What GAO Found
Federal correctional and immigration detention facilities can place individuals in restrictive housing settings in certain circumstances. Restrictive housing generally consists of one- or two-person cells that isolate individuals from the general population. U.S. Immigration and Customs Enforcement (ICE) and the Bureau of Prisons (BOP) have policies and processes that govern their use of restrictive housing. Two prior studies examined restrictive housing at BOP, both of which identified ways for BOP to improve oversight. The first was a 2014 contracted assessment and the second was a 2016 Department of Justice report.
In February 2024, GAO reported that BOP had not fully implemented 54 of 87 recommendations from these two studies. BOP had fully implemented 33, partially addressed 42, and had not taken any steps to address the remaining 12 recommendations. This was due in part to BOP not assigning responsibility for recommendation implementation to appropriate officials and not establishing a time frame for completion. GAO recommended that BOP develop and execute an approach to fully implement recommendations from these prior studies. This would include assigning implementation responsibility, establishing a time frame for completion, and monitoring progress. BOP concurred and described its planned steps.
BOP and ICE have not consistently collected or used information needed for restrictive housing oversight. In reports from 2020–2024, GAO recommended actions to improve both BOP's processes for monitoring restrictive housing operations and BOP and ICE's analysis of complaints data. For example:
In February 2024, GAO found that BOP was not monitoring key aspects of restrictive housing operations. Specifically, it did not examine the cause behind substantial racial disparity in a restrictive housing unit designed for individuals with heightened security concerns. GAO recommended that BOP conduct an evaluation to determine and address the cause of the racial disparity. BOP concurred and as of February 2024, said it would take steps to implement it.
In August 2020 and February 2024, GAO found that neither ICE nor BOP was analyzing complaint data from those in its custody to identify areas for improvement, such as concerns over restrictive housing conditions. GAO made recommendations to ICE and BOP to analyze complaint data, which could help each agency identify trends and ultimately enhance oversight. As of December 2023, ICE has taken some steps, including integrating several data systems that store detention-related information into a new system to provide enhanced analysis capabilities. As of February 2024, BOP agreed to take steps toward implementation.
Why GAO Did This Study
ICE recorded 14,581 restrictive housing placements of detained noncitizens from fiscal years 2017 through 2021. Those placements increased by 18 percent from fiscal year 2017 to 2020 before declining in 2021. As of October 2023, BOP housed about 8 percent of all incarcerated individuals (approximately 11,600) in restrictive housing. Studies have shown some potentially harmful mental and physical impacts of such placements.
This statement discusses the extent to which (1) BOP has addressed recommendations from two prior restrictive housing studies and (2) BOP and ICE have information needed to manage and oversee use of restrictive housing.
This statement is based on three prior GAO reports published from August 2020 through February 2024, along with selected updates on ICE efforts to address previous GAO recommendations. To produce those reports, GAO reviewed ICE and BOP documentation, analyzed data, and interviewed agency officials. For selected recommendation updates, GAO reviewed documents and interviewed ICE officials.
What GAO Found
GAO identified nine Department of Homeland Security (DHS) groups that are focused on sharing information internally within the department. GAO found the purpose of these groups was generally to facilitate information sharing for one of the following three purposes: (1) leadership decision-making; (2) internal policymaking, or (3) threat identification.
Categories of Department of Homeland Security (DHS) Internal Information Sharing Groups and Their Purpose
Note: These groups were operational any time from January 1, 2020, through September 30, 2023.aDHS discontinued the Operations Deputies Board in 2022 as part of a departmental reorganization initiative.
Although there was no evidence of unnecessary duplication among these nine groups, GAO found that some of the groups' purposes and activities had the potential for overlap. In those instances, GAO also found that agency officials associated with these groups described activities to leverage their respective resources and information—a leading interagency collaboration practice—to mitigate possible duplication. For example, according to DHS officials, the Homeland Security Intelligence Council, which is composed of less senior staff than the Counter Threats Advisory Board, schedules its meetings to occur a month or so before board's meetings. This allows the more detailed information from the council meetings to inform meetings of more senior staff serving on the board.
Why GAO Did This Study
GAO was asked to review the number and purpose of groups DHS uses to promote information sharing across its headquarters offices and components. This report (1) describes the various groups DHS uses to promote internal information sharing and their purpose and operating status and (2) identifies the extent to which any similar groups collaborate to avoid duplicating efforts.
GAO identified information sharing groups with select characteristics that were operational any time between January 1, 2020, and September 30, 2023, the most recent calendar years at the time GAO distributed its request for information to DHS. GAO reviewed documentation, such as charters, policies, and procedures, and interviewed relevant DHS headquarters and component officials about the history of the information sharing groups it identified.
For more information, contact Triana McNeil at: 202-512-8777 or McNeilT@gao.gov.
What GAO Found
The Department of Health and Human Services (HHS) estimated a combined total of over $100 billion in improper payments in the Medicare and Medicaid programs in fiscal year 2023. This represents 43 percent of the government-wide total of estimated improper payments that agencies reported for that year.
Improper Payments Estimates for Fiscal Year 2023
Note: Estimates also include payments whose propriety cannot be determined due to lacking or insufficient documentation.
The Centers for Medicare & Medicaid Services (CMS), within HHS, has taken several steps in response to GAO recommendations to help reduce improper payments in Medicare and Medicaid. These actions have resulted in billions of dollars in federal savings. For example:
Improved fraud prevention in Medicare. CMS implemented capabilities that automatically stopped payments of certain improper and non-payable claims. These improvements generated an estimated almost $2 billion in savings over a 5-year period.
Improved Medicaid managed care oversight. CMS worked with states and audit contractors to improve oversight. This included an exponential increase in investigations of managed care providers, from 16 in 2016 through 2018 to 893 in 2019 through 2021. Preliminary results indicate that the audits are identifying overpayments.
In the current fiscal environment, addressing improper payments and providing sufficient oversight of program spending, more generally, is particularly important. Federal spending for Medicare and Medicaid has grown by almost 80 percent over the past decade and growth in these and other health programs is projected to continue.
Health Care and Other Government Program Spending, Actual and Projected
CMS and congressional action on GAO recommendations related to Medicare and Medicaid has resulted in over $200 billion in financial benefits since 2006. Action on recommendations that remain unimplemented would further enhance program integrity and save billions of dollars in Medicare and Medicaid spending.
Provider screening and enrollment. GAO recommended CMS expand its review of states' implementation of provider screening and enrollment requirements in Medicaid, and monitor progress when states are not fully compliant. For Medicare, GAO recommended that CMS implement a risk-based plan for revalidating enrollment for Medicare providers after pauses during the COVID-19 pandemic.
Prepayment claim reviews in Medicare. GAO recommended that CMS seek legislative authority to allow Recovery Auditors to conduct prepayment claim reviews, which are generally more cost effective than postpayment reviews in preventing improper payments.
Equalizing certain Medicare payments. GAO recommended that Congress take action to address that Medicare pays more for certain services based on where they are provided. Congress has taken some actions. For example, this committee proposed and the House passed legislation to equalize payments for certain drug administration services. Taking additional steps to equalize payments has been estimated to save Medicare $141 billion over 10 years.
Telehealth. In response to the COVID-19 pandemic, HHS temporarily waived certain Medicare restrictions on telehealth and use increased dramatically. We recommended CMS comprehensively assess the quality of telehealth services in Medicare, which is needed to ensure those services are medically necessary, among other things.
Medicaid demonstrations. In response to GAO recommendations, CMS has made changes to its policies for ensuring that demonstrations do not increase federal spending, reducing federal liabilities by over $120 billion. Additional action by CMS and Congress could result in further savings.
State auditors. State auditors play an important role in Medicaid oversight and have identified improper payments and other deficiencies through their reviews. GAO recommended that CMS use trends in state auditor findings to inform its Medicaid oversight and share information on the status of actions to address findings with state auditors.
Why GAO Did This Study
In 2023, the Medicare program spent an estimated $1.0 trillion to provide health care services for approximately 66 million elderly and disabled individuals. This involved processing over a billion transactions. Medicaid is a joint federal-state program that finances health care for low-income and medically needy individuals. It is the second largest health care program by expenditures, with an estimated $849 billion in federal and state spending for services provided to about 90 million individuals in 2023.
Medicare and Medicaid are complex and large programs. They represented 26 percent of federal program spending in fiscal year 2023. The programs are susceptible to improper payments, as well as potential mismanagement and fraud, waste, and abuse. As a result, GAO added Medicare to its High-Risk list in 1990 and Medicaid in 2003.
This testimony focuses on examples of steps taken by CMS to reduce improper payments in Medicare and Medicaid, as well as actions still needed by CMS and Congress. It draws on GAO's reports issued and recommendations made from 2008 through 2024 on the Medicare and Medicaid programs and known steps CMS has taken to address these recommendations as of March 2024.
What GAO Found
The amount of funding available for Department of Defense (DOD) counternarcotics and counter–transnational organized crime activities changed from about $750 million in fiscal year (FY) 2018 to about $580 million in FY 2022. In FY 2022, DOD allocated most of the funding to support detection and monitoring activities and allocated the remainder to support intelligence activities and efforts, such as constructing training facilities, in partner nations.
DOD's six geographic combatant commands—DOD components responsible for efforts in designated geographic areas—coordinate on activities. However, three reported varying understandings of their roles in an overlapping joint operation area, including confusion over the management of air and naval operations. Although DOD required the three commands to develop agreements defining their responsibilities, the three commands have not fully documented their roles in the overlapping joint operation area. Without such agreements, confusion about the commands' responsibilities in the area may continue, reducing DOD's ability to disrupt the transport of illicit drugs to the U.S.
Map Showing Overlap of Joint Operation Area
DOD has not assessed the agency-wide effectiveness of its counternarcotics and counter–transnational organized crime activities and does not have a plan for future assessments. DOD has defined its strategic objectives, strategies, and performance goals. But contrary to key practices, it has not identified measurable outcomes for each strategic objective. As a result, DOD cannot measure progress toward these objectives. Officials also said they intend to assess agency-wide progress but have not developed a plan to do so. Assessing agency-wide progress toward its strategic objectives would better position DOD to make decisions about priorities, resource allocations, and strategies for improvements.
Why GAO Did This Study
The U.S. government has identified illicit drugs, as well as the criminal organizations that produce and traffic them, as significant threats to both the U.S. and partner nations. DOD is the lead department responsible for detecting and monitoring the aerial and maritime transport of illicit drugs to the U.S.
Senate report 117-130 accompanying the FY 2023 National Defense Authorization Act contains a provision for GAO to examine issues related to counternarcotics and counter–transnational organized crime activities. This report examines (1) funding available for DOD's activities and funding allocation in FYs 2018 through 2022; (2) the extent to which DOD components coordinate activities; and (3) how DOD assessed the effectiveness of these activities, and the extent to which its future assessments align with key practices.
GAO reviewed DOD documents and data about its authorities, funding, and activities, including coordination and performance management. GAO also interviewed DOD officials, including officials at headquarters and combatant commands.
What GAO Found
GAO estimated total direct annual financial losses to the government from fraud to be between $233 billion and $521 billion, based on data from fiscal years 2018 through 2022. The range reflects the different risk environments during this period. Ninety percent of the estimated fraud losses fell in this range.
GAO collected data from three key sources to develop the estimate: investigative data, such as the number of cases sent for prosecution and the dollar value of closed cases; Office of Inspector General (OIG) semiannual report information; and confirmed fraud data reported to the Office of Management and Budget (OMB) by agencies. GAO organized these data around three fraud categories—adjudicated, detected potential, and undetected potential. Model design and validation were also informed by 46 fraud studies. OIG and other knowledgeable officials agreed with these categories and subcategories.
Categories of Fraud-Related Data Used in GAO's Estimate
GAO's approach is sensitive to the assumptions made about fraud and accounts for data uncertainty and limitations. GAO used a well-established probabilistic method for estimating a range of outcomes under different assumptions and scenarios where there is uncertainty. The estimate does not include fraud loss associated with federal revenue or fraud against federal programs that occurs at the state, local, or tribal level unless federal authorities investigated and reported it. GAO's estimate is in line with other estimates of fraud losses from the United Kingdom and Association of Certified Fraud Examiners, among others.
As a first of its kind government-wide estimate of federal dollars lost to fraud, there are known uncertainties associated with the model and underlying data important to interpreting the results. These include caveats related to
applying the estimate to agencies or programs. GAO's model was developed to estimate government-wide federal fraud. The fraud estimate's range represents 3 to 7 percent of average federal obligations. These percentages should not be applied at the agency or program level. While every federal program and operation is at risk of fraud, the level of risk can vary substantially. Controls, growth or shrinkage of budget, and the emergence of new fraud schemes are some reasons the risk level can vary;
drawing conclusions about pandemic fraud. GAO's estimate is based on data from fiscal years 2018 through 2022. The data include time periods and programs with and without pandemic-related spending. Therefore, the estimate includes, but is not limited to, pandemic-related spending fraud. While the upper range of the estimate is associated with higher-risk environments, it is not possible to break out a subset of our government-wide estimate to describe pandemic program fraud;
comparing with improper payment estimates. GAO's estimate is not comparable to improper payment estimates. Improper payment estimates are based on a subset of federal programs, using a methodology not designed to identify fraud. GAO has also consistently reported that the federal government does not know the full extent of improper payments and has long recommended that agencies improve their improper payment reporting. In contrast, GAO's fraud estimate includes all federal programs and operations and is based on fraud-related data. With these differences in scope and data, the upper end of GAO's estimated fraud range exceeded annual improper payment estimates; and
assuming the estimate is predictive. GAO's estimate is not based on a predictive model. Factors such as the amount of emergency spending, the effectiveness of federal fraud risk management, and the nature of new fraud threats could substantially impact the scale of future fraud.
GAO has previously issued Matters for Congressional Consideration and recommendations to improve agencies' program integrity, including fraud risk management. Fraud estimation provides opportunities to improve fraud risk management, according to OIG and agency officials. For example, estimates can demonstrate the scope of the problem, improve oversight prioritization, and help determine the return on investment from fraud risk management activities. While it is not possible to eliminate fraud, with a better understanding of the costs, agencies will be better positioned to manage the risk.
How Fraud Estimates Can Improve Fraud Risk Management
OIG and agency officials noted challenges in producing fraud estimates, such as limited available fraud-related data and use of varying terms and definitions of fraud for recording data. These data gaps and variability result in information that cannot be readily compared or consolidated to determine the extent of fraud across the federal government. Guidance for collecting and reporting fraud-related data is currently limited to OIG semiannual reports and confirmed fraud reported by agencies to OMB, which are not designed to support fraud estimation. With guidance targeted to the purpose of fraud estimation, agencies and OIGs would be better positioned to collect and report data on potential and adjudicated fraud in support of estimation efforts.
OIG and agency officials also noted the utility of agency or program-level estimates compared with government-wide estimates. They further noted the need for expertise and data-analytics capacity to produce estimates. GAO previously reported that agencies identified limitations in expertise, data, and tools as a significant challenge for their fraud risk management efforts. These challenges could also impact agencies' ability to develop effective fraud estimates at a program or agency level. The Department of the Treasury's Office of Payment Integrity (OPI) supports agencies facing such challenges. OPI's resources are dedicated to preventing and detecting improper payments through a variety of data-matching and data-analytics services. Therefore, OPI is well positioned—with the expertise, data, and analytic tools—to evaluate and advance methods that the federal government can take to estimate fraud in support of fraud risk management.
Why GAO Did This Study
All federal programs and operations are at risk of fraud. Therefore, agencies need robust processes in place to prevent, detect, and respond to fraud. While the government obligated almost $40 trillion from fiscal years 2018 through 2022, no reliable estimates of fraud losses affecting the federal government previously existed.
As part of GAO's work on managing fraud risks, this report (1) estimates the range of total direct annual financial losses from fraud based on 2018-2022 data and (2) identifies opportunities and challenges in fraud estimation to support fraud risk management.
GAO estimated the range of total direct annual financial losses from fraud based on 2018-2022 data using a Monte Carlo simulation model. GAO identified opportunities and challenges through interviews and data collection focused on 12 agencies representing about 90 percent of federal obligations.
What GAO Found
Private health plans contract with pharmacy benefit managers (PBM) to administer their prescription drug benefits and help control costs. Each of the five states selected for review—Arkansas, California, Louisiana, Maine, and New York—enacted a variety of laws to regulate PBMs.
Fiduciary or other “duty of care” requirements. Four of the five states (California, Louisiana, Maine, and New York) enacted laws to impose a duty of care on PBMs. The laws varied from imposing a fiduciary duty—that is, a requirement to act in the best interest of the health plan or other entity to which the duty is owed—to what state regulators described as “lesser” standards such as a requirement to act in “good faith and fair dealing.”
Drug pricing and pharmacy reimbursement requirements. The five states enacted a variety of laws relating to drug pricing and pharmacy payments, such as laws limiting PBMs' use of manufacturer rebates and their ability to pay pharmacies less than they charge health plans—a practice referred to as “spread pricing.”
Transparency, including licensure and reporting requirements. To increase the transparency of PBM operations, the five states enacted laws that require PBMs to be licensed by or registered with the state, or both, and to report certain information such as drug pricing, fees charged, and the amounts of rebates received and retained.
Pharmacy network and access requirements. The five states also enacted laws regarding pharmacy networks and patient access. Examples include laws prohibiting discrimination against unaffiliated pharmacies and limiting patient co-pays charged by PBMs.
The regulators GAO interviewed from selected states described lessons learned regarding PBM regulation. Examples include the following.
Regulators in four states said that providing regulators with broad regulatory authority was more effective than enacting specific statutory provisions. Doing so allowed regulators to address emerging issues without new legislation, according to regulators from one state.
Some regulators also stressed the need for robust enforcement of PBM laws and effective penalties to enforce them. Two pharmacy associations GAO interviewed concurred with these views, while a health plan association said that monitoring is needed to ensure compliance with PBM requirements. Three regulators also said that clear reporting requirements and definitions helped ensure consistent enforcement.
The Department of Labor provided technical comments on a draft copy of this report, which GAO incorporated as appropriate.
Why GAO Did This Study
Prescription drug spending by private health plans climbed to nearly $152 billion in 2021, an 18 percent increase from 2016. Health plans generally rely on PBMs to process claims, develop pharmacy networks, and negotiate rebates from drug manufacturers. However, some researchers and stakeholders have questioned certain PBM practices, such as PBMs retaining a share of the rebates and use of spread pricing. In response, states have begun to enact legislation addressing PBMs, with all 50 states having enacted at least one PBM-related law between 2017 and 2023.
GAO was asked to review states' regulation of PBMs serving private health plans. Among other things, this report describes actions selected states have taken to regulate PBMs, and lessons learned that state regulators identified for PBM regulation.
GAO focused on a selection of five states that have enacted a wide range of PBM laws, based on existing inventories maintained by national policy research organizations, such as the National Conference of State Legislatures. GAO reviewed states' laws and interviewed state regulators as well as a variety of other stakeholders. These included state pharmacy associations and state health plan associations in each of the five states, and four national organizations representing interests of PBMs, patients, employers, and drug manufacturers, respectively.
For more information, contact John E. Dicken at (202) 512-7114 or dickenj@gao.gov.
What GAO Found
The F-35 Lightning II aircraft (F-35) is the Department of Defense's (DOD) most ambitious and costly weapon system and its most advanced fighter aircraft. DOD operates and sustains about 630 F-35 aircraft and plans to buy about 2,500 total by the mid-2040s with a projected planned life into the 2080s.
However, DOD's projected costs for sustaining the F-35 continue to increase while planned use of the aircraft declines. Specifically:
Sustainment cost estimates have increased 44 percent, from $1.1 trillion in 2018 to $1.58 trillion in 2023.
DOD's planned use of the F-35 and its availability have decreased. The Air Force, Navy, and Marine Corps project they will fly the F-35 less than originally estimated on an annual basis. The F-35 fleet's overall availability has trended downward considerably over the past 5 years, and none of the variants of the aircraft (i.e., the F-35A, F-35B, and F-35C) are meeting availability goals.
The Air Force, Navy, and Marine Corps' have made progress in meeting their affordability targets (i.e., the amount of money they project they can afford to spend per aircraft per year for operating the aircraft). This is due in part to the reduction in planned flight hours, and because the Air Force increased the amount of money it projects it can afford to spend. DOD currently estimates the Air Force will pay $6.6 million annually to operate and sustain an individual aircraft. This continues to be well above the $4.1 million original target. In June 2023, the Air Force increased the amount of money it can afford to spend per F-35 aircraft to $6.8 million per year.
DOD has pursued cost savings efforts and continues to look for new ways to reduce costs. However, DOD officials generally agree that these efforts are not likely to fundamentally change the estimated costs to operate the aircraft.
Why GAO Did This Study
DOD plans to use the F-35 aircraft through 2088 and plans to spend over $2 trillion on acquisition and sustainment. The National Defense Authorization Act for Fiscal Year 2022 includes a provision for GAO to conduct an annual review of F-35 sustainment efforts, including DOD's ability to reduce sustainment costs, or otherwise maintain the affordability of the F-35 fleet. This report provides information on the F-35's sustainment cost estimates over the life of the program, actions taken by the F-35 Joint Program Office to reduce sustainment costs, and the extent to which the F-35 fleet has met performance goals. GAO analyzed DOD's F-35 sustainment cost estimates and performance data and interviewed cognizant DOD officials about these issues.
What GAO Found
As of February 2024, DOD testing had not detected any per-and polyfluoroalkyl substances (PFAS) in the active drinking water shaft at Joint Base Pearl Harbor-Hickam. PFAS are a large group of heat and stain resistant chemicals that can persist in the environment—including in water, soil, and air—for decades or longer. In November 2022, during maintenance activities 1,300 gallons of aqueous film-forming foam (AFFF) concentrate was released from a pipe in a tunnel at the Red Hill Bulk Fuel Storage Facility at Joint Base Pearl Harbor-Hickam in Hawaii. Because AFFF—a product used to fight flammable liquid fires—contains PFAS, this incident raised concerns about PFAS in the installation's drinking water and how the Department of Defense (DOD) remediates PFAS contamination at the installation.
Following the AFFF release, DOD took immediate action to ensure the AFFF was contained and removed from the affected area. Both DOD and the Environmental Protection Agency (EPA) have since completed investigations of the November 2022 AFFF release and issued final reports. Both investigations recommended that (1) increased government oversight of AFFF-related activities at the Red Hill facility was necessary, (2) all AFFF concentrate should be removed from the Red Hill facility, and (3) the AFFF system at Red Hill should be decommissioned.
On April 10, 2024, EPA announced a National Primary Drinking Water Regulation establishing allowable levels of 4 parts per trillion for certain PFAS in drinking water (one part per trillion is equivalent to a single drop of water in 20 Olympic-sized swimming pools). Prior to this, PFAS in drinking water were not regulated at the federal level. However, in 2016, under the authority of the Safe Drinking Water Act, EPA published health advisory levels of 70 parts per trillion for certain PFAS in drinking water. Since 2016, DOD has had policies in place for monitoring PFAS levels in drinking water at its installations at 70 parts per trillion. Joint Base Pearl Harbor-Hickam regularly monitors for PFAS in its active drinking water shaft at frequencies required by DOD policy and requests by EPA and the state of Hawaii. While PFAS have not been detected in the active drinking water shaft at the installation, low amounts of PFAS falling below 70 parts per trillion have been detected in the installation's two inactive drinking water shafts. These two shafts are currently not in use and according to DOD officials, the PFAS detected are not due to the November 2022 AFFF release. According to DOD policy and officials we met with, DOD will implement and comply with the April 2024 EPA regulation.
PFAS contamination at Joint Base Pearl Harbor-Hickam is being addressed by DOD's environmental restoration program. Through this program the Navy has identified 32 sites of known or potential PFAS contamination (e.g., soil or groundwater) at Joint Base Pearl Harbor-Hickam and is taking steps to assess these sites and, where appropriate, develop plans for their long-term cleanup. The Navy has finalized its preliminary assessment and site inspection reports for these 32 sites, with recommendations for the areas in 20 of these sites to advance to the in-depth remedial investigation phase of the environmental cleanup program. The remaining 12 sites were found to have no documentation of past use of AFFF or other potentially PFAS-containing products or materials.
Why GAO Did This Study
DOD has policies related to monitoring PFAS levels in drinking water at its installations, long term cleanup of PFAS contamination, and use and disposal of products containing PFAS. According to EPA, exposure to certain PFAS may have adverse effects on human health, including effects on fetal development, the immune system, and the thyroid, and may cause liver damage and cancer.
GAO was asked to examine DOD efforts to address PFAS contamination at Joint Base Pearl Harbor-Hickam. This report describes DOD's response to the November 2022 AFFF release at the installation; DOD processes for ongoing monitoring and long-term cleanup of PFAS at Joint Base Pearl Harbor-Hickam; and DOD's and EPA's policies addressing PFAS in the environment.
To conduct this work, GAO reviewed and summarized information from previous GAO reports and relevant DOD, EPA, and state of Hawaii guidance, policies, and other documentation on regulating release, response, use, and disposal of PFAS-containing substances. GAO interviewed DOD, EPA, and state of Hawaii officials and conducted a site visit to Joint Base Pearl Harbor-Hickam to observe the site of the November 2022 AFFF release. GAO met with Navy and state of Hawaii officials to understand the Navy's response to and cleanup of the release, as well as ongoing efforts to monitor and cleanup PFAS at Joint Base Pearl Harbor-Hickam.
For more information, contact Alissa Czyz at (202) 512-3058 or CzyzA@gao.gov.
What GAO Found
Community development financial institutions (CDFI) are lenders that provide financial products and services to underserved communities, and minority depository institutions (MDI), which can be certified as CDFIs, are generally banks or credit unions primarily owned by minority individuals or serving minority populations. In response to GAO's survey of CDFIs and MDIs, many small CDFIs and MDIs reported they lack the technology needed to provide online services or to underwrite loans, manage operations, and conduct outreach more efficiently. Officials GAO interviewed from some small institutions said their limited technology—such as lack of ability to provide mobile banking—constrains their ability to serve underserved communities. Technology costs and limited staff capacity were the most common reasons CDFIs and MDIs cited for not being able to obtain the technology they need, according to a GAO survey. These institutions reported that additional funding and training related to technology could help them address these challenges.
Challenges CDFIs and MDIs Reported Frequently or Always Prevented Them from Acquiring New Technology
The CDFI Fund has increased the grant funding CDFIs can use for improving their technology but has not provided technology-related training. CDFI Fund certifies financial institutions (including eligible MDIs) as CDFIs and provides financial and technical assistance. Over the last 10 years, total CDFI Fund technical assistance grants increased from $3.6 million to $25.2 million per year. The CDFI Fund's strategic plan states it will develop training programs targeting key issues affecting CDFIs. However, it has not created any new training or materials since 2020, and none related to technology. Fund officials said they were aware of the impact of technology capacity on small CDFIs' ability to serve their communities and grow. They said they have considered creating training and materials to help CDFIs build technology capacity, but they do not have a time frame for doing so. Such resources could help CDFIs implement the technology they need to increase lending to underserved communities.
Why GAO Did This Study
CDFIs and MDIs target loans to traditionally underserved businesses and individuals. Prior GAO work identified challenges some CDFIs and MDIs had accessing emergency lending capital during the COVID-19 pandemic, raising questions about whether they had the technology capacity needed to best serve their communities.
GAO was asked to review CDFIs' and MDIs' technology capacities and potential federal solutions to address any technology challenges. This report examines (1) CDFI and MDI officials' views on their technology capacity and challenges, and (2) available federal resources for improving CDFI and MDI technology.
GAO surveyed a sample of 711 CDFI and MDI officials in June and July 2023 and generalized results to the population as a whole and to small and large institutions. GAO also reviewed relevant federal laws and regulations and agency funding documents, strategic plans, and other program documentation, including those from Treasury. In addition, GAO interviewed representatives from 23 judgmentally selected CDFIs and MDIs, and officials from Treasury and federal financial regulators.
What GAO Found
The Defense Health Agency (DHA) uses its clinical adverse action process to investigate concerns about a health care provider's quality of care, and if warranted, to take action to limit or prohibit the care a provider is allowed to deliver. GAO reviewed 55 clinical adverse action cases at four selected military medical treatment facilities and found that they did not always adhere to certain requirements. For example, in more than one-third of the cases, the facilities did not adhere to the DHA requirement to establish a deadline for the investigation of a provider. GAO found that, while DHA monitors facilities' adherence by conducting an audit of each case and by monitoring the process, DHA's monitoring approach does not include information needed to assess adherence to many of the facility-level steps of the clinical adverse action process.
GAO also found that DHA did not always report providers within required time frames to the National Practitioner Data Bank. This database is an electronic repository administered by the federal government that is used by hospitals and others across the health care industry to obtain information on providers with histories of substandard care or misconduct. GAO found that while DHA reported all 14 of the providers from the four facilities in GAO's review who received a final clinical adverse action, DHA did not meet the 30-day reporting requirement for four providers.
Defense Health Agency Adherence to Requirements for Reporting 14 Final Clinical Adverse Actions to the National Practitioner Data Bank
DHA's approach to monitoring its clinical adverse action process does not include information needed to assess adherence to certain requirements, such as whether DHA reports providers within required time frames. Further, DHA has not established timeliness requirements for many of the DHA-level steps in the process, such as legal reviews and appeal panel meetings. GAO found it took DHA almost one year on average to complete its steps for 14 cases that resulted in final clinical adverse actions. While DHA's procedures state that the purpose of the clinical adverse action process is to ensure timely resolution of issues and reporting, GAO found that DHA does not sufficiently monitor its timeliness. Such deficiencies could present risks to the quality and safety of care that military service members and their families receive in DOD facilities.
Why GAO Did This Study
Like all health care delivery settings, concerns may arise about the quality and safety of care delivered by individual health care providers in the Department of Defense's (DOD) military medical treatment facilities. DHA and its medical facilities share responsibility for investigating concerns and determining whether to take clinical adverse action against providers. DHA is also responsible for reporting any actions taken against providers to regulatory bodies for use among the health care industry.
Senate Report 117-39 accompanying the National Defense Authorization Act for Fiscal Year 2022 includes a provision for GAO to review DOD's clinical adverse action process. GAO's review examines adherence to DHA clinical adverse action requirements at four selected facilities and at the DHA-level. GAO reviewed documentation of 55 clinical adverse action cases initiated between October 2019 and September 2022 by four facilities, selected to obtain variation in location and the number of clinical adverse actions conducted. Additionally, GAO reviewed DHA procedures and interviewed DHA officials and facility staff.
In fiscal year 2023, GAO’s work yielded $70.4 billion in financial benefits, a return of about $84 for every dollar invested in GAO. Our average return on investment for the past 6 years is $133 to $1. In 2023 we also identified 1,220 other benefits that led to improved services to the American people, strengthened public safety, and spurred improvements across the government. GAO’s High Risk Series this past year resulted in $32.9 billion in financial benefits and 468 program and operational improvements. GAO is also helping advance agencies’ efforts and related Congressional oversight to prevent, detect, and respond to fraud, waste, and abuse. For instance, in FY 2023 we estimated that the amount of unemployment insurance fraud during the COVID-19 pandemic was likely between $100 billion and $135 billion.
For our fiscal year 2025 budget, GAO is requesting $916.0 million in appropriated funds and $59.8 million in offsets and supplemental appropriations. This will maintain 3,600 full-time equivalents (FTE). These resources will enable GAO to continue to meet the priority needs of the Congress including five key areas of importance to the nation and Congress:
National Security Enterprise. GAO evaluates an array of national security efforts in areas such as military readiness, space programs, and the U.S. nuclear complex.
Fraud Prevention. We examine government efforts to safeguard programs from fraud by focusing agencies more on prevention.
Science and Technology. GAO’s growing portfolio of ongoing and future work includes many aspects of artificial intelligence, medical research and applications, critical minerals recovery, and quantum computing.
Cybersecurity. GAO assesses the development and execution of a comprehensive national cybersecurity strategy, the cybersecurity of 16 critical infrastructure sectors across the U.S., and the security of federal information systems.
Health Care Costs. GAO examines the sustainability and integrity of the Medicare and Medicaid programs, Veterans Affairs, DOD, and Indian Health Service health care services.
Our fiscal year 2025 budget request also supports GAO’s IT modernization and space optimization efforts. We will transition processes to Cloud Services and enhance cybersecurity. This will allow GAO to grow in agility and better engage IT Modernization strategies. In addition, we will advance space optimization projects to increase leasable space in headquarters and decrease leased space in the field. We will also continue addressing a maintenance backlog at the headquarters building.
Background
GAO’s mission is to support Congress in meeting its constitutional responsibilities and to help improve the performance and ensure the accountability of the federal government for the benefit of the American people. We provide nonpartisan, objective, professional and reliable information to Congress, federal agencies, and to the public. GAO recommends hundreds of improvements across the full breadth and scope of the federal government’s responsibilities.
In fiscal year 2023 alone, GAO issued 671 products, and 1,345 new recommendations. Congress used our work extensively to inform its decisions on key fiscal year 2023 and 2024 legislation.
Since fiscal year 2002, GAO’s work has resulted in over:
$1.38 trillion dollars in financial benefits; and
Over 28,000 program and operational benefits that helped to change laws, improve public safety, and promote sound management throughout government.
As a non-partisan, fact-based service organization, GAO is committed to providing program and technical expertise to support Congress. This includes crafting legislation; overseeing the executive branch; evaluating government programs, operations, and spending priorities; and assessing information from outside parties.
For more information, contact A. Nicole Clowers at (202) 512-4400 or clowersa@gao.gov.
What GAO Found
The Bureau of Land Management (BLM) and Forest Service process the most applications from telecommunications providers to install communications use equipment or facilities—including for broadband internet—on federal property. However, GAO found that from fiscal years 2018 through 2022, BLM and Forest Service did not have sufficiently reliable—i.e., accurate and complete data—to determine the processing time for 42 percent and 7 percent, respectively, of their communications use applications. These agencies lacked the necessary controls to ensure staff entered key information, such as start and end dates, in their electronic systems. Without accurate, complete data to determine processing times, the agencies cannot track the extent to which they are complying with the statutory requirement that they grant or deny applications within 270 days.
For those communications use applications with sufficient data, BLM and Forest Service reduced their average processing time by 57 percent from fiscal years 2018 through 2022. However, despite this overall improvement, about half of the applications either exceeded the 270-day deadline or did not have sufficiently accurate and complete information to determine if they met the deadline.
Selected Agencies' Performance in Processing Communications Use Permit Applications Within the 270-Day Deadline, Fiscal Years 2018—2022
Officials from BLM and Forest Service said that applicant non-responsiveness and staffing issues contributed to the delays in processing communications use applications. Forest Service has taken some steps to improve processing, including hiring additional staff, but neither agency has fully analyzed or addressed reasons why many applications processing time exceeded the deadline. Moreover, neither agency has a method to alert staff to applications that are at risk of exceeding the 270-day deadline. Until BLM and Forest Service address issues that contribute to delays and establish methods to flag at-risk applications, the agencies may continue to miss the deadline at similar rates, which could cause delays and increased costs in deploying needed broadband infrastructure.
Why GAO Did This Study
Millions of Americans do not have broadband access, which has become essential for online activities like work, school, and health care. With the federal government investing billions of dollars in expanding access in the coming years, new broadband infrastructure will frequently cross federal lands or connect to federal buildings, which requires a federal permit. Legislation requires that executive agencies process applications for communications use permits—including for broadband infrastructure—within 270 days of receipt.
GAO was asked to review issues related to processing federal broadband permits. This report examines the extent to which selected agencies (1) used reliable data to track application processing times for communications use permits; and (2) processed communications use applications by the required deadline.
GAO analyzed federal permitting data; reviewed laws and reports on the application review process; and interviewed agency officials.
The Coronavirus State and Local Fiscal Recovery Funds, established under the American Rescue Plan Act of 2021, allocated $350 billion to Tribes, states, the District of Columbia, localities, and U.S. territories to help cover a broad range of costs stemming from the health and economic effects of the COVID-19 pandemic. This snapshot updates the status of these funds.
The Big Picture
Most ($325.5 billion) of the $350 billion in Coronavirus State and Local Fiscal Recovery Funds (SLFRF) were allocated to states, the District of Columbia, and local governments. SLFRF recipients have until December 31, 2024, to obligate their SLFRF awards and generally have until December 31, 2026, to spend their awards.
The Department of the Treasury, which administers the SLFRF, requires recipients to submit project and expenditure reports quarterly or annually—depending on the recipient type, population, and award size. The reports detail recipients’ uses of SLFRF funds, including obligations and spending amounts. The most recent quarterly reports reflect this information as of September 30, 2023.
This snapshot includes aggregate data on obligation and spending amounts that SLFRF recipients reported to Treasury as of September 30, 2023, the most recent reporting available when this snapshot was issued. The snapshot updates our October 2023 report on states’ and localities’ obligations and spending amounts, as of March 31, 2023 (GAO-24-106753). Our prior report also includes detailed information on Treasury’s reporting requirements for SLFRF recipients.
What GAO’s Work Shows
States’ Reported Obligations
As of September 30, 2023, states and the District of Columbia reported obligating 73 percent ($142.4 billion) of their $195.8 billion in SLFRF awards. All states reported obligating at least 25 percent of their SLFRF awards and 23 states reported obligating over 75 percent. Minnesota and North Dakota reported obligating the largest share of their awards (over 99 percent and 100 percent, respectively), while New Jersey and West Virginia reported obligating the smallest shares (36 percent and 33 percent, respectively).
States’ Reported Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Obligations, as of Sept. 30, 2023
States’ Reported Spending
As of September 30, 2023, states and the District of Columbia reported spending 53 percent ($103.7 billion) of their $195.8 billion in SLFRF awards. All but eight states reported spending at least 25 percent of their awards. Eight states reported spending 75 percent or more of their awards. Minnesota and Alaska each reported spending the largest share of their awards (99 percent and 96 percent, respectively). Oklahoma and South Carolina reported spending the smallest shares (5 percent each).
States’ Reported Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Spending, as of Sept. 30, 2023
Localities’ Reported Obligations and Spending
As of September 30, 2023, a total of 26,442 localities reported SLFRF obligations and expenditures, either through an annual report (as of March 31, 2023) or a quarterly report (as of September 30, 2023). Smaller localities—referred to as non-entitlement units of local government (NEU)—comprised the majority of reporting localities (22,361) but received the smallest amount of allocations ($18.9 billion) in the aggregate, compared to counties and metropolitan cities (which we refer to as cities throughout this snapshot).As of September 30, 2023, a total of 26,442 localities reported SLFRF obligations and expenditures, either through an annual report (as of March 31, 2023) or a quarterly report (as of September 30, 2023). Smaller localities—referred to as non-entitlement units of local government (NEU)—comprised the majority of reporting localities (22,361) but received the smallest amount of allocations ($18.9 billion) in the aggregate, compared to counties and metropolitan cities (which we refer to as cities throughout this snapshot).
Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Allocations Received, by Locality Type, as of Sept. 30, 2023
Number of localities reporting
Amount of SLFRF allocation (in billions)
Citiesa
1,105
$47.7
Counties
2,976
$59.4
Non-entitlement units of local governmentb
22,361
$18.9
Total
26,442
$126.1
Source: GAO analysis of Department of the Treasury data. I GAO-24-107472aCities refer to metropolitan cities as defined in 42 U.S.C. § 803(g)(4).bNon-entitlement units of local government as defined in 42 U.S.C. § 803(g)(5).
In their annual or quarterly reports, these localities reported obligating 64 percent ($80.1 billion) and spending 47 percent ($59.4 billion) of their $126.1 billion in SLFRF allocations.
Cities, counties, and NEUs in the aggregate each reported obligating between 61 and 65 percent of their awards. Cities received the second largest amount of allocations ($47.7 billion), but they reported spending the largest amount of their awards (54 percent), compared to counties and NEUs (each reporting spending 43 percent of their awards).
Localities’ Reported Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Obligations and Spending, as of Sept. 30, 2023
aCities refer to metropolitan cities as defined in 42 U.S.C. § 803(g)(4).bNon-entitlement units of local government as defined in 42 U.S.C. § 803(g)(5).
We will continue to review states’ and localities’ reported obligations and spending, as well as their uses of SLFRF awards.
For more information, contact Jeff Arkin at (202) 512-6806 or ArkinJ@gao.gov.
What GAO Found
The Justice40 Initiative is the administration's goal for 40 percent of the overall benefits of certain federal investments to flow to disadvantaged communities. GAO reviewed six Justice40 programs in three selected agencies—the Environmental Protection Agency (EPA), Federal Emergency Management Agency (FEMA), and U.S. Department of Agriculture (USDA). GAO found that each agency adjusted program mechanisms to increase access to funding for underserved communities, including Tribes and eligible Indigenous communities (tribal applicants), in response to the Justice40 Initiative as well as other agency initiatives.
However, certain program characteristics create barriers to tribal applicants' ability to access selected covered Justice40 programs, including cost shares, administrative burdens, and certain statutory and regulatory requirements. For example, EPA has a mechanism to reduce administrative burdens for recipients by combining funds from multiple grants into a single budget. Agency officials told GAO that grants funded by the Infrastructure Investment and Jobs Act and Inflation Reduction Act are not eligible for this mechanism. Agencies have taken actions to identify statutory and regulatory barriers to access for tribal recipients. Additional actions to document and discuss these barriers with affected stakeholders to determine any additional statutory and regulatory changes needed could help tribal applicants more readily access covered programs, consistent with the Justice40 goal and executive orders.
Examples of Historic Barriers to Tribes' Access to Federal Programs
Selected agencies consulted with Tribes on new programs, funding opportunities, and related topics, such as equity assessments. However, the extent to which these efforts informed agency implementation of Justice40 is unclear because the agencies generally did not make related consultation results publicly available. Consistent with executive orders and presidential memoranda, considering publicly sharing high-level consultation summaries could help ensure Tribes have access to information about prior tribal input on federal programs. In turn, this information could inform Tribes' future input on Justice40 and reduce their administrative burdens. Additionally, GAO's review of the selected agencies' online consultation tracking systems and interviews with agency officials found that the agencies did not consult with Tribes specifically about the Justice40 Initiative. Interim implementation guidance directs agencies to consult with stakeholders, including Tribes, when determining Justice40 covered program benefits. Agencies have additional opportunities to consult with Tribes and conduct outreach on Justice40 implementation to ensure meaningful input.
Why GAO Did This Study
Underserved communities—including federally recognized Tribes and other historically marginalized people—experience a disproportionate share of adverse socioeconomic and environmental conditions, according to GAO's prior work. Executive Order 14008 established the Justice40 Initiative with the goal of delivering to disadvantaged communities 40 percent of the overall benefits of certain federal investments. In determining Justice40 benefits, guidance directed agencies to consult with Tribes and other stakeholders to ensure meaningful involvement.
GAO was asked to review agencies' implementation of the Justice40 Initiative with respect to tribal applicants. This report reviews the actions selected agencies took to (1) adjust programs to direct funding to tribal recipients, and (2) consult with Tribes and conduct outreach to Indigenous communities regarding the initiative. GAO examined laws, executive orders, presidential memoranda, guidance, and policies; and interviewed officials from three selected agencies, leadership from six Tribes, and representatives from seven tribal organizations. GAO selected a mix of agencies and programs based on tribal participation, funding mechanisms, and types of programs.
What GAO Found
The Coast Guard began offering video and telephone telehealth appointments to its personnel in 2021 in response to the COVID-19 pandemic, according to officials. The Coast Guard piloted an updated video telehealth platform in 2022 across behavioral health clinics, with full deployment to primary care settings occurring in September 2023. The service continues to formalize its telehealth program; for example, the Coast Guard formalized its telehealth policy in December 2023, and Coast Guard officials told GAO they are working on establishing standardized scheduling practices for telehealth appointments and improving their monitoring capabilities.
According to Coast Guard officials and documents, the benefits of telehealth include increasing access to medical care for personnel located in remote locations and maximizing staff resources at Coast Guard clinics. Challenges the Coast Guard identified include issues with the Coast Guard's IT infrastructure that may, for example, limit the use of telehealth while at sea due to inconsistent internet connectivity aboard Coast Guard vessels.
GAO found that the Coast Guard has plans to address these challenges. For example, the service is in the process of improving its internet capabilities aboard its vessels and is developing standardized scheduling practices for telehealth appointments in Coast Guard clinics.
Why GAO Did This Study
The James M. Inhofe National Defense Authorization Act for Fiscal Year 2023 includes a provision for GAO to report on aspects of the Coast Guard's telehealth program. This report describes how the Coast Guard uses telehealth to provide medical care to its active duty personnel, as well as describes telehealth benefits and challenges identified by Coast Guard officials and documents.
To conduct this work, GAO reviewed Coast Guard telehealth policy and guidance documentation, interviewed officials, and conducted site visits to three Coast Guard clinics and three afloat sickbays. Additionally, GAO obtained and reviewed data on the Coast Guard's use of video telehealth from the Defense Health Agency, which manages the video platform. GAO analyzed data from October 2022, the earliest data available at the time of the request, through December 2023, the most recent available at the time of GAO's work.
For more information, contact Alyssa M. Hundrup at (202) 512-7114 or hundrupa@gao.gov.
Recent comments