School-age children without internet access may have difficulty in completing homework. Those without in-home fixed access may go online wirelessly outside the home to do homework. A provision was included in statute for GAO to review wireless internet access for school-age children in lower-income households. This report examines (1) challenges lower-income school-age children who lack in-home fixed internet face in doing homework involving internet access, and (2) selected school district efforts to expand wireless access for students and the federal role in those efforts. GAO analyzed 2017 CPS data; reviewed six local projects that were selected based in part on education industry stakeholders' recommendations, that included a range of geographic locations, and that took steps to address the homework gap; compared FCC efforts to federal standards for internal controls and pilot-program design best practices; reviewed FCC and Department of Education documents; and interviewed 17 stakeholders, including school districts. According to GAO's analysis of 2017 Census Bureau Current Population Survey (CPS) data, children ages 6 to 17 in lower-income households are more likely than peers in higher-income households to lack high-speed in-home internet and rely on mobile wireless service. GAO found that students who use mobile wireless for homework may face challenges, including slower speeds and limitations smartphones present in completing tasks like typing papers. These “underconnected” students may seek out ways to access wireless internet outside of the home to do homework; however, these methods also pose challenges (see figure). The inequity in internet access—and therefore in the ease of doing homework involving access—between students of varying income levels is known as the “homework gap.” Efforts by six selected projects involving seven school districts expanding wireless access for students who may lack it at home varied. According to officials with most school district projects GAO reviewed, rules for the Federal Communications Commission's (FCC) E-rate program, which allows schools to purchase discounted internet equipment, may limit schools' ability to provide wireless access off-premises. Specifically, off-premises access is not eligible for E-rate support, and schools that provide such access using existing services supported by E-rate must reduce their E-rate discounts. FCC conducted a pilot project in 2011 and 2012 to help decide whether to make wireless off-premises access eligible for E-rate support, but FCC did not determine and execute a methodology to assess the potential costs, benefits, and challenges of doing so. In 2016, FCC received two requests from school districts seeking waivers of rules to allow them to use E-rate program support to provide off-premises access, but FCC has not made a decision on the waivers. Determining and executing a methodology to analyze data about the potential benefits, costs, and challenges of easing E-rate rules on off-premises use and publishing the results could provide transparency to stakeholders such as school districts. This step could also help FCC act on pending and future waiver-of-rule requests and broader changes to rules that may help schools address the homework gap.


Section 1115 demonstrations are a significant component of Medicaid spending and affect the care of millions of beneficiaries. The Patient Protection and Affordable Care Act required the Department of Health and Human Services (HHS) to establish procedures to ensure transparency in approvals of new demonstrations and extensions to existing demonstrations. The act did not address amendments, which are subject to long-standing guidance on public input. GAO was asked to examine the transparency of demonstration approvals. Among other things, this report examines CMS's transparency policies and procedures for new demonstrations and extensions, and amendments to existing demonstrations. To review a variety of approval types across a large number of states, GAO examined all approvals of new demonstrations and extensions of and amendments to existing demonstrations granted from January 2017 through May 2018. GAO also conducted in-depth reviews of one approval in each of seven states, selected to include at least two approvals of each type. GAO reviewed demonstration documentation for these states, and interviewed state and federal Medicaid officials. GAO also assessed CMS's procedures against federal internal control standards. Medicaid demonstrations allow states flexibility to test new approaches for providing coverage and delivering Medicaid services. Since 2012, the Centers for Medicare & Medicaid Services (CMS), which oversees demonstrations, has developed procedures to improve the transparency of the approval process. For example, CMS reviews demonstration applications (including for new demonstrations, extensions, and amendments to existing demonstrations) for their compliance with applicable transparency requirements, including that states seek public input on their applications. However, GAO found weaknesses in CMS's policies for ensuring transparency. Changes to pending applications for new demonstrations or extensions. CMS lacks policies for ensuring transparency when states submit major changes to pending applications. For two of the four approvals of new demonstrations or extensions GAO reviewed in-depth, states submitted changes to their applications that could have significant effects on beneficiaries (such as disenrollment or other penalties) without first obtaining public comment on these changes at the state level. Amendments to existing demonstrations. CMS's transparency requirements for amendments are limited. For example, CMS does not require amendment applications to include how the changes may affect beneficiary enrollment or report on concerns raised in state public comments. However, states have proposed major changes—such as work and community engagement requirements—through amendments, raising concerns that major changes to states' demonstrations are being approved without a complete understanding of their impact.


Section 1115 demonstrations are a significant component of Medicaid spending and affect the care of millions of low-income and medically needy individuals. In 2018, CMS announced a new policy allowing states to test work requirements under demonstrations and soon after began approving such demonstrations. Implementing work requirements can involve various administrative activities, not all of which are eligible for federal funds. GAO was asked to examine the administrative costs of demonstrations with work requirements. Among other things, this report examines (1) states' estimates of costs of administering work requirements in selected states, and (2) CMS's oversight of these costs. GAO examined the costs of administering work requirements in the first five states with approved demonstrations. GAO also reviewed documentation for these states' demonstrations, and interviewed state and federal Medicaid officials. Additionally, GAO assessed CMS's policies and procedures against federal internal control standards. Medicaid demonstrations enable states to test new approaches to provide Medicaid coverage and services. Since January 2018, the Centers for Medicare & Medicaid Services (CMS) has approved nine states' demonstrations that require beneficiaries to work or participate in other activities, such as training, in order to maintain Medicaid eligibility. The first five states that received CMS approval for work requirements reported a range of administrative activities to implement these requirements. These five states provided GAO with estimates of their demonstrations' administrative costs, which varied, ranging from under $10 million to over $250 million. Factors such as differences in changes to information technology systems and numbers of beneficiaries subject to the requirements may have contributed to the variation. The estimates do not include all costs, such as ongoing costs states expect to incur throughout the demonstration. GAO found weaknesses in CMS's oversight of the administrative costs of demonstrations with work requirements. No consideration of administrative costs during approval. GAO found that CMS does not require states to provide projections of administrative costs when requesting demonstration approval. Thus, the cost of administering demonstrations, including those with work requirements, is not transparent to the public or included in CMS's assessments of whether a demonstration is budget neutral—that is, that federal spending will be no higher under the demonstration than it would have been without it. Current procedures may be insufficient to ensure that costs are allowable and matched at the correct rate. GAO found that three of the five states received CMS approval for federal funds—in one case, tens of millions of dollars—for administrative costs that did not appear allowable or at higher matching rates than appeared appropriate per CMS guidance. The agency has not assessed the sufficiency of its procedures for overseeing administrative costs since it began approving demonstrations with work requirements.


Section 961 of the Dodd-Frank Wall Street Reform and Consumer Protection Act directs SEC to assess and report annually on internal supervisory controls and procedures applicable to staff performing examinations, investigations, and securities filing reviews. The act also contains a provision for GAO to report on SEC's internal supervisory control structure and staff procedures. GAO's last report was in 2016 ( GAO-17-16 ). This report examines SEC's internal supervisory control framework and assessment of staff procedures, the design of selected controls, and the operation of selected controls. GAO analyzed SEC's internal supervisory control framework and related policies and guidance and evaluated the design and execution of a non-generalizable sample of controls selected because they addressed high-risk processes. As of fiscal year 2018, the Securities and Exchange Commission's (SEC) internal supervisory control framework—which provides guidance for division and office staff responsible for assessing the effectiveness of internal supervisory controls —reflected federal internal control standards. GAO determined that SEC's framework included elements covering each of the five components of internal control—control environment, risk assessment, control activities, information and communication, and monitoring. However, SEC does not have written policies or guidance to ensure that relevant SEC divisions and offices systematically assess the effectiveness of procedures applicable to staff who perform examinations of registered entities, enforcement investigations, and reviews of corporate securities filings. Establishing such policies would provide SEC greater assurance that these procedures are effective at achieving their objectives. All the SEC controls GAO evaluated were designed consistent with standards, and a majority operated as intended. SEC guidance and federal internal control standards state that (1) controls should be designed to address objectives and respond to risks and (2) control activities should be implemented through policies, including documentation requirements, and include detail to enable management to monitor control execution. Control design. All 39 controls GAO evaluated included design elements to achieve SEC's control objectives and respond to risks it identified. However, 10 of these 39 controls did not include key attributes, such as requirements to document, and set time frames for, control execution (see fig.). Control operation. GAO could not assess the operation of three of 18 selected controls because documentation of control execution did not exist. Of the remaining controls, 12 operated as intended and three partially operated as intended. Examples of controls that operated as intended include SEC's approval of examinations and tracking of investigations. By more consistently following SEC guidance and federal internal control standards for developing control activities, including documentation requirements, relevant SEC divisions and offices would enhance their ability to monitor and ensure the effectiveness of their internal supervisory controls. Legend: Corporation Finance = Division of Corporation Finance; Enforcement = Division of Enforcement; OCIE = Office of Compliance Inspections and Examinations; and OCR = Office of Credit Ratings. Source: GAO analysis of Securities and Exchange Commission (SEC) documents. | GAO-20-115


Senate Standing Rule XXIII, Privilege of the Floor, designates those afforded access to the Senate floor while the Senate is in session. In addition to sitting Senators, the rule lists several eligible positions, including certain current and former congressional, executive, and judicial officials; state and territorial governors; the mayor of the District of Columbia; members of foreign national legislatures; the nation's highest ranking military leaders; and, under specified circumstances, congressional staff members assisting Senators on the floor. Over its history, the Senate has amended the floor privilege rule to add or clarify positional categories. The Senate has also agreed to a number of resolutions and unanimous consent (UC) agreements that affect the interpretation of the rule. The Senate, by resolution or UC, frequently provides temporary floor access to non-designated individuals. Less commonly, it has agreed to temporarily restrict access to the Senate floor. Such restrictions have occurred in advance of the Senate's move to its current chamber in 1859 and during the impeachment trials of Presidents Andrew Johnson (1868), Bill Clinton (1999), and Donald Trump (2020). In 2007, the Senate amended Rule XXIII to exclude lobbyists from the floor, even if these individuals would otherwise be granted floor privileges under the rule. Rule XXIII permits certain staff members of individual Senators and Senate committees and joint committees to have access to the floor "when in the discharge of their official duties." Staff access is further regulated by policies outlined in a recurring UC agreement approved at the start of each Congress, as well as those policies established by the Senate Rules and Administration Committee. For instance, each Senator is limited to two staff members on the floor at the same time. The Office of the Sergeant at Arms (SAA) enforces Senate Rule XXIII, as well as any associated resolutions or UC agreements, regarding floor access. This report analyzes the evolution of the floor privileges rule over time. Notable changes to the rule or its interpretation are provided, such as the first time a female staff member accessed the Senate floor (1946); when the Senate agreed to resolutions to accommodate staff with disabilities (e.g., allow the use of a service dog in the chamber, 1997); and when it permitted Senators, accompanied by their infant children, to vote on the Senate floor (2018). The report also addresses how staff members are granted floor privileges and how that access is limited by Rule XXIII and its associated regulations. Access via the SAA's web portal, TranSAAct, is discussed, as well as the use of unanimous consent requests to afford access to individuals not listed in TranSAAct or to enable more than two staff members from the same Senate office on the floor at one time.


Serious disruptions for certain industries caused by the COVID-19 (coronavirus) pandemic have led to calls for federal government assistance to affected industries. Direct federal financial assistance to the private sector on a large scale is unusual, except for geographically narrow assistance following natural disasters. Nonetheless, assistance to business sectors affected by COVID-19 would not be the first occasion on which the federal government has aided troubled or financially distressed industries. Historically, aidâsometimes popularly referred to as "government bailouts"âhas taken many forms and has occurred under a wide variety of circumstances. Past assistance has involved such instruments as loan guarantees, asset purchases, capital injections, direct loans, and regulatory changes, with the specific mix of policies varying significantly from case to case. These differences make it somewhat subjective as to what should be defined as a "bailout." To help inform congressional debate, this report examines selected past instances in which the government has aided troubled industries, providing information about the way in which such assistance was structured, the role of Congress, and the eventual cost. In order to provide greater detail, the examples all involve cases in which federal assistance was (1) widely available to firms within an industry rather than being targeted to a particular firm; (2) extraordinary in nature rather than a type of assistance that is routinely provided; and (3) motivated primarily by a desire to prevent industry-wide business failures. The coverage is not exhaustive, and excludes cases in which assistance was targeted at individual firms rather than at entire industries. In some of these cases, the government was able to recoup much or all of its assistance through fees, interest, warrants, and loan or principal repayments. In others, there were no arrangements made for recoupment or repayment. The episodes considered include the following: Railroad Restructuring (1957-1987) Farm Credit System Crisis (1980s) Savings and Loan Crisis (1980s-1990s) Airline Industry (2001-2014) Auto Industry (2008-2014) Troubled Asset Relief Program (TARP) Bank Support (2008-present) Money Market Mutual Fund Guarantee (2008-2009) Agricultural Trade-Aid (2018-2019) Assessing extraordinary assistance can be difficult as particular episodes may play out over decades and full data about assistance may be difficult to collect and analyze. Congress has sometimes included particular oversight and reporting requirements in statutes authorizing aid. In addition, there are broader policy concerns raised by government assistance that may be impossible to quantify and do not get captured in tallies of the government's income and expenses. Possible benefits of assistance may include avoiding potentially long-lasting disruptions to consumers, workers, local communities, and the overall economy; averting losses to federally guaranteed retirement funds; and maintaining federal tax revenues. Potential drawbacks to assistance include the possibility that it may reduce competition by rewarding incumbents over new entrants and distort the affected product market by causing (or prolonging) overproduction; that it may cause "moral hazard" if firms respond to government assistance by acting with less financial prudence in the future; and that it can delay an industry's adjustment to structural problems such as high production cost and excess capacity. In every case, federal assistance to certain industries may raise questions about the fairness of providing assistance to some businesses but not to others.


As COVID-19 has spread throughout the United States, it has reduced domestic economic activity and disrupted domestic and international supply chains for goods and services, including food and agricultural products. These disruptions have produced an immediate and very strong demand shock on the U.S. food supply chain that has sent many commodity prices sharply lower. The food supply chain refers to the path that raw agricultural commodities take from the farm where they are produced, through the food processing and distribution network to the consumer where they are used. Supply chain disruptions have been primarily due to two factors: widespread shutdowns of all but essential businesses; and uncertainty about the availability of labor for the food distribution networkâwhether from illness, fear of illness, or immigration status. The food supply chain has been deemed essential; however, many institutional purchasers (including restaurants, hotels, schools, and entertainment venues) have been closed. According to the U.S. Department of Agriculture (USDA), U.S. consumers normally spend 54% of their food and drink dollars on away-from-home food purchases. Thus, prior to the COVID-19 pandemic a large share of U.S. food products traveling through the food supply chain was going to institutional buyers, often in bulk or vendor-ready form, for away-from-home consumption. In order to redirect this food product flow towards retail outlets and at-home consumption, much of this food would require processing into more consumer-usable forms, repackaging, and relabeling. This requires some level of retooling by food packagers and processors. In addition, several plants in the food processing industry, including meat processing plants, have experienced severe COVID infection outbreaks among workers and been forced to shut (at least temporarily). Several industry groups from the U.S. agricultural sector have released estimates of the economic damage experienced by producers and ranchers. Most of these early assessments are limited to evaluating the effect of the price decline on any unsold production of crops or livestock remaining under farmer's control, and the unexpected marketing costs of unsold products due to the shutdown of most institutional buying of agricultural products. Cumulatively, industry estimates of COVID-related losses approach $40 billion (this would represent over 10% of annual cash receipts). The effect on farm net income is expected to be similarly negative. In response to the COVID-19 pandemic, Congress has passed and the President has signed four supplemental appropriations acts ( P.L. 116-123 , P.L. 116-127 , P.L. 116-136 , and P.L. 116-139 ) that have included both direct and indirect funding for the U.S. agricultural sector. On April 17, 2020, Secretary of Agriculture Sonny Perdue announced the Coronavirus Food Assistance Program (CFAP), valued at $19 billion, to provide immediate financial relief to farmers, ranchers, and consumers in response to the COVID-19 national emergency. According to Secretary Perdue, CFAP will include $16 billion in direct payments to producers that have been impacted by the sudden drop in commodity prices and the disruption in food supply chains that has occurred since the outbreak, and $3 billion in commodity purchases for distribution through food banks, faith-based organizations, and other nonprofit organizations. CFAP direct payments are intended to partially offset the loss of market revenue from the price decline, and the unexpected carry-cost of unsold commodities for producers and ranchers of products that have been negatively affected by COVID-19. USDA has released limited information on the specifics of how CFAP's direct payment program will be implemented. Many of the program specifics are expected to be delineated in an expedited rulemaking process. CFAP direct payments are expected to go out to producers by the end of May or early June. CFAP's commodity purchase and distribution program serves the dual roles of supporting commodity market prices by temporarily increasing demand, and of expanding the availability of food distribution to consumers that have lost their jobs or have limited resources. Expectations are that it will be operated differently than, and separate from, existing USDA commodity purchase programs such as Section 32 or Food and Nutrition Service (FNS) food distribution programs in two major ways. First, USDA plans to purchase about $100 million per month of fresh produce, $100 million per month of dairy products, and $100 million per month of meat products (chicken and pork). Second, the CFAP purchase program intends for vendors to deliver household-ready boxesâpotentially a diversified mix of the previously mentioned produce, meat and dairy productsâwhich are ready for more convenient and immediate distribution ("off the truck and into the trunk") that is consistent with social distancing. Initial program delivery may be as early as May 15. The program is expected to operate through the end of 2020. Potential congressional concerns include how to channel assistance to industries affected by COVID-19, long-term effects of the pandemic, and the capacity of rural banks to help with recovery. Several issues related to CFAP and the U.S. agricultural sector in a post-COVID economy that could be of potential interest to Congress are presented at the end of this report.


Several federal laws, executive orders, and regulations seek to promote equal employment opportunity by prohibiting employers from discriminating in employment on the basis of race and gender, among other things, and generally require companies contracting with the federal government to comply with affirmative action and other equal employment opportunity provisions. The EEOC and OFCCP are the primary federal agencies that enforce these requirements. Although federal law also generally prohibits employment discrimination based on religion, faith-based organizations may hire based on religion. Some federal grant programs contain statutory restrictions prohibiting this practice; however, since a 2007 DOJ legal opinion, federal agencies have allowed faith-based grantees to use RFRA as a basis for seeking an exemption to allow religious-based hiring. GAO has issued three reports since September 2016 that address equal employment opportunity ( GAO-16-750 , GAO-18-69 , and GAO-18-164 ). This testimony is based on these three reports and discusses 1) OFCCP and EEOC's progress in addressing prior GAO recommendations and 2) equal employment opportunity exemptions for faith-based organizations. To update the status of prior recommendations, GAO reviewed agency guidance and documentation and interviewed agency officials. The Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) and the Equal Employment Opportunity Commission (EEOC) face challenges in overseeing compliance by employers and federal contractors with applicable federal equal employment opportunity requirements. In its 2016 report, GAO made six recommendations to OFCCP and in its 2017 report made five additional recommendations to OFCCP and one to EEOC to strengthen program oversight. OFCCP has implemented four recommendations, but seven require additional agency action to be fully implemented, as does the one to EEOC. For example: In 2016, GAO found that OFCCP's oversight was limited by reliance on contractors' voluntary compliance with affirmative action plan requirements. OFCCP has taken steps to develop a new web portal for collecting those plans annually, but has not yet obtained Office of Management and Budget approval for the collection or launched the portal. GAO also found OFCCP's oversight was limited by a lack of timely staff training. OFCCP has taken steps to implement a new training curriculum, but has not yet implemented its new learning management system that will help ensure timely and regular training. In 2017, GAO found that EEOC had not consistently captured information on industry codes, which limits EEOC's ability to identify trends by industry sector and conduct sector-related analyses. EEOC has not yet completed development of its Employer Master List that will include industry codes. GAO also found that OFCCP's methodology for identifying equal employment disparities by industry might not accurately identify industries at greatest risk of noncompliance with affirmative action and nondiscrimination requirements. OFCCP has taken steps to develop a new methodology, but needs to further refine it to ensure that it will identify industries at greatest risk. From fiscal years 2007 through 2015, few faith-based grantees sought an exemption from nondiscrimination laws related to religious-based hiring under the Religious Freedom Restoration Act of 1993. In October 2017, GAO found that the Departments of Justice (DOJ), Health and Human Services (HHS), and Labor (DOL) had awarded funding to at least 2,586 grantees through at least 53 grant programs that restricted grantees from making employment decisions based on religion. The number of relevant grant programs could be higher because GAO could not identify all such programs due to data limitations. Across the three agencies, GAO identified 117 grantees that were potentially faith-based organizations (FBO). Of the 117 potential FBOs, nine DOJ grantees were FBOs certified as being exempt from statutory restrictions on religious-based hiring. All three agencies required grantees seeking an exemption to self-certify that they were eligible for the exemption, but the agencies' processes for reviewing and approving exemption requests varied. In August 2019, OFCCP issued a proposed rule to clarify the scope and application of the religious exemption to help organizations with federal contracts and subcontracts and federally assisted construction contracts and subcontracts better understand their obligations.


Sexual harassment is degrading and illegal. Studies show it has a negative effect on the ability of women to engage in research at the same level as men. Title IX prohibits sexual harassment and other forms of sex discrimination in education programs that receive federal funding, and federal agencies are required to enforce the law at universities they fund. In fiscal year 2018, the most recent year for which data were available during GAO's review, U.S. universities were awarded about $27 billion in federal grants for STEM research. GAO was asked to review federal efforts to help prevent sexual harassment at universities that receive such grants. This report examines, among other things, (1) how selected federal agencies receive, investigate, and resolve Title IX complaints; (2) the extent to which selected agencies have established an overall plan for their sexual harassment prevention efforts for university grantees, including for communicating and evaluating these efforts and (3) the extent to which selected agencies collaborate on efforts to prevent sexual harassment at universities they fund for STEM research. GAO reviewed agencies' relevant regulations and documentation and interviewed agency officials. The five agencies GAO reviewed provided approximately 80 percent of federal science, technology, engineering, and mathematics (STEM) research grants since fiscal year 2015. From fiscal year 2015 through 2019, four of the five agencies received few complaints—including sexual harassment—under Title IX from individuals at universities. Inconsistent with federal regulations implementing Title IX, two of the agencies—the Departments of Energy (DOE) and Agriculture (USDA)—lack finalized procedures for complaints and thus cannot ensure they are consistently handling complaints. Sex-discrimination concerns—including sexual harassment—can also be raised by individuals outside of the Title IX complaint process (see table). However, only two agencies—the National Science Foundation (NSF) and Department of Health and Human Services (HHS)—publicly communicate the option to notify them of concerns. The other three—DOE, the National Aeronautics and Space Administration (NASA), and USDA—received no concerns in fiscal year 2019 and may be missing opportunities to obtain information for Title IX oversight. All five agencies have established grantee sexual harassment prevention efforts beyond those required by Title IX. However, none of the agencies have goals and plans for all of their efforts, and thus they lack clear ways to evaluate how well these efforts are working and to identify any needed improvements. They may also be missing opportunities to coordinate and integrate prevention activities. Additionally, the Department of Justice (DOJ) reconstituted an interagency discussion group on Title IX in 2016, where all five agencies share information about their activities. However, DOJ has not fully adopted two leading practices for collaboration: agreeing on agency roles and responsibilities and developing mechanisms to monitor, evaluate, and report collaborative efforts. Officials at one agency said clarifying agencies' roles and responsibilities would improve the group. Adopting leading practices would help enhance and sustain collaboration.


Sexual violence–which can include crimes such as rape and other forms of sexual coercion–is widely acknowledged as a problem on college campuses. Although Education collects some data on sexual violence at colleges that receive federal funding, measuring the prevalence of campus sexual violence has proven difficult, due in part to underreporting of these incidents to law enforcement. While some researchers have used surveys to gather additional information regarding sexual violence on college campuses, estimates from these surveys can vary widely due to factors such as differing methodologies and response rates. This report examines (1) key stakeholders' views on the strengths and limitations of campus climate surveys on sexual violence, (2) approaches selected colleges have taken to survey their students, and (3) the role federal agencies play in helping colleges develop and implement these surveys. GAO reviewed documentation for three widely administered survey instruments, and relevant federal laws, regulations, and guidance. GAO interviewed 25 stakeholders, including researchers; Education and Justice officials; officials in four states that required or recommended campus climate surveys as of January 1, 2017, a date selected to allow time for implementation; and 10 colleges—including seven that conducted campus climate surveys—selected based on program length (2- or 4-year), geographic diversity, and other factors. Campus climate surveys that examine sexual violence occurring on individual college campuses have several strengths and limitations, according to stakeholders GAO interviewed. Strengths. Nearly all stakeholders said colleges can use these surveys to gather more comprehensive information about incidents of campus sexual violence, such as those not previously reported to the colleges or law enforcement. Surveys can also provide information on students' knowledge of the colleges' procedures for reporting incidents, among other topics, which can help colleges identify areas for improvement. Limitations. Most stakeholders said getting students to respond can be challenging. In addition, about half of stakeholders said some colleges may not have the resources to effectively administer these surveys, and results across colleges that use different surveys may not be comparable. The seven selected colleges that conducted surveys reported using various approaches to survey their students about the incidence of campus sexual violence. Each college used one of three widely used surveys, but six modified them to some extent. Six colleges sent the survey to all undergraduates, and one surveyed a representative sample of students. Colleges also reported using multiple outreach strategies to increase participation, including offering incentives, such as gift cards, to students who completed the survey; using social media; and involving student leaders (see figure). Colleges' reported response rates ranged from less than 10 percent to more than 60 percent. The Departments of Justice (Justice), Education (Education), and Health and Human Services (HHS) have created and disseminated informational resources for colleges interested in conducting campus climate surveys. For example, from 2014 to 2017, Justice made funding available for the development of a campus climate survey instrument for public use, and developed technical assistance materials covering various topics, including how to choose survey respondents and protect their confidentiality. In addition, in 2015, Education issued guidance encouraging colleges to develop ways to survey students about the campus climate. Justice and HHS have also funded grant programs that allowed grantees to use some funding to conduct campus climate surveys.


Since 1946, the United States has provided an estimated total of $346 billion (obligations in current dollars) in foreign assistance to the Middle East and North Africa (MENA) region. For FY2021, overall bilateral aid requested for MENA countries amounts to $6.6 billion, or about 15% of the State Department's International Affairs budget request. The State Department estimates that the Middle East stands to receive 42% of the geographically specific assistance in the budget request, more than any other region. As in previous years, more than 90% would support assistance for Israel, Egypt, and Jordan. The region also receives a sizable portion of annual emergency humanitarian assistance appropriations, which are not included in the region-specific aid figures. Policy changes during the Trump Administration, coupled with legislation passed by Congress, have halted various types of U.S. aid to the Palestinians. The Administration withheld FY2017 bilateral economic assistance, reprogramming it elsewhere, and ceased requesting bilateral economic assistance after Palestinian leadership broke off high-level political contacts to protest President Trump's December 2017 recognition of Jerusalem as Israel's capital. After Congress passed the Anti-Terrorism Clarification Act of 2018 (ATCA, P.L. 115-253 ), the Palestinian Authority (PA) ceased accepting any U.S. aid in January 2019, including security assistance and legacy economic assistance from prior fiscal years. Amidst the COVID-19 outbreak, some Members of Congress are concerned that, due to the uncertainty surrounding the status of U.S. aid to the Palestinians, humanitarian aid to combat the disease may not reach the Palestinian population. In April, the Administration announced that it would provide $5 million in International Disaster Assistance (IDA) to the West Bank as part of its global COVID-19 response. The foreign aid data in this report is based on a combination of resources, including the U.S. Agency for International Development's (USAID) U.S. Overseas Loans and Grants (also known as the "Greenbook"), appropriations data collected by the Congressional Research Service from the State Department and USAID, data extrapolated from executive branch agencies' notifications to Congress, and information published annually in the State Department and USAID Congressional Budget Justifications. For foreign aid terminology and acronyms, see the glossary appended to the report. In order to more accurately compare the Administration's FY2021 foreign assistance request to previous years' appropriations, aid figures in this report (except where otherwise indicated) refer only to funding that is administered by the State Department or USAID and requested for individual countries or regional programs. While this represents the majority of U.S. assistance to the Middle East, it is important to note that there are several other sources of U.S. aid to the region, such as International Disaster Assistance (IDA), Migration and Refugee Assistance (MRA), and Transition Initiatives (TI). Likewise, other U.S. federal entitiesâsuch as the Departments of Defense, Commerce, and the Treasury, and the Millennium Challenge Corporationâadminister additional types of assistance. Funding for such activities is generally not requested for individual countries and regions, and it is largely excluded here. Much of the data presented in this report pre-dates the global spread of the Coronavirus Disease 2019, or COVID-19. All MENA countries, particularly poorer nations that receive foreign assistance, are expected to be affected by the outbreak; however, the extent and scale of the damage to public health and economies across the region is unknown, as is the pandemic's full impact on U.S. aid programs. As of mid-April 2020, the Administration had allocated some emergency humanitarian assistance to the region as a first response to the COVID-19 pandemic. On April 16, the State Department announced that it would provide an estimated $79 million in health assistance to various MENA countries to help prepare laboratory systems, implement a public-health emergency plan for points of entry, and activate case-finding and event-based surveillance for influenza-like illnesses. To date, Congress has appropriated almost $1.8 billion in emergency foreign assistance funds through two supplemental appropriations bills to address the impact of COVID-19. See CRS In Focus IF11496, COVID-19 and Foreign Assistance: Issues for Congress , by Nick M. Brown, Marian L. Lawson, and Emily M. Morgenstern.


Since 1968, the Department of Defense (DOD) has developed, procured, and sustained a variety of electronic systems to document the health care services delivered to servicemembers, military retirees, and their family members. DOD currently operates a number of legacy electronic health record (EHR) systems. Each system has separate capabilities and functions as a result of new or changing requirements over the past five decades. The primary legacy systems include the Composite Health Care System (CHCS), Armed Forces Health Longitudinal Technology Application (AHLTA), Essentris, and the Corporate Dental System. DOD also still uses paper medical records that are later scanned and digitally archived. Currently, only certain components of DOD's health records are accessible to the Department of Veterans Affairs (VA). In the early 1990s, concern grew about deficient interoperability between DOD and VA. This led to recommendations by various commissions on military and veterans health care calling for greater coordination and data sharing efforts between the two departments. Between 1998 and 2008, DOD and VA developed several capabilities to exchange patient health information across each department's EHR systems. However, Congress did not view these systems as an adequately integrated approach. This led to several congressional mandates being issued between 2008 and 2014, including for the development of an interoperable EHR (including a deadline to implement such system), for certain capability requirements, and for the creation of an interagency program office. After several strategy changes to meet Congress's mandates, DOD opted to acquire a commercial-off-the-shelf EHR product to replace its legacy EHR systems. The new system would be called MHS Genesis. In July 2015, DOD awarded the MHS Genesis contract to Leidos Partnership for Defense Health (LPDH). The contract includes a potential 10-year ordering period and an initial total award ceiling of $4.3 billion. DOD selected several MTFs in Washington to serve as Initial Operational Capability (IOC) sites and began fielding MHS Genesis in 2017. The designated IOC sites included: Madigan Army Medical Center, Fairchild Air Force Base, Naval Hospital Bremerton, and Naval Health Clinic Oak Harbor. The purpose of fielding MHS Genesis at the IOC sites before full deployment was to observe, evaluate, and document lessons-learned on whether the new EHR was usable, interoperable, secure, and stable. During initial deployment, DOD evaluators and IOC site personnel identified numerous functional and technical challenges. In particular, the Defense Department's Director of Operational Testing and Evaluation found that MHS Genesis was "not yet effective or operationally suitable." Technical challenges included cybersecurity vulnerabilities, network latency, and delayed equipment upgrades and operational testing. Functional challenges included lengthy issue resolution processes, inadequate staff training, and capability gaps and limitations. DOD acknowledged these issues, implemented follow-on testing ongoing corrective actions, and revised its training approach for future fielding. DOD plans to implement MHS Genesis at all military treatment facilities (MTFs) in 23 waves through 2024. Each wave spans 18 months, with a new wave commencing every three months at designated MTFs. The first deployment wave began in September 2019 at MTFs in California, Oregon, and Idaho. As DOD moves to fully implement MHS Genesis, Congress may choose to address various issues including: how oversight can be conducted on a program that spans three federal departments; what kind of interdepartmental governance structure is needed to implement the program; and how to ensure fair and open competition in future procurement decisions.


Since 1988, a series of laws have been enacted and executive orders issued related to federal goals of reducing federal fleets' petroleum use and greenhouse gas emissions. For fiscal year 2017, federal agencies were required to: (1) to acquire certain types of vehicles, (2) to use more alternative fuel, and (3) to meet targets for reducing petroleum and per-mile greenhouse gas emissions. Federal agencies were also under a directive to increase acquisitions of zero emission (electric) vehicles. GAO was asked to review federal agencies' efforts related to these fiscal year 2017 requirements. This report addresses: (1) how agencies reported meeting fleet energy requirements and how agencies efforts changed their fleets and (2) challenges agencies face related to further meeting fleet energy goals. To conduct this review, GAO surveyed 29 federal agencies subject to fleet energy requirements and selected 5 agencies—of a variety of sizes and missions—for case studies. The case studies results are not generalizable to all agencies. GAO also: (1) reported on DOE's and GSA's data on federal fleets for fiscal years 2008 through 2017, including GSA's acquisition and cost data for fiscal year 2017, the most current data available; (2) reviewed DOE's and EPA's information on agencies' performance related to fiscal year 2017 requirements; and (3) interviewed federal officials. The directives to reduce per-mile greenhouse gas emissions and increase acquisitions of electric vehicles were revoked by an Executive Order issued in May 2018. In responding to fleet management requirements over the past 10 years, agencies have incorporated an increasing number of alternative fuel vehicles into their fleets. These have been predominantly flex-fuel vehicles, as hybrid and battery electric vehicles continue to make up a small percentage of agencies' fleets (see figure). The Department of Energy (DOE) is responsible for overseeing agencies' compliance by analyzing fleet data. Most agencies reported meeting the fiscal year 2017 requirements to reduce petroleum use and per-mile greenhouse gas emissions. DOE and other agency officials attributed agencies' success in meeting these requirements to (1) acquiring low greenhouse-gas-emitting and alternative fuel vehicles, and (2) improving general fleet management such as by reducing miles traveled. According to agency officials, three challenges have continued to hinder agencies' efforts to further the goals of reducing federal fleets' petroleum use and greenhouse gas emissions. First, while hybrid and electric vehicles can offer reductions in petroleum use and greenhouse gas emissions, the costs of these vehicles and their charging infrastructure make it challenging for agencies to acquire them on a large scale. According to GSA data, agencies purchased 373 electric vehicles (sedans and minivans) in fiscal year 2017—along with about 4,500 hybrid electric sedans—out of a total of over 16,000 sedans and minivans acquired. In total, agencies spent about $10.5 million more to purchase hybrid or electric vehicles than they would have to purchase comparably sized conventionally fueled vehicles. However, agencies did not consistently track the life-cycle costs of these vehicles. Second, agencies also stated that a lack of fuel and infrastructure availability limits agencies' use of alternative fuel. Third, agency officials stated that a continuing need for larger vehicles limits the number of low greenhouse-gas-emitting vehicles agencies can acquire.


Since 1988, military departments have privatized utility systems—such as electricity, water, natural gas, and wastewater—on military installations. DOD awards privatized utility services contracts to companies who upgrade, maintain, and operate the systems. Members of Congress and stakeholders have expressed concerns over the length of time it takes to award these contracts. DOD has a goal of reducing the time frames. A House committee asked GAO to review DOD's utilities privatization. This report examines (1) the length of time to award contracts for privatized utility services, and (2) the extent to which DOD is demonstrating leading practices to collect and disseminate lessons learned. GAO reviewed data on all 21 new utility services contracts awarded from fiscal years 2016 through 2018; compared DOD's lessons learned activities with GAO's leading practices; and interviewed DOD and utility company officials. From fiscal years 2016 through 2018, Department of Defense (DOD) components awarded 21 new contracts for privatized utility services on military installations. The contracting process generally took an average of 4 years from solicitation to contract award. However, the entire pre-award contracting process could be longer, as GAO found that DOD does not maintain complete data on the time to conduct key steps in the acquisition planning phase (see table). GAO found that DOD does not maintain data on when military departments begin to consider privatization and when a complete inventory of the associated infrastructure, such as pipes and valves, is available to use in the solicitation. While no DOD regulation or policy that GAO reviewed requires the collection of data on the time to complete all pre-award activities, in 2014, Defense Logistics Agency Energy officials established milestones to plan and monitor key pre-award activities. GAO found that the length of time from receipt of requirements to contract award was reduced from an average of 61 months pre-2014 to an average of 35 months post-2014. The lessons learned efforts of DOD to shorten the time to award contracts have fully or partially demonstrated four of five leading practices. DOD's efforts include: collecting information through working groups and conferences; analyzing past privatization efforts to focus management oversight; validating changes by demonstrating new processes; storing lessons learned through revised guidance; and sharing lessons learned through working groups and training. However, as DOD does not collect consistent information on the total time to award utility services contracts, DOD is missing opportunities to use lessons learned to reduce the time. Further, DOD does not have a repository for archiving specific lessons learned from utilities privatization efforts. Rather, DOD officials note they consider lessons learned as they develop updated guidance, templates, and handbooks. Without a repository of specific lessons learned, such as conducting the privatization process, DOD is missing opportunities to collect and share lessons learned to assist stakeholders on the remaining 580 utility systems it considers available for privatization.


Since 1989, an appropriations provision, colloquially known as the “Stevens Amendment,” has reflected Congress's longstanding effort to ensure transparency and accountability in federal grant spending. GAO was asked to review agency guidance and grantee compliance related to the Stevens Amendment. This report (1) describes the guidance DOL, HHS, and Education provide to grantees regarding the Stevens Amendment; (2) examines the extent to which DOL, HHS, and Education are managing grantees' compliance with the Stevens Amendment; and (3) describes what is known about how grantees calculate the dollar amounts and percentages of their federal and nongovernmental funding disclosures. GAO asked for agency guidance documents, reviewed monitoring reports, interviewed officials on agencies' Stevens Amendment oversight efforts, and asked agencies how grantees calculate funding amounts. The Stevens Amendment is an appropriations provision that requires grantees of the Departments of Labor (DOL), Health and Human Services (HHS), and Education (Education) to disclose for a grant program the percent of the costs financed with federal funds, the federal dollar amount, and the percentage and dollar amount financed by nongovernmental funds. The provision requires that recipients of grants funded by DOL, HHS, and Education make certain funding disclosures when issuing statements, press releases, bid solicitations, and other documents describing their grant project or program. DOL, HHS, and Education generally provide written guidance to grantees with the exact text of the Stevens Amendment or a paraphrased equivalent. In addition, a number of operating divisions within HHS referenced the HHS Grants Policy Statement, which includes language equivalent to the Stevens Amendment, as a way to instruct grantees. One HHS operating division, the Health Resources and Services Administration, provided grantees with additional guidance in the form of a web page that contained examples of funding disclosure statements and frequently asked questions intended to clarify the Stevens Amendment's requirements. One DOL subagency, the Employment and Training Administration (ETA), whose active grants represented more than 95 percent of DOL's total grant dollars, had processes for managing grantees' compliance that were able to identify instances of grantee noncompliance with Stevens Amendment requirements. ETA's operating plan for grant oversight targets 26 percent of its active grants for risk-based monitoring each fiscal year, representing approximately 2,100 grants in fiscal year 2019. The other DOL subagencies either stated that they did not monitor grantees for compliance with Stevens Amendment requirements or did not have processes in place for managing grantee compliance with the requirements of the Stevens Amendment. Most HHS operating divisions said they did not review grantees for Stevens Amendment compliance. Education also did not monitor for grantee compliance with the Stevens Amendment's requirements. Regulations governing federal agencies' management of grants require federal agencies to manage and administer the federal award in a manner that ensures that programs are implemented in full accordance with U.S. statutory and public policy requirements. Without processes for managing compliance, some DOL subagencies, HHS operating divisions, and Education are unable to ensure that grant programs are being implemented by grantees in full accordance with the statutory requirements of the Stevens Amendment. Most of the subagencies and operating divisions monitoring compliance did not gather information from grantees about how the grantees calculate the dollar amounts and percentages in their Stevens Amendment funding disclosures. For example, DOL's ETA officials said that they do not know how the dollar amounts reported by grantees were calculated, and have not inquired about the level of detail factored into indirect costs involving the grantee organization's structure and the percentage of funds spent on salaries. Similarly, officials from HHS's National Institutes of Health operating division noted that calculations can be difficult given that a research program can have multiple funding streams that feed into a grant project and grantees' research portfolios are now more complex than they have been in the past.


Since 1990, there has been an annual statutory cap of 66,000 on the number of H-2B visa holders who can work for U.S. employers. DHS administers the program with support from other federal agencies including DOL. In recent years, demand for H-2B visas has exceeded the cap. To meet the needs of U.S. businesses, Congress authorized additional visas in fiscal years 2017-2019. GAO was asked to examine the effects of the annual cap on employers and U.S. workers. This report examines, among other objectives: (1) trends in the demand for H-2B visa workers, (2) selected employers' reports of the visa cap's influence on their performance and employment of U.S. workers, and (3) how federal agencies have sought to meet employers' H-2B hiring needs and protect U.S. workers. GAO analyzed nationwide data on H-2B visas and county labor market indicators. GAO interviewed 35 H-2B employers in four industries that are among the largest users of H-2B visas. The employers were in five counties selected for variation in factors including the share of H-2B workers in the workforce and the unemployment rate. GAO also reviewed relevant federal laws, regulations, and documents and interviewed federal officials and stakeholders. Employer demand for H-2B visa workers has increased as the national unemployment rate has declined. H-2B visas are intended to help employers fill temporary, non-agricultural positions when no U.S. workers are available and are subject to an annual statutory cap of 66,000. From 2010 to 2018, the number of H-2B workers requested on employer applications increased from about 86,600 to 147,600. Regarding local economic conditions, GAO found that counties with H-2B employers generally had lower unemployment rates and higher weekly wages than those without H-2B employers. Most of the 35 H-2B employers GAO interviewed said that business planning was affected by uncertainty about whether they would be able to hire the number of H-2B visa workers they requested given the statutory cap. Employers who did not receive all H-2B visas requested under the statutory cap in 2018 were somewhat more likely than those who did to report declines in revenue (see figure) and purchases of goods and services. However, GAO found no clear pattern in changes to the number of U.S. workers hired by these employers. Employers interviewed by GAO varied in how they adjusted to having fewer H-2B workers. For example, two seafood employers reported shutting down operations in the absence of H-2B workers, and employers said that barriers to finding U.S. workers included remote location and seasonality of the work. Federal agencies have identified program changes that consider employers' hiring needs and protect U.S. workers, but gaps remain in implementation. The Department of Homeland Security (DHS), in consultation with the Department of Labor (DOL), has identified options for changing the H-2B visa allocation process to address employers' uncertainty aboutreceiving visas. However, DHS and DOL have not assessed any of these options or determined which would not require Congressional action, and employers continue to struggle with uncertainty. To help ensure H-2B employers comply with U.S. worker recruitment and other requirements, DOL has audited employers' compliance with these requirements. However, in general, DOL randomly selected employers for these audits, rather than taking a risk-based approach using factors such as violation trends by industry. As a result, the agency may not be using its limited audit resources efficiently or effectively.


Since 1996, the Army has transferred more than 700,000 surplus rifles and handguns to CMP. The National Defense Authorization Act (NDAA) for Fiscal Year 1996 authorized CMP to sell certain types of surplus Army firearms to U.S. citizens, including M1 .30 caliber rifles. CMP reimburses the Army for the costs to prepare and transport surplus firearms to CMP. The NDAA for Fiscal Year 2018 required the Army during fiscal years 2018 and 2019 to transfer to CMP surplus M1911 .45 caliber handguns, including not fewer than 8,000 in fiscal year 2018 and not more than 10,000 in any fiscal year, and included a provision for GAO to conduct a review of certain matters related to CMP. Among other things, GAO examined (1) the Army and CMP's procedures to address requirements governing the transfer and sale of firearms and (2) CMP's primary sources of revenue, costs and profits, and estimated future revenue associated with the sale of surplus firearms. GAO reviewed applicable federal statutes and agreements between the Army and CMP; analyzed firearms transfer data, and CMP's Internal Revenue Service filings and internal financial documents; and visited both CMP's northern headquarters in Port Clinton, Ohio and its southern headquarters in Anniston, Alabama. The Civilian Marksmanship Program (CMP) is a federally chartered, nonprofit corporation that, among other things, instructs U.S. citizens in marksmanship; promotes practice and safety in the use of firearms; and sells surplus Army firearms (see figure), ammunition, repair parts, and other supplies. CMP is required to give priority to activities that benefit firearms safety, training, and competition for youth and that reach as many youth participants as possible. CMP also charges fees for individuals to participate in some of its programs. The Army and CMP have established procedures to address federal requirements for the transfer and sale of surplus firearms. Both organizations established procedures to carry out the transfer of surplus Army firearms as identified in a 2016 Memorandum of Understanding (MOU) and a 2018 Memorandum of Agreement, both between the Army and CMP. To address requirements for selling surplus firearms, CMP uses a combination of procedures, including an application requiring prospective customers to provide proof of citizenship and age, among other things, and a check against the National Instant Criminal Background Check System. Per the MOU, the Army's Tank-automotive and Armaments Command oversees the Army's costs and reimbursements from CMP for certain costs associated with storing, transporting, and administering the transfer of surplus firearms. The primary source of CMP's revenues from fiscal years 2008 through 2017 was from the sale of surplus rifles, which, according to CMP's internal financial documents, generated $196.8 million in revenue. CMP also sold commercial ammunition and memorabilia, which, according to the same documents, generated $76.4 million in revenue. Further, according to its Internal Revenue Service filings for this time frame, CMP reported earning $49.8 million in interest and dividends from its investment account. CMP began selling surplus M1911 handguns in November 2018 and had just begun generating revenue from these sales at the time of GAO's review. The profit that CMP realized from the sales of surplus rifles could not be determined because CMP's methodology to calculate expenses did not account for all of CMP's costs associated with the sale of these rifles. GAO estimates future sales of CMP's surplus handgun and rifles currently available for sale could generate as much as $104.9 million, or enough to fund CMP's operations for several years. Further, as of September 30, 2017, CMP reported having cash of $3.6 million, and an investment account valued at $188.6 million. This could also allow CMP to continue operations for several years.


As Congress actively considers Social Security reform options, one area of interest is Social Security policy levers to aid vulnerable groupsâwidows, low earners, caregivers, older beneficiaries, spouses, and never-married individuals. In the context of widows, researchers and policymakers have raised concerns about both benefit adequacy and benefit equity. In 2017, about 18% of all individuals aged 60 or older were widows; however, nearly 26% of individuals aged 60 or older living in poverty were widows. Benefit adequacy concerns stem from the facts that the widow has outlived the spouse, may contend with a reduced monthly income after the spouse's death, may confront significant medical and long-term care expenses associated with the deceased spouse's end-of-life care, and is at risk of outliving retirement resources and incurring significant expenses for long-term care. The focus tends to be on widows (women) rather than widowers (men). In 2017, the poverty rate was 14.6% for widowed women aged 60 or older and 10.8% for widowed women aged 60 or older receiving Social Security benefits, compared with 10.5% and 7.7%, respectively, for widowed men aged 60 or older. Benefit equity concerns stem from Social Security program rules that provide higher benefits to one-earner couples than to two-earner couples with identical lifetime earnings and Social Security payroll tax contributions. More equitable program rules, reflecting changes in family structure and work patterns of husbands and wives, would provide equal benefits for equal contributions. Several approaches to modifying Social Security benefits to aid widows are available. One approach is to adjust the Social Security program policy levers that most directly affect widows. These levers include the widow(er)'s limit, the provision of credits for delayed claiming, the parameters around benefits for disabled widows, and the lump-sum death benefit. Another approach is to develop an alternative widow benefit, envisioned as a percentage of the couple's combined Social Security benefits while both were alive, with the widow receiving the higher of this alternative benefit amount and the current-law widow benefit. Finally, proposals that would aid other vulnerable groupsâenhanced benefits for low earners, reduced marriage requirements for divorced spouse and divorced survivor benefits, increased benefits for older beneficiaries, caregiver credits, and paid family leaveâalso would aid widows who are members of those targeted groups.


Since 1999, more than 700,000 people have died of a drug overdose in the United States, with about 48,000 dying of an opioid overdose in 2017 alone. The DEA administers and enforces the Controlled Substances Act as it pertains to ensuring the availability of controlled substances, including certain prescription drugs, for legitimate use while limiting their availability for abuse and diversion. The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, enacted in 2018 included a provision for GAO to study the reporting of suspicious opioid orders on a real-time basis nationally using computer algorithms. This report examines, among other things, how DEA obtains and uses industry-reported data to identify and address suspicious opioid orders and opportunities for DEA to improve these efforts, such as using computer algorithms or real-time reporting. GAO analyzed program documentation and DEA data, and interviewed DEA and industry officials as well as officials from national associations representing distributors, investigators, state boards of pharmacy, and other federal and state agencies. The Drug Enforcement Administration (DEA) collects industry-reported data on the sale and purchase of controlled substances and prescription drugs, including opioids. It uses these data to support ongoing investigations into the diversion of such substances into the illegal market place and to identify investigative leads for its field division offices. GAO identified deficiencies associated with DEA's drug diversion efforts, including the following: Limited proactive and robust analysis of industry-reported data. While DEA's current data systems are not designed to conduct real-time analysis, and it conducts some analyses of industry-reported data, such as in response to requests from its field division offices, DEA could conduct more analyses using automated computer algorithms to help identify questionable patterns in the data. For example, DEA could analyze data to identify unusual volumes of deleted transactions or unusual volumes of drugs that were disposed of rather than sold. It could also analyze data to identify trends in distribution or drug purchases in a given geographic area. Other analysis DEA could perform is to look for unusual patterns when comparing drug orders in one geographic area with other nearby areas. These analyses could potentially help DEA proactively identify suspicious activities or registrants that may warrant investigation. No data governance structure to manage all drug transaction data. Although DEA has guidance, policies and procedures for the use of some information systems, it has not established a formal data governance structure to manage all data it collects and maintains, which are integral to its diversion control activities. A data governance structure is defined as an institutionalized set of policies and procedures for providing data governance throughout the life cycle of developing and implementing data standards. Industry and technology councils, domestic and international standards-setting organizations, and federal entities endorse the use of a governance structure to oversee the development, management, and implementation of data standards, digital content, and other data assets. While DEA began efforts to develop a governance structure, it is in the early stages of development and does not have additional details or documentation of its efforts. An effective data governance structure could help DEA ensure its important data assets are consistently and fully utilized.


Since 2000, there has been substantial growth in Medicare payments for hospice services and the number of Medicare beneficiaries using hospice. This growth has been accompanied by an increase in the number of providers (primarily an increase in for-profit providers), reaching approximately 4,500 providers by 2017. GAO was asked to review aspects of Medicare's hospice program. This report, among other things, (1) compares quality scores and other potential indicators of quality for for-profit and non-profit hospices; and (2) examines opportunities for strengthening CMS's oversight of hospice providers. GAO analyzed CMS data on hospice care for 2014 through 2017—the latest years for which full-year data were available at the time of GAO's analysis—and reviewed research on hospice care. GAO interviewed CMS officials, researchers, provider associations, a survey agency association, and a non-generalizable sample of hospice providers selected in part through referrals from other stakeholders. GAO also reviewed relevant statutes, regulations, documents, and enforcement data. Medicare's hospice benefit provides palliative care to beneficiaries with terminal illnesses and a life expectancy of 6 months or less. GAO's review of 2017 data from the Centers for Medicare & Medicaid Services (CMS) found that for-profit and non-profit hospices had, on average, similar scores on CMS's current quality measures that indicate hospice performance in areas such as pain assessment and discussion of beneficiary treatment preferences. However, for-profits were more often among the subset of providers with the lowest scores on certain quality measures GAO reviewed. In addition to analyzing providers' scores on CMS quality measures, GAO analyzed provider performance on other indicators, identified by researchers, that could signal quality issues and found performance varied among for-profit and non-profit hospices. One of the other quality indicators GAO analyzed was the rate of beneficiaries discharged from hospice prior to death, which in some cases could indicate dissatisfaction with care leading to the beneficiary's decision to leave the hospice provider. In addition, GAO examined the number of provider visits to give medical and emotional support within the last few days of a beneficiary's life. With regard to these indicators, for 2017, GAO found the following, among other things: 472 hospice providers (462 for-profits and 10 non-profits) had a high rate of discharging beneficiaries prior to death (50 percent or more were discharged). According to research, a high discharge rate could, in some cases, be an indicator of poor quality of care or of provider misuse of the benefit, in that the hospice may be enrolling beneficiares who are not eligible for hospice care. 83 providers (80 for-profits and 3 non-profits) did not have hospice staff (such as nurses, physicians, or nurse practitioners) visit beneficiaries within the last 3 days of their life—a critical time in providing quality care, according to researchers GAO interviewed. CMS's oversight of the quality of care provided by hospice providers consists primarily of inspections—called surveys—of hospice providers. GAO found that, while CMS instructs surveyors to review previous survey findings and complaints, CMS does not instruct surveyors to use information on providers' performance on quality measures or other potential indicators of quality as part of the survey process. For example, CMS does not instruct surveyors to consider whether a hospice provided staff visits during beneficiaries' last week of life. According to research, this information could be used to enhance the survey process. GAO also found that CMS is limited to one enforcement option—termination of the Medicare provider agreement—which CMS uses rarely and generally only when providers fail to correct within the required time frame the most serious violations of federal health and safety requirements. According to two researchers, additional remedies, such as civil monetary penalties, could enhance CMS's oversight by addressing performance problems that do not merit termination and incentivize agencies to improve quality of care. CMS uses a range of remedies for other provider types, such as home health agencies and nursing homes, but lacks authority to impose such additional sanctions on hospices.


Since 2005, federal funding for disaster assistance has totaled at least $450 billion, including a 2019 supplemental appropriation of $19.1 billion for recent disasters. In 2018 alone, 14 separate billion-dollar weather and climate disaster events occurred across the United States, with total costs of at least $91 billion, including the loss of public and private property, according to the National Oceanic and Atmospheric Administration. Disaster costs likely will increase as certain extreme weather events become more frequent and intense due to climate change, according to the U.S. Global Change Research Program, a global change research coordinating body that spans 13 federal agencies. In 2013, GAO included “Limiting the Federal Government’s Fiscal Exposure by Better Managing Climate Change Risks” on its high-risk list. The cost of recent weather disasters has illustrated the need to plan for climate change risks and invest in climate resilience, which can reduce the need for far more costly steps in the decades to come. This statement summarizes GAO’s findings from its October 2019 report on climate resilience and federal investment (GAO-20-127). Specifically, it focuses on (1) the extent to which the federal government has a strategic approach for investing in climate resilience projects; (2) key steps that provide an opportunity to strategically prioritize projects for investment; and (3) the strengths and limitations of options for focusing federal funding on these projects. To perform this work, GAO reviewed about 50 relevant reports and interviewed 35 stakeholders with expertise in climate resilience and related fields, including federal officials, researchers, and consultants. GAO also identified domestic and international examples of governments that invest in climate resilience and related projects. The federal government has invested in individual projects that may enhance climate resilience, but it does not have a strategic approach to guide its investments in high-priority climate resilience projects. In GAO’s March 2019 update to its list of federal programs at high risk for fraud, waste, abuse, and mismanagement, or most in need of transformation, GAO reported that one area of government-wide action needed to reduce federal fiscal exposure is in the federal government’s role as the leader of a strategic plan that coordinates federal efforts and informs state, local, and private-sector action. For this 2019 update, GAO assessed the federal government’s progress since 2017 related to climate change strategic planning against five criteria and found that the federal government had not met any of the criteria for removal from the high-risk list. Further, as of August 2019, no action had been taken to implement 14 of GAO’s 17 recommendations to improve federal climate change strategic planning. Additionally, no federal agency, interagency collaborative effort, or other organizational arrangement has been established to implement a strategic approach to climate resilience investment that includes periodically identifying and prioritizing projects. Such an approach could supplement individual agency climate resilience efforts and help target federal resources toward high-priority projects. Based on its review of prior GAO work, relevant reports, and stakeholder interviews, GAO found six key steps that provide an opportunity for the federal government to strategically identify and prioritize climate resilience projects for investment. These are (1) defining the strategic goals of the climate resilience investment effort and how the effort will be carried out, (2) identifying and assessing high-risk areas for targeted resilience investment, (3) identifying potential project ideas, (4) prioritizing projects, (5) implementing high-priority projects, and (6) monitoring projects and climate risks. GAO also identified two options—each with strengths and limitations—for focusing federal funding on high-priority climate resilience projects. The options are (1) coordinating funding provided through multiple existing programs with varied purposes and (2) creating a new federal funding source specifically for investment in climate resilience. In addition, GAO identified opportunities to increase the impact of federal funding options on climate resilience, including ensuring adequate and consistent funding and encouraging nonfederal investment in climate resilience.


Since 2005, federal funding for disaster assistance is at least $450 billion, including approximately $19.1 billion in supplemental appropriations signed into law on June 6, 2019. In 2018 alone, there were 14 separate billion-dollar weather and climate disaster events across the United States, with a total cost of at least $91 billion, according to the National Oceanic and Atmospheric Administration. The U.S. Global Change Research Program projects that disaster costs will likely increase as certain extreme weather events become more frequent and intense due to climate change. The costs of recent weather disasters have illustrated the need for planning for climate change risks and investing in resilience. Resilience is the ability to prepare and plan for, absorb, recover from, and more successfully adapt to adverse events, according to the National Academies of Science, Engineering, and Medicine. Investing in resilience can reduce the need for far more costly steps in the decades to come. Since February 2013, GAO has included Limiting the Federal Government's Fiscal Exposure by Better Managing Climate Change Risks on its list of federal program areas at high risk of vulnerabilities to fraud, waste, abuse, and mismanagement or most in need of transformation. GAO updates this list every 2 years. In March 2019, GAO reported that the federal government had not made measurable progress since 2017 to reduce fiscal exposure to climate change. This testimony—based on reports GAO issued from October 2009 to March 2019—discusses (1) what is known about the potential economic effects of climate change in the United States and the extent to which this information could help federal decision makers manage climate risks across the federal government, (2) the potential impacts of climate change on the federal budget, (3) the extent to which the federal government has invested in resilience, and (4) how the federal government could reduce fiscal exposure to the effects of climate change. GAO has made 62 recommendations related to the Limiting the Federal Government’s Fiscal Exposure by Better Managing Climate Change Risks high-risk area. As of December 2018, 25 of those recommendations remained open. The estimated economic effects of climate change, while imprecise, can convey useful insight about potential damages in the United States. In September 2017, GAO reported that the potential economic effects of climate change could be significant and unevenly distributed across sectors and regions (see figure). This is consistent with the recent findings of the U.S. Global Change Research Program's Fourth National Climate Assessment, which concluded, among other things, that the continued increase in the frequency and extent of high-tide flooding due to sea level rise threatens America's trillion-dollar coastal infrastructure. Information about the potential economic effects of climate change could inform decision makers about significant potential damages in different U.S. sectors or regions. According to prior GAO work, this information could help decision makers identify significant climate risks as an initial step toward managing them. The federal government faces fiscal exposure from climate change risks in several areas, including: Disaster aid: due to the rising number of natural disasters and increasing reliance on federal assistance. GAO has previously reported that the federal government does not adequately plan for disaster resilience. GAO has also reported that, due to an artifically low indicator for determining a jursidiction's ability to respond to disasters that was set in 1986, the Federal Emergency Management Agency risks recommending federal assistance for juridisctions that could recover on their own. Federal insurance for property and crops: due, in part, to the vulnerability of insured property and crops to climate change impacts. Federal flood and crop insurance programs were not designed to generate sufficient funds to fully cover all losses and expenses. The flood insurance program, for example, was about $21 billion in debt to the Treasury as of April 2019. Further, the Congressional Budget Office estimated in May 2019 that federal crop insurance would cost the federal government an average of about $8 billion annually from 2019 through 2029. Operation and management of federal property and lands: due to the hundreds of thousands of federal facilities and millions of acres of land that could be affected by a changing climate and more frequent extreme events. For example, in 2018, Hurricane Michael devastated Tyndall Air Force Base in Florida, with a preliminary repair estimate of $3 billion. The federal budget, however, does not generally account for disaster assistance provided by Congress or the long-term impacts of climate change on existing federal infrastructure and programs. GAO has reported that more complete information about fiscal exposure could help policymakers better understand the trade-offs when making spending decisions. Further, federal investments in resilience to reduce fiscal exposures have been limited. As GAO has reported, enhancing resilience can reduce fiscal exposure by reducing or eliminating long-term risk to people and property from natural hazards. For example, a 2018 interim report by the National Institute of Building Sciences estimated approximate benefits to society in excess of costs for several types of resilience projects. While precise benefits are uncertain, the report estimated that for every dollar invested in designing new buildings to particular design standards, society could accrue benefits amounting to about $11 on average. The federal government has invested in individual agency efforts that could help build resilience within existing programs or projects. For example, the National Climate Assessment reported that the U.S. military integrates climate risks into its analysis, plans, and programs. In additon, as GAO reported in March 2019, the Disaster Recovery Reform Act of 2018 could improve resilience by allowing the President to set aside a portion of certain grants for pre-disaster mitigation. However, the federal government has not undertaken strategic government-wide planning to manage climate risks. GAO's March 2019 High-Risk report identified a number of recommendations GAO has made related to fiscal exposure to climate change. The federal government could reduce its fiscal exposure by implementing these recommendations. Among GAO's key government-wide recommendations are: Entities within the Executive Office of the President (EOP) should work with partners to establish federal strategic climate change priorities that reflect the full range of climate-related federal activities; Entities within EOP should use information on potential economic effects from climate change to help identify significant climate risks and craft appropriate federal responses; Entities within EOP should designate a federal entity to develop and update a set of authoritative climate observations and projections for use in federal decision making, and create a national climate information system with defined roles for federal agencies and certain nonfederal entities; and The Department of Commerce should convene federal agencies to provide the best-available forward-looking climate information to organizations that develop design standards and building codes to enhance infrastructure resilience.


Since 2005, federal funding for disaster assistance is at least $450 billion, including approximately $19.1 billion in supplemental appropriations signed into law on June 6, 2019. In 2018 alone, there were 14 separate billion-dollar weather and climate disaster events across the United States, with a total cost of at least $91 billion, according to the National Oceanic and Atmospheric Administration. The U.S. Global Change Research Program projects that disaster costs will likely increase as certain extreme weather events become more frequent and intense due to climate change. The costs of recent weather disasters have illustrated the need for planning for climate change risks and investing in resilience. Resilience is the ability to prepare and plan for, absorb, recover from, and more successfully adapt to adverse events, according to the National Academies of Science, Engineering, and Medicine. Investing in resilience can reduce the need for far more costly steps in the decades to come. Since February 2013, GAO has included Limiting the Federal Government's Fiscal Exposure by Better Managing Climate Change Risks on its list of federal program areas at high risk of vulnerabilities to fraud, waste, abuse, and mismanagement or most in need of transformation. GAO updates this list every 2 years. In March 2019, GAO reported that the federal government had not made measurable progress since 2017 to reduce fiscal exposure to climate change. This testimony—based on reports GAO issued from October 2009 to October 2019—discusses 1) what is known about the potential economic effects of climate change in the United States and the extent to which this information could help federal decision makers manage climate risks across the federal government, (2) the fiscal exposure facing the federal government due to climate risks and current efforts to address that exposure, (3) the extent to which the federal government has invested in resilience to climate change impacts, and (4) how the federal government could reduce fiscal exposure to the effects of climate change. GAO had made 62 recommendations related to the Limiting the Federal Government’s Fiscal Exposure by Better Managing Climate Change Risks high-risk area. As of December 2018, 25 of those recommendations remained open. The estimated economic effects of climate change, while imprecise, can convey useful insight about potential damages in the United States. In September 2017, GAO reported that the potential economic effects of climate change could be significant and unevenly distributed across sectors and regions (see figure). This is consistent with the 2018 findings of the U.S. Global Change Research Program's Fourth National Climate Assessment, which concluded, among other things, that the continued increase in the frequency and extent of high-tide flooding due to sea level rise threatens America's trillion-dollar coastal infrastructure. Information about the potential economic effects of climate change could inform decision makers about significant potential damages in different U.S. sectors or regions. According to prior GAO work, this information could help decision makers identify significant climate risks as an initial step toward managing them. The federal government faces fiscal exposure from climate change risks in several areas, including: Disaster aid: due to the rising number of natural disasters and increasing reliance on federal assistance. GAO has previously reported that the federal government's fragmented and reactive approach to funding disaster resilience presented challenges to effective reduction of climate-related risks. GAO has also reported that, due to an artificially low indicator for determining a jurisdiction's ability to respond to disasters that was set in 1986, the Federal Emergency Management Agency risks recommending federal assistance for jurisdictions that could recover on their own. Federal insurance for property and crops: due, in part, to the vulnerability of insured property and crops to climate change impacts. Federal flood and crop insurance programs were not designed to generate sufficient funds to fully cover all losses and expenses. The flood insurance program, for example, was about $21 billion in debt to the Treasury as of April 2019. Further, the Congressional Budget Office estimated in May 2019 that federal crop insurance would cost the federal government an average of about $8 billion annually from 2019 through 2029. Operation and management of federal property and lands: due to the hundreds of thousands of federal facilities and millions of acres of land that could be affected by a changing climate and more frequent extreme events. For example, in 2018, Hurricane Michael devastated Tyndall Air Force Base in Florida, with a preliminary repair estimate of $3 billion. As we reported in October 2019, our past work shows an absence of government-wide strategic planning for climate change. Specifically, our past work has identified limitations related to strategic planning for climate change that includes a lack of coordination, prioritization, and consolidation of strategic priorities. In our March 2019 High-Risk Update, we assessed the federal government's progress since 2017 related to climate change strategic planning against five criteria and found that the federal government had not met any of the criteria for removal from the high-risk list. Federal investments in resilience to reduce fiscal exposures have been limited. As GAO has reported, enhancing resilience can reduce fiscal exposure by reducing or eliminating long-term risk to people and property from natural hazards. For example, a 2018 interim report by the National Institute of Building Sciences estimated approximate benefits to society in excess of costs for several types of resilience projects. While precise benefits are uncertain, the report estimated that for every dollar invested in designing new buildings to particular design standards, society could accrue benefits amounting to about $11 on average. GAO's March 2019 High-Risk report identified a number of recommendations GAO has made related to fiscal exposure to climate change. The federal government could reduce its fiscal exposure by implementing these recommendations. Among GAO's key government-wide recommendations are: Entities within the Executive Office of the President (EOP) should work with partners to establish federal strategic climate change priorities that reflect the full range of climate-related federal activities; Entities within EOP should use information on potential economic effects from climate change to help identify significant climate risks and craft appropriate federal responses; Entities within EOP should designate a federal entity to develop and update a set of authoritative climate observations and projections for use in federal decision making, and create a national climate information system with defined roles for federal agencies and certain nonfederal entities; and The Department of Commerce should convene federal agencies to provide the best-available forward-looking climate information to organizations that develop standards and building codes to enhance infrastructure resilience. Further, in October 2019, GAO reported that Congress could consider establishing a federal organizational arrangement to periodically identify and prioritize climate resilience projects for federal investment. GAO also issued the Disaster Resilience Framework to serve as a guide for analysis of federal action to facilitate and promote resilience to natural disasters, including resilience to climate change.


Since 2007, the FAA has provided more than $37 billion in grants to airports to fund capital development and is responsible for ensuring compliance with requirements airports assume when they accept these grants. One such requirement is that the airports provide users equal access to airport services such as fueling and parking. Recently, an industry group and pilots raised concerns about the transparency and reasonableness of prices charged for these and other services at airports. GAO was asked to examine FBOs' pricing and FAA's oversight of related airport grant assurances. This report examines: (1) the transparency of FBO prices, (2) the factors that influence prices, and (3) the extent to which FAA ensures compliance with federal airport grant assurances related to FBO activities. GAO analyzed FAA data related to complaints from 2013 through 2018 and reviewed relevant literature, key laws and regulations, and program documentation. GAO developed a statistical model to analyze variation in fuel prices across airports in the contiguous United States. GAO interviewed FAA compliance staff at headquarters and all regional offices, as well as a non-probability selection of stakeholders. Fixed base operators (FBO) at airports (see figure) offer a variety of services to pilots and passengers. While anyone can view fuel prices offered by FBOs online, other service fees, such as for aircraft parking, can vary by type of aircraft and are not always available online, although they can be obtained by calling the FBO. Recently, industry groups developed the “Know Before You Go” campaign that calls for greater transparency of FBO prices. Some of the FBOs GAO interviewed list their fees online; however, others do not. Stakeholders GAO interviewed––including general aviation pilots, airports, FBOs, and industry groups––said FBOs' costs to build and maintain facilities—such as hangars and fueling facilities—as well as operating expenses such as labor and fuel––influence their prices. Stakeholders also said that demand for FBOs' services can influence prices, such as when seasonal demand affects operations at an airport near a ski resort. Finally, they also said that competition affects FBO's prices. GAO's statistical model confirmed a correlation between many cost and demand factors and aviation fuel prices and found higher prices at airports with higher costs and demand. This model also found that on-airport competition is associated with lower prices at the country's busiest airports: Prices for aviation fuels were lower at such airports with more than one FBO. However, not all airports can support more than one FBO due to, for example, the amount of business each gets. Airports receiving Federal Aviation Administration (FAA) grants must meet “grant assurances” such as charging reasonable and not unjustly discriminatory prices for services, including prices charged by FBOs. FAA officials said FAA oversight relies on (1) airports' consent to adhere to grant assurances; (2) training and outreach; and (3) complaints. Since 2013, in complaints received by FAA, GAO found few complaints about FBOs' prices. GAO found each regional office independently records additional inquiries. FAA is moving to collect regional inquires centrally, and by 2020 that step may allow FAA to stay abreast of apparent nationwide trends or issues with any grant assurance concerns.