Improved CMS Oversight Is Needed to Better Protect Residents from Abuse In our June 2019 report, we found that, while abuse deficiencies cited in nursing homes were relatively rare from 2013 through 2017, they became more frequent during that time, with the largest increase in severe cases. Specifically, abuse deficiencies comprised less than 1 percent of the total deficiencies in each of the years we examined, which is likely conservative. Abuse in nursing homes is often underreported by residents, family, staff, and the state survey agency, according to CMS officials and stakeholders we interviewed. However, abuse deficiencies more than doubled—from 430 in 2013 to 875 in 2017—over the 5-year period. (See appendix II.) In addition, abuse deficiencies cited in 2017 were more likely to be categorized at the highest levels of severity— deficiencies causing actual harm to residents or putting residents in immediate jeopardy—than they were in 2013. In light of the increased number and severity of abuse deficiencies, it is imperative that CMS have strong nursing home oversight in place to protect residents from abuse; however, we found oversight gaps that may limit the agency’s ability to do so. Specifically, we found that CMS: (1) cannot readily access data on the type of abuse or type of perpetrator, (2) has not provided guidance on what information nursing homes should include in facility-reported incidents, and (3) has numerous gaps in its referral process that can result in delayed and missed referrals to law enforcement. Information on Abuse and Perpetrator Types Is Not Readily Available In our June 2019 report, we found that CMS’s data do not allow for the type of abuse or perpetrator to be readily identified by the agency. Specifically, CMS does not require the state survey agencies to record abuse and perpetrator type and, when this information is recorded, it cannot be easily analyzed by CMS. Therefore, we reviewed a representative sample of 400 CMS narrative descriptions—written by state surveyors—associated with abuse deficiencies cited in 2016 and 2017 to identify the most common types of abuse and perpetrators. From this review, we found that physical abuse (46 percent) and mental/verbal abuse (44 percent) occurred most often in nursing homes, followed by sexual abuse (18 percent). Furthermore, staff, which includes those working in any part of the nursing home, were more often the perpetrators (58 percent) of abuse in deficiency narratives, followed by resident perpetrators (30 percent) and other types of perpetrators (2 percent). (See appendix III for examples from our abuse deficiency narrative review.) CMS officials told us they have not conducted a systematic review to gather information on abuse and perpetrator type. Further, based on professional experience, literature, and ad hoc analyses of deficiency narrative descriptions, CMS officials told us they believe the majority of abuse is committed by nursing home residents and that physical and sexual abuse were the most common types. This understanding does not align with our findings on the most common types of abuse and perpetrators represented in CMS’s data on deficiencies cited as abuse. Without the systematic collection and monitoring of specific abuse and perpetrator data, CMS lacks key information and, therefore, cannot take actions—such as tailoring prevention and investigation activities—to address the most prevalent types of abuse or perpetrators. To address this, we recommended that CMS require state survey agencies to report abuse and perpetrator type in CMS’s databases for deficiency, complaint, and facility-reported incident data and that CMS systematically assess trends in these data. HHS concurred with our recommendation and stated that it plans to implement changes in response. As of November 2019, HHS had not implemented the recommendation. Facility-Reported Incidents Lack Key Information Despite federal law requiring nursing homes to self-report allegations of abuse and covered individuals to report reasonable suspicions of crimes against residents, in June 2019 we reported that CMS had not provided guidance to nursing homes on what information they should include in facility-reported incidents, contributing to a lack of information for state survey agencies and delays in their investigations. Specifically, officials from each of the five state survey agencies told us that the documentation they receive from nursing homes for facility-reported incidents can lack key information that affects their ability to triage incidents and determine whether an investigation should occur and, if so, how soon. For example, officials from two state survey agencies we interviewed said they sometimes have to conduct significant follow-up with the nursing homes to obtain the information they need to prioritize the incident for investigation—follow-up that delays and potentially negatively affects investigations. Incomplete incident reports from nursing homes are particularly problematic given that nearly half of abuse deficiencies cited between 2013 and 2017 were identified through facility-reported incidents, which is dramatically different than the approximately 5 percent of all types of deficiencies that were identified in this manner. Therefore, facility-reported incidents play a unique and significant role in identifying abuse deficiencies in nursing homes, making it critical that incident reports provided by nursing homes include the information necessary for state survey agencies to prioritize and investigate. To address this issue, we recommended that CMS develop and disseminate guidance— including a standardized form—to all state survey agencies on the information nursing homes and covered individuals should include on facility-reported incidents. HHS concurred with our recommendation and stated that it plans to implement changes in response. As of November 2019, HHS had not implemented the recommendation. Gaps Exist in CMS Process for State Survey Agency Referrals to Law Enforcement and MFCUs In June 2019, we identified gaps in CMS’s process for referring incidents of abuse to law enforcement and, if appropriate, to MFCUs. These gaps may limit CMS’s ability to ensure that nursing homes meet federal requirements for residents to be free from abuse. Specifically, we identified issues related to (1) referring abuse to law enforcement in a timely manner, (2) tracking abuse referrals, (3) defining what it means to substantiate an allegation of abuse—that is, the determination by the state survey agency that evidence supports the abuse allegation, and (4) sharing information with law enforcement. We made recommendations that CMS address each of these four gaps in the referral process, and HHS concurred with each recommendation and stated that it plans to implement changes in response. As of November 2019, HHS had not implemented these recommendations. One of the gaps in CMS’s process is related to referring abuse to law enforcement in a timely manner. For example, law enforcement investigations can be significantly delayed because CMS requires a state survey agency to make referrals to law enforcement only after abuse is substantiated—a process that can often take weeks or months. Officials from one law enforcement agency and two MFCUs we interviewed told us the delay in receiving referrals limits their ability to collect evidence and prosecute cases—for example, bedding associated with potential sexual abuse may have been washed, and a victim’s wounds may have healed. As such, we recommended that CMS require state survey agencies to immediately refer to law enforcement any reasonable suspicion of a crime against a resident. HHS concurred with our recommendation and stated that it plans to implement changes in response. As of November 2019, HHS had not implemented this recommendation. In conclusion, while nursing home abuse is relatively rare, our June 2019 report shows that abuse deficiencies cited in nursing homes are becoming more frequent, with the largest increase in severe cases. It is imperative that CMS have more complete and readily available information on abuse to improve its oversight of nursing homes. It is also essential that CMS require state survey agencies to immediately report incidents to law enforcement if they have a reasonable suspicion that a crime against a resident has occurred in order to ensure a prompt investigation of these incidents. Chairman Neal, Ranking Member Brady, and Members of the Committee, this concludes GAO’s statement for the record. GAO Contact and Staff Acknowledgments For further information about this statement, please contact John E. Dicken at (202) 512-7114 or dickenj@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement. In addition to the contact named above, key contributors to this statement were Karin Wallestad (Assistant Director), Sarah-Lynn McGrath (Analyst-in-Charge) and Summar C. Corley. Also contributing to the underlying report for this statement were Luke Baron, Julianne Flowers, Laurie Pachter, Vikki Porter, Kathryn Richter, and Jennifer Whitworth. Appendix I: Summary of GAO Reports on the Health and Welfare of the Elderly We have issued a number of reports reviewing the health and welfare of the elderly in multiple settings. For example, since January 2015, we have issued reports on the incidence of abuse in nursing homes and what is known about the incidence of abuse in assisted living facilities. Reports often included key recommendations. (See table 1.) Appendix II: Severity of Abuse Deficiencies Cited in Nursing Homes, 2013 through 2017 Appendix II: Severity of Abuse Deficiencies Cited in Nursing Homes, 2013 through 2017 CMS restructured its deficiency code system beginning on November 28, 2017. Due to these coding changes, we did not analyze CMS data cited by surveyors after the implementation of that change. Percentages may not add to 100 due to rounding. Appendix III: Examples from a Representative Sample of Nursing Home Abuse Deficiency Narratives, 2016-2017 Related GAO Reports Elder Abuse: Federal Requirements for Oversight in Nursing Homes and Assisted Living Facilities Differ. GAO-19-599. Washington, D.C.: August 19, 2019. Nursing Homes: Improved Oversight Needed to Better Protect Residents from Abuse. GAO-19-433. Washington, D.C.: June 13, 2019. Elder Justice: Goals and Outcome Measures Would Provide DOJ with Clear Direction and a Means to Assess Its Efforts. GAO-19-365. Washington, D.C.: June 7, 2019. Management Report: CMS Needs to Address Gaps in Federal Oversight of Nursing Home Abuse Investigations That Persisted in Oregon for at Least 15 Years. GAO-19-313R. Washington, D.C.: April 15, 2019. Medicaid Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare is Needed. GAO-18-179. Washington, D.C.: January 5, 2018. Medicaid Managed Care: CMS Should Improve Oversight of Access and Quality in States’ Long-Term Services and Supports Programs. GAO-17- 632. Washington, D.C.: August 14, 2017. Medicaid Personal Care Services: CMS Could Do More to Harmonize Requirements across Programs. GAO-17-28. Washington, D.C.: November 23, 2016. Nursing Homes: Consumers Could Benefit from Improvements to the Nursing Home Compare Website and Five-Star Quality Rating System. GAO-17-61. Washington, D.C.: November 18, 2016. Elder Abuse: The Extent of Abuse by Guardians is Unknown, but Some Measures Exist to Help Protect Older Adults. GAO-17-33. Washington, D.C.: November 16, 2016. Skilled Nursing Facilities: CMS Should Improve Accessibility and Reliability of Expenditure Data. GAO-16-700. Washington, D.C.: September 7, 2016. Nursing Home Quality: CMS Should Continue to Improve Data and Oversight. GAO-16-33. Washington, D.C.: October 30, 2015. Antipsychotic Drug Use: HHS Has Initiatives to Reduce Use among Older Adults in Nursing Homes, but Should Expand Efforts to Other Settings. GAO-15-211. Washington, D.C.: January 30, 2015. This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.


Information on the Potential Economic Effects of Climate Change in the United States Could Help Federal Decision Makers Better Manage Climate Risks We reported in September 2017 that while estimates of the economic effects of climate change are imprecise due to modeling and information limitations, they can convey useful insight into broad themes about potential damages in the United States. We also reported that according to the two national-scale studies available at the time that examined the economic effects of climate change across U.S. sectors, potential economic effects could be significant and these effects will likely increase over time for most of the sectors analyzed. For example, for 2020 through 2039, one of the studies estimated from $4 billion to $6 billion in annual coastal property damages from sea level rise and more frequent and intense storms. In addition, the national-scale studies we reviewed and several experts we interviewed for the September 2017 report suggested that potential economic effects could be unevenly distributed across sectors and regions. For example, one of the studies estimated that the Southeast, Midwest, and Great Plains regions will likely experience greater combined economic effects than other regions, largely because of coastal property damage in the Southeast and changes in crop yields in the Midwest and Great Plains (see fig. 1). This is consistent with the findings of the Fourth National Climate Assessment. For example, according to that assessment, the continued increase in the frequency and extent of high- tide flooding due to sea level rise threatens America’s trillion-dollar coastal property market and public infrastructure sector. As we reported in September 2017, information on the potential economic effects of climate change could help federal decision makers better manage climate risks, according to leading practices for climate risk management, economic analysis we reviewed, and the views of several experts we interviewed. For example, such information could inform decision makers about significant potential damages in different U.S. sectors or regions. According to several experts and our prior work, this information could help federal decision makers identify significant climate priorities as an initial step toward managing climate risks. Such a first step is consistent with leading practices for climate risk management and federal standards for internal control. For example, leading practices from the National Academies call for climate change risk management efforts that focus on where immediate attention is needed. As noted in our September 2017 report, according to a 2010 National Academies report, other literature we reviewed, and several experts we interviewed, to make informed choices, decision makers need more comprehensive information on economic effects to better understand the potential costs of climate change to society and begin to develop an understanding of the benefits and costs of different options for managing climate risks. The Federal Government Faces Fiscal Exposure from Climate Change Risks, but Our Past Work Shows an Absence of Government-Wide Strategic Planning The federal government faces fiscal exposure from climate change risks in a number of areas, and this exposure will likely increase over time, as we concluded in September 2017. In the March 2019 update to our High-Risk List, we summarized our previous work that identified several of these areas across the federal government, including programs related to the following: Disaster aid. The rising number of natural disasters and increasing reliance on federal assistance are a key source of federal fiscal exposure, and this exposure will likely continue to rise. Since 2005, federal funding for disaster assistance has been at least $450 billion. In September 2018, we reported that four hurricane and wildfire disasters in 2017 created an unprecedented demand for federal disaster resources and that Hurricanes Harvey, Irma, and Maria ranked among the top five costliest hurricanes on record. Subsequently, the fall of 2018 brought additional catastrophic disasters such as Hurricanes Florence and Michael and devastating California wildfires, with further needs for federal disaster assistance. Disaster costs are projected to increase as certain extreme weather events become more frequent and intense due to climate change—as USGCRP observed and projected. We reported in July 2015 that the federal government’s fragmented and reactive approach to funding disaster resilience presented challenges to effective reduction of climate-related risks. In addition, our prior work found that the Federal Emergency Management Agency’s (FEMA) primary indicator for determining whether to recommend that a jurisdiction receive disaster assistance—which was set in 1986—is artificially low because it does not accurately reflect the ability of state and local governments to respond to disasters. Without an accurate assessment of a jurisdiction’s capability to respond to a disaster without federal assistance, we found that FEMA runs the risk of recommending that the President award federal assistance to jurisdictions that have the capability to respond and recover on their own. Federal insurance for property and crops. The National Flood Insurance Program (NFIP) and the Federal Crop Insurance Corporation are sources of federal fiscal exposure due, in part, to the vulnerability of insured property and crops to climate change. These programs provide coverage where private markets for insurance do not exist, typically because the risk associated with the property or crops is too great to privately insure at a cost that buyers are willing to accept. From 2013 to 2017, losses paid under NFIP and the federal crop insurance program totaled $51.3 billion. Federal flood and crop insurance programs were not designed to generate sufficient funds to fully cover all losses and expenses, which means the programs need budget authority from Congress to operate. NFIP, for example, was about $21 billion in debt to the Department of 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. The federal government owns and operates hundreds of thousands of facilities and manages millions of acres of land that could be affected by a changing climate and represent a significant federal fiscal exposure. For example, the Department of Defense (DOD) owns and operates domestic and overseas infrastructure with an estimated replacement value of about $1 trillion. In September 2018, Hurricane Florence damaged Camp Lejeune and other Marine Corps facilities in North Carolina, resulting in a preliminary Marine Corps repair estimate of $3.6 billion. One month later, Hurricane Michael devastated Tyndall Air Force Base in Florida, resulting in a preliminary Air Force repair estimate of $3 billion and upwards of 5 years to complete the work. In addition, we recently reported that the federal government manages about 650 million acres of land in the United States that could be vulnerable to climate change, including the possibility of more frequent and severe droughts and wildfires. Appropriations for federal wildland fire management activities have increased considerably since the 1990s, as we and the Congressional Research Service have reported. As we reported in October 2019, our past work shows an absence of government-wide strategic planning for climate change. Specifically, our past work identifies limitations related to strategic planning for climate change that include a lack of coordination, prioritization, and consolidation of strategic priorities. For example, we reported in October 2009 that the federal government’s emerging climate resilience activities were carried out in an ad hoc manner and were not well coordinated across federal agencies. In May 2011, we reported that federal officials did not have a shared understanding of strategic government-wide priorities related to climate change. In the same report, we found that there was not a consolidated set of strategic priorities integrating climate change programs and activities across the federal government. In our March 2019 High-Risk Update, we 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 our 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. Specifically, since our 2017 high-risk update, four ratings regressed to “not met” and one remained unchanged as “not met.” (See fig. 2.) We have made 62 recommendations related to the climate change high-risk area, 17 of which address improving federal climate change strategic planning. As of August 2019, no action had been taken toward 14 of those 17 recommendations—one dating back to 2003. Federal Investments in Resilience to Climate Change Impacts Have Been Limited Although the federal government faces fiscal exposure to climate change, its investments in resilience to climate change impacts have been limited. One way to reduce federal fiscal exposure is to enhance resilience by reducing or eliminating long-term risk to people and property from natural hazards. For example, in September 2018 we reported that elevated homes and strengthened building codes in Texas and Florida prevented greater damages during the 2017 hurricane season. In addition, one company participating in a 2014 forum we held on preparing for climate- related risks noted that for every dollar it invested in resilience efforts, the company could prevent $5 in potential losses. Finally, a 2018 interim report by the National Institute of Building Sciences examined a sample of federal grants for hazard mitigation. The interim report estimated approximate benefits to society (i.e., homeowners and communities) in excess of costs for several types of resilience projects through the protection of lives and property, and prevention of other losses, though precise benefits are uncertain. According to the interim report, for every grant dollar the federal government spent on resilience projects, over time, society is estimated to accrue benefits amounting to the following: About $3 on average from projects addressing the effects of fire in the wildland urban interface, with most benefits (approximately 70 percent) coming from the protection of property (i.e., avoiding property losses). About $5 on average from projects to address hurricane-force and tornado-force winds, with most benefits (approximately 90 percent) coming from the protection of lives. This includes avoiding deaths, nonfatal injuries, and causes of posttraumatic stress. About $7 on average from projects that buy out buildings prone to riverine flooding, with most benefits (approximately 65 percent) coming from the protection of property. The interim report also projected that society could accrue benefits amounting to about $11 on average for every dollar invested in designing new buildings to meet the 2018 International Building Code and the 2018 International Residential Code—the model building codes that the International Code Council developed—with most benefits (46 percent) coming from the protection of property. We reported in October 2009 that the federal government’s activities to build resilience to climate change were carried out in an ad hoc manner and were not well coordinated across federal agencies. We reported similar findings in October 2019. Federal agencies have included some of these activities within existing programs and operations—a concept known as mainstreaming. For example, the Fourth National Climate Assessment reported that the U.S. military integrates climate risks into its analysis, plans, and programs, with particular attention paid to climate effects on force readiness, military bases, and training ranges. However, according to the Fourth National Climate Assessment, while a significant portion of climate risk can be addressed by mainstreaming, the practice may reduce the visibility of climate resilience relative to dedicated, stand-alone approaches and may prove insufficient to address the full range of climate risks. In addition, as we reported in March 2019, the Disaster Recovery Reform Act of 2018 (DRRA) was enacted in October 2018 and could improve state and local resilience to disasters. DRRA, among other things, allows the President to set aside, with respect to each major disaster, a percentage of the estimated aggregate amount of certain grants to use for predisaster hazard mitigation and makes federal assistance available to state and local governments for building code administration and enforcement. However, it is too early to tell what impact implementing the act will have on state and local resilience. The federal government has made some limited investments in resilience, and DRRA could enable additional improvements at the state and local levels. However, we reported in October 2019 that the federal government does not have a strategic approach for investing in climate resilience projects—that is, an intentional, crosscutting approach in which the federal government identifies and prioritizes projects for the purpose of enhancing climate resilience. Federal agencies may take actions to invest in projects with potential climate resilience benefits related to their own mission areas using funds from federal programs designed for other purposes. In addition, the National Climate Assessment provides high- level information on what is known about observed and projected climate risks in the United States. However, no federal entity looks holistically at the federal government’s investments to strategically prioritize projects to ensure that they address the nation’s most significant climate risks and provide the highest net benefits relative to other potential projects. Further, we reported in September 2017 that the federal government had not undertaken strategic government-wide planning to manage significant climate risks before they become fiscal exposures. As an initial step in managing climate risks, most of the experts we interviewed for the September 2017 report told us that federal decision makers should prioritize risk management efforts on significant climate risks that create the greatest fiscal exposure. Moreover, several stakeholders told us that the federal government’s emphasis has been on funding postdisaster efforts instead of funding resilience projects before a disaster occurs. This is consistent with findings from our July 2015 report that most federal funding for hazard mitigation is only available after a disaster. In addition, according to FEMA officials, some of the agency’s hazard mitigation programs are designed to empower state and local governments to determine their mitigation funding priorities, and these state and local priorities may or may not align with the federal interest. Finally, although we did not identify a government-wide strategic approach specifically for investing in climate resilience projects, the National Mitigation Investment Strategy—a national effort under way to plan for predisaster resilience investments—represents a potential cross- agency vehicle for climate resilience planning. However, the strategy does not specifically address climate change or identify and prioritize specific climate resilience projects. The Federal Government Could Reduce Its Fiscal Exposure by Focusing and Coordinating Federal Efforts As we reported in March 2019, the federal government could reduce its fiscal exposure to climate change by focusing and coordinating federal efforts. However, the federal government is currently not well organized to address the fiscal exposure presented by climate change, partly because of the inherently complicated and crosscutting nature of the issue. We have made a total of 62 recommendations related to limiting the federal government’s fiscal exposure to climate change over the years, 12 of which have been made since February 2017. As of December 2018, 25 of these recommendations remained open. In describing what needs to be done to reduce federal fiscal exposure to climate change, our March 2019 High-Risk Report discusses many of the open recommendations.Implementing these recommendations could help reduce federal fiscal exposure. Several of them, including those highlighted below, identify key government-wide efforts needed to help plan for and manage climate risks and direct federal efforts toward common goals, such as improving resilience. Develop a national strategic plan: In May 2011, we recommended that appropriate entities within the Executive Office of the President (EOP), including the Office of Management and Budget, work with agencies and interagency coordinating bodies to establish federal strategic climate change priorities that reflect the full range of climate- related federal activities, including roles and responsibilities of key federal entities. Use economic information to identify and respond to significant climate risks: In September 2017, we recommended that the appropriate entities within EOP use information on the potential economic effects of climate change to help identify significant climate risks facing the federal government and craft appropriate federal responses. Such federal responses could include establishing a strategy to identify, prioritize, and guide federal investments to enhance resilience against future disasters. Provide decision makers with the best-available climate information: In November 2015, we reported that federal efforts to provide information about climate change impacts did not fully meet the climate information needs of federal, state, local, and private sector decision makers, which hindered their efforts to plan for climate change risks. We reported that these decision makers would benefit from a national climate information system that would develop and update authoritative climate observations and projections specifically for use in decision-making. As a result, we recommended that EOP (1) designate a federal entity to develop and periodically update a set of authoritative climate observations and projections for use in federal decision-making, which other decision makers could also access, and (2) designate a federal entity to create a national climate information system with defined roles for federal agencies and nonfederal entities with existing statutory authority. Consider climate information in design standards: In November 2016, we reported that design standards, building codes, and voluntary certifications established by standards-developing organizations play a role in ensuring the resilience of infrastructure to the effects of natural disasters. However, we reported that these organizations faced challenges in using forward-looking climate information that could help enhance the resilience of infrastructure. As a result, we recommended in the November 2016 report that the Department of Commerce (Commerce), acting through the National Institute of Standards and Technology—which is responsible for coordinating federal participation in standards organizations— convene federal agencies for an ongoing government-wide effort to provide the best-available forward-looking climate information to standards-developing organizations for their consideration in the development of design standards, building codes, and voluntary certifications. In addition, in October 2019, we recommended that Congress consider establishing a federal organizational arrangement to periodically identify and prioritize climate resilience projects for federal investment. We also identified six key steps the federal government could use to prioritize climate resilience investments and opportunities to increase the climate resilience impacts of federal funding options that Congress could use in designing the arrangement. In October 2019 we also issued the Disaster Resilience Framework to serve as a guide for analysis of federal action to facilitate and promote resilience to natural disasters. The framework identifies three key principles that can help federal efforts to promote disaster resilience, including building resilience to climate change. First, authoritative and understandable information can help decision makers identify current and future risks and the impact of risk-reduction strategies. Second, integrated analysis and strategic planning can help decision makers take coherent and coordinated resilience actions. Third, financial and nonfinancial incentives can help make long-term, forward-looking risk-reduction investments more viable and attractive among competing priorities. In conclusion, the effects of climate change have already posed and will continue to pose risks that can create fiscal exposure across the federal government, and this exposure will continue to increase. The federal government does not generally account for such fiscal exposure to programs in the budget process, and it has not undertaken strategic efforts to manage significant climate risks that could reduce the need for far more costly steps in the decades to come. To reduce its fiscal exposure, the federal government needs a cohesive strategic approach with strong leadership and the authority to manage risks across the entire range of related federal activities. The federal government could make further progress toward reducing fiscal exposure by implementing the recommendations we have made. Chairman Rouda, Ranking Member Comer, and Members of the Subcommittee, this completes my prepared statement. I would be pleased to respond to any questions that you may have at this time. GAO Contact and Staff Acknowledgments If you or your staff have any questions about this testimony, please contact J. Alfredo Gómez, Director, Natural Resources and Environment, at (202) 512-3841or gomezj@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement. GAO staff who made key contributions to this testimony are Joseph Dean Thompson (Assistant Director), Micah McMillan (Analyst in Charge), Holly Halifax, Caitlin Jackson, Richard Johnson, Joe Maher, Oliver Richard, and Kiki Theodoropoulos. This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.


Information on the Potential Economic Effects of Climate Change in the United States Could Help Federal Decision Makers Better Manage Climate Risks We reported in September 2017 that, while estimates of the economic effects of climate change are imprecise due to modeling and information limitations, they can convey useful insight into broad themes about potential damages in the United States. We reported that, according to the two national-scale studies available at the time that examined the economic effects of climate change across U.S. sectors, potential economic effects could be significant and these effects will likely increase over time for most of the sectors analyzed. For example, for 2020 through 2039, one of the studies estimated from $4 billion to $6 billion in annual coastal property damages from sea level rise and more frequent and intense storms. In addition, the national-scale studies we reviewed and several experts we interviewed for the September 2017 report suggested that potential economic effects could be unevenly distributed across sectors and regions. For example, one of the studies estimated that the Southeast, Midwest, and Great Plains regions will likely experience greater combined economic effects than other regions, largely because of coastal property damage in the Southeast and changes in crop yields in the Midwest and Great Plains (see figure 1). This is consistent with the findings of the Fourth National Climate Assessment. For example, according to that assessment, the continued increase in the frequency and extent of high-tide flooding due to sea level rise threatens America’s trillion-dollar coastal property market and public infrastructure sector. As we reported in September 2017, information on the potential economic effects of climate change could help federal decision makers better manage climate risks, according to leading practices for climate risk management, economic analysis we reviewed, and the views of several experts we interviewed. For example, such information could inform decision makers about significant potential damages in different U.S. sectors or regions. According to several experts and our prior work, this information could help federal decision makers identify significant climate priorities as an initial step toward managing climate risks. Such a first step is consistent with leading practices for climate risk management and federal standards for internal control. For example, leading practices from the National Academies call for climate change risk management efforts that focus on where immediate attention is needed. As noted in our September 2017 report, according to a 2010 National Academies report, other literature we reviewed, and several experts we interviewed, to make informed choices, decision makers need more comprehensive information on economic effects to better understand the potential costs of climate change to society and begin to develop an understanding of the benefits and costs of different options for managing climate risks. The Federal Government Faces Fiscal Exposure from Climate Change Risks, but Does Not Have Certain Information Needed to Help Make Budget Decisions The federal government faces fiscal exposure from climate change risks in a number of areas, and this exposure will likely increase over time, as we concluded in September 2017. In the March 2019 update to our High-Risk List, we summarized our previous work that identified several of these areas across the federal government, including programs related to the following: Disaster aid. The rising number of natural disasters and increasing reliance on federal assistance are a key source of federal fiscal exposure, and this exposure will likely continue to rise. Since 2005, federal funding for disaster assistance is at least $450 billion. In September 2018, we reported that four hurricane and wildfire disasters in 2017 created an unprecedented demand for federal disaster resources and that hurricanes Harvey, Irma, and Maria ranked among the top five costliest hurricanes on record. Subsequently, the fall of 2018 brought additional catastrophic disasters such as Hurricanes Florence and Michael and devastating California wildfires, with further needs for federal disaster assistance. Disaster costs are projected to increase as certain extreme weather events become more frequent and intense due to climate change—as observed and projected by USGCRP. In July 2015, we reported that the federal government does not adequately plan for disaster resilience and that most federal funding for hazard mitigation is available after a disaster. In addition, our prior work found that the Federal Emergency Management Agency’s (FEMA) indicator for determining whether to recommend that a jurisdiction receive disaster assistance—which was set in 1986—is artificially low because it does not accurately reflect the ability of state and local governments to respond to disasters. Without an accurate assessment of a jurisdiction’s capability to respond to a disaster without federal assistance, we found that FEMA runs the risk of recommending that the President award federal assistance to jurisdictions that have the capability to respond and recover on their own. Federal insurance for property and crops. The National Flood Insurance Program (NFIP) and the Federal Crop Insurance Corporation are sources of federal fiscal exposure due, in part, to the vulnerability of the insured property and crops to climate change. These programs provide coverage where private markets for insurance do not exist, typically because the risk associated with the property or crops is too great to privately insure at a cost that buyers are willing to accept. From 2013 to 2017, losses paid under NFIP and the federal crop insurance program totaled $51.3 billion. Federal flood and crop insurance programs were not designed to generate sufficient funds to fully cover all losses and expenses, which means the programs need budget authority from Congress to operate. The NFIP, 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. The federal government owns and operates hundreds of thousands of facilities and manages millions of acres of land that could be affected by a changing climate and represent a significant federal fiscal exposure. For example, the Department of Defense (DOD) owns and operates domestic and overseas infrastructure with an estimated replacement value of about $1 trillion. In September 2018, Hurricane Florence damaged Camp Lejeune and other Marine Corps facilities in North Carolina, resulting in a preliminary Marine Corps repair estimate of $3.6 billion. One month later, Hurricane Michael devastated Tyndall Air Force Base in Florida, resulting in a preliminary Air Force repair estimate of $3 billion and upwards of 5 years to complete the work. In addition, we recently reported that the federal government manages about 650 million acres of land in the United States that could be vulnerable to climate change, including the possibility of more frequent and severe droughts and wildfires. Appropriations for federal wildland fire management activities have increased considerably since the 1990s, as we and the Congressional Research Service have reported. Although the federal government faces fiscal exposure from climate change across the nation, it does not have certain information needed by policymakers to help understand the budgetary impacts of such exposure. We have previously reported that the federal budget generally does not account for disaster assistance provided by Congress—which can reach tens of billions of dollars for some disasters—or the long-term impacts of climate change on existing federal infrastructure and programs. For Example, as we reported in April 2018, the Office of Management and Budget’s (OMB) climate change funding reports we reviewed did not include funding information on federal programs with significant fiscal exposures to climate change identified by OMB and others—such as domestic disaster assistance, flood insurance, and crop insurance. A more complete understanding of climate change fiscal exposures can help policymakers anticipate changes in future spending and enhance control and oversight over federal resources, as we reported in October 2013. For budget decisions for federal programs with fiscal exposure to climate change, we found in the April 2018 report that information that could help provide a more complete understanding would include: (1) costs to repair, replace, and improve the weather- related resilience of federally-funded property and resources; (2) costs for federal flood and crop insurance programs; and (3) costs for disaster assistance programs, among other identified areas of fiscal exposure to climate change. To help policymakers better understand the trade-offs when making spending decisions, we recommended in the April 2018 report that OMB provide information on fiscal exposures related to climate change in conjunction with future reports on climate change funding. Federal Investments in Resilience to Climate Change Impacts Have Been Limited Although the federal government faces fiscal exposure to climate change, its investments in resilience to climate change impacts have been limited. One way to reduce federal fiscal exposure is to enhance resilience by reducing or eliminating long-term risk to people and property from natural hazards. For example, in September 2018 we reported that elevating homes and strengthened building codes in Texas and Florida prevented greater damages during the 2017 hurricane season. In addition, one company participating in a 2014 forum we held on preparing for climate- related risks noted that for every dollar it invested in resilience efforts, the company could prevent $5 in potential losses. Finally, a 2018 interim report by the National Institute of Building Sciences examined a sample of federal grants for hazard mitigation. The report estimated approximate benefits to society (i.e., homeowners, communities, etc.) in excess of costs for several types of resilience projects through the protection of lives and property, and prevention of other losses. For example, while precise benefits are uncertain, the report estimated that for every grant dollar the federal government spent on resilience projects, over time, society could accrue benefits amounting to the following: About $3 on average from projects addressing fire at the wildland urban interface, with most benefits (69 percent) coming from the protection of property (i.e., avoiding property losses). About $5 on average from projects to address hurricane and tornado force winds, with most benefits (89 percent) coming from the protection of lives. This includes avoiding deaths, nonfatal injuries, and causes of post-traumatic stress. About $7 on average from projects that buy out buildings prone to riverine flooding, with most benefits (65 percent) coming from the protection of property. The interim report also estimated that society could accrue benefits amounting to about $11 on average for every dollar invested in designing new buildings to meet the 2018 International Building Code and the 2018 International Residential Code—the model building codes developed by the International Code Council—with most benefits (46 percent) coming from the protection of property. We reported in October 2009 that the federal government’s activities to build resilience to climate change were carried out in an ad hoc manner and were not well coordinated across federal agencies. Federal agencies have included some of these activities within existing programs and operations—a concept known as mainstreaming. For example, the Fourth National Climate Assessment reported that the U.S. military integrates climate risks into its analysis, plans and programs, with particular attention paid to climate effects on force readiness, military bases, and training ranges. However, according to the Fourth National Climate Assessment, while a significant portion of climate risk can be addressed by mainstreaming, the practice may reduce the visibility of climate resilience relative to dedicated, stand-alone approaches and may prove insufficient to address the full range of climate risks. In addition, as we reported in March 2019, the Disaster Recovery Reform Act of 2018 (DRRA) was enacted in October 2018, which could improve state and local resilience to disasters. DRRA, among other things, allows the President to set aside, with respect to each major disaster, a percentage of the estimated aggregate amount of certain grants to use for pre-disaster hazard mitigation and makes federal assistance available to state and local governments for building code administration and enforcement. However, it is too early to tell what impact the implementation of the act will have on state and local resilience. The federal government has made some limited investments in resilience and DRRA could enable additional improvements at the state and local level. However, we reported in September 2017 that the federal government had not undertaken strategic government-wide planning to manage significant climate risks before they become fiscal exposures. We also reported in July 2015 that the federal government had no comprehensive strategic approach for identifying, prioritizing, and implementing investments for disaster resilience. As an initial step in managing climate risks, most of the experts we interviewed for the September 2017 report told us that federal decision makers should prioritize risk management efforts on significant climate risks that create the greatest fiscal exposure. However, as we reported in our March 2019 High-Risk List, the federal government had not made measurable progress since 2017 to reduce fiscal exposure in several key areas that we have identified. The High-Risk List identified Limiting the Federal Government’s Fiscal Exposure by Better Managing Climate Change Risks as an area needing significant attention because the federal government has regressed in progress toward one of our criterion for removal from the list. The Federal Government Could Reduce Its Fiscal Exposure by Focusing and Coordinating Federal Efforts As we reported in March 2019, the federal government could reduce its fiscal exposure to climate change by focusing and coordinating federal efforts. However, the federal government is currently not well organized to address the fiscal exposure presented by climate change, partly because of the inherently complicated and crosscutting nature of the issue. We have made a total of 62 recommendations related to limiting the federal government’s fiscal exposure to climate change over the years, 12 of which have been made since February 2017. As of December 2018, 25 of these recommendations remained open. In describing what needs to be done to reduce federal fiscal exposure to climate change, our March 2019 High-Risk report discusses many of the open recommendations. Implementing these recommendations could help reduce federal fiscal exposure. Several of them, including those highlighted below, identify key government-wide efforts needed to help plan for and manage climate risks and direct federal efforts toward common goals, such as improving resilience: Develop a national strategic plan: In May 2011, we recommended that appropriate entities within the Executive Office of the President (EOP), including OMB, work with agencies and interagency coordinating bodies to establish federal strategic climate change priorities that reflect the full range of climate-related federal activities, including roles and responsibilities of key federal entities. Use economic information to identify and respond to significant climate risks: In September 2017, we recommended that the appropriate entities within EOP use information on the potential economic effects of climate change to help identify significant climate risks facing the federal government and craft appropriate federal responses. Such federal responses could include establishing a strategy to identify, prioritize, and guide federal investments to enhance resilience against future disasters. Provide decision makers with the best available climate information: In November 2015, we reported that federal efforts to provide information about climate change impacts did not fully meet the climate information needs of federal, state, local, and private sector decision makers, which hindered their efforts to plan for climate change risks. We reported that these decision makers would benefit from a national climate information system that would develop and update authoritative climate observations and projections specifically for use in decision-making. As a result, we recommended that EOP (1) designate a federal entity to develop and periodically update a set of authoritative climate observations and projections for use in federal decision-making, which other decision makers could also access; and (2) designate a federal entity to create a national climate information system with defined roles for federal agencies and nonfederal entities with existing statutory authority. Consider climate information in design standards: In November 2016, we reported that design standards, building codes, and voluntary certifications established by standards-developing organizations play a role in ensuring the resilience of infrastructure to the effects of natural disasters. However, we reported that these organizations faced challenges to using forward-looking climate information that could help enhance the resilience of infrastructure. As a result, we recommended in the November 2016 report that the Department of Commerce, acting through the National Institute of Standards and Technology—which is responsible for coordinating federal participation in standards organizations—convene federal agencies for an ongoing government-wide effort to provide the best available forward-looking climate information to standards-developing organizations for their consideration in the development of design standards, building codes, and voluntary certifications. In conclusion, the effects of climate change have already and will continue to pose risks that can create fiscal exposure across the federal government and this exposure will continue to increase. The federal government does not generally account for such fiscal exposure to programs in the budget process nor has it undertaken strategic efforts to manage significant climate risks that could reduce the need for far more costly steps in the decades to come. To reduce its fiscal exposure, the federal government needs a cohesive strategic approach with strong leadership and the authority to manage risks across the entire range of related federal activities. The federal government could make further progress toward reducing fiscal exposure by implementing the recommendations we have made. Chairman Yarmuth, Ranking Member Womack, and Members of the Committee, this completes my prepared statement. I would be pleased to respond to any questions that you may have at this time. GAO Contact and Staff Acknowledgments If you or your staff have any questions about this testimony, please contact me at (202) 512-3841or gomezj@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement. GAO staff who made key contributions to this testimony are J. Alfredo Gómez (Director), Joseph Dean Thompson (Assistant Director), Anne Hobson (Analyst in Charge), Celia Mendive, Kiki Theodoropoulos, Reed Van Beveren, and Michelle R. Wong. This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.


Background Black Lung Benefits Black lung benefits include both cash assistance and medical benefits. Maximum cash assistance payments ranged from about $660 to $1,320 per month in 2018, depending on a beneficiary’s number of dependents. Miners receiving cash assistance are also eligible for medical benefits that cover the treatment of their black lung-related conditions, which may include hospital and nursing care, rehabilitation services, and drug and equipment charges, according to DOL documentation. DOL estimates that the average annual cost for medical treatment in fiscal year 2018 was approximately $9,667 per miner. There were about 25,600 total beneficiaries (primary and dependents) receiving black lung benefits during fiscal year 2018 (see fig. 1). The number of beneficiaries has decreased over time as a result of declining coal mining employment and an aging beneficiary population, according to DOL officials. Black lung beneficiaries could increase in the near term due to the increased occurrence of black lung disease and its most severe form, progressive massive fibrosis, particularly among Appalachian coal miners, according to National Institute for Occupational Safety and Health (NIOSH) officials. Benefit Adjudication Process Black lung claims are processed by the Division of Coal Mine Workers’ Compensation in the Office of Workers’ Compensation Programs (OWCP) within DOL. Contested claims are adjudicated by DOL’s Office of Administrative Law Judges (OALJ), which issues decisions that can be appealed to DOL’s Benefits Review Board (BRB). Claimants and mine operators may further appeal these agency decisions to the federal courts. If an award is contested, claimants can receive interim benefits, which are generally paid from the Trust Fund according to DOL officials. Final awards are either funded by mine operators—who are identified as the responsible employers of claimants—or the Trust Fund, when responsible employers cannot be identified or do not pay. In fiscal year 2018, black lung claims had an approval rate of about 34 percent, according to DOL data. In 2009, we reported on the benefits adjudication process and made several recommendations for DOL that could improve miners’ ability to pursue claims. An April 2015 DOL Inspector General (IG) report followed up on DOL’s progress on our recommendations and found continuing problems and raised new concerns about the black lung claims and appeals process. For instance, the IG reported that OALJ needed to address staff shortages, improve communication between its headquarters and district offices, and upgrade the training provided to judges and law clerks. To further expedite claim adjudication, the IG recommended, among other things, that OALJ begin hearing more cases remotely using video or telephone hearings to reduce judges’ travel costs and time. In fiscal year 2018, OWCP reported that it took about 335 days on average to issue a decision on a claim. This is an increase from the average of 235 days that OWCP had reported to the DOL IG for fiscal year 2014. Trust Fund Revenue and Expenditures Trust Fund revenue is primarily obtained from mine operators through the coal tax. The current coal tax rates, which took effect in 2019, are $0.50 per ton of underground-mined coal and $0.25 per ton of surface-mined coal, up to 2 percent of the sales price. Coal tax revenue is collected from mine operators by Treasury’s Internal Revenue Service and then transferred to the Trust Fund where it is then used by DOL to pay black lung benefits and the costs of administering the program. Trust Fund expenditures include, among other things, black lung benefit payments, certain administrative costs incurred by DOL and Treasury to administer the black lung benefits program, and debt repayments. When necessary for the Trust Fund to make relevant expenditures under federal law, the Trust Fund borrows from the Treasury’s general fund. When this occurs, the federal government is essentially borrowing from itself—and hence from the taxpayer—to fund its benefit payments and other expenditures. Trust Fund Borrowing Will Likely Continue to Increase through 2050 As we reported in 2018, Trust Fund expenditures have consistently exceeded revenue. The Trust Fund borrowed from Treasury’s general fund almost every year since 1979, its first complete fiscal year. We noted in our 2018 report that Trust Fund borrowing would continue to increase through 2050 due, in part, to the planned coal tax rate decrease of about 55 percent that took effect in 2019 and declining coal production. We simulated the effects of the tax rate decrease on Trust Fund finances through 2050, and reported the results of a moderate case set of assumptions related to future coal production and prices and the number of new black lung beneficiaries. These simulations were not predictions of what will happen, but rather models of what could happen given certain assumptions. Our moderate case simulation suggested that Trust Fund revenue may decrease from about $485 million in fiscal year 2018 to about $298 million in fiscal year 2019, due, in part, to the approximate 55 percent decrease in the coal tax rate. Our simulation, which incorporated EIA data on future expected coal production, also showed that annual Trust Fund revenue would likely continue to decrease beyond fiscal year 2019 due, in part, to declining coal production. Domestic coal production declined from about 1.2 billion tons in 2008 to about 775 million tons in 2017, according to EIA. Based on these projections, our moderate simulation showed that Trust Fund annual revenue may continue to decrease from about $298 million in fiscal year 2019 to about $197 million in fiscal year 2050. Future simulated Trust Fund revenue would likely be insufficient to cover combined black lung benefit payments and administrative costs, according to our moderate case simulation. Specifically, revenue may not be sufficient to cover beneficiary payments and administrative costs from fiscal years 2020 through 2050 (see fig. 2). For instance, in fiscal year 2029, simulated benefit payments and administrative costs would likely exceed simulated revenue by about $99 million. These annual deficits could decrease over time to about $4 million by fiscal year 2050 due, in part, to the assumed continued net decline in total black lung beneficiaries. If Trust Fund spending on benefit payments and administrative costs continues to exceed revenues each year, then the Trust Fund would need to continue borrowing from Treasury’s general fund to cover those costs, as well as borrowing to cover debt repayment. Our moderate simulation suggested that the Trust Fund’s outstanding debt could increase from about $4.2 billion in fiscal year 2019 to about $15.4 billion in fiscal year 2050 (see fig. 3). While our moderate case simulated a $15.4 billion Trust Fund debt in 2050, the amount could vary from about $6 billion to about $27 billion depending, in part, on future coal production and the number of new beneficiaries. Even if the Congress were to completely eliminate black lung benefits as of fiscal year 2019, the Trust Fund’s outstanding debt in fiscal year 2050 could still exceed $6.4 billion, according to our simulation. Eliminating black lung benefits, however, would generally mean that coal tax revenue would be collected solely to fund the repayment of Trust Fund debt. As we reported in 2018, other options such as adjusting the coal tax and forgiving interest or debt, could also reduce future borrowing and improve the Trust Fund’s financial position (see GAO-18-351). Preliminary Observations Raise Concerns About DOL’s Oversight of Coal Mine Operator Insurance Federal law generally requires that coal operators secure their black lung benefit liability. Operators can purchase commercial insurance for this purpose or may self-insure if they meet certain DOL conditions. For example, self-insurers must obtain collateral in the form of an indemnity bond, deposit or trust, or letter of credit in an amount deemed necessary and sufficient by DOL to secure their liability. DOL officials said that the collateral they required from the five self- insured operators that filed for bankruptcy between 2014 and 2016 was inadequate to cover their benefit liabilities. For example, the collateral DOL required from Alpha Natural Resources was about 6 percent of its estimated benefit liability. As a result, approximately $185 million of estimated benefit liability was transferred to the Trust Fund, according to DOL data. We reviewed DOL documentation related to the five operator bankruptcies. Table 1 shows the bankrupt operators; the amount of collateral each operator had at the time of bankruptcy; estimated benefit liability at the time of bankruptcy; and estimated benefit liability and number of beneficiaries that transferred to the Trust Fund, if applicable. Overall, three of these bankruptcies affected the Trust Fund, and two did not according to DOL. DOL officials told us that the bankruptcies of Arch Coal and Peabody Energy did not affect the Trust Fund because their benefit liabilities were assumed by the reorganized companies after emerging from bankruptcy. As of June 2019, there are 22 operators that are self-insured and actively mining coal, according to DOL officials. To ensure that the collateral they required from these operators was adequate to protect the Trust Fund, DOL officials said that they periodically reauthorized them which entailed, among other things, reviewing their most recent audited financial statements and claims information. DOL officials said that they prepared memos documenting these reviews and communicated with coal operators about whether their financial circumstances warranted increasing or decreasing their collateral. Table 2 provides information on the 22 self-insured operators including the date of each operator’s most recent DOL reauthorization; the amount of DOL required collateral; and the operator’s most recent estimated black lung benefit liability. Should any of these operators file for bankruptcy, they could also affect the Trust Fund because the amount of an operators’ benefit liability that is not covered by collateral could also become the responsibility of the Trust Fund. Preliminary analysis from our ongoing work indicates that DOL did not regularly monitor self-insured operators. Agency regulations state that DOL may adjust the amount of collateral required from self-insured operators when experience or changed conditions warrant. We reviewed DOL’s most recent reauthorization memos for each of the 22 operators. While some of these operators had been reauthorized more recently, we found that others had not been reauthorized by DOL in decades. One operator in particular had not been reauthorized by DOL since 1988. Additionally, for most of these operators, DOL either did not have estimates of their benefit liabilities, or the estimates were out of date (see table 2). Beginning in summer 2015, DOL officials said that they stopped permitting any new coal mine operators to self-insure as the agency worked with auditors, economists, and actuaries to develop new procedures for self-insurance. At the same time, DOL generally stopped reauthorizing the 22 self-insured operators. Earlier this year, two of these operators have filed for bankruptcy—Westmoreland Coal Company and Cloud Peak Energy—according to DOL officials. Additionally, due to deteriorating financial conditions, DOL recommended revoking another operator’s self-insurance authority (Murray Energy). However, Murray appealed this decision and DOL postponed responding to the appeal until their new self-insurance procedures are implemented, according to DOL officials. DOL’s new self-insurance procedures are currently being reviewed by OMB, and DOL officials said they did not know when they would likely be implemented. Until such procedures are implemented, DOL cannot ensure that the collateral it has required from self-insured operators is adequate to protect the Trust Fund should these operators become insolvent. Chairwoman Adams, Ranking Member Byrne, and Members of the Subcommittee, this concludes my prepared statement. I would be happy to respond to any questions you may have at this time. If you or your staff has any questions concerning this testimony, please contact me at (202) 512-7215. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement. In addition to the contact named above, Blake Ainsworth (Assistant Director), Justin Dunleavy (Analyst in Charge), Angeline Bickner, Alex Galuten, Courtney LaFountain, Rosemary Torres Lerma, Kate van Gelder, Catherine Roark, and Almeta Spencer made key contributions to the testimony. Other staff who made key contributions to the reports cited in the testimony are identified in the source products. Related GAO Products Black Lung Benefits Program: Options to Improve Trust Fund Finances, GAO-18-351 (Washington D.C: May 30, 2018). Mine Safety: Basis for Proposed Exposure Limit on Respirable Coal Mine Dust and Possible Approaches for Lowering Dust Levels, GAO-14-345 (Washington, D.C.: April 9, 2014). Black Lung Benefits Program: Administrative and Structural Changes Could Improve Miners’ Ability to Pursue Claims, GAO-10-7 (Washington, D.C.: October 30, 2009). Federal Compensation Programs: Perspectives on Four Programs for Individuals Injured by Exposure to Harmful Substances, GAO-08-628T (Washington, D.C.: April 1, 2008). Mine Safety: Additional Guidance and Oversight of Mines’ Emergency Response Plans Would Improve the Safety of Underground Coal Miners, GAO-08-424 (Washington, D.C.: April 8, 2008). Mine Safety: Better Oversight and Coordination by MSHA and Other Federal Agencies Could Improve Safety for Underground Coal Miners, GAO-07-622 (Washington, D.C.: May 16, 2007). This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.