prompt_front: You are given two reports by the government agency.



Question: Write a one-page summary of the report 1.

Report 1: According to Education, 50 3 million students were enrolled in more than 98,000 public elementary and secondary schools nationwide in the 2014- 2015 school year  These individual public schools are overseen by approximately 16,000 local educational agencies (referred to in this report as school districts) which are, in turn, overseen and supported by state educational agencies  School districts can range in size from one school (for example, in rural areas) to hundreds of schools in large urban and suburban areas  For example, the 100 largest districts in the United States together have approximately 16,000 schools and enroll about 11 million students  In addition, charter schools are public schools created to achieve a number of goals, such as encouraging innovation in public education  Oversight of charter schools can vary, with some states establishing charter schools as their own school district and other states allowing charter schools to be either a distinct school district in themselves or part of a larger district  Charter schools are often responsible for their own facilities; these may be located in non-traditional school buildings, and may lease part or all of their space  Typically, state educational agencies are responsible for administering state and federal education laws, disbursing state and federal funds, and providing guidance to school districts and schools across the state  State educational agencies frequently provide funds for capital improvements to school facilities, which school districts may use to address issues related to lead in school drinking water, among other things  Different state agencies, including agencies for education, health, and environmental protection, may provide school districts with guidance on testing and remediation of lead in school drinking water  Within a school district, responsibility for water management may be held by individuals in different positions, such as facilities managers or environmental specialists  Lead is a neurotoxin that can accumulate in the body over time with long- lasting effects, particularly for children  According to the CDC, lead in drinking water can cause health effects if it enters the bloodstream and causes an elevated blood lead level  Lead in a child’s body can slow down growth and development, damage hearing and speech, and lead to learning disabilities  For adults, lead can have detrimental effects on cardiovascular, renal, and reproductive systems and can prompt memory loss  In pregnant women, lead stored in bones (due to lead exposure prior to and during pregnancy) can be released as maternal calcium used to form the bones of the fetus, reduce fetal growth, and increase risk of miscarriage and stillbirth  The presence of lead in the bloodstream can disappear relatively quickly, but bones can retain the toxin for decades  Lead in bones may be released into the blood, re-exposing organ systems long after the original exposure  The concentration of lead, total amount consumed, and duration of exposure influence the severity of health effects  The health consequences of lead exposure can differ from person to person and are affected by the cumulative dose of lead and the vulnerability of the individual person regardless of whether the lead exposure is from food, water, soil, dust, or air  Although there are medical therapies to remove lead from the body, they cannot undo the damage it has already caused  For these reasons, EPA, CDC, and others recommend the prevention of lead exposure to the extent possible, recognizing that lead is widespread in the environment  The SDWA authorizes EPA to set standards for drinking water contaminants in public water systems  For a given contaminant the act requires EPA to first establish a maximum contaminant level goal, which is the level at which no known or anticipated adverse effects on the health of persons occur and which allows an adequate margin of safety  EPA must then set an enforceable maximum contaminant level as close to the maximum contaminant level goal as is feasible, or require water systems to use a treatment technique to prevent known or anticipated adverse effects on the health of persons to the extent feasible  Feasible means the level is achievable using the best available technology or treatment technique  In 1991 EPA issued the LCR, which it revised in 2000 and 2007, establishing regulations for water systems covered by the SDWA  Lead concentration in water is typically measured in micrograms of lead per liter of water (also referred to as “parts per billion” or ppb)  The rule established a maximum contaminant level goal of zero, because EPA concluded that there was no established safe level of lead exposure  EPA decided not to establish an enforceable maximum contaminant level, concluding that any level reasonably close to the goal would result in widespread noncompliance, and therefore was not feasible  Instead, the rule established an “action level” of 15 micrograms of lead per liter (15 ppb) in a one liter sample of tap water, a level that EPA believed was generally representative of what could be feasibly achieved at the tap  The action level is a screening tool for determining when certain follow-up actions are needed, which may include corrosion control treatment, public education, and lead service line replacement  Sample results that exceed the lead action level do not by themselves constitute violations of the rule  If the lead action level is exceeded in more than 10 percent of tap water samples collected during any monitoring period (that is, if the 90th percentile level is greater than the action level), a water system must take actions to reduce exposure  Several amendments to the SDWA are relevant to testing for lead in school drinking water  In 1988, the SDWA was amended by the Lead Contamination Control Act (LCCA), which banned the manufacture and sale of drinking water coolers with lead-lined tanks containing more than 8 percent lead; the statute defined a drinking water cooler as containing 8 percent lead or less as “lead-free ” The LCCA also required states to establish testing and remediation programs for schools  However, in 1996 a federal circuit court held that this requirement was unconstitutional  In 2011, Congress passed the Reduction of Lead in Drinking Water Act, which amended the SDWA by lowering the maximum allowable lead content in “lead-free” plumbing materials such as pipes  This provision became effective on January 4, 2014  In 2016, Congress passed the Water Infrastructure Improvements for the Nation Act which, among other things, amended the SDWA, to establish a grant program for states to assist school districts in voluntary testing for lead contamination in drinking water at schools  As a condition of receiving funds, school districts are required to test for lead using standards that are at least as stringent as those in federal guidance for schools  In March 2018, Congress appropriated $20 million to EPA for this grant program  Lead can enter drinking water when service lines or plumbing fixtures that contain lead corrode, especially where the water has high acidity or low mineral content  According to EPA, lead typically enters school drinking water as a result of interaction with lead-containing plumbing materials and fixtures within the building  Although lead pipes and lead solder were not commonly used after 1986, water fountains and other fixtures were allowed to have up to 8 percent lead until 2014, as previously mentioned  Consequently, both older and newer school buildings can have lead in drinking water  Some water in a school building is not for consumption, such as water from a janitorial sink or garden hose, so lead in these water sources presents less risk to students  (See fig  1 ) The best way to know if a school’s water is contaminated with lead is to test the water after it has gone through a school’s pipes, faucets, and other fixtures  To facilitate testing efforts, EPA suggests that schools implement programs for reducing lead in drinking water and developed the 3Ts for Reducing Lead in Drinking Water in Schools: Revised Technical Guidance (3Ts guidance) in 2006, which provides information on: (1) training school officials about the potential causes and health effects of lead in drinking water; (2) testing drinking water in schools to identify potential problems and take corrective actions as necessary; and (3) telling students, parents, staff, and the larger community about monitoring programs, potential risks, the results of testing, and remediation actions  The purpose of the 3Ts guidance is to help schools minimize students’ and staffs’ exposure to lead in drinking water  The guidance provides recommendations and suggestions for how to address lead in school drinking water, but does not establish requirements for schools to follow  According to the guidance, if school districts follow the procedures described in guidance, they will be assured their facilities do not have elevated levels of lead in their drinking water  The guidance recommends taking 250 milliliter samples of water from every drinking water source in a school building and having the samples analyzed by an accredited laboratory  Based on the test results of the samples, the guidance recommends remedial action if the samples are found to have an elevated concentration of lead, which is identified by using an action level  While school districts may have discretion to set their own action level, the 3Ts guidance strongly recommends taking remedial action if a school district finds lead at or above 20 ppb in a 250 milliliter sample of water  School districts can take a variety of actions including replacing pipes, replacing fixtures, running water through the system before consumption (known as flushing), or providing bottled water  However, since the amount of lead in school drinking water may change over time for a variety of reasons—for example, the natural aging of plumbing materials or a disturbance nearby, such as construction—the results obtained by one test are not necessarily indicative of results which may be obtained in the future  With no federal law requiring testing for lead in school drinking water, federal agencies play a limited role: Education’s mission includes fostering educational excellence and promoting student achievement, and the agency disseminates guidance to states and school districts about lead in school drinking water, but does not administer any related grants  EPA’s Office of Ground Water and Drinking Water provides voluntary guidance to schools on how to test for and remediate lead in school drinking water, as part of EPA’s mission to inform the public about environmental risks  In addition, EPA’s Office of Children’s Health Protection is responsible for working with EPA’s 10 regional offices via their healthy schools coordinators, who communicate with schools and help to disseminate the 3Ts guidance  CDC administers the School Health Policies and Practices Study, a periodic survey to monitor national health objectives that pertain to schools and school districts  The 2016 data, the most recent available, provide information on the number of school districts that periodically test for lead in their drinking water  Under the 2005 memorandum signed by these three agencies to encourage lead testing and remediation in schools, Education’s role includes working with EPA and other groups to encourage testing, and disseminating materials to schools  EPA agreed to update guidance for schools, and provide tools to facilitate testing for lead in school drinking water  CDC’s role includes identifying public health organizations to work with and facilitating dissemination of materials to state health organizations  Lead in School Drinking Water Survey Results at a Glance An estimated 43 percent of school districts tested for lead in school drinking water, but 41 percent did not, and 16 percent did not know  o Some districts tested drinking water in all sources of consumable water in all of their schools, while other school districts tested only some sources  o Among the reasons for not testing, school districts said they either did not identify a need to test or were not required to do so  Of those that tested, an estimated 37 percent of school districts found elevated lead levels—levels of lead above the district’s threshold for taking remedial action—in school drinking water  o School districts varied in terms of the threshold they used, with some using 15 ppb or 20 ppb and others using a lower threshold  School districts varied in whether they tested for lead in school drinking water and whether they discovered elevated levels of lead  For example, an estimated 88 percent of the largest 100 school districts tested compared with 42 percent of other school districts  All school districts that found elevated lead reported taking steps to reduce or eliminate the lead, including replacing water fountains or providing bottled water  Nationwide, school districts vary in terms of whether they have tested for lead in school drinking water, with many not testing  According to our survey of school districts, an estimated 43 percent tested for lead in school drinking water in at least one school in the last 12 months, while 41 percent had not tested  An estimated 35 million students were enrolled in districts that tested as compared with 12 million students in districts that did not test  An estimated 16 percent of school districts, enrolling about 6 million students, reported that they did not know whether they had tested or not  (See fig  2 ) Of school districts that tested for lead in school drinking water, some tested all consumable water sources in all of their schools, while others may have only tested some sources in all schools or all sources in some schools  Among the reasons provided by survey respondents for not testing in all schools, some said the age of the building was the primary consideration  For example, an official in one school district we visited told us they began testing in buildings constructed before 1989, but after receiving results that some water sources had elevated lead levels, the district decided to test all of their school buildings  Other reasons reported for testing some, but not all, schools included testing schools only when a complaint about discolored water was received or testing only new schools or schools that were renovated  In addition, school districts varied in whether they sampled from every consumable water source, or just some of the sources, in their schools  For example, one district official told us they took one sample from each type of water fountain in each school, assuming that, if a sampled fountain was found to have an elevated level of lead, then all of the other fountains of that type would also have elevated lead levels  However, EPA’s 3Ts guidance recommends that every water source that is regularly used for drinking or cooking be sampled  Further, stakeholders and environmental and educational officials we interviewed said that results from one water fountain, faucet, or any other consumable water source cannot be used to predict whether lead will be found in other sources  In our survey, the median amount spent by school districts to test for lead in school drinking water during the past 12 months varied substantially, depending on the number of schools in which tests were conducted (see table 1)  School districts may have paid for services such as collecting water samples, analyzing and reporting results, and consultants  For example, an official in a small, rural school district—with three schools housed in one building—told us his district spent $180 to test all eight fixtures  In contrast, officials in a large, urban school district told us they spent about $2 1 million to test over 11,000 fixtures in over 500 schools  Some school districts, especially larger ones, incurred costs to hire consultants to advise them and help design a plan to take samples, among other things  EPA’s 3Ts guidance recommends determining how to communicate information about lead testing programs with parents, governing officials, and other stakeholders before testing  Of school districts that reported testing for lead in school drinking water in our survey, an estimated 76 percent informed their local school board and 59 percent informed parents about their plans to test; similar percentages provided information about the testing results  We identified a range of approaches to communicating testing efforts in the 17 school districts we interviewed  Some school districts reported issuing press releases, putting letters in multiple languages in students’ backpacks, sending emails to parents, holding public meetings, and releasing information through social media  Before testing, one district created a website with a list of dates when it planned to test the drinking water in every one of its schools  In contrast, other school districts communicated with parents and the press only upon request  Officials in one district we visited said they did not post lead testing results on their website, because they wanted to avoid causing undue concern, adding that “more information isn’t necessarily better, especially when tests showed just trace amounts of lead ” School districts generally have discretion to determine how frequently they test for lead in school drinking water except when prescribed in state law, and most school districts responding to our survey had no specific schedule for recurring testing  Specifically, an estimated: 27 percent of school districts plan to test “as needed,” 25 percent have no schedule to conduct recurring tests, and 15 percent do not know  The remaining school districts reported a range of frequencies for conducting additional tests or said they were developing a schedule to conduct tests on a recurring basis  School district officials and stakeholders we interviewed told us that it is important to test for lead in drinking water on a recurring basis, because lead can leach into school drinking water at any time  In our survey, we asked school districts reporting that they had not tested for lead in school drinking water in the last 12 months (41 percent of districts) to provide us with one or more reasons why they had not tested  Of these school districts, an estimated 53 percent reported that they did not identify a need to test and 53 percent reported they were not required to test (see fig  3)  Of school districts that reported testing for lead in school drinking water, an estimated 37 percent of districts found elevated levels of lead in school drinking water, while 57 percent of districts did not find lead (see fig  4)  Of those that found lead in drinking water, most found lead above their selected action level in some of their schools, while some districts found lead above their action level in all of their schools  For example, officials in one large school district told us they tested over 10,000 sources of water, including drinking fountains and food preparation fixtures, and found that over 3,600 water sources had lead at or above the district’s action level of 15 parts per billion (ppb)  The findings resulted in extensive remediation efforts, officials said  Further, district officials reported different action levels they used to determine when to take steps such as replacing a water fountain or installing a filter  School districts generally may select their own action level, resulting in different action levels between districts  Of school districts that reported testing for lead in school drinking water, an estimated 44 percent set an action level between 15 ppb and 19 ppb  The action levels chosen by the rest of the school districts ranged from a low of 1 ppb whereby action would be taken if any lead at all was detected to a high 20 ppb where action would be taken if lead was found at or above 20 ppb  (See appendix II for the estimated percentage of school districts that set other action levels ) Though fewer than half of school districts reported testing for lead in school drinking water, our analysis of school districts’ survey responses shows that these estimates varied depending on the size and population density of the district as well as its geographic location  For example, among the largest 100 school districts, an estimated 88 percent reported they had tested for lead in school drinking water in at least one school in the last 12 months compared with 42 percent of all other districts nationwide  An estimated 59 percent of the largest 100 school districts that tested discovered elevated levels of lead compared to 36 percent of all other districts that tested (see table 2)  In addition, an estimated 86 percent of school districts in the Northeast region of the United States tested for lead in school drinking water, compared to less than half of school districts in other geographic regions  Similarly, about half of school districts in the Northeast and about 8 percent in the South found elevated levels of lead, compared to their selected action level  (See fig  5 ) In our survey, every school district that reported finding lead in school drinking water above their selected action level reported taking steps to reduce or eliminate the lead  For example, an estimated 71 percent said they replaced water fountains, 63 percent took water fountains out of service without replacing them, and 62 percent flushed the school’s water system (see fig  6)  School districts officials we interviewed told us they took a range of remedial actions generally consistent with those reported to us in our survey  For example, an official in one district told us that 129 of the 608 fixtures tested above the district’s action level of “any detectable level ” He said they installed filters on all of the 106 sink faucets with elevated lead and replaced all of the 23 drinking fountains with elevated lead  The district official explained that they re-tested fixtures after the filters and new fountains were installed, and did not detect any lead in their drinking water  Officials in another school district told us that approximately 3,600 of their fixtures were found to have lead above their action level of 15 ppb  They told us the district turned off the water at the affected fixtures as an interim measure and provided bottled water to students and staff  Though they had not yet finalized their plans at the time of our interview, they said they were planning to replace the fixtures and replace old pipes with new pipes  District officials said they plan to pay for their remediation efforts using local capital improvement funds from a recently-approved bond initiative  Similar to the cost of testing, the median amount spent by school districts to remediate lead in school drinking water during the past 12 months varied substantially, depending on the number of schools in which a district took action to remediate lead (see table 3)  The median expenditure for school districts taking action in one to four schools was $4,000 compared to a median expenditure for school districts taking action in 51 or more schools of $278,000  EPA regional officials provided examples of eight states that have requirements for schools to test for lead in drinking water as of September 2017: California, Illinois, Maryland, Minnesota, New Jersey, New York, Virginia, and the District of Columbia  State requirements differ in terms of which schools are included, testing protocols, communicating results, and funding  (See fig  7 ) (For a list of testing components for the eight states, see appendix IV ) According to stakeholders we interviewed, most state legislation on testing for lead in school drinking water has been introduced in the past 2 years  Of the eight states, three states have completed one round of required testing, while other states are in the early stages of implementation or have not yet begun, according to state officials  School districts in Illinois, New Jersey, and New York completed a round of testing for lead in school drinking water by December 2017  Testing in the District of Columbia was in progress as of April 2018  Minnesota requires school districts to develop a plan to test by July 2018 and California requires that water systems sample all covered public schools in their service area by July 2019  According to state officials, schools in Maryland must test by July 2020  In Virginia, no timeline for testing is indicated in the requirement  In addition, requirements in these eight states vary in terms of covered schools and frequency of testing  For example, in Maryland, all schools, including charter and private schools, are required to test their water for lead by July 2020 and must re-test every 3 years  After regulations were approved in July 2016, New Jersey required testing within a year in all traditional public schools, charter schools, and certain private schools, and re-testing every 6 years, according to state officials  Illinois’ requirement is for public and private elementary schools constructed before 2000 to test their drinking water for lead, and does not mandate re- testing  Seven of the eight states include at least some charter schools in their testing requirements (New York does not)  State testing requirements also differ in terms of action level, sample sizes, and number of samples, according to state documents  States can choose their own lead threshold or action level for remediation, and the eight states have chosen levels ranging from any detectable level in Illinois to 20 ppb in Maryland  Six of the eight states have chosen to use 250 milliliter samples of water, while California is using a one liter sample size, and Virginia delegates to school districts to choose their action level and sample size  Some states specify that all drinking water sources in a building must be tested, such as in New York and New Jersey, or allow a smaller number of samples to be tested, such as in California, which recommends that water systems take between one and five samples per school  To implement its testing requirement, the District of Columbia has installed filters in all school drinking water sources, and plans to test the filtered water from each fixture for elevated lead annually  The responsibility for the costs of testing and remediation also differ by state  According to state officials, in Minnesota, the costs of testing may be eligible for reimbursement from the state, and in the District of Columbia, the Department of General Services is responsible for the cost  California requires that public water systems cover the cost of testing for all public schools in their jurisdiction  In all other states we looked at, schools or school districts are at least partially responsible for the costs of testing  Additionally, most schools or school districts are responsible for the costs of remediation, although Minnesota, New York, and the District of Columbia will provide funds to help with the costs of remediation as well  Seven of the eight state requirements have a provision for communicating the results of lead sampling and testing in schools  For example, Minnesota requires all test results be made public and New York requires that results be communicated to students’ families  Maryland and New Jersey require that results above the action level be reported to the responsible state agency, such as the Department of the Environment or the Department of Education, and that sample results that find elevated levels of lead be communicated to students’ families  Illinois requires that all results be made available to families and that individual letters to families also be sent if lead levels over 5 ppb are found  In contrast, Virginia does not include a provision to communicate testing results in its testing requirement for schools  According to stakeholders and state officials we interviewed, states have several other common issues to consider in implementing a state testing and remediation program  First, states need to ensure that their efforts, which can be significant given the thousands of schools that operate in each state, can be completed with limited resources and by a legislated deadline  Second, coordination between relevant state agencies, which will vary by state, may be challenging  Because of the nature of testing for lead in school drinking water, multiple government agencies may be involved, necessitating a balance of responsibilities and information- sharing between these state agencies  Finally, state officials told us that imposing requirements without providing funding to implement them may be a challenge for schools in complying with testing and remediation requirements  Apart from the states with requirements to test for lead in school drinking water discussed in this report, at least 13 additional states had also provided funding or in-kind support to school districts to assist with voluntary lead testing and remediation, according to EPA regional offices  Those states are Arizona, Colorado, Idaho, Indiana, Maine, Massachusetts, Michigan, New Mexico, Ohio, Oregon, Rhode Island, Vermont, and Washington  In Massachusetts, for example, officials told us the state used $2 8 million from the state Clean Water Trust to fund a voluntary program for sampling and testing for all participating public schools in 2016 and 2017  Massachusetts contracted with a state university to assist schools with testing for lead in drinking water  When the program completed its first round of testing in February 2017, 818 schools throughout the state had participated, and the state has begun a second round of sampling with remaining funds from the Clean Water Trust  In Oregon, officials told us the state legislature provided funding for matching grants of up to $8 million to larger school districts for facilities improvements, and made $5 million of emergency funds available to reimburse school districts for laboratory fees associated with drinking water testing as part of the state’s efforts to address student safety  States can also provide technical assistance to support school districts in their efforts to test for and remediate lead in drinking water  The five states we visited provided a range of technical assistance to school districts  For example, to implement the voluntary assistance program in Massachusetts, the contracted university told us they hired 15 additional staff and assisted schools in designing sampling plans, taking samples, and sending them for testing  University officials told us they oversaw the sampling of all drinking water sources in each participating school and sent the sample to state certified laboratories for analysis  State officials encouraged schools to shut off all fixtures in which water tested at or above the action level of 15 ppb and provided guidance on actions to take, such as removing and replacing fixtures, using signage to indicate fixtures not to be used for drinking water, and implementing a flushing program  The state developed an online reporting tool so that all test results could be publicly posted  State officials also supported schools in communicating lead testing results to parents and the community  Other states we visited provided technical assistance to school districts through webinars, guidance documents, in-person presentations, and responding to inquiries  In Oregon, the state Department of Education and the state Health Authority collaborated in 2016 to provide guidance to schools on addressing lead in drinking water  The Governor issued a directive requesting all school districts test for lead in their buildings and the Health Authority requested that districts send them the results  In Texas, officials at the Commission for Environmental Quality have made presentations to schools on water sampling protocols and provided templates for school districts to communicate results  Officials told us that an increased number of school districts have contacted them in the past year seeking guidance, and, in response, they directed districts to EPA’s 3Ts guidance and a list of accredited laboratories  In Illinois, state officials partnered with the state chapter of the American Water Works Association to provide a guidance document for drinking water sampling and testing to assist schools in complying with new testing requirements  In Georgia, officials at the Department of Natural Resources told us they promote the 3Ts guidance on their website and have offered themselves as a resource on school testing at presentations with local water associations  EPA provides several voluntary resources, such as guidance, training, and technical assistance, to states and school districts regarding testing for and remediation of lead in school drinking water, but some school districts we surveyed and officials we interviewed said more information would be helpful  The Lead Contamination Control Act of 1988 (LCCA) required EPA to publish a guidance document and testing protocol to assist schools in their testing and remediation efforts  EPA’s Office of Ground Water and Drinking Water issued its 3Ts guidance which provides information on training school officials, testing drinking water in schools, and telling the school and broader community about these efforts  Of the school districts that reported in our survey using the 3Ts guidance to inform their lead testing efforts, an estimated 68 percent found the guidance extremely or very helpful for conducting tests  The Office of Ground Water and Drinking Water also developed an additional online resource—known as the 3Ts guidance toolkit—to further assist states and school districts with their lead in drinking water prevention programs by providing fact sheets and brochures for community members, among other things  Some states have used the 3Ts guidance as a resource for their state programs, according to EPA officials  For example, a New York regulation directs schools to use the 3Ts guidance as a technical reference when implementing their state- required lead testing and remediation programs  The Office of Ground Water and Drinking Water provides training to support states and school districts with their lead testing and remediation programs  In June 2017, EPA started a quarterly webinar series to highlight school district efforts to test for lead  These webinars include presentations from school officials and key partners that conducted lead testing and remediation  For example, on June 21, 2017, officials from Denver Public Schools and Denver Water presented on their efforts to test for lead in the public school system  EPA’s approach to providing guidance and technical assistance to states and school districts is determined by each of the 10 EPA regional offices  Some EPA regional offices provide the 3Ts guidance to school districts upon request and others conduct outreach to share the guidance, typically through their healthy schools coordinator when discussing other topics, such as indoor air quality and managing chemicals  EPA regional offices also provide technical assistance by request, typically through phone consultations with school districts that have questions regarding the 3Ts guidance, according to EPA headquarters officials  Officials also indicated that the agency has received more requests for technical assistance from schools over the past few years regarding lead in drinking water  Officials in EPA Regions 1 in Boston and 2 in New York City told us they provided technical assistance to school districts by conducting lead testing and analysis in school facilities and Region 9 in San Francisco provided technical assistance by reviewing school district testing protocols  For example, EPA Region 2 officials said between 2002 and 2016 they worked with one to two school districts per year to assist with their lead testing efforts  As part of this effort, the regional office provided funding for sampling and analysis  Officials said they prioritized school districts based on population size and whether the community had elevated blood lead levels  Other EPA regional office approaches included identifying resources and guidance for relevant state agencies and facilitating information sharing by connecting districts that have tested for lead with districts that are interested in doing so  However, most EPA regional offices do not provide technical assistance in the form of testing, analysis, or remediation to school districts, and some do little or no outreach to communicate the importance of testing for and remediating lead in school drinking water  According to federal standards for internal control, management should externally communicate the necessary quality information to achieve the entity’s objectives  Each EPA regional office’s approach to providing resources to states and school districts varies based on differing regional priorities and available resources, according to EPA headquarters officials  Additionally, officials said that this decentralized model of providing support and technical assistance related to lead testing and remediation in schools is appropriate because of the number of schools across the United States  However, based on our survey we found school district familiarity with the 3Ts guidance varied by geographic area (see fig  8)  An estimated 54 percent of school districts in the Northeast reported familiarity with the 3Ts guidance, compared with 17 percent of districts in the South  Furthermore, the Northeast was the only geographic area with more school districts reporting that they were familiar with the 3Ts guidance than not  This awareness corresponds with the efforts made by the state of Massachusetts and EPA’s regional offices in the Northeast to distribute the 3Ts guidance and conduct lead testing and remediation in school districts  By promoting further efforts to communicate the importance of lead testing to schools to help ensure that their lead testing programs are in line with good practices included in the 3Ts guidance, EPA regional offices that have not focused on this issue could leverage the recent efforts of other regional offices to provide technical assistance and guidance, and other forms of support  EPA’s 3Ts guidance emphasizes the importance of taking action to remediate elevated lead in school drinking water, but the agency’s guidance on a recommended action level for states and school districts is not current and contains elements that could be misleading  Although the guidance recommends that school districts prioritize taking action if lead levels from water fountains and other outlets used for consumption exceed 20 ppb (based on a 250 milliliter water sample), EPA officials told us when the guidance was originally developed in response to the 1988 LCCA requirement, the agency did not have information available to recommend an action level specifically designed for schools  Furthermore, EPA officials told us that the action level in the 3Ts guidance is not a health-based standard  However, there are statements in the guidance that appear to suggest otherwise  For example, the guidance states that EPA strongly recommends that all water outlets in all schools that provide water for drinking or cooking meet a “standard” of 20 ppb lead or less and that school officials who follow the steps included in the document, including using a 20 ppb action level, will be “assured” that school facilities do not have elevated lead in the drinking water  The use of the terms “standard” and “assured” are potentially misleading and could suggest that the 20 ppb action level is protective of health  Further, state and school district officials may be familiar with the 15 ppb action level (based on a 1 liter water sample) for public water systems aimed at identifying system-wide problems under the LCR, which may also create confusion around the 20 ppb action level included in the 3Ts guidance  According to our survey, an estimated 67 percent of school districts reported using an action level less than the 20 ppb recommended in the 3Ts guidance  We found that nearly half of school districts used action levels between 15 ppb and 19 ppb  Although these action levels— the 20 ppb from the 3Ts guidance and the 15 ppb from the LCR—are intended for different purposes, the difference creates confusion for some state and school district officials  Also, according to our survey, an estimated 56 percent of school districts reported they would find it helpful to have clearer guidance on what level of lead to use as the action level for deciding to take steps to remediate lead in drinking water  In addition, officials we interviewed in four of the five states we visited said there is a need for clearer guidance on the action level  EPA officials agreed that the difference between the two action levels creates confusion for states and school districts  In addition to wanting clearer guidance on choosing lead action levels, about half of the school districts we surveyed said they would also like additional information to help inform their lead testing and remediation programs  Specifically, school districts reported that they want information on a recommended schedule for lead testing, how to remediate elevated lead levels, and information associated with testing and remediation costs (see fig  9)  For example, an estimated 54 percent of school districts responded that they would like additional information on a testing schedule, as did officials in 10 of the 17 school districts and one of the five states we interviewed  EPA’s 3Ts guidance does not include information to help school districts determine a schedule for retesting their schools  Officials in one school district told us they need information for determining retesting schedules for lead in their school drinking water, and that—without guidance—they chose to retest every 5 years, acknowledging that this decision was made without a clear rationale  Further, an estimated 62 percent of school districts reported wanting additional information on remedial actions to take to address elevated lead  For example, officials from the Massachusetts Department of Environmental Protection told us that they would like additional guidance on evaluating remedial actions to address elevated lead in the fixtures or the plumbing system  Officials with EPA’s Office of Ground Water and Drinking Water hold quarterly meetings with regional officials to obtain input on potential improvements to the 3Ts guidance, but have not made any revisions  EPA has not substantially updated the 3Ts guidance since October 2006 and does not have firm plans or time frames for providing additional information, including on the action level and other key topics such as a recommended schedule for testing  EPA officials said that they may update the 3Ts guidance before the LCR is updated, but did not provide a specific time frame for doing so  EPA has efforts underway to reconsider the action level for the LCR, which may include a change in the action level from one that is based on technical feasibility, to one that also considers lead exposure in vulnerable populations such as infants and young children, which EPA refers to as a health-based benchmark  EPA anticipates issuing comprehensive revisions to the LCR by February 2020  While the 3Ts guidance is not contingent on the LCR, EPA officials told us they would consider updates to the 3Ts guidance, including the 20 ppb action level, as they consider revisions to the LCR  By updating the 3Ts guidance to include an action level for school districts that incorporates available scientific modeling regarding vulnerable population exposures, EPA could have greater assurance that school districts are able to limit children’s exposure to lead  EPA has emphasized the importance of addressing elevated lead levels in school drinking water through its 3Ts guidance, but has not communicated necessary information about action levels and other key topics consistent with the external communication standard under federal standards for internal control  According to EPA, CDC, and others, eliminating sources of lead before exposure can occur is considered the best strategy to protect children from potential adverse health outcomes  EPA officials also told us that clear guidance is important because testing for lead in drinking water requires technical expertise  But without providing interim or updated guidance to help school districts choose an action level for lead remediation EPA will continue to provide schools with confusing information regarding whether to remediate, which may not adequately limit potential lead exposure to students and staff  Furthermore, without important information on key topics, such as a recommended schedule for lead testing, how to remediate elevated lead levels, and information associated with testing and remediation costs school districts are at risk of making misinformed decisions regarding their lead testing and remediation efforts  Education has not played a significant role in supporting state and school districts efforts to test for and remediate lead in school drinking water, and there has been limited collaboration between Education and EPA, according to officials  In 2005, Education, EPA, CDC, and other entities involved with drinking water signed the Memorandum of Understanding on Reducing Lead Levels in Drinking Water in Schools and Child Care Facilities (the memorandum) to encourage and support schools’ efforts to test for lead in drinking water and to support actions to reduce children’s exposure to lead  According to the memorandum, Education’s role is to identify the appropriate school organizations with which to work and facilitate dissemination of materials and tools to schools in collaboration with EPA  In addition, EPA’s role is to update relevant guidance documents for school districts—resulting in the production of the 3Ts guidance in 2006—raising awareness, and collaborating with other federal agencies and associations, among other things  Education officials told us that the agency does not have any ongoing efforts related to implementing the memorandum  However, Education and EPA officials were not aware of the memorandum being terminated by either agency and told us the memorandum remains in effect  Although Education does not have any ongoing efforts related to implementing the memorandum, the agency’s websites, including the Readiness and Emergency Management for Schools Technical Assistance Center (REMS TA Center) website, and the Green Strides portal, provide links to EPA guidance and webinars on lead testing and remediation  The REMS TA Center website, which is largely focused on emergency management planning, includes a link to EPA’s 3Ts guidance and other resources on lead exposure and children, but does not provide information regarding the importance of testing for lead in school drinking water  Education’s Green Strides portal includes a link to a number of EPA’s webinars on lead in school drinking water, but does not include all of the quarterly webinars started in June 2017 to highlight school district efforts to test for lead  An Education official told us that these EPA webinars are identified by Education without coordinating with EPA officials  Further, when searching on Education’s website for lead in school drinking water, the 3Ts guidance does not show up  Education officials acknowledged that information regarding lead testing and remediation is difficult to find on Education’s website and they could take steps to make federal guidance on lead in school drinking water more accessible  The federal government has developed guidelines to help federal agencies improve their experience with customers through websites  One such resource is Guidelines for Improving Digital Services developed by the federal Digital Services Advisory Group  It states that federal agencies should take steps to make guidance easy to find and accessible  Making guidance easy to find and accessible such as by clarifying which links contain guidance; highlighting new or important guidance; improving their websites’ search function; and categorizing guidance on Education’s websites could help raise school district awareness of the guidance, which is currently low in most areas of the country  Many school districts are not familiar with EPA guidance related to lead testing and remediation  Specifically, an estimated 60 percent of school districts reported in our survey that they were not familiar with the EPA’s 3Ts guidance  Most school district officials from our site visits told us they did not have contact with EPA prior to or during their lead testing and some said they would not have thought to go to EPA for guidance  Likewise, EPA officials reported they had received feedback from school district officials indicating that they do not know where to go for information about testing for and remediating lead in drinking water  Rather, school district officials may look to their state educational agency or Education for guidance on lead testing and remediation, as they might do when looking for guidance on other topics  Education and EPA do not regularly collaborate to support state and school districts’ efforts related to lead in school drinking water, according to EPA and Education officials  Education officials said the agency does not have a role in ensuring safe drinking water in schools, and that the mitigation of environmental health concerns in school facilities is a state and local function  Therefore, the agency does not collaborate with EPA to disseminate the 3Ts guidance beyond posting links to related guidance on their websites and newsletters  EPA officials told us they do not know which office they should collaborate with at Education  EPA regional officials also said they do not collaborate with Education to disseminate the guidance to states and school districts  However, in the 2005 memorandum, EPA and Education agreed to work together to encourage school districts to test drinking water for lead; disseminate results to parents, students, staff, and other interested stakeholders; and take appropriate actions to correct elevated lead levels  There are many school districts that have not tested for lead in school drinking water, and some conducted testing without the assistance of federal guidance—although the large majority (68 percent) of school districts who use the guidance reported finding it helpful  Officials in 11 of 17 school districts we interviewed that had conducted lead testing told us they were familiar with the 3Ts guidance and 9 of those districts said they found it helpful for designing their lead testing programs  Increased encouragement and dissemination of EPA resources about lead in school drinking water by Education and EPA could help school districts test for and remediate lead in drinking water using good practices and reduce the potential risk of exposure for students and staff  Children are particularly at risk of experiencing the adverse effects of lead exposure from a variety of sources, including drinking water  While there is no federal law requiring lead testing for drinking water in most schools, some states and school districts have decided to test for lead in the drinking water to help protect students  However, there are a number of school districts that have not tested for lead and some that do not know if they have tested for lead in their drinking water, according to our nationwide survey  Even in states and school districts that have opted to test, officials may choose different action levels to identify elevated lead and may choose different testing protocols that do not test all fixtures in all schools  EPA has developed helpful guidance—3Ts—and webinars for states and school districts to support efforts to test and remediate lead in school drinking water  However, some EPA regional offices have not communicated the importance of testing for and remediating lead to states and school districts  By promoting further efforts to communicate the importance of lead testing to school districts to help ensure that their lead testing programs are in line with good practices, including the 3Ts guidance, regional offices that have not focused on this issue could build on the recent efforts of other regional offices to provide technical assistance and guidance and other forms of support  State and school district officials can use EPA’s 3Ts guidance to help ensure that their drinking water testing and remediation efforts are in line with good practices and said that it has been helpful for establishing their programs  However, statements in the guidance—which has not been updated in over a decade—that suggest the action level described will ensure that school facilities do not have elevated lead in their drinking water are misleading  In addition, state and school district officials told us that additional guidance—including information on a recommended schedule for retesting as well as on costs associated with testing and remediation—could help school districts make more informed decisions regarding their testing and remediation efforts  Without providing interim or updated guidance, EPA is providing schools with confusing and out of date information, which can increase the risk of school districts making uninformed decisions  EPA officials said they would consider updates to the 3Ts action level while the revisions to the LCR are being completed  However, the longer school districts are without the additional information they need to conduct their efforts in line with good practices and continue to rely on confusing and misleading information, the more challenges they will face in trying to limit children’s exposure to lead  After EPA revises the LCR, the agency would have greater assurance that school districts are limiting children’s exposure to lead by considering whether to develop, as part of its guidance, a health-based level for schools that incorporates available scientific modeling regarding vulnerable population exposures  Finally, although Education provides information to states and school districts on lead testing and remediation through the agency’s websites, that information is difficult to find  Further, Education’s website does not include all of EPA’s quarterly webinars to highlight school district efforts to test for lead  By making guidance accessible, Education could improve school district awareness of EPA resources about lead in school drinking water  In addition, EPA and Education should improve their collaboration to encourage and support lead testing and remediation efforts by states and school districts  EPA has the expertise to develop guidance and provide technical assistance to states and school districts, while Education, based on its mission to promote student achievement, should collaborate with EPA to disseminate guidance and raise awareness of lead in drinking water as an issue that could impact student success  Although over one-third of districts that tested found elevated levels of lead, many districts have still not been tested  Unless EPA and Education encourage additional school districts to test for lead, many students and school staff may be at risk of lead exposure  We are making a total of seven recommendations, including five to EPA and two to Education: The Assistant Administrator for Water of EPA’s Office of Water should promote further efforts to communicate the importance of testing for lead in school drinking water to address what has been a varied approach by regional offices  For example, the Assistant Administrator could direct those offices with limited involvement to build on the recent efforts of several regional offices to provide technical assistance and guidance, and other forms of support  (Recommendation 1) The Assistant Administrator for Water of EPA’s Office of Water should provide interim or updated guidance to help schools choose an action level for lead remediation and more clearly explain that the action level currently described in the 3Ts guidance is not a health-based standard  (Recommendation 2) The Assistant Administrator for Water of EPA’s Office of Water should, following the agency’s revisions to the LCR, consider whether to develop a health-based level, to include in its guidance for school districts, that incorporates available scientific modeling regarding vulnerable population exposures and is consistent with the LCR  (Recommendation 3) The Assistant Administrator for Water of EPA’s Office of Water should provide information to states and school districts concerning schedules for testing school drinking water for lead, actions to take if lead is found in the drinking water, and costs of testing and remediation  (Recommendation 4) The Assistant Secretary for Elementary and Secondary Education should improve the usability of Education’s websites to ensure that the states and school districts can more easily find and access federal guidance to address lead in school drinking water, by taking actions such as clarifying which links contain guidance; highlighting new or important guidance; improving their websites’ search function; and categorizing guidance  (Recommendation 5) The Assistant Administrator for Water of EPA’s Office of Water and the Director of the Office of Children’s Health Protection should collaborate with Education to encourage testing for lead in school drinking water  This effort could include further dissemination of EPA guidance related to lead testing and remediation in schools or sending letters to states to encourage testing in all school districts that have not yet done so  (Recommendation 6) The Assistant Secretary for Elementary and Secondary Education should collaborate with EPA to encourage testing for lead in school drinking water  This effort could include disseminating EPA guidance related to lead testing and remediation in schools or sending letters to states to encourage testing in all school districts that have not yet done so  (Recommendation 7) We provided a draft of this report to EPA, Education, and CDC for review and comment  EPA and Education provided written comments that are reproduced in appendixes VII and VIII respectively  EPA also provided technical comments, which we incorporated as appropriate  CDC did not provide comments  We also provided relevant excerpts to selected states and incorporated their technical comments as appropriate  In its written comments, EPA stated that it agreed with our recommendations and noted a number of actions it plans to take to implement them  For example, EPA said its Office of Ground Water and Drinking Water is holding regular meetings with regional offices and other EPA offices to obtain input on improving the 3Ts guidance  Potential revisions include updates to implementation practices, the sampling protocol, and the action level, including clarifying descriptions of different action levels and standards  Also, EPA said that while it has not yet determined the role of a health-based benchmark for lead in drinking water in the revised LCR, it sees value in providing states, drinking water systems, and the public with a greater understanding of the potential health implications for vulnerable populations of specific levels of lead in drinking water  EPA said it would continue to reach out to states and schools to provide information, technical assistance, and training and will continue to make the 3Ts guidance available  EPA also said it would work with Education to ensure that school districts and other stakeholders are aware of additional resources EPA is developing  In its written comments, Education stated that it agreed with our recommendations and noted a number of actions it plans to take to implement them  In response to our recommendation to improve Education’s websites, Education said it would identify and include an information portal dedicated to enhancing the usability of federal resources related to testing for and addressing lead in school drinking water  Also, Education said it is interested in increasing coordination across all levels of government and it shares the view expressed in our report that improved federal coordination, including with EPA, will better enhance collaboration to encourage testing for lead in school drinking water  Education said it would develop a plan for disseminating relevant resources to its key stakeholder groups and explore how best to coordinate with states to disseminate EPA’s guidance on lead testing and remediation to school districts  As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date  At that time, we will send copies to interested congressional committees, the Administrator of the Environmental Protection Agency, the Secretary of Education, the Director of the Centers for Disease Control and Prevention, and other interested parties  In addition, the report will be available at no charge on the GAO website at http://www gao gov  If you or your staff have any questions about this report, please contact us at (617) 788-0580 or nowickij@gao gov or (202) 512-3841 or gomezj@gao gov  Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report  GAO staff who made key contributions to this report are listed in appendix IX  In this report, we examined three objectives: (1) the extent to which school districts are testing for, finding, and remediating lead in school drinking water; (2) the extent to which states require or support testing for and remediating lead in school drinking water by school districts; and (3) the extent to which federal agencies are supporting state and school district efforts to test for and remediate lead  To address these objectives, we conducted a web-based survey of school districts, interviews with selected state and school district officials, a review of applicable requirements in selected states, a review of relevant federal laws and regulations, and interviews with federal agency officials and representatives of stakeholder organizations  We conducted this performance audit from October 2016 through July 2018 in accordance with generally accepted government auditing standards  Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives  We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives  To examine the extent to which school districts are testing for and remediating lead in school drinking water, we designed and administered a generalizable survey of a stratified random sample of U S  local educational agencies (LEA), which we refer to as school districts throughout the report  The survey included questions about school district efforts to test for lead in school drinking water, such as the number of schools in which tests were conducted, the costs of testing, and whether parents or others were notified about the testing efforts  We also asked questions about remediation efforts, such as whether lead was discovered in school drinking water, the specific remediation efforts that were implemented, and whether parents or others were notified about the remediation efforts  Further, we asked about officials’ familiarity with the Environmental Protection Agency’s (EPA) guidance entitled 3Ts for Reducing Lead in Drinking Water in Schools, (3Ts guidance) whether the guidance was used, and the extent to which it was helpful in conducting tests, remediating lead, and communicating with parents and others  We directed the survey to school district superintendents or other cognizant officials, such as facilities directors  See appendix II which includes the survey questions and estimates  We defined our target population to be all school districts in the 50 U S  states and the District of Columbia that are not under the jurisdiction of the Department of Defense or Bureau of Indian Education  We used the LEA Universe database from Department of Education’s (Education) Common Core of Data (CCD) for the 2014-2015 school year to our sampling frame  For the purpose of our survey, our sample was limited to school districts that: were located in the District of Columbia or the 50 states; had a LEA type code of 1, 2, 4, 5, 7, and 8; had one or more schools and one or more students; and were not closed according to the 2014-2015 School Year  The resulting sample frame included 16,452 school districts and we selected a stratified random sample of 549 school districts  We stratified the sampling frame into 13 mutually exclusive strata based on urban classification and poverty classification  We further stratified the school districts classified as being in a city by charter status  We selected the largest 100 school districts with certainty  We determined the minimum sample size needed to achieve precision levels of plus or minus 12 percentage points or fewer, at the 95 percent confidence level  We then increased the sample size within each stratum for an expected response rate of 70 percent  We defined the three urban classifications based on the National Center for Education Statistics (NCES) urban-centric locale code  To build a general measure of the poverty level for each school district we used the proportion of students eligible for free or reduced-price lunch (FRPL) as indicated in the CCD data and classified these into the following three groups: High-poverty – More than 75 percent of students in the school district were eligible for FRPL; Mid-poverty – Between 25 1 and 75 0 percent of students in the school district were eligible for FRPL; and Low-poverty – 25 percent or fewer students in the school district were eligible for FRPL  We assessed the reliability of the CCD data by reviewing existing documentation about the data and performing electronic testing on required data elements and determined they were sufficiently reliable for the purpose of our report  We administered the survey from July to October 2017 (the survey asked school districts to report information based on the 12 months prior to their completing the survey ) To obtain the maximum number of responses to our survey, we sent reminder emails to nonrespondents and contacted nonrespondents over the telephone  We identified that four of the 549 sampled school districts were closed and one was a “cyber-school” with no building, so these were removed from the sample  Of the remaining 544 eligible sampled school districts, we received valid responses from 373, resulting in an unweighted response rate of 68 percent  We conducted an analysis of our survey results to identify potential sources of nonresponse bias using a multivariate logistic regression model  We examined the response propensity of the sampled school districts by several demographic characteristics  These characteristics included poverty, urbanicity, and charter status  We did not find any other population characteristics significantly affected survey response propensity except those used in stratification (charter schools and the largest 100 school districts)  Based on the response bias analysis and the 68 percent response rate across stratum, we determined that estimates based on adjusted weights reflecting the response rate are generalizable to the population of eligible school districts and are sufficiently reliable for the purposes of this report  We took steps to minimize non-sampling errors, including pretesting draft instruments and using a web-based administration system  As we began to develop the survey, we met with officials from seven school districts to explore the feasibility of responding to the survey questions  We then pretested the draft instrument from April to June 2017 with officials in eight school districts—including one charter school district—in cities and suburbs in different states  In the pretests, we asked about the clarity of the questions and the flow and layout of the survey  The EPA also reviewed and provided us comments on a draft version of the survey  Based on feedback from the pretests and EPA’s review, we made revisions to the survey instrument  To further minimize non-sampling errors, we used a web-based survey, which allowed respondents to enter their responses directly into an electronic instrument  Using this method automatically created a record for each respondent and eliminated the errors associated with a manual data entry process  We express the precision of our particular sample’s results as a 95 percent confidence interval (for example, plus or minus 10 percentage points)  This is the interval that would contain the actual population value for 95 percent of the samples we could have drawn  As a result, we are 95 percent confident that each of the confidence intervals in this report will include the true values in the study population  To analyze differences in the percentages of school districts that reported they tested for lead in school drinking water and those that discovered lead, we compared weighted survey estimates generated for school districts in different levels of the following subgroups: Poverty: low poverty, mid poverty, and high poverty; Racial composition: majority-minority and majority white; Region: Northeast, South, Midwest, and West; Population density: urban, suburban, and rural/town; Urban charter school: in urban areas, charter district and non-charter Largest 100: largest 100 districts (based on student enrollment) and all other districts  For each subgroup, we produced percentage estimates and standard errors for each level and used these results to confirm the significance of the differences between weighted survey estimates  To examine school districts’ testing and remediation efforts and state support of those efforts, we conducted site visits in five states—Georgia, Illinois, Massachusetts, Oregon, and Texas—from February to October 2017  We selected these states because they varied in the extent to which they required testing of school drinking water for lead and they are located in geographic areas covered by different EPA regional offices  Within these states, we selected 17 school districts that had tested for lead in school drinking water and to achieve variation in the size and population density (urban, suburban, and rural) of the district as well as including one charter school district  Site visits generally consisted of interviews with officials in state agencies and school districts and officials in the local EPA regional office: State interviews: We interviewed officials in state environment, education, and health agencies, depending on whether they had information related to school district testing for lead in school drinking water in their state  The topics we discussed were the agencies’ roles and responsibilities related to testing for and remediation of lead in school drinking water, any related state requirements, policies, and guidance, communication and public notification about testing and remediation efforts and, as appropriate, coordination among multiple state agencies  We also discussed similar topics related to lead-based paint  In Massachusetts, we interviewed representatives with the University of Massachusetts, because of their role in implementing the state’s program to support school district efforts to test for lead in school drinking water  School Districts: Within the five site visit states, we interviewed officials in 14 school districts in person and in three school districts by phone (because we were not able to meet with them in person)  We also selected one charter school that functions as its own school district which had conducted tests for lead in school drinking water  Similar to our school district survey, the interview topics we discussed with district officials included testing for and remediation of lead in school drinking water, use of guidance (such as the 3Ts guidance) and efforts to communicate or coordinate with any federal, state, or local agencies, including any other school districts  Within 13 of the school districts, we visited at least one school in which the district had tested for lead in drinking water and, as needed, took remedial action in order to gain an in-depth understanding of their testing and remediation efforts  EPA Regional Offices: We interviewed officials in all 10 EPA Regional offices  We met in-person with officials in the regional offices 1, 4, 5, and 6 and conducted phone interviews with officials in regional offices 2, 3, 7, 8, 9, and 10  We generally discussed EPA officials’ roles and responsibilities related to testing for lead in school drinking water and paint and efforts in states and school districts in their region  Information we gathered from these interviews, while not generalizable, represents the conditions present in the states and school districts at the time of our interviews and may be illustrative of efforts in other states and school districts  As part of our effort to examine school districts’ testing and remediation efforts and state support of those efforts, we reviewed related state requirements  To determine whether states had related requirements, we asked all EPA regional offices if states in their region had requirements related to testing for lead in school drinking water  EPA provided examples of eight states (California, Illinois, Maryland, Minnesota, New Jersey, New York, Virginia, and the District of Columbia that had such requirements  We reviewed relevant laws, regulations, and policy documents for these states  We then confirmed the details of the related requirements with the appropriate state officials via structured questionnaires  Also, we used available documentation to corroborate and verify the testing requirements of the states that EPA identified  GAO did not conduct an independent search of state laws  To examine the extent to which federal agencies have collaborated in supporting state and school district efforts to test for and remediate lead, we reviewed relevant federal laws, including the Water Infrastructure Improvements for the Nation Act of 2016, Reduction of Lead in Drinking Water Act of 2011, the Safe Drinking Water Act of 1974, as amended, and the Lead Contamination Control Act of 1988; regulations, such as the Lead and Copper Rule; and guidance, such as the 3Ts guidance  We also reviewed documentation including the Memorandum of Understanding on Reducing Lead Levels in Drinking Water in Schools and Child Care Facilities signed in 2005 by EPA, Education and the Centers for Disease Control and Prevention (CDC); Federal Partners in School Health Charter; EPA training webinar information; and other relevant guidance including the 3Ts guidance tool kit  We interviewed officials from EPA’s Office of Ground Water and Drinking Water and Office of Children’s Health Protection and officials in all 10 of EPA regional offices regarding their approach to providing support to states and school district on lead testing and remediation  We interviewed officials from Education’s Office of Safe and Healthy Students and officials from the CDC  During these interviews, we interviewed officials about the Memorandum of Understanding and about the Federal Partners in School Health initiative, both of which represent collaborative efforts that address lead in school drinking water, among other topics  We evaluated federal efforts to collaborate and support lead testing and remediation in schools against federal standards for internal control, which call for agencies to communicate quality information to external parties, among other things  We also evaluated federal efforts against the Memorandum of Understanding, in which EPA, Education, and CDC agreed to encourage testing drinking water for lead and communicate with key stakeholders, among other things  To inform all of our research objectives, we interviewed representatives with the National Conference of State Legislatures, National Center for Healthy Housing, National Alliance of Public Charter Schools, the DC Public Charter School Board, and the 21st Century School Fund  We also attended a workshop entitled “Eliminating Lead Risks in Schools and Child Care Facilities” in December 2017  The questions we asked in our survey of local educational agencies (referred to in this report as school districts) are shown below  Our survey was comprised of closed- and open-ended questions  In this appendix, we include all survey questions and aggregate results of responses to the closed-ended questions; we do not provide information on responses provided to the open-ended questions  Estimates noted with superscript “a” are based on 20 or fewer responses and were not included in our findings  For a more detailed discussion of our survey methodology, see appendix I  1  Do any schools in your local educational agency (LEA) obtain drinking water from a public water system such as a city or municipal water plant? (Check one ) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) No (Skip to 20) Don’t know (Skip to 20) Section B: Testing for Lead in School Drinking Water 2  Is there a requirement that the drinking water in your LEA’s schools be tested for lead? (Please answer “Yes” regardless of whether that requirement comes from your state, municipality, local educational agency or any other governmental entity ) (Check one ) 95 percent confidence interval – lower bound (percentage) 3  Regardless of whether your LEA is required to test for lead in school drinking water, have tests been conducted for lead in the drinking water in at least one of your schools in the past 12 months? (Check one ) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) If yes to 3: 3A  What is the number of schools in which tests were conducted in the past 12 months? Estimated Number (Mean) 95 percent confidence interval – lower bound (number) 95 percent confidence interval – upper bound (number) (Respondent reported number) 3B  About how many samples were taken from sources of drinking water such as water fountains and sinks in each school? (Check one ) 95 percent confidence interval – lower bound (percentage) 3C  Did any of the following develop the sampling plan, draw the samples of water, and analyze the samples? (Check all that apply ) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) 3D  What size samples were taken? (Check one ) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) If ‘other’ to 3D: What sample size was used? 3E: To the best of your knowledge, did the personnel drawing or analyzing samples follow a testing protocol that offers guidance on developing the sampling plan, drawing samples of water, or analyzing samples? (Check one ) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) No (Skip to 3F) Don’t know (Skip to 3F) If ‘yes’ to 3E: a  To the best of your knowledge, were any of the following entities involved in developing the protocol? (Check one per row ) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) Contractor / water testing company EPA or another federal government agency A local government agency (aside from your LEA) If ‘other’ to 3Eh: What other entities were involved in developing the protocol? 3F  If tests were conducted in some schools in your LEA in the past 12 months—but were not conducted in every school—how was it determined which schools would be tested? (Check one per row ) Not applicable: tests were conducted in every school (Skip to 3G) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) If ‘other’ to 3Fe: In what other ways did your LEA use to determine which schools would be tested? 3G  How much do you estimate your LEA has spent on testing for lead in school drinking water in the past 12 months? (Please answer this question for lead testing only; the survey asks about expenditures to address concerns identified through testing later  Also, please include materials, labor, and any other expenditures related to lead testing in your estimate ) Estimated Number (Median) 95 percent confidence interval – lower bound (number) 95 percent confidence interval – upper bound (number) (Respondent reported number) 3H  Did your LEA use any of the following sources of funding for the testing in the past 12 months? (Check one per row)  95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) If ‘other’ to 3H: What other sources of funding did your LEA use? 3I  In the past 12 months, did your LEA notify the following groups that it was planning to test for lead in school drinking water before conducting the tests? (Check one per row)  95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) General public (e g , media) If ‘other’ to 3I: What other groups did your LEA notify that it was planning to test for lead in school drinking water before conducting the tests? 3J  In the past 12 months, did your LEA report the testing results to the following groups after completing the tests? (Check one per row)  95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) General public (e g , media) If ‘other’ to 3J: To what other groups did your LEA report the testing results? 3K  If ‘no’ to 3: Were any of the following a reason your LEA did not conduct any tests in any schools in the last 12 months? (Check one per row)  95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) If ‘other’ to 3K: For what other reasons did your LEA not conduct any tests in any schools in the last 12 months? 4  Does your LEA have a schedule for recurring tests to determine the amount of lead in the drinking water in your schools within any of the following time frames? (Check one ) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) Section C: Remediation of Lead in School Drinking Water 5  Has your LEA discovered any level of lead in the drinking water of any of your schools (as a result of testing) in the last 12 months? (Check one ) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) 5A  What lead concentration (measured in “parts per billion” or “ppb”) did your LEA use to initiate remedial action? (Check one ) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) If ‘other’ to 5A: What lead concentration did your LEA use to initiate remedial action? 5B  In the last 12 months, how many schools had at least one test result–including as few as one sample in one school–greater than the lead level your LEA used to initiate action? (Please answer regardless of whether these results were discovered in the first of multiple rounds of testing ) 5C To address lead discovered in school drinking water, has your LEA taken any of the following actions in any of your schools in the past 12 months? 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) 5D  If ‘no’ to every item in 5C: What are the reasons why your LEA has not taken actions in any of your schools in the past 12 months? 5E  If ‘yes’ to any item in 5C: How much do you estimate your LEA has spent on taking actions in the past 12 months? (Please include materials, labor, and any other expenditures related to lead remediation in your estimate ) Estimated Number (Median) 95 percent confidence interval – lower bound (number) 95 percent confidence interval – upper bound (number) (Respondent reported number) 5F  Did your LEA use any of the following sources of funding to take actions in the past 12 months? (Check one per row)  95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) If ‘other’ to 5F: What other sources of funding did your LEA use to take actions in the past 12 months? 5G  Did your LEA notify the following groups about its actions in the past 12 months? (Check one per row)  95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) General public (e g , media) If ‘other’ to 5G: What other groups has your LEA notified about its remedial actions in the past 12 months? 6  Does your LEA have a schedule to flush the water system as a result of concerns about lead in drinking water in at least one of your schools within any of the following time frames? (Check one ) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) 7  Does your LEA have plans to take actions to eliminate or reduce lead in school drinking water (for example, replace drinking water fountains, replace pipes) in at least one of your schools? (Check one ) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) If ‘according to a schedule’ to 7: how would you describe the schedule that your LEA has developed? Section D: Guidance Regarding Lead Testing and Remediation 8  Prior to receiving this survey, were you familiar with guidance issued by the U S  Environmental Protection Agency entitled “3Ts for Reducing Lead in Drinking Water in Schools”? (Please answer “Yes” if you had read or used the”3Ts” prior to receiving this survey ) (Check one ) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) If ‘yes’ to 8: did your LEA (or a contractor working on behalf of your LEA) follow or refer to “3Ts” during your efforts to test for or remediate lead in school drinking water? (Check one ) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) If ‘yes’ to 8A: How helpful was 3Ts for conducting tests for lead in your schools’ drinking water? (Check one ) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) If ‘yes’ to 8A: How helpful was 3Ts for remediating lead in your schools’ drinking water? (Check one ) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) If ‘yes’ to 8A: How helpful was 3Ts for communicating with parents and other stakeholders about lead in your schools’ drinking water? (Check one ) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) What else, if anything, would make 3Ts more helpful? 9  Did your LEA (or a contractor working on behalf of your LEA) use any other guidance (for example, best practices, manuals, protocols, webinars) in your LEA’s efforts to test for lead in your schools’ drinking water, take remedial actions, or for notification purposes? (Check one ) 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) What other guidance was used? 10  Would your LEA find any of the following helpful? (Check one per row)  95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) Clearer guidance on a level of lead in school drinking water at which we should take action Additional guidance on determining a schedule for 41 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) regularly testing for lead in school drinking water Additional guidance on actions to take if lead is found in school drinking water Information on the costs of testing for lead in school drinking water Information on the costs of remediating lead in school drinking water 18 95 percent confidence interval – lower bound (percentage) 95 percent confidence interval – upper bound (percentage) If ‘other guidance or information’ to 10: What other guidance or information would be helpful? Section E: Inspecting Schools for Lead Based Paint Section F: Remediation of Lead Based Paint in Schools Section G: Other Questions 16  How many schools are owned or operated by your LEA? Estimated Number (Mean) 95 percent confidence interval – lower bound (number) 95 percent confidence interval – upper bound (number) (Respondent reported number) 17  How many schools in your LEA were built before 1986? (If a building has additions, we mean the original structure/the original part of the building ) Estimated Number (Mean) 95 percent confidence interval – lower bound (number) 95 percent confidence interval – upper bound (number) (Respondent reported number) 18  How many schools in your LEA were built before 1978? (If a building has additions, we mean the original structure/the original part of the building ) Estimated Number (Mean) 95 percent confidence interval – lower bound (number) 95 percent confidence interval – upper bound (number) (Respondent reported number) 19  Is there anything else you would like to share with us regarding lead testing, inspection, or remediation efforts in your school or LEA (drinking water or paint)? 20  What is the name, title, e-mail address, and telephone number of the person responsible for completing this survey? Section H: Completion 21  Please check one of the options below  Clicking on “Completed” indicates that your answers are official and final  Your answers will not be used unless you have done this  (Check one ) 95 percent confidence interval – lower bound (percentage) Charter schools comprise a small but growing group of public schools  In contrast to most traditional public schools, many charter schools are responsible for financing their own buildings and other facilities  As a result, charters schools vary in terms of whether they own their own building or pay rent, and whether they operate in buildings originally designed as a school or in buildings which have been redesigned for educational purposes  Sometimes charter schools may also share space in their building with others, such as non-profit organizations  In addition to differences in facility access and finance, charter school governance also varies  In some states, charter schools function as their own school district, while in other states, charter schools have the option to choose between being a distinct school district or part of a larger school district  To determine the extent to which charter school districts were testing for lead in school drinking water and finding and remediating lead, our survey included charter school districts in two ways: our sampling design included three strata specifically for charter school districts in urban areas; in addition, charter school districts were retained in the sampling population, such that they could be randomly selected in our other strata  While we generally received too few responses from charter school districts to report their data separately, we are able to estimate that about 36 percent of charter school districts tested for lead in school drinking water  To learn more about experiences of charter schools, we visited one charter school district and interviewed representatives of the DC Public Charter School Board (DC PCSB)  The charter school district we visited consisted of one charter school in a building it leased  The school had 10 sources of consumable water, all of which were tested in 2016 and were found to have lead below the district’s selected action level of 15 parts per billion  Before testing, district officials met with the building owner who agreed to cover the cost of any remediation  Officials with the DC PCSB told us that it paid to have tests conducted in every charter school in the District of Columbia  According to DC PCSB officials, between March and June 2016, 95 charter schools were tested, and lead above their action level of 15 parts per billion was discovered in 20 schools  Officials estimated their testing costs to be about $100,000, which was subsequently reimbursed by the District of Columbia’s Office of State Superintendent of Education  They also said that charter schools were responsible for taking steps to remediate the lead and recommended schools flush their water systems and use filters  Communication of results Not specified 5 ppb in a 250 ml sample (from filtered fixture) The Environmental Protection Agency (EPA) provides information on its website for the public on lead in drinking water  EPA’s website includes, among other documents, a December 2005 brochure for the public and school districts entitled “3Ts for Reducing Lead in Drinking Water in Schools” (see fig 10)  In addition to the individuals named above, Diane Raynes (Assistant Director), Scott Spicer (Assistant Director), Jason Palmer (Analyst-in- Charge), Amanda K  Goolden, Rich Johnson, Grant Mallie, Jean McSween, Dae Park, James Rebbe, Sarah M  Sheehan, and Alexandra Squitieri made significant contributions to this report  Also contributing to this report were Susan Aschoff, David Blanding, Mimi Nguyen, Tahra Nichols, Dan C  Royer, Kiki Theodoropoulos, and Kim Yamane  Lead Paint in Housing: HUD Should Strengthen Grant Processes, Compliance Monitoring, and Performance Assessment  GAO-18-394  Washington, D C : June 19, 2018  Drinking Water: Additional Data and Statistical Analysis May Enhance EPA’s Oversight of the Lead and Copper Rule  GAO-17-424  Washington, D C : September 1, 2017  Environmental Health: EPA Has Made Substantial Progress but Could Improve Processes for Considering Children’s Health  GAO-13-254  Washington, D C : August 12, 2013  Lead in Tap Water: CDC Public Health Communications Need Improvement  GAO-11-279  Washington, D C : March 14, 2011  Environmental Health: High-level Strategy and Leadership Needed to Continue Progress toward Protecting Children from Environmental Threats  GAO-10-205  Washington, D C : January 28, 2010  Drinking Water: EPA Should Strengthen Ongoing Efforts to Ensure That Consumers Are Protected from Lead Contamination  GAO-06-148  Washington, D C : January 4, 2006 


Report 2: Health care practitioners prescribe opioid medications to treat pain and sometimes for other health problems, such as severe coughing  Opioid medications are available as immediate or extended release and in different forms, such as a pill, liquid, or a patch worn on the skin  Opioids slow down some processes of the body, such as breathing and heartbeat, by binding with certain receptors in the body  Over time, the body becomes tolerant to opioids, which means that larger doses of opioid medications are needed to achieve the same effect  People may use opioids in a manner other than as prescribed—that is, they can be misused  Because opioids are highly addictive substances, they can pose serious risks when they are misused, which can lead to addiction and death  Symptoms of an opioid use disorder include a strong desire for opioids, the inability to control or reduce use, and continued use despite interference with major obligations or social functioning  Another concern associated with prescribed opioids is the potential for diversion for illegal purposes, such as nonmedical use or financial gain  Research has shown that MAT—which combines behavioral therapy and the use of certain medications (methadone, buprenorphine, and naltrexone)—can be more effective in reducing opioid use and increasing retention (i e , reducing dropouts) compared to abstinence based treatment—that is when patients are treated without medication  Three medications are currently approved by FDA for use in MAT for opioid use disorders—methadone, buprenorphine, and naltrexone  Methadone: Methadone is a full opioid agonist, meaning it binds to and activates opioid receptors to help prevent withdrawal symptoms and reduce drug cravings  It has a long history of use for the treatment of opioid dependence in adults  Methadone suppresses withdrawal symptoms during detoxification therapy, which involves stabilizing patients who are addicted to opioids by withdrawing them in a controlled manner  Methadone also controls the craving for opioids during maintenance therapy, which is ongoing therapy meant to prevent relapse and increase treatment retention  Methadone can be administered to patients as an oral solution or in tablet form  Buprenorphine: Buprenorphine is a partial opioid agonist, meaning it binds to opioid receptors and activates them, but not to the same degree as full opioid agonists  It reduces or eliminates opioid withdrawal symptoms, including drug cravings  It can be used for detoxification treatment and maintenance therapy  It is available for MAT for opioid use disorder in tablet form for sublingual (under the tongue) administration, in film form for sublingual or buccal (inside the cheek) administration, and as a subdermal (under the skin) implant  Naltrexone: Naltrexone is an opioid antagonist, meaning it binds to opioid receptors but does not activate them  It is used for relapse prevention following complete detoxification from opioids  Naltrexone prevents opioid drugs from binding to and activating opioid receptors, thus blocking the euphoria the user would normally feel  It also results in withdrawal symptoms if recent opioid use has occurred  It can be taken daily in an oral tablet form or as a once-monthly injection given in a doctor’s office  Two of the three medications used to treat opioid use disorders— methadone and buprenorphine—are drugs that carry a potential for misuse  Under the Controlled Substances Act (CSA), treatment involving these medications can take place in certain authorized settings: as part of federally regulated OTPs or in other settings, such as a physician’s office, within certain restrictions  OTPs  OTPs provide MAT, including methadone and buprenorphine, for people diagnosed with an opioid use disorder  Methadone may generally only be administered or dispensed within an OTP, as prescriptions for methadone cannot be issued when used for opioid use disorder treatment  Buprenorphine may be administered or dispensed within an OTP, or may also be prescribed by a qualifying practitioner who has received a waiver from SAMHSA  Naltrexone is not a controlled substance and can be used in OTPs and other settings  Office-Based and Other Settings  Under a Drug Addiction Treatment Act of 2000 (DATA 2000) waiver, practitioners may prescribe buprenorphine to up to 30 patients in the first year of their waiver, 100 patients in the second year, and up to 275 patients in the third year  Practitioners at the 275-patient level must meet additional qualifications and requirements  Naltrexone does not have similar restrictions  HHS has implemented five key efforts from 2015 through August 2017 that focus on expanding access to MAT for opioid use disorders  Four of these are grant programs, including programs focused on health centers or primary care practices in rural areas  Targeted Capacity Expansion: Medication Assisted Treatment – Prescription Drug and Opioid Addiction (MAT-PDOA)  This grant program is administered by SAMHSA and provides funding to states to increase their capacity to provide MAT and recovery support services to individuals with opioid use disorders  Grant recipients are expected to identify a minimum of two high-risk communities within the state and partner with local government or community- based organizations to address the MAT-related treatment needs in these communities  Among other things, recipients are to use outreach and other engagement activities to increase participation in and access to MAT for diverse populations at risk for opioid use disorders  In August 2015, SAMHSA awarded 3-year grants to 11 states, under which each of the states will receive up to $1 million in each grant year  In September 2016, SAMHSA awarded 11 additional 3-year grants to other states  Total funding is expected to be up to $66 million for all 22 grants  SAMHSA announced the availability of up to 5 additional 3-year grants for fiscal year 2017  Applications for these grants of up to $2 million per year were due in July 2017 and as of August 2017 they had not been awarded  Substance Abuse Service Expansion Supplement to Health Centers  This grant program is administered by HRSA and provides funds for existing health centers to improve and expand their delivery of substance abuse services, including services with a specific focus on MAT for opioid use disorders in underserved populations  Health centers that receive these grants are required to increase the number of patients with health center-funded access to MAT for opioid use or for other substance abuse disorders treatment by adding at least one full-time substance abuse provider and supporting new or enhanced existing substance abuse services  HRSA awarded 2-year grants in March 2016 to 271 health centers  According to HRSA documents, total funding could be up to $200 million for all grants over 2 years  HRSA announced the availability of another set of grants to health centers for fiscal year 2017  Applications for these grants were due in July 2017, and as of August 2017 they had not been awarded  Increasing Access to Medication-Assisted Treatment in Rural Primary Care Practices  This grant program is administered by AHRQ and funds demonstration research projects that aim to expand access to MAT for opioid use disorders in primary care practices in rural areas of the United States  Grant recipients are expected to recruit and engage primary care providers and their practices, provide training, and support physicians and their practices in initiating treatment  The program also identifies and tests strategies for overcoming the challenges associated with implementing MAT in primary care settings and creates training and other resources for implementing MAT  AHRQ awarded these 3-year grants of up to $1 million per year to four recipients—the recipients are teams of state health departments, academic health centers, local community organizations, physicians, and others—with project start dates of September 30, 2016  According to AHRQ documents, total funding is expected to be up to $12 million for the four grants over 3 years  State Targeted Response to the Opioid Crisis Grants (Opioid STR)  This grant program is administered by SAMHSA and provides funding to states and others to increase access to treatment services for opioid use disorders, including MAT; reduce unmet treatment needs; and reduce opioid overdose deaths  Grant recipients are expected to implement or expand access to evidence-based practices, particularly the use of MAT, and to report on the number of people who receive opioid use disorder treatment, the number of providers implementing MAT, and the number of providers trained to use MAT  SAMHSA awarded 2-year grants starting in May 2017 to 50 states, the District of Columbia, four U S  territories and the free associated states of Micronesia and Palau  According to SAMHSA documents, total funding could be up to $970 million for all grants over 2 years  Figure 1 displays the implementation timeframes, the number of grants, and funding levels for the four HHS grant programs related to MAT  As the figure shows, some of these awards were made in fiscal year 2015, while others were made as recently as May 2017  As of August 2017, these efforts were ongoing  In addition to these four grant programs, HHS’s fifth key effort increases treatment capacity by expanding the waivers that practitioners may receive to prescribe buprenorphine  Specifically, SAMHSA issued a regulation that became effective August 8, 2016 increasing the number of patients that eligible practitioners can treat with buprenorphine outside of an OTP (e g , in an office-based setting)  Previously, qualified practitioners could request approval to treat up to 30 patients at a time, and after 1 year the limit could increase to 100 patients at a time upon SAMHSA approval  The new regulation expanded access to MAT by allowing eligible practitioners who have had waivers to prescribe buprenorphine to 100 patients for at least 1 year to request approval to treat up to 275 patients thereafter  Similarly, SAMHSA has implemented provisions of the Comprehensive Addiction and Recovery Act of 2016 (CARA) that expanded the types of practitioners who can receive a waiver to prescribe buprenorphine in an office-based setting to include qualifying nurse practitioners and physician assistants  CARA generally requires that these nurse practitioners and physician assistants complete 24 hours of training to be eligible for a waiver  According to HHS documents, as of early 2017, nurse practitioners and physician assistants who have completed this training could request a waiver from SAMHSA to treat up to 30 patients at a time  In addition to its five key efforts focused specifically on expanding access to MAT for opioid use disorders, HHS has other efforts with broader focuses, such as treating multiple types of substance abuse  While these efforts are not specifically focused on expanding access to MAT for opioid use disorders, they may result in expanded access to MAT  For example, CMS has approved section 1115 Medicaid demonstration projects to allow states to undertake comprehensive reforms of their delivery of substance abuse services, including provisions to enhance the use of MAT for opioid use disorders  In July 2015, CMS issued a state Medicaid Director letter informing states that they may seek approval of section 1115 demonstrations to undertake comprehensive substance use service reforms  According to CMS, all participating states are using the demonstration authority to develop a full continuum of care for individuals with substance abuse disorders, including coverage of short-term residential treatment services not otherwise covered by Medicaid  In addition, FDA has programs to help expedite development and to provide for faster review of marketing applications for certain drugs  According to FDA, it has conducted expedited reviews of Suboxone (buprenorphine and naloxone sublingual film), Vivitrol (extended release naltrexone injection) and Probuphine (buprenorphine subdermal implant)  According to some federal officials and other stakeholders that we interviewed, as part of efforts to expand access to MAT for opioid use disorder, steps are being taken to prevent the possibility that the MAT medications could, in some cases, be diverted for illicit use, misuse, or for purposes not intended by a prescriber  For example, OTPs and practitioners who request and receive a waiver to prescribe buprenorphine to treat up to 275 patients outside of an OTP setting are required under federal regulations to maintain a diversion control plan  In addition, the MAT-PDOA grant program explicitly requires grant recipients to implement a diversion control plan, though the other grant programs do not have similar additional requirements  (See appendix I for an overview of the diversion control plan requirements for OTPs and the practitioners who prescribe buprenorphine outside of an OTP ) The 2016 Surgeon General’s report on Alcohol, Drugs, and Health noted that decades of research have shown that the benefits of MAT greatly outweigh the risks associated with diversion, and that withholding these medications greatly increases the risk of relapse to illicit opioid use and overdose death  HHS officials told us that as of August 2017, the department is in the process of finalizing its approach for evaluating the implementation of its agencies’ collective efforts to address the opioid epidemic that were undertaken as part of the HHS Opioid Initiative and will continue under the new administration’s Opioid Strategy  HHS officials provided a draft of the evaluation’s schedule  According to the officials, the evaluation will include, but not be limited to, efforts to expand access to MAT  In September 2016, HHS awarded a 2-year contract to Research Triangle Institute International (RTI) to evaluate HHS agencies’ collective efforts  HHS officials told us that they are still working with RTI to finalize the evaluation approach given new leadership priorities  Specifically, in April 2017, the new Secretary of HHS announced a revised strategy for addressing the opioid epidemic that will continue to address access to MAT for opioid use disorders but also include additional priority areas  According to HHS officials, to be responsive to the new priorities, the evaluation will focus initially on whether HHS’s efforts have been implemented as intended, and officials expect the evaluation to also provide information on any challenges HHS has faced in implementing these efforts  According to HHS officials, while the evaluation of MAT expansion efforts will use information from several sources, they have not yet determined exactly which information will be used or how it will be used  This information may include, for example, results from a separate, planned evaluation of one of the grant programs, Opioid STR, as well as other information HHS agencies collect as part of their ongoing monitoring efforts for each of their individual MAT grant programs  While the reporting requirements vary across the four MAT grant programs, the grantees provide HHS with information related to expanding access to MAT  Specifically, Targeted Capacity Expansion: Medication Assisted Treatment – Prescription Drug and Opioid Addiction (MAT-PDOA): Every 6 months, grant recipients are expected to submit progress reports to SAMHSA on the planned and actual number of patients treated, as well as information on other performance measures  Increasing Access to Medication-Assisted Treatment in Rural Primary Care Practices: Grant recipients are expected to submit quarterly progress reports to AHRQ with various information, such as information on the number of physicians who have been certified to prescribe buprenorphine and the number of primary care practices successfully initiating the delivery of MAT services as a result of the grant project  Substance Abuse Service Expansion Supplement to Health Centers: Health centers that received these grants were expected to submit quarterly progress reports to HRSA through the second quarter of 2017 on the number of physicians who have obtained a DATA 2000 waiver and the number of patients who received MAT from these physicians  Health centers must now report these data elements in their annual performance reporting along with information on the number of certified nurse practitioners and physician assistants who have received a DATA 2000 waiver  State Targeted Response to the Opioid Crisis Grants (Opioid STR): Every 6 months, grant recipients are expected to submit progress reports to SAMHSA on the number of individuals who receive opioid use disorder treatment, the number who receive opioid use disorder recovery services, and the number of providers implementing MAT, among other measures  While HHS’s evaluation will focus on whether HHS’s efforts have been implemented as intended, officials told us that in the future an evaluation may also focus on the effectiveness of these efforts, including the effectiveness of efforts to expand access to MAT  Doing so would be consistent with federal standards for internal control, which call for agencies to evaluate results  HHS has some of the information that could be used in a future evaluation of the effectiveness of its efforts to expand access to MAT  In particular, an HHS document describing the department’s fiscal year 2016 – 2017 goals identifies expanding MAT access as an important strategy for the success of HHS’s longer-term goal of reducing opioid use disorders and opioid overdoses  In addition, HHS has identified three potential ways to measure access to MAT: the number of prescriptions for MAT medications, the treatment capacity of practitioners who are authorized to prescribe buprenorphine for opioid use disorders through a DATA 2000 waiver, and the treatment capacity of OTPs certified to administer methadone and other medications

ground_truth: No federal law requires testing of drinking water for lead in schools that receive water from public water systems, although these systems are regulated by the EPA. Lead can leach into water from plumbing materials inside a school. The discovery of toxic levels of lead in water in Flint, Michigan, in 2015 has renewed awareness about the danger lead exposure poses to public health, especially for children. GAO was asked to review school practices for lead testing and remediation. This report examines the extent to which (1) school districts are testing for, finding, and remediating lead in drinking water; (2) states are supporting these efforts; and (3) federal agencies are supporting state and school district efforts. GAO administered a web-based survey to a stratified, random sample of 549 school districts, the results of which are generalizable to all school districts. GAO visited or interviewed officials with 17 school districts with experience in lead testing, spread among 5 states, selected for geographic variation. GAO also interviewed federal and state officials and reviewed relevant laws and documents. An estimated 43 percent of school districts, serving 35 million students, tested for lead in school drinking water in 2016 or 2017, according to GAO's nationwide survey of school districts. An estimated 41 percent of school districts, serving 12 million students, had not tested for lead. GAO's survey showed that, among school districts that did test, an estimated 37 percent found elevated lead (lead at levels above their selected threshold for taking remedial action.) (See figure.) All school districts that found elevated lead in drinking water reported taking steps to reduce or eliminate exposure to lead, including replacing water fountains, installing filters or new fixtures, or providing bottled water. According to the Environmental Protection Agency (EPA), at least 8 states have requirements that schools test for lead in drinking water as of 2017, and at least 13 additional states supported school districts' voluntary efforts with funding or in-kind support for testing and remediation. In addition, the five states GAO visited provided examples of technical assistance to support testing in schools. EPA provides guidance and other resources to states and school districts regarding testing and remediating lead in drinking water, and the Department of Education (Education) provides some of this information on its websites. School district officials that used EPA's written guidance said they generally found it helpful. Although EPA guidance emphasizes the importance of addressing elevated lead levels, GAO found that some aspects of the guidance, such as the threshold for taking remedial action, were potentially misleading and unclear, which can put school districts at risk of making uninformed decisions. In addition, many school districts reported a lack of familiarity with EPA's guidance, and their familiarity varied by region of the country. Education and EPA do not regularly collaborate to support state and school district efforts on lead in drinking water, despite agreeing to do so in a 2005 memorandum of understanding. Such collaboration could encourage testing and ensure that more school districts will have the necessary information to limit student and staff exposure to lead. GAO is making seven recommendations, including that EPA update its guidance on how schools should determine lead levels requiring action and for EPA and Education to collaborate to further disseminate guidance and encourage testing for lead. EPA and Education agreed with the recommendations.

prompt_front: You are given two reports by the government agency.



Question: Write a one-page summary of the report 2.



Report 2:  In addition, HHS has data that could be useful for tracking progress in these areas (see table 1)  However, HHS has not adopted specific performance measures with targets specifying the magnitude of the increases HHS hopes to achieve through its efforts to expand access to MAT, and by when  For example, HHS has not established a long-term target specifying the percentage increase in the number of prescriptions for buprenorphine HHS would like to achieve, which would help to show whether efforts by HHS and others are resulting in sufficient progress in increasing prescriptions for this MAT medication  HHS has also not chosen a specific method of measuring treatment capacity or established targets associated with it, which would help to show whether a sufficient number of providers are becoming available to evaluate and treat patients who may benefit from MAT  Without specifying these performance measures and associated targets, HHS will not have an effective means to determine whether its efforts are helping to expand access to MAT  The lack of such performance measures with associated targets is inconsistent with federal internal control standards that specify that management should define objectives and evaluate results  According to these standards, using performance information such as performance measures can help agencies monitor results and determine progress in meeting program goals  In the context of HHS’s efforts to expand access to MAT, establishing appropriate performance measures with associated targets would allow HHS to determine whether its efforts are making sufficient progress or whether they need to be improved  Gauging this progress is particularly important, given the large nationwide MAT treatment gap identified in 2015 between the total number of individuals who could benefit from MAT and the limited number who can access it based on provider availability  This gap was estimated at nearly 1 million people as of 2012, and according to HHS officials and other stakeholders, lack of providers continues to be a challenge  Until HHS establishes performance measures with associated targets for the factors related to access to MAT, the department will be unable to evaluate its progress expanding access to MAT for opioid use disorders  In addition, as of August 2017, HHS has not finalized its approach for the planned evaluation activities, including timeframes  ASPE officials said that timeframes for a finalized evaluation approach had not been established because they were still working with RTI to finalize the evaluation approach given the new leadership priorities  When we spoke with the officials, they provided us with a draft evaluation schedule that covered the contract period ending September 2018  As of October 2017, HHS had not provided a finalized evaluation approach or schedule  Federal internal controls call for management to establish and operate monitoring activities and evaluate results  Without an implementation timeframe for the evaluation’s activities, HHS increases the risk that its evaluation of its agencies’ efforts will not be completed as expeditiously as possible, including an evaluation of HHS’s efforts to expand access to MAT  Officials from selected state health departments and behavioral health agencies, private health insurers, and national associations reported using several different efforts to help expand patients’ access to MAT for opioid use disorders  All of the stakeholders we interviewed reported conducting outreach efforts to communicate information about the importance of MAT and how to access it, or providing training to educate providers on prescribing MAT medications  Efforts by states  State health officials we spoke to described several planned or ongoing efforts to expand access to MAT, some of which are supported by federal funding, including federal grant programs  Officials from all five selected states told us that they are offering outreach to and training for providers to help expand access to MAT  For example, several state officials told us that they are promoting training to (1) encourage physicians to obtain authorization (DATA 2000 waivers) to prescribe buprenorphine and (2) encourage physicians with waivers to treat patients up to their patient limit or to request a higher patient limit  According to the stakeholders, all five selected states have implemented or are planning to implement a health care delivery model or approach that will expand access to MAT  Specifically, these models or approaches focus on integrating the use of MAT into primary care settings  For example, health officials from three states described use of a hub-and-spoke model  This model generally involves centralized intake and initial management of patients at a “hub” (e g , an OTP) and then connecting these patients to community providers at “spokes” (e g , primary care clinics) for ongoing care, with ongoing support provided by the hub as needed  Additionally, officials from two states described offering remote MAT-related consultations through telehealth that connects patients in rural areas with addiction specialists  According to a 2017 Healthcare Fraud Prevention and Partnership whitepaper, telehealth expands the reach of the addiction professional workforce and the existing pool of MAT providers, and it supports remote forms of behavioral therapy to make trained professionals more accessible to those in underserved or isolated communities  Officials from three states described focusing their MAT expansion efforts in various settings, such as in the criminal justice setting and emergency room departments  State health officials from four of the five states told us that programs in their states are using peer specialists (individuals who have successfully recovered from substance abuse disorders) in emergency rooms and other settings to engage with addicted patients and refer them to addiction specialists or behavioral health counselors  Officials from the selected states said that some of these and other efforts are funded through federal sources, such as MAT expansion grants awarded by SAMHSA, or with state funds to the extent they are available  Efforts by private health insurers  Officials from private health insurers reported that they are expanding access to MAT through outreach or training for providers and through the following three efforts: Eliminating the need for prior authorization to prescribe MAT medications  Officials from three insurers reported removing prior authorization requirements for MAT medications, thereby making it easier for patients to access needed MAT medications more readily, rather than undergoing a waiting period for approval to receive the medications  Other private health insurers told us that they continue to require prior authorization, intended for safety reasons and to reduce drug misuse, and officials from one insurer told us that they will allow a patient to access a limited amount of MAT medications for a period of 24 to 72 hours while making a determination about the appropriate treatment services for the patient  Modifying health benefit coverage  Officials from one private health insurance plan told us that the company is redesigning the benefit coverage for methadone and has removed member copays  This effort is intended to make MAT medications more affordable and allow members who are not able to use buprenorphine to have an alternative, such as methadone, that is not cost-prohibitive  Incentivizing providers and health insurance plan members to use MAT  Officials from four private health insurance plans described plans to offer incentives to providers or patients to use MAT  For example, officials from three health plans stated that they are offering alternative payment models or paying higher rates to providers that offer MAT, and another private health insurer is offering incentives to its members who are enrolled in behavioral health programs that provide access to MAT  Efforts by national associations  Officials we interviewed from the national associations—including the American Society of Addiction Medicine, the National Governors Association, and the Association of State and Territorial Health Officials—told us that they are helping to expand access to MAT through outreach and training for their members and by developing tools and resource guides for their members  An official from one association told us that it shares federal grant announcements, including those that are focused on expanding access to MAT, with its members  Officials from another association said it provides training to providers on how to appropriately prescribe MAT medications  In addition, officials from one association told us that they developed an opioid-related road map that identifies examples of strategies—including MAT—that state policymakers can use in their ongoing efforts to address the opioid epidemic  Examples of strategies include reducing the stigma associated with MAT through educating the public and potential providers  Another strategy in the road map is changing payment policies to expand access to MAT services, such as ensuring that Medicaid and other state health programs adequately cover all MAT medications and behavioral interventions and encouraging or requiring commercial health plans to adopt similar policies  HHS funds grant programs and has taken other steps to expand access to MAT, which has been shown to be effective in reducing the prevalence of opioid use disorders and with them, the likelihood of drug overdoses  HHS’s Opioid Initiative began in 2015, and the grants that support it are ongoing, so it is likely too early to determine how effective HHS’s efforts have been in expanding access to MAT and in meeting HHS’s other priorities related to addressing the opioid epidemic  According to HHS, access to MAT can be measured in terms of the number of prescriptions for MAT and by the treatment capacities of OTPs and practitioners who are authorized to prescribe buprenorphine  Our review suggests, however, that HHS may not be ready to perform this evaluation  While HHS told us that it may evaluate the effectiveness of its efforts in the future, the department has not established performance measures with targets that would specify the results that HHS hopes to achieve through its efforts, and by when  Furthermore, HHS has not established timeframes for the activities that will make up its planned evaluation of whether HHS’s efforts have been implemented as intended  Without performance measures with targets and evaluation timeframes, HHS increases the risk that the evaluation will not be completed in a timely manner or that HHS will not know whether its MAT- related efforts are successful or whether new approaches are needed  The evaluation is particularly important, given the hundreds of millions of dollars HHS has invested in its MAT-related grant programs  We are making the following two recommendations to HHS  The Assistant Secretary for Planning and Evaluation should establish performance measures with targets related to expanding access to MAT for opioid use disorders  (Recommendation 1) The Assistant Secretary for Planning and Evaluation should establish timeframes in its evaluation approach that specify when its evaluation of efforts to expand access to MAT will be implemented and completed  (Recommendation 2) We provided a draft of this report to HHS for review, and HHS provided written comments, which are reprinted in appendix II  HHS also provided technical comments, which we incorporated as appropriate  In its written comments, HHS concurred with both of our recommendations  Specifically, for our first recommendation to establish performance measures with targets related to expanding access to MAT for opioid use disorders, HHS stated that developing such measures is appropriate and that the department will continue to work to develop robust performance measures, including measures related to MAT, as part of its overall Opioid Strategy, which includes the department’s most recent efforts to address the opioid epidemic  For our second recommendation to establish timeframes in its evaluation approach that specify when its evaluation of efforts to expand access to MAT will be implemented and completed, HHS agreed that timeframes are important to any evaluation  HHS noted that its evaluation is being conducted under a 2-year contract that is scheduled to end in September 2018  HHS has also provided us with a draft evaluation schedule  We clarified in our report, however, that HHS has not yet provided a finalized approach for the planned evaluation or a finalized schedule establishing timeframes for the activities that will make up the evaluation  Until it finalizes its evaluation approach and establishes related timeframes, HHS increases the risk that it will not complete its planned evaluation by September 2018  We are sending copies of this report to the HHS, and appropriate congressional committees  In addition, the report will be available at no charge on the GAO website at http://www gao gov  If you or your staff have questions about this report, please contact me at (202) 512-7114 or curdae@gao gov  Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report  Major contributors to this report are listed in appendix III  According to the Department of Health and Human Services, a diversion control plan is a set of documented procedures intended to reduce the possibility that controlled substances will be transferred or used illicitly  Opioid treatment programs (OTPs) and practitioners who prescribe buprenorphine at the highest patient level through a Drug Addiction Treatment Act of 2000 (DATA 2000) waiver are required to have these plans  OTPs are programs that may administer or dispense medication- assisted treatment (MAT) for people diagnosed with an opioid use disorder, including the use of methadone and buprenorphine  In addition, under a DATA 2000 waiver, practitioners may prescribe buprenorphine for patients, up to a 30-, 100-, or 275 patient limit  An OTP must maintain a current diversion control plan that contains specific measures to reduce the possibility of diversion of controlled substances from legitimate treatment use  Per federal guidelines, the goal of the diversion control plan is to reduce the scope and significance of diversion and its impact on communities  The guidelines state that each OTP’s diversion control plan should make every effort to balance diversion control against the therapeutic needs of the individual patient  They also state that diversion control plans should address at least four general areas of concern: program environment, dosing and take-home medication, prevention of multiple program enrollment, and prescription medication misuse  The guidelines include details about each of these areas: Program environment: Diversion in the program environment can be deterred and detected by regular surveillance and the monitoring of areas in and around the program, where opportunities for diversion may exist  A visible human presence at a program’s location gives community members the opportunity to approach staff with concerns and communicates the program’s commitment to assuring a safe environment and a positive impact on the surrounding community  Dosing and take-home medication: In the area of dosing and take- home medication, diversion control encompasses careful control of inventory, attentive patient dosing, and close supervision of take- home medication  Observing a patient take his or her dose and having each of them drink and speak after dosing are fundamental components of diversion control  Take-home dosing should be provided with careful attention to regulatory compliance and the therapeutic benefit and safety these regulations are meant to promote  Prevention of multiple program enrollment: Reasonable measures should be taken to prevent patients from enrolling in treatment provided by more than one clinic or individual practitioner  An OTP, after obtaining patient consent, may contact other OTPs within a reasonable geographic distance (100 miles) to verify that a patient is not enrolled in another OTP  Misuse of prescription medication: The misuse of prescription medication has become an area of great concern nationally and impacts diversion control planning at OTPs  All OTP physicians and other healthcare providers, as permitted, should register to use their respective state’s prescription drug monitoring program (PDMP) and query it for each newly admitted patient prior to initiating dosing  The PDMP should be checked periodically (for example, quarterly) through the course of each individual’s treatment and, in particular, before ordering take-home doses as well as at other important clinical decision points  SAMHSA’s best-practice guidelines for using buprenorphine for treating opioid use disorders include multiple references to diversion, including monitoring for diversion, storage of this medication to minimize diversion, and use of formulations that may be less likely to be diverted  Specifically, the best practices state that, when possible, practitioners should use the combination buprenorphine/naloxone product, which increases safety and decreases the likelihood of diversion and misuse  Further, physicians who request and receive a waiver to prescribe buprenorphine to treat up to 275 patients outside of an OTP are required to have a diversion control plan  According to an HHS official, as of July 13, 2017, roughly 3,330 of the over 39,000 practitioners with a waiver had a 275-patient limit waiver  The majority of these practitioners, just over 27,000, have a 30-patient limit  According to SAMHSA guidance, the diversion plan should contain specific measures to reduce the possibility of diversion of buprenorphine from legitimate treatment use and should assign specific responsibilities of the medical and administrative staff of the practice setting for carrying out these measures  Further, the guidance states that the plan should address how: the environment at the practice setting can prevent onsite diversion; to prevent diversion with regard to dosing and take-home medication; and to prevent patients from receiving a prescription from more than one practitioner and later diverting some of the prescribed medication  Elizabeth H  Curda, Director, (202) 512-7114 or curdae@gao gov  In addition to the contact name above, Will Simerl, Assistant Director; Natalie Herzog, Analyst-in-Charge; La Sherri Bush; and Emily Wilson made key contributions to this report  Also contributing were Muriel Brown, Krister Friday, Sandra George, and Christina Ritchie 
Report 2:  However, as discussed later in this report, Congress has abrogated Watters 's holding that states may not examine or regulate the activities of national bank subsidiaries  While the Court adopted a broad view of preemption in Watters , it cabined the preemptive effect of the relevant NBA provision two years later in Cuomo v  C learing House Association, LLC  In that decision, the Court held that this NBA provision did not preempt an information request that the New York Attorney General (NYAG) sent to several national banks  Specifically, the NYAG had sent letters to several national banks requesting nonpublic information about their lending practices in order to determine whether the banks had violated state fair lending laws  In response, a banking trade group and the OCC argued that the relevant NBA provision—together with an OCC regulation interpreting that provision to mean that "[s]tate officials may not       prosecut[e] enforcement actions" against national banks, "except in limited circumstances authorized by federal law"—preempted the information request  The Supreme Court rejected this interpretation of the NBA's visitorial powers provision, drawing a distinction between (1) "supervision," or "the right to oversee corporate affairs," which qualify as "visitorial powers," and (2) "law enforcement " Because the Court concluded that the NYAG had issued the information requests in his "law enforcement" capacity—as opposed to "acting in the role of sovereign-as-supervisor"—it held that the NBA did not preempt the requests  As the above discussion makes clear, OCC regulations have figured prominently in litigation over the preemptive scope of federal banking law  While some commentators have contended that the NBA's text and legislature history implicitly provides the OCC with the authority to promulgate preemption rules, Congress formally recognized that the OCC has such authority in the Riegle-Neal Interstate Banking and Branching Efficiency Act of 1994 (Riegle-Neal Act)  Specifically, Section 114 of the Riegle-Neal Act provides that "[b]efore issuing any opinion letter or interpretive rule       that concludes that Federal law preempts the application to a national bank of any State law" concerning certain specified subjects, the OCC must give the public notice and an opportunity submit written comments  In the 1990s and early 2000s, the OCC exercised this authority in a number of interpretive letters and legal opinions  In these documents, the OCC took the position that federal law preempted state laws that limited the ability of national banks to: advertise; operate offices within a certain distance from state-chartered bank home offices; operate ATM machines; engage in fiduciary activities; finance automobile purchases; sell annuities; sell repossessed automobiles without an automobile dealer license; and conduct Internet auctions of certificates of deposit  In 2004, the OCC expanded upon these interpretive letters and legal opinions by issuing what one commentator has described as "sweeping" preemption rules  The OCC's 2004 preemption rules articulated a general preemption standard according to which "state laws that obstruct, impair, or condition a national bank's ability to fully exercise" its federally authorized powers "are not applicable to national banks" except "where made applicable by Federal law " This general standard accordingly expanded on Barnett Bank 's "significant interference" test in two ways  First, the OCC's 2004 standard omitted the intensifying phrase "significantly" from the Barnett Bank test  Second, the 2004 standard by its terms required that national banks be able to "fully" exercise their authorized powers—a phrase that does not appear in Barnett Bank   However, despite these facial differences with the Barnett Bank test, the OCC explained that it intended the phrase "obstruct, impair, or condition" to function "as the distillation of the various preemption constructs articulated by the Supreme Court, as recognized in Hines [ v  Davidowitz ] and Barnett Bank , and not as a replacement construct that is in any way inconsistent with those standards " Beyond this general preemption standard, the OCC's 2004 rules concluded that the NBA preempted certain categories of state laws  First, the rules provided that national banks "may make real estate loans       without regard to state law limitations concerning": licensing and registration (except for purposes of service of process); "[t]he ability of a creditor to require or obtain private mortgage insurance, insurance for other collateral, or other credit enhancements or risk mitigants, in furtherance of safe and sound banking practices"; loan-to-value ratios; terms of credit; "[t]he aggregate amount of funds that may be loaned upon the security of real estate"; escrow accounts; security property; access to and use of credit reports; disclosure and advertising; processing, origination, servicing, sale or purchase of, or investment or participation in, mortgages; disbursements and repayments; rates of interest on loans; due-on-sale clauses, with certain exceptions; and "[c]ovenants and restrictions that must be contained in a lease to qualify the leasehold as acceptable security for a real estate loan " Second, the rules provided that national banks "may make non-real estate loans without regard to state law limitations concerning" many of the same matters identified in the regulation concerning real estate lending  Finally, the rules provided that national banks "may exercise [their] deposit-taking powers without regard to state law limitations concerning": (1) abandoned and dormant accounts, (2) checking accounts, (3) disclosure requirements, (3) funds availability, (4) savings account orders of withdrawal, (5) state licensing or registration requirements (except for purposes of service of process), and (6) special purpose savings services  The OCC's 2004 rules also identified general categories of state law that the agency interpreted as surviving preemption  Specifically, the rules provided that the NBA does not preempt state laws that are consistent with federal law and involve (1) contracts, (2) torts, (3) criminal law, (4) rights to collect debts, (5) the acquisition and transfer of property, (5) taxation, (6) zoning, and, with respect to real estate lending, (7) certain homestead laws  According to the OCC's 2004 rules, such laws survive preemption so long as they "do not regulate the manner, content or extent of the activities authorized for national banks under federal law " The OCC's 2004 preemption rules proved controversial  In 2008, the United States experienced a financial crisis caused in part by reckless subprime mortgage lending and a collapse in the real estate market  In the wake of the crisis, commentators debated the role that federal preemption of state predatory lending laws played in generating the pre-2008 housing bubble  Some commentators contended that national banks played a significant role in the predatory lending that preceded the crisis, and that federal preemption "effectively gut[ted] states' ability to legislate against predatory lending practices " By contrast, others rejected the contention that preemption played a significant role in causing the crisis, arguing that national banks and their subsidiaries accounted for only a small share of subprime mortgage lending  In 2010, Congress responded to concerns over federal preemption of state consumer protection laws in Section 1044 of the Dodd-Frank Wall Street Reform and Consumer Protection Act (Dodd-Frank)  Section 1044 provides that federal law preempts such laws only if: (A) application of a State consumer financial law would have a discriminatory effect on national banks, in comparison with the effect of the law on a bank chartered by that State; (B) in accordance with the legal standard for preemption in the decision of the Supreme Court of the United States in [ Barnett Bank ], the State consumer financial law prevents or significantly interferes with the exercise by the national bank of its powers; and any preemption determination under this subparagraph may be made by a court, or by regulation or order of the Comptroller of the Currency on a case-by-case basis, in accordance with applicable law; or (C) the State consumer financial law is preempted by a provision of Federal law other than title 62 of the Revised Statutes  Beyond this general preemption standard, Section 1044 contains a number of other provisions narrowing the OCC's preemption authority  First, Section 1044 provides that courts reviewing OCC preemption determinations should accord those determinations only Skidmore deference, under which courts assess an agency's interpretation of a statute "depending upon the thoroughness evident in the consideration of the agency, the validity of the reasoning of the agency, the consistency with other valid determinations made by the agency, and other factors which the court finds persuasive and relevant to its decision " Before the enactment of Dodd-Frank, certain courts had afforded OCC preemption determinations a more permissive form of deference known as Chevron deference, according to which courts defer to agency interpretations as long as they are reasonable  Section 1044 accordingly requires that courts take a less deferential posture toward OCC preemption determinations  Second, Section 1044 provides that no OCC preemption determination "shall be interpreted or applied so as to invalidate, or otherwise declare inapplicable to a national bank, the provision of the State consumer financial law, unless substantial evidence, made on the record of the proceeding, supports the specific finding regarding the preemption of such provision in accordance with the legal standard" established by Barnett Bank   This "substantial evidence" standard is often used in cases involving the Administrative Procedure Act, which provides that courts shall hold unlawful an agency's formal rules and other determinations made on the basis of a formal hearing when they are "unsupported by substantial evidence " The Supreme Court has explained that "substantial evidence" entails "more than a mere scintilla" of evidence, and requires "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion " Third, Section 1044 provides that the OCC shall (1) "periodically conduct a review, through public notice and comment, of each determination that a provision of Federal law preempts a State consumer financial law," (2) "conduct such review within the 5-year period after prescribing or otherwise issuing such determination, and at least once during each 5-year period thereafter," and (3) "[a]fter conducting the review of, and inspecting the comments made on, the determination,       publish a notice in the Federal Register announcing the decision to continue or rescind the determination or a proposal to amend the determination " Fourth, Section 1044 provides that the OCC must submit to Congress a report addressing its decision to continue, rescind, or propose an amendment to any preemption determination  Finally, Section 1044 abrogated the Supreme Court's decision in Watters , providing that "State consumer financial laws" apply to the subsidiaries and affiliates of national banks "to the same extent" that they apply "to any person, corporation, or other entity subject to such State law " After Dodd-Frank's enactment, commentators debated the meaning of Section 1044's general preemption standard  As discussed, Section 1044's preemption standard provides that federal law preempts "State consumer financial laws" that "prevent[] or significantly interfere[]" with the powers of national banks "in accordance with the legal standard for preemption in the decision of the Supreme Court of the United States in [ Barnett Bank ] " Some commentators have argued that this language simply codifies the Barnett Bank standard and was not intended to significantly modify pre-existing law  However, others have argued that Section 1044 was intended to pare back the OCC's 2004 preemption rules, which interpreted the NBA as preempting state laws that "obstruct, impair, or condition" the powers of national banks  According to this latter group of commentators, the OCC's "obstruct, impair, or condition" standard was more expansive than Barnett Bank 's "significant interference" test, meaning that a codification of that test would modify pre-existing law  In 2011, the OCC responded to the enactment of Section 1044 by issuing a notice of proposed rulemaking that reaffirmed its pre-Dodd-Frank preemption decisions while deleting the "obstruct, impair, or condition" language from its preemption rules  While the OCC acknowledged that this language "created ambiguities and misunderstandings regarding the preemption standard that it was intended to convey," it maintained that the specific preemption determinations reflected in its 2004 rules were nevertheless consistent with Barnett Bank   The OCC accordingly proposed reaffirming the specific preemption determinations in its 2004 rules while removing the "obstruct, impair, or condition" standard  The OCC's proposal quickly generated controversy  After the OCC issued the notice, the Treasury Department's General Counsel wrote a letter to the Comptroller of the Currency arguing that the OCC's proposed rule was "inconsistent with the plain language of [Dodd-Frank] and its legislative history " Specifically, the Treasury Department argued that interpreting Section 1044 as making no significant changes to existing preemption law conflicted with "basic canons of statutory construction" and legislative history indicating that the provision was intended to "revise[]" the OCC's preemption standard  Senator Carl Levin also expressed disagreement with the proposed rules in a letter to the Comptroller, arguing that "[i]f [Congress] had wanted to leave the OCC's purported federal preemptive powers unchanged, [it] could have engaged in a very simple exercise—do nothing " Other Senators expressed support for the OCC's proposed rules  Senators Tom Carper and Mark Warner criticized the Treasury Department's letter for "ignor[ing] the clear legislative history indicating that [Section 1044] is intended to codify the Barnett case " In responding to the Treasury Department's argument that Section 1044 was intended to "revise" the OCC's preemption standards, Senators Carper and Warner argued that the OCC's proposed rules would effectuate the contemplated revision by removing the potentially troublesome "obstruct, impair, or condition" language from the agency's 2004 rules  The OCC ultimately agreed with Senators Carper and Warner  In July 2011, the OCC published a final regulation revising its preemption rules  In the final rule, the OCC concluded that "the Dodd-Frank Act does not create a new, stand-alone 'prevents or significantly interferes' preemption standard, but, rather, incorporates the conflict preemption legal standard and the reasoning that supports it in the Supreme Court's Barnett decision " The OCC's 2011 rule also deleted the phrase "obstruct, impair, or condition" from the relevant preemption standard, noting that preemption determinations based "exclusively" on that language "would need to be reexamined to ascertain whether the determination is consistent with the Barnett conflict preemption analysis " However, the rule indicated that the OCC had not identified any preemption determinations that in fact relied "exclusively" on the relevant language  The final rule also noted that all future OCC preemption determinations would be subject to Section 1044's requirement concerning "case-by-case" determinations  Since the enactment of Dodd-Frank, a number of courts have interpreted Section 1044 as codifying the Barnett Bank standard  Some courts have accordingly concluded that Barnett Bank demarcates the boundaries of the OCC's 2011 preemption rules, reasoning that those rules do not preempt any state laws that would survive preemption under the Barnett Bank test  One court has also addressed the appropriate level of judicial deference towards the OCC's 2011 preemption determinations  As discussed, Section 1044 provides that courts "shall" assess OCC preemption determinations "depending upon the thoroughness evident in the consideration of the agency, the validity of the reasoning of the agency, the consistency with other valid determinations made by the agency, and other factors which the court finds persuasive and relevant to its decision"—a standard commonly known as " Skidmore deference " In 2018, the Ninth Circuit concluded that the OCC's 2011 preemption determinations are "entitled to little, if any, deference" under Skidmore   Specifically, the Ninth Circuit reasoned that because the OCC's 2011 preemption determinations represent the agency's "articulation of its legal analysis" under Barnett Bank (as opposed to being grounded in expert factual findings), those determinations would not warrant significant deference even in the absence of Section 1044  Whether other federal circuit courts will follow the Ninth Circuit in affording minimal deference to the OCC's 2011 preemption rules remains to be seen  As the debates over Section 1044 of Dodd-Frank make clear, a number of banking preemption issues remain the subject of active debate  This final section of the report discusses three additional current issues involving banking preemption and related federalism questions  A number of recent judicial decisions have generated debate over the circumstances in which non-bank financial companies can benefit from banks' ability to "export" the maximum interest rates of their "home" states  As discussed, the Supreme Court has held that national banks may charge any interest rate allowable under the laws of their home states even when lending to borrowers in other states with stricter usury laws  After this decision, Congress extended the power to export maximum interest rates to federally insured state banks  Recently, courts have grappled with whether this exportation power extends to non-bank financial companies and debt collectors that purchase loans originated by federally insured banks  That is, courts have addressed the circumstances in which loans originated by federally insured banks remain subject to the usury laws of the banks' home states even when the loans are (1) made to borrowers in other states with stricter usury laws, and (2) subsequently purchased by non-banks, which do not possess the exportation power when they originate loans themselves  A number of courts have concluded that in certain contexts, a loan that is non-usurious when originated remains non-usurious irrespective of the identity of its subsequent purchasers—a principle that some commentators have labeled the "valid when made" doctrine  However, in 2015, the Second Circuit rejected the application of this rule in Madden v  Midland Funding , holding that non-bank debt collectors that had purchased debt originated by a national bank could not benefit from the bank's exportation power  In Madden , a New York resident brought a putative class action under New York usury law against debt collectors that had purchased her credit card debt from a Delaware-based national bank  In response, the debt collectors argued that federal law preempted the New York usury claims because the credit card debt had been originated by a Delaware-based national bank and was not usurious under Delaware law  The Second Circuit rejected this argument, reasoning that the application of New York usury law to the debt collectors did not "significantly interfere" with the national bank's powers under Barnett Bank   Specifically, the court reasoned that because the debt collectors were not national banks and were not acting "on behalf of" a national bank, the New York usury claims did not interfere with the national bank's power to export the maximum interest rates of its home state  The Second Circuit's decision in Madden has generated significant debate  In an amicus brief supporting the debt collectors' petition for re-hearing before the Second Circuit, industry groups argued that the decision threatened to seriously disrupt lending markets  Specifically, these groups argued that the court's decision would "significantly impair" banks' ability to manage their risk by selling loans in secondary credit markets—a result that would ultimately inhibit their capacity to originate loans  Similarly, in an amicus brief submitted to the Supreme Court, the OCC and the Office of the Solicitor General (OSG) argued that the Second Circuit's decision was "incorrect," reasoning that "[a] national bank's federal right to charge interest up to the rate allowed by [the NBA] would be significantly impaired if [a] national bank's assignee could not continue to charge that rate " In response, the plaintiff in Madden argued that the Second Circuit's decision is unlikely to significantly affect credit markets  Specifically, the Madden plaintiff argued that the court's decision will not disrupt credit markets because non-banks that purchase loans originated by banks retain the right to collect the balances of those loans within applicable state law usury limits  While the Second Circuit ultimately denied the debt collectors' petition for re-hearing and the Supreme Court denied their petition for a writ of certiorari, the Madden decision has attracted congressional interest  The Financial CHOICE Act—comprehensive regulatory reform legislation that passed the House of Representatives in June 2017 but did not become law—would have codified the "valid when made" doctrine and abrogated Madden   A more limited bill directed solely at codifying the "valid when made" doctrine ( H R  3299 ) also passed the House in February 2018 but did not become law  Echoing the arguments made by industry groups, the bill's sponsor contended that the Second Circuit's decision will harm credit markets and impede financial innovation  By contrast, the bill's critics argued that it would facilitate predatory lending by allowing non-banks to evade state usury laws  These proposals have not been re-introduced in the 116th Congress  In a number of cases involving the scope of the exportation doctrine, non-bank financial companies have played a more active role in the origination process than the debt collectors in Madden   Specifically, a number of these cases have involved arrangements in which a non-bank financial company solicits borrowers, directs a partner bank to originate a high-interest loan, and purchases the loan from the bank shortly after origination in order to benefit from the bank's exportation power  Some courts have held that non-banks employing these so-called "rent-a-charter" schemes are not eligible for federal preemption, reasoning that preemption depends on a transaction's economic realities rather than its formal characteristics  Specifically, these courts have concluded that non-banks do not assume their partner banks' exportation power when the economic realities surrounding a transaction indicate that the non-banks are the "true lenders " According to this "true lender" doctrine, non-banks that have established these types of relationships qualify as the "true lenders" when they possess the "predominant economic interest" in the relevant loans when the loans are originated  In these circumstances, some courts have concluded that the non-banks are not entitled to the benefits of federal preemption  Like the Second Circuit's decision in Madden , these "true lender" decisions have attracted Congress's attention  In the 115th Congress, H R  4439 would have abrogated this line of decisions by making clear that a loan's originator is always the "true lender" for purposes of the exportation doctrine  The bill's supporters argued that the "true lender" decisions threaten to undermine partnerships between banks and FinTech companies —a broad category of businesses offering digital financial products that some commentators have hailed for their innovative potential  The bill's opponents, by contrast, contended that the legislation would allow non-banks to circumvent state usury laws and questioned the value of bank-FinTech partnerships designed with that purpose in mind  H R  4439 was referred to the House Committee on Financial Services during the 115th Congress but has not been re-introduced in the 116th Congress  Congress is not alone in considering whether to extend the benefits of federal preemption to FinTech companies  In July 2018, the OCC issued a Policy Statement announcing that it will begin accepting applications for "special purpose national bank charters" (SPNB charters) from FinTech companies that are engaged in "the business of banking" but do not take deposits  In the Policy Statement, the OCC explained that the NBA provides it "broad authority" to grant national bank charters to institutions that engage in the "business of banking"—a category that includes paying checks and lending money  The OCC accordingly concluded that it has the statutory authority to grant national bank charters to FinTech companies that engage in these core banking activities  According to the OCC, SPNB charters will help foster responsible innovation and promote regulatory consistency between FinTech companies and traditional banks  The OCC further explained that it will use its existing chartering standards and procedures to evaluate applications for SPNB charters, and that FinTech companies that receive such charters "will be supervised like similarly situated national banks, including with respect to capital, liquidity, and risk management " While the OCC touted the ability of SPNB charters to "level the playing field with regulated institutions" without explicitly mentioning federal preemption, commentators have observed that preemption represents "the central benefit" offered by such charters  The OCC's decision to accept applications for national bank charters from FinTech companies has generated debate  Critics of the policy have contended that FinTech companies' interest in such charters "is virtually entirely about avoiding state consumer protection laws," and that "[f]ederal chartering should not be a move to eviscerate" such laws  State regulators have also filed lawsuits challenging the OCC's authority to charter non-depository FinTech companies  In the spring of 2017, the Conference of State Bank Supervisors (CSBS) and the New York Department of Financial Services (NYDFS) responded to an early OCC proposal to charter FinTech companies by filing suits in the U S  District Court for the District of Columbia and the U S  District Court for the Southern District of New York, respectively  The CSBS and NYDFS made substantially similar claims, arguing that (1) the NBA does not give the OCC the authority to charter non-depository institutions, (2) the Administrative Procedure Act requires the OCC to follow notice-and-comment rulemaking procedures before issuing SPNBs, (3) the OCC's decision was arbitrary and capricious, and (4) the OCC's decision violated the Tenth Amendment by invading states' sovereign powers  Both district courts dismissed the lawsuits on jurisdictional grounds, reasoning that the organizations failed to identify any imminent injuries to their members and that the case was not ripe for resolution because the OCC had not issued any SPNBs  However, after the OCC issued its Policy Statement in July 2018, both organizations filed new lawsuits that remain pending  Policymakers have also turned their attention to how federal law affects traditional banks' responses to changes in state law—namely, state-level efforts to legalize marijuana  While a number of states have legalized marijuana for medical or recreational use, federal law criminalizes the drug's sale, distribution, and possession, in addition to the aiding and abetting of such activities  Federal law also criminalizes money laundering, making it unlawful to: conduct a financial transaction involving the proceeds of a specified unlawful activity —a category that includes the sale or distribution of marijuana—"knowing that the transaction is designed       to conceal or disguise the nature, the location, the source, the ownership or the control of the proceeds       or to avoid a transaction reporting requirement under State or Federal law"; or knowingly engage in a monetary transaction in criminally derived property of a value greater than $10,000 that is derived from specified unlawful activity   Finally, the Bank Secrecy Act (BSA) and associated regulations require that financial institutions report illegal and suspicious activities to the Financial Crimes Enforcement Network (FinCEN) and maintain programs designed to prevent money laundering  Federal banking regulators have broad powers to discipline banks for violations of these laws  The Federal Reserve regularly conducts examinations of member banks that include evaluations of BSA compliance, and the FDIC has the authority to terminate a bank's deposit insurance for violations of law  Because of marijuana's status under federal law, many banks have refused to serve marijuana businesses even when those businesses operate in compliance with state law  While some small banks have offered accounts to marijuana businesses, an estimated 70 percent of marijuana businesses remain unbanked  Because of this inability to access the banking system, many marijuana businesses reportedly operate entirely in cash, raising concerns about tax collection and public safety  These perceived problems have attracted congressional interest  In March 2019, the House Committee on Financial Services approved legislation intended to minimize the legal risks associated with banking the marijuana industry  The proposed bill— H R  1595 , the SAFE Banking Act of 2019—would create a "safe harbor" under which federal banking regulators could not take various adverse actions against depository institutions for serving marijuana businesses that comply with applicable state laws ("cannabis-related legitimate businesses")  The legislation would also provide that for purposes of federal anti-money laundering law, the proceeds from transactions conducted by cannabis-related legitimate businesses shall not qualify as the proceeds of unlawful activity "solely because the transaction[s] [were] conducted by a cannabis-related legitimate business " Finally, H R  1595 would require FinCEN to issue guidance concerning the preparation of suspicious activity reports for cannabis-related legitimate businesses that is "consistent with the purpose and intent" of the bill and "does not significantly inhibit the provision of financial services" to cannabis-related legitimate businesses  Variations on some of the SAFE Banking Act's provisions have been incorporated into broader marijuana-related legislation  The Responsibly Addressing Marijuana Policy Gap Act of 2019 ( S  421 and H R  1119 ) would eliminate federal criminal penalties for persons who engage in various marijuana-related activities in compliance with state law and create a "safe harbor" from adverse regulatory action for depository institutions that serve marijuana businesses  Another Senate bill— S  1028 , the STATES Act—would provide that the Controlled Substances Act's (CSA's) marijuana-related provisions do not apply to persons acting in compliance with state marijuana regulation s, subject to certain exceptions  While the bill does not have the type of "safe harbor" for depository institutions in H R  1595 , S  421 , or H R  1119 , it contains a "Rule of Construction" clarifying that conduct in compliance with the legislation shall not serve as the basis for federal money laundering charges or criminal forfeiture under the CSA 

ground_truth: The misuse of prescription opioid pain relievers and illicit opioids, such as heroin, has contributed to increases in overdose deaths. According to the most recent Centers for Disease Control and Prevention data, in 2015 over 52,000 people died of drug overdose deaths, and about 63 percent of them involved an opioid. For those who are addicted to or misuse opioids, MAT has been shown to be an effective treatment. GAO was asked to review HHS and other efforts related to MAT for opioid use disorders. This report (1) describes HHS's key efforts to expand access to MAT, (2) examines HHS's evaluation, if any, of its efforts to expand access to MAT, and (3) describes efforts by selected stakeholders (states, private health insurers, and national associations) to expand access to MAT. GAO gathered information from HHS officials as well as a non-generalizable selection of 15 stakeholders selected based on their MAT expansion activities, among other factors. GAO also assessed HHS's evaluation plans using internal control standards for defining objectives and evaluating results. In an effort to reduce the prevalence of opioid misuse and the fatalities associated with it, the Department of Health and Human Services (HHS) established a goal to expand access to medication-assisted treatment (MAT). MAT is an approach that combines behavioral therapy and the use of certain medications, such as methadone and buprenorphine. HHS has implemented five key efforts since 2015 that focus on expanding access to MAT for opioid use disorders—four grant programs that focus on expanding access to MAT in various settings (including rural primary care practices and health centers) and regulatory changes that expand treatment capacity by increasing patient limits for buprenorphine prescribers and allowing nurse practitioners and physician assistants to prescribe buprenorphine. Some of the grant awards were made in 2015, while others were made as recently as May 2017. (See figure.) As of August 2017, efforts under all the grant programs were ongoing. Grant recipients can use funding to undertake a range of activities, such as hiring and training providers and supporting treatments involving MAT. In addition, certain providers and grant recipients are required to develop plans for preventing MAT medications from being diverted for nonmedical purposes. HHS officials told GAO that as of August 2017, the department was in the process of finalizing its plans to evaluate its efforts to address the opioid epidemic. In September 2016, HHS awarded a contract to conduct the evaluation. HHS officials told GAO that they are still working with the contractor to finalize the evaluation approach and that it will focus on whether HHS's efforts to address the opioid epidemic have been implemented as intended. HHS officials said that in the future, HHS may also evaluate whether, or to what extent, its efforts have been effective in expanding access to MAT, in addition to evaluating implementation. While HHS has some of the information that could be used in a future evaluation of the effectiveness of its efforts to expand access to MAT, it has not adopted specific performance measures with targets specifying the magnitude of the increases HHS hopes to achieve through its efforts to expand access to MAT, and by when. For example, HHS has not established a long-term target specifying the percentage increase in the number of prescriptions for buprenorphine HHS would like to achieve, which would help to show whether efforts by HHS and others are resulting in a sufficient number of prescriptions for MAT medications. HHS has also not chosen a specific method of measuring treatment capacity or established targets associated with it, which would help determine whether a sufficient number of providers are becoming available to evaluate and treat patients who may benefit from MAT. Without specifying these performance measures and associated targets, HHS will not have an effective means to determine whether its efforts are helping to expand access to MAT or whether new approaches are needed. Gauging this progress is particularly important given the large gap identified nationwide between the total number of individuals who could benefit from MAT and the limited number who can currently access it based on provider availability. In addition, GAO also found that as of August 2017, HHS had not finalized its approach for its planned evaluation activities, including timeframes. Without timeframes for the evaluation's activities, HHS increases the risk that the evaluation will not be completed as expeditiously as possible. In addition to HHS efforts to expand access to MAT, officials from selected states, private health insurers, and national associations reported using several efforts to expand patients' access to MAT for opioid use disorders. For example, several stakeholders provided GAO with the following examples of their efforts: States. State health officials from all five selected states have implemented or are planning approaches that focus on integrating the use of MAT into primary care, such as by providing services for centralized intake and initial management of patients or through telehealth that connects patients in rural areas with addiction specialists in a different location. Private health insurers. Three private health insurers reported removing prior authorization requirements for MAT medications so patients can avoid a waiting period before receiving the medications. National associations. Officials told GAO that they are conducting outreach and training for their members and developing tools and resource guides. For example, one association developed a road map with strategies that state policymakers can use to address the opioid epidemic, including strategies for reducing the stigma associated with MAT through educating the public and potential providers. GAO recommends that HHS take two actions: (1) establish performance measures with targets related to expanding access to MAT, and (2) establish timeframes for its evaluation of its efforts to expand access to MAT. HHS concurred with both recommendations.