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



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

Report 1: In March 2015, Saudi Arabia established a coalition of nations (hereinafter referred to as the Saudi-led coalition or the coalition) to engage in military operations in Yemen against the Ansar Allah/Houthi movement and loyalists of the previous president of Yemen, the late Ali Abdullah Saleh  During 2014, the United States joined Saudi Arabia in demanding that Houthi forces reverse their campaign to occupy the Yemeni capital of Sanaa, but the rapid onset of hostilities in March 2015 forced the Obama Administration to react quickly  At the start of the Saudi-led intervention on March 25, 2015, the Administration announced that the United States would provide "logistical and intelligence support" to the coalition's operations without taking "direct military action in Yemen in support of this effort " Soon thereafter, a joint U S -Saudi planning cell was established to coordinate military and intelligence support for the campaign  At the United Nations Security Council, the United States supported the passage of Resolution 2216 (April 2015), which, among other things, required member states to impose an arms embargo against the Houthi-Saleh forces and demanded that the Houthis withdraw from all areas seized during the current conflict  Since the March 2015 Saudi-led coalition intervention in Yemen, Congress has taken an active role in debating and overseeing U S  policy in the Arabian Peninsula  Members have considered legislative proposals seeking to reduce Yemeni civilian casualties resulting from the coalition's operations; improve deteriorating humanitarian conditions; end restrictions on the flow of goods and humanitarian aid; combat Iranian support for the Houthis; preserve maritime security in the Bab al Mandab Strait; and/or support continued Saudi-led coalition and U S  efforts to counter Al Qaeda and Islamic State forces in Yemen  Beyond Yemen, many Members have appeared to view the conflict through the prism of a broader regional rivalry between Saudi Arabia and Iran, and the U S  effort to limit Iran's malign regional influence  Others lawmakers have viewed the Yemen conflict as indicative of what they perceive as problems in the U S -Saudi relationship, a concern that deepened after the killing of Saudi journalist Jamal Khashoggi by Saudi government personnel in October 2018  Congress has considered but has not enacted proposals to curtail or condition U S  defense sales to Saudi Arabia  Responding to the Saudi-led intervention in Yemen also appears to be reinvigorating some Members' interest in strengthening the role of Congress in foreign policy vis-à-vis the executive branch  Debate in Congress over Yemen has featured bipartisan statements of interest in asserting the prerogatives of the legislative branch to limit executive branch power, specifically using war powers legislation and the appropriations and authorization processes to curb U S  military involvement in support of coalition operations  Congressional scrutiny of U S  policy in Yemen also has led to legislative changes to global authorities, such as the Department of Defense's authority to enter into and use acquisition and cross servicing agreements with partner militaries  Congressional interest in the Yemen conflict has evolved and grown gradually and was not widespread at the outset of the coalition's March 2015 intervention in Yemen  In early to mid-2015, congressional interest in U S  foreign policy in the Middle East centered on the Iran nuclear deal and Operation Inherent Resolve against the Islamic State in Iraq and Syria  Several months after the March 2015 intervention, the Saudi-led coalition had not achieved a conclusive victory and what modest gains had been made on the ground were offset by mounting international criticism of growing civilian casualties from coalition air strikes  In Congress, several lawmakers began to express concern about the deteriorating humanitarian situation in Yemen  In late September 2015, Representative Ted W  Lieu wrote a letter to the Joint Chiefs of Staff advocating for a halt to U S  support for the Saudi-led coalition until it instituted safeguards to prevent civilian casualties  In October 2015, 10 Members of Congress wrote a letter to President Obama urging him to "work with our Saudi partners to limit civilian casualties to the fullest extent possible " In October 2015, Senator Markey stated that "I fear that our failure to strongly advocate diplomacy in Yemen over the past two years, coupled with our failure to urge restraint in the face of the crisis last spring, may put the viability of this critical [U S -Saudi] partnership at risk " By the fall of 2015, as the Obama Administration tried to balance its concern for adhering to the laws of armed conflict with its support for Gulf partners, lawmakers began to express their concern over U S  involvement in the coalition's intervention by scrutinizing U S  arms sales to Saudi Arabia  When the Administration informally notified Congress of a proposed sale of precision guided munitions (PGMs) to Saudi Arabia, some Senators sought to delay its formal notification  After the formal notification in November 2015, Senate Foreign Relations Committee (SFRC) leaders jointly requested that the Administration notify Congress 30 days prior to associated shipments, marking the first use of this prior notification request authority  At that time, no related joint resolutions of disapproval on proposed sales of PGMs to the kingdom were introduced, but the delay and additional notification request demonstrated congressional concern  By the one-year anniversary of the Saudi-led intervention in Yemen, a more defined opposition to U S  support for the coalition had begun to coalesce amid repeated international documentation of human rights abuses and errant coalition airstrikes  In April 2016, legislation was introduced that sought to place conditions on future proposed sale notifications, previously approved sales, or transfers of PGMs to Saudi Arabia  Proposed amendments to FY2017 defense legislation would have added some similar conditions on the use of funds to implement sales of PGMs or prohibited the transfer of cluster munitions to Saudi Arabia  The PGM amendment was not considered, but the cluster munitions amendment was narrowly defeated in a June 2016 House floor vote  In the spring and summer of 2016, the United Nations held multiple rounds of peace talks in Kuwait aimed at brokering an end to the conflict  From April 2016 to August 2016, the Saudi-led coalition had largely spared Yemen's capital Sanaa from aerial strikes as part of its commitment to the cessation of hostilities  When U N -mediated peace talks collapsed in August 2016, the Saudi-led coalition resumed bombing and the war intensified  During the summer of 2016, the Obama Administration reduced some U S  support for Saudi Arabia's air campaign in Yemen by withdrawing U S  personnel assigned to a joint U S -Saudi planning cell  Nevertheless, overall U S -Saudi cooperation continued and, in August 2016, the Obama Administration notified Congress of a proposed sale of M1A2S tanks to Saudi Arabia  In response, some lawmakers wrote to request that President Obama withdraw the proposal, citing concerns about Yemen  In September 2016, joint resolutions of disapproval of the proposed tank sale were introduced in the Senate ( S J Res  39 ) and House ( H J Res  98 )  On September 21, 2016, the Senate voted to table a motion to discharge the SFRC from further consideration of S J Res  39 (71-27, Record Vote 145)  During debate over the motion, many Senators argued in favor of continued U S  support for Saudi Arabia, with Senator Lindsey Graham remarking "To those who want to vote today to suspend this aid to Saudi Arabia, people in Iran will cheer you on " In the wake of an October 2016 Saudi airstrike on a funeral hall in Sanaa that killed 140 people, the Obama Administration initiated a review of U S  security assistance to Saudi Arabia  Based on that review, it put a hold on a planned sale of precision guided munitions (PGMs) to Saudi Arabia and limited intelligence sharing, but maintained counterterrorism cooperation and refueling for coalition aircraft  In the final months of the Obama Administration, U S  Armed Forces briefly exchanged fire with forces party to the conflict  In October 2016, Houthi-Saleh forces launched anti-ship missiles at U S  Navy vessels on patrol off the coast of Yemen  The attacks against the U S  ships marked the first time U S  Armed Forces had come under direct fire in the war  The Obama Administration responded to the attacks against U S  naval vessels by directing the Armed Forces to fire cruise missiles against Houthi-Saleh radar installations  The Obama Administration described the U S  strikes as self-defense and indicated that it did not want to deepen its direct involvement in the conflict  In August and November 2016, then-Secretary of State John Kerry made several attempts to broker a peace initiative in Oman, but his efforts were rejected by the parties themselves  By the end of 114 th Congress, the war in Yemen was becoming a more significant foreign policy issue for lawmakers  While a growing number of Members were becoming critical of the U S  role in supporting the Saudi-led coalition amid a deteriorating humanitarian situation in Yemen, more lawmakers still viewed the conflict through a regional lens rather than as a localized affair  Amid significant congressional opposition to the 2015 nuclear agreement with Iran (Joint Comprehensive Plan of Action or JCPOA), some Members viewed Iran's support for the Houthi movement and the broader conflict in Yemen as an example of Iran's malign regional activities not directly addressed by the JCPOA  As the Houthis targeted Gulf state infrastructure on land and vessels at sea, their behavior was touted as evidence of Iran's growing capabilities to threaten U S  and Gulf security  Just as some Members considered the Yemen conflict primarily a proxy war between the Iran-backed Houthis and the Saudi-led coalition, others viewed it as a test of long-standing U S  commitments to supporting Saudi Arabian security  Supporters of the relationship, while acknowledging that Saudi Arabia's conduct of the war was at times problematic, argued that to curtail U S  arms sales or other defense support to the kingdom would weaken a vital partner that was under threat from a hostile nonstate actor on its southern border  Others lawmakers charged that continued U S  support for the coalition was not improving coalition behavior but damaging the U S  reputation for upholding commitments to international law and human rights  Legislation seeking to limit U S  arms sales to Saudi Arabia was not enacted in the 114 th Congress, but marked the beginning of the broader congressional debate that has continued  As the Trump Administration prepared to assume office, human rights organizations and aid groups were pressing Congress to become more attuned to the growing humanitarian crisis in Yemen  Though the Obama Administration had taken some steps, particularly in late 2016, to limit U S -coalition cooperation and restrict deliveries of PGMs to Saudi Arabia, nongovernmental groups deemed such action as insufficient  According to Human Rights Watch, "Whatever conditionality the Obama administration thought it had created—in holding up the transfer of precision munitions near the tail end of Obama's term and suspending cluster munition transfers earlier—ultimately did not have meaningful impact in reining in the continued Saudi-led coalition attacks on civilians " From the beginning of his Administration, President Donald Trump has signaled strong support for the Saudi-led coalition's operations in Yemen as a bulwark against Iranian regional interference  He initiated a review of U S  policy toward Yemen, including President Obama's October 2016 restrictions on U S  arms sales and intelligence sharing to the coalition  On March 19, 2017, just prior to his visit to Saudi Arabia, President Trump notified Congress that he was proceeding with three proposed direct commercial sales of precision guided munitions technology deferred by the Obama Administration, subject to congressional review  In May 2017, the Administration officially notified Congress of its intention to proceed with proposed sales of precision guided munitions technologies that the Obama Administration had deferred, while announcing plans to increase training for Saudi Arabia's air force on both targeting and the Law of Armed Conflict  Congress debated another resolution of disapproval ( S J Res  42 ) of these proposed PGM sales in June 2017 (see below)  After completing the policy review in July 2017, President Trump directed his Administration "to focus on ending the war and avoiding a regional conflict, mitigating the humanitarian crisis, and defending Saudi Arabia's territorial integrity and commerce in the Red Sea " As President Trump entered office, the dynamics of the conflict in Yemen were changing, and the coalition launched a new offensive along Yemen's 280-mile western coastal plain ultimately aimed at taking the strategic Houthi-held port city of Hudaydah  In early 2017, the coalition's gradual advance toward Hudaydah, coupled with an ongoing deterioration in humanitarian conditions, sparked some Members of Congress to implore the Administration to improve aid access and negotiate a cease-fire  In March 2017, several House Members wrote a letter to then-Secretary of State Rex Tillerson urging him to "use all U S  diplomatic tools to help open the Yemeni port of Hodeida [Hudaydah] to international humanitarian aid organizations " A month later, another group of House Members wrote to President Trump stating that Congress should approve any new U S  support to the coalition amid its offensive against Hudaydah  On June 13, 2017, the Senate debated another resolution ( S J Res  42 ) to disapprove of three direct commercial sales of PGMs to Saudi Arabia  During Senate floor consideration over the motion to discharge the Senate Foreign Relations Committee from further consideration of S J Res  42 , Members once again weighed various issues, such as the U S -Saudi bilateral relationship, countering Iran, and limiting U S  involvement in the war in Yemen  Some lawmakers suggested that U S  arms sales and military support to the coalition had enabled alleged violations of international humanitarian law, while others argued that U S  support to the coalition improved its effectiveness and helps minimize civilian casualties  For example, during floor debate, Senator Graham argued that "If we are worried about collateral damage in Yemen, I understand the concern  Precision weapons would help that cause, not hurt it " Senator Murphy retorted, saying "What we are asking for is to hold off on selling these precision-guided munitions until we get some clear promise—some clear assurance—from the Saudis that they are going to use these munitions only for military purposes and that they are going to start taking steps—real steps, tangible steps—to address the humanitarian crisis " On June 13, 2017, the Senate voted to reject the motion to discharge the Senate Foreign Relations Committee from further consideration (47-53, Record Vote 143), and a companion resolution was not taken up in the House ( H J Res  102 )  Representative Ro Khanna introduced a concurrent resolution ( H Con Res  81 ) pursuant to the War Powers Resolution ( P L  93-148 ) in a bid to end U S  support for the coalition's military intervention  After consultation between House leaders and supporters of the resolution on a compromise approach, the House agreed to delay expedited consideration of the resolution until after the November 2016 election and then adopted a nonbinding alternative ( H Res  599 , 366-30, 1 Present, Roll no  623)  In his first year in office, while President Trump sought to improve relations with Saudi Arabia, counter Iran, and increase U S  counterterrorism activity in Yemen, his Administration also at times took strong positions on the need for members of the coalition to improve humanitarian access, pursue a settlement to the conflict, and take measures to prevent civilian casualties  After a Houthi-fired missile with alleged Iranian origins landed deep inside Saudi Arabia in November 2017, the coalition instituted a full blockade of all of Yemen's ports, including the main port of Hudaydah, exacerbating the country's humanitarian crisis  The White House issued four press statements on the conflict between November 8 and December 8, including a statement on December 6 in which President Trump called on Saudi Arabia to "completely allow food, fuel, water, and medicine to reach the Yemeni people who desperately need it  This must be done for humanitarian reasons immediately " On December 20, 2017, the Saudi-led coalition announced that it would end its blockade of Hudaydah port for a 30-day period and permit the delivery of four U S -funded cranes to Yemen to increase the port's capability to off-load commercial and humanitarian goods  The next day, the White House issued a statement welcoming "Saudi Arabia's announcement of these humanitarian actions in the face of this major conflict " As the Saudi-led coalition intervention entered its fourth year, some in the Senate also proposed use of the War Powers Resolution as a tool for ending U S  support for the coalition's military intervention  On February 28, 2018, Senator Bernie Sanders introduced S J Res  54 , a joint resolution to "direct the removal of United States Armed Forces from hostilities in the Republic of Yemen that have not been authorized by Congress (except for those U S  forces engaged in counterterrorism operations directed at al Qaeda or associated forces) " Efforts in the Senate followed a late 2017 attempt in the House (see Table 1 below), in which a concurrent resolution directing the President to remove U S  forces from Yemen was tabled in favor of a House-passed nonbinding resolution  Throughout 2018, between Congress and the Trump Administration and within Congress itself, there was disagreement as to whether U S  forces assisting the Saudi-led coalition have been introduced into active or imminent hostilities for purposes of the War Powers Resolution  Some Members claimed that by providing support to the Saudi-led coalition, U S  forces have been introduced into a "situation where imminent involvement in hostilities is clearly indicated" based on the criteria of the War Powers Resolution  The Trump Administration disagreed  In February 2018, the Acting Department of Defense General Counsel wrote to Senate leaders describing the extent of current U S  support , and reported that "the United States provides the KSA-led coalition defense articles and services, including air-to-air refueling; certain intelligence support; and military advice, including advice regarding compliance with the law of armed conflict and best practices for reducing the risk of civilian casualties " On March 20, 2018, the Senate considered S J Res  54 on the floor  During debate, arguments centered on a number of issues, ranging from concern over exacerbating Yemen's humanitarian crisis to reasserting the role of Congress in authorizing the use of armed force abroad  After then-Foreign Relations Committee Chairman Senator Bob Corker promised to propose new legislation and hold hearings scrutinizing U S  policy in Yemen, a majority of Senators voted to table a motion to discharge the Foreign Relations committee from further consideration of S J Res  54   Senator Robert Menendez made remarks expressing conditional support for Senator Corker's approach, a view shared by some other Senators who voted to table the motion  The Foreign Relations Committee held a hearing on Yemen a month later  In parallel testimony before Congress, U S  defense officials stated that while the United States refueled Saudi aircraft and provided advice on targeting techniques, CENTCOM did not track coalition aircraft after they were refueled and did not provide advice on specific targets  Then-Assistant Secretary of Defense for International Security Affairs Robert S  Karem testified that "It's correct that we do not monitor and track all of the Saudi aircraft aloft over Yemen " During the same hearing, U S  officials acknowledged that pressure from Congress has altered how the Administration deals with the coalition over the Yemen conflict  Acting Assistant Secretary of State for Near Eastern Affairs David Satterfield told Senator Todd Young and the SFRC the following: Senator, your efforts, the efforts of your colleagues in this body and on this Committee have been exceedingly helpful in allowing the Administration to send a message from whole of government regarding the very specific concerns we have over any limitations, restrictions, constraints on the ability of both humanitarian and commercial goods specifically to include fuel to have unrestricted and expeditious entry into Yemen  And that messaging which comes from us, the Executive Branch, also comes from this body is extremely important  After the promised hearing, the Senate Foreign Relations Committee also proposed new legislation to place conditions on U S  assistance to the coalition  In May, the committee reported S J Res  58 to the Senate; it would have prohibited the obligation or expenditure of U S  funds for in-flight refueling operations of Saudi and Saudi-led coalition aircraft that were not conducting select types of operations if certain certifications cannot be made and maintained  The Senate Armed Services Committee incorporated the provisions of the SFRC-reported text of S J Res  58 as Section 1266 of the version of the FY2019 National Defense Authorization Act (NDAA) that it reported to the Senate on June 5, 2018 ( S  2987 )  The provision was modified further and passed by both the House and Senate as Section 1290 of the conference version of the FY2019 NDAA ( H R  5515 )  It was signed into law as P L  115-232 in mid-August, giving the Administration until mid-September 2018 to make certain certifications  In a statement accompanying the President's signing of P L  115-232 into law, President Trump objected to provisions such as Section 1290, stating the Administration's view that such provisions "encompass only actions for which such advance certification or notification is feasible and consistent" with "[his] exclusive constitutional authorities as Commander in Chief and as the sole representative of the Nation in foreign affairs " As Congress continued to question the role of the United States in supporting coalition operations in Yemen, the pace and scale of fighting on the ground increased dramatically by the summer of 2018  On June 12, 2018, the Saudi-led coalition launched "Operation Golden Victory," aimed at retaking the Red Sea port city of Hudaydah  As coalition forces engaged Houthi militants in and around Hudaydah, humanitarian organizations warned that if port operation ceased, famine could become widespread throughout northern Yemen  On June 12, nine Senators wrote a letter to Secretary of State Pompeo and then-Secretary of Defense Mattis saying, "We are concerned that pending military operations by the UAE and its Yemeni partners will exacerbate the humanitarian crisis by interrupting delivery of humanitarian aid and damaging critical infrastructure  We are also deeply concerned that these operations jeopardize prospects for a near-term political resolution to the conflict " Several weeks later, Senator Robert Menendez, the ranking member on the Senate Foreign Relations Committee, placed a hold on a potential U S  sale of precision guided munitions to Saudi Arabia and the United Arab Emirates  In a June 28 letter to Secretary of State Pompeo and Secretary of Defense Mattis, Senator Menendez said, I am not confident that these weapons sales will be utilized strategically as effective leverage to push back on Iran's actions in Yemen, assist our partners in their own self-defense, or drive the parties toward a political settlement that saves lives and mitigates humanitarian suffering…  Even worse, I am concerned that our policies are enabling perpetuation of a conflict that has resulted in the world's worst humanitarian crisis  On August 9, the coalition conducted an airstrike that hit a bus in a market near Dahyan, Yemen, in the northern Sa'ada governorate adjacent to the Saudi border  The strike reportedly killed 51 people, 40 of whom were children  The coalition claims that its airstrike was a "legitimate military operation" and conducted in response to a Houthi missile attack on the Saudi city of Jizan a day earlier that killed a Yemeni national in the kingdom  The U S  State Department called on the Saudi-led coalition to conduct a "thorough and transparent investigation into the incident " Several Members of Congress wrote to the Administration seeking additional information regarding U S  operations in the wake of the August 2018 coalition strike at Dahyan  Several Senators also submitted an amendment to the FY2019 Defense Department appropriations act ( H R  6157 ) that would have prohibited the use of funds made available by the act to support the Saudi-led coalition operations in Yemen until the Secretary of Defense certifies in writing to Congress that the coalition air campaign "does not violate the principles of distinction and proportionality within the rules for the protection of civilians " The provision did not apply to support for ongoing counterterrorism operations against Al Qaeda and the Islamic State in Yemen  On September 12, Secretary of State Mike Pompeo issued a certification that would allow the use of FY2019 defense funds to support in-flight refueling of coalition aircraft to continue, per the terms of Section 1290 (see discussion above) of the FY2019 National Defense Authorization Act (NDAA, P L  115-232 )  Some Members of Congress criticized the Administration's actions, asserting that the coalition has not met the act's specified benchmarks for avoiding civilian casualties in Yemen  On September 26, several House Members introduced H Con Res  138 , which sought to direct the President to remove U S  Armed Forces from hostilities in Yemen, except for Armed Forces engaged in operations authorized under the 2001 Authorization for Use of Military Force, within 30 days unless and until a declaration of war or specific authorization for such use has been enacted into law  In response to a similar initiative in the Senate, the Administration submitted a detailed argument expressing its view that U S  forces supporting Saudi-led coalition operations are not engaged in hostilities in Yemen  By late 2018, the prospect of widespread famine in Yemen coupled with international reprobation over the killing of Jamal Khashoggi pressured the Administration and the coalition to accelerate moves toward peace talks  On October 30, then-Secretary of Defense James Mattis and Secretary of State Mike Pompeo called for all parties to reach a cease-fire and resume negotiations  On November 9, Secretary Mattis further announced that effective immediately, the coalition would use its own military capabilities—rather than U S  capabilities—to conduct in-flight refueling in support of its operations in Yemen  Though fighting continued along several fronts, on December 13, 2018, Special Envoy of the United Nations Secretary-General for Yemen Martin Griffiths brokered a cease-fire centered on the besieged Red Sea port city of Hudaydah (Yemen's largest port)  As part of the U N -brokered deal (known as the Stockholm Agreement), the coalition and the Houthis agreed to redeploy their forces outside Hudaydah city and port  The United Nations agreed to chair a Redeployment Coordination Committee (RCC) to monitor the cease-fire and redeployment  The international community praised the Stockholm Agreement as a first step toward broader de-escalation and a possible road map to a comprehensive peace settlement  Also on December 13, 2018, the Senate amended and passed S J Res  54 (56-41), which, among other things, directed the President to remove U S  forces from hostilities in Yemen, except U S  forces engaged in operations directed at Al Qaeda or associated forces  In the House, lawmakers twice narrowly approved rules resolutions containing provisions that made similar resolutions directing the President to remove U S  forces from hostilities in Yemen ineligible for expedited consideration ( H Res  1142 and H Res  1176 )  On December 13, the Senate also passed S J Res  69 , which, among other things, expresses the sense of the Senate that Saudi Crown Prince Mohammed bin Salman is responsible for the murder of the journalist Jamal Khashoggi and that there is no statutory authorization for United States involvement in hostilities in the Yemen civil war  The 115th Congress frequently debated the extent and terms of the United States' involvement in the ongoing conflict in Yemen  Lawmakers questioned the extent to which successive Administrations have adhered to existing law related to providing security assistance, including sales or transfers of defense goods and defense services, while upholding international human rights standards (e g , 22 U S C  §2754 or 22 U S C  §2304)  They also enacted new legislation that would condition or prohibit the use of U S  funds for some activities related to Yemen and extend legislative oversight over the executive branch's policy toward the war in Yemen  While the House and its Rules Committee voted to make resolutions with respect to war powers and Yemen ineligible for expedited consideration, the Senate passage of S J Res  54 at the conclusion of the 115 th Congress demonstrated growth in congressional opposition to U S  involvement in the Saudi-led coalition intervention in Yemen relative to previous years  Over time, the balance of votes shifted in favor of measures that could be described as critical or restrictive of U S  support for Saudi-led coalition operations with regard to arms sales, oversight measures, and war powers measures  Nevertheless, after nearly four years of conflict, it remains difficult to identify the locus of congressional consensus about Yemen  Many in the House and Senate state that they seek to preserve cooperative U S -Saudi relations in broad terms and express concern about Iranian activities in Yemen, while also expressing support for expanded humanitarian access and efforts to bring the conflict to a close  Some lawmakers express opposition to the intervention and U S  involvement on moral grounds, citing errant coalition airstrikes and the prospect of a looming famine  Others argue the conflict's continuation creates opportunities for Iran and Sunni Islamist extremist groups to expand their influence and operations in Yemen  Still others may have come to oppose continued U S  support for the intervention based on factors not directly related to Yemen itself, including the opaque mechanisms used by the executive branch to support the coalition and/or anger with the Saudi government over the killing of Jamal Khashoggi  It remains to be seen whether recent congressional consideration of Yemen legislation is a harbinger of broader efforts by Members of Congress to reassert congressional prerogatives toward U S  foreign policy writ large  Measures to enhance oversight over U S  support to the Saudi-led coalition and U S  strategy toward Yemen have received broad bipartisan support, while proponents of other recently considered arms sales and war powers measures have used mechanisms to ensure privileged consideration of their proposals  The 116 th Congress may continue to debate U S  support for the Saudi-led coalition and Saudi Arabia's conduct of the war in Yemen  It is uncertain whether lawmakers may also broaden the scope of their oversight activities beyond the current conflict to more fully address the root causes of Yemen's chronic instability  Even if the United States is no longer an active supporter of coalition military efforts, Yemen itself has been devastated by years of war and remains the world's worst humanitarian crisis  Experts expect Yemen to require sustained international attention and financial assistance in order to help local actors reach and sustain a political settlement  This suggests that Congress may grapple with questions about the conduct of U S  diplomacy, the provision of U S  security support, and the investment of U S  assistance and defense funds for years to come 


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

ground_truth: This product provides an overview of the role Congress has played in shaping U.S. policy toward the conflict in Yemen. Summary tables provide information on legislative proposals considered in the 115th and 116th Congresses. Various legislative proposals have reflected a range of congressional perspectives and priorities, including with regard to the authorization of the activities of the U.S. Armed Forces related to the conflict; the extent of U.S. logistical, material, advisory, and intelligence support for the coalition led by Saudi Arabia; the approval, disapproval, or conditioning of U.S. arms sales to Saudi Arabia; the appropriation of funds for U.S. operations in support of the Saudi-led coalition; the conduct of the Saudi-led coalition's air campaign and its adherence to international humanitarian law and the laws of armed conflict; the demand for greater humanitarian access to Yemen; the call for a wider government assessment of U.S. policy toward Yemen and U.S. support to parties to the conflict; the nature and extent of U.S.-Saudi counterterrorism and border security cooperation; and the role of Iran in supplying missile technology and other weapons to the forces of the Houthi movement. The 116th Congress may continue to debate U.S. support for the Saudi-led coalition and Saudi Arabia's conduct of the war in Yemen, where fighting has continued since March 2015. The war has exacerbated a humanitarian crisis in Yemen that began in 2011; presently, the World Food Program reports that 20 million Yemenis face hunger in the absence of sustained food assistance. The difficulty of accessing certain areas of Yemen has made it hard for governments and aid agencies to count the war's casualties. Data collected by the U.S. and European-funded Armed Conflict Location & Event Data Project (ACLED) suggest that 60,000 Yemenis have been killed since January 2016. The Trump Administration has opposed various congressional proposals, including initiatives to reject or condition proposed U.S. arms sales or to require an end to U.S. military support to Saudi-led coalition operations in Yemen. Many in Congress have condemned the October 2018 murder of Saudi journalist Jamal Khashoggi by Saudi government personnel, and in general, the incident appears to have exacerbated existing congressional concerns about Saudi leaders and the pace, scope, and direction of change in the kingdom's policies. This product includes legislative proposals considered during the 115th and 116th Congresses. It does not include references to Yemen in Iran sanctions legislation, which are covered in CRS Report RS20871, Iran Sanctions. For additional information on the war in Yemen and Saudi Arabia, please see the following CRS products. CRS Report R43960, Yemen: Civil War and Regional Intervention. CRS Report RL33533, Saudi Arabia: Background and U.S. Relations. CRS Insight IN10729, Yemen: Cholera Outbreak.

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



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



Report 2:  In addition, HHS has data that could be useful for tracking progress in these areas (see table 1)  However, HHS has not adopted specific performance measures with targets specifying the magnitude of the increases HHS hopes to achieve through its efforts to expand access to MAT, and by when  For example, HHS has not established a long-term target specifying the percentage increase in the number of prescriptions for buprenorphine HHS would like to achieve, which would help to show whether efforts by HHS and others are resulting in sufficient progress in increasing prescriptions for this MAT medication  HHS has also not chosen a specific method of measuring treatment capacity or established targets associated with it, which would help to show whether a sufficient number of providers are becoming available to evaluate and treat patients who may benefit from MAT  Without specifying these performance measures and associated targets, HHS will not have an effective means to determine whether its efforts are helping to expand access to MAT  The lack of such performance measures with associated targets is inconsistent with federal internal control standards that specify that management should define objectives and evaluate results  According to these standards, using performance information such as performance measures can help agencies monitor results and determine progress in meeting program goals  In the context of HHS’s efforts to expand access to MAT, establishing appropriate performance measures with associated targets would allow HHS to determine whether its efforts are making sufficient progress or whether they need to be improved  Gauging this progress is particularly important, given the large nationwide MAT treatment gap identified in 2015 between the total number of individuals who could benefit from MAT and the limited number who can access it based on provider availability  This gap was estimated at nearly 1 million people as of 2012, and according to HHS officials and other stakeholders, lack of providers continues to be a challenge  Until HHS establishes performance measures with associated targets for the factors related to access to MAT, the department will be unable to evaluate its progress expanding access to MAT for opioid use disorders  In addition, as of August 2017, HHS has not finalized its approach for the planned evaluation activities, including timeframes  ASPE officials said that timeframes for a finalized evaluation approach had not been established because they were still working with RTI to finalize the evaluation approach given the new leadership priorities  When we spoke with the officials, they provided us with a draft evaluation schedule that covered the contract period ending September 2018  As of October 2017, HHS had not provided a finalized evaluation approach or schedule  Federal internal controls call for management to establish and operate monitoring activities and evaluate results  Without an implementation timeframe for the evaluation’s activities, HHS increases the risk that its evaluation of its agencies’ efforts will not be completed as expeditiously as possible, including an evaluation of HHS’s efforts to expand access to MAT  Officials from selected state health departments and behavioral health agencies, private health insurers, and national associations reported using several different efforts to help expand patients’ access to MAT for opioid use disorders  All of the stakeholders we interviewed reported conducting outreach efforts to communicate information about the importance of MAT and how to access it, or providing training to educate providers on prescribing MAT medications  Efforts by states  State health officials we spoke to described several planned or ongoing efforts to expand access to MAT, some of which are supported by federal funding, including federal grant programs  Officials from all five selected states told us that they are offering outreach to and training for providers to help expand access to MAT  For example, several state officials told us that they are promoting training to (1) encourage physicians to obtain authorization (DATA 2000 waivers) to prescribe buprenorphine and (2) encourage physicians with waivers to treat patients up to their patient limit or to request a higher patient limit  According to the stakeholders, all five selected states have implemented or are planning to implement a health care delivery model or approach that will expand access to MAT  Specifically, these models or approaches focus on integrating the use of MAT into primary care settings  For example, health officials from three states described use of a hub-and-spoke model  This model generally involves centralized intake and initial management of patients at a “hub” (e g , an OTP) and then connecting these patients to community providers at “spokes” (e g , primary care clinics) for ongoing care, with ongoing support provided by the hub as needed  Additionally, officials from two states described offering remote MAT-related consultations through telehealth that connects patients in rural areas with addiction specialists  According to a 2017 Healthcare Fraud Prevention and Partnership whitepaper, telehealth expands the reach of the addiction professional workforce and the existing pool of MAT providers, and it supports remote forms of behavioral therapy to make trained professionals more accessible to those in underserved or isolated communities  Officials from three states described focusing their MAT expansion efforts in various settings, such as in the criminal justice setting and emergency room departments  State health officials from four of the five states told us that programs in their states are using peer specialists (individuals who have successfully recovered from substance abuse disorders) in emergency rooms and other settings to engage with addicted patients and refer them to addiction specialists or behavioral health counselors  Officials from the selected states said that some of these and other efforts are funded through federal sources, such as MAT expansion grants awarded by SAMHSA, or with state funds to the extent they are available  Efforts by private health insurers  Officials from private health insurers reported that they are expanding access to MAT through outreach or training for providers and through the following three efforts: Eliminating the need for prior authorization to prescribe MAT medications  Officials from three insurers reported removing prior authorization requirements for MAT medications, thereby making it easier for patients to access needed MAT medications more readily, rather than undergoing a waiting period for approval to receive the medications  Other private health insurers told us that they continue to require prior authorization, intended for safety reasons and to reduce drug misuse, and officials from one insurer told us that they will allow a patient to access a limited amount of MAT medications for a period of 24 to 72 hours while making a determination about the appropriate treatment services for the patient  Modifying health benefit coverage  Officials from one private health insurance plan told us that the company is redesigning the benefit coverage for methadone and has removed member copays  This effort is intended to make MAT medications more affordable and allow members who are not able to use buprenorphine to have an alternative, such as methadone, that is not cost-prohibitive  Incentivizing providers and health insurance plan members to use MAT  Officials from four private health insurance plans described plans to offer incentives to providers or patients to use MAT  For example, officials from three health plans stated that they are offering alternative payment models or paying higher rates to providers that offer MAT, and another private health insurer is offering incentives to its members who are enrolled in behavioral health programs that provide access to MAT  Efforts by national associations  Officials we interviewed from the national associations—including the American Society of Addiction Medicine, the National Governors Association, and the Association of State and Territorial Health Officials—told us that they are helping to expand access to MAT through outreach and training for their members and by developing tools and resource guides for their members  An official from one association told us that it shares federal grant announcements, including those that are focused on expanding access to MAT, with its members  Officials from another association said it provides training to providers on how to appropriately prescribe MAT medications  In addition, officials from one association told us that they developed an opioid-related road map that identifies examples of strategies—including MAT—that state policymakers can use in their ongoing efforts to address the opioid epidemic  Examples of strategies include reducing the stigma associated with MAT through educating the public and potential providers  Another strategy in the road map is changing payment policies to expand access to MAT services, such as ensuring that Medicaid and other state health programs adequately cover all MAT medications and behavioral interventions and encouraging or requiring commercial health plans to adopt similar policies  HHS funds grant programs and has taken other steps to expand access to MAT, which has been shown to be effective in reducing the prevalence of opioid use disorders and with them, the likelihood of drug overdoses  HHS’s Opioid Initiative began in 2015, and the grants that support it are ongoing, so it is likely too early to determine how effective HHS’s efforts have been in expanding access to MAT and in meeting HHS’s other priorities related to addressing the opioid epidemic  According to HHS, access to MAT can be measured in terms of the number of prescriptions for MAT and by the treatment capacities of OTPs and practitioners who are authorized to prescribe buprenorphine  Our review suggests, however, that HHS may not be ready to perform this evaluation  While HHS told us that it may evaluate the effectiveness of its efforts in the future, the department has not established performance measures with targets that would specify the results that HHS hopes to achieve through its efforts, and by when  Furthermore, HHS has not established timeframes for the activities that will make up its planned evaluation of whether HHS’s efforts have been implemented as intended  Without performance measures with targets and evaluation timeframes, HHS increases the risk that the evaluation will not be completed in a timely manner or that HHS will not know whether its MAT- related efforts are successful or whether new approaches are needed  The evaluation is particularly important, given the hundreds of millions of dollars HHS has invested in its MAT-related grant programs  We are making the following two recommendations to HHS  The Assistant Secretary for Planning and Evaluation should establish performance measures with targets related to expanding access to MAT for opioid use disorders  (Recommendation 1) The Assistant Secretary for Planning and Evaluation should establish timeframes in its evaluation approach that specify when its evaluation of efforts to expand access to MAT will be implemented and completed  (Recommendation 2) We provided a draft of this report to HHS for review, and HHS provided written comments, which are reprinted in appendix II  HHS also provided technical comments, which we incorporated as appropriate  In its written comments, HHS concurred with both of our recommendations  Specifically, for our first recommendation to establish performance measures with targets related to expanding access to MAT for opioid use disorders, HHS stated that developing such measures is appropriate and that the department will continue to work to develop robust performance measures, including measures related to MAT, as part of its overall Opioid Strategy, which includes the department’s most recent efforts to address the opioid epidemic  For our second recommendation to establish timeframes in its evaluation approach that specify when its evaluation of efforts to expand access to MAT will be implemented and completed, HHS agreed that timeframes are important to any evaluation  HHS noted that its evaluation is being conducted under a 2-year contract that is scheduled to end in September 2018  HHS has also provided us with a draft evaluation schedule  We clarified in our report, however, that HHS has not yet provided a finalized approach for the planned evaluation or a finalized schedule establishing timeframes for the activities that will make up the evaluation  Until it finalizes its evaluation approach and establishes related timeframes, HHS increases the risk that it will not complete its planned evaluation by September 2018  We are sending copies of this report to the HHS, and appropriate congressional committees  In addition, the report will be available at no charge on the GAO website at http://www gao gov  If you or your staff have questions about this report, please contact me at (202) 512-7114 or curdae@gao gov  Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report  Major contributors to this report are listed in appendix III  According to the Department of Health and Human Services, a diversion control plan is a set of documented procedures intended to reduce the possibility that controlled substances will be transferred or used illicitly  Opioid treatment programs (OTPs) and practitioners who prescribe buprenorphine at the highest patient level through a Drug Addiction Treatment Act of 2000 (DATA 2000) waiver are required to have these plans  OTPs are programs that may administer or dispense medication- assisted treatment (MAT) for people diagnosed with an opioid use disorder, including the use of methadone and buprenorphine  In addition, under a DATA 2000 waiver, practitioners may prescribe buprenorphine for patients, up to a 30-, 100-, or 275 patient limit  An OTP must maintain a current diversion control plan that contains specific measures to reduce the possibility of diversion of controlled substances from legitimate treatment use  Per federal guidelines, the goal of the diversion control plan is to reduce the scope and significance of diversion and its impact on communities  The guidelines state that each OTP’s diversion control plan should make every effort to balance diversion control against the therapeutic needs of the individual patient  They also state that diversion control plans should address at least four general areas of concern: program environment, dosing and take-home medication, prevention of multiple program enrollment, and prescription medication misuse  The guidelines include details about each of these areas: Program environment: Diversion in the program environment can be deterred and detected by regular surveillance and the monitoring of areas in and around the program, where opportunities for diversion may exist  A visible human presence at a program’s location gives community members the opportunity to approach staff with concerns and communicates the program’s commitment to assuring a safe environment and a positive impact on the surrounding community  Dosing and take-home medication: In the area of dosing and take- home medication, diversion control encompasses careful control of inventory, attentive patient dosing, and close supervision of take- home medication  Observing a patient take his or her dose and having each of them drink and speak after dosing are fundamental components of diversion control  Take-home dosing should be provided with careful attention to regulatory compliance and the therapeutic benefit and safety these regulations are meant to promote  Prevention of multiple program enrollment: Reasonable measures should be taken to prevent patients from enrolling in treatment provided by more than one clinic or individual practitioner  An OTP, after obtaining patient consent, may contact other OTPs within a reasonable geographic distance (100 miles) to verify that a patient is not enrolled in another OTP  Misuse of prescription medication: The misuse of prescription medication has become an area of great concern nationally and impacts diversion control planning at OTPs  All OTP physicians and other healthcare providers, as permitted, should register to use their respective state’s prescription drug monitoring program (PDMP) and query it for each newly admitted patient prior to initiating dosing  The PDMP should be checked periodically (for example, quarterly) through the course of each individual’s treatment and, in particular, before ordering take-home doses as well as at other important clinical decision points  SAMHSA’s best-practice guidelines for using buprenorphine for treating opioid use disorders include multiple references to diversion, including monitoring for diversion, storage of this medication to minimize diversion, and use of formulations that may be less likely to be diverted  Specifically, the best practices state that, when possible, practitioners should use the combination buprenorphine/naloxone product, which increases safety and decreases the likelihood of diversion and misuse  Further, physicians who request and receive a waiver to prescribe buprenorphine to treat up to 275 patients outside of an OTP are required to have a diversion control plan  According to an HHS official, as of July 13, 2017, roughly 3,330 of the over 39,000 practitioners with a waiver had a 275-patient limit waiver  The majority of these practitioners, just over 27,000, have a 30-patient limit  According to SAMHSA guidance, the diversion plan should contain specific measures to reduce the possibility of diversion of buprenorphine from legitimate treatment use and should assign specific responsibilities of the medical and administrative staff of the practice setting for carrying out these measures  Further, the guidance states that the plan should address how: the environment at the practice setting can prevent onsite diversion; to prevent diversion with regard to dosing and take-home medication; and to prevent patients from receiving a prescription from more than one practitioner and later diverting some of the prescribed medication  Elizabeth H  Curda, Director, (202) 512-7114 or curdae@gao gov  In addition to the contact name above, Will Simerl, Assistant Director; Natalie Herzog, Analyst-in-Charge; La Sherri Bush; and Emily Wilson made key contributions to this report  Also contributing were Muriel Brown, Krister Friday, Sandra George, and Christina Ritchie 
Report 2:  As part of this exercise, the Secret Service also compared its employee work-life offerings (e g , on-site childcare and telework program) to those available at other agencies  In addition, the Secret Service developed and implemented action plans for improving employee morale  Among these action plans, for example, the component implemented a student loan repayment program and expanded its tuition assistance program’s eligibility requirements  Establish and track metrics of success for improving employee morale, and report to agency leadership on progress improving morale—fully implemented  The Secret Service tracked metrics for improving employee morale and reported the results to leadership  For example, the component tracked metrics on the percentage of the workforce, including IT staff, that participated in the student loan repayment and tuition assistance programs  In addition, the Chief Strategy Officer reported to the Chief Operating Officer the results related to meeting those metrics  Maintain leadership support and commitment to ensure continued progress in improving employee morale, and demonstrate sustained improvement in morale—partly implemented  Secret Service leadership developed and implemented initiatives that demonstrated their commitment to improving the morale of the Secret Service’s workforce  For example, since 2014, the Secret Service had worked with a contractor to identify ways to improve the morale of its entire workforce, including IT staff  However, as of June 2018, the Secret Service was unable to demonstrate that it had sustained improvement in the morale of the component’s IT staff  In particular, the component was only able to provide IT workforce-specific results from one employee morale assessment that was conducted subsequent to the consolidation of this workforce into OCIO in March 2017  These results were from an assessment conducted by the component’s Inspection Division in December 2017 (the assessment found that the majority of the Secret Service’s IT employees rated their morale as “very good” or “excellent ”) While the component also provided certain employee morale results from the Office of Personnel Management’s Federal Employee Viewpoint Survey in 2017, these results were not specific to the IT workforce  Instead, this workforce’s results were combined with those from staff in another Secret Service division  According to OCIO officials, the results were combined because, at the time of the survey, the IT workforce was administratively identified as being part of that other division  OCIO officials stated that, going forward, they plan to continue to assess the morale of the IT workforce on an annual basis as part of the Federal Employee Viewpoint Survey  In addition, the officials stated that OCIO-specific results may be available as part of the 2018 survey results, which the officials expect to receive by September 2018  By measuring employee satisfaction on an annual basis, the Secret Service should have increased knowledge of whether its initiatives that are aimed at improving employee morale are in fact increasing employee satisfaction  Agencies can use performance management systems as a tool to foster a results-oriented organizational culture that links individual performance to organizational goals  We have previously identified numerous leading practices related to performance management that are intended to enhance performance and ensure individual accountability  Among the performance management practices, agencies should (1) establish a performance management system that differentiates levels of staff performance and defines competencies in order to provide a fuller assessment of performance, (2) explicitly align individual performance expectations with organizational goals to help individuals see the connection between their daily activities and organizational goals, and (3) periodically provide individuals with regular performance feedback  The Secret Service substantially implemented the selected three leading practices associated with the performance management workforce area  Specifically, the component fully implemented one of the three practices and partly implemented the other two practices  Table 12 lists these selected leading practices and provides our assessment of the Secret Service’s implementation of the practices  Establish a performance management system that differentiates levels of staff performance and defines competencies in order to provide a fuller assessment of performance—partly implemented  The Secret Service’s performance management process requires leadership to make meaningful distinctions between levels of staff performance  In particular, the component’s performance plans for IT staff, which are developed by the Office of Human Resources and tailored by OCIO, as necessary, specify the criteria that leadership use to determine if an individual has met or exceeded the expectations associated with each competency identified in their respective performance plan  The performance plans include pre-established, department-wide competencies that are set by DHS, as well as occupational series-specific goals that may be updated by the Secret Service  However, because OCIO did not fully define and document all of its technical competency needs for the IT workforce, as discussed earlier, the Secret Service’s performance plans for IT staff did not include performance expectations related to the full set of technical competencies required for their respective positions  In addition, because OCIO officials were unable to specify a time frame for when they will identify all of the technical competency needs for the IT workforce (as previously discussed), the officials were also unable to specify a time frame for when they would update the IT workforce’s performance plans to include those relevant technical competencies  Until OCIO updates the performance plans for each occupational series within the IT workforce to include the relevant technical competencies, once identified, against which IT staff performance should be assessed, the office will be limited in its ability to provide IT staff with a complete assessment of their performance  In addition, Secret Service management will have limited knowledge of the extent to which IT staff are meeting all relevant technical competencies  Explicitly align individual performance expectations with organizational goals to help individuals see the connection between their daily activities and organizational goals—partly implemented  The Secret Service’s performance plans for IT staff identified certain goals that appeared to be related to organizational goals and objectives  For example, the performance plan for the Telecommunications Specialist occupational series (which is one of the series included in OCIO’s IT workforce) identified a goal for staff to support the voice, wireless, radio, satellite, and video systems serving the Secret Service’s protective and investigative mission  This performance plan goal appeared to be related to the component’s strategic goal on Advanced Technology, which included an objective to create the infrastructure needed to fulfill mission responsibilities  However, the Secret Service was unable to provide documentation that explicitly showed how individual employee performance links to organizational goals, such as a mapping of the goals identified in employee performance plans to organizational goals  Specifically, while Office of Human Resources officials stated that each Secret Service directorate is responsible for ensuring that employee goals map to high-level organizational goals, OCIO officials stated that they did not complete this mapping  The officials were unable to explain why they did not align the goals in their employees’ performance plans to the component’s high-level goals  According to the officials, the Secret Service is in the process of implementing a new automated tool that will require each office to explicitly align individual performance expectations to organizational goals  The officials stated that OCIO plans to use this tool to create employees’ fiscal year 2019 performance plans  By explicitly demonstrating how individual performance expectations align with organizational goals, the Secret Service’s IT staff should have a better understanding of how their daily activities contribute towards achieving the Secret Service’s goals  Periodically provide individuals with regular performance feedback—fully implemented  Secret Service leadership periodically provided their IT staff with performance feedback  Specifically, on an annual basis, OCIO staff received feedback during a mid-year and end-of-year performance feedback assessment  In our prior work, we have stressed that candid and constructive feedback can help individuals maximize their contribution and potential for understanding and realizing the goals and objectives of an organization  Further, this feedback is one of the strongest drivers of employee engagement  According to leading practices of the Software Engineering Institute, effective program oversight includes monitoring program performance and conducting reviews at predetermined checkpoints or milestones  This is done by, among other things, comparing actual cost, schedule, and performance data with estimates in the program plan and identifying significant deviations from established targets or thresholds for acceptable performance levels  In addition, the Software Engineering Institute previously identified leading practices for effectively monitoring the performance of agile projects  According to the Institute, agile development methods focus on delivering usable, working software frequently; as such, it is important to measure the value delivered during each iteration of these projects  To that end, the Institute reported that agile projects should be measured on velocity (i e , number of story points completed per sprint or release), development progression (e g , the number of user stories planned and accepted), product quality (e g , number of defects), and post-deployment user satisfaction  DHS and the Secret Service had fully implemented the selected leading practice for monitoring the performance of one program and three projects within the IITT investment, and conducting reviews of this program and these projects at predetermined checkpoints  In addition, with regard to the selected leading practice for monitoring agile projects, the Secret Service had fully implemented this practice for one of its two projects being implemented using agile and had partially implemented this practice for the other project  Table 13 provides a summary of DHS’s and the Secret Service’s implementation of these leading practices, as relevant for one program and three projects within IITT  Monitor program performance and conduct reviews at predetermined checkpoints or milestones  Consistent with leading practices, DHS and the Secret Service monitored the performance of IITT’s program and projects by comparing actual cost, schedule, and performance information against planned targets and conducting reviews at predetermined checkpoints  For example, within the Secret Service: The Enabling Capabilities program and Multi-Level Security project monitored their contractors’ costs spent to-date on a monthly basis and compared them to the total contract amounts  OCIO used integrated master schedules to monitor the schedule performance of the Enabling Capabilities program and Multi-Level Security project  OCIO also monitored the cost, schedule, and performance of the Uniformed Division Resource Management System and Events Management projects during monthly status reviews  In addition, DHS and the Secret Service conducted acquisition decision event reviews and systems engineering life cycle technical reviews of IITT’s program and projects at predetermined checkpoints and, when applicable, identified deviations from established cost, schedule, and performance targets  For example: Secret Service OCIO met with DHS’s Office of Program Accountability and Risk Management in February 2017, and with DHS’s Acting Under Secretary for Management in June 2017, to discuss a schedule breach for the Enabling Capabilities program  In particular, the Enabling Capabilities program informed DHS that the program needed to change the planned date for acquisition decision event 3 (the point at which a decision is made to fully deploy the system) in order to conduct tests in an operational environment prior to that decision event  This delay was due to the Secret Service misunderstanding the tests that it was required to conduct prior to that decision event  Specifically, the Enabling Capabilities program had conducted tests on “production representative” systems, but these tests were not sufficient to meet the requirements for acquisition decision event 3  The project team for Multi-Level Security identified that certain technical issues they had experienced would delay system deployment and full operational capability (the point at which an investment becomes fully operational)  As such, in October 2017, the project notified the Secret Service Component Acquisition Executive of these expected delays  In particular, the web browser that was intended to provide users on “Sensitive But Unclassified” workstations the ability to view information from different security levels, experienced technical delays in meeting personal identity verification requirements  The project team also described for the executive how the schedule delay would affect the project’s performance metrics and funding, and subsequently updated the project plan accordingly  Measure and monitor agile projects on, among other things, velocity (i e , number of story points completed per sprint or release), development progression (e g , the number of features and user stories planned and accepted), product quality (e g , number of defects), and post-deployment user satisfaction  Secret Service OCIO measured its two agile projects—Uniformed Division Resource Management System and Events Management— using certain agile metrics  In particular, OCIO officials measured the Uniformed Division Resource Management System and Events Management projects using key metrics related to velocity and development progression  For example, the officials measured development progression for both projects on a daily basis  In addition, OCIO officials monitored each project’s progress against these metrics during bi-weekly reviews that they conducted with each project team  The OCIO officials also tracked product quality metrics for the Uniformed Division Resource Management System  For example, on a monthly basis, the officials tracked the number of helpdesk tickets that had been resolved related to the system  In addition, on a quarterly basis, they tracked the number of Uniformed Division Resource Management System defects that (1) had been fixed and (2) were in the backlog  However, while OCIO officials received certain post-deployment user satisfaction information from end-users of the Uniformed Division Resource Management System by, among other things, tracking the number of helpdesk tickets related to the system and via daily verbal, undocumented feedback from certain Uniformed Division officers, OCIO officials had not fully measured and documented post- deployment user satisfaction with the system, such as via a survey of employees who use the system  The officials stated that they had not conducted and documented a survey because they were focused on (1) addressing software performance issues that occurred after they deployed the system to a limited number of users, and (2) continuing system deployment to the remaining users after they addressed the performance issues  OCIO officials stated that they plan to conduct such a documented survey by the end of September 2018  The results of the user satisfaction survey should provide OCIO with important information on whether the Uniformed Division Resource Management System is meeting users’ needs  The Secret Service’s full implementation of 11 of 14 component-level CIO responsibilities constitutes a significant effort to establish CIO oversight for the component’s IT portfolio  Additional efforts to fully implement the remaining 3 responsibilities, including ensuring that all IT contracts are reviewed, as appropriate; ensuring that the Secret Service’s enterprise governance policy appropriately specifies the CIO’s role in developing and reviewing the component’s IT budget formulation and execution; and ensuring agile projects measure product quality and post-deployment user satisfaction, will further position the CIO to effectively manage the Secret Service’s IT portfolio  When effectively implemented, IT workforce planning and management activities can facilitate the successful accomplishment of an agency’s mission  However, the Secret Service had not fully implemented all of the 15 selected practices for its IT workforce for any of the five areas— strategic planning, recruitment and hiring, training and development, employee morale, and performance management  The Secret Service’s lack of (1) a strategic workforce planning process, including the identification of all required knowledge and skills, assessment of competency gaps, and targeted strategies to address specific gaps in competencies and staffing; (2) targeted recruiting activities, including metrics to monitor the effectiveness of the recruitment program and adjustment of the recruitment program and hiring efforts based on metrics; (3) a training program, including the identification of required training for IT staff, ensuring that staff take required training, and assessment of performance data regarding the training program; and (4) a performance management system that includes all relevant technical competencies, greatly limits its ability to ensure the timely and effective acquisition and maintenance of the Secret Service’s IT infrastructure and services  On the other hand, by monitoring program performance and conducting reviews at predetermined checkpoints for one program and three projects associated with the IITT investment, in accordance with leading practices, the Secret Service and DHS provided important oversight needed to guide that program and those projects  Measuring projects on leading agile metrics also provided the Secret Service CIO with important information on project performance  We are making the following 13 recommendations to the Director of the Secret Service: The Director should ensure that the CIO establishes and documents an IT acquisition review process that ensures the CIO or the CIO’s delegate reviews all contracts containing IT, as appropriate  (Recommendation 1) The Director should update the enterprise governance policy to specify (1) the CIO’s current role and responsibilities on the Executive Resources Board, to include developing and reviewing the IT budget formulation and execution; and (2) the Deputy CIO’s role and responsibilities on the Enterprise Governance Council  (Recommendation 2) The Director should ensure that the Secret Service develops a charter for its Executive Resources Board that specifies the roles and responsibilities of all board members, including the CIO  (Recommendation 3) The Director should ensure that the CIO includes product quality and post-deployment user satisfaction metrics in the modular outcomes and target measures that the CIO sets for monitoring agile projects  (Recommendation 4) The Director should ensure that the CIO identifies all of the required knowledge and skills for the IT workforce  (Recommendation 5) The Director should ensure that the CIO regularly analyzes the IT workforce to identify its competency needs and any gaps it may have  (Recommendation 6) The Director should ensure that, after OCIO completes an analysis of the IT workforce to identify any competency and staffing gaps it may have, the Secret Service updates its recruiting and hiring strategies and plans to address those gaps, as necessary  (Recommendation 7) The Director should ensure that the Office of Human Resources (1) develops and tracks metrics to monitor the effectiveness of the Secret Service’s recruitment activities for the IT workforce, including their effectiveness at addressing skill and staffing gaps; and (2) reports to component leadership on those metrics  (Recommendation 8) The Director should ensure that the Office of Human Resources and OCIO adjust their recruitment and hiring plans and activities, as necessary, after establishing and tracking metrics for assessing the effectiveness of these activities for the IT workforce  (Recommendation 9) The Director should ensure that the CIO (1) defines the required training for each IT workforce group, (2) determines the activities that OCIO will include in its IT workforce training and development program based on its available training budget, and (3) implements those activities  (Recommendation 10) The Director should ensure that the CIO ensures that the IT workforce completes training specific to their positions (after defining the training required for each workforce group)  (Recommendation 11) The Director should ensure that the CIO collects and assesses performance data (including qualitative or quantitative measures, as appropriate) to determine how the IT training program contributes to improved performance and results (once the training program is implemented)  (Recommendation 12) The Director should ensure that the CIO updates the performance plans for each occupational series within the IT workforce to include the relevant technical competencies, once identified, against which IT staff performance should be assessed  (Recommendation 13) DHS provided written comments on a draft of this report, which are reprinted in appendix III  In its comments, the department concurred with all 13 of our recommendations and provided estimated completion dates for implementing each of them  For example, with regard to recommendation 2, the department stated that the Secret Service would update its enterprise governance policy and related policies to outline the roles and responsibilities of the CIO and Deputy CIO, among others, by March 31, 2019  In addition, for recommendation 13, the department stated that the Secret Service OCIO will include relevant technical competencies in performance plans, as appropriate, in the next performance cycle that starts in July 2019  If implemented effectively, these actions should address the weaknesses we identified  The department also identified a number of other actions that it said had been taken to address our recommendations  For example, in response to recommendation 8, which calls for the Office of Human Resources to (1) develop and track metrics to monitor the effectiveness of the Secret Service’s recruitment activities for the IT workforce and (2) report to component leadership on those metrics, DHS stated that the Secret Service’s Office of Human Resources’ Outreach Branch provides to the department metrics on recruitment efforts toward designated priority mission-critical occupations  However, for fiscal year 2017, only 1 of the 12 occupational series associated with the Secret Service’s IT workforce was designated as a mission-critical occupation for the component (i e , the 2210 IT Specialist series)  The 11 other occupational series were not designated as mission- critical occupations  In addition, for fiscal year 2018, none of these 12 occupational series were designated as mission-critical occupations  As such, metrics on recruiting for these IT series may not have been reported to DHS leadership  Moreover, while we requested documentation of the recruiting metrics for the Secret Service’s IT workforce and, during the course of our review, had multiple subsequent discussions with the Secret Service regarding such metrics, the component did not provide documentation that demonstrated it had established recruiting metrics for its IT workforce  Tracking such metrics and reporting the results to Secret Service leadership, as we recommended, would provide management with important information necessary to make effective recruitment decisions  Further, in response to recommendation 10, which among other things, calls for the CIO to define the required training for each IT workforce group, the department stated that the Secret Service OCIO recently developed training requirements for each workforce group, which were issued during our audit  However, while during our audit OCIO provided a list of recommended training courses, the office did not identify them as being required courses  Defining training that is required for each IT workforce group, as we recommended, would inform OCIO of the necessary training for each position and enable the office to prioritize this training, to ensure that its staff have the needed knowledge and skills  In addition to the aforementioned comments, we received technical comments from DHS and Secret Service officials, which we incorporated, as appropriate  We are sending copies of this report to the appropriate congressional committees, the Secretary of Homeland Security, the Director of the Secret Service, and other interested parties  In addition, this report is available at no charge on the GAO website at http://www gao gov  Should you or your staffs have any questions on information discussed in this report, please contact me at (202) 512-4456 or HarrisCC@gao gov  Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report  GAO staff who made major contributions to this report are listed in appendix IV  Our objectives were to evaluate the extent to which: (1) the U S  Secret Service (Secret Service) Chief Information Officer (CIO) has implemented selected information technology (IT) oversight responsibilities, (2) the Secret Service has implemented leading workforce planning and management practices for its IT workforce, and (3) the Secret Service and the Department of Homeland Security (DHS) have implemented selected performance and progress monitoring practices for the Information Integration and Technology Transformation (IITT) investment  To address the first objective, we analyzed DHS’s policies and guidance on IT management to identify the responsibilities that were to be implemented by the component-level CIO related to overseeing the Secret Service’s IT portfolio, including existing systems, acquisitions, and investments  From the list of 33 responsibilities that we identified, we then excluded the responsibility that was associated with information security, which is expected to be addressed as part of a separate, subsequent GAO review  We also excluded those responsibilities that were significantly large in scope (e g , implement an enterprise architecture) or that, in our professional judgment, lacked specificity (e g , provide timely delivery of mission IT services)  As a result, we excluded from consideration for this review a total of 10 CIO responsibilities  For the 23 that remained, we then combined certain responsibilities that overlapped with other related responsibilities  For example, we combined related responsibilities on the component CIO’s review of IT contracts  As a result, we identified 14 responsibilities for review  We validated with the acting DHS CIO that these responsibilities were key responsibilities for the department’s component-level CIOs  We then included all 14 of the responsibilities in our review  The 14 selected component-level CIO responsibilities were: 1  Develop and review the component IT budget formulation and execution  2  Manage the component IT investment portfolio, including establishing an IT acquisition review process that enables component and DHS review of component acquisitions (i e , contracts) that contain IT  3  Develop, implement, and maintain a detailed IT strategic plan  4  Ensure all component IT policies are in compliance and alignment with DHS IT directives and instructions  5  Concur with each program’s and/or project’s systems engineering life cycle tailoring plan  6  Support the Component Acquisition Executive to ensure processes are established that enable systems engineering life cycle technical reviews and that they are adhered to by programs and/or projects  7  Ensure that all systems engineering life cycle technical review exit criteria are satisfied for each of the component’s IT programs and/or projects  8  Ensure the necessary systems engineering life cycle activities have been satisfactorily completed as planned for each of the component’s IT programs and/or projects  9  Concur with the systems engineering life cycle technical review completion letter for each of the component’s IT programs and/or projects  10  Maintain oversight of their component’s agile development approach for IT by appointing the responsible personnel, identifying investments for adoption, and reviewing artifacts  11  With Component Acquisition Executives, evaluate and approve the application of agile development for IT programs consistent with the component’s agile development approach  12  Set modular outcomes and target measures to monitor the progress in achieving agile implementation for IT programs and/or projects within their component  13  Participate on DHS’s CIO Council, Enterprise Architecture Board, or other councils/boards as appropriate, and appoint employees to serve when necessary  14  Meet the IT competency requirements established by the DHS CIO, as required in the component CIO’s performance plan  To determine the extent to which the Secret Service CIO has implemented these responsibilities, we obtained and assessed relevant component documentation and compared it to the responsibilities  Specifically, we obtained and analyzed documentation including evidence of the CIO’s participation on the Secret Service governance board that has final decision authority and responsibility for enterprise governance, including the IT budget; monthly program management reports showing the CIO’s oversight of IT programs, projects, and systems; monthly status reports on program spending; the Secret Service’s IT strategic plan; the Secret Service’s enterprise governance policy; meeting minutes from the DHS board and council on which the CIO participated (i e , the CIO Council and Enterprise Architecture Board); and documentation demonstrating whether the CIO met the IT competency requirements  In addition, we obtained and analyzed relevant documentation related to the CIO’s oversight of the major IT investments on which the Secret Service was spending development, modernization, and enhancement funds during fiscal year 2017  As of July 2017, the component had one investment—IITT—that met this criterion  IITT is a portfolio investment that, as of July 2017, included two programs (one of which included three projects) and one standalone project (i e , it was not part of another program) that had capabilities that were in planning or development and modernization: the Enabling Capabilities program, Enterprise Resource Management System program (which included three projects, called Uniformed Division Resource Management System, Events Management, and Enterprise-wide Scheduling), and Multi-Level Security project  In particular, we obtained and analyzed documentation related to the CIO’s oversight of the systems engineering life cycles for IITT’s Enabling Capabilities program and the Uniformed Division Resource Management System, Events Management, and Multi-Level Security projects  This documentation included acquisition program baselines, systems engineering life cycle tailoring plans, and systems engineering life cycle technical review briefings and completion letters  We then compared the documentation against the five selected systems engineering life cycle oversight responsibilities (responsibilities 5, 6, 7, 8, and 9)  We also obtained and analyzed documentation related to the CIO’s oversight of two projects that the Secret Service was implementing using an agile methodology—Uniformed Division Resource Management System and Events Management  Specifically, we obtained and assessed documentation of (1) the CIO’s approval for these projects to be implemented using an agile methodology and (2) the agile development metrics that the CIO established for each of these projects  We then compared this documentation to the three agile development-related component-level CIO responsibilities (responsibilities 10, 11, and 12)  Further, to determine the extent to which the Secret Service CIO had established an IT acquisition (i e , contract) review process that enabled component and DHS review of component contracts that contain IT (which is part of responsibility 2), we first asked Secret Service officials to provide us with a list of all new, unclassified IT contracts that the component awarded between October 1, 2016, and June 30, 2017  The Secret Service officials provided a list of 54 contracts  We validated that these were contracts for IT or IT services by: (1) searching for them in the Federal Procurement Data System – Next Generation; (2) identifying their associated product or service codes, as reported in that system; and (3) determining whether those codes were included in the universe of 79 IT product or service codes identified by the Category Management Leadership Council  In validating the list of 54 contracts provided by the Secret Service, we determined that 5 of the contracts were not associated with an IT product or service code  As such, we removed those contracts from the list  In addition, we found that three other items identified by the component were not in the Federal Procurement Data System – Next Generation  Secret Service officials subsequently confirmed that these three items were not contracts  We therefore removed these three items from the list  As such, the final list of validated contracts identified by the Secret Service included 46 IT contracts  In addition, to identify any IT contracts that were not included in the list provided by the Secret Service, we conducted a search of the Federal Procurement Data System – Next Generation to identify all unclassified contracts that (1) the component awarded between October 1, 2016, and June 30, 2017; (2) were not a modification of a contract; and (3) were associated with 1 of the 79 IT product or service codes identified by the Category Management Leadership Council  Based on these criteria, we identified 144 Secret Service IT contracts in the Federal Procurement Data System – Next Generation (these 144 contracts included the 46 contracts previously identified by Secret Service officials)  We then asked Secret Service officials to validate the accuracy, completeness, and reliability of these data, which they did  From each of these two lists of IT contracts (i e , the list of 46 IT contracts identified by the Secret Service and the list of 144 IT contracts that we identified from the Federal Procurement Data System – Next Generation), we then selected random, non-generalizable samples of contracts, as described below  First, from the list of 46 IT contracts identified by Secret Service officials, we removed 4 contracts that had total values of less than $10,000  To ensure that we selected across all contract sizes, we randomly selected 12 contracts from the remaining list of 42 contracts, using the following cost ranges: $10,000 to $50,000 (4 contracts), more than $50,000 to less than $250,000 (4 contracts), and more than $250,000 (4 contracts)  Second, from our list of 144 IT contracts that we identified from the Federal Procurement Data System – Next Generation, we removed the 46 contracts identified by Secret Service officials  We also removed 12 contracts that had total values of less than $10,000  To ensure that we selected across all contract sizes, we randomly selected 21 contracts from the remaining list of 86 contracts, using the following cost ranges: $10,000 to $50,000 (7 contracts), more than $50,000 to less than $250,000 (7 contracts), and more than $250,000 (7 contracts)  In total, we selected 33 IT contracts for review  We separated the contracts into the three cost ranges identified above in order to ensure that contracts of different value levels had been selected  This enabled us to determine the extent to which the CIO appropriately reviewed contracts of all values  To determine the extent to which the CIO had established an IT contract approval process that enabled the Secret Service and DHS, as appropriate, to review IT contracts, we first asked Secret Service Office of the CIO (OCIO) officials for documentation of their IT contract approval process  These officials were unable to provide such documentation  Instead, the officials stated that the Secret Service CIO or the CIO’s delegate approves all IT contracts prior to award  The officials also provided documentation that identified four staff to whom the CIO had delegated his approval authority  Further, the officials stated that, in accordance with DHS’s October 2016 IT acquisition review guidance, they submitted to DHS OCIO for approval any IT contracts that met DHS’s thresholds for review, including those that (1) had total estimated procurement values of $2 5 million or more, and (2) were associated with a major investment  Based on the IT acquisition review process that Secret Service OCIO officials described, we then obtained and analyzed each of the 33 selected IT contracts and associated approval documentation to determine whether or not the Secret Service CIO or the CIO’s delegate had approved each of the contracts  In particular, we (1) reviewed the name of the contract approver on the approval documentation, and (2) compared the signature dates that were on the contracts to the signature dates that were identified on the associated approval documentation  In addition, to determine whether or not the Secret Service CIO submitted to DHS OCIO for approval the IT contracts that (1) had total estimated procurement values of $2 5 million or more, and (2) were associated with major investments, we first analyzed the 144 Secret Service IT contracts that we had previously pulled from the Federal Procurement Data System – Next Generation to determine which contracts met the $2 5 million threshold  We identified 4 contracts that met this threshold  We then requested that OCIO identify the levels (i e , major or non-major) of the investments associated with these contracts  According to OCIO officials, 3 of the 4 contracts were associated with non-major investments and 1 was not associated with an investment  As such, based on DHS’s October 2016 IT acquisition review guidance, none of these contracts needed to be submitted to DHS OCIO for review  We also interviewed Secret Service officials, including the CIO and Deputy CIO, regarding the CIO’s implementation of the 14 selected component-level responsibilities  We assessed the evidence against the selected responsibilities to determine the extent to which the CIO had implemented them  To address the second objective—determining the extent to which the Secret Service had implemented leading workforce planning and management practices for its IT workforce—we first identified seven topic areas associated with human capital management based on the following sources: The Office of Personnel Management’s Human Capital Framework  Office of Personnel Management and the Chief Human Capital Officers Council Subcommittee for Hiring and Succession Planning, End-to-End Hiring Initiative  GAO, High-Risk Series: Progress on Many High-Risk Areas, While Substantial Efforts Needed on Others  GAO, IT Workforce: Key Practices Help Ensure Strong Integrated Program Teams; Selected Departments Need to Assess Skill Gaps  GAO, Department of Homeland Security: Taking Further Action to Better Determine Causes of Morale Problems Would Assist in Targeting Action Plans  GAO, Human Capital: A Guide for Assessing Strategic Training and Development Efforts in the Federal Government  GAO, Results-Oriented Cultures: Creating a Clear Linkage between Individual Performance and Organizational Success  DHS acquisition guidance  Secret Service acquisition guidance  Among these topic areas, we then selected five areas that, in our professional judgment, were of particular importance to successful workforce planning and management  They were also previously identified as part of our high-risk and key issues work on human capital management  These areas include: (1) strategic planning, (2) recruitment and hiring, (3) training and development, (4) employee morale, and (5) performance management  We also reviewed these same sources and identified numerous leading practices associated with the five topic areas  Among these leading practices, we then selected three leading practices within each of the five areas (for a total of 15 selected practices)  The selected practices were foundational practices that, in our professional judgment, were of particular importance to successful workforce planning and management  Table 14 identifies the five selected workforce areas and 15 selected associated practices  To determine the extent to which the Secret Service had implemented the selected leading workforce planning and management practices for its IT workforce, we obtained and assessed documentation and compared it against the 15 selected practices  In particular, we analyzed the Secret Service’s human capital strategic plan, human capital staffing plan, IT strategic plan, documentation of the component’s staffing model that it used to determine the number of IT staff needed, an independent verification and validation report on the component’s staffing models, documentation of the current number of IT staff, the Secret Service’s recruitment and outreach plans, documentation of DHS’s hiring authorities (which are applicable to the Secret Service), the Secret Service’s training strategic plan, IT workforce training plan, action plans for improving employee morale, and templates used for measuring and reporting employee performance  We also interviewed Secret Service officials—including the CIO, Deputy CIO, and workforce planning staff—about the component’s workforce- related policies and documentation  Further, we discussed with the officials the Secret Service’s efforts to implement the selected workforce practices for its IT workforce  Regarding our assessments of the Secret Service’s implementation of the 15 selected workforce planning and management practices, we assessed a practice as being fully implemented if component officials provided supporting documentation that demonstrated all aspects of the practice  We assessed a practice as not implemented if the officials did not provide any supporting documentation for that practice, or if the documentation provided did not demonstrate any aspect of the practice  We assessed a practice as being partly implemented if the officials provided supporting documentation that demonstrated some, but not all, aspects of the selected practice  In addition, related to our assessments of the Secret Service’s implementation of the five selected overall workforce areas, we assessed each area as follows, based on the implementation of the three selected practices within each area: Fully implemented: The Secret Service provided evidence that it had fully implemented all three of the selected practices within the workforce area; Substantially implemented: The Secret Service provided evidence that it had either fully implemented two selected practices and partly implemented the remaining one selected practice within the workforce area, or fully implemented one selected practice and partly implemented the remaining two selected practices within the workforce area; Partially implemented: The Secret Service provided evidence that it had partly implemented each of the three selected practices within the workforce area; Minimally implemented: The Secret Service provided evidence that it partly implemented two selected practices and not implemented the remaining one selected practice within the workforce area, or partly implemented one selected practice and not implemented the remaining two selected practices within the workforce area; or Not implemented: The Secret Service did not provide evidence that it had implemented any of the three selected practices within the workforce area  To address the third objective—determining the extent to which the Secret Service and DHS have implemented selected performance and progress monitoring practices for IITT—we reviewed leading project monitoring practices and guidance from the Software Engineering Institute  First, we reviewed the practices within the Project Monitoring and Control process area of the Institute’s Capability Maturity Model Integration® for Acquisition  Based on our review, we identified four practices associated with monitoring program performance and progress  In our professional judgment, all four of these practices were of significance to managing the IITT investment given the phase of the life cycle that the investment was in  As such, we elected to include all four of these practices in our review, and combined them into one practice, as follows: Monitor program performance and conduct reviews at predetermined checkpoints or milestones by, among other things, comparing actual cost, schedule, and performance data with estimates in the program plan and identifying significant deviations from established targets or thresholds for acceptable performance levels  Next, given the agile development methodology that the Secret Service was using for certain projects within IITT, we reviewed the Software Engineering Institute’s technical note on the progress monitoring of agile contractors  Based on our review, and in consultation with an internal expert, we selected four agile metrics that the Institute identified as important for successful agile implementations and that, in our professional judgment, were of most significance to monitoring the performance of IITT’s agile projects  We then combined these four metrics into one practice, as follows: Measure and monitor agile projects on velocity (i e , number of story points completed per sprint or release), development progression (e g , the number of features and user stories planned and accepted), product quality (e g , number of defects), and post-deployment user satisfaction  To determine the extent to which DHS and the Secret Service had implemented the first selected practice, we analyzed relevant program management and governance documentation for IITT’s Enabling Capabilities program, and Multi-Level Security, Uniformed Division Resource Management System, and Events Management projects  In particular, we analyzed acquisition program baselines, DHS acquisition decision event memorandums, artifacts from DHS and Secret Service program oversight reviews, cost monitoring reports, program integrated master schedules, and program status briefings, and compared this documentation to the selected practice  We also interviewed Secret Service OCIO officials regarding the Secret Service’s and DHS’s efforts to monitor the IITT investment’s performance and progress  To determine the extent to which the Secret Service had implemented the second selected practice related to measuring and monitoring agile projects on agile metrics (i e , velocity, development progression, product quality, and post-deployment user satisfaction), we obtained and analyzed agile-related documentation for the two projects that the Secret Service was implementing using an agile methodology—Uniformed Division Resource Management System and Events Management  Specifically, to determine the extent to which the Secret Service was measuring and monitoring these two projects on metrics for velocity and development progression, we obtained and analyzed documentation, such as sprint burndown charts and monthly program status reports, and compared it to the selected practice  In addition, the agile metrics for product quality and post-deployment user satisfaction were only applicable to projects that had been deployed to users  As such, these metrics were applicable to the Uniformed Division Resource Management System (which the Secret Service had deployed to users) and were not applicable to Events Management (which the Secret Service had not yet deployed to users, as of early May 2018)  We therefore obtained and analyzed documentation demonstrating that Secret Service OCIO measured product defects for the Uniformed Division Resource Management System  We also requested documentation demonstrating that OCIO had measured and monitored post-deployment user satisfaction for this project, including via a survey  OCIO officials stated that they had not conducted such a survey and were unable to provide documentation demonstrating they had measured post- deployment user satisfaction for the Uniformed Division Resource Management System  To assess the reliability of the cost, schedule, and agile-related data that were in DHS and the Secret Service’s program management and governance documentation for the IITT investment, we (1) analyzed related documentation and assessed the data against existing agency records to identify consistency in the information, and (2) examined the data for obvious outliers, incomplete, or unusual entries  We determined that the data in these documents were sufficiently reliable for our purpose, which was to evaluate the extent to which DHS and the Secret Service had implemented processes for monitoring the IITT investment’s performance and progress  We conducted this performance audit from May 2017 to November 2018 in accordance with generally accepted government auditing standards  Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives  We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives  As of June 2018, the Secret Service’s Information Integration and Technology Transformation (IITT) investment included two programs (one of which included three projects) and one project that had capabilities that were in planning or development and modernization, as described below: Enabling Capabilities  This program is intended to, among other things, (1) modernize and enhance the Secret Service’s information technology (IT) network infrastructure, including increasing bandwidth and improving the speed and reliability of the Secret Service’s IT system performance; (2) enhance cybersecurity to protect against potential intrusions and viruses; and (3) provide counterintelligence and data mining capabilities to improve officials’ ability to perform the Secret Service’s investigative mission  Enterprise Resource Management System  This program comprises three projects that are intended to provide: a system that will enable the Secret Service’s Uniformed Division to efficiently and effectively plan, provision, and schedule missions (this project is referred to as Uniformed Division Resource Management System), a system that will unify the logistical actions (e g , assigning personnel) surrounding special events that Secret Service agents need to protect, such as the United Nations General Assembly (this project is referred to as Events Management), and a capability for creating schedules for Secret Service agents and administrative, professional, and technical staff, as well as the ability to generate reports on information such as monthly hours worked (this project is referred to as Enterprise-wide Scheduling)  Multi-Level Security  This project is intended to enable authorized Secret Service users to view two levels of classified information on a single workstation  Previously, data at various security levels were contained and used in multiple disparate systems  Multi-Level Security is intended to streamline users’ access to information at different security levels in order to enable them to more quickly and effectively perform their duties  Table 15 provides the planned life cycle cost and schedule estimates (threshold values) for each IITT program and project that had capabilities in planning or development and modernization, as of June 2018  In addition, the table describes any changes in those cost and schedule estimates, as well as the key reasons for any changes, as identified by officials from the Secret Service’s Office of the Chief Information Officer  In addition to the contact named above, the following staff made key contributions to this report: Shannin O’Neill (Assistant Director), Emily Kuhn (Analyst-in-Charge), Quintin Dorsey, Rebecca Eyler, Javier Irizarry, and Paige Teigen 

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