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



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

Report 1: Many Members of Congress became actively engaged in foreign policy debates over U S  intervention in the 1992-1995 war in Bosnia and Herzegovina (hereafter, "Bosnia")  Congress monitored and at times challenged the Bush and Clinton Administrations' response to the conflict through numerous hearings, resolutions, and legislative initiatives  Many observers contend that the United States is a stakeholder in Bosnia's future because of the strong impact of U S  intervention on the postwar Bosnian state  Nearly 25 years after warring parties in Bosnia reached the Dayton Agreement (see below), Bosnia faces numerous internal and external challenges, and the country retains geopolitical importance to U S  interests in the Western Balkans  As Congress assesses ongoing and emerging security issues in the region, including resilience against malign external influence, renewed conflict, and radicalization, Bosnia's internal politics and its role in Balkan stability may merit further examination  Bosnia has existed in various forms throughout its history: a medieval kingdom, territory held by two major empires, a federal unit, and, since 1992, an independent state  Bosnia's present international borders are largely consistent with its administrative boundaries under later periods of Ottoman Turkish rule  After World War I, Bosnia became part of the newly created Kingdom of Serbs, Croats, and Slovenes  It was one of the six constituent republics of the Socialist Federal Republic of Yugoslavia from 1945 until 1992  Bosnia's constitution stems from the U S -brokered Dayton Peace Agreement that ended the country's 1992-1995 war  It recognizes three "constituent peoples": Bosniaks, Croats, and Serbs  All three groups are Slavic  Religious tradition is considered a marker of difference among the three ethnic identities: Bosniaks are predominantly Muslim, Serbs are largely Orthodox Christian, and Croats are mostly Catholic  Although Bosnian, Croatian, and Serbian are recognized in Bosnia as distinct official languages, they are mutually intelligible  Bosniaks comprise approximately 50 1% of the population, Bosnian Serbs 30 8%, and Bosnian Croats 15 4%  In this report, Bosnian is used as a non-ethnic term for a person or institution from Bosnia  A Bosnian Serb is an ethnic Serb from Bosnia and a Bosnian Croat is an ethnic Croat from Bosnia  Bosniak refers to Slavic Muslims  Bosnia's religious and cultural diversity is one of its distinctive characteristics  Islam was introduced to part of Bosnia's population during the Ottoman period, although there were also large Catholic, Orthodox Christian, and Jewish communities  Bosnia was the most heterogeneous Yugoslav republic and the only one where no ethnic group formed an absolute majority  During the 1990s, some popular accounts of Bosnia (and the former Yugoslavia) depicted its ethnic relations as "ancient hatreds," implying that the country's ethnic groups cannot peacefully coexist and that the 1992-1995 war was unavoidable  However, many experts on the region reject this thesis  Although Bosnia has experienced episodes of communal violence and bloodshed, most recently during World War II and the 1992-1995 war, its heterogeneous population also has lived in mixed communities for periods of peace  Many experts contend that ethnic conflict often was stoked by domestic leaders who manipulated historical memory and grievances to further their own agendas, or by external powers seeking to rule Bosnia or annex its territory  In the 1980s, Yugoslavia's escalating political and economic crises fueled nationalist movements  Nationalist leaders in Serbia and Croatia appealed to Bosnian Serbs and Croats as ethnic "kin " The party that ruled Croatia for most of the 1990s, the Croatian Democratic Union (HDZ), established a sister party with the same name to mobilize Bosnian Croats and compete in Bosnia's elections  This gave Croatia an avenue of influence in Bosnian politics  Serbia, led by strongman Slobodan Milošević, likewise had influence over Bosnian Serb leaders  In Bosnia's November 1990 elections—the first competitive elections in decades—voters cast aside the ruling League of Communists party and elected ethnic parties that largely continue to dominate today  Bosnian voters backed independence in a 1992 referendum, following in the footsteps of Slovenia, Croatia, and Macedonia  Bosnian Serbs, who did not want to separate from Yugoslavia, boycotted the referendum  Bosnian Serb forces seized more than two-thirds of Bosnia's territory, and a three-year conflict followed that pitted Serb, Croat, and Bosniak forces against one another  Bosnian Serb leaders declared a "Serb Republic" ( Republika Srpska) in March 1992, while Bosnian Croat leaders proclaimed the Croat Community of Herceg-Bosnia in July  Some Bosnian Croat and Bosnian Serb leaders advocated unification with Croatia and Serbia, respectively, where government factions—including their strongman leaders—likewise wanted to carve a Greater Croatia and Greater Serbia out of Bosnia's territory  Bosniak leaders opposed dismemberment of the state  Bosnia's war was one of the most lethal conflicts in Europe since World War II  Bosnian Serb forces besieged Sarajevo for 44 months  More than 10,000 people, mostly civilians, died due to shelling, sniping, and blockade-related deprivation  Paramilitary factions from neighboring Croatia and Serbia—some of which reportedly had ties to the Croatian and Serbian government—fought alongside Bosnian Croats and Serbs  The Serb-dominated Yugoslav National Army also aided Bosnian Serb forces, giving them a military advantage  In many areas, combatants from the three groups killed or expelled members of other ethnic groups to "purify" territory that they wanted to claim as their own  This "ethnic cleansing" changed Bosnia's demographic landscape  An estimated 100,000 or more Bosnians were killed in the conflict, and roughly half of its population displaced  In addition, an estimated 20,000 or more women and girls were victims of sexual violence  Hundreds of Bosnians have been prosecuted for war crimes at the International Criminal Tribunal for the former Yugoslavia (ICTY) and in Bosnian courts  In 2016, the ICTY convicted wartime Bosnian Serb leader Radovan Karadžić of genocide and war crimes  In 2019, the tribunal rejected his appeal and increased his sentence from 40 years to life  Citizens of Croatia and Serbia have also been indicted for crimes committed in the Bosnian war  Highly publicized incidents in 1994 and 1995 underscored the war's human toll  Bosnian Serb forces bombarded a Sarajevo market in 1994 and 1995, resulting in over 100 civilian deaths  In July 1995, Serb forces commanded by Ratko Mladić seized and executed more than 8,000 Bosniak men and boys in a U N -designated safe area around the city of Srebrenica, an incident subsequently seen by some as a consequence of the international community's muddled, ineffectual response to the conflict  The International Court of Justice and ICTY subsequently ruled that the Srebrenica massacres constituted an act of genocide  Mladić was convicted of genocide and other crimes in 2017  These incidents increased pressure on U S  policymakers to take a stronger role in resolving a conflict that had largely been left to the EU and the United Nations  Under U S  command, NATO intervened in August and September 1995 with air strikes against Bosnian Serb targets, while allied Bosniak and Croat forces launched a simultaneous offensive in western Bosnia  The United States played a key role in brokering several agreements  The 1994 Washington Agreement ended the "war within a war" between Bosniaks and Croats  In November 1995, leaders from Croatia, Bosnia, and Serbia met at the Wright-Patterson Air Force base in Dayton, OH, to negotiate a peace agreement  U S  diplomat Richard Holbrooke played a crucial role in brokering the General Framework Agreement for Peace in Bosnia and Herzegovina, more commonly known as the Dayton Peace Agreement  Bosnia's complex political system is a product of the Dayton Agreement; one of its annexes serves as Bosnia's constitution (Annex 4)  Its provisions partly reflect the situation on the ground in 1995, including the subdivision of Bosnia into two ethnoterritorial entities ( Figure 1 ): Republika Srpska ("RS"), which Bosnian Serb leaders had proclaimed in 1992, and the Federation of Bosnia and Herzegovina ("FBiH," predominantly populated by Bosniaks and Croats), which was created by the 1994 Washington Agreement  Entity borders were largely drawn to form ethnic majorities, even though they also reflected territorial seizure and ethnic cleansing  Many Bosniaks view the division of Bosnia into these roughly equal entities as awarding the spoils of war to Bosnian Serbs, whom they regard as the aggressors  Many Bosnian Serbs, however, view the Serb-majority entity as a protection against marginalization  The designation of Bosniaks, Croats, and Serbs as Bosnia's three "constituent peoples" is a cornerstone of the Dayton system  Numerous government bodies have ethnic quotas requiring equal representation of the three groups  In these power-sharing institutions, delegates from each constituent group may veto measures that go against vital ethnic interests  While these arrangements make Bosnia's political system prone to gridlock, Dayton's negotiators viewed them as necessary to prevent any group from feeling marginalized in a context of low trust  Bosnia is a parliamentary republic with a high degree of decentralization  Its complex, tiered structure includes a central ("state-level") government, the two entities, the autonomous Brčko district, and cantonal and municipal governments  The central ("state-level") government covers the entirety of Bosnia  A three-member presidency is the head of state, and includes one Serb member who is elected by RS voters, and one Bosniak and one Croat member elected by FBiH voters  The Council of Ministers, led by a Chairperson, is roughly equivalent to a cabinet government and prime minister in other parliamentary systems  The Parliamentary Assembly is a state-level legislature with two chambers: a directly elected House of Representatives (42 members) and an indirectly elected House of Peoples (5 Serbs, 5 Croats, and 5 Bosniaks)  The state-level government is considered to be weak, despite some expansion of its functions in the 2000s  Its major responsibilities include foreign relations; trade, customs, and monetary policy; migration and asylum policy; defense; and intelligence  Bosnia is further subdivided into two ethnoterritorial entities: Republika Srpska (RS), where Serbs are the largest ethnic group (82%), and the Federation entity (FBiH), where Bosniaks (70%) and Croats (22%) are the largest groups  The two entities have broader policy jurisdiction than the state-level government  Governing functions that are not assigned to the state-level government fall to the entities  These include civilian policing, economic policy, fiscal policy, energy policy, and health and social policy, as well as other issues  Each entity has its own constitution, as well as a president, vice presidents, legislature, and cabinet government with a prime minister  Each entity may establish "special parallel relationships" with neighboring states (i e , Croatia and Serbia)  Numerous entity bodies also incorporate ethnic quotas  Brčko district, a border region in northeastern Bosnia, was initially administered by the international community to allay concerns about RS secession  Brčko's location interrupts RS's contiguity, and both entities initially claimed it  Brčko was later awarded to both entities, but remains a self-governing district whose population is a mix of all three constituent peoples  Some analysts believe it has been relatively more successful than the entities in passing reforms and reintegrating its divided population (e g , ethnically mixed schools with a common curriculum)  FBiH entity is further divided into ten cantons, many of which were drawn to form ethnic Bosniak or Croat majorities  The cantons have jurisdiction in many policy areas, including policing, housing, culture, and education  They also have their own constitutions—based on the FBiH constitution—as well as legislatures and cabinet-style governments  FBiH and RS are further divided into 79 and 64 municipalities, respectively  The Dayton Agreement established a strong oversight role for the international community  The Office of the High Representative (OHR) was created to monitor the implementation of civilian aspects of Dayton  The High Representative is supported by the Peace Implementation Council (PIC), a group of 55 countries and agencies  A 1997 PIC conference empowered the High Representative to impose binding decisions and sanction politicians who obstruct Dayton  Until the mid-2000s, the High Representative used these powers to remove officials deemed to be obstructive to peace and to promote what are considered among the most constructive reforms since Dayton, including merging the entities' armed forces and intelligence services and putting them under new state-level ministries  However, the High Representative's proactive role has since decreased  This is partly due to criticism that the OHR lacks democratic legitimacy and accountability  Bosnian Serb politicians have claimed that the OHR's interventions support Bosniak leaders' preference for a more centralized state  At the same time, some U S  and EU policymakers believed that the attraction of EU membership could incentivize reforms in place of the OHR's more top-down approach  The international community also plays an ongoing security role  NATO led the Implementation Force (IFOR) and the smaller Stabilization Force (SFOR) that monitored security aspects of the Dayton Peace Agreement  The initial deployment of NATO ground forces to Bosnia numbered nearly 60,000, of which the largest share (approximately one-third) was from the United States  The number of troops subsequently decreased  In 2004, NATO's peacekeeping role was transferred to the EU with the understanding that NATO would assist if necessary  The size of the EU operation (EUFOR Althea) decreased from 7,000 troops in 2004 to roughly 600 troops today  Many analysts contend that the Dayton Agreement helped hold Bosnia together after the war; they point to the absence of widespread violence since 1995 as an indicator of its success  However, observers also question whether Bosnia can function much longer under the Dayton system  They identify several key challenges: Critics claim that Bosnia's political system reinforces the country's ethnic divisions and makes ethnicity a core basis of political identity  The ethnic parties that have dominated politics since the war generally appeal to voters from their respective ethnic communities rather than all Bosnians  Critics accuse ethnic party leaders of inflaming nationalist tensions and manipulating historical memory to distract from corruption and win elections, thus aggravating rather than bridging the deep wounds that remain from the war  In some parts of Bosnia, divisions are further reproduced at the societal level through institutions like segregated schools, which separate schoolchildren from different ethnic groups and teach them different curriculum  Some analysts also contend that the system is too gridlock-prone to pass major political and economic reforms to be passed, even with the incentive of potential EU membership  Bosnia's fractured, overlapping institutions sometimes muddle policymaking jurisdiction and impede coordinated response  Furthermore, power-sharing arrangements create numerous veto points in the legislative process  Government coalitions are typically ideologically broad and unwieldy, creating a further source of potential dysfunction  One of the consequences of these barriers is that it is difficult to pass legislation  The previous state-level Parliament, for example, adopted twelve new laws over the course of its 2014-2018 term  Corruption in Bosnia has roots in the country's wartime economy  A 2000 Government Accountability Office (GAO) report stated that "organized crime and corruption pervade Bosnia's national political parties, civil service, law enforcement and judicial systems  [Ethnic] parties control all aspects of the government, the judiciary, and the economy, and in so doing maintain the personal and financial power of their members " Many observers claim that the situation has improved little since then  In 2018, the High Representative warned that the rule of law has deteriorated, while the U S  State Department describes the rule of law as "an existential issue " Bosnia's major parties allegedly siphon from the state apparatus and public enterprises in their strongholds to amass wealth and power  Furthermore, parties in power reportedly politicize hiring in Bosnia's public sector, which employs an estimated third or more of the working population  For many Bosnians, satisfactory employment depends on having the right political connections, which creates a dependence that reportedly is exploited during elections  In 2018, the outgoing U S  ambassador to Bosnia decried the "[Bosnian] politicians who seek to destabilize the country in order to remain in power at all costs for personal profit and protection " Many analysts believe that Bosnia's entrenched ethnic parties benefit tremendously from the status quo and have little incentive to reform the system  Bosnia's MPs are among the best-paid in Europe relative to local incomes, commanding six to eight times the average Bosnian salary  Parties and politicians who gain office in the government or administration often find "a remarkably efficient path to personal enrichment " Politicians are skilled at using veto points to block legislation that threatens their position in Bosnia's patronage system  According to one analyst, Bosnia's patronage system is "the raison d'etre of the political elites and is the main cause of the state's dysfunctionality and resistance to reform " Bosnia's entrenched political class may also fear penalty if serious reforms are enacted and shine the spotlight on malfeasance  Criminal indictments against leaders in neighborhood countries like Romania, Croatia, and North Macedonia highlight this risk  Analysts believe these disincentives make entrenched politicians resistant to external pressure for reform  Several major rounds of U S - and EU-brokered constitutional reform efforts, including in 2006, 2008, and 2009, ultimately failed  Germany and the United Kingdom launched a major initiative in 2014 to shift the focus from difficult constitutional reforms to seemingly more feasible socioeconomic reforms that they hoped would improve Bosnia's economy and dismantle patronage networks  The 2015 "Reform Agenda" identified economic, administrative, and legal measures to be adopted by entity- and state-level governments  The process, which required the major parties to commit in writing to the reform framework, was supported by the EU, the International Monetary Fund, the World Bank Group, and the United States  As an incentive for politicians to agree to the Agenda, the EU offered the entry into force of Bosnia's long-stalled Stabilization and Association Agreement, which marked the first step toward EU membership  However, most observers view the Reform Agenda as largely unsuccessful; many of its provisions failed when entrenched parties objected to measures that would undercut their dominance  While many officials recognize that Bosnia's political system needs reform, there is little consensus on how to change it or to generate the political will to find common ground so long as the dominant parties remain entrenched  Bosnian Serb leaders have expressed a desire to return to the "original" Dayton system, when the entities had greater competencies in security and justice  Milorad Dodik, who has dominated politics in Republika Srpska since the 2000s, has gone further by repeatedly threatening RS secession  Bosnian Croat leaders from the largest Croat party, the Croatian Democratic Union of Bosnia (HDZ-BiH), call for more autonomy for Croats, and have raised the prospect of splitting FBiH to create a third Croat-majority entity  By contrast, Bosniak leaders generally prefer more centralization and the removal of some of the institutional arrangements that they believe contribute to dysfunction and gridlock  Some Bosniak officials also have proposed dismantling the entities or eliminating FBiH's cantons  Survey research documents Bosnian citizens' anger toward the political class and their distrust of political institutions  In a 2018 International Republican Institute survey, 86% of respondents expressed belief that Bosnia is heading in the wrong direction  An estimated 170,000 individuals—disproportionately young and skilled—have emigrated since 2013  Dissatisfaction with education and healthcare, insecurity, and nepotism are cited as key motives to emigrate  Nevertheless, some analysts believe that periods of social discontent in 2014 and 2018, which challenged the system but appeared to transcend ethnic divides, suggest that strengthening Bosnian civil society could increase pressure for reform, and perhaps cultivate a new generation of party leaders  Other observers have put their hopes for reform in Bosnia's so-called "civic parties," which do not have nationalist platforms and typically mobilize voters on the basis of socioeconomic interests rather than ethnicity  While these parties have not matched the results of the ethnic parties, their electoral performance has improved in recent years  Bosnia's challenges came to the forefront during its most recent general election on October 7, 2018 (see Table 1 )  The Central Election Commission (CEC) registered 60 parties and over 3,500 candidates for state-level, entity, and cantonal offices  Observers noted that the campaign climate was more divisive and nationalist in tone than usual  Despite broad voter dissatisfaction, entrenched ethnic parties won the largest vote shares  Almost six months after the election, the parties are still negotiating over government formation at the state level and in FBiH; however, it appears that entrenched ethnic parties will continue to dominate  In March 2019, the leaders of the largest Bosniak, Croat, and Serb parties stated that they had agreed to a set of principles to guide forming the state-level government (the Council of Ministers)  Some observers viewed the improved result of civic parties (one-third of the vote in FBiH) as a positive development  Some of the most controversial outcomes concern the elections to the state-level presidency, composed of three members (one Bosniak, one Croat, and one Serb)  In a closely fought race, Šefik Džaferović, candidate of the ethnic Bosniak SDA party, narrowly defeated the candidate of the civic SDP party (36 6% and 33 5%, respectively), retaining the lock that the SDA has had on the Bosniak seat in most elections since 1996, but perhaps auguring a future victory by a civic party candidate  Prior to the election, some analysts expressed concern at the prospect of two of the three seats on the presidency being held by the nationalist Bosnian Serb leader Milorad Dodik and his ally, the nationalist Bosnian Croat politician Dragan Čović  Both politicians have explicitly or implicitly challenged the legitimacy of Bosnian statehood and called for greater ethnoterritorial autonomy  However, to the surprise of some observers, Željko Komšić of the civic Democratic Front defeated incumbent Čović for the Croat seat with 53% of the vote  Komšić was previously elected as the Croat member of the presidency in 2006 and 2010, and is considered to be a moderate political figure who generally supports centralizing reforms  In contrast to HDZ-BiH leader Čović, he does not have strong ties to the Croatian government  Komšić's election as the Croat member of the presidency in 2006 and 2010 was mired in controversy amid complaints that he only won with the support of Bosniaks who voted in the election for the Croat member on the presidency rather than the Bosniak member  Komšić identifies as Croat but has been leader of several civic parties  He comes from central Bosnia, and not from the Croat-majority western regions that are the stronghold of the HDZ  Although it is not illegal for Bosniaks to vote for the Croat seat on the presidency rather than the Bosniak seat, some Croat leaders (especially HDZ-BiH and HDZ-1990) claim that it violates the spirit of Dayton and results in illegitimate representation of Croats  Similar accusations of ethnic cross-voting surfaced after Komšić's victory in 2018  Some analysts expect Komšić's victory to harden the HDZ-BiH position on electoral reform (see "Legal Challenges," above) and possibly embolden politicians who seek a separate entity  As most pre-election polls anticipated, RS strongman Milorad Dodik defeated the more moderate incumbent Serb member of the presidency with 54% of the vote  Dodik has dominated entity politics in RS since the mid-2000s as entity prime minister and president  Analysts note that RS's political environment grew more closed as Dodik consolidated power  Dodik has run afoul of the United States and the EU by frequently threatening to hold a referendum on RS secession, questioning the legitimacy of Bosnian statehood, and cultivating close ties to Russia (see below)  The U S  Treasury Department sanctioned him in 2017 for actively obstructing Dayton  Many analysts have expressed concern that Dodik will use his new position to obstruct the workings of the central government while continuing to dictate politics in RS through loyal allies  Shortly after the election he vowed to "work above all and only for the interests of Serbs " One of his first acts as head of state was to call for Bosnia to recognize Ukraine's Crimea region as Russian territory  In December 2018, the National Assembly of RS approved the creation of several new ministries, an act that some view as an attempt to wrest competencies from the state-level government  In early 2019, the RS parliament courted controversy when it passed legislation to create a new commission to reinvestigate the events of Srebrenica, which many view as an attempt to deny or downplay the massacres  Since the election, the formation of governments has proceeded piecemeal, and legal challenges to election law in FBiH (see above, "Legal Challenges") initially cast doubt over the formation of that entity's government  The RS National Assembly approved the new entity government in December 2018  Party leaders continue to negotiate over forming governments in FBiH and the state-level Council of Ministers  Because the FBiH government did not fix electoral legislation before the election, the Electoral Commission adopted a decision to assign delegates to the House of Peoples based on the 2013 census  (The Electoral Commission's actions reportedly came amid strong pressure from U S  and EU officials)  Several Bosniak parties challenged the decision before the Constitutional Court; however, the Court declined to take on the case  Bosnia is one of Europe's poorest countries  The 1992-1995 war caused an estimated $110 billion in damage, and Bosnia's economy contracted to one-eighth of its prewar level  Despite significant reconstruction and recovery since 1995, GDP per capita was $5,148 in 2017, well below the EU average ($33,715) and that of Bulgaria ($8,031), its lowest-ranking member  Nearly one in five Bosnians lives below the poverty level  Bosnia's unemployment rate was 18% in 2018, down from 28% in 2015  Youth unemployment also declined in recent years from 60% to 46%  Nevertheless, these rates are still high by European standards  Since 2015, annual GDP growth has averaged around 3%, but it is largely driven by consumption (much of which in turn is fueled by migrant remittances)  The IMF has urged Bosnia to privatize or restructure the nearly 550 state-owned enterprises that comprise roughly 20% of its economy; many of them are unprofitable but allegedly are used by politicians as "cash cows and workplaces for loyal cadres " Bosnia participates in several free trade schemes  In 2006, it joined the Central European Free Trade Agreement (CEFTA) alongside other non-EU countries in the region, including other ex-Yugoslav neighbors  Bosnia's Stabilization and Association Agreement (SAA) with the European Union, which entered into force in 2015, provides for almost fully free trade  A free trade agreement with the European Free Trade Association (EFTA) also entered into force in 2015  The EU is Bosnia's primary trade partner  Germany, Italy, Croatia, Slovenia, and Austria are Bosnia's key EU export markets, accounting for more than half of its exports in 2017


Report 2:  Serbia, another CEFTA signatory, is also an important export market  Bosnia's major exports include vehicle seats, raw materials, leather products, textiles, energy, and wood products  The EU is also Bosnia's primary source of foreign direct investment (FDI)  In 2016, 63% of Bosnia's FDI came from EU countries, with Austria, Croatia, and Slovenia the top sources  Serbia is also a significant source of FDI (16 3%)  However, Bosnia's fragmented legal and administrative structure create a challenging investment climate  Many relevant laws differ between the two entities  Corruption, entrenched economic interests, and political instability also deter investment  As a result, FDI amounts to just 2% of Bosnia's GDP, well below the Western Balkan average of 5%  Bosnia was the region's lowest-rated country in the World Bank's 2019 Ease of Doing Business Index  U S  and EU policymakers view the NATO and EU accession processes as a positive force for democratization and reform in the Western Balkans, including Bosnia  According to analysts, this assessment informed the United States' partial retreat from the region in the 2000s and 2010s  EU membership is one of the few policy issues for which there is relatively broad consensus among Bosnia's politicians and population  The EU's "fundamentals first" approach to enlargement in the Western Balkans frontloads the accession process with meeting the core requirements of having a democratic political system and functioning market economy; in Bosnia, the EU is currently focused on issues relating to the rule of law, public administration reform, and economic development  In 2016, Bosnia submitted its application to join the EU  Its current status is potential candidate , which entitles it to receive financial assistance from the EU's Instrument for Pre-Accession Assistance II (IPA II)  Between 2014 and 2020, Bosnia is expected to receive €552 million in IPA II allocations, making the EU Bosnia's largest source of foreign assistance  Many EU member states provide additional aid to Bosnia through domestic foreign assistance programs  Bosnia's EU membership prospects are uncertain  In a 2018 progress report, the European Commission (the EU's executive) flagged Bosnia's slow implementation of reforms, including the 2015 Reform Agenda (a flagship EU initiative in Bosnia) and numerous domestic and international court rulings (see "Legal Challenges," above)  Some analysts question whether Bosnia, under its current political system, would be capable of meeting the membership requirement of harmonizing domestic legislation with the many thousands of provisions in the acquis communautaire, the cumulative body of EU legislation, case law, and regulations  In comparison to EU membership, Bosnian leaders are more divided over the issue of joining NATO  These divisions largely fall along Bosnian Serb and Bosnian Croat/Bosniak lines  Bosnian Serb opposition is rooted in resentment over NATO's role in the Bosnian war, and may also reflect a desire to remain in lockstep with neighboring Serbia, which also does not seek NATO membership  Bosnia joined NATO's Partnership for Peace in 2006 and secured an Individual Partnership Action Plan in 2008  In 2010, NATO indicated that it would launch a Membership Action Plan (MAP)—a program to help aspiring members meet membership requirements—once Bosnia meets several conditions, the most challenging of which is the reregistration of permanent defense installations from entity to state-level government  RS officials have resisted ceding control over defense installations on entity territory  Although Bosnia does not yet meet these requirements, in December 2018 NATO foreign ministers invited Bosnia to activate its MAP by submitting its first Annual National Program  Some analysts interpreted this invitation as a gesture to generate reform momentum in Bosnia's fragile post-election period  The Bosniak and Croat members of the presidency responded positively, but Bosnian Serb leaders (and most Bosnian Serbs) do not want Bosnia to join NATO  In October 2017, the RS National Assembly passed a resolution supporting military neutrality  RS President Željka Cvijanović reiterated this stance after NATO's invitation, and Dodik—now a member of the state-level presidency—also has vowed to pursue military neutrality  Bosnia's relations with Croatia and Serbia are seen as an important component of regional stability  However, bilateral relations have often been fraught as a legacy of the Bosnian war, as well as sensitivities over Croatia and Serbia's relations with Bosnian Croats and Serbs  While democratic gains in Croatia and Serbia after 2000 contributed to improved relations with Bosnia, they remain reluctant to examine or acknowledge their role in the Bosnian war  At times, Bosnian leaders have objected to what they describe as Croatian and Serbian meddling in Bosnia's affairs  Ex-Bosnian Croat member of the presidency Dragan Čović and current Bosnian Serb member of the presidency Milorad Dodik draw support from leaders in Croatia and Serbia and reportedly hold Croatian and Serbian citizenship, respectively, alongside their Bosnian citizenship  The Croatian government financially and politically backed Čović in Bosnia's 2018 elections, and Croatian politicians have raised the issue of Bosnian Croats' constitutional challenges (see above, "Legal Challenges") in forums like the European Parliament, NATO, and the United Nations  These moves prompted three former High Representatives to Bosnia to issue a joint letter expressing alarm over Croatia's "meddling" in Bosnia's internal affairs  The Croatian government also challenged the legitimacy of Željko Komšić as the Croat member of the Bosnian presidency (see above, "2018 General Election")  Some parties in Croatia hold Croatian election campaign events on Bosnian territory to mobilize Bosnian Croat voters with dual citizenship to vote in Croatia's elections  The Serbian government likewise supports Dodik, who is a frequent visitor to Belgrade  Some Serbian politicians have made statements supporting convicted Bosnian Serb war criminals, inflaming an issue that remains highly sensitive in Bosnia  Bosnia and Serbia have an unresolved demarcation dispute over approximately 40 square kilometers of border area, including a railway segment and hydroelectric power stations  Bosnia has dual citizenship treaties with Croatia and Serbia, resulting in hundreds of thousands of Bosnian Croats and Bosnian Serbs acquiring dual citizenship  This has raised jurisdictional issues in cases in which indicted war criminals hold dual citizenship  Despite occasional tensions in their relations, Croatia and Serbia are important economic partners for Bosnia  Both countries are among Bosnia's top export markets and top sources of FDI  As part of its enlargement strategy in the Western Balkans, the EU has embraced a connectivity agenda to improve regional transportation, energy, and infrastructural linkages, reserving up to €1 billion in grants for projects for the period 2015-2020  Officials believe that improved connectivity could benefit bilateral relations and contribute to regional stability  Given its strategic location and relatively small, weak states, the Balkan region has long drawn in more powerful states  Many analysts maintain that as the United States and the European Union have both scaled back their presence in the Balkans to address other issues since the late 2000s, Russia, Turkey, and China partly filled the vacuum  U S  and EU officials have expressed concern over Russian influence in the Western Balkans, particularly after Russia occupied Ukraine's Crimea region in 2014  Many analysts maintain that Russia does not have a grand strategy in the Western Balkans, but rather aims to prevent Euro-Atlantic integration and shore up its claims to great power status by asserting itself in the EU's "inner courtyard " Analysts have identified several Russian tools in the region, including playing a "spoiler" role, projecting soft power, and leveraging energy dominance  Observers contend that Russia plays a "spoiler" role in Bosnia by exacerbating ethnic divisions, backing illiberal or anti-Western political factions, and helping to militarize RS  They claim that these actions help sustain the dysfunction and gridlock that undermine Bosnia's Euro-Atlantic reform efforts  Russia has supported Bosnian Serb and Bosnian Croat nationalist leaders Milorad Dodik and Dragan Čović  Dodik's meeting with Russian President Vladimir Putin just before Bosnia's October 7, 2018 general election was one of nearly ten meetings between the two over the past three years, signaling high-level Russian support  Many experts assert that Russia has been a key ally to Dodik in resisting Western pressure to cooperate on reforms  Moscow has also supported divisive RS policies  When Dodik violated a Bosnian Constitutional Court ruling in 2016 by holding a referendum to establish a controversial "Statehood Day," Russia stood apart from the High Representative and Western diplomats by supporting the initiative  More recently, Russia stated its support for RS's controversial Srebrenica commission (see above)  Analysts have also expressed concern at Russia's apparent support for Čović, who has advocated greater autonomy for Croats and the creation of a third Croat entity  Some analysts have expressed concern at Russia's role in RS's security sector  Russian forces have trained RS police special forces on counterterrorism and intelligence  Some observers believe that these exercises contribute to militarization in RS, potentially pushing the police force beyond its civilian law enforcement mandate  Analysts caution that militarization could increase the scale of violence in any confrontation between RS and the Bosnian government  Some Bosnian Serb ultranationalist and veterans groups have fought alongside pro-Russia combatants in Ukraine, and analysts believe they could be mobilized to support RS leaders as well  Russian soft power draws upon religious and cultural kinship with Bosnian Serbs, as well as Russia's history of support during the wars of Yugoslav disintegration  Kremlin-linked media, like Sputnik and RT , amplify existing anti-Western narratives and positively shape public opinion toward Russia  Some local media further propagate Sputnik and RT articles  A 2018 National Democratic Institute media study found that RS media stories about Russia were overwhelmingly positive, while the tone of most stories about the United States and NATO was negative  Pro-Russian media glorifies the Russian military, highlights cultural and religious links between Serbs and Russians, and documents high-level meetings between RS and Russian officials  Economic relations between Russia and RS have deepened in recent years  Russia is the largest source of FDI in RS, and it is largely concentrated in the energy sector  In 2007, Russian state-owned oil company Zarubezhneft bought RS's Bosanski Brod oil refinery, motor oil processing facilities in nearby Modrica, and retailer Banjaluka Petrol  Some analysts believe that these assets—which were purchased without an open tender—give Zarubezhneft influence in RS  In addition to being an important employer, Zarubezhneft is RS's biggest taxpayer; its value-added tax and excise duty contributions reportedly account for 25% of RS budget revenue  Bosnia depends upon Russian natural gas imports via Ukraine  Energy policy is vested in the entities, and Russian natural gas provider Gazprom reportedly has used its market dominance to pit the two entities against one another and undermine projects that would diversify supplies  Many analysts believe that Turkey's influence in Bosnia has increased over the last two decades due to Ankara's close relationship with Bosniak leaders  Some Turkish officials reportedly view Bosnia as a natural sphere of influence given geographic and historical connections  Observers note that Turkish President Recep Tayyip Erdogan has at times invoked Ottoman-era ties to Bosnia and religious kinship with Bosniaks as soft power tools  Turkish influence in Bosnia has expanded since Yugoslavia's collapse  During the 1992-1995 war, Turkey gained prestige among Bosniaks by condemning the international arms embargo against Bosnia, arguing that it prevented Bosniaks from defending themselves  Turkey, as well as other predominantly Muslim countries like Iran and Saudi Arabia, reportedly supplied Bosniak forces with arms  Turkish influence has continued since the war's end  Bosnia is one of the top recipients of Turkish Cooperation and Coordination Agency assistance; much of this support is earmarked for projects to restore Ottoman-era buildings and monuments  A Turkish Cultural Center was established in Bosnia in 2003, and in 2009 the Yunus Emre Foundation, an NGO founded by the Turkish government, opened an office in Sarajevo to promote Turkish language and culture  Turkey has popular support among Bosniaks  In a 2018 International Republican Institute survey, 76% of Bosniak respondents had positive views of Turkey—the strongest support among Bosniaks for any foreign state  Many Bosnian Croats and Bosnian Serbs look to Croatia and Serbia as external protectors, and some analysts believe that Turkey has attempted to establish a similar role for itself vis-à-vis Bosniaks  Observers contend that Erdogan's ruling party has particularly strong ties to the largest Bosniak ethnic party, the SDA  Erdogan and Turkish state-owned media openly supported SDA candidate Bakir Izetbegović in his bid for the Bosniak seat on the presidency in 2014  Some observers believe that Izetbegović's clout within the SDA rests in part on his support from Erdogan  Economic relations between Bosnia and Turkey have deepened in recent years  Turkish FDI in Bosnia accounted for 5 6% of FDI flows in 2016  One notable project is a highway to connect Sarajevo to Belgrade, Serbia  After years of disagreement, Bosnian officials approved the route in February 2019  Turkey is expected to provide funding for some of the expected €3 billion in costs, although the terms of the contract are not yet resolved  Some officials, including French President Emmanuel Macron, have expressed concern over Turkey's alleged ambitions as part of broader EU concern over external influence in the Balkans  However, analysts caution that Turkey's ambitions and capabilities in the Balkans may be overstated  They note that the scope of Turkish investment is sometimes exaggerated in the media, and that proposed projects do not always come to fruition  While Russian and Turkish influence in Bosnia relies in part on soft power, China's presence in Bosnia is primarily economic  Between 2011 and 2019, Chinese investments in Bosnia amounted to an estimated $3 6 billion, primarily in the form of direct lending for energy and transportation projects  Chinese firms have contracts to construct or expand energy plants, including a €350 million loan to construct a coal-fired plant in Stanari, RS  A €1 4 billion deal was signed to construct a highway between Banja Luka and Mlinište  In March 2019, the EU Energy Community criticized the FBiH entity government's decision to guarantee a €600 million loan from China's Exim Bank to build a coal-fired power plant in Tuzla  However, some analysts caution that China's economic influence in Bosnia may be overstated at present  While China's pledged investments in high-visibility projects garner media attention, the actual amount of Chinese FDI is far less than that of the EU  Moreover, many pledged projects do not come to fruition  Nevertheless, EU and U S  officials have voiced concern over the scope of China's investments in the Balkans, as well as Chinese lending practices  Chinese loans often require recipient state governments to assume the loan burden, potentially leading to high external debt  The EU has also raised concerns that Chinese lending practices violate EU rules in public procurement because they frequently require use of Chinese contractors, laborers, or supplies  In contrast to EU funds, which are partly designed to spur reform, Chinese loans have few conditions and rules linked to transparency or reform  Finally, EU officials have expressed concern that China's economic might could be a source of leverage over recipient states that are candidates or potential candidates for EU membership and thus impede the EU's ability to speak with one voice on relations with China if they do become members  Bosnia was not a core transit country in the "Balkan Route" that hundreds of thousands of migrants and refugees followed in an attempt to reach the EU during heightened flows in 2015 and early 2016  However, recent route shifts have brought more migrant and refugee traffic through Bosnia  Since early 2018, an estimated 23,000 migrants and refugees have entered Bosnia; approximately 25% of them remain in the country  Most of them hope to enter EU territory via Bosnia's neighbor, Croatia, and from there move on and enter the EU's visa- and passport-free Schengen Area  However, the Croatian government has expanded border policing, and apprehended individuals are sent back to Bosnia  The EU provided €2 million in 2018 to help Bosnia respond to the crisis and provide shelter to migrants and refugees who are effectively stranded in Bosnia  The migration crisis has triggered a backlash from some Bosnians, particularly in Una-Sana Canton, which borders Croatia and has the highest concentration of migrants and refugees  Some residents of Bihać, Una-Sana's administrative center, protested against camps situated in their municipality in October 2018, while local authorities in Velika Kladuša, another city in the canton, reportedly obstructed the Ministry of Security's plans to house migrants in a local building  The incident illustrates local backlash as well as the state-level government's difficulty enforcing its decisions, even when it has jurisdiction  Islam was introduced to part of Bosnia's population during Ottoman rule  In socialist Yugoslavia, the semi-official Islamic Religious Community played a key role in religious affairs, including legal rulings and religious education  It was renamed the Islamic Community of Bosnia and Herzegovina in 1992, and remains an important religious institution  Islamic tradition in the Balkans, including Bosnia, is generally moderate and secular  The majority of Bosnia's practicing Muslims follow the Hanafi school of Sunni Islam  However, some analysts have expressed concern over the emergence of groups influenced or funded by state and non-state entities in the Arab Gulf states, where more conservative Hanbali Sunni practices are common  Aid workers, missionaries, and "mujahedeen" fighters from the Gulf States promoted transnational Islamist militancy and Salafist Hanbali religious doctrine during Bosnia's 1992-1995 war; Iran's government also supported Bosniak leaders and forces  After the war, Saudi Arabia provided an estimated $600 million in aid to repair and build hundreds of mosques and establish schools and cultural centers that promote socially conservative Sunni views  Iran has also maintained active cultural outreach and other ties to some Bosnian Muslims  Many analysts contend that Salafi groups have limited support in Bosnia because of the traditionally high level of secularism among Bosnian Muslims  They also note that few Bosnian Muslims who subscribe to Salafist ideas and practices have violent intentions, and many of them live in remote rural communities  While most of these groups were not originally affiliated with official religious organizations in Bosnia, the Grand Mufti of Bosnia's Islamic Community exerted pressure on them to acknowledge his authority and his right to monitor religious content  As a result, an estimated 90% of Salafi groups were brought under official structures  Nevertheless, some experts caution that radicalized groups and individuals may pose a terrorist threat despite their small numbers  Radicalized Muslims were implicated in the bombing of a police station in Bugojno in 2010 and a lone-gunman attack on the U S  Embassy in Sarajevo in 2011  The Islamic State (IS) and Nusra Front's gains in Syria and Iraq in the 2010s altered the dynamic of the terrorism threat in Bosnia and broadened the use of social media in recruitment  Between 2012 and 2017, an estimated 350 Bosnian citizens traveled from Bosnia or Bosnian diaspora communities to fight with armed groups in Iraq and Syria  More recently, returned foreign fighters are seen as a potential threat as the position of the IS and other armed groups has weakened  Bosnia's stock of illegal weapons, mines, and explosives may exacerbate the risk posed by returnees  As of December 2017, officials believed that just over 100 Bosnians remained in Syria (including women and children), roughly 50 had returned to Bosnia, and 70 had been killed in the conflict  In 2014, the Bosnian government introduced new criminal offenses to prosecute foreign terrorist fighters and recruiters  Several dozen returned fighters and domestic recruiters have been convicted of these offenses  While the U S  State Department describes Bosnia as a "cooperative counterterrorism partner," it warns that Bosnia's political fragmentation and dysfunction could undermine counterterrorism efforts  For example, in 2017 several ministries proposed new measures to tighten counterterrorism efforts; however, they were not enacted due to political gridlock in state-level and FBiH governments  Initially viewed as a "European problem," the Bosnian conflict eventually helped shape the post-Cold War role of the United States and NATO in European security  When the United States assumed greater responsibilities in resolving the conflict, its role was considerable: leading NATO airstrikes, garnering diplomatic support from Russia and European allies, persuading warring parties to agree to a ceasefire, brokering the Dayton Peace Agreement, and deploying 20,000 troops to Bosnia  According to Richard Holbrooke, the U S  official who brokered the talks, the Bosnian war was a pivotal period in U S  foreign policy in Europe: "The three main pillars of [policy]—U S -Russian relations, NATO enlargement into Central Europe, and Bosnia—had often worked against each other  Now they reinforced each other: NATO sent its forces out of area for the first time in its history, and Russian troops, under an American commander, were deployed alongside them " Some analysts and policymakers believe that the United States' strong hand in resolving the conflict and in shaping Bosnia's political system have made it a stakeholder in Bosnia's future  U S  officials, often in cooperation with the EU, have intervened to defuse crises and broker reform talks  The United States also has imposed sanctions against Bosnian officials: in addition to Dodik (see above), the U S  State Department publicly designated Bosnian Serb politician Nikola Špirić (Dodik's associate) for "significant corruption or gross violation of human rights " U S  policymakers attach strategic importance to Bosnia's stability; many analysts believe turbulence in Bosnia could reverberate in the Balkans and potentially draw in Croatia and Serbia, while instability in other parts of the region could spill over into Bosnia  When the Trump Administration indicated in 2018 that it would consider supporting a potential Serbia-Kosovo agreement to "adjust borders" between the two—a major break with the long-standing EU and U S  policy to oppose redrawing borders in the Balkans along ethnic lines—some analysts expressed concern that the Administration could reshape long-standing U S  policy toward Bosnia  However, the new U S  Ambassador to Bosnia stated in February 2019 that the U S  will continue to be "guarantor of Bosnia and Herzegovina's sovereignty and territorial integrity " On the other hand, many observers also note that U S  engagement in Bosnia (and the Western Balkans) decreased under the administrations of President George W  Bush and President Barack Obama  During this time U S  policymakers turned their focus to geopolitical crises and challenges in other parts of the globe while ceding the regional lead to the EU  Indeed, some analysts have urged the United States to assume a greater role in Bosnia, arguing that Bosnia's current crises warrant it, and that the EU and the United States are more effective in the region when they work together  Congressional interest in Bosnia dates back to the 1992-1995 war  Many Members featured prominently in foreign policy debates over U S  intervention in the conflict  In 2015, the House passed a resolution describing the Srebrenica massacres as a genocide and urging the United States to continue to support Bosnia's territorial integrity ( H Res  310 , 114 th Congress)  In the 114 th and 115 th Congresses, a bill was introduced in the Senate to establish an enterprise fund to promote economic development and the private sector in Bosnia ( S  2307 and S  864 )  In April 2018, the House Foreign Affairs Committee's Subcommittee on Europe, Eurasia, and Emerging Threats held a hearing on Bosnia's prospects ahead of its October 2018 elections  Congress's engagement with Bosnia also continues within the broader context of policy concern over the external influence of China, Turkey, and Russia in the Western Balkans and energy security  As a potential candidate for EU membership and NATO partner, Bosnia is eligible for assistance through the Countering Russian Influence Funds under the Countering America's Adversaries Through Sanctions Act (CAATSA) enacted in 2017 ( P L  115-44 )  Through congressionally approved (and sometimes expanded) foreign assistance appropriations, Bosnia has received more than $2 billion in aid since 1995  Between 1996 and 1999, the United States pledged $1 billion of the $4 billion international commitment to implementing Dayton's civilian provisions and helping to rebuild Bosnia  The cost of U S  military operations in Bosnia since 1992 is estimated at more than $10 billion ( Appendix I )  Bosnia continues to receive U S  foreign assistance, although the amount has decreased in recent years  Assistance to Bosnia in FY2015 and FY2016 was approximately $33 million each year  In FY2017, it was $53 5 million, and $41 5 million in FY2018  The Administration requested $21 million for FY2019 and $16 9 million for FY2020  Nearly 25 years after the Dayton Peace Agreement, Bosnia faces many challenges  In considering U S  relations with Bosnia, Members of Congress may consider the following questions: How can the United States encourage Bosnia's government to incorporate the legal rulings of the Bosnian Constitutional Court and the European Court of Human Rights into election legislation and the constitution? How can U S  foreign assistance be used to counter Russian influence in Republika Srpska, in particular Russia's close ties to Bosnian Serb politicians and its use of local media and Sputnik to amplify anti-U S  narratives and project pro-Russia soft power? What are the implications of potential militarization in Republika Srpska? How can the United States effectively address this alleged trend? How can the United States support a successful reform initiative that secures transparency and accountability, and facilitates a political community in which politicians and voters are committed to the Bosnian state and socioeconomic challenges that transcend all three ethnic groups? Can the Germany-U K  initiative from 2015 be revived, or is it better to start from scratch? Are the approximately 600 troops in the European Union Force mission in Bosnia sufficient to stabilize Bosnia if violence breaks out? If Serbia and Kosovo agree to normalize relations by redrawing their borders, how can U S  policymakers prevent this development from destabilizing Bosnia, particularly given Milorad Dodik's threats to seek RS secession if Kosovo is "partitioned"? How can the United States encourage Croatia and Serbia to engage in Bosnia in a manner that helps bridge ethnic divisions and contributes to Bosnia's territorial integrity and sovereignty? Given the pervasiveness of corruption in Bosnia, how can U S  assistance most effectively be used to counter it? Does foreign assistance contribute to civic groups and independent media that could serve as a check against corruption? 

ground_truth: The Centers for Medicare & Medicaid Services pays LTCHs for care provided to Medicare beneficiaries. There were about 400 LTCHs across the nation in 2016. The 21st Century Cures Act included a provision for GAO to examine certain issues pertaining to LTCHs. This report examines (1) the health care needs of Medicare beneficiaries who receive services from the two qualifying hospitals; (2) how Medicare LTCH payment polices could affect the two qualifying hospitals; and (3) how the two qualifying hospitals compare with other LTCHs and other facilities that may treat Medicare patients with similar conditions. GAO analyzed the most recently available Medicare claims and other data for the two qualifying hospitals and other facilities that treat patients with spinal cord injuries. GAO also interviewed HHS officials and stakeholders from the qualifying hospitals, other facilities that treat spinal cord patients, specialty associations, and others. GAO provided a draft of this report to HHS. HHS provided technical comments, which were incorporated as appropriate. We also provided the two qualifying hospitals summaries of information we collected from them, to confirm the accuracy of statements included in our draft report. We incorporated their comments, as appropriate. Spinal cord injuries may result in secondary complications that often lead to decreased functional independence and quality of life. The 21st Century Cures Act changed how Medicare pays certain long-term care hospitals (LTCH) that provide spinal cord specialty treatment. For these hospitals, the act included a temporary exception from how Medicare pays other LTCHs. Two LTCHs—Craig Hospital in Englewood, Colorado and Shepherd Center in Atlanta, Georgia—have qualified for this exception. GAO found that most Medicare beneficiaries treated at these two hospitals typically receive specialized care for multiple chronic conditions and other long-term complications that develop after initial injuries, such as pressure ulcers that can result in life-threatening infection. The two hospitals also provide specialty care for acquired brain injuries, such as traumatic brain injuries. GAO's simulations of Medicare payments to these two hospitals using claims data from two baseline years—fiscal years 2013 and 2016—illustrate potential effects of payment policies. LTCHs are paid under a two-tiered system for care provided to beneficiaries: they receive the LTCH standard federal payment rate—or standard rate—for certain patients discharged from the LTCH, and a generally lower rate—known as a “site-neutral” rate—for all other discharges. Under the temporary exception, Craig Hospital and Shepherd Center receive the standard rate for all discharges during fiscal years 2018 and 2019. Assuming their types of discharges remain the same as in fiscal years 2013 and 2016, GAO's simulations of Medicare payments in the baseline years indicate: Most of the discharges we examined would not qualify for the standard rate, if the exception did not apply. Medicare payments would generally decrease under fiscal year 2020 payment policy, once the exception expires. However, the actual effects of Medicare's payment policies on these two hospitals could vary based on factors, including the severity of patient conditions (e.g., Medicare payment is typically higher for more severe injuries), and whether hospitals' discharges meet criteria for the standard rate. Similarities and differences may exist between the two qualifying hospitals and other facilities that treat Medicare patients with spinal cord and brain injuries. Patients with spinal cord and brain injuries may receive care in other LTCHs, but GAO found that most Medicare beneficiaries at these other LTCHs are treated for conditions other than spinal cord and brain injuries. Certain inpatient rehabilitation facilities (IRF) also provide post-acute rehabilitation services to patients with spinal cord and brain injuries. While data limitations make a direct comparison between these facilities and the two qualifying hospitals difficult, GAO identified some similarities and differences. For example, officials from some IRFs we interviewed reported providing several of the same programs and services as the two qualifying hospitals to medically complex patients, but the availability of services and complexity of patients varied. Among other reasons, the different Medicare payment requirements that apply to LTCHs and IRFs affect the types of services they provide and the patients they treat.

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



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

Report 1: Spinal cord injuries are complex, lifelong injuries that typically result from acute traumatic damage to the spinal cord or nerves within the spinal column  In spinal cord injury patients, certain nervous system functions may be impaired temporarily or permanently lost, depending on the level and severity of the patient’s injury  In addition to lower level nervous system functioning, spinal cord injury patients may develop secondary medical complications that can further decrease functional independence and quality of life, including, but not limited to: Autonomic dysreflexia: a condition that may result in life threatening hypertension—high blood pressure—due to impaired nervous system response, below the level of spinal cord injury  Depression: a medical mood disorder—commonly affecting about one in five spinal cord injury patients—that can cause physical and psychological symptoms (including changes in sleep and appetite, and thoughts of death or suicide)  Impaired bowel and bladder functioning: potential inability to move waste through the colon and control, stop or release, urine—which can lead to other life-threatening illnesses (such as autonomic dysreflexia) and/or infections  Pressure ulcers: a common complication affecting up to 80 percent of spinal cord injury patients that results from an area of the skin or underlying tissue that is damaged due to decreased blood flow, which can occur after extended periods of inactive sitting or lying, among other ways  Pressure ulcers—also known as pressure sores or wounds—can occur years after initial injury and may also result in life- threatening infections or amputation  Spasticity: a common condition that affects 65 to 78 percent of spinal cord injury patients and can result in symptoms ranging from mild muscle stiffness to severe, uncontrollable leg movements  Syringomyelia: a rare disorder that occurs when cerebrospinal fluid— normally found outside of the spinal cord and brain—enters the interior of the spinal cord to form a cyst known as a syrinx  This cyst expands and elongates over time, destroying the center of the spinal cord  Symptoms can develop slowly and can include numbness, pain, effects on bowel and bladder function, or paralysis  While this condition can occur as a result of a trauma, such as a spinal cord injury, the majority of cases are associated with a complex brain abnormality  Acquired brain injuries occur after birth and are not hereditary, congenital, degenerative, or a result of birth trauma  Acquired brain injuries result in changes to the brain’s neuronal activity, which can affect the physical integrity, metabolic activity, or functional ability of nerve cells in the brain  Acquired brain injuries can be either non-traumatic or traumatic in nature: non-traumatic brain injuries are caused by an internal force—such as in the case of stroke, tumors, or drowning—and traumatic brain injuries are caused by an external force—such as in the case of car accidents, gunshot wounds, or falls  The severity of brain injury can often result in changes to physical, behavioral, and/or cognitive functioning  For example, according to one source, nearly 50 percent of all people with a traumatic brain injury experience depression within the first year after injury, and nearly two-thirds experience depression within 7 years post- injury  Depression can develop as a result of physical changes in the brain, emotional response to the injury, and other unrelated factors—such as family history  Due to impaired cognitive functioning, traumatic brain injury patients may also experience difficulty communicating, concentrating, and processing and understanding information  Acute care hospitals and LTCHs are paid under different Medicare payment systems by law  Acute care hospitals are paid under the inpatient prospective payment system (IPPS)  LTCHs are paid under the LTCH PPS  Under both systems, Medicare classifies patients based on Medicare diagnosis groups, which organize patients based on their conditions and the care they receive  Medicare payments for LTCHs are typically higher than payments for acute care hospitals, to reflect the average resources required to treat Medicare beneficiaries who need long-term care  Traditionally, all LTCH discharges were paid at the LTCH PPS standard federal payment rate  The Pathway for SGR Reform Act of 2013 modified the LTCH PPS by establishing a two-tiered payment system— such that certain LTCH discharges continue to be paid at the standard rate and others are paid at a generally lower, site-neutral rate  In its March 2013 report, MedPAC described concerns regarding growth in the number of LTCHs and the extent to which some of their patients may otherwise be treated appropriately in less costly settings  To continue to be eligible for the standard rate, the discharge must generally have a preceding acute care hospital stay with either an intensive care unit stay of at least 3 days or an assigned diagnosis group based on the receipt of at least 96 hours of mechanical ventilation services in the LTCH, unless an exception applies  Discharges that do not qualify for the standard rate are to receive a blended site-neutral rate—equal to 50 percent of the site-neutral rate and 50 percent of the standard rate—for discharges in cost reporting periods beginning in fiscal years 2016 through 2019, and the full site-neutral rate for discharges in cost reporting periods beginning in fiscal year 2020  Beginning with cost reporting periods in fiscal year 2020, if fewer than half of an LTCH’s discharges meet the statutory requirements to be paid at the standard rate, the LTCH will no longer receive any payments at that rate for discharges in future cost reporting periods until eligibility for receiving payments under that rate is reinstated  Under this scenario, all discharges in succeeding cost reporting periods would be paid at the generally lower rate that an acute care hospital would receive for providing comparable care until eligibility for receiving payments at the standard rate is reinstated  According to officials from HHS, the department intends to establish a process for how hospitals would have their eligibility for receiving payments at the standard rate reinstated as part of the fiscal year 2020 rule-making cycle  Since the two qualifying hospitals are currently only excepted from the statutory two-tiered payment structure for cost reporting periods beginning during fiscal years 2018 and 2019, these two hospitals must also meet the statutory 50 percent threshold in fiscal year 2020 and beyond in order to receive the standard rate for any future discharges until reinstated  See table 1 for more information on Medicare’s LTCH PPS payment policies  Two LTCHs have qualified for the temporary exception to site-neutral payments, according to CMS officials  Craig Hospital is a private, not-for- profit facility that has specialized in medical treatment, research, and rehabilitation for patients with spinal cord and brain injury since 1956  Craig Hospital is classified as an LTCH for the purposes of Medicare payment, and is licensed as a general hospital by the state of Colorado— which does not have separate designations for LTCHs  Craig Hospital has been selected as one of 14 NIDILRR Spinal Cord Injury Model Systems and one of 16 Traumatic Brain Injury Model Systems and is accredited by the Joint Commission  Shepherd Center is a private, not-for-profit facility that specializes in medical treatment, research, and rehabilitation for people with traumatic spinal cord injury and brain injury—as well as neuromuscular disorders, including multiple sclerosis  Shepherd Center is classified as an LTCH for the purposes of Medicare payment, and as a specialty hospital—which includes LTCHs—by the state of Georgia  Shepherd Center is also currently designated as a NIDILRR Spinal Cord Injury Model System and is accredited by the Joint Commission  Shepherd Center also has several CARF International accredited specialty programs  Specifically, it has CARF-accredited inpatient rehabilitation specialty programs in spinal cord injury and brain injury—for adults, children, and adolescents; and interdisciplinary outpatient medical rehabilitation specialty programs in spinal cord injury and brain injury—for adults, children, and adolescents, among others  More than half of the Medicare discharges in fiscal year 2013 at the two qualifying hospitals—43 of 75 at Craig Hospital and 47 of 88 at Shepherd Center—were within the diagnosis groups designated in section 15009(a) of the 21st Century Cures Act  (See table 2 below for more information ) Patients treated for these diagnosis groups may receive treatment for spinal disorders and injuries; medical back problems; degenerative nervous system disorders; skin grafts for skin ulcers; acquired brain injuries, such as traumatic brain injuries; or other significant traumas with major complicating and comorbid (simultaneous) conditions  Both qualifying hospitals have a variety of specialized inpatient and outpatient programs to help treat the complex health care needs of their patients, including those covered by Medicare  For example, both hospitals have wheelchair positioning clinics that can help prevent skin complications, such as pressure ulcers, that can occur in spinal cord patients  Both hospitals also have programs for those patients who need ventilator support such as diaphragmatic pacing—support for patients with respiratory problems whose diaphragm, lungs, and nerves have limited function—and ventilator weaning programs  In addition to clinical programs, both qualifying hospitals also provide transitional support, such as providing counseling and education to families of patients with these injuries  We found that most Medicare beneficiaries at the two qualifying hospitals need specialized services to manage the chronic, long-term effects of a catastrophic spinal cord or brain injury  Most of these patients are younger than 65 and ineligible for Medicare at the time of their initial injury, according to officials from the qualifying hospitals  Instead, according to officials, these patients typically become eligible for Medicare 2 years or more after their initial injury due to disability  Medicare beneficiaries at the two qualifying hospitals typically need care to manage comorbidities or the associated long-term complications of their injury  Officials from Craig Hospital said a significant number of their Medicare beneficiaries have comorbid conditions—such as diabetes or cardiac problems—upon admission, that can be further complicated by their injury  The officials said managing these comorbidities is as much of a medical challenge as managing the spinal or brain injury  Officials from both qualifying hospitals noted their Medicare beneficiaries who have a spinal cord or brain injury also frequently seek care after initial injury to address secondary complications resulting from their injury, including urinary tract infections; respiratory problems; and pressure ulcers  While the qualifying hospitals primarily treated traumatic spinal cord or brain injuries, we found that their Medicare populations differed from each other during the period from fiscal year 2013 to 2016  Specifically, Craig Hospital  Our review of Medicare claims data indicates more than 50 percent of the 246 Medicare discharges during this time were associated with Medicare diagnosis groups for spinal cord conditions  Specifically, during this time, Craig Hospital’s Medicare discharges were commonly assigned to three diagnosis groups covering spinal procedures and spinal disorders and injuries  For example, officials from Craig Hospital told us that about 60 percent of Medicare beneficiaries in fiscal year 2016 required surgical care for a spinal cord injury  According to officials, most of these patients received surgery for syringomyelia—a complication in spinal cord patients that generally develops years after their initial injury  These officials told us that Craig Hospital provided the pre- and post-operative care for those patients in fiscal year 2016; however, currently, Craig Hospital is only responsible for pre-operative assessments  The remaining 40 percent of their Medicare beneficiaries in fiscal year 2016 received care for new spinal cord injuries  Shepherd Center  Our review of Medicare claims data indicates the most common diagnosis group of the 365 Medicare discharges during this time—fiscal year 2013 to fiscal year 2016—related to treatment for skin grafts that can be associated with pressure ulcers, among other things  Shepherd Center officials confirmed that most of their Medicare beneficiaries received treatment for a pressure ulcer that occurred after initial injury which, as previously noted, can be so severe as to result in life-threatening infections  According to officials, most of their post-injury Medicare beneficiaries receive post-operative care and other wound management services following surgery to treat pressure ulcers, to ensure that the site will not tear again and to avoid reoccurrence  Other diagnosis groups for Medicare patients at Shepherd Center included those for spinal disorders and injuries and extensive operating room procedures unrelated to principal diagnosis  According to officials, beneficiaries in these diagnosis groups received treatment for a range of conditions, including traumatic injuries, urinary tract infections, neurogenic bladder and bowel or respiratory complications  Officials told us the hospital also served Medicare beneficiaries recovering from other acquired brain injuries, such as stroke, and paralyzing neuromuscular conditions, such as multiple sclerosis  Stakeholders we interviewed—including providers at other facilities— noted that traumatic spinal cord and brain injury patients—including those covered by Medicare—require significant levels of care due to the complexity of their injuries as well as the immediate and long-term complications that can occur from the injuries  For example, most stakeholders told us these patients often require lifelong care due to the complexity and reoccurrence of comorbidities or secondary complications  Some of these stakeholders noted, for example, spinal cord and brain injury patients often face mental health or psychosocial conditions, such as depression or anxiety  Some stakeholders also emphasized that many spinal cord injury patients risk secondary complications that may not occur until years after injury, such as pneumonia, pressure ulcers, and other infections  A few stakeholders told us spinal cord and brain injury patients are often among the most complex patients they treat  As such, patients with spinal cord or brain injuries often require interdisciplinary care that covers a wide range of specialties—including physiatry (rehabilitation medicine), neurology, cardiology, and pulmonology—as well as specialized equipment or technology, such as eye glance tools to control call systems or the television  Simulations of Medicare payments illustrate the potential effects of Medicare’s site-neutral payment policies, which were required by law, on the qualifying hospitals  Specifically, our simulations calculated what the qualifying hospitals would have been paid for Medicare patient discharges that occurred in two baseline years—fiscal year 2013 (baseline year 1) and fiscal year 2016 (baseline year 2)—if applicable payment policies from future years (2017 through 2021) were applied to those discharges  We selected two baseline years to account for differences in data, such as the number of discharges, between fiscal year 2016—the most recent year of complete data available at the time we began our analysis—and fiscal year 2013  Table 3 below provides a summary of Medicare discharges and payments to the qualifying hospitals during these two baseline years  Variation in utilization and patient mix across the baseline years allows the simulations to cover a range of possible changes in payments for the two hospitals  Our simulations indicated how Medicare’s payment policies could have affected these baseline payments to each qualifying hospital: Fiscal Year 2017 Blended Site-Neutral Rate Policy: Discharges that do not meet criteria to receive the standard rate are to receive a blended site-neutral rate—equal to 50 percent of the site-neutral rate and 50 percent of the standard rate  We found that while some of the baseline discharges would qualify for the standard rate, most discharges would have been paid at the blended site-neutral rate  Specifically, 8 to 20 percent of Craig Hospital’s baseline Medicare discharges would have qualified for the standard rate, resulting in simulated payments of about $3 86 million (baseline year 1) and $3 22 million (baseline year 2) under blended site-neutral rate policy  For Shepherd Center, between 23 percent and 40 percent of baseline Medicare discharges would have qualified for the standard rate, resulting in simulated payments of about $5 16 million (baseline year 1) and $5 31 million (baseline year 2)  Each of these simulated payments is an increase compared to actual payments made in the baseline years  Fiscal Years 2018 and 2019 Temporary Exception: The qualifying hospitals are receiving the standard rate for all discharges, due to the temporary exception  As a result, simulated payments under the temporary exception are about $3 74 million (baseline year 1) and $3 18 million (baseline year 2) for Craig Hospital and about $5 64 million (baseline year 1) and $5 75 million (baseline year 2) for Shepherd Center, which is an increase compared to actual payments made in the baseline years  Fiscal Year 2020 Two-Tiered Payment Rate: The temporary exception for the qualifying hospitals no longer applies; therefore, the site- neutral rate will apply to discharges not qualifying for the standard rate  We found that both qualifying hospitals would receive some payments at the standard rate, but that most of their discharges would be paid at the lower, site-neutral rate—assuming similar caseloads (e g , patient mix)  As a result, simulated baseline year payments at Craig Hospital are about $3 47 million (baseline year 1) and $3 03 million (baseline year 2), and simulated baseline payments to Shepherd are about $4 42 million (baseline year 1) and $4 55 million (baseline year 2)  The simulated payments therefore decrease compared to those in fiscal year 2019, and also generally decrease compared to actual payments made in the baseline years  Future Years Under 50 Percent Threshold: Under statute, unless 50 percent or more of the hospital’s discharges in cost reporting periods beginning during or after fiscal year 2020 qualify for the standard rate, no subsequent payments will be made to a hospital at that rate in each succeeding cost reporting period  Most of the baseline year discharges did not qualify for the standard rate, and therefore simulated payments are based on the generally lower comparable acute care rate  However, simulated payments stayed about the same between fiscal year 2020 and 2021, in part due to differences in calculations for high-cost outlier payments  A high-cost outlier payment is made to hospitals for those cases that are extraordinarily costly, which can occur because of the severity of the case and/or a particularly long length of stay  Specifically, simulated payments were about $3 49 million (baseline year 1) and $3 02 million (baseline year 2) for Craig Hospital and about $4 24 million (baseline year 1) and $4 16 million (baseline year 2) for Shepherd Center  Without the high-cost outlier payments, the simulated payments would have decreased by at least $2 million  If the mix of patients at Craig Hospital and Shepherd Center changes so that they meet the 50 percent threshold in fiscal year 2020, then simulated payments for fiscal year 2021 could be higher  As of September 2018, Craig Hospital officials told us that they expect to meet the 50 percent threshold with their current patient mix  Shepherd Center officials told us they do not expect to meet the 50 percent threshold  See figures 1 and 2 below for the results of our simulations  Our simulations of payments assume the number and type of Medicare discharges at the two qualifying hospitals remain the same as those in fiscal years 2013 and 2016  However, the full effect of payment policy on future Medicare payments to the qualifying hospitals will depend on three key factors that are subject to change: 1  Severity of patient conditions: Medicare payment is typically higher for more severe injuries, such as a traumatic injury with major comorbidities or complications, relative to less severe injuries  In the two baseline years we used for our simulations—fiscal year 2013 and fiscal year 2016—more than half of the Medicare discharges at the qualifying hospitals were associated with conditions with multiple comorbidities and complications, as indicated by the diagnosis groups, and this level of severity is reflected in the simulation results  Future payments to qualifying hospitals will depend on the extent to which the severity of patient conditions changes over time  2  Volume of discharges meeting criteria for the standard rate: As previously noted, for a hospital to receive the standard rate for a discharge, the discharge must meet certain criteria, such as having a preceding acute care hospital stay with either an intensive care unit stay of at least 3 days or an assigned diagnosis group based on the receipt of at least 96 hours of mechanical ventilation services in the LTCH  Our simulations reflect that in the two baseline years, about 23 percent of the fiscal year 2013 discharges and about 40 percent of the fiscal year 2016 discharges met the criteria to receive the standard rate for Shepherd Center; and about 8 percent of the fiscal year 2013 discharges and about 20 percent of the fiscal year 2016 discharges met the criteria for Craig Hospital  Changes to these amounts could affect future payments to the qualifying hospitals  In particular, if 50 percent or more of either hospital’s discharges beginning in fiscal year 2020 meet the standard rate criteria, then the hospitals would be eligible for payments at the standard rate in fiscal year 2021, which may result in higher payments compared to our simulations  3  Payment adjustments: LTCHs may receive a payment adjustment for certain types of discharges, such as short-stay outliers, interrupted stays, or high-cost outliers  In particular, most discharges at Craig Hospital received high-cost outlier payments (additional payments for extraordinarily costly cases) during the two baseline years—76 percent in fiscal year 2013 and 85 percent in fiscal year 2016  At Shepherd Center, at least 40 percent of discharges during the two baseline years received high-cost outlier payments—about 42 percent in fiscal year 2013 and about 58 percent in fiscal year 2016  The amount of future payments to qualifying hospitals will depend on the extent to which they continue to have a high proportion of discharges with high-cost outlier payments  In addition to the effect on payments, officials from both qualifying hospitals and some stakeholders we interviewed noted that the LTCH site-neutral payment policies may result in fewer services provided and fewer patients served by the qualifying hospitals and other LTCHs  For example, officials from Craig Hospital told us they stopped providing post- operative care to patients requiring spinal surgery, such as patients with syringomyelia, in 2016—instead referring them to other facilities—in part because these discharges do not meet the criteria for the standard rate  As of September 2018, they told us they do not plan to provide this care in the future unless the temporary exception is extended  Officials from Shepherd Center told us while they have not yet made changes to services they offer to Medicare patients, they may limit which Medicare beneficiaries they serve in the future  For example, they told us that most of their Medicare beneficiaries were admitted from home or sought care in their outpatient clinic  When the temporary exception expires after fiscal year 2019, hospital officials expected that these patients will not qualify for the standard rate  Shepherd Center officials said they may not be able to serve similar patients in future years  MedPAC officials and some stakeholders—a specialty association and health care providers with experience treating patients with similar conditions at other LTCHs—told us that some LTCHs have changed the services they offer and the patients they treat to increase the proportion of discharges that qualify for the standard rate  For example, MedPAC officials cited reports that indicate how some LTCHs have adjusted to the site-neutral policies  For example, a 2018 MedPAC report indicated that LTCHs in one large for-profit chain were able to make adjustments so that, as of September 30, 2016, close to 100 percent of their Medicare discharges met the criteria to receive the standard rate  A representative from an LTCH association told us that many LTCHs have adjusted their patient mix by increasing the number of discharges that meet criteria for the standard rate and turning away some Medicare beneficiaries to reduce the number of discharges subject to the site-neutral rate  The representative noted that certain LTCHs have already been able to adjust their patient mix because they have existing programs in place that focus on chronic, critically ill patients who would have a preceding acute care hospital stay  The representative told us that some LTCHs specialize in care for patients who do not meet the criteria to receive the standard rate and would generally be paid at the site-neutral rate; therefore, changing their patient mix is not a viable strategy for these LTCHs  According to the stakeholder, as of February 2018, about two-thirds of all LTCHs are above the 50 percent threshold  Providers from another LTCH told us that before the site-neutral payment policy went into effect, only about 40 to 45 percent of its discharges met criteria for the standard rate  However, they worked to ensure most patients referred to the LTCH would qualify for the standard rate  Officials told us patients who do not meet the criteria for that rate typically either stay longer in the acute care hospital or are transferred to a different post-acute care setting, such as a skilled nursing facility  Officials noted that, in both cases, the patient may not receive the specialized services often required for their injuries, including those patients with spinal cord or brain injuries  A provider we interviewed from another LTCH said that, historically, the LTCH has accepted patients who acquire pressure ulcers at home following discharge, but they may choose not to continue this practice because the patients’ discharges would not meet the criteria to receive the standard rate  A few of these stakeholders told us some LTCHs are in markets that do not have alternative providers of care, such as skilled nursing facilities, for patients who do not meet the criteria  These LTCHs may have difficulty adjusting their patient mix to avoid site-neutral payments  For example, a provider from one LTCH said his facility continues to take “site-neutral patients” because those patients often do not have another option to receive the specialized services they need  The provider emphasized concerns about the long-term viability of caring for those patients at the facility, because their care is paid at lower rates  Our review of Medicare claims data, other information, and interviews with stakeholders indicated the two qualifying hospitals treated Medicare beneficiaries with different conditions than most of those treated at other LTCHs  Our analysis of Medicare claims data indicates Craig Hospital and Shepherd Center treat very few patients in the Medicare diagnosis groups that are most common to other LTCHs  Specifically, for several years, MedPAC has reported that LTCH patient discharges are concentrated in a relatively small number of diagnosis groups  For example, in March 2018, MedPAC reported that 20 diagnosis groups accounted for over 61 percent of LTCH discharges at both for-profit and not-for-profit facilities, in fiscal year 2016  However, in fiscal year 2016, these diagnosis groups accounted for approximately 30 percent of Medicare discharges—26 out of 88—at Shepherd Center, and most of these discharges fell within a single diagnosis group which covers a range of conditions  Craig Hospital did not discharge any Medicare beneficiaries assigned to these 20 diagnosis groups, in fiscal year 2016  The seven diagnosis groups that were used in the statutory criteria to except Craig Hospital and Shepherd Center from site-neutral payments were also not among these 20 diagnosis groups  For more information on the 20 diagnosis groups common to LTCHs in fiscal year 2016, see Appendix III, table 5  Our review of Medicare claims data and other information indicates the two qualifying hospitals also treat a relatively small number of Medicare beneficiaries, a key distinguishing factor from most other LTCHs  In March 2018, MedPAC reported that, on average, Medicare beneficiaries account for about two-thirds of LTCH discharges  However, Medicare claims data and other information provided by the two qualifying hospitals indicate Medicare beneficiaries account for a significantly smaller proportion (about 8 percent) of patients discharged from Craig Hospital and Shepherd Center in 2016  Specifically, 40 of the 486 patients discharged from Craig Hospital in fiscal year 2016 and 75 of the 912 patients discharged from Shepherd Center in calendar year 2016, were Medicare beneficiaries  Officials from the qualifying hospitals told us they treat few Medicare patients primarily because of the younger average age of persons with spinal cord injuries and acquired brain injuries  While patients with spinal cord and brain injuries may receive care in other LTCHs, most stakeholders we interviewed also suggested the two qualifying hospitals treat patients that are different from those treated at most other LTCHs, and can offer specialized care  Officials from the two qualifying hospitals told us that, relative to most other facilities—including most traditional LTCHs—they offer a more complete continuum of care to meet the needs of patients at different stages of spinal cord and brain injury treatment, without the need to transfer to different facilities  Officials also stated that, unlike most traditional LTCHs, they are able to offer more specialized care for patients with spinal cord and brain injuries, including more comprehensive rehabilitation services  Stakeholders we interviewed generally agreed that the two qualifying hospitals have developed expertise in treating spinal cord and brain injury patients and offer intensive rehabilitation services that are not provided in most other LTCHs  In addition, officials from the Colorado Department of Health Care Policy & Financing noted that Craig Hospital treats a patient population that is different from most other LTCHs in the state of Colorado  Specifically, according to officials, in comparison to other LTCHs in the state, Craig Hospital treats: (1) a higher percentage of patients with more severe conditions, (2) more patients from outside the state of Colorado, (3) fewer patients requiring ventilator weaning or requiring wound care— conditions typically characteristic of LTCH patients—and (4) patients that are, on average, younger than most other LTCHs in the state of Colorado  In addition, a 2014 study of LTCHs conducted for the Georgia Department of Community Health found Shepherd Center was “distinctly different” from other LTCHs in the state of Georgia, and most LTCHs nationwide  Most stakeholders we interviewed suggested some IRFs provide specialty care to patients with catastrophic spinal cord, acquired brain injuries, or other paralyzing neuromuscular conditions  Most of the stakeholders we interviewed noted that—like the two qualifying hospitals—some IRFs have the expertise to treat patients with catastrophic spinal cord, acquired brain injuries, or other paralyzing neuromuscular conditions patients and thus, may also treat patients with similar conditions  According to CMS officials, IRFs are specifically designed to provide post-acute rehabilitation services to patients with spinal cord injuries, brain injuries, and other neuromuscular conditions  CMS officials noted that patients with these conditions typically respond well to intensive rehabilitation therapy provided in a resource intensive inpatient hospital environment and to the specific interdisciplinary approach to care that is provided in the IRF setting  Stakeholders also noted that patients with spinal cord injuries, brain injuries, and other neuromuscular conditions may receive care in other settings  However, some stakeholders noted that some of these providers—such as skilled nursing facilities—generally do not offer the specialized care these patients generally require  Differences in payment systems and data limitations make it difficult to directly compare the attributes of Medicare beneficiaries discharged from the two qualifying hospitals and IRFs, including the costs of care they receive  Medicare uses separate payment systems to pay LTCHs and IRFs, for care provided to beneficiaries  LTCHs are paid pre-determined fixed amounts for care provided to Medicare beneficiaries, under the LTCH PPS  Medicare beneficiaries treated in LTCHs are assigned to diagnosis groups (MS-LTC-DRGs) for each stay—based on the patient’s primary and secondary diagnoses, age, gender, discharge status, and procedures performed  IRFs are also paid pre-determined fixed amounts for care provided to Medicare beneficiaries, but under a separate system—IRF PPS  Medicare beneficiaries treated in IRFs are assigned to case-mix groups—based on age, and level of motor and cognitive function—and then further assigned to one of four tiers (within these groups) based on the presence of specific comorbidities that may increase their cost of care  According to CMS officials, because the payment groups and assignments to those groups are different, it is difficult to directly compare LTCH patients, classified in diagnosis groups, with IRF patients, classified in case-mix groups  See Appendix II for more information on these payment systems  MedPAC has previously reported the differences in patient assessment tools used by post-acute care providers undermines Medicare’s ability to compare the patients admitted, costs of care, and outcomes beneficiaries achieve in these settings, on a risk-adjusted basis  MedPAC has also reported that while similar beneficiaries can receive care in each setting, payments can differ considerably for comparable conditions, due to differences in payment systems  It has made recommendations to address these issues  The Improving Medicare Post-Acute Care Transformation Act of 2014 also requires the Secretary of HHS to collect and analyze common patient assessment information and, in consultation with MedPAC, submit a report to Congress recommending a post-acute care PPS  Such efforts may make future comparison of beneficiaries, costs of services, and outcomes of care across these settings possible  While data limitations make a direct comparison difficult, based on our review of other data and information, and interviews with stakeholders, we identified similarities and differences between the qualifying hospitals and certain IRFs that provide specialty treatment for catastrophic spinal cord injuries, acquired brain injuries, or other paralyzing neuromuscular conditions  Key similarities and differences include the following: Volume of services  Our review of Medicare claims data, other information, and interviews with stakeholders indicate that—similar to the two qualifying hospitals—some IRFs treat a high volume (at least 100) of patients with complex spinal cord injury, brain injury, and other related conditions  Officials from the two qualifying hospitals, as well as some other stakeholders we interviewed—including officials from the Christopher & Dana Reeve Foundation and the Brain Injury Association of America—emphasized the importance of facilities treating a high volume of patients with these specialized conditions, which can be an indicator of expertise in treating these patients  Our review of Medicare claims data for 1,148 IRFs in fiscal year 2016 identified 21 IRFs that treated at least 100 Medicare beneficiaries with non-traumatic and traumatic spinal cord injuries and 109 IRFs that treated at least 100 Medicare beneficiaries with non-traumatic and traumatic brain injuries  Our review of Medicare claims data indicated that, similar to the two qualifying hospitals—some IRFs also treat a high volume of patients with “catastrophic” injuries—traumatic brain injury, traumatic spinal cord injury, and major multiple traumas with brain or spinal cord injuries  Specifically, we identified 25 IRFs that treated a high volume (at least 100) of Medicare beneficiaries with catastrophic injuries, in fiscal year 2016  In the absence of patient assessment data from the facilities, we did not independently evaluate the level and severity of these patients’ injuries, which can vary due to the presence of other co-morbid conditions  The Medicare case mix indexes we reviewed for these 25 IRFs indicated that, relative to other IRFs, most of these facilities treat patients who are more resource intensive  Specialty accreditation and designation as model systems  Like Shepherd Center, some IRFs receive CARF-accreditation for specialty programs to treat spinal cord and brain injuries  According to most stakeholders, this accreditation indicates expertise in treating these patients, as CARF International has established standards using evidence-based practices, among other factors  Officials from the two qualifying hospitals also noted CARF International has a specific focus on quality and outcomes  However, officials from Shepherd Center noted similarities in care and services offered at CARF-accredited facilities would depend on the specialties for which they are certified  Most of the stakeholders we interviewed also noted that designation as a NIDILRR model system is an indicator of similar expertise in treating patients with spinal cord and brain injuries  According to the Model Systems Knowledge Translation Center, spinal cord injury and brain injury model systems are recognized as national leaders in medical research and patient care and provide the highest level of comprehensive specialty services from the point of injury through eventual re-entry into full community life  While stakeholders we interviewed from NIDILRR model systems indicated the model system designation is focused primarily on research, rather than clinical care, most noted that model systems’ research often complements the facilities’ clinical efforts to address the unique needs of these patients  Officials from HHS’s Administration for Community Living also noted that all model system grantees must provide a continuum of care—emergency care, acute medical care, acute medical rehabilitation, and post-acute care—and that can happen in various provider types  According to officials from the qualifying hospitals and stakeholders from one other NIDILRR model system we interviewed, Craig Hospital and Shepherd Center are the only two LTCHs currently classified as spinal cord injury model systems; 12 of 14 spinal cord injury model systems are IRFs  Specialized programs and services  Similar to the two qualifying hospitals, some IRFs may also offer specialized programs and services for patients with brain and spinal cord injuries, but the availability of these programs and services may vary by facility  Officials from some of the IRFs that responded to our information request—which included both NIDILRR facilities and IRFs with CARF-accredited programs—told us they provide specialized programs and services for patients with similar conditions as those treated at two qualifying hospitals, and sometimes compete with the two qualifying hospitals for the same patients  For example, each IRF reported having interdisciplinary treatment teams; the capacity to provide medical management of medically complex and high acuity patients with spinal cord injury, traumatic brain injury, or other major multiple traumas associated with a brain or spinal cord injury; family education and training; and skin and wound programs or services, among other services  However, the availability of certain services—including but not limited to ventilator-dependent weaning programs, diaphragmatic pacing, and outpatient programs for spinal cord and traumatic brain injury patients—varied by facility  Staff with specialized training and clinical expertise  Similar to the two qualifying hospitals, most facilities that responded to our information request also reported having physicians, nurses, and physical and occupational therapists with specialty training in medical rehabilitation, spinal cord, and/or brain injury  However, the number of staff with these trainings, varied by facility  In comparison to the other facilities that responded to our information request, the number of nurses and physical and occupational therapists with these specialty trainings were generally higher at Craig Hospital and Shepherd Center  According to an American Spinal Injury Association consumer guideline that the Christopher & Dana Reeve Foundation typically provides to spinal cord injury patients and families, programs should regularly admit persons with spinal cord injury each year, to develop and maintain the necessary skills to manage a person with spinal cord injury, and a substantial portion of those admitted should have traumatic injuries  Out-of-state Admissions  Officials from the two qualifying hospitals emphasized they admit a significant number of patients from out-of-state, and our review of information provided by the qualifying hospitals and a select group of IRFs indicated the qualifying hospitals admit a higher percentage of patients from out-of-state  Specifically, information provided by these IRFs indicates that less than a quarter of patients admitted to these facilities, in 2016, were from out-of-state  Information provided by Craig Hospital and Shepherd Center indicate that about half of their patients were admitted from out-of-state in 2016  Officials from the Colorado Department of Health Care Policy & Financing also noted Craig Hospital treats a higher percentage of out-of-state patients, compared to IRFs in the state  Ability to treat medically complex patients  Officials from the two qualifying hospitals told us they treat more medically complex patients and provide a more complete range of medical services to spinal cord and brain injury patients, not provided by most IRFs  Specifically, officials from the two qualifying hospitals both noted they are able to treat patients much sooner in their recovery process than most IRFs, due to their LTCH status  Officials from the Shepherd Center noted that they have a 10-bed intensive care unit which allows them to take patients with certain injures that some IRFs may not be equipped to admit—such as patients requiring advance medical management and advanced level procedural services and monitoring  Information provided by Shepherd Center indicated that, in calendar year 2017, approximately 20 percent of all inpatients were admitted to this unit and 13 percent of all inpatients were internally transferred to this unit after developing medical complications  According to officials, Craig Hospital does not have an intensive care unit, but noted their ability to similarly care for medically complex patients—including telemetry (e g , specialized heart monitoring) and one-to-one nursing care, if necessary  Most stakeholders we interviewed agreed that both qualifying hospitals’ LTCH status provides certain advantages over IRFs, such as the ability to admit some medically complex patients earlier in the recovery process and longer lengths of stay  Stakeholders from most of the IRFs we interviewed also reported having the flexibility to admit some medically complex patients requiring more advanced level monitoring and resources earlier in the recovery process—such as patients with disorders of consciousness  Officials from the two qualifying hospitals also said they offer a continuum of care that can meet patient’s changing needs, without the need to transfer them to different facilities  Information provided by Craig Hospital indicated that 83 percent of patients treated at its facility, in 2016, were discharged to home, 13 percent were discharged to another post-acute care facility, and 3 percent were discharged to an acute care hospital  In 2016, approximately 91 percent of patients treated at Shepherd Center were discharged to home, 7 percent were discharged to another post- acute care facility, and 2 percent were discharged to an acute care hospital  Information provided by the IRFs that responded to our written request varied by facility, but—similar to the two qualifying hospitals— each facility discharged more than 65 percent of patients to home  IRF payment criteria  CMS and most other stakeholders we interviewed noted that two Medicare payment policies applicable to IRFs, but not LTCHs, may contribute to their different patient populations  Specifically, to be classified for payment under Medicare’s IRF PPS, at least 60 percent of the IRF’s total inpatient population must require intensive rehabilitative treatment for one or more of 13 conditions—which includes both spinal cord and brain injury  To be admitted to an IRF, Medicare beneficiaries must reasonably be expected to actively participate in and benefit from the intensive rehabilitation therapy program, typically provided in IRFs  According to HHS, per industry standard, the intensive rehabilitation therapy program is often demonstrated by providing three hours of rehabilitation services per day for at least five days per week, but this is not the only way such intensity can be demonstrated  Officials from the two qualifying hospitals told us they generally use Medicare’s intensive rehabilitation requirement as a minimum standard for their rehabilitation patients—even though they are not held to this requirement, for the purposes of Medicare payment—but noted that some of their patients may not meet this requirement, due to their medical complexity  Length of stay and site-neutral payment requirements, for LTCHs  As previously noted, LTCHs—including the two qualifying hospitals—must have an average length of stay of greater than 25 days; IRFs are not subject to this requirement  The average length of stay for patients discharged from the Craig Hospital was about 60 days, in fiscal year 2016, and the average length of stay for patients discharged from Shepherd Center was about 53 days, in calendar year 2016  Stakeholders from the IRFs that responded to our information request reported average lengths of stay ranging from 14 to 31 days, for patients discharged in fiscal year 2016; the ranges of lengths of stay were slightly higher for spinal cord injury and traumatic brain injury inpatients for the IRFs, during the same period  LTCHs are also generally subject to site- neutral payment policy that is not applicable to IRFs and may decrease LTCHs payments for certain discharges, under Medicare  Other services provided  In addition to these Medicare specific differences, a few stakeholders we interviewed also noted the two qualifying hospitals receive additional funding from their strong philanthropic donor base that may allow them to provide other services and resources, not covered by Medicare or offered at some IRFs  For example, while a few IRFs that responded to our information request reported offering housing for families of injured patients, the two qualifying hospitals offer up to 30 days of free housing to families of newly injured rehabilitation patients, if both the family and patient live more than 60 miles from the hospital  Officials from Shepherd Center told us their revenues are supplemented by investment income and donor funds  Craig Hospital has also established a foundation that supports the hospital in achieving its goals through philanthropy  We provided a draft of this report to HHS  HHS provided technical comments, which we incorporated as appropriate  We also provided the two qualifying hospitals summaries of information we collected from them, to confirm the accuracy of statements included in our draft report  We incorporated their comments, as appropriate  We are sending copies of this report to the Secretary of Health and Human Services and other interested parties  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 at 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  This appendix describes our methodology for conducting simulations of payments for the two qualifying hospitals  We used Medicare claims data to conduct simulations of payments for the two qualifying hospitals  We first identified discharges at each hospital in two baseline years—federal fiscal years 2013 and 2016  We selected fiscal year 2016 because it was the year with the most recent data available at the time of our analysis, and we selected a second baseline year because data for 2016 was different than data for other recent years  For example, the number of discharges for one qualifying hospital declined by nearly half between fiscal years 2013 and 2016  We chose fiscal year 2013 because data from that year was used to help determine which hospitals are subject to the temporary exception  To identify how to appropriately calculate the long-term care hospital (LTCH) payment for each of these discharges in future payment years, we reviewed applicable federal regulation and documents from the Centers for Medicare & Medicaid Services (CMS) and the Medicare Payment Advisory Commission (MedPAC), and interviewed officials from both organizations  See table 4 for the relevant components in the formulas, such as Medicare severity long-term care diagnosis related group (MS-LTC-DRG) weights, identified from final rule tables  When conducting these simulations, we made the following assumptions: For simulated payments for payment policies in effect for fiscal years 2017 and 2018, we used the base rates, relative weights (e g , the MS-LTC-DRG weights), geometric mean length of stay, wage index, geographic adjustment factor, fixed-loss amounts, and outlier thresholds that were published in the final rule tables for LTCH and inpatient prospective payment system (IPPS) hospitals—also known as acute care hospitals—for each respective year  At the time we began our analysis, this information was not known for fiscal years 2019 through 2021  We chose to use the fiscal year 2018 rates when conducting simulations for payment policies in those years because historical trends showed that annual changes were minimal—about 1 percent  Therefore, to the extent that these values continue to change over time, our findings may understate or overstate the amount that the qualifying hospitals would have been paid in our baseline years based on these future payment policies  The site-neutral payment policy did not apply to discharges from the fiscal year 2013 baseline year  Therefore, we examined Medicare claims data to determine whether each discharge would have met the criteria to receive the LTCH standard rate in that year  Specifically, we determined whether each discharge had an acute care hospital stay that immediately preceded their LTCH stay  We then determined whether the time at the acute care hospital included three or more days in the intensive care unit or whether there was a code on the LTCH claim that indicated at least 96 hours of mechanical ventilation services were provided  Per Medicare’s payment policy, we assumed any discharge that met these two criteria would qualify for full LTCH payment rate, unless the case was a psychiatric or rehabilitation stay, as identified by the following MS-LTC-DRG codes: 876, 880, 881, 882, 883, 884, 885, 886, 887, 894, 895, 896, 897, 945, or 946  Under statute, unless 50 percent or more of the hospital’s discharges beginning during or after 2020 qualify for the standard rate, no subsequent payments will be made to a hospital at that rate  Therefore, when calculating simulated payments for fiscal year 2021, we applied the 50 percent threshold  At the time of our analysis, CMS had not yet finalized this policy through rule-making  As of November 2018, CMS officials told us that it is unlikely that any payment adjustment under this provision would apply until 2022 because the percentage cannot be determined until after an LTCH’s cost reporting period has ended and data have been submitted  Shepherd Center’s fiscal year is different than the federal fiscal year  Therefore, the variables used to determine whether discharges in federal fiscal year 2016 met criteria to receive the standard rate were not available to use for some of the discharges that year  Of those discharges, we assumed that the same percentage of discharges that met the criteria to receive the standard rate in Shepherd’s fiscal year—30 percent—met the criteria in federal fiscal year 2016  When calculating site-neutral payments, we assumed that each discharge would be paid at a rate comparable to that for acute care hospitals—the IPPS comparable amount rate  Site-neutral payments may also be based on the estimated cost-of-care, if it is lower than the IPPS comparable amount rate  However, over 90 percent of discharges at the qualifying hospitals were paid at the IPPS comparable amount rate in fiscal year 2016  Per CMS’s recommendation, we applied the cost-to-charge ratio that was effective October 1, 2017, for each qualifying hospital, regardless of discharge date  For Craig Hospital this value was 0 442 and for Shepherd Center this value was 0 464  According to CMS officials, in general, these values do not change significantly when they are updated during the fiscal year  Therefore, they believe that using the values effective at the start of the fiscal year is a reasonable assumption  We excluded indirect medical education adjustments and disproportionate share hospital payments that are part of the IPPS comparable amount rate because, according to CMS, they were unlikely to have much impact for these hospitals  CMS reviewed each of these assumptions and agreed they were reasonable for purposes of our analysis  CMS also verified that we were correctly applying the formulas for calculating these payments and using the appropriate values from the final rules  Figures 3 and 4 illustrate the methodology for calculating Medicare payments under the long-term care hospital (LTCH) prospective payment system (PPS) and the inpatient rehabilitation facility (IRF) PPS, respectively, as reported by the Medicare Payment Advisory Commission (MedPAC)  Appendix III: List of Common Diagnosis Groups for Long-Term Care Hospitals (LTCH) In its March 2018 annual report to the Congress, the Medicare Payment Advisory Commission (MedPAC) reported that 20 diagnosis groups accounted for over 61 percent of LTCH discharges at both for-profit and not-for-profit facilities, in fiscal year 2016  Table 5 provides a list of these 20 diagnosis groups  In addition to the contact named above, Will Simerl, Assistant Director; Kathy King; Amy Leone, Analyst-in-Charge; Todd Anderson; Sam Amrhein; LaKendra Beard; Rich Lipinski; Jennifer Rudisill; and Eric Wedum made key contributions to this report  Also contributing were Leia Dickerson, Diona Martyn, Vikki Porter, and Lisa Rogers 


Report 2: The Land and Water Conservation Fund (LWCF) Act of 1965 was enacted to "assist in preserving, developing, and assuring accessibility to     outdoor recreation resources " Two main goals of the law were to facilitate participation in recreation and "to strengthen the health and vitality" of U S  citizens  To accomplish these goals, purposes of the law included "providing funds" for federal land acquisition and for federal assistance to states generally related to outdoor recreation  The fund is authorized to receive $900 million in revenues annually under the LWCF Act  Each year the fund accrues revenues at this level  The fund accumulates the majority of its revenues from oil and gas leases on the Outer Continental Shelf (OCS)  It also accumulates revenues from the federal motorboat fuel tax and surplus property sales  However, revenues that accrue under the LWCF Act are available only if appropriated by Congress through the discretionary appropriations process  The LWCF receives additional revenue (beyond the $900 million) from OCS leasing under the Gulf of Mexico Energy Security Act of 2006 (GOMESA)  Unlike revenues under the LWCF Act, GOMESA revenues are mandatory appropriations (and thus are not subject to annual appropriation by Congress)  They can be used only for grants to states for outdoor recreation purposes  The overall level of annual appropriations (discretionary and mandatory combined) has varied widely since the fund's origin in FY1965  Of the total revenues that have accrued throughout the program's history ($40 9 billion), less than half have been appropriated ($18 9 billion) through FY2019  Thus, the unappropriated balance in the fund is estimated at $22 0 billion through FY2019  The LWCF Act outlines uses of the fund for federal and state purposes  It states that of the total made available to the fund, not less than 40% is to be used for "federal purposes" and not less than 40% is to be used to provide "financial assistance to states " The act lists the federal purposes for which the President is to allot LWCF funds "unless otherwise allotted in the appropriation Act making them available " These purposes primarily relate to the acquisition of lands and waters (and interests therein) by the federal government  With regard to state purposes, the act authorizes a matching grant program to states for outdoor recreation purposes  In practice, over the history of the LWCF, appropriations acts have provided funding for three general purposes  First, for each year since FY1965, appropriations for land acquisition have been provided to some or all of the major federal land management agencies—the Bureau of Land Management (BLM), Fish and Wildlife Service (FWS), National Park Service (NPS), and Forest Service (FS)  Second, for nearly every year since FY1965, appropriations have funded the outdoor recreation matching grant program, to assist states in recreational planning, acquiring recreational lands and waters, and developing outdoor recreational facilities  Third, beginning in FY1998, appropriations from the LWCF have been provided each year, except FY1999, to fund other federal programs with related natural resource purposes  Hereinafter, the third type of appropriations is referred to as funding other purposes   The $18 9 billion appropriated from the fund through FY2019 has been allocated in different proportions among federal land acquisition, the state grant program, and other purposes  The largest portion of the total—$11 4 billion—has been appropriated for federal land acquisition  The state grant program has received the second-largest portion, $4 8 billion  Other purposes have received the remaining $2 7 billion  Appendix A shows the total LWCF appropriation for other purposes  Congress continues to consider the extent to which the LWCF should fund purposes other than federal land acquisition and outdoor recreation grants to states  Some traditional LWCF advocates and beneficiaries have expressed concern about expanding the use of the funds, particularly if such expansion results in lower appropriations for land acquisition and outdoor recreation grants to states  Some Members of Congress, Presidents, and stakeholders have supported funding other purposes in order to draw on the balance in the fund for policy priorities, to shift the focus of the fund from land acquisition, or to achieve other goals  A number of measures introduced in recent Congresses sought to authorize funding from the LWCF for various other purposes  These measures were not enacted  They included proposals to specify an amount or percentage of funding for two programs that are currently funded by the LWCF—the Forest Legacy Program and Cooperative Endangered Species Conservation grants—although the LWCF Act does not specifically authorize this funding  Other proposals sought to authorize programs or activities that have not been funded by LWCF in the past, or that have been rarely funded by LWCF in the past  For instance, one 115 th Congress bill would have authorized LWCF funding for certain programs and activities of the major land management agencies, including deferred maintenance, critical infrastructure, visitor services, and clean-up efforts; the Payments in Lieu of Taxes Program; and certain offshore energy exploration, innovation, and education activities  As another example, one 115 th Congress bill proposed to authorize LWCF funding for financial assistance from the Secretary of Housing and Urban Development for park and recreation infrastructure projects  The balance of this report discusses the other purposes for which LWCF appropriations have been provided throughout the fund's history  It identifies the amount of funding contained in annual appropriations laws for other purposes and the types of purposes for which funds have been appropriated  A total of $72 0 million was appropriated from the LWCF for other purposes in FY1998, the first year in which LWCF was used to fund other purposes  The total included $60 0 million for maintenance needs of the four land management agencies and $12 0 million for rehabilitation and maintenance of the Beartooth Highway (in Wyoming and Montana)  In FY1998, total LWCF appropriations had spiked to approximately $969 million from the FY1997 level of about $159 million  Both the dollar amounts and the percentages of annual LWCF appropriations for other purposes have varied widely since FY1998  (See Appendix B  ) Over the most recent 10 years, LWCF appropriations for other purposes fluctuated, declining overall from $132 5 million in FY2010 to $93 3 million in FY2019 (in current dollars)  However, the FY2019 level was the highest appropriation since FY2010  Beginning in FY2011, appropriations for other purposes in each year have been less than $100 million, as was the case for FY1998-FY2000  Appropriations for other purposes were at their lowest dollar amount in FY1999, when no funds for other purposes were appropriated  The next-lowest dollar value was provided for FY2000, when a total of $20 0 million was appropriated for three purposes: Elwha River Ecosystem restoration (in Washington), deferred maintenance of the NPS, and the FS Forest Legacy program  By contrast, from FY2001 to FY2010, appropriations for other purposes exceeded $100 million in each year  In fact, during four of these years (FY2004-FY2007), the annual appropriation was between $200 million and $225 million  The appropriation surpassed $400 million in another year during the period  Specifically, the $456 0 million appropriation in FY2001 was more than double the amount provided for other purposes in any other year  These appropriations were used to fund more than a dozen programs in the Clinton Administration's Lands Legacy Initiative  In that year, total LWCF appropriations exceeded the annual authorization level, totaling nearly $1 billion  This record level of funding was provided partly in response to President Clinton's Lands Legacy Initiative, which sought $1 4 billion for about two dozen resource-protection programs, including the LWCF  It also was provided partly in response to some congressional interest in securing increased and more certain funding for the LWCF  The highest percentage of annual funds provided for other purposes occurred in FY2006 and FY2007 (59% in both years), in response to President George W  Bush's request for funding for an array of programs  For instance, in FY2007 the Bush Administration sought funding from the LWCF for 15 programs in addition to land acquisition and state grants  For that year, the appropriation for five other purposes was $216 1 million, out of a total LWCF appropriation of $366 1 million  In some years, the appropriation for other purposes was significantly less than the Administration requested  For example, for FY2008 the Bush Administration sought $313 1 million for other purposes, or 83% of the total request of $378 7 million  The FY2008 appropriation for other purposes was $101 3 million, or 40% of the LWCF total of $255 1 million  The $2 7 billion appropriated from the LWCF from FY1998 to FY2019 for other purposes represents 27% of the $10 0 billion total appropriations from LWCF during the period  FWS and FS have received the largest shares of the appropriations for other purposes, about $1 4 billion (53%) and $1 0 billion (38%), respectively  BLM, NPS, the U S  Geological Survey, and the Bureau of Indian Affairs have shared the remaining $0 2 billion (9%) of the appropriations for other purposes  (See Figure 1  ) Because there is no set of other purposes specified in the LWCF Act to be funded from the LWCF, presidents have sought funds for a variety of purposes  Congress has chosen which of these requests to fund from the LWCF, and whether to fund any additional programs from the LWCF not suggested by the President  Appropriations for other purposes have been provided for more than a dozen diverse natural resource-related programs, including facility maintenance of the land management agencies, ecosystem restoration, the Historic Preservation Fund, the Payments in Lieu of Taxes program, the FS Forest Legacy program, FWS State and Tribal Wildlife Grants, the FWS Cooperative Endangered Species Conservation Fund, U S  Geological Survey science and cooperative programs, and Bureau of Indian Affairs Indian Land and Water Claim Settlements  (See Appendix A  ) Although in earlier years several other purposes typically were funded from LWCF, since FY2008, funds have been appropriated annually only for grants under two programs: Forest Legacy and Cooperative Endangered Species Conservation Fund  (See Appendix B and Figure 2   ) The total appropriation from LWCF for these two programs (since FY1998) is $1 7 billion, or 63% of all appropriations for other purposes ($2 7 billion)  These two programs and a third grant program funded prior to FY2008 from LWCF—FWS State and Tribal Wildlife Grants—have received more than three-quarters ($2 1 billion, 79%) of the total appropriations for other purposes  The appropriations through FY2019 are $944 4 million for Forest Legacy (35% of the other purposes total), $753 3 million for Cooperative Endangered Species Conservation Fund (28% of total), and $448 5 million for State and Tribal Wildlife Grants (17% of total)  Grants under the Forest Legacy program are used to acquire lands or conservation easements to preserve private forests threatened by conversion to non-forest uses, such as agriculture or residences  FS provides matching grants to states through a competitive process that requires state approval and then national approval and ranking  The ranking is based on the importance of the project (potential public benefits from protection), the likelihood of the forest's conversion to non-forest uses, and the strategic relevance of the project, among other factors  The program is implemented primarily through state partners, usually state forestry agencies  State partners generally acquire, hold, and administer the easements or land purchases, although the federal government also may do so  The Cooperative Endangered Species Conservation Fund provides grants "for species and habitat conservation actions on non-Federal lands, including habitat acquisition, conservation planning, habitat restoration, status surveys, captive propagation and reintroduction, research, and education " In addition to appropriations from LWCF, the Cooperative Endangered Species Conservation Fund typically receives additional appropriations  In recent years, the appropriations from LWCF generally have been used for two types of land acquisition grants provided to state and territories on a matching basis  Recovery land acquisition grants have been made for acquisition of habitats in support of species recovery goals and objectives  Habitat conservation plan land acquisition grants have been made for acquisition of lands that are associated with habitat conservation plans  State and Tribal Wildlife Grants are provided to states, territories, and tribes to develop and implement programs for the benefit of fish and wildlife and their habitats, including nongame species  State and Tribal Wildlife Grants received funding from the LWCF for FY2001-FY2007; subsequently, funding has been provided from the General Fund of the U S  Treasury  Currently, the largest portion of the program is for formula grants to states and territories on a matching basis  Funds from the formula grants may be used to develop state conservation plans and to implement specific conservation projects  Smaller amounts of funding have been appropriated for competitive grants to states and territories, and to tribal governments  The competitive grant programs do not have matching requirements  Appendix A shows the total LWCF appropriations for other purposes summed from FY1998 to FY2019  Appendix B shows the other purposes that received LWCF appropriations each year, the amount of LWCF appropriations for each purpose, and the total annual appropriations for other purposes  Appendix A  Total LWCF Appropriations for Other Purposes Appendix B  Annual LWCF Appropriations for Other Purposes 

ground_truth: The Land and Water Conservation Fund (LWCF) Act of 1965 (P.L. 88-578) created the LWCF in the Treasury as a funding source to implement the outdoor recreation goals set out by the act. The LWCF Act authorizes the fund to receive $900 million annually, with the monies available only if appropriated by Congress (i.e., discretionary appropriations). The fund also receives mandatory appropriations under the Gulf of Mexico Energy Security Act of 2006 (GOMESA). The level of annual appropriations for the LWCF has varied since the origin of the fund in FY1965. The LWCF Act outlines uses of the fund for federal and state purposes. Of the total made available through appropriations or deposits under GOMESA, not less than 40% is to be used for "federal purposes" and not less than 40% is to be used to provide "financial assistance to states." The act lists the federal purposes for which the President is to allot LWCF funds "unless otherwise allotted in the appropriation Act making them available." These purposes primarily relate to acquisition of lands and waters (and interests therein) by the federal government. With regard to state purposes, the act authorizes a matching grant program to states for outdoor recreation purposes. Throughout the LWCF's history, appropriations acts typically have provided funds for land acquisition and outdoor recreational grants to states. Beginning in FY1998, appropriations also have been provided each year (except FY1999) to fund other purposes related to natural resources. The extent to which the LWCF should be used for purposes other than federal land acquisition and outdoor recreation grants to states, and which other purposes should be funded from the LWCF, continue to be the subject of legislation and debate in Congress. In the past few decades, Presidents have sought LWCF funds for a variety of other purposes. Congress chooses which if any of these requests to fund, and has chosen programs not sought by the President for a particular year. Among other programs, appropriations have been provided for facility maintenance of the land management agencies, ecosystem restoration, the Historic Preservation Fund, the Payments in Lieu of Taxes program, the Forest Legacy Program, State and Tribal Wildlife Grants (under the Fish and Wildlife Service), the Cooperative Endangered Species Conservation Fund, U.S. Geological Survey science and cooperative programs, and Bureau of Indian Affairs Indian Land and Water Claim Settlements. Since FY1998, a total of $2.7 billion has been appropriated for other purposes, of a total LWCF appropriation of $18.9 billion over the history of the fund. The Fish and Wildlife Service and the Forest Service have received the largest shares of the total appropriations for other purposes, about $1.4 billion (53%) and $1.0.billion (38%), respectively, from FY1998 to FY2019. Several agencies shared the remaining $0.2 billion (9%) of the appropriations. Both the dollar amounts and the percentages of annual LWCF appropriations for other purposes have varied widely since FY1998. The dollar amounts have ranged from $0 in FY1999 to $456.0 million in FY2001. The percentage of annual funds provided for other purposes ranged from 0% in FY1999 to a high of 59% in both FY2006 and FY2007. In some years, the appropriation for other purposes was significantly less than the Administration requested. For instance, for FY2008, the George W. Bush Administration sought $313.1 million; the appropriation was $101.3 million. The appropriation for other purposes last exceeded $100.0 million in FY2010, and most recently was $93.3 million, in FY2019. Prior to FY2008, several other purposes typically were funded each year from LWCF. Since FY2008, funds have been appropriated annually only for grants under two programs: Forest Legacy and Cooperative Endangered Species Conservation Fund. These two programs and a third grant program—State and Tribal Wildlife Grants—have received more than three-quarters ($2.1 billion, 79%) of the total appropriation for other purposes since FY1998.