Background Internet Service Types and Technologies Consumers receive broadband service from telephone, cable, mobile, satellite, and utility companies that own and operate the telecommunications infrastructure. Fixed technologies, like cable or fiber, can provide broadband to single locations like customers’ homes or businesses. Mobile technologies provide internet access wherever a customer has access to a signal. Customers connect to a mobile wireless network through a mobile device, such as a smartphone. Internet service that is high speed and provides an “always-on” connection, so users do not have to reestablish a connection each time they access the internet, is commonly referred to as “broadband.” FCC’s benchmark speed for what constitutes “advanced telecommunications capability,” a subset of broadband, has increased over time as consumers use the internet for an expanding range of purposes that requires faster speeds. In 2015, FCC set a benchmark speed for fixed advanced telecommunications capability to 25 megabits per second when downloading and 3 megabits per second when uploading (25 Mbps/3 Mbps). Internet service at various speeds allows for a variety of online activities, such as those shown in figure 1. In addition to fixed providers, satellite providers have begun meeting this benchmark, and FCC has recognized them as a viable source of advanced telecommunications capability. FCC has not set a similar benchmark for mobile services. The Federal Role in Rural Broadband Access The federal government has emphasized the importance of ensuring Americans have access to broadband, and a number of agencies provide funding to subsidize broadband deployment in areas, such as rural areas, in which the return on investment has not attracted private investment. As we have previously reported, rural areas may have features that increase costs of deploying and maintaining broadband networks. For instance, low population density, low broadband adoption rates, or mountainous or rugged terrain can make it especially costly for fixed and mobile providers to deploy infrastructure to rural areas with an expectation of getting a return on their investment. The Communications Act of 1934, as amended by the Telecommunications Act of 1996, specifies that consumers in “rural, insular, and high-cost areas” should have access to telecommunications and information services at rates that are “reasonably comparable” to rates charged for similar services in urban areas. Consequently, federal programs exist to support investment in broadband deployment for high-cost areas through federal grants, loans, and other subsidies. The largest share of federal support comes from FCC’s Universal Service Fund, which includes four component programs designed to ensure access to affordable communications for schools, libraries, rural health care providers, low-income consumers, and those in rural and high-cost areas. The largest component of the Universal Service Fund is the high- cost program—which includes the Connect America Fund and the Rural Digital Opportunity Fund—that targets financial support to rural high-cost areas for the deployment and maintenance of voice and broadband- capable networks. Table 1 shows selected federal programs funding the deployment of broadband infrastructure. FCC has other roles and responsibilities in regulating nationwide communications activities in addition to those identified above. FCC collects deployment data twice a year from broadband providers in order to better identify areas where broadband service is available. FCC, RUS, and NTIA have used and continue to use these data to inform their broadband programs. Furthermore, FCC and NTIA jointly determine the amount of spectrum—a finite natural resource that makes a variety of wireless communications possible—allocated for federal, nonfederal, and shared use. FCC also regulates the use of licensed and unlicensed spectrum through its regulatory process. GAO Reports on Broadband Programs This report’s broad view of a decade of federal efforts to advance broadband access builds on our prior work. FCC Universal Service Fund. In 2014, we examined FCC efforts to increase broadband deployment in unserved areas and identified legal, policy, and economic concerns—for example, low returns on investment—in deploying broadband in unserved and underserved areas. We also examined varying approaches for financing broadband deployment in high-cost areas, including local funding sources and a variety of ownership structures over the infrastructure. FCC deployment data. In 2014, we examined FCC’s efforts to reform its high-cost program and the extent to which FCC was collecting data to determine the effectiveness of these reforms, among other objectives. We identified gaps in FCC’s data analysis and reporting, including a lack of transparency and accountability of spending. We recommended that FCC analyze how it uses its high-cost program funding and make that analysis publicly available at least annually. FCC has taken action to implement our recommendation to address the lack of transparency and accountability of spending. In 2018, we reviewed data that FCC collected from providers to describe the locations of existing broadband infrastructure and help federal programs identify unserved and underserved areas to target for federal funding. We found that these data overstated broadband access, especially in tribal lands, and recommended that FCC take actions to improve these data. FCC concurred with the recommendations and has begun taking action, but the agency has not yet fully implemented any of the report’s three recommendations. Broadband adoption. In 2015, we stated that adopting broadband at home can provide a number of benefits, including access to employment opportunities (searching for and applying to jobs); education (research, web-based learning, and homework); and services for economic and social gain (such as telemedicine and entertainment). We reviewed federal efforts to address broadband adoption barriers that consumers face and recommended that FCC revise its strategic plan to more clearly state if broadband adoption is a priority, and if so, what outcomes FCC intends to achieve, action that the agency took the following year. We also recommended that NTIA include performance metrics for the agency’s broadband adoption efforts in its annual performance plan. Both FCC and NTIA implemented these recommendations. RUS grant and loan programs. In 2017, we assessed whether RUS’s procedures and activities related to its broadband grant and loan programs are consistent with leading management practices. We found that its activities and procedures were consistent with four leading practices and partially consistent with six leading practices. We made five recommendations to RUS to improve management practices for specific programs, like the Community Connect Program. In response, RUS implemented two of the recommendations to develop and document clear goals and performance measures for its broadband loan and grant programs and to establish and implement procedures to conduct a risk assessment of each program. RUS agreed with, but has not yet implemented, the report’s other three recommendations to: (1) conduct periodic evaluations of completed grant projects to determine the outcomes associated with these projects; (2) establish a timeline for implementing a centralized internal data system for staff to use in managing and monitoring loans and grant awards; and (3) develop, update, and maintain complete written policies and procedures for RUS’s programs as a way to retain and communicate organizational knowledge internally among agency staff. Broadband competition. In 2017, we found that infrastructure costs and other factors can affect competition among broadband providers. Such costs can limit competition in urban areas but more significantly limit competition in non-urban and less populated areas. We made two recommendations to FCC to solicit and report on the views of stakeholders regarding: (1) how well FCC’s programs promote broadband competition and (2) how varying levels of broadband deployment affect broadband prices and service quality. In response, FCC implemented these recommendations by soliciting public comments in July 2018 to seek feedback on the effectiveness of its actions addressing competition among broadband providers and on how varying levels of broadband deployment affect prices and service quality. In December 2018, FCC reported comments that it had received from this solicitation in the first version of a biennial report on the broadband market. In May 2019, FCC also reported stakeholder comments related to the agency’s broadband deployment data, including service quality data. Tribal broadband access. In 2018, we examined challenges that tribes face in accessing broadband services, focusing on two particular areas: (1) tribes’ ability to obtain and access spectrum for providing broadband and (2) tribes’ partnerships with private sector companies and others, and the ability to obtain funding to deploy broadband infrastructure on tribal lands. We found that tribes cited a number of barriers to obtaining licenses for spectrum. We also found that although tribes said partnerships with the private sector improved access to broadband, there are few such partnerships, and that tribes face regulatory barriers in applying for funding from RUS grant programs. We made three recommendations to FCC to collect data on tribal access to spectrum, analyze unused spectrum over tribal areas, and make information about available spectrum more accessible. We also made one recommendation to RUS to identify and address any regulatory barriers that may impede efforts by tribes to obtain RUS funding. FCC agreed with the recommendations, and RUS neither agreed nor disagreed with its recommendation. The agencies have not yet implemented these recommendations. Industry and Federal Investments Have Reduced Broadband Deployment Gaps and Improved How Progress Is Measured, Although Some Challenges Persist Industry Invested Billions of Dollars in Broadband According to the U.S. Census Bureau’s Annual Capital Expenditures Survey data, the telecommunications industry that provides various types of broadband services—fixed, mobile, or satellite (and other)—spent an estimated $795 billion (2018 dollars) in total capital expenditures from 2009 through 2017. Selected broadband providers that we contacted stated that they used the majority of their capital expenditures to improve the capability and reliability of their existing broadband infrastructure or expand infrastructure into new areas. For instance, one provider said it expanded wireless broadband service in Iowa and another provider constructed new towers to transmit fixed-wireless broadband signals across parts of Oklahoma. Some providers we contacted said that their capital expenditures may include funds from federal broadband programs or other items not related to broadband, such as the purchase of real or personal property or the acquisition of other broadband companies. Providers that we contacted offered few, if any, details about their investments. Instead, they said that their detailed expenditures were proprietary or they referred us to their annual reports, which contain limited information on capital expenditures. Census data showed that annual total capital expenditures increased from about $78 billion in 2009 to about $97 billion in 2017 (an increase of about 24 percent), with an average annual growth rate of about 2.8 percent. See figure 2. Industry capital expenditures for specific telecommunications sectors varied. For example, estimated expenditures for fixed services consistently exceeded estimated expenditures for mobile services, although mobile services experienced a greater increase—55 percent compared to an 8 percent increase in estimated expenditures for fixed services from 2009 through 2017. Federal Agencies Targeted Investment for Rural Deployment and Improved Their Ability to Measure Impact In comparison to industry spending, federal investment is much smaller, representing about 6 percent of total industry capital expenditures. However, this investment is critical to supporting deployment of broadband in rural areas where industry might not otherwise invest, due to potentially higher costs and lower investment returns. According to FCC, RUS, and NTIA data, federal program investments totaled about $47.3 billion (2018 dollars) to target broadband infrastructure in unserved or underserved areas from 2009 through 2017. Of these three federal agencies, FCC provided the largest share of support through the Universal Service Fund’s high-cost program—which is an ongoing program. A second agency, RUS, offered loans and grants. And NTIA primarily funded broadband deployment through the Recovery Act, which provided one-time funding for projects that are largely complete and are no longer active. To illustrate: FCC’s high-cost program. The high-cost program disbursed about $41.7 billion (2018 dollars) in support of both deployment and maintenance of voice and broadband-capable networks from 2009 through 2017. RUS’s programs. RUS provided grants or loans, or a combination of both, through a variety of funding programs. The Broadband Initiatives Program—a Recovery Act program—awarded about $2.2 billion (2018 dollars) in grants to industry for infrastructure projects in fiscal year 2010. RUS’s Community Connect Grant Program—a grant program designed to fund broadband deployment in rural areas where such service did not exist—awarded $95 million (2018 dollars) in grants from fiscal year 2009 through fiscal year 2017. In addition to these grants, RUS provided infrastructure loans that recipients must repay to the government with interest. Specifically, RUS provided about $4.0 billion (2018 dollars) in loans to private providers through the Broadband Initiatives Program, the Telecommunications Infrastructure Loan Program, and the Broadband Loan Program. NTIA’s Broadband Technology Opportunities Program, Comprehensive Community Infrastructure projects. This Recovery Act program awarded a one-time $3.3 billion in competitive grants to states, municipalities, and non-profit and commercial organizations in fiscal year 2010. Nearly all of the 116 broadband infrastructure projects have been completed. All three programs have used metrics to show progress in closing deployment gaps. Specifically, FCC has a metric for locations served, whereas RUS and NTIA measure miles of fiber-optic cable deployed, in addition to having metrics that count particular types of locations served or reported number of new subscribers. FCC collects data from providers about new locations to which they deployed broadband using high-cost program support. Deployment data submitted by providers that receive support from FCC’s high-cost program showed that they used those funds to make broadband available to about 2.3-million new residential and small business locations, mostly from 2015 through 2017. In commenting on a draft of this report, FCC stated that this figure has increased to about 4.2- million new locations. This updated figure is based on data through 2019 that are not yet publicly available; they are expected to be released later in 2020. Providers report these data to FCC, which are subject to verification by the Universal Service Administrative Company—the not-for-profit corporation designated by the FCC as the administrator of the Universal Service Fund, including the high- cost program. As of May 2020, FCC officials said that FCC has authorized Connect America Fund Phase II support to deploy broadband at 25 Mbps/3 Mbps or higher to more than 631,000 locations by 2025 or sooner. In December 2016, RUS released the final Broadband Initiatives Program progress report, which noted that the program deployed 66,521 miles of fiber-optic cable, added 5,468 wireless access points, and resulted in 334,830 subscribers receiving new or improved broadband. In December 2016, NTIA reported that the Broadband Technology Opportunities Program resulted in the deployment of 117,072 miles of new or upgraded broadband infrastructure. NTIA also reported that awardees connected nearly 26,000 community anchor institutions— such as schools, libraries, and hospitals—to broadband and provided access to nearly 14,149 homes and businesses. Although the agencies used metrics to show progress, the metrics used were not always the same, making it difficult to draw comparisons among programs. The impact of these federal programs goes beyond the number of miles of fiber or the number of subscribers. Although these programs promoted the availability and use of broadband throughout the country, our prior work found that they also stimulated economic development and created new jobs. For example, we reported in 2012 that NTIA’s and RUS’s Recovery Act programs had created about 9,000 full-time jobs. Recovery Act grantees we interviewed for our prior work gave examples of the types of economic development broadband enabled, such as tourism-oriented businesses being better able to provide web sites and online reservation systems. They also reported that broadband infrastructure improved broadband speed for schools, community colleges, and health care providers. Several studies have attempted to measure the economic benefits of broadband. A 2006 study prepared for the Department of Commerce claimed to be the first attempt to quantify the impact of broadband on economic growth. The study found that, between 1998 and 2002, communities in which broadband was available experienced more rapid growth in employment, the number of businesses, and businesses in information technology sectors, relative to comparable communities without broadband. Subsequently, other studies have attempted to assess the economic impact of broadband. For example, a 2016 study from the Hudson Institute found that rural broadband providers directly and indirectly added $24.1 billion to the U.S. economy and the rural broadband industry supported about 70,000 jobs in 2015, both through its own employment and the employment that its purchases of goods and services generated. About the same time, a 2016 broadband forum sponsored by the National Science Foundation and NTIA concluded that during the past decade, research has deepened the understanding of the potential impacts of broadband on the economy and society. The study made clear the need for more research on the impact of broadband. On December 11, 2018, FCC opened the new Office of Economics and Analytics, consisting of economists, attorneys, and data professionals to, among other things, provide economic analysis, including cost-benefit analysis, for FCC proceedings. Broadband Availability Has Increased, but Measuring Deployment Has Limitations FCC’s annual Broadband Deployment Report, which reports on broadband deployment generally and not just deployments made with FCC funding, states that broadband availability has increased both nationally and for specific segments of the population, as shown in figure 3. National: About 94.4 percent of the U.S. population had fixed broadband service available at customer premises, such as residences, with minimum speed of 25 Mbps/3 Mbps in 2018, up from 81.2 percent of the population in 2012. Rural: About 77.7 percent of the rural population had fixed broadband service available with minimum speed of 25 Mbps/3 Mbps in 2018, up from 45.7 percent of the rural population in 2012. Tribal: About 72.3 percent of tribal lands had fixed broadband service available at the same speeds in 2018, up from 32.2 percent of the tribal population in 2012. Although these data show broadband availability increasing in a variety of ways, the data also demonstrate that fixed broadband is still much more readily available to urban consumers than it is available to consumers in rural areas. FCC’s Broadband Deployment Report shows that as of 2018, about 22.3 percent of the rural population and 27.7 percent of tribal population did not have fixed broadband service available with minimum speed of 25 Mbps/3 Mbps; whereas, only about 1.5 percent of the urban population did not have fixed broadband service available at the same speed. As we will discuss later in this report, limitations with how FCC collects and uses deployment data from providers to measure broadband access overstate the extent to which broadband is available, a weakness we have pointed out and that FCC has taken steps to address. As the availability of broadband service has increased over time, some segments of the population continue to lag behind others in adopting broadband, even if it is available, and therefore are unable to benefit from it. Our prior work has shown that several factors have been, and continue to be, barriers to broadband adoption—specifically, affordability, lack of perceived relevance, and lack of computer skills. FCC identified these barriers in its National Broadband Plan of 2010, and our more recent work in 2015 showed that these three barriers persist. We found that: the cost of a subscription for internet service and the purchase of computer equipment was the most frequently identified barrier; the perception that broadband does not provide enough utility relative to its cost acted as another barrier; and the lack of exposure to or knowledge about computers, such as by those aged 65 or older and those with low levels of income and education, was another barrier. Compounding the effect of these adoption barriers is the lack of competition. FCC has reported that competition could result in lower prices and higher quality services from broadband providers. However, our prior work from 2017 found that 51 percent of the U.S. population had only one fixed broadband provider offering minimum speed of 25 Mbps/3 Mbps. According to the FCC’s 2018 Communications Marketplace Report, that percentage has decreased to about 27 percent of the U.S. population who had only one fixed terrestrial broadband provider offering minimum speed of 25 Mbps/3 Mbps. In addition, FCC’s report stated that 68 percent of the population had at least two providers and approximately 95 percent had at least one provider. Competition in rural areas can be particularly challenging as rural areas generally do not have enough demand to support multiple carriers. Federal Agencies Have Taken Action to Help Close Broadband Gaps by Modifying Funding Programs and Reforming Deployment Data Federal Agencies Have Modified Programs to Increase Broadband Support Over time, the types of technologies that provide access to broadband have evolved. Federal agencies have responded by making changes to their programs that support broadband. Specifically, FCC and RUS have expanded which types of broadband providers are eligible to receive support from their programs, allowing increased participation by satellite and wireless broadband providers. Satellite and mobile broadband may be able to overcome some impediments to access faced by other services, such as high deployment costs and geographical barriers that pose challenges for deploying broadband over fixed networks using fiber or cable. In turn, this expansion of eligibility corresponds with the shrinking gap in broadband deployment discussed previously. In the case of FCC, the agency has taken action since the 1990s to address technological changes related to broadband deployment. For example, changes in communications technology and competition in the communications marketplace led FCC to reform the high-cost program for purposes beyond maintaining telephone service, including supporting broadband deployment. In 2011, FCC adopted new rules that fundamentally changed the high-cost program and expanded the program to support broadband capable networks. Under these rules, FCC established new funding streams within the high-cost program, such as the Connect America Fund, which addresses fixed broadband availability gaps in underserved and unserved areas, and the Mobility Fund, which supports deployment of wireless networks to provide mobile broadband. FCC also updated its regulatory framework to recognize changes in existing technology and potential technologies in delivery of broadband. For example, in 2016, FCC deemed geostationary satellites eligible to participate in the second phase of the Connect America Fund. Additionally, since 2017, FCC also recognized low and medium earth orbiting satellites as broadband-capable technologies that may be eligible to participate in programs after deployment. According to FCC officials, prior to these changes, they did not consider satellite as broadband- capable due to its high signal latency and internet speeds that were below the FCC benchmark speed, issues that recent technological advances have improved. Similar to FCC, RUS funding programs used to focus funding on telephone service but over time, RUS has reformed them to provide funding for broadband infrastructure and deployment. For example, according to RUS officials, since 1995 the RUS Telecommunications program has only funded systems that were capable of providing high-speed internet and now supports broadband services. In addition to past program transformation efforts, both FCC and RUS have proposed actions to further reform or expand their programs that provide funding for broadband deployment. For example, in August 2019, FCC started the rulemaking process for the new Rural Digital Opportunity Fund. In January 2020, FCC adopted a Report and Order establishing a framework for the fund, providing up to $20.4 billion through two funding rounds, each providing support over overlapping 10-year periods. This fund is the next iteration of the high-cost program, and it continues the overarching goals of prior high-cost programs to expand service into rural areas. The Rural Digital Opportunity Fund will focus its first round of funding on census blocks that FCC deployment data have marked as completely unserved, and per the FCC order will incentivize parties participating in the program to serve tribal census blocks. Similarly, in April 2020, FCC initiated a rulemaking to establish the 5G Fund—which would replace the Universal Service Mobility Fund Phase II—and make up to $9 billion available to carriers to aid in deployment of advanced 5G mobile wireless services in rural America. In addition to FCC’s actions, RUS officials said they are planning for future funding rounds for the ReConnect Program after they have awarded the initial phase of funding. As of April 15, 2020, RUS had closed the application phase for a second round of funding under the program. Despite federal efforts to address broadband gaps, there are still limits on participation in some programs. For example, RUS’s ReConnect Program offers a mix of grants and loans to incentivize broadband infrastructure in areas not currently served by existing service providers. However, the ReConnect Program limits eligibility to fixed and satellite broadband providers, with mobile wireless networks ineligible for funding. In order to participate in FCC’s high-cost program, a provider must meet FCC’s definition of an eligible telecommunication carrier (ETC). However, our prior work and stakeholders we interviewed for this review identified barriers to attaining ETC status. As we previously reported, tribal entities cited the statutory requirements applicable to ETC designation as a primary barrier to accessing federal funds. Additionally, cable providers we spoke with for this review also said they viewed the ETC designation as a potential barrier to entry into the high-cost program. At present, FCC and states have complementary authority to make ETC designation decisions. During our 2018 review of barriers that tribes face in supporting broadband investment, FCC officials said that most of the carriers that were eligible for ETC designation at that time were the telephone companies that were in existence when the 1996 Act was enacted into law. Further, FCC officials said they determined that the statute is clear that only ETCs may receive program support, and therefore the agency does not have the authority to allow non-ETCs to receive high-cost support payments. More recently, greater numbers of companies that are not traditional telephone companies have received ETC designation, particularly in connection with the Connect America Fund Phase II. In addition to the ETC designation matter described above, industry stakeholders highlighted several other issues that can affect access to federal support, noting that these issues may require further action by relevant federal agencies or possible legislative action. The issues cited included: Technology Neutral Federal Programs: Most federal broadband programs focused on fixed technology over other technologies, but as described above, there have been reforms to broaden eligibility to other providers. Even with those reforms, industry stakeholders representing satellite and mobile service providers noted that there are program requirements that affect one technology more than another technology. For example, satellite providers that sought funding through FCC’s Connect America Fund said that, after they sought funding in 2018, FCC changed how it planned to measure latency, a change affecting only satellite providers. Spectrum Availability: Availability of adequate spectrum was cited by a range of stakeholder groups we spoke with as an issue that could affect providers’ ability to deploy services. Spectrum availability affects many broadband services. For example, in addition to satellite and mobile providers, fixed-wireless—a point-to-point or point-to- multipoint broadband service delivery option—is a type of fixed broadband service often utilized in rural areas that needs spectrum to deliver service. In its comments, FCC noted that the changes it made to the exact testing conditions were in response to requests by satellite providers and that the agency balanced changing expectations with the benefits of minimizing unnecessary burdens on carriers and their customers imposed by the testing regime. Federal Funding Mechanisms: Some industry stakeholders we spoke with noted that the programs’ funding requirements and the type of federal funding mechanism utilized—such as grants, loans, or hybrids of grants and loans—could affect a provider’s ability to access federal funds. For example, RUS awards its Reconnect Program funding through grants, loans, or both. Providers we spoke with noted that for all of the funding options, the Reconnect Program requires a lien on the funded assets. For some providers, allowing a lien against an asset would violate stockholder agreements or other aspects of their business. Additionally, representatives from an association representing state public service commissions we spoke with also stated that the FCC high-cost fund and its various funding programs should be reviewed periodically to ensure that both the contributions and funding outcomes are in the best interests of consumers and providers. Although agencies have modified their broadband funding programs to keep up with changes in broadband services, other changes that could be beneficial to the public would require statutory changes. The last major overhaul to telecommunications law occurred under the 1996 Act, which established many of the telecommunications programs that now fund broadband deployment and established statutory constructs like ETCs, which, as discussed above, can affect provider eligibility. Given the significant and ongoing changes in how Americans use the internet and the technologies that provide access to it, members of Congress have proposed legislative actions in recent years to sustain progress in closing the broadband deployment gap. Among the proposals were a range of federal funding and incentives aimed at improving funding to rural areas and addressing issues related to deployment. FCC Has Proposed Mapping Data Reforms Aimed at Improving Federal Broadband Program Administration As we previously reported, FCC’s definition of broadband availability can lead to overstatements of fixed broadband availability. For instance, in 2013 FCC began collecting broadband availability data by census blocks. The agency counts an entire census block as served if a provider reports that it does offer—or could offer without an extraordinary commitment of resources—service some, but not necessarily all, of the locations in the census block. FCC has recognized that by measuring availability at the census block level, not every person may have access to broadband in a block that the data show as served. FCC has noted that census blocks in rural areas tend to cover larger geographic areas than in urban areas and providers may only deploy service to a portion of the census block. Deployment reporting in this manner does not allow FCC to answer with certainty questions like how many Americans have broadband available to their homes or where it needs to target its resources. Several selected providers and industry associations we contacted also expressed concerns about how deployment is measured, and said the measurement approach could make it difficult for them to make informed investment and deployment decisions. In 2013, FCC declined to gather fixed broadband data at a level more granular than the census block—such as address-level data—because the agency concluded that the complexity and filing burden on the industry would outweigh the benefit. In 2018, we recommended, among other things, that FCC develop and implement methods—such as a targeted data collection—for collecting and reporting accurate and complete data on broadband access specific to tribal lands. Subsequently in 2019, FCC began to address this recommendation by establishing the Digital Opportunity Data Collection— a more granular, nationwide data broadband deployment collection effort. FCC issued a Report and Order, and Second Further Notice of Proposed Rulemaking, on this new initiative to improve the accuracy of broadband deployment mapping data in August 2019. This new initiative requires fixed broadband providers to identify their service areas using free-form geographic shapes called polygons. The polygons would identify the presence of service with more geographic precision than the current census-block method affords. Officials from FCC and USTelecom stated this new mapping effort was informed in part by a 2019 USTelecom mapping and data-collection pilot project. According to USTelecom officials, this pilot project combined several data sources to determine “serviceable locations,” which refers to specific locations or structures that could need broadband. With these serviceable locations, USTelecom’s pilot project sought to distinguish between buildings not typically needing broadband service—such as a barn or storage shed—from a primary residence or small business. According to USTelecom representatives, a combination of polygons and serviceable locations data would yield a better picture of where to target new investments in deployment to achieve the greatest increase in access to broadband. FCC officials noted that the impact of the polygon approach may vary depending on the service features of each census block. Figure 4 below shows an example of how the new polygon approach may result in improved data compared to the census block approach currently used by FCC. As part of the rulemaking, FCC has requested comments on several issues, including how providers should define their polygons, and the procedures that fixed providers should follow if their polygons are disputed. At the time it issued the report and order, FCC had ongoing investigations into the coverage maps of some wireless providers, and therefore limited the new data collection obligations to fixed broadband providers while seeking comment on how best to incorporate mobile wireless coverage data into the effort in the future. FCC also proposed the use of public input to help verify the accuracy of the polygons and sought comment on whether it should discontinue the collection of census block data if the polygon-based deployment data prove to be gathering better deployment data once it is established. Additionally, on March 23, 2020, the Broadband Deployment Accuracy and Technological Availability Act was enacted. The act directs FCC to issue final rules on data collection for both fixed and wireless deployment within 180 days. In commenting on a draft of this report, FCC noted that it is in the process of implementing the statute, and that the statute largely affirms rules that FCC adopted in August 2019 but differs in some respects. FCC also noted that, while it is working to implement the requirements of the act, it is unable to comply with all of the requirements without a further appropriation. This change has the potential to improve how both FCC and RUS target deployment gaps by providing more accurate and granular information that could better identify truly unserved areas and results in better targeting of federal funds to those areas. As we discussed above, our prior work has found that FCC’s current deployment data lack accuracy in a manner that overstates where consumers have access to broadband, which, in turn, limits federal agencies’ efforts to effectively target their broadband funds. Specifically, our 2018 report noted that overstating access increases the risk that unserved areas remain unserved, since areas that deployment data show as served are not eligible for funding. Although that report specifically looked at this risk for tribal areas, it is potentially a concern for other unserved areas. FCC officials noted that improved data would help inform future funding under the high-cost program by more accurately targeting unserved areas. RUS officials told us that they use FCC deployment data as a source for RUS mapping and program eligibility requirements for the ReConnect Program. RUS officials also believe that their program would benefit from more accurate deployment data. FCC and RUS Continue to Provide Funding while Coordinating to Avoid Overlap While efforts are under way to improve deployment data and mapping efforts, both FCC and RUS are continuing to move forward with their programs for funding broadband infrastructure in underserved and unserved areas. The lack of accurate data regarding locations that are not served by broadband may affect the ability of these agencies’ programs to target federal funds. In particular, providers and industry associations noted there was a risk of federal programs subsidizing deployment into areas that already have service, at the expense of an unserved area that does not have any service. Given this risk, FCC and RUS each have “eligible area” validation processes that they use to determine if areas are already being served and therefore ineligible for federal support. Additionally, FCC and RUS have engaged in interagency coordination efforts to keep each agency’s program staff apprised of key dates and issues in an effort to avoid overlap between the programs. Officials from both FCC and RUS have stated that their programs are complementary and noted that their eligibility validation processes reduced the likelihood of service overlaps. The agencies use different processes to determine which geographic areas are eligible for funding, and they share information about the results of these processes as they are able. According to FCC officials, the agency has used a process for validating unserved areas in connection with its support of the Universal Service high-cost program. This validation process primarily relies on providers verifying the Form 477 data they self-report, and then using that data to create and publish a list of unserved census blocks prior to awarding funding. Results from this process have informed how FCC establishes eligible areas, such as those eligible to receive funds in the Connect America Fund’s second phase of awards. A similar process is under way in connection with the Rural Digital Opportunity Fund. In an additional step to address concerns regarding program overlap, FCC officials noted that the Rural Digital Opportunity Fund would exclude census blocks that have been awarded funding through the RUS ReConnect Program. RUS’s process to verify eligible areas includes provider participation in the verification, as well as onsite testing and research by field staff, to independently verify eligibility of the geographic areas in each ReConnect grant or loan application. RUS officials said they use the publicly available FCC data on unserved areas as a key factor in eligibility decisions. Specifically, RUS officials said that they focus ReConnect eligibility on areas FCC reported as unserved as of 2015 when the first round of FCC’s Connect America Fund program was started. They also noted that throughout the application and funding process, they seek input from providers through public notices and emails to solicit feedback on whether areas selected for proposed funding are already served. After receiving provider feedback on eligible areas, RUS then deploys field staff to conduct on-location tests and other reviews as necessary to determine if the area was unserved prior to funding. In addition to their eligibility validation steps, FCC and RUS officials told us they share information about where their broadband deployment programs are funding new deployments, as well as other relevant information related to program activity, such as the timing of program applications and awards. FCC and RUS officials told us that they share program information through participation in interagency meetings and working groups that focus on broadband deployment issues and through posting relevant program information—such as funding decisions—online. For example, the Chief of the FCC’s Wireline Competition Bureau and the RUS Administrator, along with other FCC and RUS staff, met in July 2019, January 2020, and February 2020 to discuss issues related to their respective broadband funding programs, including the roll out of the Rural Digital Opportunity Fund and second round of the ReConnect Program. FCC officials told us that at these meetings agency representatives discussed the anticipated timing of elements of their respective programs and ways in which to maximize coordination and avoid overlap. Officials from both agencies also noted there has been ongoing communication between FCC and RUS at the staff level concerning program status and developments through phone calls and meetings. In addition to this ongoing coordination between RUS and FCC, representatives of FCC and RUS also said they participate in relevant working groups through the American Broadband Initiative, such as the Initiative’s Federal Funding Workstream, which meets bi-weekly to discuss broadband funding and deployment. The range of collaboration activities undertaken by RUS and FCC staff is especially important because both agencies have similar goals but different timelines for moving forward with their programs. For example, as of March 2020, FCC had the eligible area validation process under way for the Rural Digital Opportunity Fund. Although some timelines are still to be determined, FCC plans to start bidding on the program’s auction phase in October 2020. At the same time, RUS was in the midst of announcing approved projects for the first funding round of the ReConnect Program, and it had applications open for the second round with applications due by April 15, 2020. FCC officials noted that they plan to maintain close coordination with RUS to reduce the likelihood of overlap with any areas that may be deemed eligible to receive ReConnect funding in the program’s second round. Through prior reforms of their respective broadband programs, FCC and RUS have taken steps to try and effectively target federal dollars to support broadband deployment while avoiding the potential to duplicate funding in an area. Continuing to improve collaboration and information sharing regarding eligibility and program timelines will be critical for both agencies to achieve greater efficiency in their program’s ability to target funds to unserved areas and thus make progress toward closing the deployment gap. Agency Comments We provided a draft of this report to the Federal Communications Commission, the Department of Agriculture’s Rural Utilities Service, and the Department of Commerce’s National Telecommunications and Information Administration for comment. FCC and RUS provided technical comments, which we incorporated as appropriate. NTIA had no comments. We are sending copies of this report to the appropriate congressional committees, the Chairman of the Federal Communications Commission, the Secretary of the Department of Agriculture, the Secretary of the Department of Commerce, and other interested parties. In addition, the report is available at no charge on the GAO website at https://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 II. Appendix I: U.S. Broadband Providers’ Capital Expenditures Another estimate of capital expenditures by USTelecom—a broadband industry association—uses a different scope and methodology than the U.S. Census Bureau’s Annual Capital Expenditures Survey. The association reports total capital expenditures for U.S. broadband providers, as shown in table 2. USTelecom’s data include expenditures from fixed (wireline), mobile (wireless), and cable companies. Its primary source of data are publicly traded companies’ financial statements filed with the Securities and Exchange Commission. USTelecom also makes estimates for companies that do not report financial information publicly. Its data exclude some companies, such as satellite providers, telecommunication resellers, and electric utilities. USTelecom publishes estimates annually for advocacy or research purposes. Its capital expenditures data differ from the Census Bureau’s Annual Capital Expenditures Survey estimates for telecommunications industry in scope, methodology, and timing, among other things. For instance, the Census Bureau’s survey is broader in scope. Specifically, in addition to the types of companies USTelecom includes in its data, the Census Bureau’s survey data include satellite providers, resellers, and other telecommunications providers. In addition, the Census Bureau collects data through a survey instrument from both publicly traded and privately held companies across the United States. It makes statistical inferences about the capital expenditures for the entire telecommunications industry, whereas USTelecom collects data mainly from financial reports for a defined set of providers and makes estimates for companies that do not report financial information publicly. Moreover, USTelecom typically releases its capital expenditure data within a year after companies release their financial data while preliminary survey results from the Census Bureau are made public about 2 years after companies report and data reliability assessments occur and the final revised results are made public about 3 years after companies report. In addition to the USTelecom and Census Bureau estimates, investment firms, such as Goldman Sachs and UBS, also estimate or may report industry capital expenditures for selected publicly traded companies providing broadband service. Appendix II: GAO Contact and Staff Acknowledgments GAO Contact Staff Acknowledgments In addition to the contact named above, Andrew Huddleston (Assistant Director); Steve Martinez (Analyst in Charge); Oluwaseun Ajayi; Michelle Bacon; Carl Barden; Melissa Bodeau; Hannah Laufe; Dan Luo; Malika Rice; Sandra Sokol; and Betsey Ward-Jenks made key contributions to this report.


Background Intimate Partner Violence Data from CDC’s 2015 NISVS indicate that about 43.6 million women (36.4 percent) and 37.3 million men (33.6 percent) in the United States have experienced sexual violence, physical violence, and stalking by an intimate partner. Approximately 21.4 percent of women and 14.9 percent of men in the United States experienced severe physical violence by an intimate partner. About 30 million women (25.1 percent) and 12 million men (10.9 percent) reported experiencing some effect from the violence. (See fig. 1 for the most commonly reported effects of intimate partner violence, as reported by NISVS.) Intimate partner violence can also result in death. Data from U.S. crime reports suggest that 16 percent of homicide victims (about one in six) are killed by an intimate partner. Strangulation victims, in particular, are at greater risk for being killed, according to the Training Institute on Strangulation Prevention. Research has shown that certain factors increase the risk that someone may experience intimate partner violence. For example, a review of research on risk factors for women who experience intimate partner violence identified younger age, less education, unemployment, pregnancy, childhood victimization, and mental illness as being associated with higher rates of intimate partner violence. Exposure to intimate partner violence between a child’s parents or caregivers is also associated with a greater risk of intimate partner violence in adulthood, according to CDC. Adults with disabilities are also at a higher risk of violence than those without disabilities. However, research indicates that victims of intimate partner violence may be less likely than others to obtain medical or other services. Even when services are obtained, victims may be less likely than others to identify the source or extent of their injuries out of fear for their safety or reprisal. Brain Injuries Brain injuries, including those that may result from intimate partner violence, can have several causes, including physical trauma and strangulation; range in severity; and can result in a number of health consequences. TBI refers to a brain injury caused by external physical force, such as a blow to the head or shaking of the brain. Anoxic (a complete disruption of oxygen to the brain) or hypoxic (a partial disruption of oxygen to the brain) brain injury may result from strangulation or other pressure applied to the neck that restricts blood flow and air passage. TBIs and anoxic or hypoxic brain injuries may result in irreversible psychological and physical harm. Specifically, people who suffer from TBI and anoxic or hypoxic brain injuries may experience cognitive symptoms, including depression and memory loss, as well as behavioral symptoms, such as changes in mood, or difficulty sleeping, among others. The symptoms individuals experience can also vary. The signs and symptoms of an anoxic or hypoxic brain injury from strangulation can be similar to those of mild TBI, which is often referred to as a concussion. (See fig. 2.) According to the Brain Injury Association of America, a severe brain injury can be clearly identified by reviewing an individual’s symptoms, but when the brain injury is mild or moderate, providers may need to conduct further assessments or screening to diagnose the brain injury. According to NIH, providers have several options for assessing brain injury that can help determine the severity of the injury. For example, providers may evaluate a person’s level of consciousness and the severity of brain injury by attempting to elicit body movements, opening of the eyes, and verbal responses. Providers may also evaluate an individual’s speech and language skills or cognitive capabilities. Role of HHS and DOJ in Addressing Intimate Partner Violence Both HHS and DOJ support activities for individuals affected by intimate partner violence through several of their agencies. Within HHS, for example, ACF provides federal funding to support emergency shelter and services for the victims of domestic violence and their dependents, as well as the National Domestic Violence Hotline. CDC provides grants to state and local entities to develop programs aimed at preventing intimate partner violence. Additionally, HRSA—which provides funding to federally qualified health centers—provides funding to develop educational materials for health care workers, in partnership with ACF, to increase the number of individuals screened for intimate partner violence and referred to treatment services, among other things. DOJ, through its Office of Justice Programs and Office on Violence Against Women, conducts research and provides funding to help states, local governments, and nonprofit organizations’ develop programs to reduce violence against women. Many DOJ programs aim to strengthen responses at the local, state, tribal, and federal levels to domestic violence, dating violence, sexual assault, and stalking. Further, the Violence Against Women Reauthorization Act of 2013 amended federal laws to establish criminal penalties for strangulation or suffocation. Additionally, DOJ increased its support of activities focused on training to recognize and prosecute strangulation. Role of HHS in Addressing TBI HHS agencies also conduct work related to recognizing and responding to TBI. For example, NIH funds research aimed at developing knowledge about the brain and nervous system in order to reduce the effect of brain- related diseases on individuals. In addition, CDC conducts research on the prevention of TBIs, and ACL provides grants to states to help them to support individuals with brain injuries and to promote the rights of, and provide advocacy support to, those living with TBI. Efforts to Provide Education, Screen for, or Treat Brain Injuries Resulting from Intimate Partner Violence We identified 12 initiatives led by non-federal entities that focused on (1) education on brain injuries resulting from intimate partner violence by developing materials or offering training; (2) screening victims of intimate partner violence for potential brain injuries; or (3) treatment involving individuals with brain injuries resulting from intimate partner violence. Our list represents initiatives identified during the course of our review and may not be exhaustive. Some of these initiatives focus on only TBI or strangulation, while others focused on both. See appendix II for additional information on the initiatives. Training for Domestic Violence Program Staff Domestic violence program advocates we spoke to told us that before they participated in the Ohio Domestic Violence Network training, they knew their clients were having a hard time remembering things or getting their thoughts across; however, they did not know this could be the result of a brain injury. The training helped advocates identify signs and symptoms in their clients and make others aware of these symptoms. For example, advocates told us they may inform a prosecutor that a client may have a brain injury and may have difficulty remembering or sharing their experiences. The Ohio Domestic Violence Network—as a part of its Connect, Acknowledge, Respond, Evaluate (CARE) initiative—trained staff at five domestic violence programs on brain injuries, and developed educational materials for shelter staff to share with intimate partner violence victims, according to network officials. For example, we spoke to staff at a domestic violence program in Ohio who told us how the education they received from the network helped them identify the signs and symptoms of brain injury in their clients. Staff from another domestic violence program in Ohio told us as a result of CARE training they now suggest strategies to clients to assist them with their memory issues, such as writing appointment information on a whiteboard or in a planner. The Swedish Hospital Violence Prevention Program, in Illinois, provided education to physicians, medical residents, and hospital staff to increase health care provider and staff awareness of and ability to respond to brain injuries among victims of intimate partner violence, according to officials with the initiative. The Safe Futures initiative, in Connecticut, developed strangulation training materials for emergency medical personnel, law enforcement, prosecutors, and providers, as well as hosted trainings throughout Connecticut on intimate partner violence and brain injuries, according to officials with the initiative. Screening. Six of the 12 initiatives used screening tools to identify potential brain injuries among intimate partner violence victims, according to officials. Based on our review of documentation from these initiatives, we found that the screening tools generally had a series of questions about injuries to the head, the loss of consciousness, or behavior changes—symptoms that may indicate a potential brain injury. For example: Officials from three initiatives that screened victims for potential brain injuries reported using a version of the HELPS screening tool. (See fig. 4 for an example of a modified version of this screening tool used by one initiative.) Officials from one initiative told us that screening typically occurred at domestic violence shelters where staff and advocates receive training on how to screen intimate partner violence victims. Officials from the other three initiatives told us they developed their own screening methods. For example, staff at the Maricopa County Collaboration on Concussions in Domestic Violence in Arizona screen victims using a tool that measures near point of convergence, which refers to an individual’s ability to focus both eyes on a target, an approach that can be used to detect a concussion. Police officers from two participating departments in Arizona have used this tool to screen individuals when they respond to a domestic violence call, according to officials with the collaboration. Treatment. Two of the 12 initiatives included a treatment component. Officials with the Barrow Concussion and Brain Injury Center in Arizona and the Northside Hospital Duluth Concussion Institute in Georgia told us they provided treatment to victims who were referred by local domestic violence shelters. Providers affiliated with one of these initiatives told us that treatment for brain injuries resulting from intimate partner violence does not differ from treatment for other brain injuries. A provider with one of these initiatives said that treatment could include exercises and movements that decrease dizziness, vertigo, and imbalance; occupational, physical, or speech therapies; or treatment for pain management. An Intimate Partner Violence Victim’s Brain Injury Treatment Jane Doe was abused by her partner. An advocate at a domestic violence shelter screened Jane for a brain injury and referred her for assessment. She was diagnosed and began treatment for a brain injury. Jane Doe told us that the treatments she received, which included nerve blockers—often used by neurologists to lessen chronic pain—helped to relieve the persistent headaches and debilitating migraines she experienced in the aftermath of her abuse. She told us that as a result of the treatment she received, she feels better able to function. Officials from the Barrow Concussion and Brain Injury Center told us that individuals with brain injuries resulting from intimate partner violence may face a longer period of recovery compared to others with brain injuries, in part, because of living in unsafe home environments. As a result, special considerations are sometimes needed due to additional barriers faced by domestic violence victims. For example: Victims may need safety planning and housing. As a part of the Barrow Concussion and Brain Injury Center’s domestic violence initiative, a social worker will help ensure that victims’ other needs are met. Officials from the Northside Hospital Duluth Concussion Institute noted that transportation could also be a barrier for victims of intimate partner violence. As such, the Georgia Department of Public Health’s Injury Prevention Program, which partnered with the Northside Hospital Duluth Concussion Institute, planned to use CDC grant funding to provide domestic violence victims transportation from area shelters to the concussion institute for treatment. Officials from the Barrow Concussion and Brain Injury Center also told us about other considerations, such as the need to have a flexible appointment policy to account for the possibility of victims missing or canceling appointments. Of the 12 initiatives we identified, eight received federal grants from HHS or DOJ, while officials from the other four initiatives told us they were funded with state, local, or private dollars. According to HHS and DOJ officials, the grants did not have specific requirements to address the intersection of brain injuries and intimate partner violence. However, based on our review of documentation, the eight initiatives used the federal funds to focus on the intersection of these two issues. Six of these eight initiatives received funding from HHS. Of them, four were funded by HRSA or ACL grants that focused on TBI-related services and activities, and two were funded by CDC grants focused on injury and violence prevention activities. The other two initiatives were funded by DOJ’s Office of Justice Programs through grants that provide funds to support victims of crime. In addition to the federal funding received by some of the 12 initiatives, we identified other efforts and grants funded by HHS and DOJ. These efforts made educational materials on intimate partner violence and brain injuries accessible online, made ad-hoc or internal trainings available to external parties, or provided education that touched on the connection between intimate partner violence and brain injury, according to HHS and DOJ officials. For example: ACF has funded the National Resource Center on Domestic Violence and Futures Without Violence’s National Health Resource Center on Domestic Violence, which provide information related to intimate partner violence and brain injuries via websites. ACF, in collaboration with HRSA, funded an effort led by Futures Without Violence, which includes some information on TBI and strangulation in trainings for select state leadership teams working to address intersections of health, intimate partner violence, and human trafficking. DOJ’s Office on Violence Against Women provided grant funds to support the Training Institute on Strangulation Prevention, which offers training to individuals and outside entities to help them understand, recognize, and appropriately serve strangulation victims, as well as investigate and prosecute strangulation cases. DOJ’s Office on Violence Against Women has also provided grant funds used by local organizations, such as police departments, to provide ad-hoc or internal training activities on brain injuries and to serve victims with brain injuries, including those caused by strangulation. Data on the Overall Prevalence of Brain Injuries Resulting from Intimate Partner Violence Are Limited; Improved Data Could Help Target HHS Public Health Efforts Based on our review of the literature, as well as interviews with HHS officials and other non-federal stakeholders, we found that data on the overall prevalence of brain injuries resulting from intimate partner violence are limited. Specifically, available data do not provide an overall estimate of the prevalence of brain injuries resulting from intimate partner violence nationwide. While there are studies that estimate the prevalence of these injuries, these studies are also limited. Specifically, among the 28 articles we reviewed, six included an objective to estimate the prevalence of brain injuries resulting from intimate partner violence, while the remaining 22 articles examined other areas, such as health effects or awareness of brain injuries resulting from intimate partner violence, but did not have an objective to estimate prevalence. The six articles are also specific to a certain subpopulation or certain geographic locations and used different approaches to identify individuals with brain injuries. As a result, the range of reported prevalence rates on victims of intimate partner violence with brain injuries (brain injuries caused by trauma or strangulation) varied greatly (from 11 percent to about 79 percent) and were based on a range of sample sizes, from 95 people to about 1,000 people. HHS agencies also have some data collection and research efforts related to this issue; however, these efforts are limited as well. For example, CDC and NIH have efforts that may assist in better understanding the connection between brain injuries and intimate partner violence, but CDC’s efforts do not account for all causes of brain injuries and NIH has only one study focused on this connection. Further, HHS agencies treat brain injuries and intimate partner violence as separate public health issues and pursue their efforts separately—which limits their ability to better understand the connection between the issues and the overall prevalence of brain injuries that result from domestic violence. CDC officials told us that the agency’s data on the connection between brain injuries and intimate partner violence are limited, but the agency plans to address some of the limitations. For example, the officials said CDC analyzes health care claims data from emergency department visits to determine the causes of TBI. However, CDC officials told us that these data likely underestimate TBI among victims of intimate partner violence, because many do not seek medical care; for domestic violence victims who seek care, providers are unlikely to designate the individual as a victim of intimate partner violence. CDC also collects data on intimate partner violence through its NISVS. According to CDC reports, NISVS data are a key source of information on intimate partner violence, but the survey does not collect data on all types of brain injuries related to intimate partner violence. For example, the NISVS estimates the prevalence of victims of intimate partner violence who have been “knocked out after getting hit, slammed against something, or choked.” However, published estimates are based on responses to a survey question that asks individuals about being “knocked out,” which is a colloquial term commonly used to indicate a loss of consciousness. CDC officials stated that in most known incidents of mild brain injury, people do not lose consciousness. As a result, NISVS data likely understate the number of intimate partner violence victims who may have brain injuries. In order to better estimate TBIs resulting from intimate partner violence, CDC officials told us they plan to add a survey question to the NISVS to ask respondents about whether they have experienced a concussion—a common term for mild forms of TBI—due to a current or ex-partner. CDC officials told us that they have begun initial testing on several aspects of the survey, including on the additional question with the goal to begin data collection by the end of 2022, plans which are pending approval. Once the NISVS data are collected and analyzed, CDC officials said the data could help them provide a nationally representative prevalence estimate of intimate partner violence victims’ who experienced a TBI in their lifetimes. However, adding the question to the NISVS may not ensure that these data can provide a comprehensive estimate of the prevalence of brain injuries resulting from intimate partner violence. In particular, The NISVS question will focus on TBIs, and will not account for individuals with brain injuries caused by strangulation. According to educational materials developed by the Training Institute of Strangulation Prevention and used by HRSA in the training of providers and advocates, more than two-thirds of intimate partner violence victims are strangled at least once. CDC officials told us that they are able to measure acts of choking or suffocation through the NISVS, but this measure cannot be used to account for brain injuries resulting from strangulation. Additionally, CDC officials told us that the agency’s priority is to focus on TBI specifically rather than accounting for other brain injuries. Despite the focus on TBIs, CDC officials told us the NISVS data are not designed to examine whether intimate partner violence is a leading cause of TBI in comparison with other causes, such as sports or motor vehicle crashes. CDC officials said that some research and NISVS data suggest that intimate partner violence is not as large a contributor of TBIs when compared to other contributors. However, they noted that they do not have data on the proportion of TBIs resulting from intimate partner violence. Absent the ability to compare intimate partner violence as a cause of TBI against other contributors through the NISVS or other representative studies, CDC officials will continue to lack an understanding of the full scope of TBIs, their primary causes, and who is affected by them. NIH officials identified two agency efforts that could help improve what is known about the connection between brain injuries and intimate partner violence. NIH began funding a study in September 2019 that will use advanced brain imaging, blood analyses, and cognitive and psychological testing to study the effects of multiple brain injuries on women subjected to intimate partner violence. The objectives of the study are not to measure prevalence, but to examine the health effects of brain injuries resulting from intimate partner violence. NIH officials told us that this is the first study funded by NIH using brain images to investigate brain injuries resulting from intimate partner violence. NIH is also developing blood biomarkers—which are clinical diagnosis tools—for identifying mild TBI. Currently, mild TBI is generally diagnosed by taking an inventory of symptoms, but symptoms can lead to misdiagnoses, including for mental illness or a substance use disorder. NIH officials said they are in the initial stages of developing these biomarkers, which could take the place of screening tools in diagnosing a brain injury. While this effort was not initiated to better understand brain injuries among victims of intimate partner violence, biomarkers have the potential to improve the identification of TBIs, provided they are applied to domestic violence victims. Two other HHS agencies—ACL and HRSA—also have efforts that address brain injuries or intimate partner violence. However, these agencies’ efforts are generally not focused on the connection of the two issues, so they are not likely to result in more complete data on the prevalence of brain injuries resulting from intimate partner violence. Specifically: ACL provides grants to states to establish support services for individuals with brain injuries through its TBI State Partnership Program. As part of these efforts, ACL officials told us that they have begun to gather information to determine how many TBI grant recipients are using the funds to support particular populations, including individuals with TBI resulting from intimate partner violence. As of December 2019, ACL officials told us that two states (Idaho and Iowa) have used the grants to focus on individuals with TBI as a result of intimate partner violence. HRSA has proposed an effort to collect data that may assist in further understanding the health consequences of intimate partner violence. As part of its strategy to address intimate partner violence, HRSA officials recently began requiring federally qualified health centers to capture International Classification of Diseases-10 codes for intimate partner violence on health care claims beginning in 2020. This effort is not aimed at the intersection of intimate partner violence and brain injuries; the purpose of this data collection is to better understand the effect of intimate partner violence on victims’ health outcomes. While these data may currently underestimate the number of individuals affected by intimate partner violence, HRSA officials told us that their goal in collecting these data is to underscore the significance of intimate partner violence and help position providers to assist victims. Further, knowing the prevalence of brain injuries resulting from intimate partner violence and using these data could help officials further target education campaigns to providers on the potential injuries associated with intimate partner violence. Officials from HHS agencies acknowledge that the lack of prevalence data on brain injuries resulting from intimate partner violence is a challenge in addressing the intersection of these issues. However, HHS and its agencies do not have a plan for how they would collect better prevalence data, including a plan that specifies the extent to which HHS agencies should collaborate on data collection efforts. Although HHS agencies have some efforts underway, these efforts are limited or do not examine the connection between the issues. For example, CDC is working to add a question to NISVS to improve what is known about the prevalence of TBIs among victims of intimate partner violence; however, this effort overlooks brain injuries resulting from strangulation—which HRSA reports is often also experienced by these victims—because CDC’s priorities are to focus on TBIs specifically. Further, the newly funded NIH study is not intended to estimate the overall prevalence of brain injuries resulting from intimate partner violence. Having complete data on the prevalence of brain injuries resulting from intimate partner violence could strengthen HHS’s efforts to address this public health issue. HHS and its agencies acknowledge that enhancing the health and well-being of Americans is critical to their public health mission and intimate partner violence and TBIs are both prominent injury and violence issues. As part of this mission, CDC uses its Public Health Approach to guide its public health related efforts. The first step of this approach is to define the problem, which includes collecting prevalence data to understand the magnitude of the problem, where the problem exists, and whom it affects. According to CDC, such data are critical to ensuring that resources are focused on the individuals most in need. Collecting data on the prevalence of brain injuries resulting from intimate partner violence is a critical first step. With better data comes a better understanding of the overall prevalence of brain injuries resulting from intimate partner violence. This would give HHS and its agencies the information necessary to inform their efforts and allocate resources, including grant funding, to address victims of brain injuries resulting from intimate partner violence. Conclusions Intimate partner violence affects over 30 percent of women and men in the United States, and research has raised concerns about brain injuries sustained by these domestic violence victims. Officials from HHS agencies acknowledge the lack of overall prevalence data on brain injuries resulting from intimate partner violence and the adverse effect this lack of data has on understanding the intersection of these two issues. While HHS agencies have some efforts underway to address brain injuries and intimate partner violence, they are limited and address these issues separately. Therefore, HHS and its agencies have missed an opportunity to improve their public health efforts to address this issue, particularly the prevalence of the problem, where the problem exists, and whom it affects. By working together, HHS and its agencies can identify ways that each agency’s efforts could result in better prevalence data and a better overall understanding of brain injuries resulting from intimate partner violence. Improved data, in turn, could also help ensure that federal resources are allocated to the appropriate areas and used as efficiently and effectively as possible to address this public health issue. Recommendation We are making the following recommendation to HHS: The Secretary of HHS should develop and implement a plan to improve data collected on the prevalence of brain injuries resulting from intimate partner violence and use these data to inform HHS’s allocation of resources to address the issue. (Recommendation 1) Agency Comment We provided a draft of this report to HHS and DOJ for review and comment. In its written comments (reproduced in app. III), HHS concurred with our recommendation and noted that it is coordinating a plan amongst its relevant agencies to augment data collection on the prevalence of brain injuries resulting from intimate partner violence. HHS noted that these data will continue to inform the needs of this vulnerable population. HHS and DOJ also provided technical comments, which we incorporated as appropriate. We are sending copies of this report to the appropriate congressional committees, Secretary of Health and Human Services, Attorney General, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff members have any questions about this report, please contact me at (202) 512-7114 or yocomc@gao.gov. Contact points for our Office 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: Description of Literature Review and Bibliography We identified articles for our literature review through a search of bibliographic databases, including Harvard Library Think Tank Search, MEDLINE, and Scopus, using terms such as “intimate partner violence,” “domestic violence,” “traumatic brain injury,” and “strangulation.” We determined there were 57 relevant articles from 2009 through August 2019 discussing brain injuries resulting from intimate partner violence. We reviewed the 57 articles to examine brain injuries resulting from intimate partner violence, including background information on the concerns of brain injuries resulting from intimate partner violence and challenges that researchers may have identified in conducting this work. Of the 57 articles, we identified 28 that had conducted their own data analyses. We analyzed these 28 articles to examine data on prevalence rates, as well as research on health effects, treatment, and screening tools for identifying brain injuries resulting from intimate partner violence. The following articles are based on an original analysis of data. Brown, Joshua, Dessie Clark, and Apryl E. Pooley. “Exploring the Use of Neurofeedback Therapy in Mitigating Symptoms of Traumatic Brain Injury in Survivors of Intimate Partner Violence.” Journal of Aggression, Maltreatment & Trauma, vol. 28, no. 6 (2019): 764-783. Campbell, Andrew M., Ralph A. Hicks, Shannon L. Thompson, and Sarah E. Wiehe. “Characteristics of Intimate Partner Violence Incidents and the Environments in Which They Occur: Victim Reports to Responding Law Enforcement Officers.” Journal of Interpersonal Violence (2017): 1-24. Campbell, Jacquelyn C., Jocelyn C. Anderson, Akosoa McFadgion, Jessica Gill, Elizabeth Zink, Michelle Patch, Gloria Callwood, and Doris Campbell. “The Effects of Intimate Partner Violence and Probable Traumatic Brain Injury on Central Nervous System Symptoms.” Journal of Women’s Health, vol. 27, no. 6 (2018): 761-767. Cimono, Andrea, N., Grace Yi, Michelle Patch, Yasmin Alter, Jacquelyn C. Campbell, Kristin K. Gunderson, Judy T. Tang, Kiyomi Tsuyuki, and Jamila K. Stockman. “The Effect of Intimate Partner Violence and Probable Traumatic Brain Injury on Mental Health Outcomes for Black Women.” Journal of Aggression, Maltreatment & Trauma, vol. 28, no. 6 (2019): 714-731. Crowe, Allison, Christine E. Murray, Patrick R. Mullen, Kristine Lundgren, Gwen Hunnicutt, and Loreen Olson. “Help-Seeking Behaviors and Intimate Partner Violence-Related Traumatic Brain Injury.” Violence and Gender, vol. 6, no. 1 (2019): 64-71. Gagnon, Kelly L., and Anne P. DePrince. “Head Injury Screening and Intimate Partner Violence: A Brief Report.” Journal of Trauma & Dissociation, vol. 18, no. 4 (2017): 635-644. Higbee, Mark, Jon Eliason, Hilary Weinberg, Jonathan Lifshitz, and Hirsch Handmaker. “Involving Police Departments in Early Awareness of Concussion Symptoms during Domestic Violence Calls.” Journal of Aggression, Maltreatment & Trauma, vol. 28, no. 7 (2019): 826-837. Hunnicutt, Gwen, Christine Murray, Kristine Lundgren, Allison Crowe, and Loreen Olson. “Exploring Correlates of Probable Traumatic Brain Injury among Intimate Partner Violence Survivors.” Journal of Aggression, Maltreatment & Trauma, vol. 28, no. 6 (2019): 677-694. Hux, Karen, Trish Schneider, and Keri Bennett. “Screening for traumatic brain injury.” Brain Injury, vol. 23, no. 1 (2009): 8-14. Joshi, Manisha, Kristie A. Thomas, and Susan B. Sorenson. “‘I Didn’t Know I Could Turn Colors’: Health Problems and Health Care Experiences of Women Strangled by an Intimate Partner.” Social Work in Health Care, vol. 51, no. 9 (2012): 798-814. Linton, Kristen Faye. “Interpersonal violence and traumatic brain injuries among Native Americans and women.” Brain Injury, vol. 29, no. 5 (2015): 639-643. Messing, Jill T., Kristie A. Thomas, Allison L. Ward-Lasher, and Nathan Q. Brewer. “A Comparison of Intimate Partner Violence Strangulation Between Same-Sex and Different-Sex Couples.” Journal of Interpersonal Violence, vol. 00, no. 0 (2018): 1-19. Messing, Jill T., Michelle Patch, Janet S. Wilson, Gabor D. Kelen, Jacquelyn Campbell. “Differentiating among Attempted, Completed, and Multiple Nonfatal Strangulation in Women Experiencing Intimate Partner Violence.” Women’s Health Issues, vol. 28, no. 1 (2018): 104-111. Mittal, Mona, Kathryn Resch, Corey Nichols-Hadeed, Jennifer Thompson Stone, Kelly Thevenet-Morrison, Catherine Faurot, and Catherine Cerulli. “Examining Associations between Strangulation and Depressive Symptoms in Women with Intimate Partner Violence Histories.” Violence and Victims, vol. 33, no. 6 (2019): 1072-1087. Nemeth, Julianna M., Cecilia Mengo, Emily Kulow, Alexandra Brown, and Rachel Ramirez. “Provider Perceptions and Domestic Violence (DV) Survivor Experiences of Traumatic and Anoxic-Hypoxic Brain Injury: Implications for DV Advocacy Service Provision.” Journal of Aggression, Maltreatment & Trauma, vol. 28, no. 6 (2019): 744-763. Pritchard, Adam J., Amy Reckdenwald, Chelsea Nordham, and Jessie Holton. “Improving Identification of Strangulation Injuries in Domestic Violence: Pilot Data From a Researcher-Practitioner Collaboration.” Feminist Criminology, vol. 12, no. 2 (2018): 160-181. Ralston, Bridget., Jill Rable, Todd Larson, Hirsch Handmaker, and Jonathan Lifshitz. “Forensic Nursing Examination to Screen for Traumatic Brain Injury following Intimate Partner Violence.” Journal of Aggression, Maltreatment & Trauma, vol. 28, no. 6 (2019): 732-743. Reckdenwald, Amy, Ketty Fernandez, and Chelsea L. Mandes. “Improving law enforcement’s response to non-fatal strangulation.” Policing: An International Journal (2019): 1-15. Reckdenwald, Amy, Chelsea Nordham, Adam Pritchard, and Brielle Francis. “Identification of Nonfatal Strangulation by 911 Dispatchers: Suggestions for Advances Toward Evidence-Based Prosecution.” Violence and Victims, vol. 32, no. 3 (2017): 506-520. Shields, Lisa B.E., Tracey S. Corey, Barbara Weakley-Jones, and Donna Stewart. “Living Victims of Strangulation.” American Journal of Forensic Medicine and Pathology, vol. 31, no. 4 (2010): 320-325. St. Ivany, Amanda, Linda Bullock, Donna Schminkey, Kristen Wells, Phyllis Sharps, and Susan Kools. “Living in Fear and Prioritizing Safety: Exploring Women’s Lives After Traumatic Brain Injury From Intimate Partner Violence.” Qualitative Health Research, vol. 28, no. 11 (2018): 1708-1718. St. Ivany, Amanda, Susan Kools, Phyllis Sharps, and Linda Bullock. “Extreme Control and Instability: Insight Into Head Injury From Intimate Partner Violence.” International Association of Forensic Nursing, vol. 14, no. 4 (2018): 198-205. St. Ivany, Amanda, and Donna Schminkey. “Rethinking Traumatic Brain Injury from Intimate Partner Violence: A Theoretical Model of the Cycle of Transmission.” Journal of Aggression, Maltreatment & Trauma, vol. 28, no. 7 (2019): 1-23. Sullivan, Karen A, and Christina Wade. “Assault-Related Mild Traumatic Brain Injury, Expectations of Injury Outcome, and the Effects of Different Perpetrators: A Vignette Study.” Applied Neuropsychology: Adult, vol. 26, no. 1 (2019): 58-64. Sullivan, Karen A, and Christina Wade. “Does the Cause of the Mild Traumatic Brain Injury Affect the Expectation of Persistent Postconcussion Symptoms and Psychological Trauma?” Journal of Clinical and Experimental Neuropsychology, vol. 39, no. 4 (2017): 408- 418. Valera, Eve M., Aihua Cao, Ofer Pasternak, Martha E. Shenton, Marek Kubicki, , Nikos Makris, and Noor Adra. “White Matter Correlates of Mild Traumatic Brain Injuries in Women Subjected to Intimate-Partner Violence: A Preliminary Study.” Journal of Neurotrauma, vol. 36 (2019): 661-668. Valera, Eve, and Aaron Kucyi. “Brain Injury in Women Experiencing Intimate Partner-Violence: Neural Mechanistic Evidence of an “Invisible” Trauma.” Brain Imaging and Behavior, vol. 11 (2017): 1664-1677. Zieman, Glynnis, Ashley Bridwell, and Javier F. Cardenas. “Traumatic Brain Injury in Domestic Violence Victims: A Retrospective Study at the Barrow Neurological Institute.” Journal of Neurotrauma, vol. 33, (2016): 1- 5. Appendix II: Nonfederal Initiatives Focused on Intimate Partner Violence and Brain Injury The following table provides a brief overview of each of the 12 initiatives we identified based on information provided by the Department of Health and Human Services, the Department of Justice, and other stakeholders. These initiatives engage in various efforts to address intimate partner violence and brain injuries, including traumatic brain injury and anoxic injuries resulting from strangulation. Our list includes those efforts identified during the course of our review and may not be exhaustive. The descriptions of initiatives are based on our review of documentation and information obtained from interviews with officials. Appendix III: Comments from the Department of Health and Human Services Appendix IV: Staff Acknowledgements and GAO Contact GAO Contact Staff Acknowledgments In addition to the contact named above, Shannon Slawter Legeer (Assistant Director), Danielle Bernstein (Analyst-in-Charge), and Ashley Dixon made key contributions to this report. Also contributing were Leia Dickerson, Kaitlin Farquharson, Drew Long, and Ethiene Salgado- Rodriguez.