Background Scheduling Outpatient Appointments in VA Medical Facilities Enrollment is generally the first step veterans take to obtain health care services, within VA or through community care. VA’s Health Eligibility Center manages the process of accepting applications, verifying eligibility, and determining enrollment, in collaboration with VA medical centers. VA requires veterans’ enrollment applications be processed within 5 business days of receipt, including pending applications that require additional information from the applicant to process. Once enrolled, veterans can access VA health services by scheduling an appointment. VA’s scheduling policy establishes the procedures for scheduling medical appointments, as well as sets the requirements for staff directly or indirectly involved in the scheduling process (e.g., training). A scheduler at the VA medical facility is responsible for making appointments for new and established patients (i.e., patients who have visited the same VA medical center in the previous 24 months), which are then recorded in VA’s electronic scheduling system. VA scheduling policy requires patients who have requested an appointment and have not had one scheduled within 90 days to be placed on VA’s electronic wait list. VA determines wait times at each facility based on outpatient appointment information from its scheduling system. VA’s Public Websites with Appointment Wait-Time Information VA is required to publish information on appointment wait times at each VA medical facility for primary care, specialty care, and hospital care and medical services, which it does through two public websites. In November 2014, VA began posting monthly wait times for scheduling appointments at all VA medical facilities. One public website provides links to spreadsheets containing data for each VA medical facility, such as the average wait times for primary, specialty, and mental health care appointments and the number of patients on the electronic wait list. In April 2017, VA created a second public “Access and Quality in VA Healthcare” website to post both patient access data and information on VA medical facilities’ performance on various quality metrics. This website aims to help veterans find wait times at a specific facility. This information would allow veterans and their family members to use the wait-time data on this website to determine the best option for obtaining timely care. VA’s Community Care Programs In order to receive needed care in a timely manner, veterans may need to obtain care outside of VA medical facilities through one of VA’s community care programs. VA has purchased health care services from community providers through various community care programs since 1945. Veterans may be eligible for community care when they are faced with long wait times or travel long distances for appointments at VA medical facilities, or when a VA facility is unable to provide certain specialty care services. Since 2014, Congress has taken steps to expand the availability of community care for veterans. The Veterans Access, Choice, and Accountability Act of 2014 provided up to $10 billion in funding for veterans to obtain health care services from community providers. The law established a temporary program—called the Veterans Choice Program (Choice Program)—to offer veterans the option to receive hospital care and medical services from a community provider when a VA medical facility could not provide an appointment within 30 days, or when veterans resided more than 40 miles from the nearest VA facility or faced other travel burdens. VA contracted with two third-party administrators (TPA) to establish networks of community providers, schedule veteran appointments with those providers, and pay those providers for services rendered through the Choice Program. In June 2018, the VA MISSION Act of 2018 was enacted to further address some of the challenges faced by VA in ensuring timely access to care. The Act required VA to implement within 1 year a permanent community care program—the Veterans Community Care Program (VCCP). The act identified criteria that all veterans enrolled in the VA health care system would be able to qualify for care through the VCCP; for example, if VA does not offer the care or service needed by the veteran or VA cannot provide the veteran with care and services that comply with its designated access standards. The access standards include appointment wait times for a specific VA medical facility; for example, veterans may be eligible for care through the VCCP if VA cannot provide care within 20 days for primary and mental health care, and 28 days from the date of request for specialty care, unless veterans agree to a later date in consultation with their VA health care provider. VA Has Taken Actions to Address Deficiencies in Appointment Scheduling and Timeliness Identified in Prior Work, but Additional Actions Are Needed VA Has Taken Steps to Address Our Recommendation to Improve Wait-Time Measurement and Has Implemented Our Recommendation to Improve Implementation of Scheduling Policy VA has taken a number of actions to address our recommendations regarding deficiencies we found in wait-time measurement and implementation of its scheduling policy. For wait-time measurement, these actions included changes to the wait-time measurement definitions, provision and documentation of scheduler training, and improved oversight through audits, all of which have been in a state of flux for the past 6 years. On July 12, 2019, VA provided us additional updates on efforts to implement our related recommendations. This new information fully addresses one of our recommendations. VA Wait-Time Measurement In December 2012, we found that outpatient medical appointment wait times reported by VA were unreliable, and, therefore, VA was unable to identify areas that needed improvement or mitigate problems for veterans attempting to access care. VA typically has measured wait times as the time elapsed between the ‘start date’—a defined date that indicates the beginning of the measurement—and the ‘end date’, which is the date of the appointment. At the time of our 2012 report, VA measured wait times as the number of days elapsed from the start date identified as the desired date—the date on which the patient or health care provider wants the patient to be seen—to the date of the appointment. We found that the reliability of the reported wait-time measures was dependent on the consistency with which schedulers recorded the desired date in the scheduling system, as required by VA’s scheduling policy. However, VA’s scheduling policy and training documents for recording the desired date were unclear and did not ensure consistency. We observed that not all schedulers at VA medical centers that we visited recorded the desired date correctly. Therefore, we recommended that VA either clarify its scheduling policy to better define the desired date, or identify clearer wait- time measures that are not subject to interpretation and prone to scheduler error. VA concurred with the recommendation, which we have identified as among those recommendations that warrant priority attention. Actions VA has taken or is taking to address this recommendation include: changes to the start date and definitions for wait-time measurement, provision and documentation of scheduler training, and improved oversight through scheduler audits. In addition, we are currently assessing new information VA provided in July 2019, which will include obtaining additional evidence and clarification from VA to see whether it has fully addressed our concerns. VA’s Actions to Change Start Dates for Wait-Time Measurement While the terminology for the start dates of the wait-time measurement has changed several times over the past 6 years, we believe that the current definitions of the start dates are substantively the same as those we reviewed—and found to be deficient—in our 2012 report. VA subsequently introduced new terms with similar definitions—from “desired date” to “preferred date”—without fundamentally addressing the deficiency. See table 1 for the changes to and definitions of the start dates for measuring outpatient appointment wait times and wait-time goals since June 2010. As table 1 shows, for new patients and established patients seeking appointments without a return-to-clinic date specified by their provider, VA changed the terminology of the start date to preferred date in its July 2016 scheduling policy from what it had established in its June 2010 policy. However, the definition of preferred date is substantively the same as the definition of desired date in the previous scheduling policy, the latter of which we found to be subject to interpretation and prone to scheduler error in our 2012 report. We continue to believe that the preferred date is also subject to interpretation and prone to scheduler error, which poses concerns for the reliability of wait times measured using the patient’s preferred date. In its updated July 2016 scheduling policy, VA also changed the terminology of the start date to the “clinically indicated date” for established patients whose provider has documented a clinically appropriate return-to-clinic date in the patient’s electronic health record. The clinically indicated date is substantively the same as the definition of desired date for established patients in the previous scheduling directive. While VA has not clarified the definitions of start dates, VA has taken actions intended to improve the accurate recording of the clinically indicated date in three ways: 1. VA requires clinical leadership (such as the Associate Chief of Staff) at each VA medical facility to ensure that providers enter the clinically indicated date in the electronic health record for future appointments; 2. VA standardized the entry of the clinically indicated date in the electronic health record to improve the accuracy of the date, which was implemented across all VA medical facilities as of July 2018; and 3. VA created a technology enhancement to enable the automatic transfer of the clinically indicated date from the electronic health record to the scheduling system. As a result, the scheduler no longer has to retrieve the date from veterans’ electronic health records and manually enter it into the scheduling system. VA reported that this enhancement was implemented at all but three VA medical facilities as of January 2019. In July 2019, VA reported to us that the error rate for the patient indicated date (either the clinically indicated date, or in the absence of that date, the patient’s preferred date) was 8 percent of about 667,000 appointments audited in the most recent biannual audit cycle, ending March 31, 2019. VA cites an almost 18 percent improvement in reducing the number of errors caused by manual entry of the clinically indicated date due to the use of the technology enhancements. VA’s Actions to Provide and Document Scheduler Training Although VA updated its scheduling policy in 2016, we believe the instructions, which form the basis for wait-time measurement, are still subject to interpretation and prone to scheduler error, making training and oversight vital to the consistent and accurate implementation of the policy. VA reported that 97 percent of all staff who scheduled an appointment within 30 days completed the required scheduling training as of July 2, 2019. VA stated that the department will closely monitor compliance with scheduler training completion for the remaining staff. Given the high turnover among schedulers, it is important that VA remain vigilant about scheduler training, ensuring all who need it receive it. VA’s Actions to Improve Oversight through Scheduler Audits VA has taken a number of actions to improve oversight of the scheduling process through biannual scheduling audits at VA medical centers and second level audits, as well as completion of the first system-wide internal audit of scheduling and wait-time data. Biannual scheduler audits. VA’s July 2016 scheduling policy required biannual audits of the timeliness and appropriateness of schedulers’ actions and accuracy of entry of the clinically indicated date and preferred date, the start dates of wait-time measurement as identified by the revised scheduling policy. In June 2017, VA deployed a standardized scheduling audit process for staff at VA medical centers to use. As part of our recommendation follow-up in July 2019, VA reported 100 percent completion of the required biannual scheduling audits in fiscal year 2018. As noted above, VA reported to us that the error rate for the patient indicated date (either the clinically indicated date, or in the absence of that date, the patient’s preferred date) was 8 percent of about 667,000 appointments audited. While VA asserts that errors in the clinically indicated date have decreased, an error rate of 8 percent still yields errors in more than 53,000 appointments audited. Given these errors, we remain concerned about the reliability of wait times measured using preferred date (one part of the patient indicated date), and have requested additional information from VA about these errors. Second level scheduler audits. In November 2018, VA implemented a second-level scheduling audit (Audit the Auditors program), which is overseen by the VA integrated service networks tasked with oversight of VA medical facilities within their regions. Each medical center within a network region is paired with another medical center and they audit each other’s scheduling audit. Throughout the cycle, medical centers share their findings with each other and the network. The goal is to standardize scheduling audit practices across the network and to ensure reliability of the scheduler audit results. According to VA, the first cycle was completed April 30, 2019, by all VA medical centers. First internal system-wide audit of wait-time data and scheduling. In its first internal audit completed in August 2018, VA was unable to evaluate the accuracy and reliability of scheduling and the wait-time data. Specifically, VA was unable to determine the accuracy and reliability of the scheduling and wait-time data, databases, and data flow from the electronic health record and scheduling system to the VA Access and Quality website because they were not able to obtain the rules for calculating wait times. Given our continued concerns about VA’s ability to ensure the reliability of the wait-time data, we plan to obtain additional information from VA about its methodology and assessment of evidence underlying the audit findings. Scheduling Policy In December 2012, we also found inconsistent implementation of VA’s scheduling policy that impeded VA medical centers’ scheduling of timely medical appointments. Specifically, we found that not all of the clinics across the medical centers we visited used the electronic wait list to track new patients that needed medical appointments as required by VA’s scheduling policy, putting these patients at risk of being lost for appointment scheduling. Furthermore, VA medical centers’ oversight of compliance with VA’s scheduling policy, such as ensuring the completion of required scheduler training, was inconsistent across facilities. Scheduler training was particularly important given the high volume of staff with access to the scheduling system—as of July 2, 2019, VA reported there were approximately 33,000 staff that had scheduled an appointment within the last 30 days. We also found that VA medical centers identified the outdated and inefficient scheduling system as one of the problems that can impede the timely scheduling of appointments and may impact their compliance with VA’s scheduling policy. We recommended VA ensure that VA medical centers consistently and accurately implement VA’s scheduling policy, including use of the electronic wait list, as well as ensuring that all staff with access to the scheduling system completes the required training. VA concurred with this recommendation, which we also have identified as among those recommendations that warrant priority attention. VA’s actions to improve implementation of the scheduling policy, including updated information VA provided in July 2019, fully addresses this recommendation. VA issued an updated scheduling policy in July 2016 that provided clarification on scheduling roles and responsibilities for implementing the policy and business rules for scheduling appointments, such as using the electronic wait list, and required biannual scheduler audits. VA also ensured almost all schedulers received training on the updated scheduling policy and improved oversight through audits, as previously described. In addition, VA plans to rapidly deploy a single nationwide scheduling system that is intended to simplify the operating environment for schedulers and may mitigate challenges identified in our 2012 report. The new scheduling system will be a resource-based system where each provider’s schedule is visible on one screen, instead of requiring the need to toggle through multiple screens as it currently exists. VA plans to roll out the new scheduling system starting in 2020, which is expected to be implemented in coordination with the planned modernization of the electronic health records system across VA facilities. According to VA, the scheduling system will be available for use in advance of the completion of the electronic health record implementation at some sites. VA Has Taken Steps to Address Our Recommendations to Strengthen Enrollment Processes and Management of Initial Requests for Care That Affect Veterans’ Timely Appointments In addition to the recommendations we made to improve VA’s wait-time data and implementation of its scheduling policy, we have also made recommendations to address other factors that affect the timeliness by which veterans obtain appointments. These recommendations have targeted VA’s enrollment processes and its management of veterans’ initial requests for care. While VA has taken some steps to address these recommendations, they have not yet been fully addressed. For example, we have found that VA’s wait-time measures do not yet capture the time it takes the agency to enroll veterans in VA health care benefits, or manage a veterans’ initial request for care. Enrollment Process In September 2017, we found that VA did not provide its medical centers, who historically receive 90 percent of enrollment applications, with clear guidance on how to resolve pending applications, which led to delays in veteran’s enrollment. For example, we found instances in which pending applications remained unresolved for more than 3 months. We concluded these delays in resolving pending applications, along with previously documented delays due to errors in enrollment determinations, may result in veterans facing delays when obtaining health care services or incorrectly denied benefits. We made several recommendations to address these deficiencies, two of which we determined to be priority recommendations for VA to clearly define roles and responsibilities for (1) resolving pending applications and (2) overseeing the enrollment process. VA has made progress in addressing these priority recommendations by beginning to update, but not yet finalizing, its policies, procedures, and guidance on enrollment processing. In 2017, VA’s Health Eligibility Center began conducting secondary reviews of enrollment determinations. However, in fiscal year 2018, Health Eligibility Center staff found that 18 percent of rejected enrollment determinations and 8 percent of ineligible enrollment determinations that underwent secondary reviews were incorrect. These recommendations remain unimplemented as of July 2019. Initial Requests for Care Once enrolled, we have found that VA’s management of veterans’ initial request for care have led to delays; and although VA has clarified timeliness requirements, it has yet to fully capture the wait veterans experience in scheduling initial appointments. In a number of reports from 2015 to 2018, we found instances in which newly enrolled veterans were not contacted to schedule initial primary care appointments, and did not complete initial primary care appointments and mental health evaluations according to VA timeliness requirements. These delays may be understated in VA data, because VA’s wait-time measures do not take into account the time it takes VA medical center staff to contact the veteran to determine a preferred date (the starting point for wait-time measurement) from the veteran’s initial request or referral. We found that the total amount of time it took for veterans to be seen by providers was often much longer when measured from the dates veterans initially requested to be contacted to schedule an appointment or were referred for an appointment by another provider than when using the veterans’ preferred dates as the starting point. See figure 1 for an example of how the two wait-time calculations differ for an initial primary care appointment. We made several recommendations to VA, including a priority recommendation to monitor the full amount of time newly enrolled veterans wait to be seen by a provider. VA has taken several steps to address the priority recommendation, including revising an internal report to help identify and document newly enrolled veterans and monitor their appointment request status. The report is intended to help VA and its medical centers oversee the enrollment and appointment process by tracking the total time from application to appointment. However, VA is still in the process of enhancing its electronic enrollment system to capture the application date for all newly enrolled veterans. Until the enhancements are implemented, VA may not consistently capture the start date for newly enrolled veterans, which, in turn, affects the reliability of its wait-time data. The priority recommendation remains unimplemented as of July 2019. VA Has Not Implemented Recommendations to Address Wait Times and Other Choice Program Issues That Could Affect VCCP Implementation VA has not implemented several of our recommendations related to the Choice Program that could impact veterans’ timely access to care under the VCCP. These recommendations address (1) establishing achievable community care wait-time goals and a scheduling process consistent with those goals, (2) collecting accurate and complete data to systematically monitor veteran community care wait times, and (3) other factors that could adversely affect veterans’ access to community care. VA has begun taking steps to address these recommendations as it implements the VCCP. VA Still Needs to Establish Achievable Wait-Time Goals and a Scheduling Process Consistent with Those Goals to Ensure Veterans’ Timely Access to Care under the VCCP Our review of the Choice Program in June 2018 found that despite having a wait-time goal, VA developed a scheduling process for the Choice Program that was not consistent with achieving that goal. The Veterans Access, Choice, and Accountability Act of 2014 required VA to ensure the provision of care to eligible veterans within 30 days of the clinically indicated date or, if none existed, within 30 days of the veteran’s preferred date. However, we found that those veterans who were referred to the Choice Program for routine care because services were not available at VA in a timely manner could potentially wait up to 70 calendar days for care. Under VA’s scheduling processes, this potential wait time included VA medical centers having at least 18 calendar days to prepare veterans’ Choice Program referrals to TPAs and another 52 calendar days for appointments to occur as scheduled by TPAs. Based on this finding, we recommended that VA establish an achievable wait-time goal for the VCCP that will permit VA to monitor whether veterans are receiving community care within time frames that are comparable to the amount of time they would otherwise wait to receive care at VA medical facilities. We also recommended that VA should design an appointment scheduling process for the VCCP that sets forth time frames within which (1) veterans’ referrals must be processed, (2) veterans’ appointments must be scheduled, and (3) veterans’ appointments must occur that are consistent with the wait-time goal VA has established for the program. VA agreed with both recommendations, which remain unimplemented, and officials stated that they are in the process of finalizing metrics to capture wait-time performance and designing an appointment scheduling process. Without specifying wait- time goals that are achievable, and without designing appointment scheduling processes that are consistent with those goals, VA lacks assurance that veterans are receiving care from community providers in a timely manner. VA’s Monitoring of Care under VCCP Could Still Be Compromised by Incomplete and Inaccurate Data In June 2018, we reported that VA could not systematically monitor wait times for veterans accessing care under the Choice Program due to incomplete and inaccurate data. Without complete and accurate data, VA was not able to determine whether the Choice Program was achieving its goals of (1) alleviating the wait times veterans experienced when seeking care at VA medical facilities, and (2) easing geographic burdens veterans may have faced when accessing care at VA medical facilities. We made three recommendations to address VA’s incomplete and inaccurate data related to the Choice Program, and VA is taking steps to implement two of those recommendations. Incomplete Data We found that the data VA used to monitor the timeliness of Choice Program appointments captured only a portion of the total appointment scheduling process. Though VA had a 30-day wait-time goal to provide veterans with care under the Choice Program, VA’s timeliness data did not capture (1) the time VA medical centers took to prepare veterans’ referrals and send them to the TPAs, and (2) the time spent by TPAs in accepting the referrals and opting veterans into the Choice Program. For example, we found that it took VA medical center staff an average of 24 calendar days after the veteran’s need for care was identified to contact the veteran, compile relevant clinical information, and send the veteran’s referral to the TPAs. For those same authorizations, it took the TPAs an average of 14 calendar days to accept referrals and reach veterans to opt them into the Choice Program. In 2016, VA also conducted its own manual review of appointment scheduling times and found that wait times could be longer than the 30 days (see fig. 2). Specifically, out of a sample of about 5,000 Choice Program authorizations, VA analyzed (1) the timeliness with which VA medical centers sent referrals to the TPAs, and (2) veterans’ overall wait times for Choice Program care. VA’s analysis identified average review times when veterans were referred to the Choice Program to be greater- than-30-day wait time for an appointment at a VA medical facility. For example, for overall wait times (i.e., the time veterans’ need for care was identified until they attended initial Choice Program appointments), wait times ranged from 34 to 91 days across the 18 VA integrated service networks. The national average was 51 days. In September 2017, VA began implementing an interim solution to monitor overall wait times, but this solution relied on VA medical center staff consistently and accurately entering data on referrals, a process that is prone to error. In June 2018, we recommended that VA establish a mechanism to monitor the overall wait times under the VCCP. VA agreed with this recommendation, and stated that it is developing a monitoring mechanism that will be incorporated into a new system that will be fully implemented across all VA medical facilities by fiscal year 2021. Inaccurate Data We also reported that the clinically indicated dates included on referrals that VA medical centers sent to the TPAs, which are used to measure the timeliness of care, may not have been accurate, further limiting VA’s monitoring of veterans’ access to care. Our review of 196 Choice Program authorizations found that clinically indicated dates were sometimes changed by VA medical center staff before they were sent to the TPAs, which could mask veterans’ true wait times. We found that VA medical center staff entered later clinically indicated dates on referrals for about 23 percent of the 196 authorizations reviewed. We made two recommendations to improve the accuracy of the Choice Program data. For example, we recommended that VA establish a mechanism under the VCCP that prevents clinically indicated dates from being modified. VA agreed with our recommendation, and stated that a new system will interface with VA’s existing referral package to allow a VA clinician to enter in a clinically indicated date while restricting schedulers from making alterations to it. VA Has Not Addressed Other Factors That Could Adversely Affect Veterans’ Access to Care under the VCCP In June 2018, we also reported that numerous factors adversely affected veterans’ timely access to care through the Choice Program and could affect access under the VCCP. These factors included the following: (1) administrative burden caused by complexities of VA’s referral and appointment scheduling processes; (2) poor communication between VA and its medical facilities; and (3) inadequacies in the networks of community providers established by the TPAs, including an insufficient number, mix, or geographic distribution of community providers. VA has taken steps to help address these factors; however, none have been fully addressed. For example, to help address administrative burden and improve the process of coordinating veterans’ Choice Program care, VA established a secure e-mail system and a mechanism for TPAs and community providers to remotely access veterans’ VA electronic health records. However, these mechanisms only facilitate a one-way transfer of necessary information. They do not provide a means by which VA medical facilities or veterans can view the TPAs’ step-by-step progress in scheduling appointments or electronically receive medical documentation associated with Choice Program appointments. We made five recommendations to VA to address the factors that adversely affected veterans’ access to Choice Program care. VA agreed or agreed in principle with all five recommendations and has taken some steps in response to these recommendations. However, our recommendations remain unimplemented. As It Implements the VCCP, VA Has Taken Some Steps to Address Community Care Wait- Time Data and Monitoring Issues On June 6, 2019, VA began implementing the VCCP, which created a consolidated community care program. Under the VCCP, VA began determining veteran eligibility based on designated access standards, such as wait-time goals of 20 days for primary and mental health care and 28 days for specialty care and other criteria identified in the MISSION Act. According to VA officials, the implementation of the VCCP also included the use of the new Decision Support Tool—a system that combines eligibility and other information to help veterans, with assistance from VA staff, decide whether to seek care in the community. VA officials previously identified the Decision Support Tool along with another new system—known as the Health Share Referral Management system—as key efforts in addressing many of our recommendations related to VA’s community care wait-time data and monitoring issues. VA expects the Health Share Referral Management system, which will manage community care referrals and authorizations as well as facilitate the exchange of health information between VA and community providers, to be fully implemented across all VA medical facilities in fiscal year 2021. We began work in May 2019 to review VA’s implementation of the VCCP, including how it will address issues such as appointment scheduling. Preliminary Observations on VA’s Provision of Same- Day Services— Another Access Initiative In addition to the actions described above, VA has taken other steps to improve veterans’ access to care by, for example, offering veterans access to routine care without an appointment. We have ongoing work related to same-day services provided in VA primary care and mental health clinics. In order to improve access, VA implemented the same-day service initiative in 2016, and by 2018 offered same-day services in over 1000 facilities. As part of the initiative, VA medical facility staff are directed to address veterans’ primary care and mental health needs that day through a variety of methods, including face-to-face visits, telehealth, prescription refills, or by scheduling a follow-up appointment. Our ongoing work indicates that the six VA medical facilities we visited were generally providing same-day services prior to the initiative; however, according to VA officials, ongoing staffing and space shortages created challenges implementing the initiative. Our ongoing work also indicates that VA does not have performance goals and measures to determine same-day services’ impact on veterans’ access to care. We plan to issue our report on VA’s same-day services initiative in August 2019. In closing, we have identified various weaknesses in VA’s wait-time measurement and scheduling processes over the years. These weaknesses have affected not only VA’s internal delivery of outpatient care, but also that provided through community providers. As we have highlighted here, we have made a number of recommendations to address these weaknesses. VA has taken actions to address our recommendations, but additional work is needed for some. The implementation of enhanced technology, such as a new scheduling system, is crucial and will provide an important foundation for improvements. However, this is not a panacea for addressing all of the identified problems. Moving forward, VA must also continuously ensure that it has clear and consistent policies and processes, adequate oversight, and effective training. Chairman Takano, Ranking Member Roe, 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 Debra A. Draper, Director, Health Care at (202) 512-7114 or DraperD@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 were Sharon Silas (Acting Director), Ann Tynan (Assistant Director), Cathy Hamann, Aaron Holling, Akbar Husain, Kate Tussey, and E. Jane Whipple. Also contributing were Jacquelyn Hamilton and Vikki Porter.


Background School-age children can access the internet in a number of ways. Their households may subscribe to in-home fixed internet, which is generally provided by cable television or telephone companies. School-age children, and other users, can connect a variety of devices to in-home fixed service through a wired connection or a Wi-Fi connection. They may also access the internet through mobile wireless service, which is provided through cell towers, with data transmitted over radio frequency spectrum. Mobile service providers usually sell internet access as an option in mobile telephone-service plans. A number of devices may connect to mobile wireless, such as smart phones, tablets, and mobile devices that enable laptops to connect to mobile wireless service. Finally, school-age children and others may access the internet outside the home through other ways, including publicly available Wi-Fi access at places such as libraries and coffee shops. FCC has found that Americans in lower-income areas are less likely to have access to both in-home fixed and mobile wireless internet than those in higher-income areas. Similarly, according to our analysis of data from the November 2017 CPS: Computer and Internet Use Supplement, among all school-age children, those in lower-income households are less likely to use the internet at home than those in higher-income households (see fig. 1). A number of factors explain the digital divide, or the varying levels of access among different populations. For example, as we have reported in the past, rural areas tend to have conditions such as low population density or difficult terrain that can increase the costs for internet providers to deploy and maintain internet networks. Furthermore, lower-income households with access to the necessary infrastructure for internet service may not be able to afford it. (See fig. 2.) While some in-home fixed internet providers offer low-cost service for lower-income households with school-age children, according to a 2016 survey, an estimated 5 percent of households with school-age children ages 6 to 13 and incomes at or below the federal poverty guidelines had ever signed up for such programs. Lower rates of internet access by lower-income households may make it more difficult for school-age children in those households to do homework. According to a 2018 Pew Research Center survey, a higher percentage of surveyed teens in lower-income households said that the lack of a dependable computer or internet connection sometimes prevents them from finishing their homework compared to teens in higher- income households. In addition, according to the Consortium for School Networking, the lack of in-home access makes it more difficult for parents to support their children academically. Specifically, as much communication between schools and parents has moved online, the lack of access may make it difficult for parents to stay connected to teachers and be informed about school notices, homework assignments, and other important information. FCC, which regulates commercial and other nonfederal spectrum, conducts activities that affect the ability of schools to address the homework gap. Specifically, it plays a role in expanding internet access by assigning licenses for Educational Broadband Service (EBS) spectrum, which permits schools and other eligible entities to transmit educational materials electronically. Currently, EBS license holders are allowed to lease excess capacity to others, including commercial wireless providers, for up to 30 years as long as the license holder has 20 hours of educational use per week per licensed channel and reserve the right to access 5 percent of the capacity for educational use. Schools that have such leases may need to wait years to regain full use of their EBS license. Furthermore, the last opportunity for school districts to apply for new EBS licenses was in 1995, and according to FCC, EBS licenses cover about half the geographic area of the United States, with rural areas west of the Mississippi River generally lacking licenses. However, FCC recently adopted a Report and Order with rules that, once effective, will change the eligibility requirements for EBS licenses, among other things. In addition, FCC supports internet investments at schools through the E- rate program, which provides discounts on telecommunications and internet access services, internal connections, and basic maintenance of internal connections. This program provides schools with higher percentages of lower-income students greater discounts on these services; for example, the most disadvantaged schools, where at least 75 percent of students are eligible for free or reduced price school lunch, receive a 90 percent discount. All services supported by the E-rate program must be used primarily for “educational purposes,” which FCC has defined as meaning “activities that are integral, immediate, and proximate to the education of students.” Education’s Office of Educational Technology also plays a role related to internet access for students by developing national educational- technology policies and providing guidance to schools and school districts on technology use in schools. For example, in January 2017 the office issued a letter to schools and school districts about Education grant funds that could be used to support the use of technology to improve instruction and student outcomes. It also issued a report in 2017 on the use of technology in schools; the report provided guidance on how to modernize the technology needed for digital learning, such as schools’ internet networks and internet-enabled devices. Education also collects, analyzes, and reports on a range of data from schools and school districts. For example, every year from 1994 to 2005 (except 2004 due to a lack of funding according to Education officials), the department collected data on internet access in schools and classrooms. In 2008, Education conducted three similar surveys at the district, school, and teacher levels on the availability and use of a range of educational technology resources, such as networks, computers, devices that enhance the capabilities of computers for instruction, and computer software. Due to a lack of funding, Education did not conduct additional similar surveys. However, the department recently finished administering a different survey effort, funded from different sources, that we discuss later in this report. School-Age Children in Lower-Income Households Face Challenges in Doing Homework Involving Internet Access and May Be More Likely to Rely on Mobile Wireless According to our analysis of November 2017 CPS: Computer and Internet Use Supplement data, lower-income households with school-age children may be more likely than those in higher-income households to be reliant on mobile wireless service, such as through smart phones, for internet access. As seen in figure 3, among all households with school-age children, an estimated 22 percent with incomes of less than $25,000 per year use mobile wireless to access the internet but not in-home fixed high-speed internet service, in contrast to 8 percent with incomes of $75,000 or more per year. School-age children whose households only have mobile wireless internet access may face challenges in using it for homework, including: Device limitations. Students in mobile wireless-only households may have to rely on devices like smartphones that may not be well suited for academic tasks. A recent Pew survey found that an estimated 45 percent of teenagers in lower-income households say they sometimes have to do homework on a smartphone. However, most of the stakeholders we interviewed told us that smartphones are not adequate for doing homework for various reasons, including that they are too small for typing papers and that not all educational websites are compatible with smartphones. According to these stakeholders, other devices such as desktops or laptops are better suited for homework; however, among all school-age children, those in lower- income households are less likely than those in higher-income households to use these devices (see fig. 4). Data limitations. A majority of the stakeholders we interviewed said that wireless plans’ data caps—a limitation on the amount of data the subscriber can download and upload per month—could make it difficult for school-age children to do homework, because, for example, once the data cap is reached, the provider may decrease connection speeds or impose additional costs for further data use, which could hinder completion of homework. A 2016 survey found that an estimated 39 percent of lower-income households with school- age children—in this case those with incomes less than the federal poverty guidelines—had reached a data cap, compared to 25 percent of higher-income households. Varying service quality. Mobile wireless may be less reliable and slower than in-home fixed service, which can make doing homework more challenging. In 2018, FCC concluded that mobile wireless services are not full substitutes for in-home fixed service, because mobile wireless quality can be affected by user location, indoor obstructions, outdoor foliage, and weather, among other factors. In addition, we reported in 2015 that the availability and quality of mobile wireless service connections vary based on location and terrain. For example, according to officials with Albemarle County Public Schools in Virginia, while most students who participated in a recent survey indicate that they have mobile wireless internet access at home, that access may only offer poor quality connections and slow speeds due to mountainous terrain. As a result, mobile wireless access may have limited usefulness for homework purposes. A 2018 survey by the Pew Research Center found that about 20 percent of teens from lower-income households say that they sometimes have to use public Wi-Fi for homework given a lack of access at home. As shown in figure 5, stakeholders we interviewed and literature we reviewed identified a number of potential challenges students may encounter in using methods to access the internet outside the home to do their homework. Efforts by Selected School Districts to Increase Wireless Internet Access for Underconnected Students Varied, with Limited Federal Involvement School Districts, with Limited Federal Involvement, Have Taken Various Steps to Increase Wireless Internet Access for Underconnected Students The six selected school district projects we reviewed have taken various approaches to address the homework gap by providing wireless internet service to students who may lack access at home. Most of these projects provide wireless internet access to students who lack in-home fixed internet and do not necessarily limit it to students in lower-income households. In addition, all but one of these projects provide filtered access, meaning that students using these services are subject to the same usage restrictions as if they were on-site in school. Approaches included: Provide wireless hot-spot devices. The Green Bay Area Public School District in Wisconsin loans out mobile wireless hot-spot devices to students throughout the district who do not have access at home, providing them filtered internet access in their homes or elsewhere in the community. The hot-spot devices are available on loan from school libraries to any student who claims a need for one regardless of household income. Students may use district-issued Chromebooks or other internet-enabled devices, which then connect to the district’s internet resources via the hot-spot device using service provided by a commercial mobile-wireless provider. Build or use a private network. Some districts have built new or expanded existing networks to provide internet access to students using a variety of approaches. Albemarle County Public Schools in Virginia uses EBS spectrum to provide access to students in community centers in mobile home parks in this mountainous district where, according to school district officials, many students lack service at home. The district also plans to install wireless receiver devices in selected students’ homes through which those students will be able to connect internet-enabled devices via Wi-Fi. Desert Sands Unified School District in California also built out an EBS network to provide internet access to students who lack service at home. According to officials with that district, the benefit of this approach is that it involved only a one-time cost to build the network, rather than recurring annual payments to a commercial mobile-wireless provider for service. Two rural, low-income school districts in Virginia—Charlotte County Public Schools and Halifax County Public Schools—partnered with Microsoft to provide service through unlicensed white space devices (which operate on frequencies not being used by television broadcasters or 600 MHz wireless providers) to students who lack access at home, regardless of income . According to Microsoft, the use of unlicensed white space devices is a good solution to providing wireless access in rural areas where other technologies may be uneconomical and such frequencies tend to be available. Students who use this service receive a device that is installed in their home that wirelessly connects to the district’s network and transmits to other devices in the home via Wi-Fi. The Boulder Valley School District in Colorado allowed a local wireless provider to build antennas on some school buildings in order to serve its customers in exchange for providing free service to lower- income students, determined based on student eligibility for free or reduced price lunch. According to a school district official, the provider has installed antennas at three schools, providing access to students living within a 3-mile radius, and plans to install antennas at most remaining schools in the district. That official told us that this model may not work in many other school districts, as there may not be sufficient population density to make it economically beneficial for a commercial provider to agree to provide such service. Equip school buses with Wi-Fi. The Coachella Valley Unified School District, which covers a large geographic area in California where many students lack in-home fixed access, equipped its fleet of about 100 school buses with Wi-Fi in 2014, enabling students to do homework during long bus rides. A commercial mobile-wireless provider connected the Wi-Fi router on the bus to the district’s network. In order to access Wi-Fi on the buses, students had to use district-issued devices that they were allowed to bring home after school. The district also parked Wi-Fi-equipped school buses and other district vehicles overnight in neighborhoods with a high proportion of students who brought district-issued tablets home in order to provide access to students who likely lacked internet at home. However, the district stopped this initiative in 2017 due to limited funding and is now seeking out alternative funding sources to reactivate the program. While none of the projects described above used any funding from Education, the department has identified six existing grants that schools and districts could use under certain conditions to support internet investments, although not necessarily wireless investments specifically. While the purpose of each of these grant programs isn’t specific to internet investments, Education identified specific types of internet investments that these grant funds can be used for. We did not make a determination as to whether any of the grant funds could have supported the efforts we reviewed. Representatives of two of the school districts we met with stated that they would like to see additional information on Education grants that could be used to support internet investments. Education officials said the department has taken the first step to developing a strategy to share information about these grants by developing a coordinated communications strategy through its Office of Rural Engagement. They added that the department will then continue to build a broader strategy. Education is also finalizing data collection on a survey that will collect some data regarding the homework gap. As mentioned earlier, until 2008 Education collected survey data over a number of years about information technology and internet access in schools and classrooms. According to Education officials, the department stopped collecting such data due to a lack of funding. However, the department is now finalizing a survey that is collecting nationally representative data about public school teachers’ use of computers and the internet, and their knowledge of students’ access to computers and the internet outside the classroom. The survey is collecting data that pertain to the homework gap, including the extent to which schools provide wireless hot-spot devices to students to take home; the extent to which teachers think students access the internet outside of school, such as at home, libraries, or businesses; and the extent to which teachers think smartphones are useful for doing homework. According to Education, the department finished administering the survey in June 2019 and plans to release the results in April 2020. The survey data may provide Education and others, including FCC and Congress, with useful information that can inform policy and other decisions related to the homework gap, such as how best to support schools’ efforts to expand wireless access for underconnected students. FCC had a minor role in some of the school district projects by having previously granted EBS licenses to some districts that use EBS spectrum to provide wireless access. However, according to FCC documentation, many schools and school districts do not have EBS licenses—such as those in rural areas in the western United States—and some that have obtained a license now lease their capacity out on a long-term basis to commercial providers. As a result, school districts may be limited in using EBS to provide wireless access to students or have to take additional steps to use EBS. Desert Sands Unified School District officials said that the district did not have an EBS license and that the local license holder had leased it out to a commercial provider, so the district worked with that provider to build out its EBS network. Albemarle County Public Schools had leased out its EBS license to a commercial provider years ago, but because that provider was not utilizing that spectrum, the school district was able to reclaim it. FCC has taken recent steps that may affect the extent to which school districts are able to use EBS to provide wireless access. In May 2018, FCC issued a Notice of Proposed Rulemaking seeking comment on proposed changes to how it manages EBS to encourage and facilitate its efficient use. In July 2019, FCC adopted a Report and Order that makes a number of changes to the EBS spectrum and its use. Specifically, once effective, these rules will eliminate eligibility restrictions for EBS licenses and eliminate the educational use requirement of the spectrum. FCC Has Not Fully Evaluated the Possibility of Expanding the E-Rate Program to Include Off- Premises Wireless Access While FCC’s E-rate program supports schools’ connectivity by providing discounts for eligible services, program rules may limit the ability of schools and school districts to address the homework gap. Specifically, program rules specify that off-premises use of such services is not eligible for E-rate support and require that any off-premises traffic must be cost allocated out of school districts’ E-rate discounts. For example, any off- premises traffic supported by existing E-rate-supported products or services requires a reduction in the E-rate discount for those existing E- rate supported products and services. This reduction may increase costs for school districts as they would no longer receive all their potential E- rate discounts. Officials representing all six of the school district projects we reviewed suggested that program rules limiting eligibility for off- premises use and requiring cost-allocation may inhibit the ability of school districts to expand off-premises wireless access, and thus address the homework gap. For districts that do provide wireless access off-premises, E-rate program restrictions may still pose challenges. For example, according to an official with Desert Sands Unified School District, the district had to buy a separate line of internet access to avoid having that off-premises traffic travel through the district’s existing E-rate-supported network, which would have required cost-allocation and a reduction of the E-rate discount for that existing E-rate supported network. According to officials with Microsoft, Charlotte County Public Schools and Halifax County Public Schools had to separate their off-premises unlicensed white space device traffic from internet traffic that passed through E-rate-discounted access in the schools. An official with Boulder Valley School District said that the district had to terminate an earlier effort to extend access to students in a housing development after being told that it could not provide off- premises access with program-discounted equipment without cost- allocation. In September 2016, FCC issued a Public Notice requesting public comment on two petitions filed with the agency seeking to allow the petitioning school districts to use existing E-rate-program-supported services and equipment for off-premises access without having to cost- allocate that traffic out of their existing E-rate discounts. Cost allocating out that traffic would result in reduced E-rate discounts for school districts, and therefore higher costs, for existing services and equipment supported by E-rate. FCC rules allow parties to petition for waivers of rules if they can demonstrate that special circumstances warrant deviation from the existing rules and doing so serves the public interest. According to FCC officials, the petitions are pending and the agency has not yet taken further formal action on this Public Notice. The petitions are described in more detail below. In May 2016, the Boulder Valley School District filed a petition requesting a waiver of the cost allocation rules in order to use its E- rate-program-supported network to provide internet access to students at public housing facilities after school hours. In the petition, the district argued that because traffic on its E-rate program- supported network dramatically decreased after school hours, using that network to provide access during that time would not impose any additional costs on the E-rate program. Microsoft and others—including the school districts in Charlotte and Halifax counties—filed a petition in 2016 to obtain clarification that those school districts could provide wireless access to students’ homes for educational purposes by extending the districts’ existing E- rate-supported services using the districts’ unlicensed white space device network without cost allocating that traffic from the existing E- rate discounts. The petition stated that the infrastructure to provide service to unlicensed white space devices would not be funded with E-rate program funds, and that these districts were not well served by commercial internet providers. In comments filed with FCC, Microsoft argued that projects covered by both petitions would provide in-home access for students without imposing any additional costs to the E- rate program and that the projects would increase the productivity of E-rate by using existing resources more efficiently. Previously, FCC explored the possibility of making wireless off-premises access an allowable E-rate program expense—which would eliminate the requirement to cost-allocate such traffic—in a 2011 to 2012 pilot program. When establishing this pilot program, FCC noted commenter concerns regarding the potential administrative, legal, technological, and procedural challenges of expanding E-rate funding to off-campus premises. The pilot program provided funding from July 2011 to June 2012 and sought to “investigate the merits and challenges of wireless off- premises connectivity services” and to “gain a better understanding of operation and administrative issues associated with off-premises use and connectivity, as well as the financial impact on the E-rate program overall.” Furthermore, the pilot program sought to help FCC determine whether off-premises connectivity services “should ultimately be eligible for E-rate support.” FCC provided a total of $9 million in grants to 20 pilot-program participants—19 schools or school districts and one community library system—to implement projects enabling innovation in learning outside the boundaries of school buildings and the traditional school day, including those that provided off-premises wireless access and wireless devices to students. Recipients were not required to cost allocate the off-premises traffic as part of the pilot. FCC required all pilot participants to file interim and final reports that included information about project benefits, such as the extent to which students provided with wireless devices used them and the effect of increased internet access on academic outcomes; project costs; the effectiveness of measures to prevent project waste, fraud, and abuse, to filter content, and to ensure that students only used the devices for educational purposes; and lessons learned. According to FCC, those reports would allow it to assess the impact of selected pilot projects on the schools and to gather lessons learned that would help others implement similar projects in the future. In addition, FCC said it would evaluate the effectiveness of the pilot program to determine whether off- premises wireless access should be eligible for E-rate program support. While FCC received interim and final reports from most pilot participants, it did not determine a methodology for evaluating the data provided in those reports. Furthermore, FCC did not publish a report evaluating the effectiveness of the pilot program, including the potential costs, benefits, and challenges of off-premises wireless access to make a determination regarding whether off-premises access should be eligible for E-rate program support. Although the order establishing the pilot did not require FCC to determine an evaluation methodology and publish a formal analysis, according to FCC officials, staff reviewed the interim and final reports prior to the Commission adopting a 2013 Notice of Proposed Rulemaking that sought input on ways to modernize the E-rate program, including input on using E-rate-supported wireless hot-spots for community use. In two subsequent E-rate program modernization orders in 2014, the Commission did not expand the E-rate program’s support for off-premises access. FCC officials explained that given the changes in technology, costs, and student learning in recent years, the data collected from the pilot may have some limitations. FCC has not announced any plans to conduct another pilot program, and aside from its consideration of the petitions previously mentioned, FCC has not announced an intention to revisit whether off-premises wireless access should be eligible for E-rate support. Federal internal control standards state that agencies should use quality information to make decisions and communicate information to external parties. Specifically, agencies should collect data from reliable sources in a timely manner, process these data into quality information, and use that information to make informed decisions. Agencies should also communicate such information to external parties that can help the agencies achieve their objectives. Furthermore, in previous work we identified as pilot-program design best practices: determining a methodology for gathering and evaluating data, evaluating pilot results to make conclusions on whether to integrate pilot activities into broader efforts, and communicating with stakeholders—such as by publishing results. As discussed earlier, school districts we met with said that existing E-rate program rules that require cost-allocation of off-premises access to E-rate discounts limit their ability to address the homework gap and providing off-premises access remains a challenge for schools and school districts. Determining and executing a methodology for collecting and analyzing data on the potential costs, benefits, and challenges of making schools’ efforts to expand off-premises wireless access eligible for program funding could help inform FCC decisions regarding the two pending petitions and any future petitions. As petitions may only cover petitioning entities, determining and executing such a methodology could also help inform more widespread changes to E-rate rules regarding off-premises access that would affect all E-rate program recipients. FCC could collect such data through another pilot program or from school districts now providing off-premises wireless access. Publishing the results of this analysis could help FCC ensure that such information will be accessible to inform future related efforts and provide transparency to external stakeholders, including school districts. Conclusions The differences in internet access—and therefore in the ease of doing homework—between school-age children in lower-income households and those in higher-income households that are more likely to be well connected has resulted in a “homework gap” that could inhibit the academic success of underconnected students. While school districts have made efforts to address the homework gap, such efforts may be inhibited by existing restrictions in FCC’s E-rate program. Although FCC explored the possibility of making wireless off-premises access an allowable E-rate program expense in a 2011 to 2012 pilot program, FCC’s lack of an analysis of the data it collected at the time or since then means that it may not have sufficient and relevant information to make a decision on pending petitions from local school districts regarding off-premises access. Determining the best way to collect and analyze data on the potential benefits, costs, and challenges of making off-premises wireless access eligible for E-rate program support; conducting such analysis; and publishing the results could provide relevant information and transparency to external stakeholders. Doing so could also enable FCC to make a determination on whether it would be appropriate to ease restrictions on off-premises access, a step that may give school districts more flexibility in addressing the homework gap. Recommendation We are making the following recommendation to FCC: The Chairman of the Federal Communications Commission should determine and execute a methodology for collecting and analyzing data— such as conducting a new pilot program regarding off-premises wireless access or analyzing other data—to assess the potential benefits, costs, and challenges of making off-premises wireless access eligible for E-rate program support, and publish the results of this analysis. (Recommendation 1) Agency Comments We provided a draft of this report to FCC, Education, and the Department of Commerce for review and comment. FCC provided written comments, which are reproduced in appendix II. In these written comments, FCC stated that it agreed with our recommendation and noted steps it plans to take to assess the potential benefits, costs, and challenges of making off- premises broadband access eligible for E-Rate program support. FCC also provided technical comments, which we incorporated as appropriate. Education provided written comments, which are reproduced in appendix III and also provided technical comments that we incorporated as appropriate. The Department of Commerce reviewed our report and told us it did not have any comments. We are sending copies of this report to interested congressional committees, the Chairman of the FCC, the Secretary of Commerce, and the Secretary of Education. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-2834 or vonaha@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix IV. Appendix I: Scope and Methodology Our objectives for this report were to examine: (1) challenges lower- income school-age children who lack in-home fixed internet face in doing homework that involves internet access and (2) what selected school districts are doing to expand wireless internet access for their students, and the federal role in such efforts. To examine challenges lower-income school-age children who lack in- home fixed internet face in doing homework that involves internet access, we analyzed data from the Census Bureau’s November 2017 Current Population Survey: Computer and Internet Use Supplement, which is sponsored by the National Telecommunications and Information Administration (NTIA). The Computer and Internet Use Supplement collected household information from all eligible Current Population Survey households, as well as personal information from household members age 3 and older. The supplement provided data about households’ computer and internet use, and about each household member’s use of the internet from any location during the previous six months. One member of a household was generally interviewed and answered questions on behalf of every other member. Interviews were conducted from November 12–18, 2017. The probability sample selected to represent the universe consisted of approximately 56,000 households. We included variables on ages of household members to determine if the household had one or more school-age children. We considered a household to have school-age children if it had any children between the ages of 6 and 17, an age range used in other analyses of internet use by school-age children, such as analyses by NTIA and Pew Research Center. We analyzed data on the use of in-home fixed and mobile- wireless internet, as well as of various computing devices. In our analysis we also included variables on household income, to allow us to report results based on different income ranges. When analyzing responses by household income, we grouped household income into similar ranges that NTIA publishes on its Data Explorer website, but we consolidated the top two ranges used by NTIA into one range. To determine the reliability of these data, we reviewed NTIA technical documentation on the survey, interviewed NTIA officials, and compared our estimates of selected variables with estimates presented by NTIA on its website. We found these data were sufficiently reliable for reporting on data on internet and computing device use by household income levels. In addition, we conducted a literature search to review challenges lower- income school-age children who lack in–home internet face in doing homework that involves internet access. We searched multidisciplinary databases using relevant terms such as “low-income,” “wireless,” “internet,” and “school-age children.” We searched for scholarly articles, including working and conference papers, government reports, think tank publications, and trade publications published between 2013 and 2018. We reviewed the abstracts of results from the search for publications most relevant to our work and fully reviewed publications that, based on their abstract, were most suited to this engagement. We used relevant publications to support findings we collected from other sources, including interviews. We also conducted semi-structured interviews with a range of stakeholders, including education industry associations, researchers, and advocacy organizations we selected based on literature, internet searches, and recommendations from those we interviewed. Specifically, we interviewed eight education or technology industry associations or advocacy organizations, one education researcher, one technology industry researcher, and representatives of one technology company that provides internet services and products to schools. In addition, we interviewed officials with the Federal Communications Commission (FCC) and Department of Education (Education). We also reviewed a non-generalizable sample of six projects involving seven local school districts taking steps to provide wireless internet access outside of school for students who may lack internet at home. We identified these projects based on keyword searches and recommendations from other interviewed associations and researchers, as well as officials with FCC, NTIA, and Education. From this list, we then selected those projects that were frequently cited in the press or by others we interviewed; that covered a variety of geographic locations, including those in both urban and rural areas; and that included a variety of approaches to addressing the homework gap. During these interviews, we asked interviewees about a range of topics, including the extent to which school-age children have access to in-home and wireless internet and challenges faced by students who may only have mobile wireless access. In total we interviewed 17 stakeholders, including the industry associations, researchers, and school districts detailed above. We analyzed the content of the interviews to identify key challenges identified by stakeholders. These interviews did not provide a complete list of all challenges, and the results of these interviews are not generalizable but do provide insight into a range of issues. To determine what selected school districts are doing to expand wireless internet access for their students and the federal role in such efforts, we conducted semi-structured interviews with officials at the school districts listed above and officials at Microsoft regarding its efforts to expand wireless access for students who may lack internet at home. During these interviews, we asked the districts about what steps they are taking to expand wireless access, the goals and challenges of the relevant project, and the federal role in the effort. We analyzed the content of the interviews to identify key themes. We also interviewed officials with FCC and Education to determine and review federal efforts related to school initiatives to expand wireless access for students. We reviewed documentation from FCC and Education regarding relevant federal efforts including rulemaking documents such as FCC’s 2018 Notice of Proposed Rulemaking and 2019 Report and Order regarding Educational Broadcast Service spectrum. We reviewed other relevant FCC documents related to the Schools and Libraries Universal Service Support Mechanism (also known as the E-rate program), which provides schools with discounts on telecommunications and internet services. E-rate documents we reviewed included reports related the 2011 E-rate pilot program exploring off- premises wireless access. We compared FCC efforts to federal internal control standards related to using quality information and communicating externally and pilot program design best practices. We reviewed information, provided to us by department officials, on existing Education grant programs that can be used by schools and school districts to support internet investments. We also reviewed information on Education’s relevant survey efforts. We conducted this performance audit from May 2018 to July 2019 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Appendix II: Comments from the Federal Communications Commission Appendix III: Comments from the Department of Education Appendix IV: GAO Contact and Staff Acknowledgments GAO Contact Andrew Von Ah at (202) 512-2834 or vonaha@gao.gov. Staff Acknowledgments In addition to the contact above, Mark Goldstein (Director); Derrick Collins (Assistant Director); Matthew Rosenberg (Analyst in Charge); Dwayne Curry; Sherri Doughty; Rachel Frisk; Hayden Huang; Gina Hoover; Dan Luo; Josh Ormond; Cheryl Peterson; Matt Ray; Hai Tran; and Laurel Voloder made key contributions to this report.