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



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



Report 2: IHS was established within the Public Health Service in 1955 to provide health services to members of AI/AN tribes, primarily in rural areas on or near reservations  IHS provides these services directly through a network of hospitals, clinics and health stations, while also providing funds to tribally operated facilities  These federally and tribally operated facilities are located primarily in service areas that are rural, isolated, and underserved  In fiscal year 2017, IHS allocated about $1 9 billion for health services provided by federally and tribally operated facilities  Federally operated IHS facilities, which received over 5 2 million outpatient visits and over 15,000 inpatient admissions in 2016, provide mostly primary and emergency care, as well as some ancillary and specialty services in 26 hospitals, 55 health centers, and 21 health stations  According to IHS, federally operated IHS hospitals range in size from 4 to 133 beds and generally are open 24 hours a day for emergency care needs; health centers offer a range of care, including primary care services and some ancillary services, such as pharmacy, laboratory, and X-ray services, and are open for at least 40 hours a week; and health stations offer only primary care services on a regularly scheduled basis and are open fewer than 40 hours a week  The 12 IHS area offices are responsible for distributing funds to the facilities in their areas, monitoring their operation, and providing guidance and technical assistance (see fig  1)  In addition, five human resources regional offices assist the area offices in the recruitment and hiring of providers  IHS federally operated facilities employ both federal civil service personnel and Commissioned Corps officers  IHS may pay higher salaries for certain federal civil service providers through the development and implementation of special pay tables, which specify the ranges of salaries that these certain providers can receive  According to IHS officials, the Commissioned Corps officers follow the same process for applying for positions at IHS as federal civil service employees  However, the Commissioned Corps officers are uniformed health professionals whose pay and allowances are different  IHS also supplements its workforce capacity with both temporary and long-term contracts with individual physicians or a medical staffing company  IHS downloads information on all funded and active positions from the Capital Human Resource Management System, an HHS data system used for personnel and payment transactions that IHS began using in 2016 to track all employee vacancies  According to IHS officials, the accuracy of the data is verified quarterly by regional human resources officers  As the IHS health care workforce also includes Commissioned Corps officers—who have a separate personnel system—the information on Commissioned Corps officers assigned to IHS are entered into the Capital Human Resource Management System manually, according to IHS officials  According to the National Rural Health Association, the challenges of rural health care delivery are different than those in urban areas  These challenges include those related to more complex patient health status and poorer socioeconomic conditions, as well as physician workforce shortages  According to the Agency for Healthcare Research and Quality, compared with their urban counterparts, residents of rural counties are older, poorer, more likely to be overweight or obese, and sicker  Those living in rural areas also have greater transportation difficulties reaching health care providers, often traveling great distances to reach a doctor or hospital  Exacerbating these challenges is a relative scarcity of medical providers in rural areas compared to urban areas  For example, the National Center for Health Statistics reported the primary care physician- to-patient ratio in rural areas in 2012 was 39 8 physicians per 100,000 people, compared to 53 3 physicians per 100,000 in urban areas  IHS data demonstrate large percentages of vacancies for providers in the 8 areas in which IHS has substantial direct care responsibilities  As of November 2017, the overall percentage of vacancies for physicians, nurses, nurse practitioners, CRNAs, certified nurse midwives, physician assistants, dentists, and pharmacists in these areas was 25 percent, ranging from 13 to 31 percent across the areas  (See fig  2) However, variation in vacancy rates existed among provider types across IHS areas  For example, while the overall percentage of vacancies for physicians, nurses, nurse practitioners, dentists, and physician assistants each exceeded 25 percent, the vacancy rate for pharmacists was less than 25 percent  In addition, for certain provider types in some areas, more than one-third of the positions were vacant  For example, although 29 percent of the total positions for physicians across these 8 areas were vacant, the vacancy rate ranged from 21 percent in the Oklahoma City area to 46 percent in the Bemidji and Billings areas  (See fig  3 ) As another example, although 27 percent of the total positions for nurses across these 8 areas were vacant, the vacancy rate ranged from 10 percent in the Oklahoma City area to 36 percent in the Albuquerque and Bemidji areas  (See fig  4 ) Similarly, across these 8 areas 32 percent of the total positions for nurse practitioners were vacant, ranging from 12 percent in the Oklahoma City area to 47 percent in the Albuquerque area; 27 percent of the total positions for dentists were vacant, ranging from 14 percent in the Phoenix area to 39 percent in the Bemidji area; and 30 percent of the total positions for physician assistants were vacant, and although 4 of the areas had few such positions (the Albuquerque, Bemidji, Oklahoma City, and Portland areas each had 7 or fewer positions), the percentage of vacancies in the 4 areas with 15 or more such positions ranged from 21 percent in the Phoenix area to 40 percent in the Billings area  In contrast, 13 percent of the total positions for pharmacists were vacant, ranging from 3 percent in the Bemidji area to 17 percent in the Albuquerque area  For more information about the vacancies for specific clinical positions, see appendix I  While sizeable vacancies existed across provider types and areas, the majority of positions in all eight areas were occupied by civilians, and about 13 percent were filled by Commissioned Corps officers who are fulfilling assignments with a minimum 2-year term  The percentages of positions by IHS area that were vacant, filled by civilians, and filled by Commissioned Corps officers as of November 2017 are shown in figure 5  IHS officials told us they have experienced considerable challenges in filling vacancies for providers—as well as negative effects on patient care and provider satisfaction when positions are vacant  According to IHS officials, the rural locations and geographic isolation of some IHS facilities create recruitment and retention difficulties  IHS data indicate that 36 of the 102 IHS facilities, including four hospitals, are identified as isolated hardship (ISOHAR) posts  Agency documentation describes ISOHAR posts as ‘‘unusually difficult, which may present moderate to severe physical hardships for individuals assigned to that geographic location,’’ and states that physical hardships may include crime or violence, pollution, isolation, a harsh climate, scarcity of goods on the local market, and other problems  In addition, IHS has reported that insufficient housing, substandard schools, lack of entertainment opportunities, and shopping centers located more than three hours away are all typical not only of ISOHAR posts, but also of many other IHS facility locations  Officials stated that, especially for job candidates and employees with families, these can be critical factors in choosing whether or not to accept or stay in a position  For example, officials from the Portland Area office told us the Colville Service Unit has experienced challenges recruiting physicians because the service unit is 110 miles away from Spokane, and many of the smaller towns nearby have limited amenities—including limited employment opportunities for spouses and school systems that may not meet the expectations of some prospective employees  In addition to hardships generally associated with rural locations, IHS facilities can experience additional challenges specific to recruiting and retaining providers for facilities on tribal lands  For example, Navajo area officials told us that providers who are non-native or are not married to a tribal member generally must go off the reservation to find housing if it is not provided by IHS  According to IHS, the Navajo Nation is one of the largest Indian reservations in the United States, consisting of more than 25,000 contiguous square miles and three satellite communities, and extending into portions of Arizona, New Mexico, and Utah  Living off the reservation can result in long commutes, contributing to a difficult work- life balance  Furthermore, IHS officials noted, public transportation such as buses or trains do not exist in proximity to most IHS facilities  IHS facility staff told us long-standing vacancies have a direct negative effect on patient access to quality health care, as well as employee morale  Officials from multiple facilities we visited told us they have had to cut certain patient services due to ongoing provider vacancies  For example, officials from the Phoenix Area office told us the Nevada Skies Youth Wellness Center, an adolescent substance abuse treatment center, decreased the number of beds available due to staffing vacancies  Similarly, officials from the Rosebud Hospital stated the facility has diverted obstetrics patients to other facilities since July 2016 due to a shortage of physicians, nurses, and nurse anesthetists  During the diversion, those patients were referred to other hospitals in Valentine, Nebraska, and Winner, South Dakota—about 45 miles away  An official from the Sioux San Hospital said that because of vacancies in the diagnostic testing laboratory, the hospital stopped conducting Chlamydia tests in-house and instead sends specimens out to another laboratory for testing  As a result, the official stated it takes about a week longer to get the test results, which can delay treatment  In addition facility staff we interviewed told us the increased stress and fatigue of providers working to make up for staffing shortages results in decreased employee morale  These staff stated that, in some cases, this stress and fatigue has caused providers to leave IHS  One doctor we spoke with described this dynamic of vacancies begetting additional vacancies as a “never-ending cycle” for the facility  In an effort to recruit and retain permanent employees, IHS has used strategies that are similar to strategies used by VHA and tribal facilities in our review  Specifically, IHS has provided financial incentives, professional development opportunities, and some access to housing  The agency has also taken steps to recruit students and connect with potential applicants through webinars, career fairs, and conferences  IHS offers increased special salary rates for certain health care positions, as well as other financial incentives, such as recruitment and retention bonuses  IHS also offers student loan repayments, in return for health professionals’ commitment to work at IHS for a specified period of time  Special salary rates  IHS offers special higher salary rates for physicians, dentists, nurses, CRNAs, certified nurse midwives, nurse practitioners, optometrists, pharmacists, and physician assistants  IHS officials stated that special salary rates are an important recruitment and retention tool for providers, and that without them, federally operated IHS facilities would be at a competitive disadvantage with the private sector, VHA, and tribally operated facilities  In 2015 IHS reported that recruiting and retaining CRNAs was “an ongoing problem for IHS—mostly due to pay,” and the agency rarely had “a sufficient applicant pool ” IHS reported “CRNA services were integral to IHS operations” and without the ability to recruit and retain these providers, IHS was “at risk of having to curtail services to clients ” As a result, according to IHS officials, the agency developed special salary rates for CRNAs, which became effective on December 31, 2015  As of November 2017, IHS had no CRNA vacancies  However, according to IHS officials, the agency has only developed seven national special pay tables and two local special pay tables for Alaska, as of January 2018, due to a lack of human resources personnel trained in this process  Officials told us only one human resources staff person at IHS is experienced with developing special pay tables, which takes a substantial amount of work  However, they stated that this task is only one of her job responsibilities, and she can complete about one special pay table each year  In comparison, according to an official, VHA has developed and regularly revises over 3,000 special salary rates based on local market conditions  For example, IHS officials stated that Phoenix Indian Medical Center cannot offer salaries that are competitive with VHA because salaries for providers in the Phoenix area are relatively high compared to national salaries, and IHS has not developed local salary rates in the Phoenix market  For example, using pay rates effective January 7, 2018, a nurse just starting a career in the Phoenix area could make $63,871 at VHA (local pay table), versus $44,835 at IHS (national pay table)  Although offering increased salaries is an important strategy that IHS uses for recruitment, IHS still experiences challenges in offering competitive salaries  Officials from two area offices told us the maximum amount for a physician salary or certain nursing salaries were not enough for some potential hires, who sought employment elsewhere  While IHS may seek approval from HHS to exceed the maximum salary of certain pay tables, IHS officials said the approval process can be lengthy, which has resulted in the loss of promising candidates—including emergency medicine, general surgery, radiology, and anesthesiologist providers  Similarly, officials from one area office stated that federally operated IHS facilities have experienced challenges competing with other health care systems in recruiting local health care providers, including tribally operated facilities  For example, officials from the Oklahoma City area office told us their area has four of the largest American Indian tribes in the country running their own health systems  According to these officials, in addition to IHS funds, these tribes use money from other sources to pay health care salaries  IHS officials explained that, as a result, tribes can pay higher salaries and may be able to offer other incentives that IHS is unable to provide  Recruitment, relocation, and retention incentives  IHS may offer recruitment, relocation, and retention incentives  Specifically, for positions that are difficult to fill or for individuals who are unlikely to accept the position without an incentive, IHS may offer potential employees a recruitment incentive up to 25 percent of their annual salary  IHS may also pay a relocation incentive for a current employee who must relocate for a position that would otherwise be difficult to fill  In addition, IHS may pay a retention incentive of up to 25 percent of an employee’s current salary if he or she (1) has unusually high or unique qualifications or if there is a special need of the agency, which makes retention essential, or (2) is likely to leave IHS without the retention incentive  Officials from the Phoenix area office told us IHS facilities use the retention bonuses extensively for nursing staff, in particular, to help match the market pay  IHS also analyzed the recruitment and retention of nurses and, as a result of this analysis, requested an exception to the 25 percent limit on recruitment, relocation, and retention incentives, from the Office of Personnel Management (OPM)  In December, 2017, OPM approved IHS’s request to offer incentives up to 50 percent, and IHS officials told us that they are currently reviewing implementation options  Loan repayment  IHS’s Loan Repayment Program pays provider education loans in exchange for an initial two-year service commitment to practice in health facilities serving AI/AN communities  Recipients agree to serve two years in exchange for up to $20,000 per year in loan repayment funding and up to an additional $5,000 per year to offset tax liability, which IHS pays directly to the Internal Revenue Service  Loan repayment recipients can extend their initial two-year contract on an annual basis until their original approved educational loan debt is paid  In fiscal year 2017, a total of 1,267 providers—about 8 percent of the federal IHS workforce—were receiving IHS loan repayments  This included 434 new two-year contracts, 396 one-year extension contracts, and 437 providers starting the second year of their fiscal year 2016 two-year contract  However, IHS’s Loan Repayment Program is not able to pay for the loans of all providers who request it due to limited funding  According to officials in one area office, this has caused providers to either decline a job offer or leave IHS  According to IHS’s fiscal year 2019 budget justification, in fiscal year 2017, 412 providers employed by IHS who applied for loan repayment, did not receive one  An additional 376 applicants either declined a job offer because they did not receive loan repayment funding or were unable to find a suitable assignment meeting their personal or professional needs  Officials in the Billings Area Office told us several physicians stated during exit interviews that they were leaving because they did not receive the loan repayment funding they hoped to receive  According to area office officials, the Billings area lost 5 physicians in 2 weeks because they were not awarded loan repayments  In addition to its own loan repayment program, IHS has worked with HHS’s Health Resources and Services Administration (HRSA) to increase opportunities for providers to apply for loan repayment through the National Health Service Corps  Specifically, IHS worked with HRSA to increase the number of facilities deemed medically underserved and therefore designated Health Professional Shortage Areas  According to IHS, this resulted in 684 health care delivery sites for placement of National Health Service Corps providers, and the number of placements increased to 443 providers as of August 2016  As of January 2018, according to IHS officials, there were 499 providers serving at 797 eligible sites  Applicants cannot receive loan repayment from more than one program concurrently  Officials from several facilities told us they provide access to professional development opportunities for IHS employees as a retention tool  For example, Northern Navajo Medical Facility (Shiprock) officials said they are sending nurse managers and two to three potential future leaders to the American Organization of Nurse Executive trainings  Officials told us this training allows the nurses to network with private executives and look at fellowships  In addition, Chinle Comprehensive Health Care Facility officials told us they paid for a 2-year residency at University of Texas Health Science Center so one of their dentists could obtain additional training in pediatric dentistry  Officials told us that, in return, the dentist agreed to stay at the Chinle Comprehensive Health Care Facility for 6 years  In addition, Shiprock service unit officials told us they have offered their providers, through a partnership with the University of New Mexico, an online Masters of Science in Public Health program in health management  When housing is limited near IHS facilities, IHS has made some housing available to assist with recruitment and retention of providers  Area officials told us federally operated IHS facilities in the Albuquerque, Great Plains, Phoenix, Billings, and Navajo areas provide some government- subsidized housing for providers and their families  At four of the seven facilities we visited—the Kayenta Health Center, Chinle Comprehensive Health Care Facility, Rosebud Hospital, and Pine Ridge Hospital—we observed some staff housing  Kayenta Health Center  Officials from Kayenta Health Center told us that they provide 158 housing units, from 1 bedroom to 4 bedrooms  In addition, the facility has a 19-unit building, similar to a hotel (fully furnished), for temporary contract providers  Officials said they are considering opening units in this building to permanent employees  Chinle Comprehensive Health Care Facility  Officials from Chinle Comprehensive Health Care Facility told us there are 264, 1 to 4 bedroom housing units available for providers both on its campus and nearby  IHS officials also told us they provide access to 19 parking spaces for camping vehicles  Rosebud Hospital  Officials from Rosebud Hospital stated they provide 150 housing units and are also constructing a 19-unit hotel- style building  They said that most, if not all, candidates from outside of the area ask about housing unit availability when deciding whether to accept a position  Pine Ridge Hospital  Officials from Pine Ridge Hospital told us that IHS also provides 105 housing units for its employees  IHS officials explained the housing is a necessity for on-call providers because staff without on-site housing are required to commute extreme distances in very harsh environments to locate housing outside of reservation boundaries  See figure 6 for examples of government-subsidized provider housing near the Kayenta Health Center, Chinle Comprehensive Health Care Facility, Rosebud Hospital, and Pine Ridge Hospital  See appendix II for information about housing provided by one selected tribe  However, there is a greater demand for housing than IHS can provide  During our site visit, Chinle Health Care Facility officials stated that government-subsidized housing availability to meet employee demand is severely limited at all of their three facilities, and the availability of private housing in the community is “non-existent ” As a result, IHS officials from Chinle told us that some providers commute 60 to 90 minutes to work one-way each day  IHS officials told us that, after conducting a needs assessment in 2016, they determined the unmet need for housing at IHS facilities was 1,100 units  According to these officials, the needs assessment also helped them identify some of the greatest needs for housing  The President’s fiscal year 2017 budget proposal for IHS requested $12 million to build new staff housing units “in isolated and remote locations for healthcare professionals to enhance recruitment and retention ” According to agency officials, based on its needs assessment, HHS provided $24 million to build new staff housing units at the Rosebud and Pine Ridge hospitals in the Great Plains area, at the Crownpoint and Chinle health care facilities in the Navajo areas, and at the Supai clinic in the Phoenix area  IHS has also taken steps to recruit future providers by providing scholarships, externships, internships, and residency rotations to health professional students  Scholarships  IHS’s scholarship program provides financial support to qualified AI/AN candidates in exchange for a minimum 2-year service commitment within an Indian health program  Nearly 7,000 AI/AN students have received scholarship awards since the program started in 1978
Report 2:  Some state officials reported being concerned that other agencies may not feel obligated to develop these plans, in part, because CAPTA provides funding to child welfare, and other agencies may therefore believe that child welfare should be responsible for developing the plan of safe care  CPS officials we interviewed in two of our site visit states, as well as one state we followed up with, told us that they were unsure of whether their current plans will meet new CAPTA requirements because CAPTA does not define a plan of safe care  For example, Massachusetts officials said that their plans include everything that a family might need to ensure the safety of the child, including resources to ensure stabilization and reunification of a family, but they are not sure whether the plans meet new CAPTA requirements, in part because they are not familiar with the term “plan of safe care ” An official in another state was also unsure about whether his state’s “safety plans” would meet CAPTA requirements  According to the official, safety plans may include a treatment plan for mothers, and referral services, such as early intervention for the child  In practice, plans of safe care generally address gaps that place an infant at risk for harm or neglect  However, state officials we interviewed reported being unsure about what a plan of safe care should look like for families where these gaps do not exist  Also, in a written response to our survey, one state expressed uncertainty about CPS’ role if required to work with infants who do not typically receive CPS services  For example, a Pennsylvania official said that it is unclear what types of interventions child welfare should conduct with families of infants exposed to legal substances, such as medications prescribed by doctors, when the caregivers are taking their medications correctly  Similarly, officials also questioned whether a plan would be necessary, and what the plan would entail, for caregivers who are already addressing their substance use disorder and taking steps to ensure their infant’s safety  Officials from a local Kentucky CPS office described a case in which a mother was participating in medication-assisted treatment, had attended counseling three times per week throughout her pregnancy, and was continuing treatment in the postpartum period  Through CPS’ investigation, the agency found that the case was not substantiated, in part, because there were no additional services that CPS could connect her with that she was not already receiving  Officials across the three states we visited also said that state and federal drug and alcohol confidentiality restrictions may challenge their ability to monitor plans of safe care  To monitor plans of safe care, CPS staff may need access to confidential information in order to know how caregivers are progressing in treatment, particularly now that these plans must address the substance use disorder needs of the caregiver  However, federal law restricts the disclosure and use of alcohol and drug patient records maintained in connection with the performance of any federal- assisted alcohol and drug abuse program  Generally, confidential information may be disclosed in accordance with the prior written consent of the patient  State and local CPS staff we interviewed said that strict confidentiality requirements make it challenging for drug and alcohol treatment providers to share information about mothers and infants  A CPS state director from Pennsylvania said that treatment providers are often reluctant to provide CPS case workers with information or updates on a mother’s treatment, which prevents child welfare workers from fully understanding how mothers are progressing with their treatment and the extent to which those in treatment are adhering to prescribed directions as outlined by treatment providers  In addition, one official from a state we visited said state statutes regarding sharing of drug and alcohol treatment information may be more restrictive than the federal statute  Some states have developed ways to obtain confidential information about mothers in substance use disorder treatment  For example, officials from one local CPS office told us that in instances when they have to develop a long-term plan of safe care for families, they have mothers sign a release of information form in order to obtain updates about her treatment adherence from the medication- assisted treatment provider  Similarly, a local Massachusetts CPS office told us that typically staff obtain releases from mothers so that they can verify whether mothers are actively participating in their treatment and that there are no records of relapse  In HHS’ role to assist states in the delivery of child welfare services, two agencies—ACF and the Substance Abuse and Mental Health Services Administration (SAMHSA)—provided technical assistance to states through the National Center on Substance Abuse and Child Welfare (NCSACW)  In addition, in ACF’s role to administer and monitor states’ implementation of CAPTA, the agency has provided some guidance to states on the provisions pertaining to substance-affected infants and has begun its monitoring responsibilities  ACF and SAMHSA, which leads public health efforts to reduce the impact of substance abuse and mental illness, established the NCSACW in 2002  The NCSACW provides technical assistance to states, and has issued publications and hosted forums to help states develop policies and procedures around issues affecting substance-affected infants  The technical assistance has focused on a broad range of issues, including collaboration among service providers, and plans of safe care  With respect to collaboration, NCSACW has issued several studies that identify opportunities for strengthening interagency efforts to prevent, intervene, identify, and treat prenatal substance exposure  The NCSACW collaboration guides encourage states to involve CPS agencies with medical providers in an interagency collaborative setting, thereby facilitating the process for CPS agencies to be notified of substance- affected infants  Regarding plans of safe care, NCSACW has provided technical assistance and best practices to states around development of these plans  For example, in one state it has facilitated discussion groups to help the state develop a model plan  From calendar year 2011 to 2016, NCSACW processed approximately 600 requests from state CPS agencies for short-term technical assistance related to improving care for substance-affected infants and their families  This short-term technical assistance included activities such as responding to telephone inquiries, mailing information, identifying needed resources, and making referrals  The NCSACW has also provided in- depth assistance to 16 states to strengthen collaboration and linkages across child welfare, addiction treatment, medical communities, early care and education systems, and family courts to improve outcomes for substance-affected infants and their families  Through this in-depth assistance, NCSACW identified areas for improvement in states, including a lack of clarity regarding compliance with CAPTA requirements (such as identification, notification, and developing plans of safe care) and the need for state models to comply with CAPTA requirements to develop plans of safe care  In one state, the project overview report indicated that a next step for the in-depth technical assistance is to continue development of the plan of safe care model and ensure practices and protocols are in place across systems to meet CAPTA requirements  The report indicated that this will include ongoing work with hospitals to ensure consistent identification of infants with prenatal exposure and notifications to CPS  Although18 states reported in our survey that technical assistance from the NCSACW was very or extremely helpful, 11 reported that it was moderately helpful, 7 reported that it was slightly helpful, and 1 reported that it was not at all helpful  Eleven states reported that they were not familiar with this assistance  Since July 2016, when the most recent amendments to CAPTA were enacted, ACF has issued one information memorandum and two program instructions to states about provisions relating to substance-affected infants  According to an ACF official, information memoranda share information with states, while program instructions provide interpretations of the law and inform states of actions they must take  ACF issued an August 2016 information memorandum informing states of the 2016 amendments to CAPTA  The August 2016 information memorandum also provided states with best practices, drawing on an NCSACW guide on collaboration for developing multi-systemic approaches to assist child welfare, medical, substance use disorder treatment, and other systems to support families affected by opioid use disorders  In January 2017, ACF issued a program instruction which provided guidance to states on implementing the 2016 amendments to CAPTA made by CARA and informed states of the flexibilities that they have under the law  Particularly, the guidance noted that: “CAPTA does not define ‘substance abuse’ or ‘withdrawal symptoms resulting from prenatal drug exposure ’ We recognize that by deleting the term ‘illegal’ as applied to substance abuse affecting infants, the amendment potentially expands the population of infants and families subject to the provision [that states have policies and procedures in place to address their needs]  States have flexibility to define the phrase, ‘infants born and identified as being affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure,’ so long as the state’s policies and procedures address the needs of infants born affected by both legal (e g , prescribed drugs) and illegal substance abuse ” “While CAPTA does not specifically define a ‘plan of safe care,’ CARA amended the CAPTA state plan requirement       to require that a plan of safe care address the health and substance use disorder treatment needs of the infant and affected family or caregiver ” “CAPTA does not specify which agency or entity must develop the plan of safe care; therefore the state may determine which agency will develop the plans  We understand that in most instances the state already has identified the responsible agency in its procedures  When the state reviews and modifies its policies and procedures to incorporate the new safe care plan requirements in CARA, the state may wish to revisit its procedures regarding which agency develops the plan of safe care, including any role for agencies collaborating with CPS in caring for the infant and family ” In addition, in April 2017, ACF issued a program instruction on reporting requirements, including changes in those requirements brought about by the 2016 amendments to CAPTA  ACF conducted limited monitoring of states prior to the amendments passed in 2016  According to ACF officials, if presented with evidence of potential deficiencies, the agency would attempt to learn more about the state’s activities  In one instance, ACF reviewed South Carolina’s policies and found them to not be in compliance with the notification and safe care plan requirements of CAPTA  It directed the state to develop a program improvement plan to bring it into full compliance, which South Carolina submitted in April 2016  In a recent progress report (February–April 2017), South Carolina reported that it was focused on updating statutes, developing policies and procedures, training child protective service workers, and building relations with health care providers  In response to the 2016 amendments to CAPTA that added the requirement for HHS to monitor state policies and procedures to address the needs of substance-affected infants, ACF officials told us that staff in regional offices will review states’ annual reports, submitted in June 2017  In its program instruction describing the reporting requirements, ACF asked each state to submit a new Governor’s Assurance, as well as a narrative explaining what they have done in response to the amendments  Specifically, ACF asked states to provide information on any changes that were made in state laws, policies, or procedures related to identifying and referring infants affected by substance abuse to CPS as a result of prenatal drug exposure  It also requested updates on states’ policies and procedures regarding the development of plans of safe care; a description of how states have developed systems to monitor plans of safe care; and a description of any outreach or coordination efforts the states have taken to implement the amendments, among other things  According to ACF officials, as of October 1, 2017, some states have provided information and a Governor’s Assurance demonstrating compliance with the amended provisions and some states have been placed on Program Improvement Plans, but the agency does not yet have information on the status of all states  An ACF official explained that, in their annual reports, some states either acknowledged that they are trying to get legislation enacted to bring them into compliance with the law and it has failed, or that they are not in compliance, for example, because they were limiting their policies to those infants affected only by illegal substances  In addition, in May 2017, ACF issued a technical bulletin informing states of the new data collection requirements that resulted from the 2016 amendments to CAPTA  ACF stated that it intends to collect data required by the amendments to CAPTA through the National Child Abuse and Neglect Data System, beginning with states’ submission of fiscal year 2018 data  This system is maintained by ACF and contains data from states about children who have been abused or neglected  ACF issued a Federal Register notice about the proposed data elements and requested comments on the accuracy and quality of the proposed data collection, among other things; the comment period closed in July 2017  In the Federal Register notice, ACF notes that the 2016 amendments to CAPTA require it to collect information from state CPS agencies on the number of notifications from health care providers that are accepted for investigation or screened out  Further, of those infants screened in, ACF is required to collect data on the number of safe care plans developed for substance- affected infants as well as the number of infants for whom a referral was made for appropriate services, including services for the affected family or caregiver  In the Federal Register notice, ACF proposed to collect this information using a combination of existing and new data from states  Thirty-two states reported in our survey that they already collect data on the incidence of substance-affected and/or substance-exposed infants; 15 of those 32 states also collect data on the incidence of NAS  Further, 18 states reported that they collect data on the number of notifications health care providers make to CPS  Of those states, 8 reported that they collect specific data on notifications related to infants diagnosed with NAS  Most states reported in our survey that additional guidance and assistance would be extremely or very helpful (see figure 3)  For example, 38 states reported that additional guidance on requirements for health care providers to notify CPS of substance-affected infants would be extremely or very helpful  Similarly, 37 states reported that additional guidance on developing, implementing, and monitoring plans to ensure the safety and well-being of substance-affected infants would be extremely or very helpful  In written responses to our survey, states suggested ideas for additional guidance, training, and technical assistance to help them address the needs of substance-affected infants  States’ suggestions ranged from assisting in the development of substance abuse training curriculum for staff to video conferences with other states to share information about implementing CAPTA  A few states suggested that the guidance ACF has provided to date is not clear and reported grappling with the meaning of terms such as “affected” and “legal vs  illegal” substances, and two states requested “concrete guidance” and “specificity ” A few other states suggested that it would be helpful to obtain additional information about meeting the requirements of plans of safe care within the constraints of state and federal confidentiality laws, technical assistance on what plans of safe care look like, and a format for a plan of safe care  ACF officials told us that states have flexibility with implementing the law and the agency does not anticipate issuing additional written guidance on the amendments to CAPTA made by CARA  ACF officials explained, in October 2017, that they were finalizing their review of the plans that states were required to submit  These plans are expected to include details on how the states are addressing the CAPTA requirements  While ACF could not provide the number, officials reported that some of the state plans submitted to date did not meet the requirements and those states have been asked to develop program improvement plans  They expect states to work with the ACF regional offices, which will provide or facilitate technical assistance to states on their implementation of the provisions, as needed  In addition to the review of state plans, ACF officials explained that regional officials may learn about states’ needs for technical assistance through meetings or informational exchanges  Finally, the NCSACW is expected to review and prepare a summary of CAPTA state plans, current state statutes and policies and procedures relating to amended CAPTA requirements  In addition, according to ACF, NCSACW will continue to offer technical assistance on the development and implementation of plans of safe care to states  Technical assistance may include responding to requests for information, disseminating written materials and resources, and conducting webinars/conference calls  Further, ACF reported that some states will receive more in-depth technical assistance, albeit in some instances on a time-limited basis  Undertaking these actions can enhance states’ understanding of CAPTA requirements and better address known challenges such as the ones described in this report  However, more specific guidance from HHS on the issues which states have expressed confusion can assist them in better understanding CAPTA requirements and providing more effective protections and services for the children and families most in need  The opioid epidemic has generated a significant increase in the number of substance-affected infants born and diagnosed with NAS  These vulnerable infants may be at risk for child abuse and neglect if adequate supports and services are not available to ensure their safety  CAPTA requires states to have policies and procedures to address the needs of these infants and their families, including mothers with a substance use disorder  However, states have experienced challenges implementing new CAPTA requirements  Many states reported in our survey that they are not completely adhering to the law  This is reflected in ACF’s review of state plans, some of which are resulting in program improvement plans  States cite challenges that stem, in part, from ACF’s lack of specificity in providing guidance on implementing CAPTA requirements  Specifically, states report that ACF has not provided clear guidance about which substance-affected infants health care providers are required to notify CPS about, as well what a plan of safe care is and for whom it should be developed  Given the challenges that states reported facing in implementing the provisions, a majority reported wanting more help from ACF, such as trainings and teleconferences with other states, to help overcome their challenges  Additional guidance and assistance from HHS would help states better understand what they need to do to develop policies and procedures that meet the needs of children and families affected by substance use  The Secretary of HHS should direct ACF to provide additional guidance and technical assistance to states to address known challenges and enhance their understanding of CAPTA requirements, including the requirements for health care providers to notify CPS of substance- affected infants and the development of a plan of safe care for these infants  We provided a draft of this report to HHS for review and comment  HHS’s comments are reproduced in appendix I  HHS also provided technical comments, which we incorporated into our report where appropriate  HHS did not concur with our recommendation  HHS stated that: in January 2017, ACF clarified in guidance several of the issues raised in the report, including the population of infants and families covered by the provision and the state flexibility inherent in determining which infants are “affected by” substance abuse, and the terminology used in the federal law of what a “plan of safe care” is; ACF believes it is necessary to allow states the flexibility to meet the requirements in the context of their state CPS program; several of the challenges that the GAO notes are not specific to CAPTA compliance with the safe care plan and notification requirements; and it does see the value in continuing to provide technical assistance to states to address known challenges and to enhance their understanding of CAPTA requirements  With respect to HHS’ January 2017 guidance, state officials reported in our survey and during site visits that they found some terms unclear and were uncertain about what is required of them  In written responses to our survey, states reported challenges understanding how to define substance-affected under CAPTA  In addition, as we note in our report, the guidance about plans of safe care described the following: “While CAPTA does not specifically define a ‘plan of safe care,’ CARA amended the CAPTA state plan requirement       to require that a plan of safe care address the health and substance use disorder treatment needs of the infant and affected family or caregiver ” States reported in our survey and in follow-up discussions that this lack of specificity remained an ongoing challenge for them  For example, as we discuss in our report, one state that we followed up with in August 2017 was still unsure about whether its safety plans would meet CAPTA requirements for plans of safe care  In addition, as of October 2017, HHS confirmed that some state plans did not meet CAPTA requirements and that the states were asked to develop program improvement plans  Accordingly, a key ongoing challenge was not addressed by the January guidance  Regarding allowing states flexibility to meet CAPTA requirements, we acknowledge in our report that HHS said that states have flexibility  However, in our survey and site visits, states indicated that they would find it helpful for HHS to provide them with greater specificity around terms, including the degree of flexibility they are allowed  States added that this would include parameters within which they can develop policies and procedures that meet CAPTA requirements  We continue to believe that additional guidance addressing these concerns would benefit states and could be provided without imposing additional mandates  Concerning HHS’ third point that some of the issues raised in the report are not specific to CAPTA, the states we visited interpret CAPTA to require that plans of safe care be developed for all substance-affected infants who are referred to CPS  During our discussions with states and in responses to our survey, state officials did not delineate which federal requirement impacted their approach to serving children and families  As stated in our conclusion, vulnerable infants may be at risk for child abuse and neglect if adequate supports and services are not available to ensure their safety  Lastly, HHS indicated that it will continue to provide technical assistance to states and fund demonstration sites to establish or enhance collaboration across community agencies and courts  Although continuing to provide technical assistance to states should be beneficial, our findings demonstrate that additional guidance is also needed  For example, 38 states reported that additional guidance on requirements for health care providers to notify CPS of substance-affected infants would be extremely or very helpful  Similarly, 37 states reported that additional guidance on developing, implementing, and monitoring plans to ensure the safety and well-being of substance-affected infants would be extremely or very helpful  Overall, given the results of our review, we continue to believe our recommendation is warranted  Effective implementation of our recommendation should help states better implement protections for children  As agreed with your office, 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 of this report to the appropriate congressional committees and the Secretary of Health and Human Services  In addition, the report is available at no charge on the GAO website at http://www gao gov  If you or your staff have any questions about this report, please contact 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 II  Kathryn A  Larin, (202) 512-7215 or larink@gao gov  In addition to the contact above, Sara Schibanoff Kelly (Assistant Director), Ramona L  Burton (Analyst-in-Charge), Kay E  Brown, Hannah Dodd, Ada Nwadugbo, and Srinidhi Vijaykumar made key contributions to this report  Also contributing to this report were Sandra L  Baxter, James Bennett, Gina Hoover, Jessica Orr, Rhiannon Patterson, Jean McSween, and James Rebbe 

ground_truth: The combination of growing liquefied natural gas (LNG) supplies and new requirements for less polluting fuels in the maritime shipping industry has heightened interest in LNG as a maritime fuel. The use of LNG as an engine ("bunker") fuel in shipping is also drawing attention from federal agencies and is beginning to emerge as an issue of interest in Congress. In 2008, the International Maritime Organization (IMO) announced a timeline to reduce the maximum sulfur content in vessel fuels to 0.5% by January 1, 2020. Annex VI of the International Convention for the Prevention of Pollution from Ships requires vessels to either use fuels containing less than 0.5% sulfur or install exhaust-cleaning systems ("scrubbers") to limit a vessel's airborne emissions of sulfur oxides to an equivalent level. An option for vessel operators to meet the IMO 2020 standards is to install LNG-fueled engines, which emit only trace amounts of sulfur. Adopting LNG engines requires more investment than installing scrubbers, but LNG-fueled engines may offset their capital costs with operating cost advantages over conventional fuels. Savings would depend on the price spread between LNG and fuel oil. Recent trends suggest that LNG may be cheaper in the long run than conventional fuels. LNG bunkering requires specialized infrastructure for supply, storage, and delivery to vessels. To date, the number of ports worldwide that have developed such infrastructure is limited, although growth in this area has accelerated. Early adoption of LNG bunkering is occurring in Europe where the European Union requires a core network of ports to provide LNG bunkering by 2030. LNG bunkering is also advancing in Asia, led by Singapore, the world's largest bunkering port. Asian countries, together with Australia and the United Arab Emirates, have about 10 coastal ports offering LNG bunkering, with another 15 projects in development. LNG bunkering in the United States currently takes place in Jacksonville, FL, and Port Fourchon, LA—with a third facility under development in Tacoma, WA. Bunkering of LNG-fueled cruise ships using barges also is planned for Port Canaveral, FL. The relative locations of other U.S. ports and operating LNG terminals suggest that LNG bunkering could be within reach of every port along the Eastern Seaboard and in the Gulf of Mexico. On the West Coast, the ports of Los Angeles and Long Beach, CA, are near the Costa Azul LNG terminal in Ensenada, MX. Seattle and Tacoma are adjacent to the proposed Tacoma LNG project. Since 2015, Jones Act coastal ship operators have taken steps to transition their fleets to use cleaner burning fuels, including LNG. Shippers of dry goods to Alaska, Hawaii, and Puerto Rico have taken delivery or have ordered LNG-fueled and LNG-capable vessels from U.S. shipyards in Philadelphia, PA, and Brownsville, TX. Another company operates five LNG-powered offshore supply vessels built in Gulfport, MS. Depending upon LNG conversions, the global LNG bunker fuel market could grow to several billion dollars by 2030. If U.S. LNG producers were to supply a significant share of this market—on the strength of comparatively low LNG production costs—LNG bunkering could increase demand for U.S. natural gas production, transportation, and liquefaction. Opportunities in LNG-related shipbuilding might be more limited, as most shipbuilding occurs overseas, although domestically-constructed LNG bunkering barges could be one area of economic growth. Finally, engineering and construction firms could benefit from new opportunities to develop port infrastructure for LNG storage and transfer. However, while vessel conversion to LNG fuel may increase demand for U.S.-produced natural gas, it partially could be offset by reduced demand for U.S.-produced crude oil or refined products. Furthermore, while LNG can reduce direct emissions from vessels, fugitive emissions and environmental impacts from natural gas production and transportation could reduce overall emissions benefits. While the LNG industry has experienced few accidents, the Coast Guard has been developing new standards to address unique safety and security risks associated with LNG in vessel operations. The overarching consideration about LNG bunkering in the United States is uncertainty about how the global shipping fleet will adapt to the IMO sulfur standards over time. This uncertainty complicates decisions related to both private investment and public policy. Although Congress has limited ability to influence global shipping, it could influence the growth of LNG bunkering through the tax code and regulation, or through policies affecting the LNG industry or domestic shipping industry as a whole. Evaluating the potential implications of LNG bunkering within the context of broader energy and environmental policies may become an additional consideration for Congress. If LNG bunkering expands significantly, Congress also may examine the adequacy of existing measures to ensure the safety and security of LNG vessels, storage, and related facilities.

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



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

Report 1: The combination of growing supplies of liquefied natural gas (LNG) and new requirements for less polluting fuels in the international maritime shipping industry has heightened interest in LNG as a maritime fuel  For decades, LNG tanker ships have been capable of burning boil-off gas from their LNG cargoes as a secondary fuel  However, using LNG as a primary fuel is a relatively new endeavor; the first LNG-powered vessel—a Norwegian ferry—began service in 2000  Several aspects of LNG use in shipping may be of congressional interest  LNG as an engine, or "bunker," fuel potentially could help the United States reduce harmful air emissions, it could create a new market for domestic natural gas, and it could create economic opportunities in domestic shipbuilding  However, U S  ports would need specialized vessels and land-based infrastructure for LNG "bunkering" (vessel refueling) as well as appropriate regulatory oversight of the associated shipping and fueling operations  The storage, delivery, and use of LNG in shipping also has safety implications  These and other aspects of LNG bunkering may become legislative or oversight issues for Congress  One bill in the 115 th Congress, the Waterway LNG Parity Act of 2017 ( S  505 ), would have imposed excise taxes on LNG used by marine vessels on inland waterways  This report discusses impending International Maritime Organization (IMO) standards limiting the maximum sulfur content in shipping fuels, the market conditions in which LNG may compete to become a common bunker fuel for vessel operators, and the current status of LNG bunkering globally and in the United States  A broader discussion of oil market implications is outside the scope of this report  The IMO is the United Nations organization that negotiates standards for international shipping  Its standards limiting sulfur emissions from ships, adopted in 2008, have led vessel operators to consider alternatives to petroleum-based fuels to power their ships  In 1973, the IMO adopted the International Convention for the Prevention of Pollution from Ships (MARPOL)  Annex VI of the convention, which came into force in 2005, deals with air pollution from ships  The annex established limits on nitrogen oxide (NO x ) emissions and set a 4 5% limit on the allowable sulfur content in vessel fuels  In 2008, the IMO announced a timeline to reduce the maximum sulfur content in vessel fuels from 4 5% to 0 5% by January 1, 2020  Annex VI requires vessel operators to either use fuels containing less than 0 5% sulfur or install exhaust gas-cleaning systems ("scrubbers") to limit a vessel's sulfur oxide (SO x ) emissions to a level equivalent to the required sulfur limit  MARPOL is implemented in the United States through the Act to Prevent Pollution from Ships ()  The United States effectively ratified MARPOL Annex VI in 2008 when President Bush signed the Maritime Pollution Prevention Act ( P L  110-280 )  The act requires that the U S  Coast Guard and the Environmental Protection Agency (EPA) jointly enforce the Annex VI emissions standards  MARPOL's Annex VI requirements are codified at 40 C F R  §1043  They apply to U S -flagged ships wherever located and to foreign-flagged ships operating in U S  waters  In addition to its global sulfur standards, MARPOL Annex VI provides for the establishment of Emissions Control Areas (ECAs), which are waters close to coastlines where more stringent emissions controls may be imposed  The North American ECA limits the sulfur content of bunker fuel to 0 1% of total fuel weight, an even lower bar than that set by the IMO 2020 standards  This standard is enforced by Coast Guard and EPA in waters up to 200 miles from shore  Currently, most ships operating in the North American ECA meet the emissions requirements by switching to low-sulfur fuels once they enter ECA waters  The European Union also has an ECA with a 0 1% limit on sulfur in bunker fuels, and the Chinese government is considering putting the same standard in place  The IMO 2020 emissions requirement applies to vessels of 400 gross tons and over, which is estimated to cover about 110,000 vessels worldwide  However, analysts indicate that many of the smaller vessels in this group already burn low-sulfur fuel  Accounting for these smaller vessels, one estimate is that about 55,000 vessels currently burn high-sulfur fuel  Ship owners have two main options for meeting the emission requirements with existing engines: burn low-sulfur conventional fuel (or biofuels) or install scrubbers to clean their exhaust gases  Alternatively, ship owners may opt to install new LNG-fueled engines to comply with the IMO standard  The simplest option for vessel owners to comply with the IMO sulfur standards, and the one that appears most popular, is switching to low-sulfur fuel oils or distillate fuels  Although switching to low-sulfur fuels would increase fuel costs compared to conventional, high-sulfur fuels, it would require little or no upfront capital cost and would allow ocean carriers to use existing infrastructure to bunker ships at ports  Anticipating widespread adoption of this approach, many analysts predict that the implementation of the IMO 2020 regulations will drive up demand for low-sulfur fuel and, therefore, significantly increase its price above current levels  Such a trend could also reduce demand for high-sulfur fuels, increasing the price spread between low- and high-sulfur bunkers fuels  Switching to lower-sulfur fuel could increase fuel cost across the industry by up to $60 billion in 2020 for full compliance with the IMO standards  Moreover, while it may allow vessels to meet the existing IMO sulfur standards, low-sulfur fuel does not necessarily support compliance with potential future IMO emissions standards, especially with respect to greenhouse gases (GHGs) such as carbon dioxide (CO 2 ) discussed later in this report  Scrubbers are systems which remove sulfur from a vessel's engine exhaust emissions  A ship with a scrubber would be capable of meeting the IMO 2020 standard while using conventional high-sulfur fuel  Retrofitting a scrubber on an existing engine can cost several million dollars, however, before factoring in the lost revenue from taking the ship out of service for a month for the installation  Therefore, while using a scrubber will allow a ship to continue using (currently) cheaper high-sulfur fuel, it may take years to recover the initial investment  For example, one industry study estimates that, in the case of a typical tanker, a scrubber installation could cost $4 2 million with a payback time of approximately 4 8 years  Furthermore, scrubbers installed to capture sulfur emissions might have to be further refitted or replaced to comply with any future IMO standards for GHG emissions  The rate of scrubber adoption could affect the financial impacts of installing them in terms of fuel costs  Scrubbers ultimately offset some or all of their initial costs because they allow vessel operators to continue using relatively inexpensive high-sulfur fuel  However, the return on investment for scrubbers depends on the relative prices of high- and low-sulfur bunker fuels  The demand—and therefore, prices—for low-sulfur and high-sulfur fuels will be affected by how many vessels use the respective fuels under the IMO standards that take effect in 2020  For example, limited scrubber adoption could result in more vessels demanding more low-sulfur fuel oil, creating upward pressure on low-sulfur fuel prices  Under such a scenario, scrubbers would provide greater fuel cost savings for vessels that installed them  Alternatively, high-sulfur fuel could become more costly due to refinery production cutbacks (because shippers will not be allowed to burn it without scrubbers)  In this case, the economic benefits of scrubbers would be diminished  Given the uncertain fuel supply and demand dynamics, it is difficult for vessel operators to know how big the market distortions from scrubber installation could be or how many other operators may choose to install scrubbers  As of September 2018, there were approximately 660 ships retrofitted with scrubbers and over 600 ships under construction with plans to install scrubbers  By 2020, projecting additional construction orders, some analysts predict about 2,000 vessels could have scrubbers installed  However, even with higher demand for the technology, the ability of vessel owners to install scrubbers is constrained; analysts estimate that current maximum capacity for installing scrubbers is be between 300 to 500 ships per year  Another option for ship owners to comply with the IMO 2020 sulfur standards is to switch to engines that burn LNG as a bunker fuel  LNG-fueled vessels emit only trace amounts of sulfur oxides in their exhaust gases—well below even the 0 1% fuel-equivalent threshold in some of the ECA zones—so they would be fully compliant with the IMO standards  As a secondary benefit, using LNG as an engine fuel also would reduce particulate matter (PM) emissions relative to both high- and low-sulfur marine fuel oils  Furthermore, LNG vessels have the potential to emit less CO 2 than vessels running on conventional, petroleum-based fuels  However, LNG vessels would have the potential to result in more fugitive emissions of methane, another GHG, because methane is the primary component of natural gas, further discussed below  Installing an LNG-fueled engine can add around $5 million to the cost of a new ship  Retrofitting existing ships appears to be less desirable because of the extra space required for the larger fuel tanks (new ships can be designed with the larger fuel tanks)  The costs of retraining crews to work with LNG engines could also factor into a vessel operator's decision about switching to LNG  However, apart from their lower emissions, LNG-fueled engines may offset their capital costs with fuel cost advantages over engines burning petroleum-derived fuels  These savings would depend on the price spread between natural gas and fuel oil—which has been volatile in recent years  The likelihood that switching to LNG will produce long-term fuel costs savings relative to conventional fuels is, therefore, a critical consideration for many vessel owners  The 1920 Merchant Marine Act (known colloquially as the Jones Act) requires that vessels engaged in U S  domestic transport be built domestically  Many newly built domestic ships receive a federal loan guarantee under the Maritime Administration's so-called "Title XI" program  In 2014, the program was modified to include the use of "alternative energy technologies" to power ships as part of the relevant criteria in evaluating a loan application  The Maritime Administration counts LNG-fueled engines as an "alternative energy technology" and may be more likely to approve loan applications for ships with LNG-capable engines  Since the North American ECA was established in 2015, Jones Act coastal ship operators have taken steps to transition their fleets to use cleaner burning fuels, including LNG  The three Jones Act operators that ship dry goods to Alaska, Hawaii, and Puerto Rico have taken delivery or have ordered LNG-fueled and LNG-capable vessels from U S  shipyards in Philadelphia, PA, and Brownsville, TX  Harvey Gulf International has put into service five LNG-powered offshore supply vessels that service offshore oil rigs  Some Jones Act tanker operators that have recently built or ordered vessels have chosen to install LNG-ready engines while other operators have chosen to install scrubbers on their existing fleet  Ship engines and scrubbers for the Jones Act fleet do not have to be manufactured in the United States because they are not considered an integral part of the hull or superstructure of a ship  Seagoing barges, known as articulated tug barges, are also a significant portion of the domestic coastal fleet, especially for moving liquid cargoes  However, these vessels traditionally have burned lower-sulfur fuels and thus the ECA has not prompted fleet conversions  IMO fuel requirements do not apply to river barges operating on the nation's inland waterway system, although this fleet potentially could be a market for LNG as fuel  Bunkering vessels (small tankers with hoses for refueling ships) in U S  waters must also be Jones Act compliant  Barges are the predominant method for bunkering ships in U S  ports  An LNG bunkering vessel for the Port of Jacksonville—the first Jones Act-compliant LNG bunkering vessel to enter service in the United States—was built in 2017 by Conrad Shipyards in Orange, TX  Recent energy sector trends suggest that LNG may be cheaper in the long-run than petroleum-based, low-sulfur fuels  However, these price movements are correlated to some extent  Many existing long-term LNG contracts link LNG prices to oil prices (although such contract terms are on the decline), even in the spot market  Starting in 2008, the advent of shale natural gas production dramatically decreased natural gas prices in the United States  Natural gas spot prices in the United States at the Henry Hub—the largest U S  trading hub for natural gas—averaged around $3/MMBtu (million British Thermal Units) in 2018, about a quarter of the peak in average price a decade before, just prior to the shale gas boom ( Figure 1 )  Liquefying natural gas into LNG adds around $2/MMBtu to the production cost  Including additional producer charges and service costs would bring the total cost of LNG available at a U S  port (based on the 2018 average price in Figure 1 ) to approximately $6/MMBtu  Shipping of LNG from the United States to Asia or Europe adds from $1 to $2/MMBtu, so, based on the 2018 average cost in Figure 1 , LNG delivered to a port overseas would cost on the order of $7 to $8/MMbtu under long-term contracts, depending upon timing and location  Higher or lower prices could occur for specific long-term contracts and in the LNG spot market (i e , for individual cargoes), based on the location and the supply and demand balance at the time  In general, the U S  market will have the lowest-priced LNG  Northern Asia will have the highest LNG prices due to the region's comparative lack of pipeline gas supplies and its distance from LNG suppliers  Figure 2 compares LNG spot market prices in the Japan LNG market—the highest-priced LNG market—to spot prices for two common petroleum-based bunker fuels, low-sulfur gas oil and high-sulfur fuel oil  As the figure shows, over the last five years, Japan LNG generally has been cheaper than low-sulfur fuel and more expensive than high-sulfur fuel on an energy-equivalent basis (i e , per MMbtu)  However, Japan LNG and high-sulfur fuel prices converged in 2018  As the figure shows, spot prices for LNG deliveries to the Japan market fell below $6/MMBtu in 2016 from a high above $16/MMBtu in 2013  Likewise, low-sulfur gas oil prices have doubled, and high-sulfur fuel oil prices have tripled, since 2016  The volatility of the bunker fuel markets and the global LNG market lead to considerable unpredictability about the relative prices among fuels going forward  LNG may become increasingly price-competitive versus low-sulfur fuel as the 2020 IMO sulfur standards take effect  As discussed above, many analysts predict prices for low-sulfur gas oil, which are already higher than those for high-sulfur fuel oil, to increase significantly after 2020 due to a standards-driven rise in demand  Although fuel prices as shown in Figure 2 indicate favorable economics for LNG versus low-sulfur fuel, if prices for high-sulfur fuel oils collapse as some expect after the 2020 IMO regulations enter into force, it is possible that LNG could lose its price advantage over residual fuel oils  Likewise, the price spread between low-sulfur gasoil and high-sulfur fuel oil would increase, incentivizing more carriers to install scrubbers to capitalize on the savings in fuel costs by continuing to burn high-sulfur fuel  An additional complication is the variability of LNG prices by region  Many shipping lines are global operators seeking low-priced fuel worldwide, but unlike the global oil market, natural gas markets are regional  Because the price of LNG can vary significantly by region, the relative economics of LNG versus other bunker fuels would also vary by region  Another uncertainty in the market for LNG bunkering is the discrepancy between the spot price for traded LNG and the price for LNG sold as bunker fuel in ports  Added costs associated with marketing, storing and transporting LNG in bunkering operations (discussed below) would likely require ports to charge a rate for LNG bunker fuel above spot market prices  These additional overhead costs are likely to vary among ports  Before factoring in any effect of IMO standards on fuel prices, and assuming a favorable LNG-fuel oil price spread, it still could take years for the savings generated by using LNG to pay back the capital costs of switching fuels  Through May 2018, there were 122 LNG-powered vessels in operation and another 135 ordered or under construction  Many of the first LNG vessels delivered and ordered were Norwegian-flagged vessels, as the Norwegian government has subsidized LNG-fueled vessels with a "NO x Fund " The fund provides LNG-operated ships with an exemption from the country's tax on NO x emissions  As an alternative to committing to LNG as a fuel, some vessel owners may hedge their bets by opting to install "LNG-ready" engines, which can burn low-sulfur fuel oil currently, but are designed to make future LNG conversion easier  The number of LNG ships that may be in operation by 2030 is difficult to predict  First, as noted above, growth in LNG powered vessels is likely to be driven primarily by new builds rather than retrofits  However, the shipping industry has experienced nearly a decade of vessel overcapacity and slow growth  Weak growth in the shipping industry could result in slower growth in vessel orders overall and, therefore, fewer orders for LNG-powered vessels  Of new vessels ordered, or set to be delivered, in 2018 or after, 13 5% (by tonnage) are LNG-fueled—up from 1 4% in 2010  If this trend continues, demand for LNG from the shipping industry could still be relatively high, even if overall growth in the shipping industry remains slow  Because LNG bunkering infrastructure among global ports is currently limited, vessels that use large amounts of fuel and travel predictable routes—along which LNG is available—are the most suitable for LNG fuel  For this reason, cruise ships, vehicle ferries, and container ships initially may be the most likely vessel types to adopt LNG as bunker fuel  Order books have reflected this assessment: one quarter of all cruise ships on order by tonnage at the end of 2017 were LNG-powered  Likewise, a major container ship line, CMA CGM, recently announced that it was ordering nine extra-large container ships powered by LNG  The carrier stated that the fuel tanks will displace space for "just a few containers" and said it intends to refuel these ships just once on their round trip voyages between Asia and Europe  Conversely, LNG fuel adoption may be less likely for oil tankers  Half the global oil tanker fleet operates on the shipping spot market (also known as the "tramp" market), meaning that ship owners enter into contracts with cargo owners only for a single voyage  In this kind of trade, many oil tankers lack a consistent route  Having to limit spot contracts only to ports that may bunker LNG could reduce the arbitrage opportunities of tankers  Dry bulk cargo vessels (carrying grain, coal, and other commodities) also typically operate in the tramp market  LNG-powered vessels have lower direct exhaust emissions than comparable vessels using petroleum-derived fuels  However, the lifecycle—or "well-to-wake"—GHG emissions (especially of methane) and of volatile organic compound emissions from natural gas production, transportation, and liquefaction complicates the comparison  One study in 2015 concluded, "performing a ['well-to-wake'] GHG study on LNG used as a marine fuel is more complex than previously thought  Further studies are needed     to investigate this subject " A 2016 study found that the relative GHG emissions benefits of LNG versus conventional fuel oil on a "well-to-wake" basis was highly dependent upon fugitive methane emissions in the LNG supply chain  A 2017 study funded by NGVA Europe, an association which promotes the use of natural gas in vehicles and ships, concluded that LNG as a bunker fuel provides a 21% well-to-wake reduction in GHG emissions compared to convention fuel oil  Evaluating such studies is beyond the scope of this report, although they indicate uncertainty about environmental benefits of LNG fuel, which may require further examination  Despite concerns over lifecycle emissions from the natural gas supply chain, in the short term, ships that pair LNG engines with newer vessel designs could reduce onboard GHG emissions  However, whether these GHG emission reductions would be sufficient to meet the future standards could become another issue for ship owners  The IMO has set a provisional goal of reducing GHG emissions from ships by 50% by 2050  Depending upon the state of engine technology, LNG-fueled ships might become less viable if GHG limits were to be established well before 2050  Concerns about such GHG limits might lead to a decrease in orders of LNG-powered ships over time  Commercial vessels have a typical lifespan of over 20 years, so firms ordering new ships have to take into account compliance with potential standards issued decades in the future  If renewable fuels, such as biodiesel, become more available and cheaper in the coming decades, renewable fuel-powered ships may take over part of the market that LNG-powered ships could occupy  A key requirement for ocean carriers to adopt LNG as an engine fuel is the availability of LNG bunkering facilities  Because LNG is extremely cold (-260 °F) and volatile, LNG bunkering requires specialized infrastructure for supply, storage, and fuel delivery to vessels  Depending upon the specific circumstances, LNG bunkering could require transporting LNG to a port from an offsite liquefaction facility for temporary storage at the port, or building an LNG liquefaction terminal on site  Alternatively, LNG could be delivered from offsite facilities directly to vessels in port via truck or supply vessel ( Figure 3 )  Truck-to-vessel LNG bunkering, in particular, provides some fueling capabilities without large upfront capital investments  LNG tanker trucks could also bring LNG to a storage tank built on site at the port, which could then bunker the LNG to arriving ships via pipeline  Supplying LNG using tanker trucks in this way may face capacity limitations due to truck size, road limitations, or other logistical constraints, but it has been demonstrated as a viable approach to LNG bunkering at smaller scales  The predominant method of bunkering today with high-sulfur fuel is vessel to vessel, either by a tank barge or smaller tanker  The type of infrastructure needed to temporarily store (if needed) and deliver LNG within a given port would depend on the size and location of the port, as well as the types of vessels expected to bunker LNG  Truck to ship bunkering is best suited for supporting smaller and mid-sized vessels, such as ferries or offshore supply vessels (OSVs) that support offshore oil platforms  Liquefaction facilities built on site can provide the greatest capacity of any LNG bunkering option, for example, to provide fuel for large vessels in transoceanic trade  However, constructing small-scale liquefaction facilities to produce and deliver LNG on site requires considerable planning and significant capital investment, in one case on the order of $70 million for a mid-sized port  Each LNG bunkering option in Figure 3 may be a viable means to begin LNG bunkering service in a given port  However, ports may face practical constraints as bunkering increases in scale  For example, a container port of significant size typically has multiple terminals, so even with an on-site liquefaction facility, it may need additional infrastructure or supply vessels for moving LNG to other port locations where a cargo ship might be berthed  There may also be port capacity and timing constraints upon the movement of LNG bunkering barges trying to refuel multiple large vessels in various locations around a crowded port  To date, the LNG bunkering operations already in place or in development are comparatively small, but scale constraints could become a factor as LNG bunkering grows and might require additional bunkering-related port investments  Early adoption of LNG bunkering occurred in Europe, where the first sulfur ECAs were created in 2006 and 2007  Through Directive 2014/94/EU, the European Union requires that a core network of marine ports be able to provide LNG bunkering by December 2025 and that a core network of inland ports provide LNG bunkering by 2030  This mandate has been promoted, in part, with European Commission funds to support LNG bunkering infrastructure development  In addition, the European Maritime Safety Agency published regulatory guidance for LNG bunkering in 2018  Over 40 European coastal ports have LNG bunkering capability currently in operation—primarily at locations on the North Sea and the Baltic Sea, and in Spain, France, and Turkey  These locations include major port cities such as Rotterdam, Barcelona, Marseilles, and London  Another 50 LNG bunkering facilities at European ports are in development  LNG bunkering is also advancing in Asia, led by Singapore, the world's largest bunkering port  Singapore has agreed to provide $4 5 million to subsidize the construction of two LNG bunkering vessels  The Port of Singapore plans to source imported LNG at the adjacent Jurong Island LNG terminal, loading it into the bunkering vessels for ship-to-ship fueling of vessels in port  Singapore also has signed a memorandum of understanding with 10 other partners—including a Japanese Ministry and the Chinese Port of Ningbo-Zhoushan—to create a focus group aimed at promoting the adoption of LNG bunkering at ports around the world  In Japan, one consortium is implementing plans to begin vessel-to-vessel LNG bunkering at the Port of Keihin in Tokyo Bay by 2020  Japan's NYK line, a large ship owner, recently announced that it had reached an agreement with three Japanese utilities to add LNG bunkering to ports in Western Japan  Asian countries, together with Australia and the United Arab Emirates, currently have around 10 coastal ports offering LNG bunkering, with another 15 projects in development  Some LNG bunkering operations in Europe and Asia are associated with existing LNG marine terminals, which already have LNG storage and port infrastructure in place  However, many smaller operations—including most of the projects in development—employ trucking, dedicated bunkering vessels, on-site liquefaction, and other means to extend LNG availability beyond the ports with major LNG terminals  LNG bunkering is not so advanced in South America, although with nine operating LNG marine terminals (one for export), and another six in development, South America also could support significant LNG bunkering operations in the near future  LNG bunkering in the United States currently takes place in two locations—Jacksonville, FL, and Port Fourchon, LA—with a third bunkering facility under development in Tacoma, WA  The LNG facilities in these ports serve the relatively small U S -flag domestic market  Bunkering of LNG-fueled cruise ships also is planned for Port Canaveral, FL  However, ports in North America have significant potential to expand the nation's LNG bunkering capability  Jacksonville is the largest LNG bunkering operation at a U S  port  One bunkering facility at the port, developed by JAX LNG, initially began truck-to-ship refueling operations in 2016 for two LNG-capable container ships  (The LNG is sourced from a liquefaction plant in Macon, GA  ) In August 2018, upon delivery of the Clean Jacksonville bunker barge, the facility began to replace truck-to-ship bunkering with ship-to-ship bunkering  In the future, the barge plans to source LNG from a new, small-scale liquefaction plant which JAX LNG is currently constructing at the port  A second facility at Jacksonville's port, operated by Eagle LNG, provides LNG bunkering sourced from a liquefaction plant in West Jacksonville  Eagle LNG also is constructing an on-site liquefaction and vessel bunkering facility in another part of the port, expected to begin service in 2019  Taken together, the JAX LNG and Eagle LNG facilities is expected to establish Jacksonville as a significant LNG-bunkering location with the capability to serve not only the domestic fleet but larger international vessels as well  In 2015, Harvey Gulf International Marine (Harvey) began LNG bunkering operations in the Gulf of Mexico to fuel its small fleet of LNG-powered offshore supply vessels serving offshore oil rigs  Harvey has since constructed a $25 million facility at its existing terminal in Port Fourchon to store and bunker LNG sourced from liquefaction plants in Alabama and Texas  The facility can provide truck-to-ship bunkering services for LNG-fueled offshore supply vessels, tank barges, and other vessels  A Harvey subsidiary has ordered two LNG bunkering barges to enable ship-to-ship fueling in the future  Puget Sound Energy has proposed an LNG liquefaction and bunkering facility at the Port of Tacoma, WA  Vessels traveling between Washington and Alaska typically spend the entire journey within the 200-mile North America ECA  Consequently, vessel owners operating along these routes have been interested in LNG as bunker fuel  TOTE Maritime, for example, a ship owner involved in trade between Alaska and the lower 48 states, has begun the process of retrofitting the engines of two of its container ships to be LNG-compatible  The proposed Tacoma LNG facility would be capable of producing up to 500,000 gallons of LNG per day and would include an 8 million gallon storage tank  The facility would serve the dual purposes of providing fuel for LNG-powered vessels and providing peak-period natural gas supplies for the local gas utility system  Its total construction cost reportedly is expected to be $310 million  Community and environmental concerns have slowed the progress of the proposal, which is still under regulatory review  Puget Sound Energy originally planned to put the LNG facility into service in late 2019; however, permitting issues appear likely to delay its opening until 2020 or later—if it is eventually approved  Q-LNG Transport, a company 30% owned by Harvey, has placed orders for two LNG bunkering barges to provide ship-to-ship LNG fueling as well as "ship-to-shore transfers to small scale marine distribution infrastructure in the U S  Gulf of Mexico and abroad " Q-LNG's first barge initially is expected to provide fuel to new LNG-fueled cruise ships based in Port Canaveral (and, potentially, Miami), while service from its second barge is still uncommitted  Initial plans are for the LNG to be sourced from the Elba Island LNG import/export terminal near Savannah, GA—approximately 230 nautical miles away—although the company may seek to develop an on-site LNG storage facility in the future  As noted above, U S  LNG bunkering activities thus far have been limited to a handful of vessels in domestic trade and tourism  LNG bunkering for the much larger fleet of foreign-flag ships carrying U S  imports and exports is still to be developed  As in Europe and Asia, domestic ports located near major LNG import or export terminals may serve as anchors for expanded LNG bunkering operations  Figure 4 shows existing LNG import and export terminals in North America  LNG can be liquefied from pipeline natural gas (or imported natural gas) and stored in large quantities at these facilities  The LNG can then be bunkered on site or transported to bunkering facilities elsewhere in the region by truck, rail, or barge  As discussed above, the distance between Port Canaveral and Elba Island in Q-LNG's bunker sourcing plan is 230 nautical miles  Taking this distance as a measure of how far away LNG can be sourced and barged economically, it is possible to extrapolate which U S  ports are within reach of a potential supply of LNG for vessel bunkering  Table 1 lists the top 20 U S  container shipment ports in the United States and their proximity to existing LNG import/export terminals  Of these top 20 ports, 12 are less than 230 nautical miles from an operating LNG terminal  Distances between LNG terminals and the other East Coast ports are not much greater, suggesting that LNG for vessel bunkering could be within reach of every U S  port along the Eastern Seaboard and in the Gulf of Mexico  On the West Coast, the ports of Los Angeles and Long Beach—the two largest U S  ports—are relatively close to the Costa Azul LNG import terminal in Ensenada, MX  Seattle and Tacoma are far from Ensenada, but would be served by the proposed Tacoma LNG bunkering project, if constructed  LNG bunkering for Seattle and Tacoma alternatively could be sourced from an existing LNG port facility around 100 nautical miles north in Vancouver, BC, which is expanding to provide LNG bunkering services to international carriers  Alaska's existing LNG export terminal currently is inactive, but potentially could supply LNG bunker fuel in the Pacific Northwest as well  Although existing LNG import or export terminals in North America could supply LNG for regional bunkering operations, such activities would require additional investment for infrastructure such as LNG transfer facilities and bunker barges  CRS is not aware of any public announcements among the LNG terminals above to develop bunkering operations  However, at least one LNG terminal owner, Cheniere Energy, which operates LNG terminals in Louisiana and Texas, identifies vessel bunkering as one source of future LNG demand growth worldwide  The IMO adopted safety standards for ships using natural gas as a bunker fuel in 2015  The standards, which took effect in 2017, apply to all new ships and conversions of ships (except LNG tankers, which have their own standards)  The IMO standards address engine design, LNG storage tanks, distribution systems, and electrical systems  They also establish new training requirements for crews handling LNG and other low flashpoint fuels  As is the case for the sulfur standards, the IMO LNG safety standards apply to all IMO member nations, including the United States  In addition, a number of U S  federal agencies, especially the Coast Guard and the Federal Energy Regulatory Commission, have jurisdiction over specific aspects of domestic LNG storage infrastructure and bunkering operations  The Coast Guard has the most prominent role in LNG bunkering, given its general authority over port operations and waterborne shipping  In 2015, the Coast Guard issued two guidelines for the handling of LNG fuel and for waterfront facilities conducting bunkering operations  In 2017, the Coast Guard issued additional guidelines to Captains of the Port, the local Coast Guard officials responsible for port areas, for conducting safe LNG bunkering simultaneously with other port operations  The guidelines advise on quantitative risk assessment of facilities bunkering LNG, which allows Captains of the Port to assess the risks posed to crews and facilities  The Federal Energy Regulatory Commission (FERC) plays a role in LNG bunkering due to its jurisdiction over the siting of LNG import and export terminals under the Natural Gas Act of 1938  Specifically, FERC asserts approval authority over the place of entry and exit, siting, construction, and operation of new LNG terminals as well as modifications or extensions of existing LNG terminals  Notwithstanding this siting authority, FERC reportedly does not intend to assert jurisdiction over the permitting of LNG bunkering facilities, but it may require amendment of permits it has issued for LNG import or export terminals to account for bunkering operations added afterwards  In addition to the Coast Guard and FERC, other federal agencies may have jurisdiction over specific aspects of LNG bunkering operations in U S  ports under a range of statutory authorities  For example, the Pipeline and Hazardous Materials Safety Administration within the Department of Transportation regulates the safety of natural gas pipelines and certain associated LNG storage facilities (e g , peak-shaving plants)  LNG facilities also may need to comply with the Occupational Safety and Health Administration's regulations for Process Safety Management of Highly Hazardous Chemicals  Other federal agencies, including the Environmental Protection Agency, the U S  Army Corps of Engineers, and the Transportation Security Administration, may regulate other aspects of LNG bunkering projects  CRS is not aware of new regulations to date among these agencies specifically addressing LNG bunkering  World production of LNG has been rising rapidly over the last few years, driven by growth in the natural gas sector in new regions—especially Australia and the United States  According to one industry analysis ( Figure 5 ), global LNG supply is expected to increase from 300 to 400 million metric tons per annum (MMtpa) from 2017 to 2021 based on new LNG liquefaction projects already operating or under development  An additional 150 MMtpa appears likely to come online after that  Collectively, LNG supply from these new liquefaction projects could exceed projections of demand, which would put downward pressure on LNG prices  While increases in the global supply of LNG do not necessarily translate directly into an increase in LNG available for bunkering, such increases could provide options for LNG bunkering in more ports  Estimating potential demand for LNG in the maritime sector is complicated and uncertain  One study of future LNG demand for bunkering, specifically, projects that LNG-powered vessels in operation and under construction as of June 2018 will require between 1 2 and 3 0 MMt of LNG per year  The study's review of several LNG consumption forecasts in the maritime sector shows a consensus projection between 20 to 30 MMt per year by 2030  This level of demand growth implies an increase in LNG-powered vessel construction from the current rate of around 120 ships per year to between 400 and 600 new builds per year  If these levels were reached, they could create a significant new market for LNG suppliers  Assuming a Henry Hub spot market price of $4/MMBtu in 2030, the annual market for LNG in shipping could be worth $2 9 billion to $5 8 billion, before accounting for liquefaction and transportation charges  Some studies have projected the LNG bunkering market to be even larger and to grow more quickly  However, key variables—such as the prices of Henry Hub natural gas and crude oil, the number of new vessel orders, and the future costs of emissions technology—are notoriously hard to predict with accuracy  Thus, it is not assured that natural gas consumption in the maritime sector will absorb more than a small amount of the global liquefaction capacity in development  The IMO sulfur standards apply to ship owners globally, as does the development of new LNG supply and bunkering infrastructure  In addition to these factors, domestic LNG bunkering also may be influenced by considerations more specific to the United States  These considerations include growth of the U S  natural gas supply, domestic shipbuilding opportunities, and LNG safety and security  Because of its leading role in global natural gas production, the United States has a particular interest in any new source of natural gas demand  According to the Energy Information Administration, the United States has been the world's top producer of natural gas since 2009, when it surpassed Russia  In 2017, increases in production outstripped increases in domestic gas consumption, leading to the United States becoming a net exporter of natural gas for the first time in nearly 60 years  As discussed above, North America (primarily the United States) is expected to add the most new LNG production capacity through 2030 when including projects that are operating, under construction, and likely (according to investment analysts)  Past increases in U S  LNG exports were driven by greater throughput at the Sabine Pass LNG export terminal—the only operating U S  LNG export terminal in 2017  In March 2018, the Cove Point terminal in Maryland became the second operating U S  LNG export terminal  Four additional projects under construction or commissioning are set to nearly triple U S  liquefaction by the end of 2019  This increase in liquefaction capacity likely will motivate LNG producers to secure new buyers  Figure 6 shows estimated LNG prices for various locations around the world as of October 2018  As the figure shows, LNG prices are substantially lower in North America than in Asia, Europe, and South America  Even after adding $1 00 to $2 00/MMBtu to transport the LNG to overseas ports, LNG produced in the United States is globally competitive at these prices  If LNG from the new liquefaction capacity coming online can be produced and delivered with similar economics, the cost advantage may create an opportunity for U S  LNG in bunker supply  There are over 400 petroleum fuel bunkering ports in the world, but 60% of bunkering in recent years has happened in six countries: Singapore, the United States, China, the United Arab Emirates, South Korea, and the Netherlands  Of these countries, only the United States is a significant LNG producer  Therefore, the United States could be a favorable source of LNG for domestic bunkering and for bunkering at the other major ports  While the LNG industry historically has had a good safety record, there are unique safety risks associated with LNG in vessel operations  Leakage of LNG during LNG shipping or bunkering can pose several hazards  LNG is stored at temperatures below -162 °C (-260 °F), far below the -20°C at which the carbon steels typically used in shipbuilding become brittle  Consequently, extreme care must be taken to ensure that LNG does not drip or spill onto ship hulls or decking because it could lead to brittle fracture, seriously damaging a ship or bunkering barge  LNG spilled onto water can pose a more serious hazard as it will rapidly and continuously vaporize into natural gas, which could ignite  The resulting "pool fire" would spread as the LNG spill expands away from its source and continues evaporating  A pool fire is intense, far hotter and burning far more rapidly than oil or gasoline fires, and it cannot be extinguished; all the LNG must be consumed before it goes out  Because an LNG pool fire is so hot, its thermal radiation may injure people and damage vessels or property a considerable distance from the fire itself  Many experts agree that a large pool fire, especially on water, is the most serious LNG hazard  Leaks of boil-off gas (the small amount of LNG that vaporizes in storage) can also release natural gas into a port area and cause fires or explosions  Major releases of LNG from large LNG carriers would be most dangerous within 500 meters of the spill and would pose some risk at distances up to 1,600 meters from the spill  While a bunkering barge or a vessel using LNG for fuel contains far less LNG than large LNG carriers, LNG spills in bunkering operations could still be a significant concern  Risks associated with bunkering LNG are complicated in ports seeking to engage in "simultaneous operations" during the bunkering process  Simultaneous operations entail loading and unloading cargo and personnel from a ship, maintenance, and other logistical operations performed while a ship is bunkering  Accidents that occur during such operations (for example, the operation of heavy machinery near pipes transporting LNG) can result in a spill of LNG which can threaten workers positioned near the site of operations  LNG tankers, bunkering vessels, and land-based facilities could be vulnerable to terrorism  Bunkering tanks or vessels might be physically attacked to destroy the LNG they hold—and vessels might be commandeered for use as weapons against port or coastal targets  Potential terrorist attacks on LNG terminals or tankers in the United States have long been a key concern of the public and policymakers in the context of large scale LNG imports or exports because such attacks could cause catastrophic fires in ports and nearby populated areas  For example, a 2007 report by the Government Accountability Office stated that, "the ship-based supply chain for energy commodities," specifically including LNG, "remains threatened and vulnerable, and appropriate security throughout the chain is essential to ensure safe and efficient delivery " Affected communities and federal officials continue to express concern about the security risks of LNG  The potential risks from terrorism to LNG bunkering infrastructure may be different than those of larger LNG import or export operations due to smaller quantities of LNG involved, but the risks may become more widespread if LNG bunkering operations are established in more locations  The Maritime Transportation Security Act (MTSA, P L  107-295 ) and the International Ship and Port Facility Security Code give the Coast Guard far-ranging authority over the security of hazardous materials in maritime shipping  The Coast Guard has developed port security plans addressing how to deploy federal, state, and local resources to prevent terrorist attacks  Under the MTSA, the Coast Guard has assessed the overall vulnerability of marine vessels, their potential to transport terrorists or terror materials, and their use as potential weapons  The Coast Guard has employed these assessments to augment port security as necessary and to develop maritime security standards for LNG port facilities  The IMO's overall framework for controlling vessels emissions (MARPOL Annex VI) has been in place since 2005  While the United States, as an IMO member, is subject to the IMO's 2020 sulfur standards, the international standards apply equally to all parties and all vessels  The impacts of sulfur standards on bunker fuel have been an important consideration, but IMO member nations have agreed to the standards independent of any particular energy policies  Moreover, MARPOL Annex VI preceded the U S  shale gas boom, so commitment to that initial IMO framework could not have anticipated United States' current role as a dominant energy producer  Any changes within the international shipping fleet to install sulfur scrubbers, fuel engines with LNG, or switch to other low sulfur fuels, are being driven primarily by market forces in fuel supply, shipbuilding, and shipping—not by any particular push to favor one fuel over another  Nonetheless, given its particular status, the question arises whether the standards may create an economic opportunity for the United States, in energy or otherwise  More specifically, could international adoption of LNG as a bunker fuel create an important new market for U S  natural gas producers, shipbuilders, or infrastructure developers? As discussed above, depending upon the adoption of LNG bunkering in the global fleet, the LNG bunker fuel market could grow to several billion dollars by 2030  If U S  LNG producers were to supply a significant share of this market—on the strength of comparatively low LNG production costs—LNG bunkering could increase demand for U S  natural gas production, transportation, and liquefaction  Opportunities in LNG-related shipbuilding might be more limited, as most of this occurs overseas, with the exception of Jones Act vessels  In the latter case, demand for domestically-constructed LNG bunkering barges could be one significant area of economic growth  Engineering and construction firms could benefit from new opportunities to develop new port infrastructure for LNG storage and transfer  While likely limited in number, such port facilities could be complex, high value projects costing tens or hundreds of millions of dollars to complete  Such projects could create jobs in engineering, construction, and operation, which could be important to local communities  Although LNG bunkering could present the United States with new economic opportunities, it may pose challenges as well  Rising demand for LNG in the maritime sector could increase natural gas prices for domestic consumers  In addition to being the world's largest natural gas producer, as of 2018, the United States is also the world's largest producer of crude oil and the second largest bunkering hub  Consequently, while vessel conversion to LNG bunkering may increase demand for U S -produced natural gas, it could be partially offset by reduced demand for U S -produced crude oil or refined products  Exactly how changing demand in one sector could affect the other is unclear  Furthermore, while LNG can reduce pollutant emissions from vessels, emissions and environmental impacts from increased natural gas production and transportation could increase overall emissions  Much of the net environmental impact depends upon practices in the natural gas industry, which are the subject of ongoing study and debate  Although new LNG bunkering infrastructure can create jobs, as the Tacoma LNG projects shows, the construction of such port facilities can be controversial for reasons of safety, security, and environmental impact  Overarching the considerations above is uncertainty about how the global shipping fleet will adapt to the IMO sulfur standards over time  This uncertainty complicates decisions related to both private investment and public policy  LNG-fueled ships still account for only a fraction of the U S  and global fleets, and it may take several decades for significant benefits of LNG-powered vessels to be realized  It is also possible that alternative ship fuels, including biofuels, electric engines, and hybrid engines, will become more economically viable in coming years  Given the uncertainty surrounding the future of LNG as a ship fuel, it is hard to predict the potential benefits or costs that LNG bunkering may provide to the United States  Until now, the private sector has added LNG-fueled vessels to fleets in the United States in a piecemeal manner under existing federal statutes and regulation  Congress could encourage the growth of LNG bunkering by various means, such as providing tax incentives to support the construction of LNG bunkering facilities and vessels, addressing any statutory or regulatory barriers to bunkering facility siting or operations, and providing funding for technical support to domestic carriers seeking to adopt LNG technology  Alternatively, Congress could seek to encourage competing bunker fuel options, such as biofuels, by incentivizing them in similar ways  In addition, Congress could also affect growth in LNG bunkering through policies affecting the LNG industry or domestic shipping industry as a whole  Changes in federal regulation related to natural gas production, or changes to the Jones Act, for example, while not directed at LNG bunkering, could nonetheless affect its economics  Therefore, evaluating the potential implications on LNG bunkering of broader energy, environmental, or economic objectives may become an additional consideration in congressional oversight and legislative initiatives  If LNG bunkering expands significantly in U S  ports, Congress also may examine the adequacy of existing measures to ensure the safety and security of LNG vessels, storage, and related facilities 


Report 2:  The awards include (1) scholarships for candidates enrolled in preparatory or undergraduate prerequisite courses in preparation for entry to a health professions school, (2) pre-graduate scholarships for candidates enrolled in courses leading to a bachelor’s degree, including pre-medicine, pre-dentistry, and pre-podiatry, and (3) health professions scholarships for candidates who are enrolled in an eligible health profession degree program  According to IHS, in fiscal year 2017, there were 805 new scholarship applications submitted  After evaluating the applications, 331 applications were deemed eligible for funding, and the program was able to fund 108 new awards  The IHS Scholarship program also reviewed applications from previously awarded scholars who were continuing their education  In fiscal year 2017, 154 continuation awards were funded  In addition to the scholarship program, according to IHS officials, the agency funds two medical students enrolled at the Uniformed Service University of the Health Sciences each year  Each graduate agrees to a 10-year obligation to IHS after medical school graduation and completion of training  In future years, IHS endeavors to fund two additional medical students at the Uniformed Service University of Health Sciences  Externships and internships  IHS provides scholarship recipients with opportunities to receive clinical experience in IHS facilities  In fiscal year 2017, the agency funded 94 students, who were employed for 30 to 120 workdays per calendar year  In addition, IHS provides externships to students temporarily called to active duty as Commissioned Corps officers through the Commissioned Officer Student Training and Extern Program (COSTEP)  IHS officials said that the agency funded about 60-70 students in COSTEP in 2016  IHS also offers a Virtual Internship program through a partnership with the Department of State  Virtual interns spend 10 hours a week from September through May working remotely on their projects, which have included producing bilingual Navajo and English videos for rural health clinics, developing Navajo-specific health education materials on palliative care, improving behavioral health data collection methods, and creating social media strategies and campaigns for health promotion  For the 2017-2018 academic year, about 15 students are participating in virtual internships with IHS  Residency rotations  IHS service units offer rotation opportunities for medical, nursing, optometry, dental, and pharmacy residents as a recruitment tool because research shows students are likely to stay and practice medicine in the area where they studied  For example, the Oklahoma City area has a Memorandum of Agreement with the Oklahoma State College of Medicine, which permits area officials to annually recruit up to two residents from the current year’s residency class to become federal employees while completing their residency program  For every year that IHS sponsors the residents’ position at the university, the resident has a one-year service obligation  In addition, IHS officials from Chinle stated that the service unit participates in educational agreements with numerous universities and residency programs to host medical students, nursing students, and medical residents for rotations  According to officials, recent graduates from residency programs applying for permanent positions with the Chinle Comprehensive Health Care Facility often cite prior rotations at the service unit, or word of mouth from students or residents who have rotated through the service unit, as a reason for applying  The IHS Pharmacy Resident Program is another recruitment program that offers residency training to pharmacists who are willing to serve in high-need locations  Pharmacy residents who are Commissioned Corps officers are required to complete 2 years of service at an IHS federal or tribal facility  Twenty-six Commissioned Corps and civilian pharmacists participate in the Pharmacy Residency Program  See app  II for information on residency programs at tribally operated facilities  IHS officials said they have conducted webinars and career fairs in an attempt to connect with health professional students  For example, in 2016, IHS conducted two informational webinars to recruit Commissioned Corps applicants to facilities in the Great Plains area with critical clinical vacancies  According to IHS officials, approximately 60 applicants attended the two webinars, resulting in 15 nurse hires  In addition, Nashville area officials stated that the area office conducted a marketing campaign at the National Congress of American Indians Conference  Officials explained that the area office provided information about desirable aspects of living in the Nashville area and collected e-mail addresses and areas of interest from potential job candidates  IHS’s Office of Human Resources also partners with HRSA’s Bureau of Health Workforce by participating in nationwide virtual career fairs to promote the National Health Service Corps scholarship and loan repayment opportunities  IHS has also worked with the Office of the Surgeon General to increase the recruitment and retention of Commissioned Corps officers  In May 2017, the Office of the Surgeon General gave IHS priority access to new Commissioned Corps leads—meaning IHS has at least 30 days to make contact with potential applicants to the Commissioned Corps before other agencies have the opportunity to contact them  According to IHS officials, since being given priority access to Commissioned Corps leads, the agency has made 20 direct clinical care selections, of which 15 have entered on duty  In addition to its recruitment and retention strategies, IHS uses strategies to mitigate the negative effects of vacancies by helping to maintain patient access to services, and helping to reduce provider burnout when positions are vacant  Specifically, IHS provides telehealth services; implements alternative staffing models, including hiring nurse practitioners and physician assistants in lieu of physicians; temporarily assigns Commissioned Corps officers to alternate duty stations as needed; and contracts with temporary providers  IHS’s telehealth services include two agency-wide programs that provide teleophthalmology and telebehavioral health services  Teleophthalmology  The IHS Joslin Vision Network (IHS-JVN) Teleophthalmology Program provides annual diabetic eye exams to AI/AN patients in almost all IHS areas with federally operated facilities  According to IHS, patients’ retinal images are scanned locally and sent to a reading center where doctors interpret the images and report back  Officials told us the IHS-JVN program examined 22,000 patients in 2016  Telebehavioral health  The Telebehavioral Health Center of Excellence provides direct care services through video conferencing to patients at remote facilities from providers at IHS facilities that are able to provide the services  These services are provided in all IHS areas with federally operated facilities, and more than 5,800 patient visits occurred in 2016  Additionally, officials told us there are regional telebehavioral health programs, such as in the Oklahoma City area that, combined with the Telebehavioral Health Center of Excellence, saw over 10,000 patients in 2016  IHS officials stated that patients appreciate the telebehavioral services in their communities, because they are the only behavioral health services available in many communities  The IHS psychiatrist who provides services is located in Oklahoma City because, according to IHS officials, it is easier to recruit providers to a more urban location  In addition to these agency-wide telehealth programs, IHS officials identified multiple other local telehealth arrangements that facility staff have developed to help maintain patient access to medical services  For example, there is a diabetes consultant for the Portland area who conducts telenutrition services  There is also a teledermatology program for the Phoenix Area federal facilities operated out of the Phoenix Indian Medical Center  Additionally, several service units—including Pine Ridge Hospital, Rosebud Hospital, and the Sioux San Medical Center—have contracts for emergency department telehealth services  Figure 7 shows telehealth equipment in the Rosebud Hospital emergency department  Staff from multiple facilities told us they have implemented alternative staffing models to focus on hiring for non-physician practitioner positions because these positions are slightly easier to fill  For example, Northern Navajo Medical Center officials told us the facility, facing an emergency department physician shortage, hired physician assistants and nurse practitioners instead  These officials said they converted two physician positions into four physician assistant and nurse practitioner positions  In addition, Chinle officials stated that they added two physician assistants to the urgent care department due to complaints about patient wait times, and patient wait times have decreased as a result  Officials also mentioned dental therapists as an additional type of clinical professional who may be added to the Chinle Health Care Facility staffing model because the service unit has been unable to recruit and retain enough dentists to meet patient need  IHS officials stated that they have worked with the Office the Surgeon General to deploy Commissioned Corps officers, mainly to the Great Plains area, and have also coordinated voluntary temporary duty assignments of Commissioned Corps officers (within IHS and from other agencies) to temporarily fill staffing shortages or meet other mission- critical needs  IHS officials stated that Commissioned Corps officers may also be temporarily assigned to an IHS site to provide services, such as behavioral health support during a suicide cluster  IHS officials from 9 of the 10 geographic areas with federally operated facilities and all seven facilities in our review told us they regularly use temporary contract providers—such as through locum tenens contracts and contracts with university fellowship programs—to maintain patient access to care when positions are vacant  Locum tenens  Officials from the Kayenta Health Center said they contract with temporary providers to compensate for vacancies, and the facility contracts with about 9 providers who rotate to fill 3 vacant emergency department positions  Officials from the Portland area stated that they use temporary providers when there is a staffing shortage with providers  They explained that the Portland area has provider vacancies that have been open for years, and temporary providers fill these vacancies for an extended period of time, usually with a rotating series of providers  Chinle Health Care Facility officials said temporary providers, when of sufficiently high quality, have been recruited to join the permanent corps of civilian service staff  However, they told us locum tenens can cost between $50,000-$200,000 more annually than permanent physicians’ salaries, exclusive of benefits, depending on the specialties and hourly rates associated with the contracts  They said they are finding that increasingly higher hourly rates are needed to ensure a sufficient supply of high-quality temporary providers  IHS officials at all levels of the agency told us they prefer to hire permanent providers, rather than use locum tenens contracts  Facility officials explained that persistent turnover in temporary staff may jeopardize continuity of care  For example, Sioux San Medical Center officials expressed concern about the quality of the care provided by temporary contractors, as well as the consistency of the care provided because the contractors rotate frequently  IHS officials told us that many providers prefer to be on contract due to the higher compensation rates as a contractor, even when taking federal benefits into account  University physicians  IHS officials explained that area offices may also contract with university fellowship programs to provide visiting providers  For example, according to IHS, the Chinle Health Care Facility has entered into long-term contractual agreements with two academic fellowship programs—University of California-San Francisco Health Program and the University of Utah Global Health Fellowship  Officials told us these programs provide U S  residency- trained, board certified physicians interested in global health to work 6-month assignments alternating with another fellow at an international site  In addition, IHS officials stated that the Navajo area office is collaborating with the University of California-San Francisco and its global health fellowship to assign global health fellows to a Navajo Area site for 6 months out of each year  The officials explained that 24 fellows were placed in Navajo-area facilities in 2017 at costs substantially lower than that of locum tenens contracts  According to IHS, the Great Plains area office has collaborated with the University of Washington’s global health fellowship program to assign global health fellows in Internal Medicine to Pine Ridge Hospital for 11- month placements  Agency-wide information on the extent to which facilities use these temporary providers, and the amount spent on them, is not readily available to IHS leadership  While IHS has agency-wide information on vacancies through the Capital Human Resource Management System, IHS delegates the acquisitions process for temporary provider contracts to the head of each area-level Contracting Office  Therefore, agency-wide information on the number of full-time equivalent employees that are temporary providers working at IHS facilities, as well as the cost of these providers, is not readily available  As discussed, officials we spoke with at IHS facilities told us that temporary providers can cost more depending on the specialties and hourly rates  Without agency-wide information on the extent to which such providers are used, IHS is not fully informed about facilities’ reliance and expenditures on temporary providers or their potential effect on patient care, which is inconsistent with federal internal control standards regarding the availability of relevant information to facilitate management decision making and performance monitoring  Specifically, federal internal controls standards state that agency management should obtain, process, and use quality information to make informed decisions and evaluate the agency’s performance in achieving key objectives and addressing risks  IHS’s lack of agency-wide information on the costs and number of temporary providers used at its facilities impedes its ability to make decisions about how best to target its resources to address gaps in provider staffing and ensure that health services are available and accessible across IHS facilities  Maintaining a stable clinical workforce capable of providing quality and timely care is critical for IHS to ensure that comprehensive health services are available and accessible to American Indian/Alaska Native people  However, despite efforts to recruit and retain providers, IHS continues to face considerable challenges to overcome its long-standing struggle to fill sizeable provider vacancies, including geographic isolation and limited amenities  Although IHS is authorized to offer recruitment and retention incentives, such as loan repayments and subsidized housing, the demand for these incentives has been greater than the agency can meet due to resource constraints  However, more complete information on contract providers could help IHS officials make decisions on where to better target its limited resources to address gaps in provider staffing and ensure that health services are available and accessible to American Indian/Alaska Native people across IHS facilities  We are making the following recommendation to IHS: The Director of IHS should obtain, on an agency-wide basis, information on temporary provider contractors, including their associated cost and number of full-time equivalents, and use this information to inform decisions about resource allocation and provider staffing  (Recommendation 1) We provided a draft of this report to HHS and the Department of Veterans Affairs (VA) for review and comment  We received written comments from HHS that are reprinted in appendix III  HHS concurred with our recommendation  In its comments, HHS stated that IHS plans to update its policies by December 2018 to include a centralized reporting mechanism requirement for all temporary contracts issued for providers  HHS also stated that, upon finalization of the policy, IHS will broadly incorporate and implement the reporting mechanism agency-wide and maintain it on an annual basis  HHS also provided technical comments, which we incorporated as appropriate  VA provided comments on a draft of this report in an email, stating that VA officials continue to work to improve recruitment and retention of providers at VHA to ensure that they have the correct number of providers with the appropriate skills  We are sending copies of this report to HHS, the Department of Veterans Affairs, and appropriate congressional committees  In addition, the report will be available at no charge on GAO’s website at http://www gao gov/  If you or your staff have any questions about this report, please contact me at (202) 512-7114 or farbj@gao gov  Contact points for our Office of Congressional Relations and Office of Public Affairs can be found on the last page of this report  Other major contributors to this report are listed in appendix IV  Appendix I: Provider Vacancies with the Indian Health Service (IHS) IHS data collected in November 2017, included the number of positions and vacancies for several types of providers, including physicians, nurses, dentists, pharmacists, nurse practitioners, certified registered nurse anesthetists, certified nurse midwives, and physician assistants  Most of these positions are in the 8 of 12 IHS areas in which IHS has substantial direct care responsibilities  Vacancies for nurse practitioners, nurse midwives, dentists, pharmacists, and physician assistants are provided in this appendix  Nurse practitioners  Nationwide, 97 of 303 positions were vacant in November 2017, and vacancy rates in the 8 areas in which IHS has substantial direct care responsibilities ranged from 12 percent in the Oklahoma City area to 47 percent in the Albuquerque area  (See fig  8) Certified nurse midwives  Nationwide, 8 of 55 positions were vacant in November 2017  See table 1  Dentists  Nationwide, 81 of 306 positions were vacant in November 2017 and vacancy rates in the 8 areas in which IHS has substantial direct care responsibilities ranged from 14 percent in the Phoenix area to 39 percent in the Bemidji area  (See fig  9 ) Pharmacists  Nationwide, 80 of 637 positions were vacant in November 2017 and vacancy rates in the 8 areas in which IHS has substantial direct care responsibilities ranged from 3 percent in the Bemidji area to 17 percent in the Albuquerque area  (See fig  10 ) Physician assistants  Nationwide, 37 of 125 positions were vacant in November 2017  See table 2  Tribal officials from the Chickasaw Nation and Choctaw Nation described their use of strategies to address vacancies, which were very similar to strategies used by the Indian Health Service (IHS)  Like the IHS, one tribe uses the availability of housing units near its medical facility as a recruitment tool for health care providers  Both tribes that described their strategies to recruit and retain providers told us they use their physician residency program in Family Medicine as a recruitment tool  Availability of housing units near the medical facility  Tribal officials from the Choctaw Nation told us the tribe uses housing units—58 housing units that range from studio apartments to multi- room houses—as a recruitment strategy for providers  The provider housing units are occupied by physicians, as well as by physician residents who need housing during their residency or for medical students doing clinical rotations through the facility  According to tribal officials, a factor they considered in making housing units available for providers was the location of its hospital in a rural area of Oklahoma, in a town with a population of about 1,000, which lacks sufficient housing  In September 2017, tribal officials told us all the available housing units were occupied, and the tribe was in the process of constructing at least two 4-bedroom houses  See fig  11 for photos of a completed multi-room house and one under construction  Offering the housing units to provider staff is also part of the tribe’s overall strategy of offering quality-of-life benefits to attract and retain providers  Implementing Accredited Physician Residency Programs  Tribal officials we interviewed noted that they developed physician training programs—specifically graduate medical education, commonly known as residency training—which they use as an important recruitment tool for physicians  One tribe has implemented its Family Medicine residency program, while the other tribe intends for its Family Medicine residency program to be operational in July 2018  Both residency programs are accredited by the American Osteopathic Association, in addition to the American College of Osteopathic Family Practice for one tribe and the American Council for Graduate Medical Education for the other tribe  One program is accredited for 3 resident physicians per year for a total of 9 physician residents at a time, while the other program is accredited for 4 resident physicians per year  We previously found that physicians may practice in geographic areas similar to those where they complete their residency training  Tribal officials with the implemented Family Medicine residency program told us it is successful in that they hired 7 of the 9 residents who completed the residency program  There is also a retention benefit—current providers have the opportunity to stay up-to-date on the latest medical treatment methods by serving as either mentors or as faculty for the residents  In addition to the contact named above, Kathleen M  King (Director), Ann Tynan (Assistant Director), Kelly DeMots (Assistant Director/Analyst-in- Charge), Sam Amrhein, Kristen Anderson, Muriel Brown, Kaitlin Farquharson, Peter Mann-King, Maria Ralenkotter, Lisa Rogers, and Jennifer Whitworth made key contributions to this report 

ground_truth: IHS is charged with providing health care to AI/AN people who are members or descendants of 573 tribes. According to IHS, AI/AN people born today have a life expectancy that is 5.5 years less than all races in the United States, and they die at higher rates than other Americans from preventable causes. The ability to recruit and retain a stable clinical workforce capable of providing quality and timely care is critical for IHS. GAO was asked to review provider vacancies at IHS. This report examines (1) IHS provider vacancies and challenges filling them; (2) strategies IHS has used to recruit and retain providers; and (3) strategies IHS has used to mitigate the negative effects of provider vacancies. GAO reviewed IHS human resources data for the provider positions that the agency tracks. GAO also reviewed policies, federal internal control standards, and legal authorities related to providers in federally operated IHS facilities. GAO interviewed IHS officials at the headquarters and area level and at selected facilities. GAO selected facilities based on variation in their number of direct care outpatient visits and inpatient hospital beds in 2014. Indian Health Service (IHS) data show sizeable vacancy rates for clinical care providers in the eight IHS geographic areas where the agency provides substantial direct care to American Indian/Alaska Native (AI/AN) people. The overall vacancy rate for providers—physicians, nurses, nurse practitioners, certified registered nurse anesthetists, certified nurse midwives, physician assistants, dentists, and pharmacists—was 25 percent, ranging from 13 to 31 percent across the areas. IHS officials told GAO that challenges to filling these vacancies include the rural location of many IHS facilities and insufficient housing for providers. Officials said long-standing vacancies have a negative effect on patient access, quality of care, and employee morale. IHS uses multiple strategies to recruit and retain providers, including offering increased salaries for certain positions, but it still faces challenges matching local market salaries. IHS also offers other financial incentives, and has made some housing available when possible. In addition, IHS uses strategies, such as contracting with temporary providers, to maintain patient access to services and reduce provider burnout. Officials said these temporary providers are more costly than salaried employees and can interrupt patients' continuity of care. However, IHS lacks agency-wide information on the costs and number of temporary providers used at its facilities, which impedes IHS officials' ability to target its resources to address gaps in provider staffing and ensure access to health services across IHS facilities. GAO recommends that IHS obtain, on an agency-wide basis, information on temporary provider contractors, including their associated cost and number of full-time equivalents, and use this information to inform decisions about resource allocation and provider staffing. IHS concurred with GAO's recommendation.