary by state and may rely on other mechanisms—such as requiring approval before services are provided—to ensure compliance with coverage policies. Although Medicare and Medicaid pay for similar services, the same documentation for the same service can be sufficient in one program but not the other. The substantial variation in the programs' improper payments raises questions about how well the programs' documentation requirements help identify causes of program risks. As a result, CMS may not have the information it needs to effectively address program risks and direct program integrity efforts. CMS's Medicaid medical reviews may not provide the robust state-specific information needed to identify causes of improper payments and address program risks. In fiscal year 2017, CMS medical reviews identified fewer than 10 improper payments in more than half of all states. CMS directs states to develop corrective actions specific to each identified improper payment. However, because individual improper payments may not be representative of the causes of improper payments in a state, the resulting corrective actions may not effectively address program risks and may misdirect state program integrity efforts. Augmenting medical reviews with other sources of information, such as state auditor findings, is one option to better ensure that corrective actions address program risks.


In fiscal year 2017, U.S. universities were awarded over $15 billion in federal grant funding for STEM research. Federal agencies are required to enforce Title IX—a law prohibiting discrimination on the basis of sex in education programs receiving federal financial assistance—including at universities they fund. Sexual harassment is not only degrading and illegal, it has a negative effect on the ability of women to engage in research at the same level as men. GAO was asked to review federal efforts to help prevent sexual harassment by STEM research grantees. This testimony is based on ongoing GAO work and provides preliminary observations on selected agencies: (1) availability of staff and budget to address sexual harassment complaints at universities they fund for STEM research; (2) efforts to establish and communicate policies and procedures for university grantees on preventing sexual harassment; and (3) steps taken to promote information sharing and collaboration among agencies to prevent sexual harassment at universities they fund for STEM research. GAO selected five federal agencies that together funded approximately 80 percent of STEM research from fiscal year 2015 through 2017, the latest data available. GAO reviewed these agencies' relevant regulations and documentation. GAO also interviewed agency officials as part of GAO's ongoing work. Based on preliminary information, the availability of agency staff and budget varies across the five selected agencies for efforts to address sexual harassment complaints at universities that use federal funds for Science, Technology, Engineering, and Mathematics (STEM) research. While four of the five agencies received three or fewer sexual harassment complaints from individuals at grantee universities from 2015 through 2019, changes to agency grantee policies or requirements could impact the number of complaints an agency receives and the amount of resources an agency needs to address them. The five selected agencies have established and communicated sexual harassment prevention policies to university grantees to varying degrees. Agencies vary in how they have: Provided detailed policies to grantees on sexual harassment. Three agencies—the National Aeronautics and Space Administration (NASA), Health and Human Services (HHS) National Institutes of Health (NIH), and the National Science Foundation (NSF)—have communicated relatively detailed policies on sexual harassment by issuing multiple forms of guidance, such as grantee policy manuals and best practices documents. In contrast, the Department of Energy (DOE) and Department of Agriculture (USDA) National Institute of Food and Agriculture (NIFA) communicated through more general documents, including policy statements that do not specifically address grantees. Modified grant terms and conditions . Two agencies are modifying the terms and conditions of grants to require grantees to report sexual harassment. NSF now requires grantees to increase transparency by reporting findings of sexual harassment to NSF, and NASA plans to implement the same requirement. Evaluated effectiveness of grantee policies. To date, the five agencies have not evaluated the effectiveness of their grantee policies and procedures to prevent sexual harassment, although two agencies are in the process of planning such evaluations. Based on our preliminary analysis and interviews, all five selected agencies have taken some steps to promote information sharing and collaboration among agencies on the prevention of sexual harassment. But they also noted challenges to these efforts, such as the lack of information on sexual harassment cases. These challenges may increase the risk that universities or agencies are unknowingly funding researchers with a history of past sexual harassment findings. The White House's Office of Science and Technology Policy has taken steps to create an interagency working group by establishing a joint committee in May 2019 under the National Science and Technology Council with NIH, NSF, DOE, and the National Institute of Standards and Technology Directors. The committee plans to address challenges in the research environment, including the lack of uniform federal sexual harassment policies.


In fiscal year 2018, DOD provided health care services to more than 9 million eligible beneficiaries through TRICARE, its regionally structured health care program. In each of its two regions (East and West), DOD uses contractors to manage health care delivery through civilian providers. The NDAA 2017 required a number of changes to the TRICARE program through its contracts. Specifically, it required DOD to implement a strategy with 13 specific elements—related to provider networks, telehealth services, and referrals, among other areas—for its contracts. The NDAA 2017 and the accompanying Senate Report 114-255 included provisions for GAO to examine DOD's managed care support contract acquisition process and requirements. This report (1) describes changes DOD made to its TRICARE contracts and acquisition process between its T-3 and T-2017 contracts and (2) examines the extent to which DOD implemented the 13 elements as required by the NDAA 2017, among other things. GAO reviewed and analyzed relevant federal statutes, T-3 and T-2017 planning and contracting documents, and interviewed DOD officials and TRICARE contractors. The Department of Defense (DOD) made selective changes to its TRICARE managed care support contracts and acquisition process from the third generation of contracts (T-3) to the fourth generation (T-2017) of contracts. According to DOD officials, the contracts are generally the same, and changes were made to clarify or streamline TRICARE requirements and administrative processes. Officials told GAO they prioritized the continuation of beneficiary services, rather than implement significant contract changes that could potentially be disruptive. Some of the T-2017 changes include a reduction from three to two contract regions and a different method for paying the contractors. GAO found that DOD has partially implemented six of the 13 elements required by the National Defense Authorization Act for Fiscal Year 2017 (NDAA 2017), in its T-2017 contracts. DOD leadership explained that they decided to implement each of the 13 elements separately rather than by developing a single strategy that addressed all of the elements. DOD officials explained that some of the 13 elements will be implemented through modifications to the T-2017 contracts, while others will be addressed in the fifth generation of managed care support contracts (T-5), which are expected to be awarded in 2021. While DOD has taken steps to begin implementing some of the required elements, GAO found that DOD lacks plans with specific time frames and actions needed to fully implement all of the elements. As a result, it is unclear exactly how and when all 13 elements will be implemented.


In fiscal year 2018, Medicaid covered approximately 75 million individuals at an estimated cost of $629 billion, $393 billion of which were federal funds. Medicaid eligibility is governed by a network of federal and state laws and regulations. In assessing eligibility for Medicaid, states must determine whether applicants meet eligibility criteria, such as financial and citizenship requirements. The accuracy of eligibility decisions has implications for federal and state spending. The Patient Protection and Affordable Care Act made significant changes to Medicaid eligibility rules beginning in 2014, including new ways of calculating income and new requirements related to electronically verifying applicants' information. Yet, little is known about the accuracy of states' Medicaid eligibility determinations since these changes were implemented. GAO was asked to review Medicaid eligibility determinations. This report describes, among other things, what is known about the accuracy of Medicaid eligibility determinations, and CMS's efforts to recoup funds related to eligibility errors. GAO reviewed 47 state and federal audits of Medicaid eligibility determinations across 21 states published between 2014 and 2018. GAO also reviewed relevant federal laws and regulations, and interviewed CMS officials. The Department of Health and Human Services provided technical comments on a draft of this report, which GAO incorporated as appropriate. States are responsible for determining applicants' eligibility for Medicaid, including verifying eligibility at application, redetermining eligibility, and disenrolling individuals who are no longer eligible. The Centers for Medicare & Medicaid Services (CMS) oversees states' Medicaid eligibility determinations. CMS did not publish an updated national Medicaid eligibility improper payment rate from 2015 through 2018 as states implemented the Patient Protection and Affordable Care Act. CMS released an updated rate in November 2019 that reflected new information on eligibility errors from 17 states. In lieu of complete and updated data, GAO reviewed 47 state and federal audits published between 2014 and 2018 related to 21 states' eligibility determinations. The identified accuracy issues did not always result in erroneous eligibility determinations. For example, some audits found applicants were determined eligible based on incomplete financial information, but when the audits reviewed additional information they found that the applicants still would have been eligible for Medicaid; and eligibility determinations complied with state policies and federal requirements, but noted that changes in state practices—such as using additional data sources to verify applicant information or checking sources more frequently—could improve eligibility determinations. While CMS is generally required to disallow, or recoup, federal funds from states for eligibility-related improper payments if the state's eligibility error rate exceeds 3 percent, it has not done so for decades, because the method it used for calculating eligibility error rates was found to be insufficient for that purpose. To address this, in July 2017, CMS issued revised procedures through which it can recoup funds for eligibility errors, beginning in fiscal year 2022. In addition, the President's fiscal year 2020 budget request includes a legislative proposal to expand the agency's authority to recoup funds related to eligibility errors. During this period of transition, federal and state audits will continue to provide important information about the accuracy of states' eligibility determinations.


In fiscal year 2018, federal agencies spent more than $36 billion on construction contracts, with more than 45 percent going to small business. Typically, construction projects involve some degree of change as the project progresses. Some federal construction contractors have raised concerns that delays in processing contract changes and making payments creates challenges, particularly for small businesses. Section 855 of the National Defense Authorization Act for Fiscal Year 2019 requires agencies to report information related to how quickly they finalize contract changes. GAO was asked to review federal construction contract change processes and timeframes. GAO (1) identified factors that affect the time it takes to finalize contract changes, and (2) assessed the extent to which selected agencies monitor time frames for finalizing contract changes. GAO reviewed relevant regulations and agency policies, analyzed available data, and interviewed officials from GSA's Public Buildings Service and USACE—two agencies with large amounts of obligations on construction—and two industry associations. Multiple factors affect the time it takes to finalize a construction contract change. For example, preparing cost estimates can be time consuming, particularly for complex changes. Yet the time may be used to help ensure the government has adequate cost data to inform negotiations. In addition, according to agency officials, miscommunication during the contract change process—which can lead to problems such as unauthorized work undertaken by the contractor—can result in additional reviews and longer time frames. According to U.S. Army Corps of Engineers (USACE) data, most of its construction contract changes are finalized within 60 days. Some take much longer, however (see figure). Agency officials and industry representatives agreed that perceptions differ about the length of the contract change process. For example, because a change can impact the contractor's cost and schedule immediately, the contractor typically perceives that the process starts earlier—and lasts longer—than the government does. Neither GSA nor USACE regularly monitors how long it takes to finalize construction contract changes, limiting management's ability to identify and respond to problems. Internal controls require agencies to collect and use quality data for management purposes such as monitoring agency activities. GSA systems do not collect data that permit analysis of contract change timeframes at the headquarters level. USACE systems produce contract change data for its districts, but data consolidation and calculations must be done manually and are not done regularly. Neither agency has a strategy in place to address these issues. Without regular review of these timeframes, USACE and GSA contracting officials may be unaware of any existing or potential problems, such as long process times that may affect project schedules. In addition, these data system limitations are likely to create difficulties for agencies when providing the information required by new legislation.


In fiscal year 2018, foreign nationals filed nearly 13,000 VAWA self-petitions alleging domestic abuse by a U.S. citizen or LPR family member. The Immigration and Nationality Act, as amended by VAWA, provides for immigration relief for self-petitioning foreign nationals who are victims of battery or extreme cruelty committed by their U.S. citizen or LPR family member. The self-petition process allows such victims to obtain classification as an immigrant and ultimately apply for LPR status. GAO was asked to review fraud risks in the self-petition process and how, if at all, DHS assists U.S. citizens or LPRs who may have been falsely identified as domestic abusers. This report examines the extent to which (1) USCIS has adopted relevant leading practices in GAO's Fraud Risk Framework for the self-petition program; and (2) DHS provides assistance to U.S. citizens or LPRs who may have been falsely identified as domestic abusers in the self-petition process, and steps DHS takes when suspected fraud is identified. GAO reviewed documents, interviewed officials, analyzed program data, and assessed the agency's approach to managing fraud risks against GAO's Fraud Risk Framework. Within the Department of Homeland Security (DHS), U.S. Citizenship and Immigration Services (USCIS) has responsibility for the Violence Against Women Act (VAWA) self-petition program for foreign national victims of battery or extreme cruelty committed by their U.S. citizen or lawful permanent resident (LPR) spouse or parent, or their adult U.S. citizen son or daughter. According to USCIS officials, the self-petition program is vulnerable to fraud, such as self-petitioners' use of false or forged documents. USCIS has adopted some, but not all, of the leading practices in GAO's Fraud Risk Framework. While USCIS has established a culture and a dedicated entity to manage fraud risks for the program, it has not fully assessed fraud risks and determined a fraud risk profile to document its analysis of the types of fraud risks the program could be vulnerable to. Further, the number of self-petitions filed has grown by more than 70 percent over the past 5 fiscal years. At the end of fiscal year 2018, USCIS had received 12,801 self-petitions and had over 19,000 self-petitions pending adjudication. Planning and conducting regular fraud risk assessments would better position USCIS to identify fraud risks when reviewing self-petitions. USCIS has instituted some fraud controls, such as developing antifraud training for self-petition adjudicators, but has not developed and implemented a risk-based antifraud strategy based on a fraud risk assessment. Developing and implementing an antifraud strategy would help USCIS better ensure its controls are addressing potential fraud risks in the program. DHS provides assistance to victims of immigration-related crimes and refers suspected self-petition fraud for review and investigation. Within DHS, U.S. Immigration and Customs Enforcement provides professional services and assistance to potential victims of immigration-related crimes, including self-petition fraud. As shown in the figure below, USCIS also has a referral process for suspected fraud in self-petitions, which may result in a referral for criminal investigation. According to agency data, from fiscal year 2014 to March 2019, USCIS created 2,208 fraud referral leads and cases that involved a VAWA self-petition. Total leads and cases increased from 198 in fiscal year 2014 to 801 in fiscal year 2019 as of March 2019, an increase of about 305 percent.


Almost 7 million children aged 3 to 21 received special education services under Part B of the Individuals with Disabilities Education Act (IDEA) in school year 2016-17. IDEA contains options parents and school districts may use to address disputes that arise related to the education of a student with a disability. These options include mediation and due process complaints, which can be used by parents and school districts; and state complaints, which can be used by any organization or individual, including the child's parent, alleging an IDEA violation. GAO was asked to review parents' use of IDEA dispute resolution options. This report examines (1) how often IDEA dispute resolution options are used, and whether use in selected states varies across school district-level socioeconomic or demographic characteristics; and (2) what challenges parents face in using IDEA dispute resolution options and how Education and selected states help facilitate parents' use of these options. GAO reviewed publicly available data on dispute resolution at the state level and collected data at the school district level from five states—Massachusetts, Michigan, New Jersey, Ohio, and Pennsylvania—selected based on the number of disputes initiated and school district characteristics, among other factors. GAO also reviewed relevant federal laws, regulations, and Education and state documents; and interviewed Education officials, state officials, staff from organizations providing technical assistance in these five states, and other national advocacy organizations. In school year 2016-17, 35,142 special education disputes were filed nationwide, and in five selected states GAO reviewed, dispute resolution options varied across school districts with different socioeconomic and demographic characteristics. The Individuals with Disabilities Education Act (IDEA) provides parents several ways to file and resolve disputes about plans and services that school districts provide to students with disabilities. A greater proportion of very high-income school districts had dispute resolution activity as well as higher rates of dispute activity than very low-income districts in most of the five states GAO reviewed. GAO also found that in most of these states, a smaller proportion of predominately Black and/or Hispanic districts had dispute resolution activity compared to districts with fewer minority students; however, predominately Black and/or Hispanic districts generally had higher rates of such activity. Technical assistance providers and others told GAO that parents used dispute resolution most often for issues related to school decisions about evaluations, placement, services and supports, and discipline of their children. Note: “Very high-income” districts are those in which 10 percent or fewer of students are eligible for free or reduced-price school lunch (FRPL). In “Very low-income” districts, 90 percent or more of students are eligible for FRPL. Parents may face a variety of challenges in using IDEA dispute resolution, and the Department of Education and states provide several kinds of support that, in part, may address some of these challenges. Stakeholders cited challenges such as paying for attorneys and expert witnesses at a due process hearing, parents' reluctance to initiate disputes because they feel disadvantaged by the school district's knowledge and financial resources, and parents' lack of time off from work to attend due process hearings. Education and state agencies provide technical assistance to support parents' understanding of their rights under IDEA and to facilitate their use of dispute resolution options, for example, by providing informational documents and phone help lines to parents.


In fiscal year 2018, nearly 13 million students and their families received over $122 billion in federal assistance to help them pursue higher education through programs authorized under Title IV of the Higher Education Act of 1965, as amended. Education administers these programs, and is responsible, along with accreditors and states, for maintaining accountability and protecting the federal investment in student aid for higher education. This testimony summarizes the findings and recommendations from GAO's prior reports, issued between 2014 and 2018, examining Education's role in: (1) recognizing accrediting agencies, (2) overseeing the financial condition of schools, and (3) overseeing schools' student loan default rates. This statement also updates the status of selected recommendations and a matter for congressional consideration. GAO has identified opportunities to strengthen federal higher education accountability in three areas: educational quality, financial stability, and federal student loan defaults. Educational quality. Accreditors—independent agencies responsible for ensuring that schools provide a quality education—must be recognized by the Department of Education (Education) as reliable authorities on educational quality. The accreditors can issue sanctions, including terminations and probations, to schools that do not meet accreditor standards. However, GAO previously found that schools with weaker student outcomes were, on average, no more likely to be sanctioned by accreditors than schools with stronger student outcomes, and Education does not make consistent use of sanction data that could help it identify insufficient accreditor oversight. In 2014, GAO recommended that Education use accreditor data in its recognition review process to determine whether accreditors are consistently applying and enforcing their standards to ensure schools provide a quality education. Education agreed with the recommendation, but has yet to use this data in this manner. Financial stability. Education uses a financial composite score to measure the financial health of schools participating in federal student aid programs, and increases its oversight of schools when it identifies concerns to protect against the risk of school closures. School closures, although rare, can result in hundreds of millions of dollars in unrepaid federal student loans and displacement of thousands of students. However, the composite score has been an imprecise risk measure, predicting only half of closures from school years 2010-11 through 2015-16. This is due in part to the fact that the composite score does not reflect changes in accounting practices and standards, relies on outdated financial measures, and is vulnerable to manipulation. Despite these limitations, Education has not updated the composite score since it was first established more than 20 years ago. In 2017, GAO recommended that Education update its financial composite score. Education has proposed some revisions, but changes have not yet been implemented to protect students and taxpayers against financial risks. Student loan defaults. According to federal law, schools may lose their ability to participate in federal student aid programs if a significant percentage of their borrowers default on their student loans within the first 3 years of repayment. However, GAO previously found that some schools managed these default rates by hiring consultants that encouraged borrowers with past-due payments to put their loans in forbearance, an option that allows borrowers to temporarily postpone payments and bring past due loans current. Although Education officials and student loan experts said forbearance is intended to be a short-term option, GAO's analysis of Education data found that 20 percent of borrowers who began repaying their loans in 2013 had loans in forbearance for 18 months or more. These borrowers defaulted more often in the fourth year of repayment, when schools are not accountable for defaults, suggesting long term forbearance may have delayed—not prevented—default. In 2018, GAO suggested that Congress consider statutory changes to strengthen schools' accountability for student loan defaults. Legislation has not yet been enacted.


In fiscal year 2018, of the roughly 6 million veterans who received services from VHA, approximately 2 million had a diagnosis for at least one mental health condition. Treatments for such mental health conditions can include psychotropic medications or non-pharmacologic therapies, which can be prescribed or offered by VA providers in outpatient settings including primary and specialty care. GAO was asked to review how mental health treatment decisions are made by providers in VAMCs and monitored by VHA. This report examines, among other things, (1) factors that contribute to providers' treatment decisions for veterans with mental health conditions, (2) VHA's guidance for documenting mental health treatment plans, (3) VHA's monitoring of whether providers document their consideration of different treatment options, and (4) VHA's efforts to improve the treatment of veterans prescribed psychotropic medications. GAO reviewed VHA documents and a nongeneralizable sample of veterans' medical records from five VAMCs (selected for variety in facility complexity and location); analyzed data on psychotropic medication prescribing; and interviewed VHA and VAMC officials. Officials from the five selected Department of Veterans Affairs (VA) medical centers (VAMC) GAO spoke with reported various factors that contribute to providers' mental health treatment decisions, including decisions regarding the prescribing of psychotropic medications and the offering of non-pharmacologic therapy. Examples of reported factors include: VAMC resources, such as the availability of appointments with mental health providers in specialty care, and the complexity of veterans' mental health conditions, such as the veterans' diagnoses and treatment history. Officials with VA's Veterans Health Administration (VHA) told GAO that specialty mental health care providers are expected to document mental health treatment plans in an easily identifiable way in veterans' medical records, but VHA has not developed guidance explicitly addressing this expectation. For example, VHA's mental health services handbook requires that treatment plans include certain components, but does not specify where to document the plan within a veteran's medical record. As a result, there is a risk that a provider may be unable to readily access information about a veteran's mental health treatment, including the use of medication or therapy, during changes in a veteran's care. VHA has not monitored whether mental health providers in specialty care document the required consideration of different treatment options—such as psychotropic medications or non-pharmacologic therapy—within mental health treatment plans. VHA officials told GAO that VHA relies on the Joint Commission (an independent, not-for-profit organization that accredits and certifies health care organizations) to assess specialty mental health treatment plans as part of the organization's accreditation process for each VAMC. However, the Joint Commission's standards do not specifically assess whether providers consider different treatment options. As a result, VHA cannot ensure that providers are considering all available treatment options and providing the most appropriate treatments to each veteran. VHA has taken steps to improve veterans' mental health treatment through the Psychotropic Drug Safety Initiative (PDSI)—an initiative focused on the safe and effective prescribing of certain psychotropic medications. For example, the first phase included a performance metric aimed at decreasing the percentage of veterans with post-traumatic stress disorder receiving one or more outpatient prescriptions for a benzodiazepine (a medication used to treat anxiety) because of risks associated with the medication. VHA reported a nationwide 5.4 percentage point decrease in the prescribing of this medication for these patients, as well as improvements in the majority of the initiative's other performance metrics.