"Privileged" Nominations Every year the Senate routinely considers whether to give its advice and consent to hundreds of nominations submitted by the President. From start to finish, the confirmation process can be a lengthy one, even for relatively noncontroversial nominees. Each nomination is typically referred to one or more committees having subject matter jurisdiction over the position. Committees may bear a significant workload in examining nomineesâoften including questionnaires, optional public hearings, and individual meetings with Senatorsâto determine whether to report a nomination to the full Senate. Once a committee has reported a nomination or been discharged from its further consideration, the Senate may take up a nomination for deliberation, though a cloture process may be required to ensure a final vote to confirm. As part of an effort to streamline the nominations process during the 112 th Congress (2011-2012), a standing order of the Senate, S.Res. 116 , created a new designation of certain nominations as "privileged." These so-called privileged nominations are subject to special procedures that may save the time of committees in processing these appointments. In total, there are 285 positions to which nominations are privileged, the majority of which are part-time appointments to oversight boards and advisory commissions, but they also include full-time chief financial officers and certain assistant secretaries to cabinet-level agencies. A full list of privileged nominations, organized by their committees of jurisdiction, can be found in Appendix . This report first examines, in detail, the special procedures under which privileged nominations are processed, as well as the action by which a Senator may have a privileged nomination referred to its committee of jurisdiction. It then provides a brief legislative history of S.Res. 116 and subsequent legislation that has created additional privileged nominations. Finally, this report includes data on and a discussion of Senators' requests to refer privileged nominations to committee. Figure A-1 contains an example of the "Privileged Nominations" section of the Senate's Executive Calendar . Consideration of Privileged Nominations The sections below discuss each step of how a privileged nomination might be processed under potentially expedited procedures before consideration by the full Senate. Pursuant to Section 1(d) of S.Res. 116 , any Senator may insist that a privileged nomination be referred to its committee of jurisdiction, making it no longer eligible for procedures under S.Res. 116 . Further discussion of when and why a Senator might make such a request follows after the sections on consideration. Receipt in Senate Unlike a typical nominationâwhich, when received by the Senate, is usually referred to its committee of jurisdictionâa privileged nomination goes directly to the "Privileged Nominations" section of the Executive Calendar . There, the nominee and position to which he or she was nominated is to be recorded, along with the date the nomination was received by the Senate. An example page of the "Privileged Nominations" section of the Executive Calendar appears in Figure A-1 . The same day a privileged nomination is received in the Senate, the Office of the Executive Clerk sends a notification form to its committee of jurisdiction. This transmittal from the Executive Clerk is not a referral of the nomination to the committee but rather serves to inform the committee it should proceed to request information from the nominee. A column in the Privileged Nominations section of the Executive Calendar entitled "Information Requested by Committee" is marked with a "Yes" to denote this transaction. Information Requested and Received by Committee Though under the terms of S.Res. 116 , privileged nominations are not referred to their committees of jurisdiction, these committees are still responsible for obtaining certain background information from nominees before they can be considered by the full Senate. Section 1(b) of S.Res. 116 directs that the "appropriate biographical and financial questionnaires" be collected by committees of jurisdiction from privileged nominees. This broad requirement gives committees some discretion in determining what information to collect. As a result, committee practices on obtaining information from privileged nominees can vary. Once a nominee has responded to a committee's questionnaires, the chair is required to notify the Executive Clerk in writing that the appropriate information has been received. This requirement is fulfilled, in practice, when the committee returns the notification form to the Executive Clerk's office. When a committee has affirmed receipt of the requested information from a nominee, that date is recorded under the "Requested Information Received" column in the Privileged Nominations section of the Executive Calendar . Senators have 10 session days from this date (and any time prior to this point, starting from the day the nomination was received in the Senate) to request that the nomination be referred to its committee of jurisdiction. After 10 session days have passed, the nomination is then moved to the "Nominations" section of the Executive Calendar and is eligible to be called up for consideration on the Senate floor (after lying over for one day or, by unanimous consent, immediately). Privileged nominations that have been considered under these procedures are to appear in the Nominations section of the Executive Calendar with the designation "Placed on the Calendar pursuant to S.Res. 116 , 112 th Congress" under the "Reported By" column, along with the date it first appeared there. Final Consideration Under Regular Procedures Once a privileged nomination has moved to the Nominations section of the Executive Calendar , there is no expedited process under which the Senate can proceed to consider or vote on it. Instead, these nominations are equally eligible for consideration as any other found on the Nominations section of the Executive Calendar . As a result, even privileged nominations that may have moved quickly through the expedited committee process could face lengthy wait periods before being brought up for consideration by the full Senate. Some privileged nominations never receive a vote on the Senate floor and are returned to the President when the Senate adjourns sine die at the end of the first or second session of a Congress or when it recesses for more than 30 days. Referral of a Privileged Nomination to Committee As noted earlier, pursuant to Section 1(d) of S.Res. 116 , any Senator may trigger, on his or her own behalf or the behalf of any identified Senator, that a privileged nomination be referred to its committee of jurisdiction for consideration under normal procedures. Any such request compels the referral of the nomination to committee. Senators do not need to obtain recognition on the floor to make such a request, nor are they required to provide a reason for their request. Instead, a form for this purpose is available at the dais on the Senate floor. A Senator's request is then to be reflected in that day's Congressional Record , and the nomination is to be referred to its committee of jurisdiction. Additional data on requests for the referral of a privileged nomination can be found in Table 1 . Senators may make such requests for a variety of reasons. Senators may have concerns over the qualifications or fitness of an individual to serve in the position to which he or she was nominated. Referring the nomination to committee ensures that it will need the support of a majority of the committee to be reported to the Senateâa higher threshold than under the procedures of S.Res. 116 , which require only that the committee's chair affirm that the requested biographical and financial information has been received. Alternatively, a Senator may desire more time for individual meetings with Senators or a public hearing where a nominee's credentials can be extolled, perhaps increasing the chances of a favorable floor vote. Legislative History on the Creation of Privileged Nominations S.Res. 116, 112th Congress The creation of privileged nominations and the special procedures applied to them were part of a larger effort to reform the confirmation process in the Senate during the 112 th Congress (2011-2012). On January 5, 2011, Majority Leader Harry Reid and Minority Leader Mitch McConnell engaged in a brief colloquy to discuss the pace of processing nominations in the Senate, noting the increasing volume of Senate-confirmed positions and the need for reform. Connecting the oftentimes laborious confirmation process with difficulty in finding capable nominees, Majority Leader Reid said: Clearly, all Presidents are entitled to choose well-qualified individuals to serve in their administration. In the vast majority of instances, the individuals nominated by the President are not controversial, but many have faced delays before assuming their positions. These delays mean critical decision-makers are not in place. And, the delays make it harder to find qualified peopleâmany great nominees simply cannot wait around for months as the stress and uncertainty affects their families and careers. We need to do better in the 112 th Congress. The two leaders agreed to form a bipartisan nominations reform working group, consisting of Senators Chuck Schumer and Lamar Alexander, the chair and ranking minority member of the Committee on Rules and Administration; Senators Joe Lieberman and Susan Collins, the chair and ranking minority member of the Committee on Homeland Security and Governmental Affairs; and the floor leaders themselves. By the end of March, members of the group had introduced two measures: S. 679 , the Presidential Appointment Efficiency and Streamlining Act of 2011, and, S.Res. 116 , a resolution to provide for expedited Senate consideration of certain nominations subject to advice and consent. S.Res. 116 was submitted on March 30, 2011, by Senator Schumer on behalf of himself and 14 other Senatorsâincluding all members of the nominations reform working groupâand was referred to the Committee on Rules and Administration. The Rules Committee met on May 11 and ordered the resolution reported favorably by voice vote without amendment. The Senate took up S.Res. 116 for consideration on June 29. Three amendments to the resolution were proposed and considered, with a package of negotiated and technical changesâreferred to as a "managers' amendment"âultimately being agreed to. The first amendment, proposed by Senator Tom Coburn, contained language requiring reporting requirements on legislation creating new federal programs. The amendment was not agreed to, 63-34, after failing to achieve a two-thirds threshold for adoption, pursuant to an earlier unanimous consent agreement. A second amendment, proposed by Senator Tom Harkin on behalf of Senator Tom Udall, would have amended Senate Rule XXII to establish a majority-vote threshold for invoking cloture on executive branch nominees. This amendment was ruled out of order by the chair. The final amendment, offered by Senator Schumer, included provisions that expanded the positions to be considered as privileged nominations (including several full-time chief financial officers and certain assistant secretaries) and required that future legislation proposing new presidentially appointed positions be accompanied by a justification report. The amendment was adopted by unanimous consent. The Senate agreed to S.Res. 116 , as amended, by a vote of 89-8, on June 29, 2011. Terrorism Risk Insurance Program Reauthorization Act of 2015 H.R. 26 , the Terrorism Risk Insurance Program Reauthorization Act of 2015, during the 114 th Congress (2015-2016), created a new 13-member Board of Directors for the National Association of Registered Agents and Brokers and designated these positions as privileged nominations established by S.Res. 116 (112 th Congress). To date, this legislation marks the first and only expansion of the privileged nominations category. The language establishing these new privileged nominations first appeared in the 113 th Congress (2013-2014) with the introduction of S. 534 , the National Association of Registered Agents and Brokers Reform Act of 2013. The legislative history of S. 534 offers no additional comment on the designating of these 13 positions as privileged nominations. Nonetheless, these positions fit the general profile of the type of nominations for which expedited consideration was designed (e.g., part-time boards and commissions). Privileged Nominations Referred to Committee The Senate has considered 467 privileged nominations since S.Res. 116 was agreed to on June 29, 2011. Of those 467, 22 (4.7%) have been referred to committee at the request of a Senator. This rate of referral suggests that Senators are generally deferential to the expedited committee consideration of privileged nominations. Table 1 provides data on these 22 instances of requested referrals. Each entry contains identifying information about the nomination, including the Congress when the nomination was submitted, the name of the nominee, the position to which he or she was nominated, and the final disposition of the nomination by the Senate. Table entries also note the committee of jurisdiction for each nomination and a column indicating whether the Senator requesting referral was a member and/or leader of that committee at the time he or she made the request. As previously discussed, under the provisions of S.Res. 116 , any Senator has the right to request that a privileged nomination be referred to its committee of jurisdiction. The vast majority of these requests have been by a Senator on the nomination's committee of jurisdiction. Of the 22 instances where a privileged nomination has been referred, 20 have been made by a Senator from the committee of jurisdiction. Furthermore, 14 of those 20 requests were made by either the chair or ranking member of the committee of jurisdiction. Appendix. Privileged Nominations


"The Afghanistan Papers" On December 9, 2019, the Washington Post published a series of documents termed "the Afghanistan Papers" (herineafter "the Papers"). The Papers comprise two sets of documents: Notes and transcripts of interviews with more than 400 U.S. and other policymakers conducted between 2014 and 2018 by the Special Inspector General for Afghanistan Reconstruction (SIGAR), and Approximately 190 short memos (referred to as "snowflakes") from former Secretary of Defense Donald Rumsfeld, dating from 2001 to 2004. The Washington Post contends that "the Lessons Learned interviews broadly resemble the Pentagon Papers, the Defense Department's top-secret history of the Vietnam War," although the SIGAR interviews and Pentagon Papers differ in several key ways. Perhaps most importantly, the Pentagon Papers were a contemporaneous recounting of the Vietnam War based mostly on classified material from the Office of the Secretary of Defense; the SIGAR Lessons Learned documents are unclassified records of interviews with a wide array of policymakers carried out as many as 15 years after the events described. The documents, and the Washington Post stories that accompany them, suggest that U.S. policies in Afghanistan often were poorly planned, resourced, and/or executed. These apparent shortcomings contributed to several outcomes that either were difficult to assess or did not fulfill stated U.S. objectives. The documents, released at a time when the United States is engaged in talks with the Taliban aimed at ending the 18-year U.S. military presence in the country, have attracted attention, and some Members of Congress have called for further investigation into U.S. policy in Afghanistan. However, there is debate over how revelatory the SIGAR interviews are, with some analysts contending that the information they contain was available at the time and remains so today (see " Reactions to "the Afghanistan Papers" below). SIGAR "Lessons Learned" Interviews SIGAR, an independent investigative body created by Congress in 2008, conducted interviews with hundreds of U.S. and other policymakers as part of a lessons learned project, a self-assigned effort to "identify and preserve lessons from the U.S. reconstruction experience in Afghanistan, and to make recommendations to Congress and executive agencies on ways to improve our efforts in current and future operations." Since 2015, SIGAR has published seven lessons learned reports on topics such as corruption, counternarcotics, and U.S. efforts to reintegrate ex-combatants. The Washington Post obtained the interview notes and transcripts after submitting a series of Freedom of Information Act (FOIA) requests beginning in August 2016. In response to an October 2017 lawsuit against SIGAR filed by the newspaper, SIGAR released the first document, a 10-page 2015 interview with Michael Flynn (who had served in several senior military capacities in Afghanistan). SIGAR subsequently released other requested documents to the Washington Post . After federal agencies reviewed the documents to determine whether they contained classified material, the final batch of interviews was delivered in August 2019. In total, SIGAR conducted 428 interviews with U.S., European, and Afghan officials. Sixty-two interviewees are identified while 366 are redacted; the Washington Post has sued SIGAR to disclose those names because, it argues, "the public has a right to know which officials criticized the war." SIGAR contends that those individuals should be seen as whistleblowers and may face professional or other harm if their identities are made public. As of January 2020, a decision from the U.S. District Court in Washington, DC, remains pending. Main Themes In reviewing the Papers, which total roughly 2,000 pages and evade simple characterization, several key themes emerge, as outlined below. Dates in parentheses or noted in the text indicate when the interview was conducted. Quotes in this report, unless noted in the text as direct quotes from transcripts, are from SIGAR notes of interviews; CRS cannot independently verify or otherwise characterize the documents and the interviews the documents purport to describe. At least four of the named interviewees have contested the views attributed to them by SIGAR. Negative Effects of U.S. Funding The most frequently discussed subject in the SIGAR interviews was (a) the large sum of U.S. money ($132 billion in development assistance since 2001) that poured into Afghanistan and (b) the extent to which much of it was reportedly wasted, stolen, exacerbated existing problems, or created new ones. Nearly every SIGAR interviewee who discussed the issue argued that Afghanistan, one of the world's poorest and least developed countries in 2001, was unable to make use of the amount of financial resources that the U.S. and its international partners channeled into the country. Variations of the phrase "absorptive capacity" were repeated throughout the SIGAR interviews. One unnamed national security official offered some specificity, saying that Ashraf Ghani, then the Afghan Finance Minister and now President, had said in 2002 that "the Afghan capacity to absorb money was $2 billion a year, max. Everything else was wasted money" (October 1, 2014). The United States alone has contributed over $7 billion a year on average since 2001. In answering why the United States delivered so much money into Afghanistan, many interviewees pointed to U.S. domestic politics. One U.S. Agency for International Development (USAID) official said, "How much money was put into political, military, and development [aid] became a proxy for our commitment" (December 9, 2015). This was largely driven by executive branch agencies, according to one unnamed official, who observed that the U.S. Office of Management and Budget (OMB) proposed reductions between 2005 and 2007 because money from previous years remained unspent (April 13, 2015). However, other policymakers rejected these reductions, arguing that "the political signal by a budget reduction at [a] turning point in the war effort would adversely affect overall messaging and indirectly reconstruction efforts on the ground. The articulation of goals for the purpose of budgeting and programming was largely secondary to the political implications of budgeting." However, some of those interviewed by SIGAR faulted Congress, not executive branch agencies, for wasteful spending. The same USAID official quoted above (December 9, 2015) said, "The Hill was complicit. They gave more money than was requested. Every year they asked why we weren't doing our jobs, but they gave the same amount of money or more." Douglas Lute, the Deputy National Security Advisor for Iraq and Afghanistan under President George W. Bush and President Obama, noted that Congress was subject to the same kinds of political pressures that drove executive branch officials to push for higher budgets in the absence of evidence that the funds would be effective: In terms of appropriations, Congress appropriated what the administration asked for.... The thought is that if we don't spend, [the Government Accountability Office] or committees on the Hill will stop us from getting more funding. This leads to spend, spend, spend. The reason this is happening: no one is paying attention in an interagency sense to resources.... We were also pouring money into huge infrastructure projects to obligate money that was appropriated to show we could spend it. And we were building infrastructure in ways that Afghanistan could never sustain or even use in some cases. This approach to resource allocation extended down the chain of command, according to some interview subjects. An unnamed U.S. Army civil affairs officer said that costs kept rising because "We had no reason to negotiate or hold contractors' feet to the fire because the money kept coming no matter what.... We didn't get credit for saving money; in fact, we got credit for spending it" (July 12, 2016). Another said (on June 27, 2016) that because he or she was not given guidance on how to measure the impact of certain projects, "dollar figures were always the metric. No one said that money spent should be our metric, but without guidance, it was the only metric we could use.... We did not stop and look back at what happened and whether it was effective. The emphasis was on completing more projects." What was the impact of this flow of money on Afghanistan itself? Nearly all SIGAR interviewees contended that U.S. funding improved conditions in the country with regard to health, education, and other human development indicators, at least partly given the low level of the country's development in 2001 (see " Other Voices: U.S. Efforts as Relatively Successful " below). However, some positive assessments were qualified: one unnamed Afghan official said that "Yes, we have made gains, and generally speaking, life is better for people." However, he or she goes on to ask, "When we compare the gains to the resources, were the gains enough? No. ... Were the gains that were made sustainable? No. Most of the gains remain fragile" (October 21, 2015). For some interviewees, this influx of money also created or exacerbated problems. One of the problems most often raised was the money's apparent role in helping drive corruption, which continues to undermine the very Afghan state that the funds were intended to support. Andrew Wilder, the Vice President of Asia Programs at the United States Institute of Peace, said in his SIGAR interview that, "Giving Afghans so much money actually delegitimized the government, which was either perceived to become more corrupt or actually became more corrupt as a result, and favored specific communities at the expense of others" (January 25, 2017). Beyond the possibility for Afghans to redirect U.S. aid flows for political purposes, several interviewees argued that U.S. assistance had a structural bias that created perverse incentives for Afghans. Former Afghan deputy cabinet minister Tariq Esmati said (on December 12, 2016) that "all the attention was to the insecure districts. And the districts that were relatively secure also became insecure in order to get some programs." One USAID official put it more bluntly: development programs targeted "worse case scenarios and [the] most insecure areas" which "rewarded bad behavior. Governors in [more secure areas] would come to Kabul and ask, "what do I have to do to get love from [the] Americans, blow some shit up?" (November 18, 2016). In many cases, interviewees pointed to the grant contracting system to explain why so much money was wasted and to argue that few of the benefits were actually reaped by Afghans themselves. A senior U.S. official said (on December 11, 2015) We would buy American products, American grain, American consultants, American security experts, and they would implement our aid programsâ¦. The Afghans used to tell me that somewhere between 10-20% actually shows up in Afghanistan, and less than 10% ever gets to a village. So you [the United States] tell us [the Afghans] that you just spent a billion dollars as we see $50 million worth of roads. You [the United States] hire a big contractor and inside the beltway consultant, who then hires 15 subcontractors. The first guy takes 20%, then next level takes 20% who would go hire a bunch of expensive American experts to do [for 10 times the price] what Afghan diaspora refugees or Indian experts could do.... [These Americans we hire] travel to Afghanistan first class or at least business class with five security guys each.... The money you spend doesn't get to the village, doesn't really help the Afghan government. Beyond the practical effect of enabling corruption, some interviewees argued that ready U.S. money warped Afghan political culture (from a July 31, 2015, interview with a U.N. official): Afghan perceptions of the US were shaped by the Emergency Loya Jirga and Constitutional Loya Jirga [consultative assemblies held in 2002-2003].... Religious leaders were approached [and they] received nice packages from the US in return for accepting certain measures on women, human rights. The perception that was started in that period: If you were going to vote for a position that the [U.S. government] favored, you'd be stupid to not get a package for doing it. So that even those in favor would ask for compensation.... So from the beginning, their experience with democracy was one in which money was deeply embedded. Unclear U.S. Goals Many of the interviewees argued that, from the beginning, the U.S. engagement in Afghanistan, supported by the flow of money noted above, lacked a clear goal. One unnamed former National Security Council (NSC) staffer said, "I don't think we had an end state in mind. We kept planning; conditions kept changing. We were solving problems but there was no end state vision that you could point to" (January 5, 2015). According to many respondents, lack of clarity was a product of how many objectives the U.S. had in Afghanistan. One USAID official (May 18, 2015) described U.S. policy as having "a present under the Christmas tree for everyone. By the time you were finished you had so many priorities and aspirations it was like no strategy at all. If you have 50 priorities then you don't have any priorities at all." This confusion reportedly extended even into specific areas of U.S. policy. An unnamed former United Nations official said in a June 1, 2015, interview that "on reconstruction, there was not a clear understanding of what we were trying to achieve; [there were] no clear objectives." On counternarcotics (CN), a former State Department official said that it was "unclear what the goal of CN was" (June 29, 2015). Competing Priorities The proliferation of U.S. goals in Afghanistan apparently led to another complication: U.S. actions to achieve some of these objectives undermined others. Interviewees repeatedly discussed this dynamic, particularly when referring to the U.S. project as being divided into military and nonmilitary lines of effort. According to interviewees, when U.S. security interests clashed with interests less directly tied to security, the former almost always prevailed. The two areas that the interviews identified as particularly compromised, given an emphasis on security or other issues, were counternarcotics and anti-corruption. A State Department counternarcotics contractor told SIGAR on September 16, 2016, that "To the best of my knowledge chief of mission [in the U.S. embassy] never carried [the] message about CN to [the] Afghan government. Attitude was 'got so much else on my plate I have no time to deal with drugs.'" A senior U.S. official put it simply: "They [the United States] would payoff â¦ local leaders to not fight them and would turn away when local leaders grew poppy" (March 29, 2016). On anti-corruption, the contrast may have been even clearer: a USAID official said that the view of senior U.S. officials was "Be patient, we can get back to corruption. We have higher priorities on getting the bad guys" (August 24, 2015). In July 2015, a Treasury Department official attributed the U.S. "failure to be more aggressive" on prosecuting those responsible for the 2010 collapse of Kabul Bank (KB) to the higher importance placed on security objectives: "Petraeus made the point that yes KB is bad, but we're fighting a war here, there are bigger issues at stake." Sometimes even U.S. counternarcotics and anti-corruption goals, which appeared symbiotic according to some interviewees, were at odds: a former U.S. defense official said on May 17, 2016, that U.S. payments to governors to reduce poppy cultivation actually "undermined good governance. People saw us as complicit working with corrupt governors to take out opposition" when those governors targeted the opium cultivation of their political opponents but left alone opium cultivation of their allies. Some U.S. officials argued that these contradictions were unavoidable, and that the United States had no choice but to pursue security interests over other, and by definition secondary, objectives. A former U.S. official at the U.S. Embassy said (on May 31, 2015) of the U.S. decision to partner with warlords with records of corruption or human rights abuses, "I'm not so sure we should have done it any differently. These 'warlords' equaled the ground force that just defeated the Taliban and al Qaedaâon the ground with US SOF [Special Operations Forces]. ... [T]hese weren't just random bandits running around." Organizational Confusion and Competition While U.S. efforts in Afghanistan were dominated by the Department of Defense, given the wide array of U.S. interests in Afghanistan, U.S. policy formulation and execution required input from many federal departments and agencies. The problems associated with trying to coordinate among all of these entities, and with the complex series of bureaucratic structures erected to facilitate that coordination, were another consistent theme of the SIGAR interviews. By most accounts, interagency coordination was a consistent problem that various structures failed to solve. The performance of the Washington, D.C.-based Afghanistan Interagency Operation Group (AOIG), which was created in 2003, was co-chaired by the Department of State and National Security Council, and met weekly, generally received favorable reviews from interviewees. The State Department's Coordinator for Reconstruction and Stabilization (SCRS), on the other hand, attracted particular criticism: various officials stated that it was "expensive and time-consuming ... initially structured to fail and at the end it only made life horrible for everybody else" (June 25, 2015) and "failed at the operation level" (July 10, 2015). The State Department's Special Representative for Afghanistan and Pakistan (SRAP), established in 2009 and closed in 2017, also generally was criticized. One typical critique, from an unnamed State Department official in a December 10, 2014, interview, said that "the model is not sustainable. Desk officers are supposed to develop regional experience throughout their career so they have a couple of languages and they continually rotate back to their area or region of specialization.... The SRAP set up created parallel structures." Anti-corruption, counternarcotics, and other mission priorities rarely fit neatly under one agency or department's purview. The wide range of actors with equities in programs in these areas arguably bred not just confusion but competition. One former development contractor said about counternarcotics (interview on June 8, 2016) that there was "nobody really in charge, no one on top of the heap and saying to everyone this is what you need to do. Competitive personalities [were] not concerned about what makes sense but could they build their career." That competition, in turn, also presented opportunities for Afghans to exploit. An unnamed former US ambassador described for SIGAR interviewers on December 14, 2015, that "[former Afghan president Hamid] Karzai was trying to figure out how to manipulate the U.S., manipulating different U.S. agencies against one another for leverage. â¦ The mission starts to lose coherence; you have agencies snapping at each other' s ankles [italics original]." Surveying the numerous problems of interagency coordination, Marin Strmecki, Secretary of Defense Rumsfeld's special advisor on Afghanistan, recommended (interview on October 19, 2015) a more unified command structure: When we operate in something like [Afghanistan], there needs to be unity of command, not unity of effort. So if it is a situation [where] there is a lot of lead flying in the air, it makes sense for the general of whatever task force that is deployed to be in charge of both the military and civilian elements. So the ambassador would essentially be his chief political officer. He should be able to give orders to that chief political officer just as he would another subordinate. Similarly, if it is more a stabilization operations and there is not as much lead flying in the air, the military should be put under the ambassadorâ¦. Our current system works if you are lucky and you get a Khalilzad and Barno or a Petraeus and Crocker, where for some reason they all agree on the priorities and work well together. They are in sync. That is basically luck. Lack of Expertise Multiple SIGAR interviewees criticized U.S. policies that they claimed either failed to generate relevant expertise within the U.S. government or even disincentivized the creation or application of that expertise in Afghanistan. For instance, regional subject matter expertise was a frequently cited problem. A number of interviewees criticized the United States for not training U.S. staff in local languages. Without knowledge of these languages, U.S. officials were reportedly less able to learn from, build trust with, or effectively partner with Afghan counterparts. Former director of intelligence for the NATO-led military effort Michael Flynn said that when we get to Afghanistan [in 2009], there is only one officer on the ISAF staff that could speak Dari â¦ but he was only there briefly. The Air Force pulled him out in like July and sent him to Japan.... [W]e laughed about it because this is how insane this [system] is.... Even today, we are still in Afghanistan and you go tell me how many actual U.S. members of the military or policy [community], or from State who speak Dari or Pashto. That is a shame and that is a policy decision. The most commonly cited problem, regardless of the interviewee's national origin, position in government, or time of service in Afghanistan, was the loss of expertise and trust brought about by short-term deployments. A commonly repeated theme, as one U.S. official put it (April 12, 2016), was that the U.S. did not have one "14 year engagement, [but] had 14 1-year engagements." Numerous interviewees described the problems created by short tours as the greatest detriment to U.S. policy success: "At the strategic level, the single most disabling factor was our failure to maintain long-term leadership at the Embassy and at our military commands. We should have someone in the job for 3 to 5 years for continuity" (former U.S. official at the embassy in Kabul, May 31, 2015). "If you take away one thing, the one year rotation for USAID, DOS [Department of States] and DOD [Department of Defense] personnel is the biggest obstacle to success and the biggest single factor in our failure" (former USAID official David Marsden, December 3, 2015). "Biggest problem was turnover of people â¦ the result is no institutional memory" (June 27, 2016). The interview records suggest that there was no consensus on how to solve this problem. One proffered solution was higher pay for government employees deployed to Afghanistan: Strmecki said in his interview that talented staff leave "the government for our contractors and NGOs and our other implementing partners because [they] pay them so much more." However, one unnamed legal advisor who worked in Kabul said (on October 30, 2017) higher pay for some U.S. positions meant that those who filled the jobs "had very little understanding of the cultureâthey came in because the salary was lucrative.... [T]hey saw this as a couple of years of opportunity to get rid of their house mortgages." Lack of expertise arguably exacerbated many of the other problems facing U.S. policy. At times, Afghans reportedly exploited the lack of knowledge and institutional memory to shape U.S. policy to meet their own ends. In one extreme case, Afghanistan expert Thomas Johnson described how "we were used by the tribes" because suspects taken into custody by the United States as terrorists were actually "traditional tribal enemies that [U.S. partners] claimed were Taliban" (January 7, 2016). Multinational Coalition: Too Many Cooks? U.S. efforts in Afghanistan have been aided from the outset by a multinational coalition. From combat, to training Afghan forces, to providing development assistance, U.S. allies and partners have made significant contributions. However, this work has not been without complications, and many of the SIGAR interviewees who worked on coordinating U.S. and international efforts discussed what they saw as deficiencies. The system that emerged in Afghanistan became known as the "lead nation" system, whereby each policy area was overseen by a different country: for example, Italy focused on developing Afghanistan's justice sector, Germany worked with Afghan police, and the British initially were responsible for counternarcotics. However, according to former National Security Advisor Stephen Hadley, "With this [multilateral] approach, everyone had small pieces of the sector and it then meant that [their respective policy areas] became everyone's second or third order priority so nothing got done." Generally, interviewees who observed or participated in the system described it as disorganized: John Wood, NSC director for Afghanistan 2007-2009, said, "Everyone has a piece of the pie but [there's] no coherence.... Each lead nation left to determine how to approach thingsâeach changed frequently. Even if things lined up with the lead nation none of them moving at same pace" (June 17, 2015). The difference in pacing and approach was explained by an unnamed NSC staffer, who argued "tasks were conditioned by what countries were willing to do," which "created some tensions between the coalition and the nation states" (July 14, 2015). Iraq as a Distraction Those U.S. officials SIGAR interviewed who worked on Afghanistan in the first decade of the war held a near-universal judgment that the U.S. invasion of Iraq in March 2003 distracted U.S. attention and diverted U.S. financial and other resources, allowing the Taliban to regroup. Former U.S. Ambassador to NATO Nicholas Burns described Iraq as the "higher priority" and Afghanistan as "the less acute theater." According to an unnamed NSC staffer (October 21, 2014) More specifically regarding why the U.S. and Department of Defense were anxious for someone else to take a robust leading role in Afghanistan, it was so we could have greater resources and capability to prioritize Iraq. ... From early spring 2002, during my time at the Secretary's office, until 2011, Afghanistan has to be looked at with one eye on what is happening in Iraq. Even in the early and tail end (2009-2011) days, either materially or politically, it all seemed to be about Iraq. It was hard to come to terms with the reality that your whole portfolio is a secondary effort or, at worst, an "economy of force" mission. Your job was not to win, it was to not lose â¦ We are bleeding resources away as things get worse in Iraq, and we were looking for more ways to make do in Afghanistanâ¦. In hindsight, there was a window between late 2002-2003 and early 2005 where there was relative peace in Afghanistan. The Taliban was on its heels and people were not that disillusioned. One official (interviewed on September 23, 2015) said that between 2005 and 2007, "Iraq was all we could handle." Another said that a "significant pressure in the 2003 to 2010 timeframe was the draw of resources toward Iraq and away from Afghanistan" (April 13, 2015). By the time the United States began to draw down forces in Iraq and refocus on Afghanistan, many observers argued that the damage was already done: the Afghan state's military and governing capabilities (both effectively nonexistent in 2001) had not been adequately developed, allowing for the rise of a new Taliban insurgency that further undermined those abilities. One unnamed U.S. official said in a February 9, 2016, interview, "In all honesty, Afghanistan got neglected when we went to Iraq and when we got back to Afghanistan, we didn't have enough capacity." Pakistan's Support for the Taliban The war in Iraq arguably distracted U.S. policymakers from dealing with Pakistan's role in facilitating the Taliban's comeback. Early on, Pakistan "was not seen as bad guys," according to an international aid consultant in an October 9, 2015, interview. A number of interviewees, particularly senior U.S. officials, attributed the Taliban's resurgence, and the resulting failure of the U.S. to solidify gains in Afghanistan, to material support for the group from, and its safe havens in, Pakistan. A good deal of material related to the sensitive issue of Pakistani support for the Taliban appeared to be redacted, but the issue still emerged throughout the interviews. Most interviewees who addressed the subject argued that U.S. and Pakistani interests in Afghanistan were fundamentally incompatible. One unnamed DOD or NSC staffer told SIGAR in an October 1, 2014, interview, "The belief that Pakistan's national interest aligned with the US because [then-Pakistani leader Pervez] Musharraf joins the [U.S.] effort after 9/11 is a false belief." According to this view, the positive role Pakistan played with regard to Al Qaeda blinded U.S. policymakers to the Pakistanis' support for the Taliban. As Strmecki said in his October 19, 2015, interview, Because of people's personal confidence in Musharraf and because of things he was continuing to do in helping police up a bunch of the al-Qaeda in Pakistan, there was a failure to perceive the double game that he starts to play by late 2002, early 2003. You are seeing the security incidents start to go up and it is out of the safe havens. I think that the Afghans and Karzai himself, are bringing this up constantly even in the earlier parts of 2002. They are meeting unsympathetic ears because of the belief that Pakistan was helping us so much on al-Qaeda. With U.S. attention to the issue reportedly low, Pakistan maintained support for the Taliban in order to maintain some of Pakistan's influence in Afghanistan. In at least one account, Pakistani leaders were forthright in private about this strategy. In the transcript of his January 11, 2016, interview with SIGAR, Ryan Crocker, who served as U.S. ambassador to both Pakistan (2004-2007) and Afghanistan (2011-2012), quoted then-head of Pakistan's intelligence agency (ISI, Inter-Services Intelligence) Ashfaq Kayani as telling him You know, I know you think we're hedging our bets, you're right, we are because one day you'll be gone again, it'll be like Afghanistan the first time [when the United States turned away from Afghanistan after the Soviet withdrawal in 1989], you'll be done with us, but we're still going to be here because we can't actually move the country. And the last thing we want with all of our other problems is to have turned the Taliban into a mortal enemy, so, yes, we're hedging our bets. Other Problems Beyond the main themes discussed above, other issues impacting U.S. policymaking in Afghanistan surfaced throughout the SIGAR interviews: Positivity bias (e.g., Flynn interview on November 11, 2015: "As intelligence makes it way up higher [within the bureaucracy], it gets consolidated and really watered down; it gets politicized â¦ because once policymakers get their hands on it, and frankly once operational commanders get their hands on it, they put their twist to itâ¦. Operational commanders, State Department policymakers, and Department of Defense policymakers are going to be inherently rosy in their assessments.") Not considering greater inclusion of or interaction with the Taliban at the outset (e.g., U.N. official on August 27, 2015: "Lesson learned: if you get a chance to talk to the Taliban, talk to themâ¦. At that moment [2001], most â¦ Taliban commanders were interested in joining the government.") Powers granted to Afghanistan's central government (e.g., unnamed U.S. official, October 18, 2016: "why did we create centralized gov't in a place that has never had one â¦ set us up for failure") Other Voices: U.S. Efforts as Relatively Successful Some of the officials interviewed by SIGAR lauded arguable gains made and facilitated by the international community's work in Afghanistan since 2001, a perspective not generally included in the Washington Post stories. A number of interviewees argued, as one unnamed U.S. official did on June 2, 2015, "There's not enough recognition of the scale of achievements in Afghanistanâ¦. Afghanistan has given a higher return on investment than almost any other reconstruction effort. From 2002-2012, [Afghanistan] made more progress in human development than any other country." Others contended (as referenced above) that one cannot assess the success or failure of U.S. efforts without considering the state of the country in 2002: "We have to remember what we were starting with in Afghanistan. Afghans were starting with nothing. Social and economic development was at the lowest level possible. And that's why Taliban and al Qaeda found a home there, and why we went inâ¦. You must look at where we were, what we tried to do, and where we got to" (unnamed senior State Department official April 26, 2016). Some officials outside the United States echoed these sentiments in their interviews. A Danish official said on June 30, 2015, despite corruption and all of the other problems, "we'd be worse off without our [Afghanistan] intervention. The development side has had an impressive record." Abdul Jabar Naimee, who has served as governor of several eastern Afghan provinces, said in his March 6, 2017, interview I am seeing that in the [W]est a thinking is going that they helped the Afghans but it was useless. This is a completely a wrong assumption. In the three provinces where I have been working as governor, in all the three places when I have share[d] programs with the people, or I have participated in the projects['] events, I have seen people are happy with the help they have receivedâ¦. The assumption that people of Afghanistan are not happy with the help that was done for their improvement, this assumption is wrong, people are grateful for the help and they still benefit from the work that was done. Snowflakes (Rumsfeld Memos)8 Former Secretary of Defense Donald Rumsfeld's "snowflakes" (the last of which is dated December 22, 2004), unlike the SIGAR interviews, provide a contemporaneous view into one senior policymaker's thinking over the first several years of the U.S. effort in Afghanistan. Because they are brief and relatively informal, there are risks in taking them as representative of U.S. policy as a whole, but their on-the-ground perspective could still be useful in assessing U.S. policy in Afghanistan. They may also demonstrate that various perceptions noted in the SIGAR interviewsâsuch as that Afghanistan was less of a priority than Iraqâhad merit. Many of the approximately 200 snowflakes are minor; some notable excerpts are below. Rumsfeld apparently did not anticipate long-term U.S. financial support for Afghan security forces. In an April 8, 2002, memo to Secretary of State Colin Powell, Rumsfeld wrote, "The U.S. spent billions freeing Afghanistan and providing security. We are spending a fortune every day. There is no reason on earth for the U.S. to commit to pay 20 percent for the Afghan army. I urge you to get DoS turned around on thisâthe U.S. position should be zero [underline original]. We are already doing more than anyone." Rumsfeld expressed continual concern about not having a plan (e.g., "I am convinced we have to have a plan for Afghanistan and that nobody else in the government is going to do it unless we do. What do you propose?" (October 17, 2002) Rumsfeld expressed an eagerness to reduce U.S. commitments in Afghanistan. In a September 25, 2003, memo to Under Secretary of Defense for Policy Doug Feith, he wrote, "We need a good conceptual speech that describes where the responsibility is (and moves the blame if it fails away from the U.S.), namely on the Afghan people and on the international community." Rumsfeld sought greater input over non-Department of Defense equities. He wrote to White House Chief of Staff Andrew Card on August 19, 2002, requesting "that I have an opportunity to interview any person who is proposed for Ambassador to Afghanistan, before the selection gets made and before the President is involved. The post is very important for the Department of Defense and I would like to have a good sense of who it might be and why." There is some evidence that Afghanistan, by 2003, may not have been a major focus for Rumsfeld. Rumsfeld received a November 7, 2003, letter from Afghan Uzbek leader Abdul Rashid Dostum, who painted a picture of widespread Taliban activity and said "please do not forget the battle against terrorist and extremists in Afghanistan." Rumsfeld forwarded the letter in a memo to CENTCOM Commander General John Abizaid on November 18, 2003, describing the letter as "worrisome" and saying "if he [Dostum] is correct that the Taliban are in control of that many areas within Afghanistan, that is news to me." Reactions to "the Afghanistan Papers" The Washington Post 's "Afghanistan Papers" have attracted significant attention, though policymakers and outside analysts disagree about whether they contain new and relevant information and, if so, what effect this information should have on U.S. policy in Afghanistan going forward. In Congress, most of the Members who reacted publicly did so to reiterate previous calls to remove U.S. troops from Afghanistan. Senator Tom Udall spoke on the Senate floor about the Papers on December 12, voicing support for S.J.Res. 12 , introduced in March 2019 by Udall and Senator Rand Paul. The resolution would, among other provisions, mandate the removal of all U.S. forces from Afghanistan within a year of enactment. Senator Kirsten Gillibrand called for Senate hearings to investigate "these deeply concerning revelations about the Afghan war," and Representative Max Rose said that the Papers demonstrated that "the time to end this war and bring our troops home honorably is now." Top U.S. defense officials largely defended the U.S. conduct of the war, arguing that the Papers did not constitute evidence that former officials had lied to the American public, and that the Papers, as part of a Lessons Learned project, were structured to invite criticism, in hindsight, of the war effort. Pentagon Spokesman Jonathan Hoffman said on December 12, 2019, I would quibble with the idea that we weren't providing [accurate information] in the past. I think what we see from the report from the Washington Post is, looking at individuals giving retrospectives years later on what they may have believed at the time ... those statements appeared for the most part to be people looking back retrospectively on things that they had said previouslyâand using hindsight to speak to comments they had made. Secretary of Defense Mark Esper dismissed claims that officials had lied, saying, "For 18 years now, the media has been over there [in Afghanistan]â¦. The Congress has been there multiple timesâ¦. We've had the SIGAR there. We've had IGs there. This has been a very transparentâit's not like this war was hiding somewhere and now all of a sudden there's been a revelationâ¦. So [the] insinuation that there's been this large-scale conspiracy is just, to me, ridiculous." Chairman of the Joint Chiefs of Staff General Mark Milley, appearing alongside Esper, said, "I know that I and many, many others gave assessments at the time based on facts that we knew at the time. And those were honest assessments, and they were never intended to deceive neither the Congress nor the American people." SIGAR Special Inspector General John Sopko wrote a December 17, 2019, letter to the editor of the Washington Post disputing some of the Post 's characterizations and saying that "the Afghanistan Papers is an important contribution to public discourse about the war in Afghanistan. But it is not a 'secret' history. SIGAR has written about these issues for years, including in seven Lessons Learned reports and more than 300 audits and other products." On January 15, 2020, Sopko testified in front of the House Foreign Affairs Committee that U.S. policy in Afghanistan has been characterized by "institutional hubris and mendacity" and that "We have incentivized lying to Congress.... [T]he whole incentive is to show success and to ignore failure and when there's too much failure, classify it or don't report it." Outside observers have offered differing views of the Papers. One concurred with the Post 's assessment that in the Papers, "officials' indictment of policies for which they themselves were responsible lays bare the massive institutional deceit that forms the heart of what the United States has done" in Afghanistan. Other observers have taken a softer line. One wrote, "it is apparent from the documents that many officials in power attempted to 'spin' a spiraling Afghanistan conflict for the public," though they did so because "the U.S. government has every incentive to paint a better picture of progress than is the reality on the ground." Still others have argued that the Papers contain little that has not already been readily and publicly available for years: "the only new information here is the identity of those making the criticisms." Those making this argument have pointed to reports from SIGAR (including their seven publicly released Lessons Learned reports for which the interviews in "the Afghanistan Papers" were conducted) and other inspectors general, as well as media, academic, and other public accounts. One summarizes, "In short, if you're surprised by the Afghanistan Papers, you haven't been paying attention." Another observer criticizes the Post for "putting sensationalist spin on information that was not classified, has already been described in publicly available reports, only covers a fraction of the 18 years of the war, and falls far short of convincingly demonstrating a campaign of deliberate lies and deceit." Given that there has been evidence of shortcomings in the U.S. war and development effort for years, one observer argues that "Afghanistan is best seen, not as a morality play, but as a classic foreign policy dilemma in which all the options are bad ones": Reasonable people can debate, with the benefit of hindsight, whether the United States should have accepted these risks as the price of avoiding another two decades of war. But the tragic dilemma of Afghanistan is that there have always been costs of withdrawal as well as costs of continued intervention. Possible Questions for Congress "The Afghanistan Papers" raise a number of potential questions for Congress to consider as Members evaluate the Trump Administration's Afghanistan policies. U.S. Strategy . What role, if any, has Congress played in compelling successive executive branch administrations to articulate U.S. strategy and/or policy goals in Afghanistan? What are the means by which Congress has attempted to shape or influence those goals? What have been the most and least effective of those means? Congressional Oversight . Members of Congress have conducted oversight of executive branch policy through various means, including appointing a special inspector general, public and closed hearings, Member and staff delegations to Afghanistan, letters to executive branch officials, and public statements. What have been the most and least effective methods of congressional oversight? U.S Aid: Budgeting. To what extent has Congress scrutinized executive branch funding requests? Have appropriated U.S. funding levels differed from those requests and if so, what changes have been made and why? To what extent have congressional budgeting decisions in Afghanistan been made due to political expediency? How, if at all, can Members of Congress insulate budgeting or other policymaking processes from political pressures? U.S. Aid: Conditionality. What conditions has Congress imposed on U.S. aid to Afghanistan and why? How, if at all, have those conditions impacted the delivery of U.S. aid, Afghan government actions, U.S.-Afghan relations, and congressional interactions with the executive branch? What kinds of changes, if any, to the Foreign Assistance Act or other relevant pieces of legislation might make U.S. development assistance more effective? Reporting . What has been the impact of congressionally mandated reporting on policy or outcomes? How, if at all, does Congress use these reports? What are the most and least useful reports that Congress receives on U.S. military and development efforts in Afghanistan? How, if at all, does Congress require agencies to evaluate their programs, and how does this inform reports to Congress? Has there been any evolution in specific monitoring and evaluation requirements? Bureaucracy. How has Congress shaped executive branch structure? Have these efforts been helpful? How direct a role should Congress play in mandating the establishment or nature of offices or other bureaucratic structures within the executive branch that work on Afghanistan? Personnel Issues . To what extent have U.S. efforts in Afghanistan been hampered by the frequent personnel turnover cited by many SIGAR interviewees? How, if at all, have congressional actions improved, undermined, or otherwise affected the ability of federal agencies to train and deploy capable workforces in Afghanistan? What congressional action, if any, is needed to help the executive branch, or individual departments, address this issue? Recommendations . What are the most important things that Congress could have been doing over the past 18 years to ensure U.S. success in Afghanistan? What can (and should) Congress do going forward?


About the U.S. Department of Health and Human Services (HHS) The mission of HHS is to "enhance the health and well-being of Americans by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services." HHS is currently organized into 11 main agencies, called operating divisions (listed below), which are responsible for administering a wide variety of health and human services programs, and conducting related research. In addition, HHS has a number of staff divisions within the Office of the Secretary (OS). These staff divisions fulfill a broad array of management, research, oversight, and emergency preparedness functions in support of the entire department. HHS Operating Divisions Eight of the HHS operating divisions are part of the U.S. Public Health Service (PHS). PHS agencies have diverse missions in support of public health, including the provision of health care services and supports (e.g., IHS, HRSA, SAMHSA); the advancement of health care quality and medical research (e.g., AHRQ, NIH); the prevention and control of disease, injury, and environmental health hazards (e.g., CDC, ATSDR); and the regulation of food and drugs (e.g., FDA). The three remaining HHS operating divisionsâACF, ACL, and CMSâare not PHS agencies. ACF and ACL largely administer human services programs focused on the well-being of vulnerable children, families, older Americans, and individuals with disabilities. CMSâwhich accounts for the largest share of the HHS budget by farâis responsible for administering Medicare, Medicaid, and the State Children's Health Insurance Program (CHIP), in addition to certain programs related to private health insurance. (For a summary of each operating division's mission and links to agency resources related to the FY2021 budget request, see the Appendix .) Context for the FY2021 President's Budget Request The Budget and Accounting Act of 1921 (P.L. 67-13), as amended, requires the President to submit an annual consolidated federal budget to Congress at the beginning of each regular congressional session, not later than the first Monday in February. Many of the proposals in the President's budget would require changes to laws that govern mandatory spending levels or policies, which are typically established on a multiyear or permanent basis. Discretionary spending , however, which is roughly one-third of the budget, is decided and controlled each fiscal year through the annual appropriations process. While Congress is ultimately not required to adopt the President's proposals or recommendations, the submission of the President's budget typically initiates the congressional budget process and informs Congress of the President's recommended spending levels for agencies and programs. The FY2021 President's budget request was submitted to Congress on February 10, 2020. Less than two months before this, all 12 of the annual appropriations acts for FY2020 had been enacted into law on December 20, 2019. The FY2020 funding levels shown in FY2021 President's budget materials generally reflect enacted annual levels, with limited exceptions. The exceptions include cases in which full-year mandatory funds had not yet been provided for programs typically funded outside of the annual appropriations process (e.g., mandatory funding for the Temporary Assistance for Needy Families Block Grant or the Community Health Center Fund). In such cases, the FY2021 President's budget generally uses estimated FY2020 funding levels based on annualized amounts provided in the most recent short-term funding extensions. Because some FY2020 amounts have not been finalized, this report generally refers to FY2020 funding levels as estimates , whereas amounts for earlier years are called actual or final . In addition, amounts shown for FY2020 do not include supplemental appropriations or other spending effects resulting from coronavirus disease response measures that have been enacted since the FY2021 President's budget request was submitted. Overview of the FY2021 HHS Budget Request Under the President's budget request, HHS would spend an estimated $1.370 trillion in outlays in FY2021 (see Table 1 ). This is $48 billion (+4%) more than estimated HHS outlays in FY2020 and about $156 billion (+13%) more than actual HHS outlays in FY2019. Historical estimates by the Office of Management and Budget (OMB) indicate that HHS has accounted for at least 20% of all federal outlays in each year since FY1995. Most recently, OMB estimated that HHS accounted for 27% of all federal outlays in FY2019, and projects that it would account for 28% of outlays if all proposals in the President's budget request were enacted. Figure 2 displays proposed FY2021 HHS outlays by major program or spending category in the President's request. As this figure shows, mandatory spending typically accounts for the vast majority of the HHS budget. In fact, two mandatory spending programsâMedicare and Medicaidâare expected to account for 86% of all estimated HHS spending in FY2021. Medicare and Medicaid are entitlement programs, meaning the federal government is required to make mandatory payments to individuals, states, or other entities based on criteria established in authorizing law. This figure also shows that discretionary spending accounts for about 8% of estimated FY2021 HHS outlays in the President's request. Although discretionary spending represents a relatively small share of total HHS spending, the department nevertheless receives more discretionary funding than most federal departments. According to OMB data, HHS accounted for almost 8% of all discretionary budget authority across the government in FY2019. The Department of Defense was the only federal agency to account for a larger share of all discretionary budget authority in that year (50%). Budgetary Resources Versus Appropriations As previously mentioned, the HHS budget reflects funding from a broad set of budgetary resources that includes, but is not limited to, the amounts provided to HHS through the annual appropriations process. As a result, certain amounts shown in FY2021 HHS budget materials (including amounts for prior years) will not match amounts provided to HHS by annual appropriations acts and displayed in accompanying congressional documents. There are several reasons for this, discussed briefly below. Mandatory and Discretionary Spending Mandatory spending makes up a large portion of the HHS budget. Whereas all discretionary spending is controlled and provided through the annual appropriations process, all mandatory spending is controlled by the program's authorizing statute. In most cases, that authorizing statute also provides the funding for the program (e.g., State Children's Health Insurance Program). However, the budget authority for some mandatory programs (including Medicaid), while controlled by criteria in the authorizing statute, must still be provided through the annual appropriations process; such programs are commonly referred to as appropriated entitlements or appropriated mandatories . Certain budget documents may show only discretionary spending, while others may also show some or all types of mandatory spending. HHS in the Appropriations Process The HHS budget request accounts for the department as a whole, while the appropriations process divides HHS funding across three different appropriations bills. Most of the department's discretionary appropriations are provided through the Departments of Labor, Health and Human Services, and Education, and Related Agencies (LHHS) Appropriations Act. However, funding for certain HHS agencies and activities is provided in two other billsâthe Departments of the Interior, Environment, and Related Agencies Appropriations Act (INT) and the Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Appropriations Act (AG). Table 2 lists HHS agencies by appropriations bill. Each of these three appropriations acts provides discretionary HHS funding. In some cases, these acts also provide the necessary funding for appropriated mandatories at HHS. However, authorizing laws provide funding for other mandatory spending programs. Proposed Law and Current Law Estimates for Mandatory Programs HHS budget materials include two different estimates for mandatory spending programs when appropriate: proposed law and current law . The p roposed law estimates take into account changes in mandatory spending proposed in the FY2021 HHS budget request. Such proposals would generally need to be enacted into law to affect the budgetary resources ultimately available to the mandatory spending program. HHS materials may also show a current law or current services estimate for mandatory spending programs. These estimates assume that no changes will be made to existing policies, and instead estimate mandatory spending for programs based on criteria established in current authorizing law. The HHS budget estimates in this report reflect the proposed law estimates for mandatory spending programs, but readers should be aware that other HHS, OMB, or congressional estimates might reflect current law instead. User Fees and Other Types of Collections In some cases, agencies within HHS have the authority to expend user fees and other types of collections that effectively supplement their appropriations. In addition, agencies may receive transfers of budgetary resources from other sources, such as from the Public Health Service Evaluation Set-Aside (also referred to as the PHS Tap) or one of the mandatory funds established by the Patient Protection and Affordable Care Act (ACA; P.L. 111-148 , as amended). Budgetary totals that account for these sorts of resources in the HHS estimates are often referred to as being at the program level . HHS agencies that have historically had notable differences between the amounts in the appropriations bills and their program level include, for instance, FDA (due to user fees) and AHRQ (due to transfers). Scorekeeping and Display Conventions The Administration may choose to follow different conventions than those of congressional scorekeepers for its estimates of HHS programs. For example, certain transfers of funding between HHS agencies (or from HHS to other federal agencies) that occurred in prior fiscal years, or are expected to occur in the current fiscal year, may be accounted for in the Administration's estimates but not necessarily in the congressional documents. HHS Budget by Operating Division Figure 3 provides a breakdown of the FY2021 HHS budget request by operating division. When taking into account mandatory and discretionary budget authority (i.e., total budget authority), CMS accounts for the largest share of the request: nearly $1.3 trillion. The majority of the CMS budget request would go toward mandatory spending programs, such as Medicare and Medicaid. Spending on Medicare and Medicaid is expected to increase from FY2020 levels under the President's request, both in terms of proposed law and current law estimates. The request also includes a number of legislative proposals that would reduce spending on these programs (relative to current law, but not the prior year) if enacted. When looking exclusively at discretionary budget authority (as illustrated in Figure 3 and detailed in Table 3 ), funding for CMS is comparatively smaller, accounting for $3.7 billion of the HHS discretionary request. Discretionary CMS funds primarily support program operations and federal administrative activities, though some funds also go toward efforts to reduce health care fraud and abuse. The largest share of the HHS discretionary request would go to the PHS agencies: roughly $64.8 billion in combined public health funding for FDA, HRSA, IHS, CDC, ATSDR, NIH, and SAMHSA (no funds would go to AHRQ under the request ). NIH would receive the largest amount of discretionary budget authority of any single HHS operating division: $37.7 billion. This represents a decrease of roughly $2.6 billion (-6%) from FY2020. All of the existing NIH institutes and centers would receive a decrease under the request. The majority of the proposed NIH budget would support biomedical research performed by hospitals, medical schools, universities, and other research institutions around the country. ACF would receive the second-largest discretionary funding level among the HHS operating divisions: $20.2 billion. This would represent a decrease of roughly $4.2 billion (-17%) from FY2020. The majority of the discretionary ACF request (more than 80%) would go to early childhood care and education programs, such as Head Start and the Child Care and Development Block Grant. As has been the case since FY2018, the budget proposes to eliminate several ACF programs, including the Low Income Home Energy Assistance Program (LIHEAP) and the Community Services Block Grant (CSBG). Table 4 puts the FY2021 request for each HHS operating division and the Office of the Secretary into context, displaying it along with estimates of funding provided over the four prior fiscal years (FY2017-FY2019). These totals are inclusive of both mandatory and discretionary funding. The amounts in this table are shown in terms of budget authority (BA) and outlays. BA is the authority provided by federal law to enter into contracts or other financial obligations that will result in immediate or future expenditures involving federal government funds. Outlays occur when funds are actually expended from the Treasury; they could be the result of either new budget authority enacted in the current fiscal year or unexpended budget authority that was enacted in previous fiscal years. As a consequence, the BA and outlays in this table represent two different ways of accounting for the funding that is provided to each HHS agency through the federal budget process. For example, Table 4 shows $0 in FY2021 BA for AHRQ because the President's budget proposes to eliminate this agency; however, the table shows an estimated $299 million in FY2021 AHRQ outlays, reflecting the expected expenditure of funds previously provided to the agency. Appendix. HHS Operating Divisions: Missions and FY2021 Budget Resources This appendix provides for each operating division a brief summary of its mission, the applicable appropriations bill, the FY2021 budget request level, and links to additional resources related to that request. Food and Drug Administration (FDA) The FDA mission is focused on regulating the safety, efficacy, and security of human foods, dietary supplements, cosmetics, and animal foods; and the safety and effectiveness of human drugs, biological products (e.g., vaccines), medical devices, radiation-emitting products, and animal drugs. It also regulates the manufacture, marketing, and sale of tobacco products. Relevant Appropriations Bill: Agriculture, Rural Development, Food and Drug Administration, and Related Agencies (AG) FY2021 Request: BA: $3.293 billion Outlays: $3.552 billion Additional Resources Related to the FY202 1 Request: Congressional Justification (all-purpose table on p. 19), https://www.fda.gov/media/135078/download BIB chapter (p. 20), https://www.hhs.gov/sites/default/files/fy-2021-budget-in-brief.pdf#page=24 Health Resources and Services Administration (HRSA) The HRSA mission is focused on "improving health care to people who are geographically isolated, economically or medically vulnerable." Among its many programs and activities, HRSA supports health care workforce training; the National Health Service Corps; and the federal health centers program, which provides grants to nonprofit entities that provide primary care services to people who experience financial, geographic, cultural, or other barriers to health care. Relevant Appropriations Bill: LHHS FY2021 Request: BA: $11.444 billion Outlays: $11.951 billion Additional Resources Related to the FY2021 Request: Congressional Justification (all-purpose table on p. 17), https://www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-justification-fy2021.pdf BIB chapter (p. 28), https://www.hhs.gov/sites/default/files/fy-2021-budget-in-brief.pdf#page=32 Indian Health Service (IHS) The IHS mission is to provide "a comprehensive health service delivery system for American Indians and Alaska Natives" and "raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level." IHS provides health care for approximately 2.2 million eligible American Indians and Alaska Natives through a system of programs and facilities located on or near Indian reservations, and through contractors in certain urban areas. Relevant Appropriations Bill: Departments of the Interior, Environment, and Related Agencies (INT) FY2021 Request: BA: $6.391 billion Outlays: $6.479 billion Additional Resources Related to the FY202 1 Request: Congressional Justification (all-purpose table on p. 8), https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/FY_2021_Final_CJ-IHS.pdf BIB chapter (p. 37), https://www.hhs.gov/sites/default/files/fy-2021-budget-in-brief.pdf#page=41 Centers for Disease Control and Prevention (CDC) and Agency for Toxic Substances and Disease Registry (ATSDR) The CDC mission is focused on "disease prevention and control, environmental health, and health promotion and health education." CDC is organized into a number of centers, institutes, and offices, some focused on specific public health challenges (e.g., injury prevention) and others focused on general public health capabilities (e.g., surveillance and laboratory services). In addition, the ATSDR is headed by the CDC director. For that reason, the ATSDR budget is often shown within CDC. Following the conventions of the FY2021 HHS BIB, ATSDR's budget request is included in the CDC totals shown in this report. ATSDR's work is focused on preventing or mitigating adverse effects resulting from exposure to hazardous substances in the environment. Relevant Appropriations Bills: LHHS (CDC) INT (ATSDR) FY202 1 Request (CDC and ATSDR combined): BA: $7.134 billion Outlays: $8.174 billion Additional Resources Related to the FY202 1 Request: CDC Congressional Justification (all-purpose table on p. 25), https://www.cdc.gov/budget/documents/fy2021/FY-2021-CDC-congressional-justification.pdf ATSDR Congressional Justification, https://www.cdc.gov/budget/documents/fy2021/FY-2021-ATSDR-congressional-justification.pdf BIB chapter (p. 43), https://www.hhs.gov/sites/default/files/fy-2021-budget-in-brief.pdf#page=47 National Institutes of Health (NIH) The NIH mission is focused on conducting and supporting research "in causes, diagnosis, prevention, and cure of human diseases" and "in directing programs for the collection, dissemination, and exchange of information in medicine and health." NIH is organized into 27 research institutes and centers, headed by the NIH Director. (The FY2021 President's budget assumes that AHRQ's functions will be consolidated within NIH, in the new National Institute for Research on Safety and Quality [NIRSQ]. This assumption is reflected in the figures below. ) Relevant Appropriations Bill: LHHS FY2021 Request: BA: $37.905 billion Outlays: $39.807 billion Additional Resources Related to the FY2021 Request: Congressional Justification (all-purpose table on p. 15), available at https://officeofbudget.od.nih.gov/pdfs/FY21/br/1-OverviewVolumeSingleFile-toPrint.pdf BIB chapter (p. 54), available at https://www.hhs.gov/sites/default/files/fy-2021-budget-in-brief.pdf#page=58 Substance Abuse and Mental Health Services Administration (SAMHSA) The SAMHSA mission is focused on reducing the "impact of substance abuse and mental illness on America's communities." SAMHSA coordinates behavioral health surveillance to improve understanding of the impact of substance abuse and mental illness on children, individuals, and families, and the costs associated with treatment. Relevant Appropriations Bill: LHHS FY2021 Request: BA: $5.598 billion Outlays: $5.984 billion Additional Resources Related to the FY202 1 Request: Congressional Justification (all-purpose table on p. 6), https://www.samhsa.gov/sites/default/files/about_us/budget/fy-2021-samhsa-cj.pdf BIB chapter (p. 63), https://www.hhs.gov/sites/default/files/fy-2021-budget-in-brief.pdf#page=67 Agency for Healthcare Research and Quality (AHRQ) The AHRQ mission is focused on research to make health care "safer, higher quality, more accessible, equitable, and affordable." Specific AHRQ research efforts are aimed at reducing the costs of care, promoting patient safety, measuring the quality of health care, and improving health care services, organization, and financing. The FY2021 President's budget proposes eliminating AHRQ and consolidating certain key AHRQ functions within NIH, in the new National Institute for Research on Safety and Quality (NIRSQ). Relevant Appropriations Bill: LHHS FY202 1 Request: BA: $0 Outlays: $0.303 billion Additional Resources Related to the FY202 1 Request: Congressional Justification for the proposed National Institute for Research on Safety and Quality, https://www.ahrq.gov/sites/default/files/wysiwyg/cpi/about/mission/budget/2021/FY_2021_CJ_NIRSQ.pdf There is no FY2021 BIB chapter for AHRQ. Centers for Medicare & Medicaid Services (CMS) The CMS mission is focused on supporting "innovative approaches to improve quality, accessibility, and affordability" of Medicare, Medicaid, the State Children's Health Insurance Program (CHIP), and private insurance, and on supporting private insurance market reform programs. The President's budget estimates that in FY2021, "over 145 million Americans will rely on the programs CMS administers including Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the [Health Insurance] Exchanges." Relevant Appropriations Bill: LHHS FY2021 Request: BA: $1,297.294 billion Outlays: $1,232.275 billion Additional Resources R elated to the FY2021 Request: Congressional Justification (all-purpose table on p. 9), https://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget/FY2021-CJ-Final.pdf BIB chapter (p. 69), https://www.hhs.gov/sites/default/files/fy-2021-budget-in-brief.pdf#page=73 Administration for Children and Families (ACF) The ACF mission is focused on promoting the "economic and social well-being of children, youth, families, and communities." ACF administers a wide array of human services programs, including Temporary Assistance for Needy Families (TANF), Head Start, child care, the Social Services Block Grant (SSBG), and various child welfare programs. Relevant Appropriations Bill: LHHS FY202 1 Request: BA: $54.976 billion Outlays: $57.489 billion Additional Resources Related to the FY2021 Request: Congressional Justification (all-purpose table on p. 6), https://www.acf.hhs.gov/sites/default/files/olab/fy_2021_congressional_justification.pdf BIB chapter (p. 141), https://www.hhs.gov/sites/default/files/fy-2021-budget-in-brief.pdf#page=145 Administration for Community Living (ACL) The ACL mission is focused on maximizing the "independence, well-being, and health of older adults, people with disabilities across the lifespan, and their families and caregivers." ACL administers a number of programs targeted at older Americans and the disabled, including Home and Community-Based Supportive Services and State Councils on Developmental Disabilities. Relevant Appropriations Bill: LHHS FY202 1 Request: BA: $2.097 billion Outlays: $2.153 billion Additional Resources Related to th e FY2021 Request: Congressional Justification (not yet available online); see excerpts, including a downloadable version of the all-purpose table, at https://acl.gov/about-acl/budget BIB chapter (p. 159), https://www.hhs.gov/sites/default/files/fy-2021-budget-in-brief.pdf#page=163