What GAO Found NASA major projects aim to explore the solar system, advance aeronautic technologies, and return U.S. astronauts to the lunar surface through the Artemis missions. These major projects are increasingly focused on Artemis—building a sustained human presence on the moon and ultimately traveling to Mars. The cost and schedule performance of NASA's 18 major projects in development (those that are building and testing their designs) generally remained unchanged over the last year. The four projects that experienced annual cost growth collectively reported over $500 million in overruns. NASA's human spaceflight crew capsule, known as the Orion Multi-Purpose Crew Vehicle program, accounts for over $360 million of this total annual cost growth. Most major NASA projects since GAO's first assessment in 2009 have avoided significant cost overruns. GAO found that of the 53 major projects that have completed development or are currently in the final phase of development, 30 remained under the statutory threshold for reporting cost overruns. Specifically, these 30 project's development costs did not exceed their baselined cost estimates by 15 percent or more. When a project's overrun rises to this threshold, NASA is required to take certain steps. For example, it must notify congressional committees of the overrun and update the project's cost or schedule plans. At the same time, Artemis and Artemis-related cost overruns are an increasing proportion of the portfolio's overall overruns. Three Artemis projects account for nearly $7 billion of the total overruns—or almost half of the overruns collectively experienced by the 53 projects. Accumulated Cost Overruns for 53 NASA Major Projects That Completed or Are in Final Phase of Development Since GAO's First Annual Assessment in 2009 The growing Artemis portfolio could drive cost performance in the future, since NASA recently initiated nine new Artemis projects with estimated total costs over $20 billion. These projects are interdependent, meaning that challenges and delays in one can create challenges and delays for all of them. Further, delays to mission dates can also increase costs. As the Artemis projects progress in development, the agency has taken steps to help manage and mitigate risks, such as creating more oversight of programs through the Moon to Mars office. Why GAO Did This Study The National Aeronautics and Space Administration (NASA) plans to invest about $74 billion in estimated life cycle costs for its portfolio of major projects (those with costs over $250 million). House explanatory statements have included provisions for GAO to prepare status reports on these projects. GAO assessed the (1) cost and schedule performance of NASA's major projects in development, and (2) historical cost performance of NASA's major projects included in GAO annual reviews since 2009. This report also includes summaries of NASA's 38 major projects. GAO collected and analyzed data on the 38 current NASA major projects, visited NASA facilities, and interviewed officials. GAO analyzed cost and schedule performance for 18 projects in development with cost and schedule baselines. GAO also collected and analyzed cost data for 53 historical projects that have completed or are in the final stage of development.

What GAO Found The Department of Veterans Affairs (VA) and Department of Defense (DOD) have shared mutually beneficial medical and other services through 185 sharing agreements, as of April 2025. For example, veterans may receive care at DOD facilities for services including surgery, orthopedics, and mental health. These agreements can result in greater access to care for veterans and cost savings for the federal government, in part because of the discounted rate that VA and DOD pay each other for health care delivered under such sharing agreements. Department of Veterans Affairs Medical Clinic Located on a Military Base VA and DOD collect information on the characteristics of all sharing agreements as well as referrals of veterans to DOD facilities made through sharing agreements; however, the departments do not evaluate the effectiveness of sharing agreements. Officials told GAO that they use the number of sharing agreements and the continuation of agreements as measures of the agreements' value. However, VA and DOD could maximize the benefits of these agreements by developing a performance management process, including establishing performance goals for the agreements, evaluating progress towards the goals, and making changes as appropriate. VA and DOD have taken some steps to identify new or expanded sharing opportunities, including tracking space-sharing projects through a committee. However, the departments largely rely on local officials to identify potential areas for new and expanded sharing, which may result in missed opportunities for sharing. Developing a systematic, department-level process to identify and implement opportunities for new and expanded sharing agreements could help ensure the departments maximize sharing, which could in turn help improve patients' access to care as well as reducing costs. Why GAO Did This Study VA and DOD operate two of the nation's largest health care systems. Together, these systems serve over 18 million beneficiaries. VA's health care system includes approximately 170 medical centers and 1,200 clinics, while DOD's health care system includes more than 700 medical facilities worldwide. VA and DOD have entered into agreements to share health care services to improve access to and cost effectiveness of care. GAO was asked to review the departments' use of sharing agreements. This report describes the number and types of sharing agreements; examines the extent to which VA and DOD assess them; and examines how VA and DOD identify opportunities for new or expanded sharing agreements, among other topics. GAO reviewed VA and DOD documents and data, including active sharing agreements as of April 2025; conducted site visits to 12 VA and DOD facilities with active agreements, selected to represent diversity in geography and the type of sharing taking place; and interviewed VA and DOD officials.

What GAO Found The U.S. territories' levels of public debt vary, along with the factors that affect each of their capacities for economic growth and debt repayment. To assess their ability to repay debt, GAO used the most recently available audited financial statements. Audited financial statements for some territories are almost 2 years late, and independent auditors have identified issues that raise data reliability concerns for the available statements. These financial reporting limitations can lead to poor financial decisions and lost access to capital markets. Geographic Locations of U.S. Territories Commonwealth of Puerto Rico: As of June 30, 2022, total public debt outstanding was $52.8 billion, 47 percent of gross domestic product (GDP). Negotiations and litigation to restructure the electric utility debt are ongoing, and the utility has been struggling to make its pension payments in the meantime. Guam: As of September 30, 2023, total public debt outstanding was $2.5 billion. 2023 GDP data are not available, but the fiscal year 2022 total public debt was $2.6 billion, about 38 percent of GDP. Its tourism industry has not returned to pre-COVID-19 levels, but U.S. military investment is bolstering the economy. U.S. Virgin Islands (USVI): As of September 30, 2021, total public debt outstanding was more than $2.2 billion, or 50 percent of GDP. USVI's electric utility has critical financial and operational problems, which create challenges for residents and can inhibit economic development. Commonwealth of the Northern Mariana Islands (CNMI): As of September 30, 2021, total public debt outstanding was $121.1 million, about 13 percent of GDP. Its tourism-reliant economy has limited prospects for recovery, and the challenges to meet its financial obligations have deepened. American Samoa: As of September 30, 2023, total public debt outstanding was $145.4 million. While 2023 GDP data are not available, the fiscal year 2022 total public debt was $152.4 million, about 18 percent of GDP. Its continued economic reliance on a single tuna cannery presents risks. Why GAO Did This Study The five permanently inhabited U.S. territories—the Commonwealth of Puerto Rico, Guam, USVI, CNMI, and American Samoa—have borrowed through financial markets to bridge the gap between tax receipts and the financial resources required to fund government programs. The territories all face challenges to achieving continued economic growth and financial accountability, both of which are key to debt management. GAO has previously reported on some of the common challenges, including (1) the location of the islands, which leads to a high cost of energy and imported goods; (2) increasing vulnerability to frequent and severe episodes of extreme weather; (3) undiversified economies based on few industries with limited job opportunities; and (4) outmigration and population loss. In 2016, Congress passed and the President signed the Puerto Rico Oversight, Management, and Economic Stability Act. It contains a provision for GAO to review the territories' public debt every 2 years. This is the fifth report in this series. In this report, for each of the five territories, GAO presents public debt figures and describes risk factors that may affect their ability to repay public debt, among other updates. GAO analyzed audited financial statements for fiscal years 2020 through 2023, as available. GAO also reviewed demographic and economic data and interviewed officials from the territories' governments. For more information, contact Yvonne D. Jones at JonesY@gao.gov or Latesha Love-Grayer at LoveGrayerL@gao.gov.

What GAO Found Over the last 30 years, the Department of Defense (DOD) has used different acquisition strategies to procure launches for military satellites from commercial providers. DOD's most recent acquisition strategy—Phase 3—responds to DOD's evolving and growing demand for launch services and infrastructure. Phase 3 is a dual lane approach intended to lower government launch costs, ensure mission success and access to space, and facilitate competition. Lane 1: Expands DOD's supply of newer commercial providers that can meet a subset of launch requirements. Lane 2: Assures DOD's access to space with three commercial providers, which must meet all launch requirements for a specified number of DOD's most critical payloads. DOD is also taking steps to upgrade its launch infrastructure, which is strained by the increased rate of launches. In addition to military launches, companies use federal ranges to meet their own commercial launch needs—and commercial launches have more than quadrupled since 2021. Commercial Launches at Federal Launch Sites Have Quadrupled Since 2021 Increases in commercial launches have resulted in DOD providing more support to commercial entities, but DOD has struggled to accurately bill companies for direct costs. Until recently, DOD could not collect and be reimbursed for indirect costs for commercial space launch services, which include the actual costs of maintaining, operating, upgrading, and modernizing DOD space-related facilities. Recent legislation allows DOD to be reimbursed for indirect costs within certain limitations, but DOD does not have clear cost collection and reimbursement guidance for support services at launch ranges, potentially missing opportunities to recoup millions of dollars. DOD has limited payload processing capacity and lacks sufficient commercial scheduling information to manage payload processing, which is when the payload is integrated with the launch vehicle before it is transported to the launch pad. The lack of insight into commercial processing schedules hinders DOD's efforts to coordinate processing for its own payloads. As a result, it lacks a critical tool to ensure effective coordination and efficient use of its existing and future processing capacity. Why GAO Did This Study Commercial and military activities in space have grown considerably in the last decade, with continued growth expected. This growth will increase the demand on the federal launch infrastructure that supports these activities. DOD has already invested billions of dollars into launch systems and infrastructure. To support the growing demand, DOD expects to spend over $18 billion on launch services and infrastructure over the next 5 years. A Senate report includes a provision for GAO to assess DOD's Phase 3 strategy. GAO's report addresses (1) DOD's Phase 3 strategy to meet its national security space launch demand and (2) the extent to which DOD is addressing launch-related challenges as it executes Phase 3. To conduct this work, GAO reviewed documentation, analyzed launch data, and visited all three federally owned launch ranges. GAO also interviewed DOD officials, other federal agency officials, and contractor representatives involved in launch activities.

What Participants Discussed During the forum, participants identified approaches in five key areas that could help reduce health care spending or increase the value for that spending (see figure). Key Areas Identified by Participants at GAO’s Forum on Health Care Spending in the U.S. Supporting a high-functioning primary care system by providing more resources for team-based care through a payment model that combines fee-for-service payment with a fixed amount paid to providers regardless of the services provided. This could improve continuity of care and care coordination and help decrease unnecessary services and inappropriate tests. Expanding the health care workforce by increasing the graduate medical education opportunities to help address shortages and the uneven distribution of physicians across the country. Increasing compensation and other benefits could also attract and retain home health workers and nursing assistants. Expanding the workforce could increase access to care and reduce the need for costly services, such as institutional care (hospitalization or nursing home care). Reforming health care pricing and promoting high-value care by adopting pricing strategies used by other countries particularly in cases where prices for medical services and pharmaceuticals exceed their clinical value. Reforming Medicare physician payments by revising the Medicare physician fee schedule particularly in cases where it may incentivize physicians to provide specialty care services (e.g., diagnostic imaging) over primary care services (e.g., clinical diagnosis), or to provide more services than are necessary. Mitigating anticompetitive incentives and practices by implementing entirely site-neutral payments in Medicare, wherein Medicare pays the same rate for a medical service regardless of the site where it is performed. This could reduce the incentives for hospitals and physician practices to consolidate. Participants agreed that legislative action, federal investment, or both would be needed to implement most of the approaches discussed. Why GAO Convened This Forum For many years, GAO has raised the alarm about the federal government being on an unsustainable long-term fiscal path. One of the key drivers of federal debt is spending on federal health programs, such as Medicare and Medicaid. Spending on federal health programs is projected to increase at a faster rate than the gross domestic product (GDP) over the next 30 years. As the population ages and health care costs increase, GAO projects that federal spending on health care programs will be 8.5 percent of the GDP in 30 years. Efforts to contain these costs have been met with mixed success. On October 22, 2024, GAO convened a diverse panel of 30 health care experts to focus on the challenges of health care spending. The purpose of the panel was to help advance the dialogue and identify issues associated with one of the most perplexing problems facing the government. It comprised federal government officials, academics, researchers, clinicians, and industry experts who represented a range of expertise and experiences. Participants discussed approaches to reduce health care spending and enhance value received for that spending, among other things. The viewpoints summarized in the report do not necessarily represent the views of all participants, their affiliated organizations, or GAO. GAO provided participants the opportunity to review a draft of this summary. Their comments were incorporated as appropriate. For more information, contact Jessica Farb at FarbJ@gao.gov.

What GAO Found Under coastwise laws, U.S. vessel owners and operators engaged in domestic trade generally must use U.S.-built vessels. The construction of vessels in U.S. shipyards helps to support the U.S. maritime industry, which plays a vital role in national defense. Because U.S.-built vessels generally cost more than foreign-built ones, the Maritime Administration has four financial assistance programs to encourage or improve U.S. shipbuilding. The Federal Ship Financing Program generally offers loan guarantees for vessel construction at U.S. shipyards. In the last 5 years, the program executed two loan guarantees for two vessel owners totaling nearly $400 million. The two tax deferral programs, the Construction Reserve Fund Program and the Capital Construction Fund Program, allow vessel owners or operators to defer paying tax on certain eligible deposits that are placed into an account and can be used to fund projects at U.S. shipyards. In 2024, seven vessel owners or operators had a Construction Reserve Fund program account, and 137 vessel owners or operators had a Capital Construction Fund Program account. Finally, the Small Shipyard Grant program provides grants to small shipyards for equipment or training. In fiscal year 2024, this program had $8.75 million in available funds and had 78 grant applications from shipbuilding or repair companies requesting just under $50 million. These four financial assistance programs have provided some support for vessel owners or operators and shipyards, but the programs' administration does not follow leading practices for assessing program performance. For example, the Maritime Administration cannot determine to what extent the programs are effective in growing the U.S. maritime fleet because it has not established measurable goals for, or assessed the performance of, these programs. Doing so would allow the Maritime Administration to identify any changes that could better increase the nation's shipbuilding capacity to promote national security and economic prosperity. An April 2025 Executive Order established United States policy to revitalize and rebuild domestic shipbuilding and requires certain actions to grow the U.S. maritime fleet. In addition, the 31 industry stakeholders GAO interviewed identified challenges facing vessel owners or operators and shipyards competing within the U.S. domestic maritime industry. They also had ideas to address those challenges (see table). Selected Industry Stakeholders' Ideas to Address Challenges Facing Domestic Vessel Owners or Operators and Shipyards Challenge Ideas Domestic vessel owners or operators face competition with other modes of transportation, such as trucks. Encourage the use of domestic vessels to carry cargo along rivers or between coastal ports. Shipyards face workforce challenges from “boom-and-bust” cycles created by fluctuating demand for new vessel construction. Smooth the workflow through economies of scale, such as through large, consistent federal vessel procurements. Shipyards face challenges with aging infrastructure. Expand the Small Shipyard Grant program, and encourage foreign investment. Source: GAO analysis of 31 stakeholders' statements. | GAO-25-107304 Why GAO Did This Study Concerns over the state of U.S. commercial shipbuilding have grown in recent years. Such concerns are particularly related to the nation's capacity to meet government shipbuilding and repair needs that are critical to national defense. The James M. Inhofe National Defense Authorization Act for Fiscal Year 2023 includes a provision for GAO to review efforts to support the U.S. commercial maritime industry. This report addresses, among other topics, (1) the use of the Maritime Administration's programs to encourage or improve U.S. shipbuilding and the extent to which they follow leading practices and (2) ideas identified by selected stakeholders to address challenges facing the maritime industry. GAO reviewed Maritime Administration documents and compared its four financial assistance programs with leading practices for performance management. GAO also surveyed domestic vessel owners and operators and shipbuilding or repair companies. GAO also visited selected shipyards and interviewed government officials and 31 industry stakeholders selected to provide a range of perspectives on the Maritime Administration's programs and the maritime industry's ability to contribute to national defense.

What GAO Found In June 2024, GAO identified 20 priority recommendations for the Department of Transportation (DOT). Since then, DOT has implemented four of those recommendations, including taking actions to improve vehicle and pedestrian safety. In addition, GAO removed the priority status from one recommendation related to DOT oversight of the air ambulance industry due to actions taken by Congress to enhance the information DOT has to conduct oversight. In June 2025, GAO identified six new priority recommendations for DOT, bringing the total number to 21. These recommendations involve managing cybersecurity risks and information technology, improving transparency and communication, developing plans to address safety risks, and reducing fraud and abuse risks. DOT's continued attention to these issues could lead to significant improvements in government operations. Why GAO Did This Study Priority open recommendations are the GAO recommendations that warrant priority attention from heads of key departments or agencies because their implementation could save large amounts of money; improve congressional and/or executive branch decision-making on major issues; eliminate mismanagement, fraud, and abuse; or ensure that programs comply with laws and funds are legally spent, among other benefits. Since 2015, GAO has sent letters to selected agencies to highlight the importance of implementing such recommendations. For more information, contact Heather Krause at KrauseH@gao.gov.

What GAO Found Some key technologies currently used in wildfire management include: Satellites, which provide data that are integrated into models for wildfire forecasting, including data on terrain, vegetation, and weather. They are also used for detection and monitoring, although some satellites face resolution issues, data lags, and other limitations. Aircraft and drones, which can deploy to the scene to collect information on a fire’s location and its potential to spread. Aircraft and drones with thermal cameras can see through smoke and dense trees, helping to locate fires and determine their intensity. Challenges include safety issues for aircraft pilots and limited drone lifespan (3 to 5 years, or less in harsh conditions). Cameras and air sensors, whichare used in several states for wildfire detection, sometimes in extensive networked systems. For example, in 2024, Hawaiian Electric stated that it began deploying high-resolution cameras with artificial intelligence (AI) for early fire detection. For both cameras and sensors, installation, data transmission, and fire verification may be challenging in remote areas. Sensors may require dense networks to operate accurately. AI tools have the potential to improve modeling for wildfire forecasting and response. AI may help address key limitations of the traditional mathematical models used for wildfire. For example, AI can: Allow models to use more data by speeding up data assimilation, the process of updating forecasts with the most current observations. Rapidly flag potential inaccuracies for human review. Potentially reduce uncertainty in some situations when data do not exist or are insufficient, by using prior information to create plausible synthetic data. However, use of AI in this field faces challenges. For example, AI requires extensive up-front work to ensure the data are readily usable by AI tools, which can be costly. AI also presents a risk of conveying inaccurate information, which can put lives and property at risk. In addition, historical data are limited for rare events, which may limit the utility of AI for forecasting extreme wildfires. Why GAO Did This Study Annually, wildfires in the U.S. cause an average of 12 deaths and cost at least $3.2 billion. Wildfire severity has increased across much of the country, a trend that is expected to continue. Current and emerging technologies have the potential to save lives and property by improving forecasting, detection, mitigation, and response. This testimony provides information on selected technologies and on the benefits and limitations of AI tools to enhance use of these technologies. This statement is based on prior GAO work, including a 2023 report on the use of AI to model wildfires and other natural hazards; a 2025 report on wildfire detection technologies such as satellites, aircraft, drones, cameras, and sensors; and prior GAO reports on forest management, wildfire staffing, and interagency coordination on wildfire response.

What GAO Found Funding for Commerce’s Bureau of Industry and Security (BIS) grew by $97 million and roughly doubled from fiscal years 2013 through 2024. During this timeframe, the number of funded positions in BIS went from 403 to 585—an overall increase of 182 positions. About $58 million (60 percent) of BIS’s 12-year funding increase was appropriated in fiscal years 2022 and 2023. BIS primarily used these recent increases in two areas. First, to bolster implementation and enforcement of export controls in response to Russia’s 2022 invasion of Ukraine. Second, to create a new office focused on securing the U.S. information and communications technology and services supply chain. However, BIS does not have a long-term workforce plan to determine its resource needs. Instead, BIS assesses its staffing needs on an annual basis as part of the budget request process. BIS last conducted a bureau-wide workforce planning effort in 2016. Comprehensive, long-term workforce planning would help BIS leadership determine the size and composition of its workforce needed to meet its expanding workload and better position it to reduce the risk of exporting sensitive, dual-use items to an adversary. BIS oversees an interagency export license review process which includes reviews by the Departments of Defense (DOD), Energy (DOE), and State. However, challenges to information-sharing and limited consultation compromise the integrity of these reviews. For example, BIS does not provide the agencies ready access to all relevant information about export license applications, which is housed in multiple classified and unclassified systems. Providing reviewing agencies with easy access to all information relevant to license applications would help ensure reviews are well informed. In addition, officials from reviewing agencies told us that BIS has sometimes removed agreed upon license conditions without consultation. According to BIS, it removed conditions that were redundant or inconsistent with standard licensing provisions. Consulting with reviewing agencies prior to changing or removing conditions would help ensure that licensing decisions fully reflect national security risks and other concerns. Key Steps in Interagency Review Process for Commerce’s Bureau of Industry and Security Export License Applications, as of April 2025   Why GAO Did This Study To address varied foreign policy and national security concerns, the U.S. government has increasingly used export controls. For example, the U.S. has imposed export controls to restrict access to advanced semiconductors that could aid the People’s Republic of China in developing military systems powered by artificial intelligence. BIS is primarily responsible for reviewing applications and issuing licenses to exporters of dual-use technologies that could be used for both civilian and military purposes. DOD, DOE, and State also play roles in reviewing export license applications. GAO was asked to review BIS’s resources and processes for export licensing. This report examines (1) BIS's resources from fiscal years 2013 through 2024, (2) the extent to which BIS has conducted workforce planning, and (3) the extent to which BIS shares information and consults with reviewing agencies. GAO reviewed legislation and agency documents; interviewed Commerce, DOD, DOE, and State officials; and analyzed agency funding, staffing, and workload data.

What GAO Found State Medicaid programs predominantly rely on managed care to provide coverage. In 2022, just over 75 percent of Medicaid beneficiaries (about 74 million beneficiaries) received coverage through managed care. Under Medicaid managed care, states contract with managed care plans and generally pay them a fixed monthly amount per beneficiary (i.e., a capitation payment) to provide a set of covered services. The Centers for Medicare & Medicaid Services (CMS), the federal agency that oversees Medicaid, develops an improper payment estimate for Medicaid. This estimate consists of three components: managed care, fee-for-service, and eligibility. For the managed care component, CMS reviews a sample of the payments that states made to their Medicaid managed care plans. CMS checks to see if those payments were made correctly based on the information in the state’s Medicaid information system and managed care plan contract. In recent years, including 2024, the improper payment estimate for Medicaid managed care has been at or near 0 percent. This means CMS found few to no errors in states’ payments to their Medicaid managed care plans. Components of the Improper Payment Estimate for Medicaid and Estimates Reported in 2024 Note: These components are part of the Payment Error Rate Measurement program, which identifies improper payments in Medicaid. For more information, see figure 2 in GAO-25-107770. CMS’s estimate of improper payments in Medicaid managed care does not include a review of payments from managed care plans to providers. GAO and others, including the Department of Health and Human Services’ Office of Inspector General (HHS-OIG) and some state auditors, have identified program integrity risks related to Medicaid managed care payments that are not accounted for in the improper payment estimate. These include, for example, payments from managed care plans to providers for services that were not delivered or lacked necessary documentation, and capitation payments made by the state for the same beneficiary with multiple identification numbers. CMS conducts audits related to managed care, which can identify program integrity risks not captured in the improper payment estimate. For example, CMS audits can determine if managed care plans paid providers for services that were not delivered. CMS increased the number of audits it conducts, in part, in response to a GAO recommendation. As a result, between October 2021 and February 2025, CMS completed 899 audits of managed care providers and opened 155 managed care plan audits. Through these audits, CMS has identified over $33 million in overpayments; nearly $23 million of these overpayments are the federal share, which the agency is working to recover. Why GAO Did This Study Improper payments are payments that should not have been made, that were made in an incorrect amount, or whose appropriateness cannot be determined due to lacking or insufficient documentation. They have been a long-standing and significant problem in the federal government. Consistent with the Payment Integrity Information Act of 2019, CMS develops an improper payment estimate for Medicaid, a federal-state health financing program for certain low-income and medically needy individuals. House Report 117-389, which accompanied the Legislative Branch Appropriations Act, 2023, includes a provision for GAO to provide quarterly reports on improper payments. In this 10th quarterly report, GAO describes how CMS develops the improper payment estimate for Medicaid managed care and its other oversight efforts to identify program integrity risks related to managed care. GAO reviewed relevant federal statutes and regulations, as well as documentation of CMS’s methodology for the improper payment estimate. In addition, GAO reviewed reports by the HHS-OIG and state auditors in five states selected for variation in geographic location and size of the Medicaid managed care population. GAO also interviewed officials from CMS, the HHS-OIG, and an organization that represents state auditors.

What GAO Found Crisis line data show it had about 3.8 million customer interactions from fiscal year 2021 through 2024, with the number increasing each year. GAO found the crisis line faces challenges in several areas: Customers with complex needs. The crisis line provides specialized training to responders in a unit that addresses complex callers. However, these callers are increasingly being routed to responders who may not have received the training, raising service quality and staffing concerns that could put customers at risk. Chat and text. Procedures for staff in this unit—such as responding to more than one customer at once—as well as how the unit is staffed may have adverse effects. These include increased responder burnout, which could also put customers at risk. Chat routing process. The chat platform did not automatically change the status of responders who were not available to respond timely to a chat (e.g., responders who were on a break or experiencing internet outages). As a result, chat customers could be redirected between two unavailable responders, or the chats could be abandoned. Further, in July 2024, the Department of Veterans Affairs (VA) determined that, as a non-clinical service, the procedure the crisis line used to disclose incidents to customers or their representatives in cases when actions or inactions created a significant risk of harm to the customer was not applicable. The crisis line withdrew the procedure and a new one has not been established. This runs counter to VA's goal of building trust with stakeholders through transparency and accountability. Why GAO Did This Study An average of 17.6 U.S. veterans died by suicide per day in 2022—the most recent data available. Preventing suicide is a top stated priority of the VA. VA runs the Veterans Crisis Line: a 24/7 phone, chat, and text service, staffed by crisis responders who support veterans and their family and friends (i.e., customers). This testimony is based on GAO's report publicly released today on the Veterans Crisis Line (GAO-25-107182). In preparing that report, GAO obtained, reviewed, and analyzed crisis line documents as well as data from fiscal years 2021 through 2024; interviewed crisis line and VA officials; surveyed all crisis line responders; and conducted interviews with a non-generalizable sample of eight responders.

Why This Matters An average of 17.6 U.S. veterans died by suicide per day in 2022—the most recent data available. This was more than double the rate for nonveterans. Preventing suicide is a top stated priority of the Department of Veterans Affairs (VA). VA runs the Veterans Crisis Line: a 24/7 phone, chat, and text service, staffed by crisis responders who support veterans and their family and friends (i.e., customers). GAO Key Takeaways Crisis line data show it had about 3.8 million customer interactions from fiscal year 2021 through 2024, with the number increasing each year (see figure). We found the crisis line faces challenges: Customers with complex needs. The crisis line provides specialized training to responders in a unit that addresses complex callers. However, these callers are increasingly being routed to responders who may not have received the training, raising service quality and staffing concerns that could put customers at risk. Chat and text. Procedures for staff in this unit—such as responding to more than one customer at once—as well as how the unit is staffed may have adverse effects, including increased customer wait times and responder burnout, which could also put customers at risk. Further, in July 2024, VA determined that, as a non-clinical service, the procedure the crisis line was using to disclose incidents to customers or their representatives in cases when actions or inactions created a significant risk of harm to the customer was not applicable. The crisis line withdrew the procedure and a new one has not been established. This runs counter to VA’s goal of building trust with stakeholders through transparency and accountability. Number of Veterans Crisis Line Customer Interactions, Fiscal Years 2021-2024 How GAO Did This Study We obtained, reviewed, and analyzed crisis line documents as well as data from fiscal years 2021 through 2024; interviewed crisis line officials; surveyed all crisis line responders and conducted interviews with a non-generalizable sample of eight responders.

What GAO Found Spacecraft and space systems are operating in a cyber threat environment with increased risks of attack and mission disruption. To help protect systems at federal agencies such as National Aeronautics and Space Administration (NASA), the National Institute of Standards and Technology developed cybersecurity risk management guidelines. The guidelines include seven key risk management steps: prepare , categorize systems, select controls, implement controls, assess control implementation, authorize the system, and continuously monitor security control effectiveness. NASA fully or partially implemented all steps of its cybersecurity risk management program for selected systems. However, partial determinations indicate that NASA did not perform key activities within the steps. For example: For the prepare step, NASA did not have an approved organization-wide risk assessment. Such an assessment is essential to identifying and mitigating the highest priority cyber threats across the enterprise. Regarding the monitor step, selected systems did not document system-level continuous monitoring strategies due in large part to the lack of guidance on how to do so. Without documented strategies that are fully understood by key cyber personnel, organizations face increased risks of data breaches, delayed detection of threats, and slower responses to attacks. The following table summarizes the extent to which NASA implemented each risk management step for the four selected systems. Extent to Which National Aeronautics and Space Administration (NASA) and Selected Systems Implemented Risk Management Steps Risk management step Implementation by NASA organization Preparea ◐   Implementation across selected systems Categorize ◐ Select ◐ Implement ● Assess ◐ Authorize ◐ Monitor ◐ Legend: ●—implemented; ◐—partially implemented; ○—not implemented Source: GAO analysis of NASA documentation. | GAO-25-108138 aFor the review of the Prepare step, GAO evaluated the organizational-level activities and not the system-level activities. Developing, implementing, and maintaining a comprehensive cybersecurity risk management program is critical to protecting NASA's systems and information, detecting suspicious activity, and responding to incidents. Without a strong risk management program covering the selected systems, NASA faces increased risks that cyber incidents could result in loss of mission data, or decreased lifespan or capability of space systems. Why GAO Did This Study NASA's space development project portfolio includes 36 major projects. Over the lifecycle of these projects, NASA plans to invest about $80 billion in them. GAO was asked to review cybersecurity risk management at NASA. This report assesses the extent to which NASA implemented cybersecurity risk management for selected major projects. GAO reviewed NASA policies and guidance regarding cybersecurity risk management. GAO selected a nongeneralizable sample of two major projects and two associated systems for each project. For the four selected systems, GAO analyzed system authorization documentation and compared it to seven key cybersecurity risk management steps and associated activities. GAO also interviewed project and cybersecurity officials. This report is a public version of a sensitive report issued in March 2025. Information that NASA deemed sensitive has been omitted.

Why This Matters Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment requirements provide a range of preventive and medically necessary health care services to eligible children. Services include well-child screenings to identify potential medical issues, and treatment to improve or maintain the child’s health. The Centers for Medicare & Medicaid Services (CMS) oversees states’ provision of Medicaid. GAO Key Takeaways State Medicaid programs often contract with managed care plans to deliver health care services, including well-child screenings and treatment. In fiscal year 2022, the most recent data available, about 85 percent of the 33 million children covered by Medicaid were enrolled in managed care plans. Three states we reviewed had programs that withheld a small portion of managed care plans’ funding. The funding was then used to reward plans that improved performance on well-child screening and treatment quality measures. Medicaid officials in Ohio and Washington said their programs were effective tools to encourage plans to improve performance, such as the extent to which eligible children receive well-child screenings. Results from North Carolina are not yet available, but officials said they may add more quality measures. Selected managed care plans developed incentives for children, their caregivers, and providers to improve the extent to which children receive screenings and treatment. For example, Rhode Island offered children a teddy bear for completing a blood lead screening. Some plans offered providers support with coordinating care. Also, some plans increased payment rates for certain services to encourage improved access to screenings, including behavioral health screenings. Example of a Medicaid Periodic Well-Child Screening and Identification for Treatment How GAO Did This Study We reviewed documentation and interviewed Medicaid officials from a non-generalizable sample of four states with large child Medicaid managed care populations. We also reviewed CMS guidance, and interviewed CMS, two managed care plans per state, and seven stakeholder organizations, including those representing children. For more information, contact Michelle B. Rosenberg at rosenbergm@gao.gov.

What GAO Found The U.S. Coast Guard faces increasing challenges operating and maintaining its fleet of 241 cutters—vessels 65 feet or greater in length with accommodations for crew to live on board. Since fiscal year 2019, the cutter fleet's availability to conduct missions generally declined due, in part, to increasing equipment failures. Across the cutter fleet, the number of instances of serious cutter maintenance issues increased by 21 percent from 3,134 in fiscal year 2018 to 3,782 in fiscal year 2023. As a result, more cutters are operating in a degraded state and at an increased risk of further maintenance issues. Coast Guard Cutter Penobscot Bay at a Major Repair Facility in Baltimore, Maryland Two maintenance challenges that are particularly impactful are increasing deferred maintenance and delays in obtaining obsolete parts. In fiscal year 2024, the Coast Guard deferred $179 million in cutter maintenance, almost nine times the amount deferred in 2019 (based on inflation-adjusted values). Due to delays in receiving critical parts needed for repairs, the Coast Guard cannibalizes cutters by moving working parts between cutters. The Coast Guard lacks complete information to address the impacts of these challenges. Systematically collecting data on, and assessing, deferred maintenance and parts obsolescence could enable the Coast Guard to better prioritize projects and funding. The Coast Guard has not fully addressed the impacts of personnel shortages that are a major challenge to operating and maintaining the cutter fleet. Cutter crew and support positions are short staffed, with vacancy rates increasing from about 5 percent in fiscal year 2017 to about 13 percent in fiscal year 2024. Cutter personnel workload has increased to meet mission demands and cutters often deploy without a full crew, which the Coast Guard does not account for in its staffing data. Regularly collecting and assessing data on staff availability could help ensure the Coast Guard is fully considering the workload faced by cutter crews and support personnel when making decisions on personnel assignments. Why GAO Did This Study The Coast Guard, a multi-mission military service within the Department of Homeland Security (DHS), is responsible for ensuring the safety, security, and stewardship of more than 100,000 miles of U.S. coastline and inland waterways. It relies heavily on its cutter fleet to meet these mission demands. In 2012, GAO reported that the Coast Guard's legacy cutters were approaching, or had exceeded, their expected service lives and that their physical condition was generally poor. GAO was asked to review how the cutter fleet has changed since 2012. This report examines, among other things, the Coast Guard's (1) challenges in operating and maintaining its cutter fleet, and (2) the extent it has determined its cutter-related workforce needs. GAO analyzed available Coast Guard documentation and data for the period 2012-2024 on types of cutters, cutter availability, and cutter usage time. GAO also conducted site visits to observe facility operations and interviewed Coast Guard officials, including maintenance officials and cutter crews representing a mix of cutter types and geographic locations.