Background Family Caregiver Program Organizational Structure Within VHA, the Caregiver Support Program Office, VISNs, and VAMCs all have a role in administering and overseeing the Family Caregiver Program. Caregiver Support Program Office. The Caregiver Support Program Office administers the Caregiver Support Program, which has two main components— 1. the Family Caregiver Program, which is available to eligible post-9/11 veterans, and their qualified caregivers, and 2. the Program of General Caregiver Support Services, which is available to covered veterans from any service era and their qualified caregivers. The Caregiver Support Program Office develops policy and procedures and provides guidance, oversight, and support for both components of the Caregiver Support Program. As of April 2019, this office had 11 full-time staff, with authorization to hire eight additional staff. VISNs. Each of VHA’s 18 VISNs has a lead official for the Family Caregiver Program—either a VAMC CSC who serves in the VISN lead role for at least 25 percent of the CSC’s time or a VISN employee who is responsible for the Family Caregiver Program as one of their VISN duties. The VISN lead official’s role is to provide guidance to CSCs within the VISN and to help address their questions or concerns. VISN lead officials are also responsible for disseminating information, collecting data when needed, conducting quality assurance audits, assisting and coordinating responses to inquiries from the Caregiver Support Program Office, and monitoring the Family Caregiver Program workload across the VISN. VAMCs. The program is administered at the local level at 140 VAMCs. Each VAMC has staff that are assigned to the program on either a full- time or part-time basis, as well as other VAMC staff that may assist with specific Family Caregiver Program-related activities as a collateral duty. VAMC staff assigned to the Family Caregiver Program may include the following: CSCs. CSCs are the primary program staff administering the program at VAMCs. They are generally licensed clinical social workers or registered nurses. CSCs have clinical responsibilities that may include identifying and coordinating appropriate interventions for caregivers or referrals to other VA or non-VA programs, such as mental health treatment, respite care, or additional training and education. CSCs also have administrative responsibilities that may include responding to inquiries about the program, overseeing the application process, and entering information about applications and approved caregivers into IT systems. During the first quarter of fiscal year 2019, there were approximately 436 CSCs assigned to 140 VAMCs. Administrative staff. Administrative staff are typically responsible for activities such as mailing communications to program applicants and participants, scheduling appointments, entering data into CAT, and otherwise supporting the administrative needs of the program. During the first quarter of fiscal year 2019, 24 of the 140 VAMCs or health care systems had administrative staff members assigned to the program. Clinical staff. Some VAMCs have clinical staff assigned to the program, which can include registered nurses, doctors, nurse practitioners, occupational therapists, or psychologists. These staff typically conduct in-home monitoring and may help with clinical eligibility determinations of veterans during the application process. During the first quarter of fiscal year 2019, 17 VAMCs had approximately 12 full-time-equivalent doctors, nurse practitioners, occupational therapists, and psychologists assigned to the program. Other VAMC clinical staff who are not assigned to the Family Caregiver Program may assist the program as a collateral duty. For example, they may serve as members of the clinical eligibility team or assist with program monitoring—including quarterly contacts and annual home visits—or program appeals (see fig. 1). Funding for Family Caregiver Program Staff The Caregiver Support Program Office directly funds the salaries for staff assigned to the Family Caregiver Program at VAMCs. Specifically, it funds the salaries of the CSCs, as well as some other staff who are assigned to the program, such as administrative staff or clinical staff. However, some VAMCs may also choose to fund additional staff for the program, if they identify a need. Additionally, the portion of time spent by VAMC staff assisting the program as a collateral duty may be reimbursed by the Caregiver Support Program Office. Family Caregiver Program Application Process To participate in the program, caregivers and veterans must submit applications to their local VAMC or to VHA’s Health Eligibility Center. CSCs manage the multi-step application process, which includes administrative and clinical eligibility determinations, among other requirements (see fig. 2). According to VHA policy, VAMCs should review applications for the program within 45 days. However, this review can be extended up to 90 days if the veteran’s caregiver has not completed required training, or the veteran is hospitalized during the application process. Family Caregiver Program Monitoring Once caregivers and veterans are enrolled in the Family Caregiver Program, VHA policy requires CSCs or other VAMC clinical staff to periodically monitor the veteran’s overall health and well-being and the adequacy of the care and supervision being provided by the caregiver. This monitoring is to be documented in CAT as well as in the Computerized Patient Record System because it is a clinical encounter. The monitoring includes quarterly contacts. These contacts are supposed to occur every 90 calendar days, unless otherwise clinically indicated. They may be conducted as home visits, or if approved by the veteran’s primary care team, the contacts can be completed via telephone, a face-to-face visit at a VHA medical facility, or using clinical video telehealth. annual home visits. Caregivers and veterans must receive at least one home visit each year. According to Caregiver Support Program Office officials, the annual home visit counts as one of the quarterly contacts. If a veteran demonstrates an improvement or decline in their functioning while in the program, VAMC staff are supposed to reassess the veteran to determine whether they remain clinically eligible for the program or whether a change in the stipend tier level (increase or decrease) may be appropriate. A reassessment may result in a discharge from the program, a tier level change, or no change. However, the VA Secretary announced a moratorium on discharges and tier level decreases on December 21, 2018 due to continued concerns from veterans, caregivers, and others about VAMCs’ inconsistent application of eligibility requirements. According to Caregiver Support Program Office officials, there is no current timeline for when the moratorium will be lifted. VA Office of Inspector General Review of the Family Caregiver Program In August 2018, the VA Office of Inspector General (VA OIG) issued a report on its review of the Family Caregiver Program, which focused on whether the program effectively provided services and support to qualified veterans and their caregivers. The VA OIG found that program applications were not reviewed in a timely manner, eligibility criteria were not consistently applied, caregivers and veterans were not routinely monitored, and that VHA had failed to effectively establish a governance structure that promoted program management accountability. The VA OIG made six recommendations to improve the program, including recommendations to establish a governance structure and to assess the adequacy of the program’s staffing levels at VAMCs. In May 2019, the VA OIG reported that the program had implemented the two recommendations related to establishing a governance environment and designating VISN lead officials for the program. Specifically, the Family Caregiver Program issued an updated directive for the program and additional standard operating procedures in October 2018 to address the governance environment recommendation and issued a memorandum regarding VISN lead officials in January 2019 to address the VISN lead official recommendation. According to the VA OIG, the remaining recommendations have not yet been implemented. VA MISSION Act The VA MISSION Act, which was enacted in June 2018, included provisions directing VA to implement an IT system to support the Family Caregiver Program and the incremental expansion of program eligibility. Specifically, the Act required VA to implement an IT system by October 1, 2018. According to the Act, the IT system is to allow for data assessment and comprehensive monitoring of the program. The VA MISSION Act also required VA to submit an initial report to Congress regarding the status of the planning, development, and deployment of this system within 90 days of enactment of the Act and a final report by October 1, 2019. The final report is to include a certification by the VA Secretary that the system has been implemented, along with a description of how the Secretary is using the system to monitor the workload of the program. In addition, the VA MISSION Act requires an incremental expansion of eligibility for the Family Caregiver Program. Specifically, within 2 years of the VA Secretary certifying the IT system for the Family Caregiver Program, VHA is to expand program eligibility to caregivers of veterans with a serious injury incurred or aggravated in the line of duty on or before May 7, 1975 or on or after September 11, 2001. Two years after this initial expansion of eligibility, VHA is to further expand program eligibility to include any veteran with a serious injury incurred or aggravated in the line of duty and in need of personal care services as specified in the statute. Staffing Requirements for the Family Caregiver Program Allow Variation across VAMCs; VHA Lacks Complete and Accurate Staffing Data for the Program Family Caregiver Program Staffing Varies across VAMCs The Caregiver Support Program Office policy requires every VAMC to have at least one full-time CSC to administer the program. The policy also requires VAMCs to have an eligibility determination process, but does not specify staffing requirements for that process beyond stating that “appropriate” providers should be involved. This broad guidance provides VAMCs with flexibility in determining which providers to include in the eligibility determination process. We found that each of the four VAMCs we visited staff their Family Caregiver Program differently, including both the staff assigned to the program as well as other VAMC staff assisting the program as a collateral duty. While all four VAMCs had at least one CSC on staff, as required, other staff assigned to the program varied and included administrative staff, a non-CSC social worker, and non-CSC registered nurses. Furthermore, the differences we identified with VAMC staff assisting the program as a collateral duty included staff that assist with clinical eligibility determinations as well as staff that assist with other program requirements. Specifically, each of the four VAMCs had assembled their own clinical eligibility teams, which varied in composition and could include physicians, therapists, or mental health professionals. Other variations with staff assisting the program included three VAMCs that utilized members of the Home Based Primary Care team to assist with initial home visits, quarterly contacts, and annual home visits, and a VAMC that used physicians to assist the program with assigning stipend tier levels (see table 1). VHA Lacks Complete and Accurate Information on Family Caregiver Program Staffing We found that VHA’s Caregiver Support Program Office does not have complete and accurate staffing information for the Family Caregiver Program. First, the Caregiver Support Program Office does not have complete information on all staff supporting the program. The office only tracks staff funded by the Caregiver Support Program Office, but does not track program staff that are VAMC-funded or other VAMC staff that assist the program as a collateral duty. For example, one site we visited had a VAMC-funded nurse that conducted quarterly contacts and home visits, but this nurse was not being tracked by the program office. Similarly, the program office was not tracking the time and resources related to VAMCs’ clinical eligibility team members. At each of the four VAMCs we visited, members of the clinical eligibility teams dedicated between 3 and 12 hours a month preparing for and attending the eligibility meetings. Furthermore, although the program’s VISN lead officials collect data on the Caregiver Support Program Office funded positions at each VAMC annually at a minimum and submit these data to the Caregiver Support Program Office, there is no documented process to validate the data’s accuracy. VHA employs a process that relies on VISN lead officials collecting data from facilities, and as a result, the overall accuracy of the data depends on the accuracy of the data VAMCs report. Based on our review of the staffing data, we identified discrepancies between the Caregiver Support Program Office’s staffing data for the first quarter of fiscal year 2019 and the number of staff we observed at all four VAMCs we visited. At two VAMCs, the number of CSCs that the Caregiver Support Program Office reported was higher than what we found. Caregiver Support Program Office officials said that these staffing discrepancies could be due to vacant positions. However, officials at the two VAMCs did not indicate that they had vacant positions at the time of our site visits. The third VAMC had a part-time registered nurse staffed to the program that was not included in the Caregiver Support Program Office’s staffing data even though this position was funded by VHA. Caregiver Support Program Office officials could not provide a reason for this discrepancy. The fourth VAMC had an administrative staff member funded by the Caregiver Support Program Office that was not included in the staffing data. Additionally, the Caregiver Support Program Office does not know the exact number of CSCs assigned to the program. The program office funds CSC positions, which can be filled by registered nurses or social workers. The program office also funds registered nurses who are not CSCs. However, the program office’s staffing data does not distinguish between the two types of registered nurse positions because they do not currently have the capability to collect such staffing details. As a result, Caregiver Support Program Office officials told us they could not identify registered nurses who are CSCs from other registered nurses assigned to the program. Officials reported that they are working on finding a way to collect details on the types of registered nurse positions. Although Caregiver Support Program Office officials said that they are taking steps to collect more information about the staff involved in supporting the Family Caregiver Program to prepare for the MISSION Act expansion, these efforts do not fully address the problems with data completeness and accuracy that we identified. Officials said that they are starting to collect data on the Family Caregiver Program staff more frequently. Specifically, the program plans to collect information on Caregiver Support Program Office funded staff at each VAMC from the VISN lead officials quarterly instead of annually, to align with how other national programs collect such data. During the course of this review officials said they had begun working on updating the method they use to collect staffing data. Caregiver Support Program Office officials said that this revised data collection instrument will include mandatory fields and data entry rules to ensure that the data reported are more consistent. However, officials did not provide any timelines for when they will begin using the updated method. Program officials have begun to develop a staffing model in anticipation of future program growth when eligibility expands to include pre-9/11 veterans. To create the staffing model, officials are identifying current program staff at the VHA, VISN, and VAMC levels and the tasks these staff perform. However, officials indicated that the model will use Caregiver Support Program Office staffing data because those are the only staffing data available for the program. As a result, VAMC-funded staff and collateral staff will not be included. Consequently, the completeness of the staffing model will be compromised and the current and future staffing resources identified by the model may not accurately estimate the program’s needs. The lack of complete and accurate staffing data for the Family Caregiver Program is inconsistent with federal internal control standards that require management to use quality information to achieve its objectives. Without complete and accurate information about the total number and types of staff that support the program, VHA does not know whether the program’s staffing approach and available resources are sufficient to meet the program’s requirements as well as the needs of participating caregivers and veterans. Furthermore, without complete and accurate staffing data, it is unclear how the Caregiver Support Program Office will develop projections of the staff that will be needed to enroll and support additional caregivers and veterans when the Family Caregiver Program’s eligibility is expanded as required by the MISSION Act. VHA Monitors VAMCs’ Performance Processing Applications but Lacks System-Wide Data to Monitor Required Contacts with Caregivers and Veterans VHA Monitors VAMCs’ Reviews of Family Caregiver Program Applications and Has Taken Steps to Improve Timeliness Within VHA, the Caregiver Support Program Office monitors the timeliness of VAMCs’ processing of applications for the Family Caregiver Program. Specifically, Caregiver Support Program Office officials told us that they review a monthly report from CAT. These reports show the number of applications in process at each VAMC and how long they have been in process. Officials also said that they share this information with VISN lead officials each month. However, since the inception of the program, VAMCs have had difficulty meeting VHA’s requirement to review applications within 90 days. Our analysis of CAT data found that about 68 percent of the 17,576 applications submitted from October 2017 through September 2018 were reviewed within 90 days. In January 2019, a memorandum was issued that required all VAMCs to develop action plans to address application processing delays beyond 90 days. Further, any VAMCs with more than 10 applications beyond 120 days or any exceeding 365 days were required to submit their action plans to the Caregiver Support Program Office. As a result of this memo, 11 VAMCs have submitted action plans. Caregiver Support Program Office officials said that they have assigned staff to monitor the action plans and have discussed the plans with the leadership of the VISNs that oversee these VAMCs. Additionally, in February 2019, VHA established a national level performance metric to measure application processing timeliness for the program that will be updated on a monthly basis, according to Caregiver Support Program Office officials. VHA’s goal is for 90 percent of Family Caregiver Program applications submitted in fiscal year 2019 to be processed within 90 days. The May 2019 report from CAT shows that 94 percent of the 1,246 current applications have been in process 90 days or less. VHA Lacks System-Wide Data on the Extent to Which VAMC Staff Have Completed Required Contacts and Visits with Caregivers and Veterans VHA’s Caregiver Support Program Office lacks system-wide data from CAT or other sources on the completion of VAMCs’ required quarterly contacts and annual home visits conducted with caregivers and veterans in the Family Caregiver Program. Although these contacts and visits are supposed to be documented in CAT, the system has limited reporting capabilities. As a result, Caregiver Support Program Office officials are unable to obtain system-wide data that would allow them to monitor VAMCs’ completion of these requirements. Furthermore, officials could not readily provide these data for the four VAMCs we visited because doing so would have required them to manually review each veteran’s record (921 records across the four VAMCs). Given CAT’s reporting limitations, some VAMC and VISN lead officials we spoke with indicated that they have developed their own methods for tracking contacts and visits at the facility or regional levels. For example, officials at one VAMC told us they had developed a spreadsheet for the purpose of tracking quarterly contacts and annual home visits. Further, the VISN lead officials from one VISN told us that their VAMCs report information on their ability to schedule and complete contacts and visits on a monthly basis. The program office does not collect these data from the VAMCs or VISNs. The Caregiver Support Program Office has been able to collect limited information on the extent to which quarterly contacts and annual home visits are completed through 1) bi-annual audits of a sample of Family Caregiver Program participant records that are rolled into in an annual report and 2) site visits to select VAMCs. Caregiver Support Program Office officials told us that the audits of program participants’ records serve as their main source of information on the completion of required contacts and visits. However, the focus of the audits vary each year, which means that officials cannot monitor trends in performance over time because the information is not comparable year-to-year. For example, in fiscal years 2017 and 2018, the focus was on the records of caregivers and veterans who had been discharged from the program, and in fiscal year 2016, the focus was on newly approved caregivers and veterans. In addition, because the audits are focused on a random sample of individual participants’ records, they do not provide the Caregiver Support Program Office with information to determine whether individual VAMCs are meeting these requirements. Program office officials also told us that their site visits to VAMCs include a review of the processes for required quarterly contacts and annual home visits. As of January 2019, program office officials had conducted 16 site visits since fiscal year 2016— representing about 11 percent of VAMCs. Caregiver Support Program Office officials also report that they intend to develop a site visit plan as part of MISSION Act implementation planning. Without system-wide data on VAMCs’ monitoring efforts, the program office does not know whether contacts and visits are being completed as required or whether VAMCs may need more staff to conduct them. The VAMC officials we spoke with acknowledged that their ability to complete quarterly contacts and annual home visits was dependent upon having enough staff. For example, one VAMC official reported that its facility did not complete an entire quarter of contacts and visits to caregivers and veterans because they did not have sufficient staffing resources. Similarly, a VISN lead official said that the VAMCs in its network also have had trouble meeting monitoring requirements due to insufficient staff. The lack of system-wide data on VAMCs’ completion of required contacts and visits is inconsistent with federal internal control standards that require management to use quality information to achieve their objectives. Furthermore, without these data, the Caregiver Support Program Office is also limited in its ability to estimate the additional staff that will be needed to conduct these contacts and visits once the program’s eligibility expands. VA Has Yet to Implement an IT System That Fully Supports the Family Caregiver Program VHA and OIT have worked jointly over the last four years to both fix and replace the existing Family Caregiver Program IT system, CAT, but these efforts have not led to the implementation of an IT system that fully supports the needs of the program. The VA MISSION Act included provisions that directed the department to implement an IT system for the Family Caregiver Program by October 1, 2018 and required certification of the system from the VA Secretary by October 1, 2019. However, the department reported to congressional committees in October 2018 that meeting the system implementation deadline of the VA MISSION Act was not feasible. Consequently, that deadline has not yet been met. Specifically, VHA and OIT undertook two related efforts beginning in 2015: CAT Rescue was initiated in July 2015 as a short-term project intended to improve both the quality of CAT’s data and the system’s reliability and security. However, schedule delays and significant defects identified during system testing contributed to CAT Rescue’s termination in April 2018. According to OIT officials, the department spent about $2.86 million on CAT Rescue. However, the project did not deliver viable software improvements. Caregivers Tool (CareT), a companion project to CAT Rescue, was initiated in September 2015 and was intended to produce a replacement for CAT. The project was to develop and deliver a replacement system with expanded capabilities, such as easier caregiver application submission and enhanced caregiver program analysis capabilities. However, the CareT acquisition depended on CAT Rescue, which did not deliver the needed data improvements. When CAT Rescue was terminated, data improvement and migration activities that were previously part of CAT Rescue were moved to the CareT project and contract extensions were necessary to allow more time for system development and testing in relation to these expanded requirements. Subsequently, OIT and VHA Caregiver Support Program Office officials acknowledged that development delays and the number and critical nature of system defects identified during user acceptance testing had led to the VHA Caregiver Support Program Office’s loss of confidence in CareT as a viable replacement for CAT. As a result, VA suspended the CareT acquisition in January 2019 to assess the way forward. Ultimately, work on CareT ended in late February 2019. According to OIT officials, the department spent about $8.11 million on CareT between 2015 and 2019. However, no fully functioning system replacement was delivered as intended. VA commissioned two independent assessments that examined issues impacting the CAT Rescue and CareT projects. These assessments, completed by Digital Service at VA and the MITRE Corporation in early 2019, cited a number of deficiencies that likely contributed to the termination of CAT Rescue and impacted the ability of CareT to successfully deliver new system capabilities. For example, the assessments identified deficiencies in the following areas: Requirements management: The department did not effectively implement a process for requirements development and prioritization. As a result, OIT, program office staff, and the development contractors did not have a shared understanding of how the system was to perform. In addition, the requirements identified may have been overly complex and insufficient to facilitate IT development. Efforts to elaborate on the requirements over the course of the projects were not consistent and led to delays. Further, significant defects identified during testing were not effectively prioritized and requirements remained unmet. Leadership: CAT Rescue and CareT did not have stable leadership and experienced staff throughout the department’s efforts to address issues with the program. Specifically, there was a lack of sustained leadership or a product owner needed to create and enforce a technical vision across contractors and the department. Without such leadership, there was a lack of effective governance and shared accountability across VHA, OIT, and the development contractor. According to the assessments, these deficiencies, among others, have resulted in VA’s inability to successfully deliver IT improvements as planned. We have previously reported that successfully overcoming challenges in areas such as those identified in the independent assessments of CAT Rescue and CareT is critical to increasing an agency’s odds for delivering an IT system acquisition. With the loss of confidence in CareT as a viable solution and the subsequent results of the independent assessments, VA has redirected its efforts for a third time and initiated a new project, referred to as the Caregiver Record Management Application (CARMA), in March 2019. Specifically, CARMA is focused on acquiring a solution to CAT using a commercial product that is to be configured to fit the needs of the Family Caregiver Program and support the program’s expansion. The first CARMA release, planned for late October 2019, is intended to replace CAT and improve program reporting. According to program officials, this release is expected to include expanded capabilities needed to develop system-wide reports on the completion of the required quarterly contacts and annual home visits. The second release, planned for January 2020, is intended to refine initial functionality and improve stipend processing capabilities. Additional product releases are expected at least through the summer of 2020 to incorporate new capabilities, such as online application submissions for veterans and the ability to connect to existing VA systems that manage veteran and caregiver identity and relationship management. However, it is unclear what additional work may be necessary to accommodate the expansion of the Family Caregiver Program given that the department is only in the early stages of planning. Further, the department has not yet established a target date for certifying CARMA. According to OIT officials, the cost for CARMA is estimated to be between $5.7 million and $6.3 million, but additional costs for licensing and modifications to legacy systems are also expected. As of June 2019, OIT and VHA with assistance from the Digital Service at VA had taken steps to identify key project stakeholders, estimate costs, establish a timeline, and compile the initial set of requirements for implementing the first release. The department had also identified a Product Manager, who is to be responsible for coordinating efforts between OIT and VHA. According to officials from the Digital Service at VA, the CARMA project plans to use a better, more agile approach for managing requirements. In addition, the staff asserted that the department has established and filled the new Product Manager position, which is intended to improve project leadership. Despite these actions, VA has not yet demonstrated results to show whether these changes will be sufficiently effective to overcome the issues that contributed to the failure of both CAT Rescue and CareT. It is also not yet certain when VA will successfully implement and certify its IT system as required by the VA MISSION Act. Further, because the expansion of the program is contingent on the certification by the VA Secretary that the IT system fully supports the program, continued delays with the IT system will postpone needed assistance for caregivers and veterans who may qualify for these benefits when eligibility requirements are expanded. Thus, it will be important that VA ensure that the actions taken to improve requirements management and leadership of the CARMA project are effectively implemented in order to improve the likelihood that the project will deliver an IT system that fully supports the Family Caregiver Program. Conclusions As VA prepares for the expansion of the Family Caregiver Program to include caregivers of veterans who served prior to September 11, 2001, it will be important that VA have an informed understanding of the staffing resources needed to support the program. However, we found that VA continues to struggle to have the information and tools needed to effectively monitor the Family Caregiver Program. Since the Family Caregiver Program was implemented in 2011, it has experienced difficulties in meeting program requirements, such as for monitoring program enrollees, potentially impacting the caregivers and veterans it is intended to support. As both we and the VA OIG have reported, determining and ensuring there are sufficient program staff to support the program is one of VHA’s greatest obstacles in meeting program requirements. In particular, VHA’s Caregiver Support Program Office does not have complete and accurate staffing data with which to assess current and future staffing levels because it is not collecting data on all VAMC staff who support the program, and the data that are collected are not validated. The Caregiver Support Program Office is further impeded in its ability to assess whether VAMCs’ staffing levels for the program are adequate because it lacks system-wide data on the completion of periodic contacts and visits with caregivers and veterans. While the new IT system should address this issue, the program office would benefit from having an interim method to collect this information as VA’s previous efforts to fix and replace CAT have not been successful. Until the program office has reliable data for oversight and planning, the difficulties VA has experienced since the Family Caregiver Program was implemented could be further exacerbated when the program’s eligibility expands to include the caregivers of veterans of all eras. Recommendations for Executive Action We recommend that the Secretary of the VA direct the Under Secretary for Health to take the following actions: Collect complete staffing data for the Family Caregiver Program that includes Caregiver Support Program Office funded staff, VAMC funded staff, and staff that assist the program as a collateral duty at each VAMC. (Recommendation 1) Establish a process to ensure that the Family Caregiver Program staffing data that are collected and reported to the Caregiver Support Program Office are accurate. (Recommendation 2) Identify and use an interim method to collect data from VAMCs on their completion of required quarterly contacts and annual home visits with caregivers and veterans that can be used until a new IT system is implemented. (Recommendation 3) Agency Comments VA provided written comments on a draft of this report, which are reprinted in appendix I. In its written comments, VA concurred with all three recommendations. VA also provided technical comments, which we incorporated as appropriate. With respect to our recommendation on collecting complete staffing data, VA concurred and stated it is in the process of developing a data collection mechanism that will allow for the capture of more specific data about staffing roles and disciplines of Family Caregiver Program staff. VA also concurred with our recommendation to establish a process that ensures that the staffing data collected and reported to the Caregiver Support Program Office are accurate. VA stated that the VISN lead officials will be responsible for reviewing and validating the staffing data submitted and that the data collection mechanism under development for this purpose will have data validation processes in place for its data fields to ensure that the data entered by VISN leads are accurate. VA also concurred with our recommendation that it needs to identify and use an interim method to collect data on the completion of required quarterly contacts and annual home visits that can be used until a new IT system is implemented. In its technical comments, VA noted that data on quarterly contacts and annual home visits with caregivers and veterans are also captured in the Computerized Patient Record System because these visits are considered clinical encounters, which we note in our report. VA further stated that staff should be able to track the workload entered into the Computerized Patient Record System if VAMCs have appropriately set up their IT systems with the designated code for this program. VA asserted that in response to our recommendation it is exploring the feasibility of using data from the Computerized Patient Record System as an interim solution for monitoring the completion of quarterly contacts and annual home visits system-wide. Additionally, VA reiterated that the first release of CARMA, which it plans to release in October 2019, should include the capabilities necessary to develop system-wide reports on the completion of required quarterly contacts and annual home visits. We are sending copies of this report to the Secretary of Veterans Affairs, the appropriate congressional committees, 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 have any questions about this report, please contact Sharon M. Silas at (202) 512-7114 or silass@gao.gov or Carol C. Harris at (202) 512-4456 or harriscc@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs are on the last page of this report. GAO staff who made major contributions to this report are listed in appendix II. Appendix I: Comments from the Department of Veterans Affairs Appendix II: GAO Contacts and Staff Acknowledgments GAO Contacts Staff Acknowledgments In addition to the contacts named above, Bonnie Anderson (Assistant Director), Mark Bird (Assistant Director), Alison Goetsch (Analyst-in- Charge), Emily Loriso, and Jennifer Stavros-Turner made key contributions to this report. Also contributing were Jennie F. Apter, Chris Businsky, Krister Friday, Monica Perez-Nelson, and Ethiene Salgado- Rodriguez. Related GAO Products VA Health IT: Use of Acquisition Best Practices Can Improve Efforts to Implement a System to Support the Family Caregiver Program. GAO-19- 581T. Washington, D.C.: May 22, 2019. Veterans Affairs: Addressing IT Management Challenges Is Essential to Effectively Supporting the Department’s Mission. GAO-19-476T. Washington, D.C.: April 2, 2019. VA Health Care: Improvements Needed to Manage Higher-Than- Expected Demand for the Family Caregiver Program. GAO-15-245T. Washington, D.C.: December 3, 2014. VA Health Care: Actions Needed to Address Higher-Than-Expected Demand for the Family Caregiver Program. GAO-14-675. Washington, D.C.: September 18, 2014. Information Technology: Critical Factors Underlying Successful Major Acquisitions. GAO-12-7. Washington, D.C.: October 21, 2011.


Background Family Separations at the Southwest Border According to DHS and HHS officials, DHS has historically separated a number of children from accompanying adults at the border and transferred them to HHS custody, but these separations occurred only in certain circumstances. For example, DHS might separate families if the parental relationship could not be confirmed, if there was reason to believe the adult was participating in human trafficking or otherwise a threat to the safety of the child, or if the child crossed the border with other family members such as grandparents without proof of legal guardianship. HHS has traditionally treated these children as unaccompanied alien children (UAC)—children who (1) have no lawful immigration status in the United States, (2) have not attained 18 years of age, and (3) have no parent or legal guardian in the United States or no parent or legal guardian in the United States available to provide care and physical custody. The Attorney General’s April 2018 memorandum, also referred to as the “zero tolerance” policy, directed Department of Justice (DOJ) prosecutors to accept all referrals of all improper entry offenses from DHS for criminal prosecution, to the extent practicable. According to DHS officials, in implementing the April 2018 memo, DHS’s U.S. Customs and Border Protection (CBP) began referring a greater number of individuals apprehended at the border to DOJ for criminal prosecution, including parents who were apprehended with children. In these cases, referred parents were placed into U.S. Marshals Service custody and separated from their children because minors cannot remain with a parent who is arrested on criminal charges and detained by U.S. Marshals Service. In cases where parents were referred to DOJ for criminal proceedings and separated from their children, DHS and HHS officials stated they treated those children as UAC. In such cases, DHS transferred these children to the custody of HHS’s Office of Refugee Resettlement (ORR) and ORR placed them in one of their shelter facilities, as is the standard procedure for UAC. The President’s executive order issued on June 20, 2018, directed, among other things, that the Secretary of Homeland Security maintain custody of alien families during any criminal improper entry or immigration proceedings involving their family members, to the extent possible. This order stated that the policy of the administration is to maintain family unity, including by detaining alien families together where appropriate. In addition, on June 26, 2018, a federal judge ruled in the Ms. L. v. ICE case that certain separated parents must be reunited with their minor children (referred to in this testimony statement as the “June 2018 court order”). In this case, the American Civil Liberties Union filed a federal lawsuit on behalf of certain parents (referred to as class members) who had been separated from their children. As of September, 10, 2018, the government had identified 2,654 children of potential class members in the Ms. L. v. ICE case, which we discuss in greater detail later in this statement. As of January 31, 2019, this litigation was ongoing. Care and Custody of Unaccompanied Alien Children (UAC) Under the Homeland Security Act of 2002, responsibility for the apprehension, temporary detention, transfer, and repatriation of UAC is delegated to DHS, and responsibility for coordinating and implementing the placement and care of UAC is delegated to HHS’s ORR. CBP’s U.S. Border Patrol (Border Patrol) and Office of Field Operations (OFO), as well as DHS’s ICE, apprehend, process, temporarily detain, and care for UAC who enter the United States with no lawful immigration status. ICE’s Office of Enforcement and Removal Operations (ERO) is generally responsible for transferring UAC, as appropriate, to ORR, or repatriating them to their countries of nationality or last habitual residence. Under the William Wilberforce Trafficking Victims Protection Reauthorization Act of 2008 (TVPRA), UAC in the custody of any federal department or agency, including DHS, must be transferred to ORR within 72 hours after determining that they are UAC, except in exceptional circumstances. In addition, the 1997 Flores v. Reno Settlement Agreement (Flores Agreement) sets standards of care for UAC while in DHS or ORR custody, including, among other things, providing drinking water, food, and proper physical care and shelter for children. In 2015 and 2016, we reported on DHS’s and HHS’s care and custody of UAC, including the standard procedures that DHS follows to transfer UAC to ORR. ORR’s UAC policy guide states that the agency requests certain information from DHS when DHS refers children to ORR, including, for example, how DHS determined the child was unaccompanied. Depending on which DHS component or office is referring the child to ORR, DHS may provide information on the child in an automated manner directly into ORR’s UAC Portal—the official system of record for children in ORR’s care—or via email. ORR has cooperative agreements with residential care providers to house and care for UAC while they are in ORR custody. The aim is to provide housing and care in the least restrictive environment commensurate with the children’s safety and emotional and physical needs. In addition, these care providers are responsible for identifying and assessing the suitability of potential sponsors—generally a parent or other relative in the country—who can care for the child after the child leaves ORR custody. Release to a sponsor does not grant UAC legal immigration status. Children are scheduled for removal proceedings in immigration courts to determine whether they will be ordered removed from the United States or granted immigration relief. Once at the shelter, shelter staff typically conduct an intake assessment of the child within 24 hours, and then are to provide services such as health care and education. According to ORR’s UAC policy guide, shelter staff are responsible for meeting with the child to begin identifying potential sponsors, which can include parents. To assess the suitability of potential sponsors, including parents, ORR care providers collect information from potential sponsors to establish and identify their relationship to the child. For example, the screening conducted of potential sponsors includes various background checks and in June 2018, ORR implemented increased background check requirements that were outlined in an April 2018 memorandum of agreement with DHS. These changes required ORR staff to collect fingerprints from all potential sponsors, including parents, and all adults in the potential sponsor’s household and transmit the fingerprints to ICE to perform criminal and immigration status checks on ORR’s behalf. ICE was to submit the results to ORR, and ORR used this information, along with information provided by, and interviews with, the potential sponsors, to assess their suitability. However, in December 2018, ORR revised its background check policy to limit criminal and immigration status checks conducted by ICE to the potential sponsor, unless concerns about other adult household members are raised via a public records check, there is a documented risk to the safety of the child, the child is particularly vulnerable, or the case is referred for a home study. HHS and DHS Planning for Family Separations According to HHS and DHS officials we interviewed, the departments did not take specific steps in advance of the April 2018 memo to plan for family separations or a potential increase in the number of children who would be referred to ORR because they did not have advance notice of the memo. Specifically, ORR, CBP, and ICE officials we interviewed stated that they became aware of the April 2018 memo when it was announced publicly. Though they did not receive advance notice of the April 2018 memo, ORR officials stated that they were aware that increased separations of parents and children were occurring prior to the April memo. According to ORR officials, the percentage of children referred to ORR who were known to have been separated from their parents rose by more than tenfold from November 2016 to August 2017 (0.3 to 3.6 percent). In addition, the ORR shelter and field staff we interviewed at four ORR facilities in Arizona and Texas told us they started noticing an increase in the number of children separated from their parents in late 2017 and early 2018, prior to the April 2018 memo. The DHS officials we interviewed stated that, in some locations across the southwest border, there was an increase in the number of aliens CBP referred to DOJ for prosecution of immigration-related offenses after an Attorney General memo issued in April 2017. This memo prioritized enforcement of a number of criminal immigration-related offenses, including misdemeanor improper entry. In addition, CBP officials stated that there may have been an increase in children separated from non-parent relatives or other adults fraudulently posing as the child’s parents. According to ORR officials, in November 2017, ORR officials asked DHS officials to provide information about the increase in separated children. In response, DHS officials stated that DHS did not have an official policy to separate families, according to ORR officials. A few months prior to the April 2018 memo, ORR officials said they saw a continued increase in separated children in their care. ORR officials noted that they considered planning for continued increases in separated children, but HHS leadership advised ORR not to engage in such planning since DHS officials told them that DHS did not have an official policy of separating families. From July to November 2017, the Border Patrol sector in El Paso, Texas conducted an initiative to address an increase in apprehensions of families that sector officials had noted in early fiscal year 2017. Specifically, Border Patrol officials in the sector reached an agreement with the District of New Mexico U.S. Attorney’s Office to refer more individuals who had been apprehended, including parents who arrived with minor children, for criminal prosecution. Prior to this initiative, the U.S. Attorney’s Office in this district had placed limits on the number of referrals it would accept from Border Patrol for prosecution of immigration offenses. According to Border Patrol officials, under this initiative, the U.S. Attorney’s Office agreed to accept all referrals from Border Patrol in the El Paso sector for individuals with violations of 8 U.S.C. § 1325 (improper entry by alien) and § 1326 (reentry of removed aliens), consistent with the Attorney General’s 2017 memo directing federal prosecutors to prioritize such prosecutions. For those parents placed into criminal custody, Border Patrol referred their children to ORR’s care as UAC. According to a Border Patrol report on the initiative, the El Paso sector processed approximately 1,800 individuals in families and 281 individuals in families were separated under this initiative. Border Patrol headquarters directed the sector to end this initiative in November 2017, and Border Patrol officials stated that there were no other similar local initiatives that occurred prior to the Attorney General’s 2018 memo. DHS and HHS Systems for Indicating When Children Were Separated from Parents When the April 2018 memo was released, there was no single database with easily extractable, reliable information on family separations. DHS and HHS subsequently updated their data systems in the spring and summer of 2018, but it is too soon to know the extent to which these changes, if fully implemented, will consistently indicate when children have been separated from the parents or will help reunify families, if appropriate. Specifically, prior to April 2018, CBP’s and ORR’s data systems did not include a designated field to indicate that a child was unaccompanied as a result of being separated from his or her parent, and ORR officials stated that such information was not always provided when children were transferred from DHS to HHS custody. According to agency officials, between April and August 2018, the agencies made changes to their data systems to help notate in their records when children are separated from parents. Regarding DHS, CBP’s Border Patrol and OFO made changes to their data systems to allow them to better indicate cases in which children were separated from their parents; however, ORR officials told us in September 2018, that they had been unaware that DHS had made these systems changes. According to Border Patrol officials, Border Patrol modified its system on April 19, 2018, to include yes/no check boxes to allow agents to indicate that a child was separated from their parent(s). However, Border Patrol officials told us that information on whether a child had been separated is not automatically included in the referral form sent to ORR. Rather, agents may indicate a separation in the referral notes sent electronically to ORR, but they are not required to do so, according to Border Patrol officials. While the changes to the system may make it easier for Border Patrol to identify children separated from their parents, ORR officials stated ORR may not receive information through this mechanism to help it identify or track separated children. Prior to this system modification, Border Patrol agents typically categorized a separated child as an unaccompanied child in its system and did not include information to indicate the child had been separated from a parent. CBP’s OFO, which encounters families presenting themselves at ports of entry, also modified its data system and issued guidance to its officers on June 29, 2018, to track children separated from their parents. OFO officials have access to the UAC Portal but typically email this information to ORR as part of the referral request. According to OFO officials, prior to that time, OFO designated children separated from their parents as unaccompanied. ORR updated the UAC Portal to include a check box for indicating that a child was separated from his or her parents. According to ORR officials, ORR made these changes on July 6, 2018, after the June 20 executive order and June 2018 court order to reunify families. According to ORR officials, prior to July 6, 2018, the UAC Portal did not have a systematic way to indicate whether a child was designated as unaccompanied as a result of being separated from a parent at the border. The updates allow those Border Patrol agents with direct access to the UAC Portal to check this box, and Border Patrol issued guidance on July 5, 2018, directing its agents to use the new indicator for separated children in the UAC Portal and provide the parent’s alien number in the UAC Portal when making referrals to ORR as of July 6, 2018. However, ORR officials also said that DHS components with access to the UAC Portal are not yet utilizing the new check box consistently. Staff at three of the four shelters we visited in Arizona and Texas in July and August of 2018 said that in most, but not all cases during the spring of 2018, DHS indicated in the custody transfer information that a child had been separated. Staff at one shelter estimated that for approximately 5 percent of the separated children in its care there was no information from DHS indicating parental separation. In these cases, shelter staff said they learned about the separation from the child during the shelter’s intake assessment. Staff at the same shelter, which cares for children ages 0 to 4, noted that intake assessments for younger children are different from intake for older children, as younger children are unable to provide detailed information on such issues as parental separation. While the updates that OFO and ORR have made to their data systems are a positive step, they do not fully address the broader coordination issues we identified in our previous work. Specifically, we identified weaknesses in DHS and HHS’s process for the referral of UAC. In 2015, we reported that the interagency process to refer and transfer UAC from DHS to HHS was inefficient and vulnerable to errors because it relied on emails and manual data entry, and documented standard procedures, including defined roles and responsibilities, did not exist. To increase the efficiency and improve the accuracy of the interagency UAC referral and placement process, we recommended that the Secretaries of DHS and HHS jointly develop and implement a documented interagency process with clearly defined roles and responsibilities, as well as procedures to disseminate placement decisions, for all agencies involved in the referral and placement of UAC in HHS shelters. In response, DHS officials told us DHS delivered a Joint Concept of Operations between DHS and HHS to Congress on July 31, 2018, which provides field guidance on interagency policies, procedures, and guidelines related to the processing of UAC transferred from DHS to HHS. DHS submitted the Joint Concept of Operations to us on September 26, 2018, in response to our recommendation. We are reviewing the extent to which the Joint Concept of Operations includes a documented interagency process with clearly defined roles and responsibilities, as well as procedures to disseminate placement decisions, for all agencies involved in the referral and placement of unaccompanied children, including those separated from parents at the border, in HHS shelters. Moreover, to fully address our recommendation, DHS and HHS should implement such interagency processes. DHS and HHS Actions to Reunify Families in Response to the June 2018 Court Order DHS and HHS took various actions in response to the June 26, 2018, court order to identify and reunify children separated from their parents. The June 2018 court order required the government to reunite class member parents with their children under 5 years of age within 14 days of the order, and for children age 5 and over, within 30 days of the order. HHS officials told us that there were no specific procedures to reunite children with parents from whom they were separated at the border prior to the June 2018 court order. Rather, the agency used its standard procedures, developed to comply with the William Wilberforce Trafficking Victims Protection Reauthorization Act of 2008 (TVPRA), to consider potential sponsors for unaccompanied children in their custody; if a parent was available to become a sponsor, reunification with that parent was a possible outcome. DHS and HHS Efforts to Identify Potential Class Members. To create the list of potential class members (that is, those parents of a separated child covered under the lawsuit) eligible for reunification per the June 2018 court order, DHS and HHS officials told us that they generated the list based on children who were in DHS or HHS custody on that date. As a result, DHS and HHS officials told us that a parent of a separated child would only be a class member if his or her child was detained in DHS or HHS custody on June 26, 2018. After developing the class list, DHS and HHS officials told us that they next determined whether class members were eligible for reunification, as a class member could be determined ineligible for reunification if it was determined that the parent was unfit or presented a danger to the child. Parents of children who were separated at the border but whose children were released by ORR to sponsors prior to the June 2018 court order were not considered class members, and according to HHS officials, the department was not obligated to reunite them with the parent or parents from whom they were separated. Further, HHS officials told us that they do not know how many such children separated from parents at the border were released to sponsors prior to the order and that the court order does not require the department to know this information. Because there was no single database with information on family separations, HHS officials reported using three methods to determine which children in ORR’s custody as of June 26, 2018, had been separated from parents at the border: 1. Data Reviewed by an Interagency Data Team. An interagency team of data scientists and analysts—led by HHS’s Office of the Assistant Secretary for Preparedness and Response with participation from CBP, ICE, and ORR—used data and information provided by DHS and HHS to identify the locations of separated children and parents, according to HHS officials. 2. Case File Review. HHS reported that more than 100 HHS staff reviewed about 12,000 electronic case files of all children in its care as of June 26, 2018 for indications of separation in specific sections of each child’s case file, such as the phrases “zero tolerance,” “separated from ,” and “family separation.” 3. Review of Information Provided by Shelters. According to HHS officials, shelter staff were asked to provide lists of children in their care who were known to be separated from parents based on the shelter’s records. On the basis of its reviews, as of September 10, 2018, the government had identified 2,654 children of potential class members in the Ms. L. v. ICE case. Of the 2,654 children, 103 were age 0 to 4 and 2,551 were age 5 to 17. As previously discussed, the number of children of potential class members does not include those who were separated from parents but released to sponsors prior to the June 2018 court order or the more than 500 children who were reunified with parents by CBP in late June 2018, because these children were never transferred to ORR custody. As of September 10, 2018, 2,217 of the 2,654 identified children had been released from ORR custody, according to a joint status report filed in the Ms. L. v. ICE case. About 90 percent of the released children were reunited with the parent from whom they were separated and the remaining children were released under other circumstances. Children released under other circumstances could include those released to another sponsor such as a parent already in the United States, another relative, or an unrelated adult, or children who turned 18. Staff at one ORR facility we visited told us they planned to release some children under these circumstances. As of December 11, 2018, the government had identified additional possible separated children of potential class members for a total of 2,816. It had released 2,657 and 159 remained in ORR custody. However, the government has also reported that 79 of the children it initially identified as separated had not been separated from a parent. Excluding those 79 children from the 2,816 total would bring the total number of children separated to 2,737. Plan for Reunifying Children with Class Member Parents Within and Outside ICE’s Custody. The process used to reunify separated children with their class member parents in the Ms. L. v. ICE case evolved over time based on multiple court hearings and orders, according to HHS officials. After the June 2018 court order, HHS officials said the agency planned to reunify children using a process similar to their standard procedures for placing unaccompanied children with sponsors. However, according to agency officials, the agency realized that it would be difficult to meet the court’s reunification deadlines using its standard procedures and began developing a process for court approval that would expedite reunification for class members. As a result, from June 26, 2018 to July 10, 2018, the reunification process was refined and evolved iteratively based on court status conferences, according to HHS officials. ORR field and shelter staff we interviewed noted the impact of the continually changing reunification process; for example, staff at one shelter told us there were times when they would be following one process in the morning but a different one in the afternoon. On July 10, 2018, the court approved reunification procedures for the class members covered by the June 2018 court order. In the July 10, 2018 order that outlined these procedures, the court noted that the standard procedures developed by ORR pursuant to the TVPRA were meant to address “a different situation, namely, what to do with alien children who were apprehended without their parents at the border or otherwise” and that the agency’s standard procedures were not meant to apply to the situation presented in the Ms. L. v. ICE case, which involves parents and children who were apprehended together and then separated by government officials. The reunification procedures approved in the Ms. L. v. ICE case apply only to reunification of class members with their children and included determining (1) parentage and (2) whether the parent is fit to take care of the child or presents any danger to the child. Specifically: 1. Determining Parentage. Before July 10, 2018, to determine parentage for children ages 0 to 4, HHS officials said they initially used DNA swab testing instead of requiring documentation, such as birth certificates, stating that DNA swab testing was a prompt and efficient method for determining biological parentage in a significant number of cases. On July 10, 2018, the court approved the use of DNA testing “only when necessary to verify a legitimate, good-faith concern about parentage or to meet a reunification deadline.” HHS officials told us that at that point, to determine parentage, ORR relied on the determinations made by DHS when the family was separated and information ORR shelter staff had already collected through assessments of the children in their care. Unless there were specific doubts about the relationship, ORR did not collect additional information to confirm parentage, according to HHS officials. 2. Determining Fitness and Danger. To reunify class members, HHS also followed the procedures approved by the court on July 10, 2018 for determining whether a parent is fit and whether a parent presents a danger to the child. HHS used the fingerprints and criminal background check of the parent conducted by DHS when the individual was first taken into DHS custody rather than requiring the parent and other adults living in the household to submit fingerprints to ORR, as potential sponsors were typically required to do for unaccompanied children. According to HHS officials, ORR personnel also reviewed each child’s case file for any indication of a safety concern, such as allegations of abuse by the child. HHS did not require fingerprints of other adults living in the household where the parent and child will live. HHS also did not require parents to complete an ORR family reunification application as potential sponsors are typically required to do for unaccompanied children. The specific procedures for physical reunification varied depending on whether the parents were inside or outside of ICE custody. DHS and HHS took steps to coordinate their efforts to reunify children with parents who were in ICE custody, but experienced challenges. Generally, for parents in ICE custody, DHS transported parents to a detention facility close to their child and HHS transported the child to the same facility. At the facility HHS transferred custody of the child to ICE for final reunification. HHS officials said that in some instances children had to wait for parents for unreasonably long amounts of time and parents were transported to the wrong facilities. In one case, staff at one shelter told us that they had to stay two nights in a hotel with the child before reunification could occur. According to HHS officials, for families in which the parent was released into the interior of the United States, the reunification process involves ORR officials and shelter staff attempting to establish contact with the parent and determining whether the parent has “red flags” for parentage or child safety. These determinations are based on DHS-provided criminal background check summary information and case review of the child’s UAC Portal records. In cases where no red flags are found, HHS transports the child to the parent or the parent picks the child up at the ORR shelter. For more information on DHS and HHS reunification procedures for class member parents inside and outside ICE custody, see GAO-19-163. Chair DeGette, Ranking Member Guthrie, and Members of the Subcommittee, this concludes our prepared remarks. We would be happy to answer any questions that you may have. GAO Contacts and Staff Acknowledgments For further information regarding this testimony, please contact Kathryn A. Larin at (202) 512-7215 or larink@gao.gov or Rebecca Gambler at (202) 512-8777 or gamblerr@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement. Individuals who made key contributions to this testimony include Kathryn Bernet (Assistant Director), Elizabeth Morrison (Assistant Director), David Barish (Analyst-in-Charge), Andrea Dawson, Jason Palmer, and Leslie Sarapu. In addition, key support was provided by Susan Aschoff, James Bennett, Sarah Cornetto, Michael Kniss, Sheila R. McCoy, Jean McSween, Jan Montgomery, Heidi Nielson, and Almeta Spencer. This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. 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Background Family reunification and the admission of immigrants with needed skills are two of the major principles underlying U.S. immigration policy. As a result, current law weights the allocation of immigrant visas heavily toward individuals with close family in the United States and, to a lesser extent, toward individuals who meet particular employment needs. The diversity immigrant category was added to the Immigration and Nationality Act (INA) by the Immigration Act of 1990 ( P.L. 101-649 ) to stimulate "new seed" immigration (i.e., to foster new, more varied migration from other parts of the world). Diversity visas are allocated to natives of countries from which the combination of immediate relatives, family preference, and employment preference immigrant admissions were lower than a total of 50,000 over the preceding five years combined. Legislative Origins The Immigration Amendments of 1965 replaced the national origins quota system, which prioritized European source countries, with equally distributed per-country ceilings. In the 1980s, some Members of Congress began expressing concern that U.S. legal immigration admissions were skewed in favor of immigrants from Asia and Latin America because of the 1965 amendments. The first legislative response to this concern occurred in Section 314 of the Immigration Reform and Control Act of 1986 (IRCA), which allowed an extra 5,000 immigrant visas per year for FY1987 and FY1988 to be distributed to natives of 36 countries that had been adversely affected by the 1965 changes to the INA. Over 1 million people applied for what was then called the NP-5 program, and visas were made available according to the chronological order in which qualified applications were mailed to the State Department (DOS). Natives of Ireland received the largest proportion (31%) of the NP-5 visas, followed by natives of Canada (21%) and Great Britain (11%). In 1988, Congress extended the NP-5 program for two more years and made 15,000 additional immigrant visas available each year in FY1989 and FY1990. What is now known as the diversity immigrant category was added to the INA by P.L. 101-649 and went fully into effect in FY1995. Section 132 of P.L. 101-649 provided 40,000 visas per year for a transitional program during FY1992-FY1994 for certain natives of foreign states that were adversely affected by the 1965 changes to the INA. At least 40% of these visas were earmarked for natives of Ireland. The current diversity visa category had an annual allocation of 55,000 visas when it went into effect in FY1995. While the diversity visa category has not been directly amended since its enactment, P.L. 105-100 , the Nicaraguan Adjustment and Central American Relief Act of 1997 (NACARA), temporarily decreased the 55,000 annual ceiling to 50,000. Beginning in FY2000, the 55,000 ceiling has been reduced by 5,000 annually to offset immigrant visas made available to certain unsuccessful asylum seekers from El Salvador, Guatemala, and formerly communist countries in Europe who are being granted immigrant status under special rules established by NACARA. The 5,000 offset is temporary, but it is not clear how many years it will be in effect to handle these adjustments of status. Eligibility Criteria and Application Process To be eligible for a diversity visa, the INA requires that a foreign national must have at least a high school education or the equivalent, or two years of experience in an occupation that requires at least two years of training or experience. The applicant or the applicant's spouse must be a native of one of the countries listed as a foreign state qualified for the DV program. Minor children of the qualifying diversity immigrant, as well as the spouse, may accompany as lawful permanent residents (LPRs) and are counted toward the 50,000 annual limit. Because the demand for diversity visas is much higher than the supply, a lottery is used to randomly select who may apply for one of the 50,000 diversity visas available annually. (See Figure 1 for an illustration of the process). There is no fee to enter the diversity lottery. Registration for the FY2020 diversity lottery began on October 3, 2018, and closed on November 6, 2018. Beginning on May 7, 2019, and continuing through September 30, 2020, those who registered can use an online system to find out if they had been selected. The FY2018 lottery had 14.7 million entries, representing over 23 million people (including family members). From the millions of entries, approximately 100,000 selectees are randomly chosen. Being chosen as a selectee ("lottery winner") does not guarantee receipt of a diversity visa; rather, it identifies those who are eligible to apply for one. To receive a visa, selectees must successfully complete the application process (including security and medical screenings and in-person interviews) by the end of the fiscal year for which they registered for the lottery or they lose their eligibility. DV applicants, like all other foreign nationals applying to come to the United States, must pay applicable fees and undergo reviews and biometric background checks performed by DOS consular officers abroad and Department of Homeland Security (DHS) immigration officers upon entry to the United States. Individuals selected for a diversity visa who are residing in the United States as nonimmigrants must undergo reviews by U.S. Citizenship and Immigration Services (USCIS) prior to adjusting to LPR status. These reviews, which include an in-person interview, are intended to ensure that the applicants are not inadmissible under the grounds spelled out in Section 212(a) of the INA. Grounds for inadmissibility include health, criminal history, security and terrorist concerns, public charge, illegal entry, and previous removal. Trends in Source Regions and Countries The diversity immigrant visa program currently makes 50,000 visas available annually to natives of countries from which immigrant admissions were lower than a total of 50,000 over the preceding five years. USCIS implements a formula for allocating visas according to statutory specifications: visas are divided among six global geographic regions, and each region and country is identified as either high admission or low admission based on how many immigrant visas each received over the previous five-year period. Higher proportions of diversity visas are allocated to low-admission regions and low-admission countries. Each country is limited to 7%, or 3,500, of the total, and the INA provides that Northern Ireland be treated as a separate foreign state. The distribution of diversity visas by global region of origin has shifted over time (see Figure 2 ). From FY1995 through FY2001, foreign nationals from Europe garnered a plurality of diversity visas, ranging from 38% to 47% of the total. In the early 2000s, the share of DV recipients from Africa was on par with those from Europe. Europe's share dropped by nine percentage points from FY2005 to FY2006 as the shares from African and Asian countries continued to increase. Since FY2008, Europe has accounted for smaller shares than Africa or Asia. Latin America (which includes South America, Mexico, Central America, and the Caribbean), Oceania, and North America accounted for less than 8% each year. In total, from FY1995 through FY2017 immigrants from Africa accounted for 40% of diversity immigrants, while Europeans accounted for 31% and Asians for 25%. These trends are consistent with the statutory formula Congress outlined to allocate diversity visas. Figure 3 presents the countries from which at least 1,000 DV immigrants were admitted in the first five years that the program was in full effect (FY1995-FY1999) and the most recent five years for which data are available (FY2013-FY2017). Early in the program, most of the top countries were in Europe (particularly Eastern Europe) and Africa. In more recent years, there has been a shift toward Africa and Asia. Certain countriesâsuch as Ethiopia, Ukraine, and Egyptârank high across many years of the program, while othersâsuch as Ireland, Poland, and Venezuelaâare limited to particular periods of time. From FY1995-FY2017, natives of six countries received at least 40,000 diversity visas in total: Ethiopia (67,832), Nigeria (58,563), Egypt (56,862), Ukraine (52,654), Albania (47,136), and Bangladesh (40,847). Characteristics of Diversity Immigrants Regions of Birth As one would expect, diversity immigrants come from different parts of the world that differ from the leading immigrant-sending regions. Department of Homeland Security data ( Figure 4 ) reveal that Africa accounted for 43% of diversity immigrants admitted in FY2017, but 11% of all LPRs admitted that fiscal year. Europeans made up 7% of all LPRs admitted in FY2017, but 22% of diversity immigrants. In contrast, Latin America (Mexico, Central America, the Caribbean, and South America) was the sending region for 43% of all LPRs admitted in FY2017, but provided 4% of the diversity immigrants during that fiscal year. North America (excluding Mexico) and Oceania account for a small percentage of LPRs admitted by any means. The distribution of LPR admissions and DV admissions from Asia illustrates the impact of the two-step visa allocation formula, which considers both regional and national admissions levels. Asia includes many top-sending countriesâsuch as China, India, and the Philippinesâfor family- and employment-based LPRs, making it a high-admission region. Yet it also includes low-admission countriesâsuch as Nepal, Iran, and Uzbekistanâthat rank high for their number of diversity visas. As a result, as Figure 4 illustrates, in FY2017 foreign nationals from Asia represented a somewhat more equivalent share of the 1.1 million LPRs (38%) in relation to their share (30%) of diversity LPRs in contrast to the other world regions. Age and Sex Diversity immigrants are, on average, younger than other LPRs. Department of Homeland Security data (see Figure 5 ) reveal that DV immigrants are more likely to be working-age adults and their children, and less likely to be over the age of 40 than LPRs overall. Also, the foreign-born population of the United States is more likely to be in the prime working-age group (i.e., ages 25 to 64) than the native-born population, and diversity immigrants have a younger age distribution than the foreign-born population as a whole. In addition, 56% of diversity immigrants in FY2017 were male compared to 46% of all LPRs. Marital Status Diversity immigrants were less likely to be married than LPRs generally (47% versus 58%) in FY2017, perhaps a function of their relative youth. Over half (52%) of diversity immigrants were single, in contrast to 36% of LPRs overall. Few of either group were likely to be widowed, divorced, or separated. Educational Attainment and Labor Market Characteristics Recent critics of the diversity immigrant visa have argued against the program on the grounds that individuals do not need high levels of education or work experience to qualify for the DV program and that the U.S. admissions system should prioritize "high-skilled" immigrants. Neither DHS nor DOS publish data on the educational attainment of DV immigrants, but other sources provide some information. According to now-dated data from the New Immigrant Survey, a widely cited, nationally representative, longitudinal study of individuals who obtained LPR status in 2003, those who entered as principals via the diversity visa category had, on average, 14.5 years of schooling when they entered the United States, which was higher than those who were admitted on family-based visas as spouses or siblings of U.S. citizens (13.0 and 11.5 years, respectively), but lower than those who were admitted as principal employment-based immigrants (15.6 years). Similarly, DV immigrants were more likely to be fluent in English than most family-based immigrants (except for immigrant spouses of native-born U.S. citizens), but less likely than employment-based immigrants to be fluent in English. Using the same data source, the Migration Policy Institute found that 50% of DV immigrants who entered in 2003 had a college degree (32% with a bachelor's and 18% with a graduate degree). It is likely that the educational attainment of recent DV immigrants is higher than it was for those represented in the New Immigrant Survey, given that more recently arrived immigrants have higher levels of education overall than their predecessors. Government data on other labor market characteristics of DV immigrants are also limited. According to the New Immigrant Survey, DV immigrants who entered in 2003 had higher initial unemployment rates than employment-based immigrants and those who immigrated as spouses of U.S. citizens, but lower unemployment rates than those who immigrated as siblings of U.S. citizens. Four to six years after U.S. entry, however, DV immigrants' unemployment rates had dropped significantly and were similar to those of all other groups except employment-based principals (who had the lowest rates at both initial entry and four to six years later). DV immigrants' hourly earnings were similarly situated between that of employment-based immigrant category (which had the highest earnings) and that of the sibling category (which had the lowest). Among male immigrants earning wages, those who entered on diversity visas had the highest percentage growth in real hourly wages between initial entry and re-sampling four to six years later. Impact of the DV Program on Immigrant Diversity Given its name and the discourse about "new seed" immigrants that preceded the creation of the diversity visa, the question arises whether the DV program has led to an increase in the diversity of immigrant flows to the United States. Leading up to and since its enactment, some observers have noted that, regardless of its name, the DV program was intended to benefit Irish and Italian constituents who had been negatively affected by the Immigration Act of 1965 that resulted in an increase in immigration from Asia and Latin America. During the transition period after the program was created (FY1992-FY1994), at least 40% of diversity visas were earmarked for Irish immigrants, and 92% of diversity visas in FY1994 went to Europeans. Since its full implementation in FY1995, however, immigrants from a wider range of countries and regions have entered via the program (see " Regions of Birth " above). The DV program's small size relative to total annual immigrant admissions (DV admissions make up about 5% of annual LPR admissions) limits its impact on the make-up of the immigrant population. Former Representative Bruce Morrison, who helped create the program, stated in a 2005 hearing that it was not Congress's intent to diversify the immigrant flow as a whole ("It could not have possibly done so at the 50,000 number"), but rather to add a new pathway for those who would not be able to enter under the family- or employment-based systems. By that standard, the program arguably fulfills its objectives, having admitted more than 1 million immigrants from under-represented countries since FY1995 (see Figure 3 ). Another way to assess the program's impact is to analyze the diversity of annual LPR flows before and after the DV program was established. Using a measure of diversity called the entropy index, CRS found that in FY1990, before the DV program was in effect, the diversity of LPR admissions was 0.52. In every year from FY1995 (when the DV program went into full effect) through FY2017 (the most recent data available), the diversity of annual LPR admissions was higher than in 1990, ranging from 0.67 to 0.72. In each of those years, the diversity of LPR admissions not including the DV admissions was lower than it was with DV admissions included (see the Appendix ), indicating that the admission of DV immigrants does increase the diversity of annual LPR admissions. A full analysis of the impacts of the DV program on admission numbers would also take into account individuals whom DV immigrants subsequently sponsor through the family-based admissions system. Because administrative data on immigrant admissions do not specify these linkages, this type of direct analysis is not currently possible. However, admissions data suggest that, at least for Africans, the DV has led to an increase in immigration via the family-based system (particularly immediate relatives). From 1992 to 2007, admissions of Africans based on family sponsorship grew faster than other categories of admissions for Africans, including diversity, which remained fairly stable over the time period. The DV seems to have diversified the African flow itself by boosting emigration from non-English speaking African countries (whereas English-speaking African countries have longer histories of U.S. immigration and are therefore more likely to be the source of sponsoring immigrant family members). Selected Legislative Action Legislation related to the Diversity Immigrant Visa has focused largely on eliminating the program. Bills to eliminate the diversity visa category have been introduced in nearly every Congress since the program was created and have passed one chamber on more than one occasion. Most recently, S. 744 in the 113 th Congress, a comprehensive immigration reform bill that the Senate passed in 2013 by a vote of 68 to 32, would have eliminated the program. Other bills introduced in the past would have raised the annual limit of diversity visas or temporarily re-allocated diversity visas for other purposes. In the 116 th Congress, several bills to eliminate the DV program have been introduced, including H.R. 479 , H.R. 2278 , S. 1103 , and S. 1632 . In contrast, H.R. 3799 would raise the annual diversity visa allocation to 80,000. Selected Policy Questions As Congress weighs whether to eliminate or revise the diversity visa category, it may want to consider various policy questions pertinent to this discussion. Is it fair to have the diversity visa category when there are family members and prospective employees who have been waiting for years for visas to become available? Given the 3.7 million approved family-based and employment-based petitions waiting for a visa to become available at the close of FY2018, some argue that the 50,000 diversity visas should be used for backlog reduction in these visa categories. Others might observe that the family-based, employment-based, and diversity visa categories are statutorily designed as independent pathways to LPR status and that the problems of the family-based and employment-based backlogs should be addressed separately. Some also argue that the DV program increases fairness in the immigration system by making visas available to individuals who would not otherwise have a chance of obtaining one and by discouraging illegal immigration through expanding access to the legal immigration system. Should the United States base admissions decisions on nationality? Some argue that the diversity visa program reverts to discriminatory national origin quotas, which Congress eliminated through the 1965 amendments to the Immigration and Nationality Act. However, there are other examples of admissions policies that effectively discriminate based on nationality (e.g., H-2A, H-2B, E, and TN nonimmigrant visas, the Visa Waiver Program, and the per country caps on family- and employment-based LPR admissions, all of which limit admissions by nationality). Some also argue that admissions decisions should be based on higher levels of education, job experience, and language skills, or family ties to U.S. residents, rather than country of origin and being selected at random via a lottery. In contrast, others argue that the program bolsters equity of opportunityâa quintessential American valueâby providing a pathway for individualsâparticularly those from Africa, Eastern Europe, and the former Soviet Unionâwho do not have family or employer connections in the United States. Some also argue that the more than one million immigrants who have moved to the United States as a result of the program have enriched the United States culturally and economically, and strengthened the nation's global connections. Some also argue that efforts to end it are racially motivated or point out that for most of U.S. history, Africans in particular had little opportunity to come to the United States other than as slaves. Is a lottery the best way to choose applicants for diversity visas? Some equate the use of a lottery system in the DV program to awarding "green cards" at random and argue that luck should not come into play in U.S. admissions decisions. Others argue that, given the millions of interested applicants every year, a lottery is a fair method of reducing the applicant pool because it gives all entrants who meet the program's qualifications an equal chance to apply for a diversity visa. They also cite the use of a lottery in other over-subscribed visa categories such as the H-1B and H-2B temporary worker classifications to illustrate that U.S. immigration policy considers it a reasonable tool. Is the diversity visa lottery more vulnerable to fraud and misuse than other immigration pathways? Some observers concerned about immigration fraud surrounding the DV program reference a 2003 State Department Office of Inspector General report and a 2007 GAO report which found fraud vulnerabilities in the DV program. They may also cite the 2017 and 2018 complaints filed by the Department of Justice (DOJ) in two cases seeking the denaturalization of individuals who had gained admission (in 1997 and 2001) to the United States through the DV program. In the first case, DOJ filed a complaint to denaturalize four Somali-born diversity visa recipients who falsely claimed to be a family. In the second case, DOJ filed a complaint to denaturalize a diversity visa recipient who obtained naturalization without having disclosed two prior orders of removal. Those defending the fraud protections of the DV program counter that DOS has since revised the diversity lottery procedures to address fraud vulnerabilities, including a requirement to submit a recent photograph, the addition of biographic and facial recognition checks to reduce duplicate entries, a policy requiring the disqualification of entrants who fail to list their spouse and children on their entries, and technical improvements to limit manipulation of entries by automated bots. They also argue that the risk of fraud is not unique to the DV program and refer to the numerous fraud investigations and arrests of immigrants who entered the United States via other visa categories and the significant resources that DOS commits to fraud prevention for all immigrant and nonimmigrant visa applications through its Fraud Prevention Units at posts overseas. In addition, on June 5, 2019, DOS published an interim final rule to require diversity visa entrants to provide certain information from a valid, unexpired passport on the electronic entry form. This rule is intended to make it more difficult for third parties to submit unauthorized entries, because third parties are less likely to have individuals' passport numbers. Are there national security reasons to eliminate the diversity visa? Some assert that the difficulties of performing background checks in many of the countries whose natives currently qualify for the DV program, as well as broader concerns about terrorism, justify the elimination of the category. Some cite the 2004 warning of the DOS Deputy Inspector General that the diversity visa lottery "contains significant vulnerabilities to national security" from state sponsors of terrorism. They argue that DV immigrants, by definition, are not required to have employer or family ties in the United States and thus may be more likely to have nefarious intent. They cite the case of a New Jersey resident responsible for killing eight people with his rental truck in lower Manhattan in 2017, who had immigrated to the United States from Uzbekistan on a diversity visa. In response to that event, the Trump Administration called on Congress to immediately terminate the diversity visa lottery program. Others respond that immigrants coming to the United States in other immigrant visa categories are not restricted if they come from these same countries, and further argue that background checks for national security risks are performed on all prospective immigrants seeking to come to the United States. They also point to the 2005 DOS Inspector General's testimony that DOS's Bureau of Consular Affairs strengthened the DV program by complying with most of the recommendations in the OIG's 2003 report. They similarly note the testimony of one of the creators of the DV Program who contended that "it is absurd to think that a lottery would be the vehicle of choice for terrorists" and that attention should instead be focused on greater security risks. They also point out that since the creation of the Visa Security Program in 2003, DHS has aided consular officers in extensively vetting individuals applying for visas. They also reference a 2007 GAO report stating: "We found no documented evidence that DV immigrants from these, or other, countries posed a terrorist or other threat. However, experts familiar with immigration fraud believe that some individuals, including terrorists and criminals, could use fraudulent means to enter or remain in the United States." Are there foreign policy reasons to continue the diversity visa program? Citing the millions of diversity visa lottery entries every year from around the world, some argue that the DV program is an efficient means of boosting American goodwill and "soft power" abroad, and that a diversity of immigrant origins helps the United States better respond to the challenges of globalization. Some also cite the value of remittances sent by diversity immigrants to their countries of origin as international development assistance without U.S. government expense. Others argue that the DV program encourages "brain drain" from developing countries, a concern which acknowledges that many DV immigrantsâparticularly from Africaâpossess education and skills beyond the minimum requirements for program eligibility. Are the reasons that led to establishment of the diversity visa (e.g., to stimulate "new seed" immigration) still germane? Supporters of the DV program argue that it honors the United States' history as a destination for enterprising immigrantsâthe "self-selected strivers" âwho arrive without family ties but with a desire to work hard for a better life. Some point to the present-day preponderance of immigrants from a handful of countries and argue that the diversity visa fosters new and more varied migration to counterbalance an admissions system weighted disproportionately to family-based immigration, which tends to perpetuate the dominance of certain countries. They also point to wide support for legislation that would remove or raise the 7% per-country limits on family- and employment-based immigrant admissions, which would likely result in further concentration of immigrant flows from the top sending countries. Even with the per-country limits and DV program in place, the total foreign-born population has become more concentrated in the top ten source countries compared to 1990 (see " Impact of the DV Program on Immigrant Diversity "). Others argue that, after almost 30 years, the diversity visa category has run its course. They might cite the countriesâsuch as Pakistan, Brazil, Nigeria, and Bangladeshâthat formerly qualified for the DV program and no longer do due to their increase in admissions, or the growth in immigration from Africa, Eastern Europe, and parts of Asia as an indication that the need for "new seed" immigration has been met. Others counter that these trends indicate that the program is meeting its goals and should be continued. They further argue that in many countries around the world, the diversity visa remains the only accessible avenue for immigrating to the United States. Appendix. Entropy Index Methodology and Results The entropy index (also called the Shannon index) is a measure of the diversity of a population. Diversity can be defined as the "relative heterogeneity of a population." It is at its maximum when all subpopulations are present in equal proportions (for the purposes of this report, when each country of birth receives an equal number of LPR admissions). The formula for the entropy index is where H is the entropy index, k is the country-of-origin group, and P is the proportion of the total from each country-of-origin group. The index can be standardized by dividing by its maximum, log K. Doing so results in a range of 0 (for the case where all of the population is in one subpopulation) to 1.0 (for the case where all subpopulations are present in equal proportions). For this report, the standardized entropy index was calculated by year for country of birth of total LPR admissions, LPR admissions minus DV admissions, and DV admissions. This was calculated after creating a standardized list of countries across all years so that K was held constant. As shown in Figure A-1 , between FY1995 and FY2017, the entropy index varied, but in all years the index was higher when DV LPRs were included.