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



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

Report 1: Created in 1968, the SFSP is authorized under the Richard B  Russell National School Lunch Act and generally provides free meals to children age 18 and under in low-income areas during certain periods when school is not in session  Specifically, the SFSP operates during school summer vacation periods between May through September, vacation periods in any month for programs operating on a continuous school calendar, and certain other times for areas affected by an unanticipated school closure, such as for a natural disaster  However, the majority of SFSP meals are served to children during the summer months  In fiscal years 2007 through 2016, federal expenditures on SFSP increased, according to FNS data, though there was a slight decrease between fiscal years 2015 and 2016 (see fig  1)  The SFSP is administered at the federal level by FNS through its national and regional offices  FNS is responsible for issuing regulations, instructions, and guidance; reviewing states’ program management and administration plans; overseeing program administration; and reimbursing states for meals served that meet program requirements  At the state level, the program is administered by state agencies and locally operated by state-approved sponsors, such as school districts, local government entities, or private nonprofit organizations  State agencies are responsible for approving, providing training to, and inspecting and monitoring sponsors and meal sites  Sponsors, in turn, are responsible for monitoring their SFSP meal sites, managing the meal service, and providing training to administrative staff and site operators  A sponsor may operate one site or multiple sites  Sites are physical locations in the community where children receive and consume meals in a supervised setting  According to FNS guidance, sites may be located in a variety of settings, including schools, parks, community centers, health clinics, hospitals, apartment complexes, churches, and migrant camps  States may approve different types of SFSP meal sites, including open sites, closed enrolled sites, and camps  Open sites operate in an area where at least half of the children are eligible for free or reduced-price school meals (referred to as “area eligible”), according to data from entities such as schools or the U S  Census Bureau  Children are generally eligible for free or reduced-price school meals if their households have incomes at or below 185 percent of federal poverty guidelines  At open sites, meals are made available to all children in the area, and all meals served that meet program requirements are reimbursable  Closed enrolled sites, on the other hand, are open only to enrolled children, as opposed to the community at large  At closed enrolled sites, meals served to all children in attendance are reimbursable as long as at least half of the enrolled children are eligible for free or reduced-price school lunch  Unlike other types of sites, camps are reimbursed only for meals served to children who have been individually determined to be eligible for free or reduced-price school meals  SFSP meals must meet certain requirements in order to be eligible for federal reimbursement; for example, the meals must be served and consumed on-site at an approved site  Federal reimbursements for summer meals are provided for each breakfast, lunch, supper, or snack served to an eligible child at an eligible site that also meets federal requirements for menu components, scheduled meal times, and nutrition  For example, to meet nutritional requirements, a lunch or a supper must, at a minimum, include four components: 2 ounces of meat or a comparable serving of a meat alternate, 3/4 cup of fruits and/or vegetables (at least two kinds), a slice of bread or a comparable serving of another grain, and a cup of milk  In 2017, the federal reimbursement rate was $3 83 or $3 77 for each eligible SFSP lunch or supper served, depending on the type of meal site  Each site may serve up to two meals or one meal and one snack per day  Some flexibilities are available to FNS in implementing the SFSP program, under its waiver and demonstration authorities  Specifically, the National School Lunch Act authorizes the Secretary of Agriculture to waive, upon request of a state or eligible service provider, certain program requirements established under the National School Lunch Act or the Child Nutrition Act of 1966, as amended, including some for the SFSP  In order to grant a waiver request, the Secretary must determine that the waiver would facilitate the state or service provider’s ability to carry out the purpose of the program, and that the waiver will not increase the overall cost of the program to the federal government, among other things  In the event a waiver request is submitted, the Secretary is required to act promptly and state in writing whether the waiver request is granted or denied, and why  The Secretary is also required to periodically review the performance of waiver recipients, and submit an annual report to Congress summarizing the use of waivers and their effectiveness, among other details  In addition to this waiver authority, the Secretary is also authorized to carry out demonstration projects to develop and test methods of providing access to summer meals for low-income children in urban and rural areas, to reduce or eliminate the food insecurity and hunger of low-income children and improve their nutritional status  The Secretary is required to provide for an independent evaluation of the demonstration projects carried out under this authority, and submit an annual report to Congress on the status of each project and the results of the evaluations  The total number of SFSP meals served nationwide during the summer— one indicator of program participation—increased from 113 million meals in fiscal year 2007 to 149 million meals in fiscal year 2016, or by 32 percent, according to our analysis of FNS data  The number of SFSP meals served has generally increased from year to year over this 10-year period  Most recently, meals decreased by 6 percent from 156 million meals in summer 2015 to 149 million meals in summer 2016, according to our analysis of FNS data (see fig  2)  Factors that may have affected year-to-year fluctuations include changes in funding for summer programs, sponsor participation, weather, and the number of weekdays available for sites to serve meals within a given summer, according to FNS and state agency officials we interviewed  For example, state agency officials in one of the three selected states we visited said they believe that reductions in state and local funding for summer programs that also provide meals, and turnover of sponsors, including losing one of the state’s largest sponsors in a recent summer, affected the total number of SFSP meals served in their state in 2016  According to our analysis of FNS data, SFSP lunches served in the summer months increased by over 17 million from fiscal year 2007 through fiscal year 2016, accounting for almost half of the total increase in the number of SFSP meals served in that period  However, when comparing across each of the meal types, supper and breakfast had the largest percentage increases over the 10-year period, 50 and 48 percent, respectively (see table 1)  In comparison, the number of SFSP lunches served increased by 26 percent from fiscal years 2007 through fiscal year 2016  From fiscal year 2007 through fiscal year 2016, there were increases in the numbers of meals served in both SFSP and NSLP, the largest child nutrition assistance program  Specifically, SFSP lunches served in July increased from 32 million to 40 million, or 24 percent, from fiscal year 2007 to 2016, and NSLP lunches served in March increased from 328 million to 376 million meals, or 15 percent, according to our analysis of FNS data  Although the programs generally serve similar populations, different factors likely affected the number of meals served by each program, in part because NSLP serves children in schools during the school year and SFSP serves children in a variety of settings during the summer months  Although states report the actual number of SFSP meals served to FNS, they estimate the number of children participating in SFSP, and information obtained from our state survey and FNS indicate that these participation estimates have been calculated inconsistently  FNS instructs state agencies on how to calculate a statewide estimate of children’s participation in the SFSP, referred to as average daily attendance (ADA), using sponsor-reported information on the number of meals served and days of operation in July of each year  However, states’ methods for calculating ADA have differed from state to state and from year to year, according to our review of states’ survey responses and FNS documents  For example, although FNS directed states to include the number of meals served in each site’s primary meal service— which may or may not be lunch—some states, according to our survey and FNS data, were calculating ADA using only meals served at lunch  FNS officials told us that these states were therefore not following the agency’s instructions  Further, some states have changed their methods for calculating ADA over time—five states reported in our survey that the method they used to calculate ADA in fiscal year 2016 differed from the one they used previously  While FNS clarified its instructions in May 2017 to help improve the consistency of states’ ADA calculations moving forward, ADA remains an unreliable estimate of children’s daily participation in SFSP for at least two reasons, according to our analysis  (See sidebar for the revised ADA calculation instructions ) First, ADA is based on summary data that does not account for existing variation in site days of operation, and second, it is based on July data, which does not reflect the month with the greatest number of meals served in every state  According to our analysis, ADA is an unreliable estimate of children’s participation in SFSP because it currently does not account for existing variation in the number of days that each site serves meals to children  Specifically, because FNS’s instructions indicate that sites’ ADAs are to be combined to provide a statewide ADA estimate, differences in the number of days of meal service are disregarded  As a result, ADA does not reflect the average number of children served SFSP meals daily throughout the month  Our analysis of site-level data from one of the selected states illustrates this limitation  In this state, multiple sites reported an ADA of 60 for July, yet two of those sites served meals to children on only 1 day of the month and another site served meals to children on 20 days  Although 120 children were served SFSP meals only 1 day in July across two of these sites, the combined ADA across all three sites, which we calculated following FNS’s instructions, inaccurately suggests an average of 180 children were participating in SFSP at these sites on a daily basis in July  According to our analysis, ADA is also an unreliable estimate of children’s participation in SFSP because it currently does not account for state variation in the month with the greatest number of SFSP meals served, potentially leading to an underestimate  According to FNS officials, the agency instructs states to calculate ADA for July because officials identified this as the month with the largest number of meals served nationwide  However, because of reasons such as state variations in school calendars, July is not the month with the largest number of meals served in every state  In one of the selected states, Arizona, using July to calculate ADA cuts the estimate almost in half  Specifically, we followed FNS’s instructions and calculated that Arizona’s ADA was 14,987 in July 2016 compared to 26,772 in June 2016  Nationwide, in summer 2016, 26 states served more SFSP meals in June or August than in July, according to our analysis of FNS data  However, without site level data on meals served and operating days, the extent to which these states had higher ADAs in June or August as compared to July is unknown  In its May 2017 memo to states revising the ADA calculation instructions, FNS said that it is critical that the agency’s means of estimating children’s participation in the SFSP is as accurate as possible because it helps inform program implementation at the national level and facilitates strategic planning and outreach to areas with low participation  In addition, Standards for Internal Control in the Federal Government state that agencies should maintain quality data and process it into quality information that is shared with stakeholders to help achieve agency goals  Although FNS has also collected information on other data that states collect on the SFSP, the agency has not yet used this information to help improve its estimate of children’s participation in the program  In 2015, FNS published a Request for Information, asking whether states or sponsors collect any SFSP data that are not reported to FNS  While FNS received responses from only 15 states, these responses suggest that some states collect additional data, such as site-level data that may allow for an improved estimate of children’s SFSP participation, potentially addressing the issues we found in our analysis  In response to the information FNS received, they followed up with up to 9 of the 15 states in 2016 and 2017 to explore the feasibility of collecting additional data and improving estimates of children’s participation  Although they took these steps, FNS officials told us they are cognizant of the burden on states and site operators that would be associated with additional reporting requirements  At this time, the agency has not taken further action to improve the estimate, such as addressing the reliability issues caused by variation in the number of operating days of meal sites and in the months with the greatest number of meals served by state  As a result, FNS’s understanding of children’s participation in the SFSP remains limited, which impairs its ability to both inform program implementation and facilitate strategic planning and outreach to areas with low participation  Other federal programs that operate solely in the summer, as well as those operating year-round, help feed low-income children in the summer months  These programs include the NSLP Seamless Summer Option, which provides nutrition assistance benefits solely in the summer, and several federal programs that operate year-round  In July 2016, in addition to the 70 million meals provided through the SFSP, 26 million meals were provided to low-income children through school food authorities participating in the NSLP’s Seamless Summer Option, according to FNS data  The Seamless Summer Option was established in 2004, and according to FNS, streamlines administrative requirements to encourage school food authorities providing free or reduced-price meals during the school year under the NSLP and SBP to continue providing meals to low-income children when school is not in session  For example, officials from a national organization involved in summer meals told us the Seamless Summer Option makes it easier for school food authorities to provide summer meals because they continue working with the same state agency, reporting the same information to the state, and operating without having to transition to a separate program  Nonetheless, school food authorities can choose to provide free summer meals to children through either the SFSP or Seamless Summer Option, and the majority of states (34) reported in our survey that a greater proportion of school food authorities participated in the SFSP than the Seamless Summer Option in summer 2016  According to FNS and selected state officials, this may be related to the generally lower meal reimbursement rates school food authorities participating in the Seamless Summer Option receive compared to the rates received by those participating in the SFSP  In summer 2016, the Seamless Summer Option added to the geographic availability of summer meal sites in two of the three states we visited as part of our review  School food authorities provided summer meals through the Seamless Summer Option in Arizona and Illinois, but not in Massachusetts, based on our analysis of data provided by these states  In Arizona and Illinois, school food authorities participating in the Seamless Summer Option added 643 and 298 summer meal sites, respectively, in the month with the largest number of SFSP meals served in each state (see fig  3)  In addition, some of the Seamless Summer Option sites in these two states provided meals to children in areas where there were no SFSP sites  For example, Seamless Summer Option sites provided meals in areas near the northeastern and southwestern corners of Arizona that lacked nearby SFSP sites  In addition to the SFSP and the Seamless Summer Option, the Summer Electronic Benefit Transfer for Children (Summer EBT) demonstration provided nutrition assistance benefits to 209,000 low-income children in summer 2016 in select areas across 6 states and 2 Indian Tribal Organizations, according to FNS officials  Since the summer of 2011, Summer EBT benefits have been provided to eligible households on an electronic benefits transfer card, which households use to purchase eligible foods at authorized retailers  Specifically, the demonstration has provided monthly benefits of $30 or $60 per eligible child to households with children in areas with a perceived high level of need, based on the demonstration grantees’ assessments of the percentage of children eligible for free or reduced-price school meals and the availability of the SFSP  Consistent with this, three of the states that participated in Summer EBT in 2016 reported through our survey that these benefits helped children who were unable to access summer meals through the SFSP or the Seamless Summer Option  Further, according to an FNS- funded evaluation, Summer EBT improved food security among low- income children who participated in the demonstration  Specifically, the evaluation found the receipt of these benefits reduced the number of children in the demonstration experiencing very low food security between 2011 and 2013 by one-third  Some low-income children also receive nutrition assistance in the summer through federal programs that operate year-round  According to FNS data, in June 2016, 5 8 million infants and children participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and 3 million children participated in the Child and Adult Care Food Program (CACFP)  In addition, an average of 19 2 million children participated each month in the Supplemental Nutrition Assistance Program (SNAP) in fiscal year 2016, according to FNS data  These benefits are provided year-round, including when school is in session and children may also be eligible to receive school meals  In our previous work on federal domestic food assistance programs, we reported that no one program alone is intended to meet a household’s full nutritional needs  At that time, several officials and providers told us that the variety of food assistance programs offers eligible individuals and households different types of assistance and can help households fill the gaps and address the specific needs of individual members  For example, a mother with two children may rely on SNAP for her household’s basic groceries, the NSLP to feed a school-age child during the school year, and WIC to obtain supplemental foods for herself and an infant  Some low-income children also receive summer meals through nonfederal programs, according to our state survey and interviews with organizations involved in summer meals  Twenty-seven states reported in our survey that they were aware of other state- or non-state-funded programs that provided children of low-income households with meals in their states during the summer months  According to our analysis of state survey responses, local faith-based organizations and foodbanks were the most common types of entities operating these types of programs  Similarly, officials from FNS and two regional organizations we interviewed said they were aware of children receiving summer meals through nonfederal programs operated by faith- based and other community organizations  In addition, SFSP site operators at 6 of the 30 meal sites we visited in the selected states told us nearby foodbanks and faith-based organizations may also be providing children with free meals to some extent  For example, one of the meal sites we visited was operated by a foodbank that, in addition to the SFSP, provided food boxes to those in need and distributed food to other local community organizations to provide to persons in need of immediate assistance, including families with children  Although FNS and the majority of states do not collect data on nonfederal programs, results from our state survey and interviews with SFSP providers and organizations involved in summer meals indicate the reach of nonfederal programs is limited  In our survey, states reported that the geographic coverage of these nonfederal programs varied by state, with 11 states indicating that they operated in some portions of the state—the most common state response  In addition, 16 states reported that they were not aware of any nonfederal programs providing summer meals to children in their state (see fig  4)  Similarly, SFSP site operators at 24 of the 30 meal sites we visited were unaware of nonfederal programs providing meals to children in the areas in which they operated  In addition, officials from several national organizations involved in summer meals told us children have very few options for receiving summer meals beyond the federal summer meals programs  Specifically, officials from one national organization explained that food is often a significant part of the cost of a summer activity program for children and suggested that is one reason why organizations choose to participate in the SFSP  Although the SFSP provides for federal reimbursement of eligible meals and certain administrative and operating costs, nonfederal programs that provide children with summer meals may choose not to participate in the SFSP for several reasons, according to officials we interviewed from several organizations involved in summer meals  For example, some nonfederal program providers may not participate in the SFSP because they are unaware the program exists  Additionally, some nonfederal program providers may be aware of the SFSP, but choose not to participate because they do not want to follow certain program requirements, such as the nutrition or meal pattern standards  In addition, some providers may not participate in the program because they do not think they can handle certain aspects of the administrative workload associated with the SFSP  For example, a state official we interviewed told us the administrative workload associated with the SFSP can be particularly challenging, especially for smaller sponsors  Similarly, officials from a regional organization involved in summer meals told us one of the providers they work with who operated 10 meal sites chose to leave the SFSP because the paperwork required to operate the sites was too administratively burdensome for their volunteer site operators  States and SFSP providers reported challenges with meal sites, participation, and administration, though federal, state, and local entities have taken steps to improve these areas  Half or more of states reported in our survey that SFSP issues related to meal site availability, such as in rural areas, increasing children’s participation, and program administration were moderately to extremely challenging (see fig  5)  Overall, 41 states reported facing at least one challenge with the SFSP, while 9 reported facing none  Availability of transportation, low population density, and limited meal sites pose challenges for SFSP in rural areas, according to states we surveyed, selected national organizations, and state and local officials in the three selected states we visited  More than two-thirds of states in our survey reported they faced a moderate to extreme challenge with limited options in rural areas to transport children to summer meal sites (37), as well as with the distance to summer meal sites in rural areas resulting in low child turnout that affects the financial viability of site sponsorship (36)  As officials from one national organization explained, it may not be cost- effective for sponsors to operate in remote or rural areas if there are not enough meal sites or children participating in the program  Similarly, a sponsor in one of the selected states indicated that there are large parts of the state where the distances between meal sites are substantial, and travel between them takes several hours  An official from one of the selected states said transportation challenges can lead to underserved rural areas, including Indian reservations  Of the three states we reviewed, each had rural areas with few or no federally funded meal sites in summer 2016  However, a majority of the children in some of those areas were eligible for free or reduced price school meals, according to Census data provided by FNS, and would therefore be “area eligible” for the purposes of SFSP  For example, as shown in figure 6, “area eligible” locations in rural western parts of Arizona did not have any SFSP or Seamless Summer Option meals sites in June 2016, the month with the greatest number of summer meals served in that state  States and SFSP providers have responded to challenges with meal sites in rural areas by using other meal delivery approaches—efforts that FNS has supported through information sharing and grants  For example, according to one national organization involved in summer meals, some SFSP providers offer vans or buses to transport children to meal sites or partner with local bus authorities to give children free rides to meal sites  Instead of transporting children to sites, other sponsors transport meals to children through mobile meal delivery, an alternative summer meal model used in 48 states according to our survey  In this model, sponsors deliver meals by bus, using a route with state-approved stops in a community, and children consume the meal at the stop under a supervised setting  According to FNS officials and representatives from national organizations, this approach can be particularly helpful for providing summer meals to children in rural areas  State officials in two selected states told us they use mobile meal delivery to help fill gaps in meal service and help children overcome the lack of transportation or resources in their community  To serve children in very remote areas with limited resources, a sponsor in one of the selected states reported piloting a model involving delivering frozen meals every other week to such areas and supplying equipment, such as freezers and microwaves, to support meal service  To help sponsors address challenges related to meal sites in rural areas, FNS has shared information on alternative delivery models through its SFSP toolkit and webinars and has also provided related grant funding  For example, in summer 2011 and 2012, FNS funded the Meal Delivery demonstration project to provide meals to children in rural areas where low population density, long distances, and transportation issues made it difficult for children to get to SFSP sites, making site and sponsor operation financially unsustainable  The demonstration project funded meals to children in rural areas of Delaware, Massachusetts, and New York, providing food delivery to homes or drop-off sites near homes of eligible children  More than half the states (30) in our survey reported they faced a moderate to extreme challenge reaching low-income children in communities that are not area eligible  Areas in which fewer than 50 percent of children qualify for free or reduced-price meals during the school year are not eligible to have open summer meal sites at which all children who come to the site can receive a free meal  As a result, some children who are eligible for free and reduced-price meals during the school year do not have open summer meal sites located in close proximity to their residences, according to several national organization officials and SFSP providers  Eligible children in these areas may instead be limited to other types of SFSP sites, such as closed enrolled summer meal sites, or nonfederal programs providing meals, if available  For example, in one of the selected states, a sponsor of SFSP sites funded meals without federal support at one site that they operated as an open site in order to serve low-income children residing in low-income housing  These children did not otherwise have access to a federally funded summer meals site, according to these officials, because the broader area was part of a school district that had a greater than 50 percent proportion of children from higher-income families  Recognizing that some children may reside in an area that is not area eligible but is immediately adjacent to such an area, FNS has allowed additional flexibility in establishing area eligibility for open meal sites  Specifically, in 2014 and 2016 policy memos, FNS expanded the ways in which states and sponsors can use Census data to establish area eligibility  For example, FNS has allowed states and sponsors to average Census data across adjacent geographic areas to determine area eligibility  FNS noted that these additional flexibilities help ensure meal sites can be located in more areas in which poor economic conditions exist  Nearly all states (50) reported in our survey that the availability of meal sites throughout the summer months was a factor critical to the success of the SFSP, yet more than half the states (27) also reported they faced a moderate to extreme challenge with limited meal site days of operation  Nineteen of the 40 states that provided information about site days of operation reported 1 day as the shortest length of operation for SFSP sites in their state in fiscal year 2016  Limited meal site days of operation was a significant challenge in one of the three selected states we visited, as almost one-quarter of sites operated for only 1 to 2 weeks across a 2-month period in summer 2016, and an additional half of sites operated for 3 to 4 weeks across that same period, according to our analysis of state data  In contrast, in the other two selected states, the majority of sites (64 and 76 percent, respectively) operated for 5 or more weeks during a 2-month period  SFSP sites may have limited days of operation for various reasons, such as constraints with program administration and costs, according to interviews with a national organization official and a sponsor in one of the selected states  Some SFSP providers and national organizations involved in summer meals have responded to these challenges by working to extend the days of operation of meal sites—efforts that FNS has supported through related grant funding  Officials from one meal site located at a school in one of the selected states told us that 2017 was the first year the site stayed open an additional 4 weeks after summer school classes ended in an effort to expand participation, an extension made possible through support from an experienced sponsor  In addition, officials from a national organization involved in sponsoring summer meals told us they encourage their local sites to operate in August—a month where there are generally fewer summer meal service offerings—to meet children’s needs  At the federal level, under its demonstration authority, FNS funded the Extending Length of Operation Incentive project, a grant which provided an additional 50-cent reimbursement for all lunch meals served at sites in Arkansas in 2010 that offered meals for 40 or more days  Two-thirds of states (34) reported through our survey that they also faced a moderate to extreme challenge with a lack of awareness of summer meal sites among children and families, a challenge also mentioned by SFSP providers in the selected states  Meal site operators in one selected state noted that making families aware that all children may receive a meal for free at open sites can be a challenge  For example, one sponsor operating a meal site in a school said the perception among some is that the meal program is only for children attending summer school, and not for others in the community  Although that site had outside banners and advertising to help address that misperception, another SFSP provider explained that having sufficient funds to market the SFSP and increase awareness among families is also a challenge  To address these challenges, state agencies, some SFSP providers, and FNS have taken steps to help promote awareness of the SFSP  For example, nearly all states (47) reported in our survey that they have increased their outreach efforts for the SFSP in the last 5 years  More than half of states (36) also reported increases in overall SFSP participation during that time, which they believe were related to their outreach efforts  The majority of states in our survey reported conducting outreach on the SFSP to groups including children, parents and guardians, and schools, among others, using methods such as flyers, email, newspapers, and social media (see fig  7)  Further, state agency officials and sponsors in the selected states reported that they have developed partnerships with state and local advocacy groups and community leaders, among others, to promote the SFSP  For example, one state agency official said they partner with local advocacy organizations to field calls from parents seeking information about summer meal sites through their hunger hotline  FNS has promoted the use of such partnerships, as well as traditional and social media, to raise awareness of the SFSP  In addition, FNS developed the Summer Meals Site Finder, an online mapping tool that provides information on summer meal sites nationwide  Attracting children of all ages to SFSP meal sites can also be a challenge, according to states and SFSP providers  More than half of the states (31) reported in our survey that they faced a moderate to extreme challenge with limited youth and teen participation at summer meal sites, and an official from a national organization involved in the SFSP explained that it is difficult to attract children to a meal site when the site is focused solely on food  Similarly, 46 states in our survey reported that providing age- appropriate programming and enrichment activities for children at summer meal sites is a factor critical to the success of the SFSP  However, some meal sites may lack the resources to add activities, according to some SFSP providers in the selected states as well as FNS and national organization officials  Attracting teens can be particularly challenging, in part because of meal service time periods, a lack of age- appropriate activities, and stigma, according to national organizations and providers we interviewed  For example, early morning meal sites generally attract younger kids as teens may be apt to sleep later in the summer, and teens may also perceive a stigma in participating in a free meal program and may face peer pressure not to eat  In addition, meal offerings at SFSP sites may also present challenges to teen participation  Specifically, because FNS bases minimum portion size requirements for meals on the needs of younger children, meals are not always adequate to meet the nutritional needs of teens, according to one sponsor we interviewed  Across the 30 meal sites in the 3 states we visited in summer 2016, we observed variety in the meals served during different meal services  (see fig  8 ) States and SFSP providers have collaborated with others and sought specific types of sites to help provide enrichment activities and attract certain age groups—efforts that FNS has supported through information sharing and related grant funding  Sponsors in the selected states said they have focused on partnerships with groups such as those focused on youth development, churches, libraries, and police or fire departments, to offer age-appropriate activities for children (see fig  9)  For example, programs with local police departments, such as Cops N Kids in one selected state, or libraries in two selected states, provided meal services in combination with youth development or other enrichment activities  (See sidebar for highlights on the Cops N Kids program ) One national organization official said activities at SFSP sites can help take away the stigma around the program because children are not just there for the meal  Efforts to rebrand the SFSP as a community event where entire families can participate at the meal site also can have this effect, which is why some sponsors in the selected states said they partnered with foodbanks to donate meals for adults  In addition, a sponsor in one selected state told us they adjusted their meal offerings to match the needs of children of different age groups, for example, by serving meals to younger children earlier in the day and meals to teens later in the day  To support participation from children of all ages, FNS has shared information on age-appropriate activities through its SFSP toolkit and provided related grant funding  For example, in 2010, FNS funded the Activity Incentive demonstration project, in which sponsors in Mississippi were provided with mini-grants to increase enrichment and recreational activities, such as education, tutoring, sports and games, arts and other activities, to draw children to meal sites  More than half the states reported in our survey that they faced a moderate to extreme challenge with limited state agency staffing (27), a limited amount of federal funding for SFSP administration (27), as well as ensuring sponsor participation to meet needs (28)  In addition, 28 states reported in our survey that they faced a moderate to extreme challenge with sponsors not following program requirements  Limited staffing can affect a state agency’s ability to conduct efforts aimed at increasing participation, identifying potential sponsors, and reviewing and monitoring sponsors, according to national organization and state officials we interviewed  For example, increases in sponsors and sites requires additional staff and time to conduct pre-approval visits, sponsor and site reviews, vendor reviews, and technical assistance visits, which directly affects the amount of funding needed to support staff salaries and travel reimbursement, according to one state in our survey  However, because the SFSP administrative funds FNS provides to states are based on the number of meals served in the previous year, increasing the number of staff to help increase SFSP participation is difficult, according to a national organization official we interviewed  States reported a moderate to extreme challenge with the following issues related to ensuring sponsor participation: a lack of sponsors to meet summer meal needs, a lack of awareness of the summer meal program among potential sponsors or sites, completing federal requirements for monitoring of SFSP sponsors, and identifying potential sponsors  State agencies responsible for administering the SFSP reported relying on other resources and partners to help with program administration— strategies that FNS has supported through information sharing and its online tools  As discussed earlier, all three selected state agencies we interviewed told us they partner with advocacy groups to help expand and conduct outreach on the SFSP  Additionally, more than half the states in our survey reported several factors—which may ease the administrative burden on states—as critical to the success of the SFSP, including partnerships with SFSP sponsors (49) and retaining sponsors and sites over multiple summers (51)  To support states’ use of alternative funding sources to help administer the SFSP, FNS has shared information on federal, state, and private funding and grant opportunities  FNS also developed the online Capacity Builder tool, which 35 states reported in our survey was moderately to extremely useful in identifying or confirming meal site eligibility in fiscal year 2017  Seventeen states reported in our survey that ensuring summer meal sites are in safe locations was moderately to very challenging, a challenge that some states and SFSP providers have taken steps to help address  State officials and SFSP providers in the selected states reported that when crime has occurred near a site, there are concerns about ensuring children’s safety while they are consuming meals at the site, as well as the safety of site staff delivering meals  Some sponsors noted, in particular, parents’ concerns for the safety of their children at meal sites in light of criminal activities in the surrounding area  To ensure children continue to have access to meals, some sponsors noted that in the event of an immediate threat at an outdoor meal site, site staff are sometimes able to bring children to a nearby indoor space instead  States and SFSP provider officials in two selected states told us they have also used other strategies, including partnerships with local law enforcement agencies, to help address safety concerns during the meal service and ensure children have access to meals  For example, national organizations involved in summer meals and sponsor officials in the selected states said they encourage partnerships with local police departments to use police escorts at meal sites or to follow mobile meal routes in situations where safety at the meal site is a concern  When violence or crime has occurred near a site, some states and SFSP sponsors have also sought flexibility from FNS with respect to the federal requirement that children consume summer meals on site, according to state and local officials  FNS has used its available authorities to grant some states and sponsors flexibility with respect to the requirement that children consume summer meals on site, such as when safety at the site is a concern; however, FNS has not clearly communicated to all states and sponsors the circumstances it considers when deciding whether to grant this flexibility  According to our review of letters FNS sent to multiple states approving their requests for this type of flexibility, the agency identified a consistent set of circumstances that needed to be met for it to grant this flexibility  These circumstances were described in the letters the agency sent to states and generally included verification that violent crime activities occurred within both a 6-block radius of the meal site and 72 hours prior to the meal service  FNS’s letters to states indicate that when documentation was provided to the agency showing that these circumstances existed at a summer meals site on a particular day or days, meals consumed by children off site on those days were eligible for federal reimbursement  Although FNS has issued guidance on the general processes for requesting flexibility from program requirements under its waiver and demonstration authorities, these guidance documents do not detail the specific circumstances that the agency considers when deciding whether to grant flexibility from the on-site requirement due to safety concerns  FNS has communicated this information only in its responses to specific state and sponsor requests, and it has not communicated these circumstances more broadly to all states and sponsors  FNS officials explained that they review state and sponsor requests for flexibility due to safety concerns on a case-by-case basis  However, they also acknowledged that the set of circumstances used for approval of state and sponsor requests for flexibility, which we identified in their letters to states, has been used repeatedly  Further, states and sponsors reported challenges obtaining the specific data needed for approval of a site for this type of flexibility, hampering some providers’ efforts to ensure safe delivery of meals  For example, state agency and sponsor officials in one selected state said obtaining the crime data needed to qualify for the flexibility can be an administrative burden on sponsors, and these data are not consistently available in a timely manner  According to state agency and sponsor officials in one of the selected states, daily crime statistics are not available in all areas, and while a sponsor can sometimes access current data on crime in a city, the most recent available data on crime in suburban areas are sometimes one year old  FNS is aware of state and local challenges obtaining the necessary crime data, according to our discussions with FNS officials  FNS officials acknowledged that while they have granted some state and sponsor requests to allow children to consume meals off site in certain areas where violence or crime has occurred, some sponsors were unable to implement the flexibility because they could not obtain the necessary crime data  To help achieve agency objectives and address related risks, the Standards for Internal Control in the Federal Government state that agencies should communicate key information to their internal and external stakeholders  Although FNS officials told us they do not have one set of circumstances under which they approve these requests, our review found only one set of circumstances under which this type of flexibility has been approved  However, FNS has not broadly communicated the circumstances it considers in deciding whether to approve requests for flexibility with respect to the requirement that children consume summer meals on site in areas with violence or crime  Unless FNS shares this information with all states and sponsors, states and sponsors will likely continue to be challenged to use this flexibility, hindering its usefulness in ensuring safe summer meal delivery to children  In addition, FNS has issued reports to Congress evaluating some of its demonstration projects, as required under its statutory authorities, but the agency has not issued any such reports to Congress specifically on the use of flexibilities with respect to the on-site requirement in areas where safety is a concern  As previously discussed, the agency is required to annually submit certain reports to Congress regarding the use of waivers and evaluations of projects carried out under its demonstration authority  Furthermore, Standards for Internal Control in the Federal Government state that management should use quality information to make informed decisions and evaluate the entity’s performance in achieving key objectives and addressing risks  Yet, FNS has not evaluated nor reported on the use of waivers and demonstration projects in cases where safety was a concern  Although FNS requests reports from state agencies or sponsors that have received flexibility with summer meals delivery under FNS’s demonstration and waiver authorities, FNS officials told us they have not assessed whether their use of these flexibilities to address safety issues has been effective in ensuring safe meal delivery  FNS officials told us that they have not evaluated or reported on these flexibilities, in part, because they have limited information on their outcomes  Without understanding the impact of its use of these flexibilities, neither FNS nor Congress knows whether these flexibilities are helping provide meals to children  In addition to the challenges with safety at meal sites, sponsors also sometimes face administrative challenges when participating in multiple child nutrition programs that are operated by different state agencies or divisions within the same agency, according to officials from national and regional organizations and sponsors we interviewed  For example, officials from national organizations involved in summer meals told us the management of each child nutrition program and processes related to applications, funding, and oversight are fragmented in many states  For example, a sponsor in one of the selected states told us aspects of the SFSP and CACFP sponsor applications are highly duplicative and estimated it took 42 hours last year to complete duplicative paperwork  Another sponsor that provides school meals during the school year told us they had to fill out 60 additional pages of paperwork to provide summer meals, which coupled with having a state contact for the SFSP that was different from the one they worked with for the NSLP, was a significant burden for them  Officials from one national organization told us a lack of interoperability of some state agencies’ data systems has caused challenges and administrative burden for some sponsors  For example, in some states, different agencies oversee child nutrition programs, yet are unable to share data on sponsor approval, and therefore, sponsors are required to submit similar information to both, according to these officials  Duplicative paperwork can be particularly burdensome for some SFSP providers, as national organization officials and SFSP providers in the selected states said completing SFSP application paperwork can be especially challenging when a sponsor has staff shortages or no dedicated SFSP staff  Some selected states have worked with SFSP sponsors to help minimize the administrative burden  For example, state agency officials from one of the selected states said they have connected less-experienced sponsors to more-experienced sponsors in the community to help them with program administration  In one case, an experienced SFSP sponsor partnered with a small sponsor new to the program to help with SFSP administration, including helping them understand program rules and paperwork requirements  One SFSP sponsor also noted that their state agency took additional steps to ease administrative burden, such as making the forms for the CACFP more consistent with those for the SFSP and streamlining certain requirements for large and experienced sponsors, which the sponsor found helpful  At the federal level, FNS has established program and policy simplifications to help lessen the administrative burden on sponsors participating in multiple child nutrition programs, though the persistence of these challenges indicate that information about these simplifications has not reached all relevant state agencies  While FNS officials told us that some of the duplicative requirements may be a function of differences in statute, FNS provided guidance to states in 2011 and 2014 on simplified application procedures for institutions participating in CACFP that also wish to apply for SFSP  FNS noted in its guidance that in states where CACFP and SFSP are administered by different state agencies, state agencies are encouraged to work together to share information and streamline the application and agreement process as much as possible  FNS also addressed these simplifications in a state agency meeting in November 2017  Additionally, FNS provided guidance to states in 2012 on simplified application and review procedures for school food authorities participating in the NSLP that wish to also participate in the SFSP  Although FNS has shared this information with states in an attempt to make them aware of streamlining options, FNS officials noted that some states may choose not to implement them  Standards for Internal Control in the Federal Government state that management should externally communicate the necessary quality information to achieve the entity’s objectives, as well as periodically evaluate the methods of communication to ensure communication is effective and appropriate  FNS’s existing guidance addresses options for streamlining administrative requirements for sponsors participating in multiple child nutrition programs  However, information on program and policy simplifications available for sponsors participating in both NSLP and SFSP has not been shared with states recently, and challenges in this area persist, indicating this information has not reached all relevant state agencies  Without further efforts from FNS to disseminate information on current options for streamlining administrative requirements across child nutrition programs, overlapping and duplicative administrative requirements may limit children’s access to meals by discouraging sponsor participation in child nutrition programs  The purpose of the SFSP is to continue to provide children in low-income areas with nutritious meals over the summer when school is no longer in session, and to that end, the program provided 149 million SFSP meals to children in fiscal year 2016  Although meals served are one indicator of participation, FNS’s current estimates of children participating in SFSP are unreliable  Without additional understanding of children’s participation in the SFSP, FNS lacks information critical for informing program implementation, strategic planning, and outreach  The majority of states nationwide and SFSP providers in the three states we visited reported experiencing a number of challenges with the SFSP, and FNS has taken important steps to address these challenges  Two key challenges identified by officials in the selected states and national organizations we interviewed are ensuring summer meal sites are in safe locations, and meeting administrative requirements when participating in multiple child nutrition programs  FNS has taken steps to address these challenges by providing flexibilities in how meals are delivered to children and streamlining options for those providers participating in more than one child nutrition program  However, a lack of clarity concerning the circumstances under which FNS grants flexibilities in areas of violence and crime, and a lack of information on its use of these flexibilities and their impact on program administration, hinder efforts to ensure program goals are met  Furthermore, absent a reminder to states regarding existing options for streamlining administration across multiple nutrition programs, some providers may continue to be discouraged from participating in these programs due to duplicative and burdensome administrative requirements, which may ultimately limit the provision of nutritious meals to children  We are making the following four recommendations to FNS: The Administrator of FNS should improve its estimate of children’s participation in the SFSP by focusing on addressing, at a minimum, data reliability issues caused by variations in the number of operating days of meal sites and in the months in which states see the greatest number of meals served  (Recommendation 1) The Administrator of FNS should communicate to all SFSP stakeholders the circumstances it considers in approving requests for flexibility with respect to the requirement that children consume SFSP meals on-site in areas that have experienced crime and violence, taking into account the feasibility of accessing data needed for approval, to ensure safe delivery of meals to children  (Recommendation 2) The Administrator of FNS should evaluate and annually report to Congress, as required by statute, on its use of waivers and demonstration projects to grant states and sponsors flexibility with respect to the requirement that children consume SFSP meals on-site in areas experiencing crime or violence, to improve its understanding of the use and impact of granting these flexibilities on meeting program goals  (Recommendation 3) The Administrator of FNS should disseminate information about existing flexibilities available to state agencies to streamline administrative requirements for sponsors participating in the SFSP and other child nutrition programs to help lessen the administrative burden  For example, FNS could re-distribute existing guidance to state agencies that explains available flexibilities and encourage information sharing  (Recommendation 4) We provided a draft of this report to the Secretary of the USDA for review and comment  FNS officials provided technical comments, which we incorporated as appropriate  In addition, in oral comments, FNS officials, including the Deputy Administrator for Child Nutrition Programs, generally agreed with the recommendations in the report  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 the Secretary of the USDA and interested congressional committees  The report will also be available at no charge on the GAO website at www gao gov  If you or your staff have any questions about this report, please contact me at (202) 512-7215 or larink@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 IV  This appendix discusses in detail our methodology for addressing three research objectives: (1) What is known about participation in the Summer Food Service Program (SFSP) and how has it changed in the last 10 years? (2) What other programs help feed low-income children over the summer? and (3) What challenges exist, if any, in providing summer meals to children, and to what extent does the U S  Department of Agriculture’s (USDA) Food and Nutrition Service (FNS) provide assistance to states and sponsors to address these challenges? In addition to the methods we discuss below, to address all three research objectives, we reviewed relevant federal laws, regulations, and guidance; interviewed FNS officials in its headquarters and seven regional offices; and interviewed a broad range of regional and nationwide organizations involved in the SFSP  In addition, we coordinated with officials in USDA’s Office of Inspector General on their ongoing work in this area  To address our first objective about participation in the SFSP, we analyzed FNS data on meals served for fiscal years 2007 through 2016  Specifically, we analyzed the total number of meals served nationwide through the SFSP from fiscal year 2007 through fiscal year 2016  Each month, states report to FNS the number of meals served by meal type (breakfast, lunch, snack, and supper) and the number of meals served by meal and sponsor type (e g , government, nonprofit, etc ) using the FNS- 418 form  To add context on these trends, we also analyzed and compared the number of SFSP lunches served in July with the number of free and reduced-price lunches served to children in March through the National School Lunch Program (NSLP), the largest child nutrition assistance program, from fiscal year 2007 through fiscal year 2016  Each month, states report to FNS the number of meals served through the NSLP using the FNS-10 form  To assess the reliability of SFSP and NSLP data, we (1) performed electronic testing of relevant data elements, (2) reviewed existing information about the data and the system that produced them, and (3) interviewed agency officials knowledgeable about the data  Electronic testing included, but was not limited to, checks for missing data elements, duplicative records, and values outside a designated range or valid time period  We determined that these data were sufficiently reliable to identify the number of SFSP meals served and assess change over time  To further examine what is known about participation in the SFSP, we also reviewed FNS’s data on estimates of children’s participation in the program and determined that these estimates have been calculated inconsistently and are unreliable  To assess the reliability of these data, we reviewed documentation about the estimates, interviewed FNS officials, and asked states about the estimate calculation in our survey  As described in our findings, FNS does not collect data on the number of children participating in the SFSP  Instead, FNS relies on states’ estimates of children’s participation, which are based on other data reported by sponsors, such as the number of meals served and meal service days in July  To address our second objective about other programs that help feed children in the summer, we reviewed FNS’s estimate of the number of meals served through the NSLP’s Seamless Summer Option in fiscal year 2016  FNS does not collect data on the number of meals served through the Seamless Summer Option  Instead, FNS annually estimates the number of Seamless Summer Option meals served nationally by aggregating the number of free and reduced-price breakfasts, lunches, and snacks served through the School Breakfast Program (SBP) and NSLP in July  As previously noted, states report these data monthly to FNS  Although FNS does not know the actual number of meals served through the Seamless Summer Option, agency officials told us they believe the number of summer meals provided through the NSLP is small relative to the number of meals served through the Seamless Summer Option during the summer months  They noted that their use of July NSLP data to estimate the Seamless Summer Option meals likely overestimates the number of these meals for July and underestimates the number of these meals for the entire summer  To assess the reliability of the July NSLP data, we (1) performed electronic testing of relevant data elements, (2) reviewed existing information about the data and the system that produced them, and (3) interviewed agency officials knowledgeable about the data  Electronic testing included, but was not limited to, checking for missing data and data that fell outside of a reasonable range or date for the specific time period (July)  We determined that these data were sufficiently reliable to describe the number of meals served  In addition to the data FNS requires states to report, some states collect summer meals data at the meal site level and we used such data from the three selected states to address all three objectives  For objective one, to examine the number of meals served and days of operation at each summer meals site, we analyzed site-level data for 2 months from summer 2016, including the month with the largest number of SFSP meals served in each selected state: Arizona (June and July 2016), Illinois (July and August 2016), and Massachusetts (July and August 2016)  Each state also provided us with data on the number and types of meals served at each SFSP site, the site location, and the duration of time each site operated over the summer  Using the data provided by the states, we calculated the average daily attendance (ADA) for each meal site based on FNS’s instructions and examined the variation in ADA across sites and months  For our second objective on other programs, these selected states provided similar site level data for the state’s Seamless Summer Option sites, if applicable  We assessed the reliability of these data by (1) performing electronic testing of relevant data elements, (2) reviewing existing information about the data and the system that produced them, and (3) interviewing agency officials knowledgeable about the data  We determined that the data were sufficiently reliable for the purposes of this report  For both our second objective on other programs and third objective about challenges in providing summer meals to children, we also examined meal site availability in the three selected states by mapping the locations of meal sites  On the maps, we included fiscal year 2016 area eligibility data from FNS’s Capacity Builder mapping tool, as provided by FNS  The site area eligibility data from FNS’s Capacity Builder is based on the U S  Census Bureau’s 5-Year American Community Survey (ACS) estimates of children ages 0-12 and 0-18 eligible for free and reduced-price meals by Census block group and tract  According to FNS officials, FNS obtains 5-Year ACS estimates annually from the U S  Census Bureau and updates its site area eligibility in the Capacity Builder accordingly  For fiscal year 2016, FNS used 2009- 2013 ACS data to identify and include site area eligibility in its Capacity Builder  To help inform all of our research objectives, we conducted a survey of the state agencies that oversee the SFSP in the 50 states and the District of Columbia  We administered our web-based survey between August and October 2017 and received 100 percent response rate  The survey included questions about participation in the SFSP, factors critical to the overall success of the SFSP, outreach efforts, federal technical assistance, barriers and challenges in providing summer meals, alternative summer feeding models, the NSLP’s Seamless Summer Option and the federal Summer Electronic Benefit Transfer for Children demonstration, and nonfederal programs that provide children of low- income households with meals during the summer months  The survey also requested data on SFSP sites participating in the program in fiscal year 2016 and the method state agencies used to calculate ADA in SFSP on the FNS-418 form in fiscal year 2016  Because this was not a sample survey, there are no sampling errors  However, the practical difficulties of conducting any survey may introduce nonsampling errors, such as variations in how respondents interpret questions and their willingness to offer accurate responses  We took steps to minimize nonsampling errors, including pretesting draft instruments and using a web-based administration system  Specifically, during survey development, we pretested draft instruments with SFSP staff from four states (Michigan, New Mexico, North Carolina, and South Dakota) in May 2017  We selected the pretest states based on information provided by officials from FNS’s regional offices and national organizations involved in summer meals about state administration of summer meals programs, with the goal of selecting a group of states with varied experiences  In the pretests, we were generally interested in the clarity, precision, and objectivity of the questions, as well as the flow and layout of the survey  For example, we wanted to ensure definitions used in the surveys were clear and known to the respondents, categories provided in close-ended questions were complete and exclusive, and the ordering of survey sections and the questions within each section were appropriate  We revised the final survey based on pretest results  Another step we took to minimize nonsampling errors was using a web-based survey  Allowing respondents to enter their responses directly into an electronic instrument created a record for each respondent in a data file and eliminated the need for and the errors associated with a manual data entry process  We did not fully validate specific information that states reported through our survey  To help inform all of our objectives and gather information about the SFSP directly at the local-level, we conducted 30 site visits in three states: Arizona (12 sites), Illinois (8 sites), and Massachusetts (10 sites) between June and July 2017, and interviewed organizations involved with the SFSP in each site visit state  We used U S  Census Bureau data to select states and local areas within those states based on a high proportion of children in poverty, a mix of urban and rural locations, as well as a mix of sponsor and site type and diverse locations  We visited a wide variety of site locations including, but not limited to, schools, parks, community recreation areas, and libraries  At each SFSP site, we gathered information on local level factors related to SFSP participation and administration by interviewing the organization sponsoring the site, the site operators and staff, and those participating at the site using semi-structured questions  While interviewing SFSP sponsor organizations, we collected information on the sponsors’ roles in the SFSP, characteristics of the sites the organizations sponsored, outreach efforts, any challenges or barriers to SFSP administration and any efforts to address such challenges, relationships with the state agencies that administer the SFSP, relationships with FNS (national and regional offices), and the availability of nonfederally funded programs that provide meals to low-income children over the summer  During the interviews with site operators and staff, we collected information about site operation (e g , site operating days, meals offered, etc ), any challenges to providing SFSP meals to children and any efforts to address such challenges, outreach efforts, and the proximity of the next closest meal site  The information we collected from those participating at the sites included their perspectives on the SFSP food, site food consumption habits, ease of travel to the site, and access to other SFSP sites  At each site, we made observations as to how the food was provided to the children, food consumption and waste, the approximate age range of the children being served, and availability of programs or activities (e g , recreational sports)  Using semi-structured questions, we also interviewed the state agencies responsible for administering the SFSP in the site visit states to gather further information on how the SFSP is administered in each state, statewide participation in the program, related data collection activities, any challenges to administering the program and any efforts to address such challenges, related outreach efforts, alternative meal delivery models being employed by SFSP sponsors, FNS guidance or technical assistance, and the availability of nonfederally funded programs that provide meals to low-income children over the summer  For states that indicated there were other challenge(s), we provided an open-ended question that requested a description of the challenge(s) and 14 states provided descriptions of other challenges, not shown here  For states that indicated there were other challenge(s), we provided an open-ended question that requested a description of the challenge(s) and 8 states provided descriptions of other challenges, not shown here  In addition to the contact named above, Rachel Frisk (Assistant Director), Claudine Pauselli (Analyst-in-Charge), Melissa Jaynes, and Matthew Nattinger made key contributions to this report  Also contributing to this report were Susan Aschoff, Sarah Cornetto, Ying Long, Jean McSween, Mimi Nguyen, Almeta Spencer, and Ashanta Williams 


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: The SFSP, a federal nutrition assistance program, is intended to provide food to children in low-income areas during periods when area schools are closed for vacation. In the last decade, federal expenditures for SFSP have increased as the program has expanded, according to USDA data. GAO was asked to review the SFSP. This report examines (1) what is known about SFSP participation, (2) other programs that help feed low-income children over the summer, and (3) challenges, if any, in providing summer meals to children and the extent to which USDA provides assistance to address these challenges. GAO reviewed relevant federal laws, regulations, and guidance; analyzed USDA's SFSP data for fiscal years 2007 through 2016; surveyed state agencies responsible for administering the SFSP in 50 states and the District of Columbia; visited a nongeneralizable group of 3 states and 30 meal sites, selected based on Census data on child poverty rates and urban and rural locations; analyzed meal site data from the 3 states; and interviewed USDA, state and national organization officials, and SFSP providers, including sponsors and site operators. Nationwide, the total number of meals served to children in low-income areas through the Summer Food Service Program (SFSP) increased from 113 to 149 million (about 32 percent) from fiscal year 2007 through 2016. The U.S. Department of Agriculture (USDA) directs states to use the number of meals served, along with other data, to estimate the number of children participating in the SFSP. However, participation estimates have been calculated inconsistently from state to state and year to year. In 2017, USDA took steps to improve the consistency of participation estimates, noting they are critical for informing program implementation and strategic planning. However, GAO determined that the method USDA directs states to use will continue to provide unreliable estimates of participation, hindering USDA's ability to use them for these purposes. Other federal and nonfederal programs help feed low-income children over the summer to some extent, according to states GAO surveyed and SFSP providers and others GAO interviewed. For example, in July 2016, USDA data indicate about 26 million meals were served through a separate federal program that allows school meal providers to serve summer meals. Some children also received summer meals through nonfederal programs operated by faith-based organizations and foodbanks, though GAO's state survey and interviews with providers and national organizations indicate the reach of such efforts is limited. States and SFSP providers reported challenges with meal sites, participation, and program administration; USDA has taken steps to address these areas. Specifically, in GAO's survey, a majority of states reported challenges with availability and awareness of meal sites, as well as limited program participation and administrative capacity. National, state, and local officials have taken steps to address these issues, such as increasing outreach and offering activities to attract participation. In addition, 17 states in GAO's survey and providers in the states GAO visited reported a challenge with ensuring meal sites are in safe locations. To address this safety issue, USDA has granted some states and sponsors flexibility from the requirement that children consume meals on-site. However, USDA has not broadly communicated the circumstances it considers when granting this flexibility. Further, some states and sponsors that have requested this flexibility reported difficulty obtaining data to show these circumstances exist, hampering their ability to ensure safe meal delivery. GAO is making four recommendations, including that USDA improve estimates of children's participation in SFSP and communicate the circumstances it considers when granting flexibilities to ensure safe meal delivery. USDA generally agreed with GAO's 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:  Then-Department of State Legal Adviser Harold Koh stated November 9, 2009, that the United States has determined that its "national security interests cannot be fully ensured consistent with the terms" of the CCM  The Barack Obama Administration announced on November 25, 2011, that the United States would continue to implement the DOD policy on cluster munitions issued June 19, 2008, which recognized the need to minimize harm to civilians and infrastructure but also reaffirmed that "cluster munitions are legitimate weapons with clear military utility " The central directive in the Pentagon's policy was the unwaiverable requirement that cluster munitions used after 2018 must leave less than 1% of unexploded submunitions on the battlefield  Prior to that deadline, U S  use of cluster munitions that did not meet this criterion required combatant commander approval  On November 30, 2017, then-Deputy Secretary of Defense Patrick Shanahan issued a revised policy on cluster munitions  The memorandum describing the policy noted that [c]luster munitions provide the Joint Force with an effective and necessary capability to engage area targets, including massed formations of enemy forces, individual targets dispersed over a defined area, targets whose precise location are not known, and time-sensitive or moving targets  Cluster munitions are legitimate weapons with clear military utility, as they provide distinct advantages against a range of threats in the operating environment  Additionally, the use of cluster munitions may result in less collateral damage than the collateral damage that results from use of unitary munitions alone  Since the inception of the 2008 policy, in the midst of extended combat operations in Iraq and Afghanistan, we have witnessed important changes in the global security environment and experienced several years of budgets that under-invested in replacement systems and the modernization of the Joint Force more broadly  Our adversaries and our potential adversaries have developed advanced capabilities and operational approaches specifically designed to limit our ability to project power  Both Shanahan and Admiral Harry Harris Jr  have also argued that sustaining the current U S  cluster munitions arsenal is necessary to prepare for a potential conflict with North Korea  The revised policy reverses the 2008 policy that established an unwaiverable requirement that cluster munitions used after 2018 must leave less than 1% of unexploded submunitions on the battlefield  Combatant commanders can use cluster munitions that do not meet the 1% or less unexploded submunitions standard in extreme situations to meet immediate warfighting demands  Furthermore, the new policy does not establish a deadline to replace cluster munitions exceeding the 1% rate, and these munitions will be removed only after new munitions that meet the 1% or less unexploded submunitions standard are fielded in sufficient quantities to meet combatant commander requirements  However, the new DOD policy stipulates that the department "will only procure cluster munitions containing submunitions or submunition warheads" meeting the 2008 UXO requirement or possessing "advanced features to minimize the risks posed by unexploded submunitions " Specifically, DOD's revised policy stipulates the following: Continuing or beginning with their respective FY2019 budgets, the military departments will program for capabilities to replace cluster munitions currently in active inventories that do not meet the above-described standards for procuring new cluster munitions  The department's annual Program and Budget Review will be used to assess the sufficiency of the replacement efforts  The department's operational planners should plan for the availability of cluster munitions  The approval authority to employ cluster munitions that do not meet the standards prescribed by this policy for procuring new cluster munitions, however, rests with the combatant commanders  In accordance with their existing authorities, commanders may use cluster munitions that meet the standards prescribed by this policy for procuring new cluster munitions  The military departments and combatant commands, in keeping with U S  legal obligations under CCW Protocol V on Explosive Remnants of War and consistent with past practices, will continue to record and retain information on the use of cluster munitions and provide relevant information to facilitate the removal or destruction of unexploded submunitions  The military departments and combatant commands will maintain sufficient inventories and a robust stockpile surveillance program to ensure operational quality and reliability of cluster munitions  In extremis, to meet immediate warfighting demand, combatant commanders may accept transfers of cluster munitions that do not meet the above-described cluster-munition procurement standards  Cluster munitions that do not meet the standards prescribed by this policy for procuring new cluster munitions will be removed from active inventories and demilitarized after their capabilities have been replaced by sufficient quantities of munitions that meet the standards in this policy  The department will not transfer cluster munitions except as provided for under U S  law  The operational use of cluster munitions that include Anti-Personnel Landmines (APL) submunitions shall comply with presidential policy  Furthermore, the Deputy Secretary of Defense Expect(s) the Department to achieve the goals in this policy as rapidly as industry can support  Combatant Commanders will continue to ensure that the employment of cluster munitions is consistent with the law of war and applicable international agreements in order to minimize their harmful effects on civilian populations and infrastructure  In developing a new generation of cluster munitions less dangerous to civilians, DOD will need to determine whether such a high level of performance is achievable under both controlled laboratory conditions and real-world conditions  Factors such as delivery technique, landing in soft or muddy ground, getting caught in trees and vegetation, and submunitions being damaged after dispersal or landing could result in an appreciable number of dud submunitions, even if they have a self-deactivation feature  DOD and the services have been and are currently involved in efforts to reduce cluster munitions failure rates  The Army's Alternative Warhead Program (AWP) is intended to assess and recommend new technologies to reduce or eliminate cluster munitions failure rates  The AWP program is viewed as particularly relevant, as the Pentagon estimates that "upward of 80 percent of U S  cluster munitions reside in the Army artillery stockpile " In December 2008, the Army decided to cease procurement of a Guided Multiple Launch Rocket System (GMLRS) warhead—the Dual-Purpose Improved Conventional Munition (DPICM) warhead—because its submunitions had a dud rate up to 5%  The Air Force has also acquired cluster munitions that comply with the less than 1% failure rate—the CBU-97 Sensor Fuzed Weapon (SFW) and the CBU-105 WCMD/SFW  While DOD's new 2017 cluster munitions policy calls for DOD to continue its efforts to meet the 1% or less unexploded submunitions standard "as rapidly as industry can support," it is not yet known how this policy will affect the aforementioned programs or how it could result in the establishment of new programs  It may be argued that even with advances in "sensor-fuzed" type submunitions that seek out and destroy certain targets, cluster munitions are still essentially an indiscriminate area weapon in an era where precision weapons are increasingly becoming the military norm  In Operation Desert Storm in 1991, only about 10% of ordnance used were precision-guided, but by the time of the Iraq invasion in 2003, "the ratio of 'smart' to dumb weapons was nearly reversed " Since then, this trend toward greater precision has continued, if not accelerated with the development of precision rocket, artillery, mortar munitions, and smaller precision aerial bombs designed to reduce collateral damage  Given current and predicted future precision weaponry trends, cluster munitions might be losing their military relevance—much as chemical weapons did between World War I and World War II  According to the State Department, the U S  military suspended its use of cluster munitions in Iraq and Afghanistan in 2003  For subsequent military operations, where cluster munitions would otherwise have been the weapon of choice, Congress might review what types of weapons were substituted in place of cluster munitions and how effective they were in achieving the desired tactical results  Also worth considering are effects-based weapons systems and operations, which seek to achieve the same or similar effect against a potential target without applying a "kinetic solution" such as a cluster munition  Such insights could prove valuable in analyzing U S  policy options on the future of cluster munitions  DOD's November 2017 revised policy on cluster munitions potentially raises a number of issues for possible congressional consideration  With limits on cluster munition use after 2018 rescinded, how does this affect combatant commanders' operational plans in their respective theaters? Does this mean a lesser degree of military risk because combatant commanders can employ cluster munitions to meet warfighting demands, possibly translating into fewer forces needed to achieve the same result when the 2008 policy was in effect? Despite DOD emphasis on achieving a 1% or less unexploded submunitions standard "as rapidly as industry can support," will DOD funding restrictions slow or stall programs previously intended to replace those systems that exceeded 1% because there no longer is an urgent operational need to replace those systems? In a similar manner, will defense industry view this as a renewed opportunity to develop systems with a 1% or less unexploded submunitions standard or take a more sanguine view that since DOD is no longer time constrained to develop and field 1% or less weapons that funding these programs will be less of a priority and, therefore, an unprofitable venture? Another possible issue for consideration is how this U S  policy reversal on the military use of cluster munitions will be perceived by the international community and how this might affect future U S  and international military treaty initiatives  Consolidated Appropriations Acts The Consolidated Appropriations Act, 2010 ( P L  111-117 ), which the President signed into law December 16, 2009, prohibits the provision of military assistance for cluster munitions, the issuing of defense export licenses for cluster munitions, or the sale or transfer of cluster munitions or cluster munitions technology unless "the submunitions of the cluster munitions, after arming, do not result in more than 1 percent unexploded ordnance across the range of intended operational environments " Moreover, any agreement "applicable to the assistance, transfer, or sale of such cluster munitions or cluster munitions technology" must specify that the munitions "will only be used against clearly defined military targets and will not be used where civilians are known to be present or in areas normally inhabited by civilians " Subsequent appropriations laws have included similar provisions; the most recent is the Consolidated Appropriations Act, 2019 ( P L  116-6 ), which the President signed into law on February 15, 2019  

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.