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



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



Report 2: USDA’s Food and Nutrition Service (FNS) is responsible for promulgating SNAP program regulations, ensuring that state officials administer the program in compliance with program rules, and authorizing and monitoring retailers from which recipients may purchase food  States are responsible for determining applicant eligibility, calculating the amount of their benefits, issuing benefits on Electronic Benefit Transfer (EBT) cards—which can be used like debit cards to purchase food from authorized retailers—and investigating possible program violations by recipients  SNAP recipients are subject to various work requirements  Generally, all SNAP recipients ages 16 through 59, unless exempted by law or regulation, must comply with work requirements, including registering for work, reporting to an employer if referred by a state agency, accepting a bona fide offer of a suitable job, not voluntarily quitting a job or reducing work hours below 30 hours a week, and participating in a SNAP E&T program or a workfare program—in which recipients perform work on behalf of the state—if assigned by the state agency  SNAP recipients are generally exempt from complying with these work requirements if they are physically or mentally unfit, responsible for caring for a dependent child under age 6 or an incapacitated person, employed for 30 or more hours per week or receive weekly earnings which equal the minimum hourly rate set under federal law multiplied by 30, or are a bona fide student enrolled half-time or more in any recognized school training program, or institution of higher education, amongst other exemptions  SNAP recipients subject to the work requirements—known as work registrants— may lose their eligibility for benefits if they fail to comply with these requirements without good cause  One segment of the work registrant population, SNAP recipients ages 18 through 49 who are “able-bodied,” not responsible for a dependent child, and do not meet other exemptions—able-bodied adults without dependents (ABAWDs)—are generally subject to additional work requirements  In addition to meeting the general work requirements, ABAWDs must work or participate in a work program 20 hours or more per week, or participate in workfare, in which ABAWDs perform work to earn the value of their SNAP benefits  Participation in SNAP E&T, which is a type of work program, is one way for ABAWDs to meet the 20 hour per week ABAWD work requirement, but other work programs are acceptable as well  Unless ABAWDs meet these work requirements or are determined to be exempt, they are limited to 3 months of SNAP benefits in a 36-month period  At the request of states, FNS may waive the ABAWD time limit for ABAWDs located in certain areas of a state or an entire state under certain circumstances  A waiver may be granted if the area has an unemployment rate of over 10 percent or there are an insufficient number of jobs to provide employment for these individuals  If the time limit is waived, ABAWDs are not required to meet the ABAWD work requirement in order to receive SNAP for more than 3 months in a 36-month period yet they must still comply with the general work requirements  Federal requirements for state SNAP E&T programs were first enacted in 1985 and provide state SNAP agencies with flexibility in how they design their SNAP E&T programs, including who to serve and what services to offer  The state has the option to offer SNAP E&T services on a voluntary basis to some or all SNAP recipients, an approach commonly referred to as a voluntary program  Alternatively, the state can require some or all SNAP work registrants to participate in the SNAP E&T program as a condition of eligibility, an approach commonly referred to as a mandatory program  Further, states determine which service components to provide participants through their SNAP E&T programs, although they must provide at least one from a federally determined list  This list includes job search programs, job search training programs, workfare, programs designed to improve employability through work experience or training, education programs to improve basic skills and employability, job retention services, and programs to improve self-sufficiency through self- employment  Total federal expenditures on SNAP E&T programs were more than $337 million in fiscal year 2016  States are eligible to receive three types of federal funding available for state SNAP E&T programs: 100 percent funds—formula grants for program administration, 50 percent federal reimbursement funds, and ABAWD pledge funds—grants to states that pledge to serve all of their at-risk ABAWDs  The Office of Management and Budget has designated SNAP as a high- priority program due to the estimated dollar amount in improper payments—any payments that should not have been made or were made in an incorrect amount (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements  According to USDA’s fiscal year 2015 agency financial report, $2 6 billion, or 3 66 percent, of all SNAP benefits paid in fiscal year 2014 were improper, the most recent year for which data are available  SNAP improper payments are caused by variances in any of the key factors involved in determining SNAP eligibility and benefit amounts, and, according to USDA, household income was the most common primary cause of dollar errors  States review the accuracy of SNAP payments to recipients on an ongoing basis, and FNS assesses the accuracy of state reviews and determines a national improper payment rate annually  FNS and states share responsibility for addressing SNAP fraud, which can occur through the eligibility process and when benefits are being used  Specifically, recipients may commit eligibility fraud when they misrepresent their household size, income, or expenses in order to fraudulently obtain SNAP benefits  Another type of fraud—trafficking— occurs when recipients exchange benefits with authorized retailers or other individuals for cash or non-food items (e g  rent or transportation)  In a typical retailer trafficking situation, for example, a retailer may charge $100 to a recipient’s EBT card and give the recipient $50 in cash instead of $100 in food  The federal government reimburses the retailer $100, which results in a fraudulent $50 profit to the retailer  State agencies are directly responsible for preventing, detecting, investigating, and prosecuting recipient fraud, including eligibility fraud and trafficking by SNAP recipients, under the oversight and guidance of FNS  States play a key role in preventing fraud when determining eligibility for SNAP  State agencies collect applicant information, such as household income and employment, and verify it through data matches with other information sources  After benefits are issued, the agencies may monitor EBT transaction data to identify spending patterns that may indicate trafficking  If an individual or household intentionally violates SNAP rules, such as by trafficking or making false or misleading statements in order to obtain benefits, states conduct administrative disqualification hearings or, in some cases, refer the case for criminal prosecution  FNS is responsible for authorizing and overseeing retailers who participate in the program—totaling more than 263,000 in fiscal year 2017—including investigating potential retailer trafficking  In order to participate in SNAP, a retailer applies to FNS and demonstrates that they meet program requirements, such as those on the amount and types of food that authorized stores must carry  FNS verifies a retailer’s compliance with these requirements and generally authorizes retailers for 5 years  FNS then monitors retailers’ continued compliance with program requirements and administratively disqualifies, or assesses money penalties on, those who are found to have trafficked benefits  To this end, FNS officials collect and monitor EBT transaction data to detect irregular patterns of transactions that may indicate trafficking and also conduct undercover investigations  If found to be trafficking, retailers are generally permanently disqualified from SNAP or incur a monetary penalty in lieu of permanent disqualification  According to FNS data, about 14 percent of SNAP recipients, or about 6 1 million, were work registrants who were subject to work requirements, and about 0 5 percent of SNAP recipients, or about 200,000, participated in state SNAP E&T programs, in an average month of fiscal year 2016  (See fig  1 ) According to FNS, most SNAP recipients are exempt from work requirements  For example, according to FNS, almost two-thirds of SNAP recipients were children, elderly, or adults with a disability in an average month of fiscal year 2016—groups that are generally exempt  Further, adults who are already working at least 30 hours a week are also exempt from SNAP work requirements, and according to FNS data, more than 31 percent of non-elderly adult SNAP recipients were employed in an average month of fiscal year 2016  SNAP work registrants who are not participating in SNAP E&T programs may be participating in other activities to meet work requirements or eligible for other exemptions  FNS officials told us that the state data reported to FNS on SNAP E&T participants are the best and most recent data available on this group, yet they also have limitations, which we will continue to explore in our ongoing work  In recent years, the number and percentage of SNAP recipients and work registrants participating in SNAP E&T programs appears to have decreased, according to FNS data  From fiscal year 2008 through fiscal year 2016, the average monthly number of SNAP E&T participants decreased from about 256,000 to about 207,000, or by 19 percent, according to state data on SNAP E&T participants reported to FNS  (See fig  2 ) However, over the same time period, the average monthly number of SNAP recipients appears to have increased from about 27 8 million to about 43 5 million, and work registrants appears to have increased from about 3 million to about 6 1 million, according to FNS data  As a result, the percentage of total SNAP recipients participating in SNAP E&T programs decreased from about 0 9 to about 0 5 percent, and the percentage of SNAP work registrants participating in these programs decreased from approximately 8 1 percent to 3 4 percent, from fiscal year 2008 through fiscal year 2016  Available information suggests the characteristics of SNAP E&T participants are generally similar to those of SNAP work registrants who do not participate in these programs  A recent FNS study, which surveyed SNAP E&T participants and SNAP work registrants who had not participated in SNAP E&T, found that members of the two groups had similar demographic characteristics, including age and gender, and received similar monthly SNAP benefit amounts  Further, at the time they were surveyed, about one third of each group were employed, and their average wage rates were similar, at about $10 per hour  State SNAP agencies have broad flexibility in how they design their SNAP E&T programs, and the characteristics of these programs have changed in several ways over the last decade  For example, states have increasingly moved from mandatory to voluntary programs, focused on serving ABAWDs, and partnered with state and local organizations to deliver services  According to FNS data, states have increasingly moved from mandatory to voluntary SNAP E&T programs in recent years  In fiscal year 2010, 17 states operated voluntary programs; however, by fiscal year 2017, 35 states operated voluntary programs, according to FNS data  (See fig  3 ) FNS officials told us that they have been actively encouraging states to provide more robust employment and training services, such as vocational training or work experience, through voluntary programs  They said that they believe these types of robust services are more effective in moving participants toward self-sufficiency, but that funding may not be sufficient to provide these to the large numbers of participants served in mandatory programs  In addition, FNS officials told us that voluntary programs are less administratively burdensome than mandatory programs, as they allow states to focus on serving motivated participants rather than sanctioning non-compliant individuals  According to FNS officials, when states move to a voluntary program, they generally experience a decline in SNAP E&T participation—a trend consistent with our analysis of FNS data—which may have contributed to the decline in overall SNAP E&T participation  Of the 22 states or territories that changed from a mandatory to a voluntary program from fiscal year 2010 through fiscal year 2016, according to FNS data, 13 experienced a decrease in SNAP E&T participation—ranging from a 21 percent decrease to a 93 percent decrease  Overall, voluntary programs are generally smaller than mandatory programs, according to our analysis of FNS data  In fiscal year 2016, for example, the 32 states or territories operating voluntary programs together served less than half of the total number of SNAP E&T participants served by the 21 states or territories operating mandatory programs, although these two groups of states had similar numbers of new work registrants  Furthermore, states operating voluntary programs served an average of nearly 7,000 SNAP E&T participants per state, while states operating mandatory programs served an average of 23,000 SNAP E&T participants per state  Evidence suggests that states have increased their focus on serving ABAWDs—a sub-population of SNAP recipients subject to benefit time limits and additional work requirements—through SNAP E&T, as related waivers have expired in recent years, according to FNS data  During and after the 2007-2009 recession, the majority of states operated under statewide waivers of the ABAWD time limit due to economic conditions  However, as the economy recovered, most statewide waivers expired, and the ABAWD time limit was reinstated  For example, according to FNS data, in fiscal year 2011, 45 states or territories had a statewide waiver and 7 states had a partial waiver—one applying to certain localities  By fiscal year 2017, the number of states or territories with a statewide waiver had decreased to 9, while 27 states had partial waivers  FNS officials and state SNAP agency officials we spoke with in some states told us that, as the waivers have ended, state SNAP E&T programs have become increasingly focused on serving ABAWDs  Although state data on SNAP E&T programs reported to FNS suggest a greater percentage of ABAWDs have been participating in these programs in recent years, according to FNS officials, these data have limited usefulness in assessing state trends in serving ABAWDs for several reasons  For example, in recent years, FNS officials learned that there was widespread confusion among states regarding the need to track ABAWDs when waivers were in place, and that as a result, some states had not been tracking ABAWDs or properly documenting SNAP recipients’ ABAWD status  This is consistent with what some of the selected states we spoke with reported  As part of our ongoing work, we are continuing to explore the availability and reliability of data on ABAWDs  State SNAP agencies have increasingly partnered with other state and local organizations, such as workforce agencies, community-based social service providers, and community colleges, to provide services to SNAP E&T participants in recent years, according to FNS and states we selected for our review  In fiscal year 2018, nearly all states partnered with at least one other organization to deliver SNAP E&T services, with the majority partnering with more than one, according to an analysis by FNS  In recent years, FNS has urged states to make use of the broad network of American Job Centers  The American Job Centers, also known as one- stop centers, are funded through the Department of Labor’s Employment and Training Administration and designed to provide a range of employment-related services, such as training referrals, career counseling, job listings, and similar employment-related services, to job seekers under one roof  Our prior work has highlighted the value of coordination between federally funded employment and training programs to ensure the efficient and effective use of resources  Despite encouraging such partnerships, FNS officials said that American Job Centers typically provide lighter touch services to SNAP E&T participants, such as job search and job search training, and they therefore may not be well suited for SNAP E&T participants who have multiple barriers to employment  In our 2003 work on SNAP E&T, we found that while workforce system programs offered some of the activities needed by SNAP E&T participants, officials from 12 of the 15 states we contacted said that most participants were not ready for these activities, in part, because they lacked basic skills, such as reading and computer literacy, that would allow them to successfully participate  An alternative service delivery strategy that FNS has promoted is the development of third party partnerships with community-based social service providers, community colleges, and other entities to help states enhance their SNAP E&T programs  According to FNS, in this model, third party organizations use non-federal funding to provide allowable SNAP E&T services and supports, which are then eligible for 50 percent federal reimbursement funds through the state’s SNAP E&T program  According to FNS officials, third party partnerships enable states to leverage additional resources, grow their SNAP E&T programs, and reach more SNAP participants  In addition, FNS officials said that these partnerships allow states to improve their program outcomes by tapping into providers currently serving communities that include SNAP recipients  Federal 50 percent reimbursement funds expended increased from nearly $182 million to more than $223 million, or by 23 percent, from fiscal year 2007 to fiscal year 2016  FNS has taken steps to increase federal support of states’ SNAP E&T programs by increasing the number of federal staff responsible for SNAP E&T and providing additional technical assistance to states  Specifically, FNS officials said that in 2014, they created the Office of Employment and Training to provide support and oversight for the SNAP E&T program and expanded SNAP E&T staff in FNS headquarters from one to five fulltime employees  FNS has also taken steps to increase technical assistance to states  For example, they have developed tools, including the SNAP E&T Operations Handbook, intended to help states implement and grow their program, and by adding a dedicated SNAP E&T official in each of FNS’s seven regional offices  According to FNS, regional officials have targeted technical assistance to states on, for example, developing third-party partnerships, and they have emphasized evidence-based approaches to administering the program, such as providing skills-based training for in-demand occupations  FNS officials rely on various information sources to oversee states’ SNAP E&T programs, including participant outcome data reported by states for the first time in January 2018  For example, FNS officials conduct management evaluation reviews of states, annually review states’ SNAP E&T plans for compliance, and collect data from states on program participation and expenditures  In addition, as of January 2018, FNS has begun receiving new data on SNAP E&T program participants and outcomes from states  These data include employment outcomes, such as the number of SNAP E&T participants in unsubsidized employment after participation in the program, and participant characteristics, such as the number of participants entering the program with a high school degree or equivalent  FNS officials said that although states generally submitted the new data on time, states experienced challenges that likely affected the accuracy of the data  For example, some states needed to manually collect data on participant characteristics due to the limited capacity of their data systems  Further, according to FNS officials, some states did not correctly interpret certain reporting definitions or time periods  To address these challenges, FNS officials have been providing technical assistance to states to help them refine their participant and outcome data reports  Officials told us that they expect the states to submit revised reports by May 2018; we will examine these data and related issues in our ongoing work  FNS and the states partner to address issues that affect program integrity, including improper payments and fraud, and FNS has taken some steps to address challenges in these areas, but concerns remain  For example, regarding SNAP recipient and retailer fraud, FNS has taken some steps to address challenges identified in our 2006 and 2014 reports related to fraud committed by SNAP recipients and authorized retailers, but more remains to be done  We currently have ongoing work to assess the steps FNS and states have taken to address our recommendations related to recipient and retailer fraud and other program vulnerabilities  In 2016, we reviewed SNAP improper payment rates and found that states’ adoption of program flexibilities and changes in federal SNAP policy in the previous decade, as well as improper payment rate calculation methods, likely affected these rates  For example, when states adopted available SNAP policy flexibilities that simplified or lessened participant reporting requirements, these changes reduced the opportunity for error and led to a decline in the improper payment rate, according to a USDA study  In addition, we found that the methodology SNAP used to calculate its improper payment rate was generally similar to the methodologies used for other large federal programs for low- income individuals, including Medicaid, Earned Income Tax Credit, and Supplemental Security Income  However, we also found that some of the procedural and methodological differences in the rate calculation among these programs likely affected the resulting improper payment rates, such as how cases with insufficient information or certain kinds of errors were factored into the improper payment rate  In 2014, USDA identified SNAP improper payment data quality issues in some states and has since been working with the states to improve improper payment estimates  Although USDA reported national SNAP improper payment estimates for benefits paid through fiscal year 2014, USDA did not report a national SNAP improper payment estimate for benefits paid in fiscal years 2015 or 2016  In response to a report from USDA’s Office of Inspector General that identified concerns in the application of SNAP’s quality control process, which is used to identify improper payments, USDA began a review of state quality control systems in all states in 2014  According to USDA, due to the data quality issues uncovered in 42 of 53 states during the reviews, the improper payment rates for those states could not be validated, and the department was unable to calculate a national improper payment rate for benefits paid in fiscal year 2015  To address the data quality concerns, USDA updated guidance, provided training to relevant state and federal staff, and worked with states to update their procedures to ensure consistency with federal guidelines  According to USDA, the department also required individual states to develop corrective action plans to address issues identified and monitored progress to ensure states took identified actions  On June 30, 2017, USDA notified the states that the department would not release a national SNAP improper payment rate for benefits paid in fiscal year 2016 and remained focused on conducting the fiscal year 2017 review  FNS has increased its oversight of state anti-fraud activities in recent years by developing new guidance and providing training and technical assistance to states on detecting fraud by SNAP recipients and reporting on anti-fraud activities to FNS  In 2014, we reported on 11 selected states’ efforts to combat SNAP recipient fraud and made several recommendations to FNS to address the challenges states faced  We found that FNS and states faced challenges in the following areas: Guidance on use of data tools to detect fraud: States faced challenges using FNS-recommended data tools to detect fraud, and FNS is in the process of developing improved guidance to address this concern  Specifically, FNS’s guidance on the use of EBT transaction data to uncover potential patterns of benefit trafficking lacked the specificity states needed to uncover such activity, and we recommended FNS develop additional guidance  Since then, FNS contracted with a private consulting firm to provide 10 states with technical assistance in recipient fraud prevention and detection, which included exploring the use of data analytics to analyze and interpret eligibility and transaction data to identify patterns or trends and create models that incorporate predictive analytics  FNS officials also recently told us that the agency is developing a SNAP Fraud Framework to provide guidance to states on improving fraud prevention and detection  FNS officials anticipated releasing the framework in mid- 2018  Tools for monitoring e-commerce websites: We also found FNS- recommended tools for automatically monitoring potential SNAP trafficking on e-commerce websites to be of limited use and less effective than manual searches, and FNS has developed but not finalized guidance on using such tools  We recommended that FNS reassess the effectiveness of its current guidance and tools for states to monitor e-commerce and social media websites  In August 2017, FNS officials told us that they had developed revised guidance for states on using social media in detection of SNAP trafficking  According to FNS, the guidance will be incorporated into the SNAP Fraud Framework  Staff levels: During the time of our 2014 work, most of our 11 selected states reported difficulties conducting fraud investigations due to reduced or stagnant staff levels while numbers of SNAP recipients had greatly increased, but FNS decided not to make changes to address this issue  Specifically, 8 of the 11 states we reviewed reported inadequate staffing due to attrition, turnover, or lack of funding  Some states suggested changing the financial incentive structure to promote fraud investigations because agencies were not rewarded for cost-effective, anti-fraud efforts that could prevent ineligible people from receiving benefits  Specifically, when fraud by a SNAP recipient is discovered, a state may generally retain 35 percent of any recovered overpayments  However, there are no recovered funds when a state detects potential fraud by an applicant and denies the application  To help address states’ concerns about resources needed to conduct investigations, we recommended in our 2014 report that FNS explore ways that federal financial incentives could be used to better support cost-effective anti-fraud strategies  FNS reported that it took some steps to explore alternative financial incentives, through a review of responses to a Request for Information in the Federal Register  However, FNS decided not to pursue bonus awards for anti-fraud and program integrity activities  Given that FNS has not made changes in this area, state SNAP fraud agencies may continue to report resource concerns in addressing fraud  Reporting guidance: We also found that FNS did not have consistent and reliable data on states’ activities because of unclear reporting guidance, and FNS has since revised its data collection form and provided training on the changes  To improve FNS’s ability to monitor states and obtain information about more efficient and effective ways to combat recipient fraud, we recommended in 2014 that FNS take steps, such as providing guidance and training, to enhance the consistency of what states report on their anti-fraud activities  In response, FNS revised the form used to collect recipient integrity information and changed the reporting frequency from annual to quarterly, effective fiscal year 2017  FNS officials also reported providing training to approximately 400 state agency and FNS regional office personnel on the updates to the form and related instructions  In our ongoing work, we are further reviewing states’ use of data analytics to identify SNAP recipient fraud, including that which may be occurring during out-of-state transactions  Because transactions that may appear suspicious—such as those made out-of-state—may in fact be legitimate, states may use data analytic techniques to include additional factors that may help them better target their efforts to identify potential fraud  However, states may have different levels of capacity for using data analytics to detect fraud  We are examining how 7 selected states are using data analytics and identifying the advantages and challenges states have experienced in doing so  We are also assessing FNS’s efforts to assist states in implementing GAO’s leading practices for data analytics outlined in GAO’s Framework for Managing Fraud Risks in Federal Programs outlined in GAO’s Framework for Managing Fraud Risks in Federal Programs  In addition, we are conducting our own analysis of EBT out-of-state SNAP transaction data  We expect to report on our findings later this year  FNS has taken some steps to prevent, detect, and respond to retailers who traffic SNAP benefits since our last report on the issue in 2006, but trafficking continues to be a problem  For example, in February 2018, a federal jury convicted a grocery store operator in Baltimore on charges of wire fraud in connection with a scheme to traffic more than $1 6 million in SNAP benefits for food sales that never occurred  The grocery store operator paid cash for SNAP benefits, typically paying the recipient half the value of the benefits and keeping the other half for himself  In our 2006 report, we found that SNAP was vulnerable to retailer trafficking in several areas, including: Requirements for food that retailers must stock to participate in SNAP: In 2006, we found that FNS had minimal requirements for the amounts of food that retailers must stock, which could allow retailers more likely to traffic into the program, although the agency has since taken steps to increase these requirements  In our 2006 report, FNS officials said that they authorized stores with limited food stock to provide access to food in low-income areas where large grocery stores were scarce  At that time, retailers were generally required to stock a minimum of 12 food items (at least 3 varieties of 4 staple food categories, such as fruits and vegetables), but FNS rules did not specify how many items of each variety would constitute sufficient stock  FNS officials told us that a retailer that only carries small quantities of food, such as a few cans of one kind of vegetable, may intend to traffic  In 2016, FNS promulgated a final rule increasing food stock requirements  FNS officials told us that these new rules are designed to encourage stores to provide more healthy food options for recipients and discourage trafficking  According to FNS, retailers are now generally required to stock at least 36 food items (a certain variety and quantity of staple foods in each of the 4 staple food categories)  Focus on high-risk retailers: We also found in 2006 that FNS had not conducted analyses to identify characteristics of retailers at high risk of trafficking and to target its resources—a shortcoming FNS has since taken some steps to address  For example, we reported that some stores may be at risk of trafficking because one or more previous owners had been found trafficking at the same location  However, FNS did not have a system in place to ensure that these retailers were quickly targeted for heightened attention  In addition, once a store was authorized to participate in the program, FNS staff typically would not inspect the store again until it applied for reauthorization 5 years later  We recommended that FNS identify the stores most likely to traffic and provide earlier, more targeted oversight to those stores  In 2009, FNS began establishing risk levels for each authorized retailer, identifying high-risk stores as those with a prior permanent disqualification at that location or a nearby location  In 2013, FNS required all high-risk retailers to go through reauthorization and to provide additional documentation regarding store ownership  That same year, FNS also consolidated its retailer management functions, including those for authorizing stores and analyzing EBT transaction data, into a single national structure known as the Retailer Operations Division  FNS officials told us that this structure enables the agency to identify and deploy their investigative resources to the areas of highest risk nationally, rather than within a given region  Penalties to deter retailer trafficking: We also found in our 2006 report that FNS’s penalties for retailer trafficking may be insufficient to deter traffickers, and since then, FNS has proposed—but not finalized—rules to increase them  FNS imposes administrative penalties for retailer trafficking—generally a permanent disqualification from the program or a monetary penalty  FNS relies on the USDA Office of Inspector General (OIG) and other law enforcement entities to conduct investigations that can lead to criminal prosecutions  In our 2006 report, we recommended that FNS develop a strategy to increase penalties for trafficking  The Food, Conservation, and Energy Act of 2008 (known as the 2008 Farm Bill) gave USDA authority to impose higher monetary penalties, and the authority to impose both a monetary penalty and program disqualification on retailers found to have violated relevant law or regulations (which includes those found to have trafficked)  In 2012, FNS proposed regulatory changes to implement these authorities  However, FNS has not finalized these rules, and as of fall 2017, the rules were considered “inactive ” In our ongoing work, we are continuing to assess FNS’s efforts to prevent, detect, and respond to retailer trafficking, as well as examining what is known about the extent of retailer trafficking nationwide  As part of this work, we are continuing to review FNS’s response to our prior recommendations, as well as related recommendations made by USDA’s OIG  We are also studying FNS’s periodic estimates of the rate of retailer trafficking, expressed as the dollar value and percentage of all SNAP benefits that were trafficked and the percentage of retailers involved  These data suggest an increase in the estimated rate of retailer trafficking since our 2006 report  However, we and others, including a group of experts convened by FNS, have identified some limitations with the retailer trafficking estimates  For example, the trafficking rate is calculated based on a sample of retailers that FNS considers most likely to traffic  Although FNS adjusts the data to better represent the broader population of authorized retailers, it is uncertain whether the resulting estimates accurately reflect the extent of trafficking nationwide  We are reviewing these limitations and FNS’s efforts to address them in our ongoing work  Chairman Jordan, Chairman Palmer, Ranking Member Krishnamoorthi, Ranking Member Raskin, and Members of the Subcommittees, this completes my prepared statement  I would be pleased to respond to any questions that you may have at this time  If you or your staff have any questions about this testimony, please contact Kathryn Larin, Director, Education, Workforce, and Income Security Issues at (202) 512-7215 or LarinK@gao gov  Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement  GAO staff who made key contributions to this testimony include Rachael Chamberlin, Celina Davidson, Swati Deo, Rachel Frisk, Alexander Galuten, Danielle Giese, Kristen Jones, Morgan Jones, Lara Laufer, Monica Savoy, and Kelly Snow  This is a work of the U S  government and is not subject to copyright protection in the United States  The published product may be reproduced and distributed in its entirety without further permission from GAO  However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately 
Report 2:  Effective beginning March 2016, VA issued a contract modification that eliminated the requirement that community providers must submit medical documentation as a condition of receiving payment for their claims  Data from one TPA showed a reduction in non-clean claims following the implementation of this contract modification  For example, starting in April 2016, after this modification was executed, almost 100 percent of claims submitted to TriWest were classified as clean claims, as opposed to 49 percent of claims submitted in March 2016  However, when the modification first went into effect in March 2016, TriWest and Health Net officials stated that they processed a large amount of claims from community providers that had previously been pended or denied because they lacked medical documentation and, in turn, submitted a large number of invoices to VA for reimbursement  As previously discussed, to help address the increased number of TPA invoices, VA issued lump-sum payments to the TPAs during this time period  Modification of timely filing requirement  In February and May 2018, VA issued waivers that gave TPAs the authority to allow providers to resubmit rejected or denied claims more than 180 days after the end of the episode of care if the original claims were submitted timely—that is, within 180 days of the end of the episode of care  VA officials stated that the waivers were intended to reduce the number of rejected and denied claims by giving community providers the ability to resubmit previously rejected or denied claims for which the date of service occurred more than 180 days ago  VA’s waivers were implemented as follows: In February 2018, VA issued a waiver that allowed community providers to resubmit certain claims rejected or denied for specific reasons when the provider or TPA could verify that the provider made an effort to submit the claim prior to the claims submission deadline  In May 2018, VA issued a second waiver that removed the 180 day timeliness requirement for all Choice Program claims  The waiver also provided instructions to the TPAs on informing providers that they may resubmit claims rejected or denied for specific reasons and how the TPAs are to process the resubmitted claims  In regards to the first waiver, TPA officials stated that the processing of those resubmitted claims adversely affected the timeliness of the TPAs’ payments to community providers because the waiver resulted in a large influx of older claims  As the second waiver was in the process of being implemented by the two TPAs at the time we conducted our work, we were unable to determine if the second waiver affected the TPAs’ provider payment timeliness  Changes to authorization of care requirement  VA issued a contract modification in January 2017 to expand the time period for which authorizations for community providers to provide care to veterans under the Choice Program are valid  In addition, in May 2017, VA expanded the scope of the services covered by authorizations, allowing them to encompass an overall course of treatment, rather than a specific service or set of services  According to VA officials, the changes VA made related to the authorization of care requirement were also intended to reduce the need for secondary authorization requests (SAR)  Community providers request SARs when veterans need health care services that exceed the period or scope of the original authorizations  Community providers are required to submit SARs to their TPA, which, in turn, submits the SARs to the authorizing VA medical facility for review and approval  Both Health Net and TriWest officials told us that since VA changed the time frame and scope of authorizations, the number of SARs has decreased  Despite efforts to decrease the number of SARs, payment delays or claim denials are likely to continue if SARs are needed  We found that VA is not ensuring that VA medical facilities are reviewing and approving SARs within required time frames  VA policy states that VA medical facilities are to review and make SAR approval decisions within 5 business days of receipt  However, officials from one of the TPAs and 7 of the 15 providers we interviewed stated that VA medical facilities are not reviewing and approving SARs in a timely manner  According to TriWest officials, as of May 2018, VA medical facilities in their regions were taking an average of 11 days to review and make approval decisions on SARs, with four facilities taking over 30 days for this process  According to an official from VA’s Office of Community Care, VA does not currently collect reliable national data to track the extent of nonadherence to the VA policy to review and make SAR approval decisions within 5 business days  The official told us that instead, VA relies on employees assigned to each Veterans Integrated Service Network to monitor data on VA medical facilities’ timeliness in making these SAR approval decisions  If a VA medical facility is found not to be in adherence with the SAR policy, the official told us that staff assigned to the Veterans Integrated Service Network attempt to identify the reasons for nonadherence, and perform certain corrective actions, including providing education to the facility  Despite these actions, the official told us that there are still VA medical facilities not in adherence with VA’s SAR approval policy  According to a VA official, VA is in the process of piloting software for managing authorizations that will allow VA to better track SAR approval time frames across VA medical facilities in the future  However, even after this planned software is implemented, if VA does not use the data to monitor and assess SAR approval decision time frames VA will be unable to ensure that all VA medical facilities are adhering to the policy  Standards for internal control in the Federal Government state that management should establish and operate monitoring activities to evaluate whether a specific function or process is operating effectively and take corrective actions as necessary  Furthermore, monitoring such data will allow VA to identify and take actions as needed to address any identified challenges VA medical facilities are encountering in meeting the required approval decision time frames  Without monitoring data to ensure that all VA medical facilities are adhering to the SAR approval time frames as outlined in VA policy, community providers may delay care until the SARs are approved or provide care without SAR approval  This in turn increases the likelihood that the community providers’ claims will be denied  Further, continued nonadherence to VA’s SAR policy raises concerns about VA’s ability to ensure timely approval of SARs when VA medical facilities assume more responsibilities for ensuring veterans’ access to care under the forthcoming Veterans Community Care Program  We found that VA and its TPAs have taken steps to educate community providers in order to help prevent claims processing issues that have contributed to the length of time TPAs have taken to pay these providers  Despite these efforts, 9 of the 15 providers we interviewed reported poor customer service when attempting to resolve claims payment issues  While VA’s contracts with the TPAs do not include requirements for educating and training providers on the Choice Program, both TPAs have taken steps to educate community providers on how to successfully submit claims under the Choice Program  Specifically, TriWest and Health Net officials told us that they have taken various steps to educate community providers on submitting claims correctly, including sending monthly newsletters, emails, and faxes to communicate changes to the Choice Program; updating their websites with claims processing information; and holding meetings with some providers monthly or quarterly to resolve claims processing issues  Officials from both TPAs also told us that they provided one-on-one training to some providers on the claims submission process to help reduce errors when submitting claims  In addition, VA’s RFP for the Veterans Community Care Program contracts includes requirements to provide an annual training program curriculum and an initial on-boarding and ongoing outreach and education program for community providers, which includes training on the claims submission and payment processes and TPA points of contact  VA and the TPAs have also made efforts to help providers resolve claims processing issues and outstanding payments  For example, VA launched its “top 20 provider initiative” in January 2018 to work directly with community providers with high dollar amounts of unpaid claims and resolve ongoing claims payment issues  This initiative included creating rapid response teams to work with community providers to settle unpaid claim balances within 90 days and working with both TPAs to increase the number of clean claims paid in less than 30 days  In addition, VA has developed webinars on VA’s community care programs and—in conjunction with trade organizations and health care systems—has delivered provider education on filing claims properly  TriWest officials stated that it has educated the customer service staff at its claims processing sub-contractor, who field community provider calls regarding claims processing issues, to help ensure that the staff are familiar with Choice Program changes and can effectively assist community providers and resolve claims processing issues  Internal TriWest data show that providers’ average wait time to speak to a customer service representative about claims processing issues decreased from as high as 18 minutes in 2016 to as low as 2 5 minutes in 2018  Health Net officials were unable to provide data, but stated that since the fourth quarter of 2017, Health Net has decreased the time it takes for a community provider to speak with a customer service representative by adding additional staff and extending the hours in which providers can call with questions  In addition, Health Net officials stated that they have required customer service staff to undergo additional training related to resolving claims processing issues  Despite these efforts, 7 of the 10 providers that participate in the Health Net network and 2 of the 7 providers that participate in the TriWest network we interviewed between April and June 2018 told us that when they contact the TPAs’ customer service staff to address claim processing questions, such as how to resolve claim rejections or denials, they experience lengthy hold times, sometimes exceeding one hour  In addition, 7 of the 15 providers we spoke with told us they typically reach employees who are unable to answer their questions  According to these providers, this experience frustrated them, as they often did not understand why a claim had been denied or rejected, and they required assistance correcting the claim so it could be resubmitted  One community provider stated that their common practice to resolve questions or concerns was to call customer service enough times until they received the same answer twice from a TPA representative  In addition, 5 of the 10 Health Net providers we interviewed stated that they have significant outstanding claim balances owed to them  One of these providers—who reported over $3 million in outstanding claims—stressed the importance of being able to effectively resolve claims issues with TPA customer service staff, as the administrative burden of following up on outstanding claim balances takes time away from caring for patients  The issues concerning customer service wait times and TPA staff inability to resolve some claims processing issues reported by community providers appear to be inconsistent with VA contractual requirements  VA’s current Choice Program contracts require the TPAs to establish a customer call center to respond to calls from veterans and non-VA providers  The contract requires specified levels of service for telephone inquiries at the call center  For example, VA requires TPA representatives to answer customer service calls within an average speed of 30 seconds or less and requires 85 percent of all inquiries to be fully and completely answered during the initial telephone call  However, VA officials explained that VA does not enforce the contractual requirement for responding to calls from community providers  Furthermore, according to these officials, VA allows the TPAs to prioritize calls from veterans  Officials from VA’s Office of General Counsel, Procurement Law Group, confirmed that this requirement does apply to the TPAs’ handling of calls from community providers  Because VA does not enforce the customer service requirement for providers, VA has not collected data on or monitored the TPAs’ compliance with these requirements for providers’ calls  As previously stated, standards for internal control in the Federal Government state that management should establish and operate monitoring activities to evaluate whether a specific function or process is operating effectively and take corrective actions as necessary  Without collecting data and monitoring customer service requirements for provider calls, VA does not have information on the extent to which community providers face challenges when contacting the TPAs about claims payment issues that could contribute to the amount of time it takes to successfully file claims and receive reimbursement for services under the Choice Program  This, in turn, poses a risk to the Choice Program to the extent that community providers who face these challenges decide not to serve veterans under the Choice Program  Looking forward, VA has included customer service requirements in its RFP for the Veterans Community Care Program contracts, and VA officials have told us that these requirements are applicable to provider calls  For example, the RFP includes a requirement for its future TPAs to establish and maintain call centers to address inquiries from community providers and has established customer service performance metrics to monitor call center performance  Monitoring data on provider calls under the contracts will be important as Veterans Community Care Program TPAs will continue to be responsible for building provider networks, processing claims, and resolving claims processing issues  The Choice Program relies on community providers to deliver care to eligible veterans when VA is unable to provide timely and accessible care at its own facilities  Although VA has taken steps to improve the timeliness of TPA claim payments to providers, VA is not collecting data or monitoring compliance with two Choice Program requirements, and this could adversely affect the timeliness with which community providers are paid under the Choice Program  First, VA does not have complete data allowing it to effectively monitor adherence with its policy for VA medical facilities to review SARs within 5 days of receipt, which impacts its ability to meet the requirement  To the extent that VA medical facilities delay these reviews and approvals, community providers may have to delay care or deliver care that is not authorized, which in turn increases the likelihood that the providers’ claims will be denied and the providers will not be paid  Second, VA requires the TPAs to establish a customer call center to respond to calls from veterans and non-VA providers  However, VA does not enforce the contractual requirement for responding to calls from community providers and allows the TPAs to prioritize calls from veterans  Consequently, VA is not collecting data, monitoring, or enforcing compliance with its contractual requirements for the TPAs to provide timely customer service to providers  As a result, VA does not have information on the extent to which community providers face challenges when contacting the TPAs about claims payment issues, which could contribute to the amount of time it takes to receive reimbursement for services  To the extent that these issues make community providers less willing to continue participating in the Choice Program and the forthcoming Veterans Community Care Program, they pose a risk to VA’s ability to successfully implement these programs and ensure veterans’ timely access to care  We are making the following two recommendations to VA: Once VA’s new software for managing authorizations has been fully implemented, the Undersecretary for Health should monitor data on SAR approval decision time frames to ensure VA medical facilities are in adherence with VA policy, assess the reasons for nonadherence with the policy, and take corrective actions as necessary  (Recommendation 1) The Undersecretary for Health should collect data and monitor compliance with the Choice Program contractual requirements pertaining to customer service for community providers, and take corrective actions as necessary  (Recommendation 2) We provided a draft of this report to VA for review and comment  In its written comments, reproduced in appendix I, VA concurred with our two recommendations and said it is taking steps to address them  For example, VA plans to implement software in spring 2019 that will automate the SAR process and allow for streamlined reporting and monitoring of SAR timeliness to ensure ongoing compliance  Additionally, VA has included provider customer service performance requirements and metrics in its Veterans Community Care Program RFP, and will require future contractors to provide a monthly report to VA on their call center operations and will implement quarterly provider satisfaction surveys  We are sending copies of this report to the Secretary of Veterans Affairs, the Under Secretary for Health, appropriate congressional committees, and other interested parties  This report is also available at no charge on the GAO Web site at http://www gao gov  If you or your staff have any questions about this report, please contact Sharon M  Silas at (202) 512-7114 or silass@gao gov  Contact points for our Offices of Congressional Relations and Public Affairs are on the last page of this report  GAO staff who made major contributions to this report are listed in appendix II  In addition to the contact named above, Marcia A  Mann (Assistant Director), Michael Zose (Analyst-in-Charge), and Kate Tussey made major contributions to this report  Also contributing were Krister Friday, Jacquelyn Hamilton, and Vikki Porter 

ground_truth: Foreign assistance is the largest component of the international affairs budget and is viewed by many as an essential instrument of U.S. foreign policy. On the basis of national security, commercial, and humanitarian rationales, U.S. assistance flows through many federal agencies and supports myriad objectives. These include promoting economic growth, reducing poverty, improving governance, expanding access to health care and education, promoting stability in conflict regions, countering terrorism, promoting human rights, strengthening allies, and curbing illicit drug production and trafficking. Since the terrorist attacks of September 11, 2001, foreign aid has increasingly been associated with national security policy. At the same time, many Americans and some Members of Congress view foreign aid as an expense that the United States cannot afford given current budget deficits. In FY2017, U.S. foreign assistance, defined broadly, totaled an estimated $49.87 billion, or 1.2% of total federal budget authority. About 44% of this assistance was for bilateral economic development programs, including political/strategic economic assistance; 35% for military aid and nonmilitary security assistance; 18% for humanitarian activities; and 4% to support the work of multilateral institutions. Assistance can take the form of cash transfers, equipment and commodities, infrastructure, or technical assistance, and, in recent decades, is provided almost exclusively on a grant rather than loan basis. Most U.S. aid is implemented by nongovernmental organizations rather than foreign governments. The United States is the largest foreign aid donor in the world, accounting for about 24% of total official development assistance from major donor governments in 2017 (the latest year for which these data are available). Key foreign assistance trends in the past decade include growth in development aid, particularly global health programs; increased security assistance directed toward U.S. allies in the anti-terrorism effort; and high levels of humanitarian assistance to address a range of crises. Adjusted for inflation, annual foreign assistance funding over the past decade was the highest it has been since the Marshall Plan in the years immediately following World War II. In FY2017, Afghanistan, Iraq, Israel, Jordan, and Egypt received the largest amounts of U.S. aid, reflecting long-standing aid commitments to Israel and Egypt, the strategic significance of Afghanistan and Iraq, and the strategic and humanitarian importance of Jordan as the crisis in neighboring Syria continues. The Near East region received 27% of aid allocated by country or region in FY2017, followed by Africa, at 25%, and South and Central Asia, at 15%. This was a significant shift from a decade prior, when Africa received 19% of aid and the Near East 34%, reflecting significant increases in HIV/AIDS-related programs concentrated in Africa between FY2007 and FY2017 and the drawdown of U.S. military forces in Iraq and Afghanistan. Military assistance to Iraq began to decline starting in FY2011, but growing concern about the Islamic State in Iraq and Syria (ISIS) has reversed this trend. This report provides an overview of the U.S. foreign assistance program by answering frequently asked questions on the subject. It is intended to provide a broad view of foreign assistance over time, and will be updated periodically. For more current information on foreign aid funding levels, see CRS Report R45168, Department of State, Foreign Operations and Related Programs: FY2019 Budget and Appropriations, by Susan B. Epstein, Marian L. Lawson, and Cory R. Gill.

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



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

Report 1: U S  foreign aid is the largest component of the international affairs budget, for decades viewed by many as an essential instrument of U S  foreign policy  Each year, the foreign aid budget is the subject of congressional debate over the size, composition, and purpose of the program  The focus of U S  foreign aid policy has been transformed since the terrorist attacks of September 11, 2001  Global development, a major objective of foreign aid, has been cited as a third pillar of U S  national security, along with defense and diplomacy, in the national security strategies of the George W  Bush and Barack Obama Administrations  Although the Trump Administration's National Security Strategy does not explicitly address the status of development vis-à-vis diplomacy and defense, it does note the historic importance of aid in achieving foreign policy goals and supporting U S  national interests  This report addresses a number of the more frequently asked questions regarding the U S  foreign aid program; its objectives, costs, and organization; the role of Congress; and how it compares to those of other aid donors  It attempts not only to present a current snapshot of American foreign assistance, but also to illustrate the extent to which this instrument of U S  foreign policy has evolved over time  Data presented in the report are the most current, consistent, and reliable figures available, generally updated through FY2017  Dollar amounts come from a variety of sources, including the U S  Agency for International Development (USAID) Foreign Aid Explorer database (Explorer) and annual State, Foreign Operations, and Related Programs (SFOPS) appropriations acts  As new data are obtained or additional issues and questions arise, the report will be revised  Foreign aid abbreviations used in this report are listed in Appendix B   In its broadest sense, U S  foreign aid is defined under the Foreign Assistance Act of 1961 (FAA), the primary legislative basis of foreign aid programs, as any tangible or intangible item provided by the United States Government [including "by means of gift, loan, sale, credit, or guaranty"] to a foreign country or international organization under this or any other Act, including but not limited to any training, service, or technical advice, any item of real, personal, or mixed property, any agricultural commodity, United States dollars, and any currencies of any foreign country which are owned by the United States Government     (§634(b)) For many decades, nearly all assistance annually requested by the executive branch and debated and authorized by Congress was ultimately encompassed in the foreign operations appropriations and the international food aid title of the agriculture appropriations  In the U S  federal budget, these traditional foreign aid accounts have been subsumed under the 150 (international affairs) budget function  By the 1990s, however, it became increasingly apparent that the scope of U S  foreign aid was not fully accounted for by the total of the foreign operations and international food aid appropriations  Many U S  departments and agencies had adopted their own assistance programs, funded out of their own budgets and commonly in the form of professional exchanges with counterpart agencies abroad—the Environmental Protection Agency, for example, providing water quality expertise to other governments  These aid efforts, conducted outside the purview of the traditional foreign aid authorizing and appropriations committees, grew more substantial and varied in the mid-1990s  The Department of Defense (DOD) Nunn-Lugar effort provided billions in aid to secure and eliminate nuclear and other weapons, as did Department of Energy activities to control and protect nuclear materials—both aimed largely at the former Soviet Union  Growing participation by DOD in health and humanitarian efforts and expansion of health programs in developing countries by the National Institutes of Health and Centers for Disease Control and Prevention, especially in response to the HIV/AIDS epidemic, followed  During the past 15 years, DOD-funded and implemented aid programs in Iraq and Afghanistan to train and equip foreign forces and win hearts and minds through development efforts were often considerably larger than the traditional military and development assistance programs provided under the foreign operations appropriations  The recent decline in DOD activities in these countries has sharply decreased nontraditional aid funding  In FY2011, nontraditional sources of assistance, at $17 3 billion, represented 35% of total aid obligations  By FY2017, nontraditional aid, at $9 7 billion, represented 19% of total aid, still a significant proportion  While the executive branch has continued to request and Congress to debate most foreign aid within the parameters of the foreign operations legislation, both entities have sought to ascertain a fuller picture of assistance programs through improved data collection and reporting  Significant discrepancies remain between data available for traditional versus nontraditional types of aid and, therefore, the level of analysis applied to each  (See text box , "A Note on Numbers and Sources," below ) Nevertheless, to the extent possible, this report tries to capture the broadest definition of aid throughout  Foreign assistance is predicated on several rationales and supports a great many objectives  The importance and emphasis of various rationales and objectives have changed over time  Throughout the past 70 years, there have been three key rationales for foreign assistance National Security has been the predominant theme of U S  assistance programs  From rebuilding Europe after World War II under the Marshall Plan (1948-1951) and through the Cold War, U S  aid programs were viewed by policymakers as a way to prevent the incursion of communist influence and secure U S  base rights or other support in the anti-Soviet struggle  After the Cold War ended, the focus of foreign aid shifted from global anti-communism to disparate regional issues, such as Middle East peace initiatives, the transition to democracy of eastern Europe and republics of the former Soviet Union, and international illicit drug production and trafficking in the Andes  Without an overarching security rationale, foreign aid budgets decreased in the 1990s  However, since the September 11, 2001, terrorist attacks in the United States, policymakers frequently have cast foreign assistance as a tool in U S  counterterrorism strategy, increasing aid to partner states in counterterrorism efforts and funding the substantial reconstruction programs in Afghanistan and Iraq  As noted, global development has been featured as a key element in U S  national security strategy in both Bush and Obama Administration policy statements  Commercial Interests  Foreign assistance has long been defended as a way to either promote U S  exports by creating new customers for U S  products or by improving the global economic environment in which U S  companies compete  Humanitarian Concerns  Humanitarian concerns drive both short-term assistance in response to crisis and disaster as well as long-term development assistance aimed at reducing poverty, hunger, and other forms of human suffering brought on by more systemic problems  Providing assistance for humanitarian reasons has generally been the aid rationale most broadly supported by the American public and policymakers alike  The objectives of aid generally fit within these rationales  Aid objectives include promoting economic growth and reducing poverty, improving governance, addressing population growth, expanding access to basic education and health care, protecting the environment, promoting stability in conflictive regions, protecting human rights, promoting trade, curbing weapons proliferation, strengthening allies, and addressing drug production and trafficking  The expectation has been that, by meeting these and other aid objectives, the United States will achieve its national security goals as well as ensure a positive global economic environment for American products, and demonstrate benevolent and respectable global leadership  Different types of foreign aid typically support different objectives  But there is also considerable overlap among categories of aid  Multilateral aid serves many of the same objectives as bilateral development assistance, although through different channels  Military assistance, economic security aid—including rule of law and police training—and development assistance programs may support the same U S  political objectives in the Middle East, Afghanistan, and Pakistan  Military assistance and alternative development programs are integrated elements of American counternarcotics efforts in Latin America and elsewhere  Depending on how they are designed, individual assistance projects can also serve multiple purposes  A health project ostensibly directed at alleviating the effects of HIV/AIDS by feeding orphan children may also stimulate grassroots democracy and civil society through support of indigenous NGOs while additionally meeting U S  humanitarian objectives  Microcredit programs that support small business development may help develop local economies while at the same time enabling client entrepreneurs to provide food and education to their children  Water and sanitation improvements both mitigate health threats and stimulate economic growth by saving time previously devoted to water collection, raising school attendance for girls, and facilitating tourism, among other effects  In 2006, in an effort to rationalize the assistance program more clearly, the State Department developed a framework that organizes U S  foreign aid around five strategic objectives, each of which includes a number of program elements, also known as sectors  The five objectives are Peace and Security; Investing in People; Governing Justly and Democratically; Economic Growth; and Humanitarian Assistance  Generally, these objectives and their sectors do not correspond to any one particular budget account in appropriations bills  Annually, the Department of State and USAID develop their foreign operations budget request within this framework, allowing for an objective and program-oriented viewpoint for those who seek it  An effort by the State Department to obtain reporting from all departments and agencies of the U S  government on aid levels categorized by objective and sector is ongoing  USAID's Explorer website (explorer usaid gov) currently provides a more complete picture from all parts of the U S  government (see Table 1 )  The 2006 framework introduced by the Department of State organizes assistance by foreign policy strategic objective and sector  But there are many other ways to categorize foreign aid, one of which is to sort out and classify foreign aid accounts in the U S  budget according to the types of activities they are expected to support, using broad categories such as military, bilateral development, multilateral development, humanitarian assistance, political/strategic, and nonmilitary security activities (see Figure 1 )  This methodology reflects the organization of aid accounts within the SFOPS appropriations but can easily be applied to the international food aid title of the Agriculture appropriations as well as to the DOD and other government agency assistance programs with funding outside traditional foreign aid budget accounts  In FY2017, these many aid accounts provided $49 9 billion in obligated assistance  For FY2017, U S  government departments and agencies obligated about $16 2 billion in bilateral development assistance, or 33% of total foreign aid, primarily through the Development Assistance (DA) and Global Health (Global Health-USAID and Global Health-State) accounts and the administrative accounts that allow USAID to operate (Operating Expenses, Capital Investment Fund, and Office of the Inspector General)  Other bilateral development assistance accounts support the development efforts of distinct institutions, such as the Peace Corps, Inter-American Foundation (IAF), U S -African Development Foundation, Trade and Development Agency, Millennium Challenge Corporation (MCC), and National Endowment for Democracy (NED)  Development assistance programs aim to foster sustainable broad-based economic progress and social stability in developing countries  This aid is managed largely by USAID and is used for long-term projects in a wide range of areas  Many programs share the objective in the State Department framework of "promoting economic growth and prosperity " Agriculture programs focus on reducing poverty and hunger, trade-promotion opportunities for farmers, and sound environmental practices for sustainable agriculture  Private sector development programs include support for business associations and microfinance services  Programs for managing natural resources and protecting the global environment focus on conserving biological diversity; improving the management of land, water, and forests; encouraging clean and efficient energy production and use; and reducing the threat of global climate change  Programs supporting the objective of "governing justly and democratically" include support for promoting rule of law and human rights, good governance, political competition, and civil society  Programs with the objective of "investing in people" include support for basic, secondary, and higher education; improving government ability to provide social services; water and sanitation; and health care  By far the largest portion of bilateral development assistance is devoted to global health  These programs include treatment of HIV/AIDS and other infectious diseases, maternal and child health, family planning and reproductive health programs, and strengthening the government health systems that provide care  Most funding for HIV/AIDS, malaria, and tuberculosis is directed through the State Department's Office of the Global AIDS Coordinator to other agencies, including USAID and the Centers for Disease Control and Prevention  The latter agency and the National Institutes for Health also conduct programs funded by Labor-Health and Human Services (HHS) appropriations  In addition to providing emergency food aid in crisis situations, a portion (about 25% in FY2017) of the Food for Peace (FFP) Title II international food aid program (also referred to as P L  480, named after the 1954 law that authorized it)—funded under the Agriculture appropriations—provides nonemergency food commodities to private voluntary organizations (PVOs) or multilateral organizations, such as the World Food Program, for development-oriented purposes  FFP funds are also used to support the "farmer-to-farmer" program, which sends hundreds of U S  volunteers as technical advisors to train farm and food-related groups throughout the world  In addition, the McGovern-Dole International Food for Education and Child Nutrition Program, a program begun in 2002, provides commodities, technical assistance, and financing for school feeding and child nutrition programs  A share of U S  foreign assistance—4% in FY2017 ($2 1 billion)—is combined with contributions from other donor nations to finance multilateral development projects  Multilateral aid is funded largely through the International Organizations and Programs (IO&P) account and individual accounts for each of the Multilateral Development Banks (MDBs) and global environmental funds  For FY2017, the U S  government obligated $2 1 billion for development activities managed by international organizations and financial institutions, including contributions to the United Nations Children's Fund (UNICEF); the United Nations Development Program (UNDP); and MDBs, such as the World Bank  The U S  share of donor contributions to each of the MDB concessional (subsidized) and nonconcessional (market rate) loan windows varies widely  For the largest MDB, the World Bank, the United States has contributed about 20 5% to the nonconcessional lending window (the International Development Associations [IDA]) and about 17 3% to the nonconcessional lending window (the International Bank for Reconstruction and Development [IBRD])  In determining the U S  share of donor contributions to the various multilateral institutions, the U S  faces the challenge of finding the right balance between the benefits of burden sharing and the constraints of sharing control when determining multilateral priorities  For FY2017, obligations for humanitarian assistance programs amounted to $8 9 billion, 18% of total assistance  Unlike development assistance programs, which are often viewed as long-term efforts that may have the effect of preventing future crises from emerging, humanitarian assistance programs are devoted largely to the immediate alleviation of human suffering in emergencies, both natural and man-made, as well as problems resulting from conflict associated with failed or failing states  The largest portion of humanitarian assistance is managed through the International Disaster Assistance (IDA) account by USAID, which provides relief and rehabilitation efforts to victims of man-made and natural disasters, such as the economic and social dislocations caused by the 2014/2015 Ebola epidemic, and the ongoing crises in Syria, South Sudan, Yemen, and Venezuela  A portion of IDA is used for food assistance through the Emergency Food Security Program  Additional humanitarian assistance goes to programs administered by the State Department and funded under the Migration and Refugee Assistance (MRA) and the Emergency Refugee and Migration Assistance (ERMA) accounts, aimed at addressing the needs of refugees and internally displaced persons  These accounts support a number of refugee relief organizations, including the U N  High Commission for Refugees and the International Committee of the Red Cross  The Department of Defense provides disaster relief under the Overseas Humanitarian, Disaster, and Civic Assistance (OHDACA) account of the DOD appropriations  (For further information on humanitarian programs, see CRS In Focus IF10568, Overview of the Global Humanitarian and Displacement Crisis , by Rhoda Margesson ) The bulk of FFP Title II Agriculture appropriations—$1 3 billion in obligations, about 75% of total Food for Peace Act in FY2017—are used by USAID, mostly to purchase U S  agricultural commodities, for emergency needs, supplementing both refugee and disaster programs  (For more information on food aid programs, see CRS Report R45422, U S  International Food Assistance: An Overview , by Alyssa R  Casey ) A few accounts promote special U S  political and strategic interests  Programs funded through the Economic Support Fund (ESF) account generally aim to promote political and economic stability, often through activities indistinguishable from those provided under regular development programs  However, ESF is also used for direct budget support to foreign governments and to support sovereign loan guarantees  For FY2017, USAID and the State Department obligated $4 8 billion, nearly 10% of total assistance, through this account  For many years, following the 1979 Camp David accords, most ESF funds went to support the Middle East Peace Process—in FY1997, for example, 87% of ESF went to Israel, Egypt, the West Bank and Jordan  Those proportions have declined significantly in recent decades  In FY2007, 22% of ESF funding went to these countries and, in FY2017, 25%  Since the September 2001 terrorist attacks, ESF has largely supported countries of importance in the U S  global counterterrorism strategy  In FY2007, for example, activities is Afghanistan and Pakistan received 17% of ESF funding (25% in FY2017)  Over the years, other accounts have been established to meet specific political or security interests and then were dissolved once the need was met  One example is the Assistance to Eastern Europe and Central Asia (AEECA) account, established in FY2009 to combine two aid programs that met particular strategic political interests arising from the demise of the Soviet empire  The SEED (Support for East European Democracy Act of 1989) and the FREEDOM Support Act (Freedom for Russia and Emerging Eurasian Democracies and Open Markets Support Act of 1992) programs were designed to help Central Europe and the newly independent states of the former Soviet Union (FSA) achieve democratic systems and free market economies  With funding decreasing as countries in the region graduated from U S  assistance, Congress discontinued use of the AEECA account in the FY2013 appropriations  Increasing requests and appropriations for countries in the former Soviet Union threatened by Russia, however, led to its re-emergence in the FY2017 and succeeding SFOPS appropriations  In the recent past, several DOD-funded nontraditional aid programs directed at Afghanistan also supported development efforts  The Afghanistan Infrastructure Fund and the Business Task Force wound down as the U S  military presence in that country declined; the Commander's Emergency Response Program (CERP) still exists  The latter two programs had earlier iterations as well in Iraq  Several U S  government agencies support programs to address global concerns that are considered threats to U S  security and well-being, such as terrorism, illicit narcotics, crime, and weapons proliferation  In the past two decades, policymakers have given greater weight to these programs  In FY2017, they amounted to $2 9 billion, 6% of total assistance Since the mid-1990s, three U S  agencies—State, DOD, and Energy—have provided funding, technical assistance, and equipment to counter the proliferation of chemical, biological, radiological, and nuclear weapons  Originally aimed at the former Soviet Union under the rubric cooperative threat reduction (CTR), these programs seek to ensure that these weapons are secured and their spread to rogue nations or terrorist groups prevented  In addition to nonproliferation efforts, the Nonproliferation, Anti-Terrorism, Demining and Related Programs (NADR) account, managed by the State Department, encompasses civilian anti-terrorism efforts such as detecting and dismantling terrorist financial networks, establishing watch-list systems at border controls, and building developing country anti-terrorism capacities  NADR also funds humanitarian demining programs  The State Department is the main implementer of counternarcotics programs  The State-managed International Narcotics Control and Law Enforcement (INCLE) account supports counternarcotics activities, most notably in Afghanistan, Pakistan, Peru, and Colombia  It also helps develop the judicial systems—assisting judges, lawyers, and legal institutions—of many developing countries, especially in Afghanistan  DOD and USAID also support counternarcotics activities, the former largely by providing training and equipment, the latter by offering alternative crop and employment programs  The United States provides military assistance to U S  friends and allies to help them acquire U S  military equipment and training  At $14 5 billion, military assistance accounted for about 29% of total U S  foreign aid in FY2017  The Department of State administers three programs, with corresponding appropriations accounts that are then implemented by DOD  Foreign Military Financing (FMF) is a grant program that enables governments to receive equipment and associated training from the U S  government or to access equipment directly through U S  commercial channels  Most FMF grants support the security needs of Israel, Egypt, Jordan, Pakistan, and Iraq  The International Military Education and Training program (IMET) offers military training on a grant basis to foreign military officers and personnel  Peacekeeping funds (PKO) are used to support voluntary non-U N  peacekeeping operations as well as training for an African crisis response force  Since 2002, DOD appropriations have supported FMF-like programs, training and equipping security forces in Afghanistan and Iraq  These programs and the accounts that fund them are called the Afghanistan Security Forces Fund (ASFF) and, through FY2012, the Iraq Security Forces Fund (ISFF)  Beginning in FY2015, similar support was provided Iraq under the Iraq Train and Equip Fund  The DOD-funded programs in Afghanistan and Iraq accounted for more than half of total military assistance in FY2017  How and in what form assistance reaches an aid recipient can vary widely, depending on the type of aid program, the objective of the assistance, and the agency responsible for providing the aid  Federal agencies may implement foreign assistance programs using funds appropriated directly to them or funds transferred to them from another agency  For example, significant funding appropriated through State Department and Department of Agriculture accounts is used for programs implemented by USAID (see Figure 2 )  The funding data in this section reflect the agency that implemented the aid, not necessarily the agency to which funds were originally appropriated  For 50 years, USAID has implemented the bulk of the U S  bilateral economic development and humanitarian assistance  It directly implements the Development Assistance, International Disaster Assistance, and Transition Initiatives accounts, as well as a USAID-designated portion of the Global Health account  Jointly with the State Department, USAID co-manages ESF, AEECA, and Democracy Fund programs, which frequently support development activities as a means of promoting U S  political and strategic goals  Based on historical averages, according to USAID, the agency implements more than 90% of ESF, 70% of AEECA, 40% of the Democracy Fund, and about 60% of the Global HIV/AIDS funding appropriated to the State Department  USAID also implements all Food for Peace Act Title II food assistance funded through agriculture appropriations  USAID obligated an estimated $20 55 billion to implement foreign assistance programs and activities in FY2017  The agency's staff in 2018 totaled 9,747 , of which about 67% were working overseas, overseeing the implementation of hundreds of projects undertaken by thousands of private sector contractors, consultants, and nongovernmental organizations  DOD implements all SFOPS-funded military assistance programs—FMF, IMET, PKO, and PCCF—in conjunction with the policy guidance of the Department of State  The Defense Security Cooperation Agency is the primary DOD body responsible for these programs  DOD also carries out an array of state-building activities, funded through defense appropriations legislation, which are usually in the context of training exercises and military operations  These sorts of activities, once the exclusive jurisdiction of civilian aid agencies, include development assistance to Iraq and Afghanistan through the Commander's Emergency Response Program (CERP), the Iraq Relief and Reconstruction Fund, and the Afghanistan Infrastructure Fund, and elsewhere through the Defense Health Program, counterdrug activities, and humanitarian and disaster relief  Training and equipping of Iraqi and Afghan police and military, though similar in nature to some traditional security assistance programs, has been funded and implemented primarily through DOD appropriations, though implementing the Iraq police training program was a State Department responsibility from 2012 until it was phased out in 2013  In FY2017, the Department of Defense implemented an estimated $14 50 billion in foreign assistance programs  The Department of State manages and co-manages a wide range of assistance programs  It is the lead U S  civilian agency on security and refugee related assistance, and has sole responsibility for implementing the International Narcotics and Law Enforcement (INCLE) and Nonproliferation, Antiterror, and Demining (NADR) accounts, the two Migration and Refugee accounts (MRA and ERMA), and the International Organizations and Programs (IO&P) account  State is also home to the Office of the Global AIDS Coordinator (OGAC), which manages the State Department's portion of Global Health funding in support of HIV/AIDS programs, though many of these funds are transferred to and implemented by USAID, the National Institutes of Health, and the Centers for Disease Control and Prevention  In conjunction with USAID, the State Department manages the Economic Support Fund, AEECA assistance to the former communist states, and Democracy Fund accounts  For these accounts, the State Department largely sets the overall policy and direction of funds, while USAID implements the preponderance of programs  In addition, the State Department, through its Bureau of Political-Military Affairs, has policy authority over the Foreign Military Financing (FMF), International Military Education and Training (IMET), and Peacekeeping Operations (PKO) accounts, and, while it was active, the Pakistan Counterinsurgency Capability Fund (PCCF)  These programs are implemented by the Department of Defense  Police training programs have traditionally been the responsibility of the International Narcotics and Law Enforcement (INL) Office in the State Department, though programs in Iraq and Afghanistan were implemented and paid for by the Department of Defense for several years  State is also the organizational home to the Office of U S  Foreign Assistance Resources (formerly the Office of the Director of Foreign Assistance), known as "F," which was created in 2006 to coordinate U S  foreign assistance programs  The office establishes standard program structures and definitions, as well as performance indicators, and collects and reports data on State Department and USAID aid programs  The State Department implemented about $7 66 billion in foreign assistance funding in FY2017, though it has policy authority over a much broader range of assistance funds  The U S  Department of Health and Human Services implements a range of global health programs through its various component institutions  As an implementing partner in the President's Emergency Plan for Aids Relief (PEPFAR), a large portion of HHS foreign assistance activity is related to HIV prevention and treatment, including technical support and preventing mother to child transmission of HIV/AIDS  The Centers for Disease Control and Prevention participates in a broad range of global disease control activity, including rapid outbreak response, global research and surveillance, information technology assistance, and field epidemiology and laboratory training  The National Institutes of Health (NIH) also conduct international health research that is reported as assistance  In FY2017, HHS institutions implemented $2 66 billion in foreign assistance activities  The Department of the Treasury's Under Secretary for International Affairs administers U S  contributions to and participation in the World Bank and other multilateral development institutions  In this case, the agency manages the distribution of funds to the institutions, but does not implement programs  Presidentially appointed U S  executive directors at each of the banks represent the United States' point of view  Treasury also deals with foreign debt reduction issues and programs, including U S  participation in the Highly Indebted Poor Countries (HIPC) initiative, and manages a technical assistance program offering temporary financial advisors to countries implementing major economic reforms and combating terrorist finance activity  For FY2017, the Department of the Treasury managed foreign assistance valued at about $1 85 billion  Created in February 2004, the Millennium Challenge Corporation (MCC) seeks to concentrate significantly higher amounts of U S  resources in a few low- and lower-middle-income countries that have demonstrated a strong commitment to political, economic, and social reforms relative to other developing countries  A significant feature of the MCC effort is that recipient countries formulate, propose, and implement mutually agreed multi-year U S -funded project plans known as compacts  Compacts in the 27 recipient countries selected to date have emphasized construction of infrastructure  The MCC is a U S  government corporation, headed by a chief executive officer who reports to a board of directors chaired by the Secretary of State  The Corporation maintains a relatively small staff of about 300  The MCC obligated about $1 01 billion in FY2017  A number of other government agencies play a role in implementing foreign aid programs  The Peace Corps, an autonomous agency with FY2017 obligations of $445 million, supports about 7,300 volunteers in 65 countries  Peace Corps volunteers work in a wide range of educational, health, and community development projects  The Trade and Development Agency (TDA), which obligated $58 million in FY2017, finances trade missions and feasibility studies for private sector projects likely to generate U S  exports  The Overseas Private Investment Corporation (OPIC) provides political risk insurance to U S  companies investing in developing countries and finances projects through loans and guarantees  Its insurance activities have been self-sustaining, but credit reform rules require a relatively small appropriation to back up U S  guarantees and for administrative expenses  The Better Utilization of Investments Leading to Development Act of 2018 (BUILD Act), signed into law in October 2018 ( P L  115-254 ), authorized consolidation of OPIC and USAID's Development Credit Authority into a new U S  International Development Finance Corporation (IDFC), which is expected to become operational in fall 2019  For FY2017, as for most prior years, OPIC receipts exceeded appropriations, resulting in a net gain to the Treasury  The Inter-American Foundation and the African Development Foundation, obligating $25 8 million and $20 2 million, respectively, in FY2017, finance small-scale enterprise and grassroots self-help activities aimed at assisting poor people  Most U S  assistance is now provided as a grant (gift) rather than a loan, so as not to increase the heavy debt burden carried by many developing countries  However, the forms a grant may take are diverse  The most common type of U S  development aid is project-based assistance (77% in FY2017), in which aid is channeled through an implementing partner to complete a project  Aid is also provided in the form of core contribution to international organizations such as the United Nations, technical assistance, and direct budget support (cash transfer) to governments  A portion of aid money is also spent on administrative costs ( Figure 3 )  Within these categories, aid may take many forms, as described below  Although it is the exception rather than the rule, some countries receive aid in the form of a cash grant to the government  Dollars provided in this way support a government's balance-of-payments situation, enabling it to purchase more U S  goods, service its debt, or devote more domestic revenues to developmental or other purposes  Cash transfers have been made as a reward to countries that have supported the United States' counterterrorism operations (Turkey and Jordan in FY2004), to provide political and strategic support (both Egypt and Israel annually for decades after the 1979 Camp David Peace Accord), and in exchange for undertaking difficult political and economic reforms  Assistance may be provided in the form of food commodities, weapons systems, or equipment such as generators or computers  Food aid may be provided directly to meet humanitarian needs or to encourage attendance at a maternal/child health care program  Weapons supplied under the military assistance program may include training in their use  Equipment and commodities provided under development assistance are usually integrated with other forms of aid to meet objectives in a particular social or economic sector  For instance, textbooks have been provided in both Afghanistan and Iraq as part of a broader effort to reform the educational sector and train teachers  Computers may be offered in conjunction with training and expertise to fledgling microcredit institutions  Since PEPFAR was first authorized in 2004, antiretroviral drugs (ARVs) provided to individuals living with HIV/AIDS have been a significant component of commodity-based assistance  Although once a significant portion of U S  assistance programs, construction of economic infrastructure—roads, irrigation systems, electric power facilities, etc —was rarely provided after the 1970s  Because of the substantial expense of these projects, they were to be found only in large assistance programs, such as that for Egypt in the 1980s and 1990s, where the United States constructed major urban water and sanitation systems  The aid programs in Iraq and Afghanistan supported the building of schools, health clinics, roads, power plants, and irrigation systems  In Iraq alone, more than $10 billion went to economic infrastructure  Economic infrastructure is now also supported by U S  assistance in a wider range of developing countries through the Millennium Challenge Corporation  In this case, recipient countries design their own assistance programs, most of which, to date, include an infrastructure component  Transfer of knowledge and skills is a significant part of most assistance programs  The International Military Education and Training Program (IMET) provides training to officers of the military forces of allied and friendly nations  Tens of thousands of citizens of aid recipient countries receive short-term technical training or longer-term degree training annually under USAID programs  More than one-quarter of Peace Corps volunteers are English, math, and science teachers  Other aid programs provide law enforcement personnel with anti-narcotics or anti-terrorism training  Many assistance programs provide expert advice to government and private sector organizations  The Department of the Treasury, USAID, and U S -funded multilateral banks all place specialists in host government ministries to make recommendations on policy reforms in a wide variety of sectors  USAID has often placed experts in private sector business and civic organizations to help strengthen them in their formative years or while indigenous staff are being trained  While most of these experts are U S  nationals, in Russia, USAID funded the development of locally staffed political and economic think tanks to offer policy options to that government  USAID, the Inter-American Foundation, and the African Development Foundation often provide aid in the form of small grants directly to local organizations to foster economic and social development and to encourage civic engagement in their communities  Grants are sometimes provided to microcredit organizations, such village-level women's savings groups, which in turn provide loans to microentrepreneurs  Small grants may also address specific community needs  Recent IAF grants, for example, have supported organizations that help resettle Salvadoran migrants deported from the United States and youth programs in Central America aimed at gang prevention  Under the Foreign Assistance Act of 1961, the President may determine the terms and conditions under which most forms of assistance are provided  In general, the financial condition of a country—its ability to meet repayment obligations—has been an important criterion of the decision to provide a loan or grant  Some programs, such as humanitarian and disaster relief programs, were designed from the beginning to be entirely grant activities  During the past two decades, nearly all foreign aid—military as well as economic—has been provided in grant form  While loans represented 32% of total military and economic assistance between 1962 and 1988, this figure declined substantially beginning in the mid-1980s, until by FY2001, loans represented less than 1% of total aid appropriations  The de-emphasis on loan programs came largely in response to the debt problems of developing countries  Both Congress and the executive branch have generally supported the view that foreign aid should not add to the already existing debt burden carried by these countries  In the FY2019 budget request, the Trump Administration encouraged the use of loans over grants when providing military assistance (Foreign Military Financing), but Congress did not include language in support of that proposal in the enacted FY2019 appropriation ( P L  116-6 )  Although a small proportion of total current aid, there are significant USAID-managed programs that guarantee loans, meaning the U S  government agrees to pay a portion of the amount owed in the case of a default on a loan  A Development Credit Authority (DCA) loan guarantee, in which risk is shared with a private sector bank, can be used to increase access to finance in support of any development sector  The DCA is to be transferred from USAID in 2019 to the new IDFC, established by the BUILD Act of 2018 ( P L  115-254 ), to enhance U S  development finance capacity  Under the Israeli Loan Guarantee Program, the United States has guaranteed repayment of loans made by commercial sources to support the costs of immigrants settling in Israel from other countries and may issue guarantees to support economic recovery  USAID has also provided loan guarantees in recent years to improve the terms or amounts of financing from international capital markets for Ukraine and Jordan  In these cases, assistance funds representing a fraction of the guarantee amount are provided to cover possible default  Between 1946 and 2016, the United States loaned $112 7 billion in foreign economic and military aid to foreign governments, and while most foreign aid is now provided through grants, $9 18 billion in loans to foreign governments remained outstanding at the end of FY2016  For nearly three decades, Section 620q of the Foreign Assistance Act (the Brooke amendment) has prohibited new assistance to the government of any country that falls more than one year past due in servicing its debt obligations to the United States, though the President may waive application of this prohibition if he determines it is in the national interest  The United States has also forgiven debts owed by foreign governments and encouraged, with mixed success, other foreign aid donors and international financial institutions to do likewise  In some cases, the decision to forgive foreign aid debts has been based largely on economic grounds as another means to support development efforts by heavily indebted, but reform-minded, countries  The United States has been one of the strongest supporters of the Heavily Indebted Poor Country (HIPC) Initiative and the Multilateral Debt Relief Initiative (MDRI)  These initiatives, which began in the late 1990s, include participation of the World Bank, the International Monetary Fund, and other international financial institutions in a comprehensive debt workout framework for the world's poorest and most debt-strapped nations  The largest and most hotly debated debt forgiveness actions have been implemented for much broader foreign policy reasons with a more strategic purpose  Poland, during its transition from a communist system and centrally planned economy (1990—$2 46 billion); Egypt, for making peace with Israel and helping maintain the Arab coalition during the Persian Gulf War (1990—$7 billion); and Jordan, after signing a peace accord with Israel (1994—$700 million), are examples  Similarly, the United States forgave about $4 1 billion in outstanding Saddam Hussein-era Iraqi debt in November 2004 and helped negotiate an 80% reduction in Iraq's debt to creditor nations later that month  Most development and humanitarian assistance activities are not directly implemented by U S  government personnel but by private sector entities, such as individual personal service contractors, consulting firms, universities, private voluntary organizations (PVOs), or public international organizations (PIOs)  Generally speaking, U S  government foreign service and civil servants determine the direction and priorities of the aid program, allocate funds while keeping within legislative requirements, ensure that appropriate projects are in place to meet aid objectives, select implementers, and monitor the implementation of those projects for effectiveness and financial accountability  Both USAID and the State Department have promoted the use of public-private partnerships, in which private entities such as corporations and foundations are contributing partners, not paid implementers, in situations where business interests and development objectives coincide  In FY2017, the United States provided some form of bilateral foreign assistance to more than 150 countries  Aid is concentrated heavily in certain countries, reflecting the priorities and interests of United States foreign policy at the time  Table 2 identifies the top 15 recipients of U S  foreign assistance for FY1997, FY2007 and FY2017  As shown in the table above, there are both similarities and sharp differences among country aid recipients for the three periods  The most consistent thread connecting the top aid recipients over the past two decades has been continuing U S  strategic interests in the Middle East, with large programs maintained for Israel and Egypt and, for Iraq, following the 2003 invasion  Two key countries in the U S  counterterrorism strategy, Afghanistan and Pakistan, made their first appearances on the list in FY2002 and continued to be among the top recipients in FY2017  In FY1997, one sub-Saharan African country appeared among leading aid recipients; in FY2017, 7 of the 15 are sub-Saharan African  Many are focus countries under the PEPFAR initiative to address the HIV/AIDS epidemic; South Sudan receives support as a newly independent country with multiple humanitarian and development needs  In FY1997, three countries from Eastern Europe and the former Soviet Union made the list, as many from the region had for much of the 1990s, representing the effort to transform the former communist nations to democratic societies and market-oriented economies  None of those countries appear in the FY2017 list  In FY1997, four Latin American countries make the list; no countries from the region appear in FY2017  On a regional basis, the Middle East/North Africa (MENA) region has received the largest share of U S  foreign assistance for many decades  Although economic aid to the region's top two recipients, Israel and Egypt, began to decline in the late 1990s, the dominant share of bilateral U S  assistance consumed by the MENA region was maintained in FY2005 by the war in Iraq  Despite the continued importance of the region, its share slipped substantially by FY2017 as the effort to train and equip Iraqi forces diminished  Since September 11, 2001, South and Central Asia has emerged as a significant target of U S  assistance, rising from a roughly 3% share 20 years ago to 16% in FY2007 and 15% in FY2017, largely because of aid to Afghanistan and Pakistan  Similarly, the share represented by African nations has increased from 10% and 19%, respectively, in FY1997 and FY2007, to 25% in FY2017, largely due to the HIV/AIDS initiative that funnels resources mostly to African countries and to a range of other efforts to address the region's development challenges  Meanwhile, the share of aid to Europe/Eurasia, which greatly surpassed that of Africa in FY1997, has declined significantly in the past decade, to about 4% in FY2017, with the graduation of many East European aid recipients and the termination of programs in Russia  The Ukraine was responsible for about one third of aid to that region in FY2017  East Asia/Pacific has remained at a low level during the past two decades, while Latin America's share has risen and fallen based on U S  interest in Colombia and a few Central American countries as aid has shifted to regions of more pressing strategic interest (see Figure 4 )  There are several methods commonly used for measuring the amount of federal spending on foreign assistance  Amounts can be expressed in terms of budget authority (funds appropriated by Congress), obligations (amounts contractually committed), outlays or disbursements (money actually spent)  Assistance levels are also sometimes measured as a percentage of the total federal budget, as a percentage of total discretionary budget authority (excluding mandatory and entitlement programs), or as a percentage of the gross domestic product (GDP) (for an indication of the national wealth allocated to foreign aid)  By nearly all of these measures, foreign aid resources fell gradually on average over several decades since the historical high levels of the late 1940s and early 1950s ( Appendix A )  This downward trend was sporadically interrupted, largely due to major foreign policy initiatives such as the Alliance for Progress for Latin America beginning in 1961, the infusion of funds to implement the Camp David Middle East Peace Accords in 1979, and an increase in military assistance to Egypt, Turkey, Greece and others in the mid-1980s  The lowest point in U S  foreign aid spending since World War II came in 1997, when foreign assistance obligations fell to just above $20 billion (in 2017 dollar terms)  ( Figure 5 ) While foreign aid consistently represented just over 1% of U S  annual gross domestic product in the decade following World War II, it fell gradually to between 0 2% and 0 4% for most years in the past three decades  Foreign assistance spending has comprised, on average, around 3% of discretionary budget authority and just over 1% of total budget authority each year since 1977, though the percentages have sometimes varied considerably from year to year  Foreign aid dropped from 5% of discretionary budget authority in 1979 to 2 4% in 2001, before rising sharply in conjunction with U S  activities in Afghanistan and Iraq starting in 2003  As a portion of total budget authority, foreign assistance reached 2 5% in 1979, but has hovered below 1 5% since 1987  In 2017, foreign assistance was estimated to account for 4 1% of discretionary budget authority and 1 2% of total budget authority ( Figure 6 ; Appendix A )  As previously discussed, since the September 11, 2001, terrorist attacks, foreign aid funding has been closely tied to U S  counterterrorism strategy, particularly in Iraq, Afghanistan, and Pakistan  Bush and Obama Administration global health initiatives, the creation of the Millennium Challenge Corporation, and growth in counter-narcotics activities have driven funding increases as well  The Budget Control Act of 2011, and the drawdown of U S  military forces in Iraq, and to some degree Afghanistan, led to a notable dip in aid obligations in FY2013, but aid levels have risen again with efforts to address the crisis in Syria, counter-ISIL activities, and humanitarian aid  The use of the Overseas Contingency Operations (OCO, discussed below) designation has enabled this growth despite the BCA limitations  Figure 7 shows how trends in foreign aid funding in recent decades can be attributed to specific foreign policy events and presidential initiatives  The Obama Administration's FY2012 international affairs budget proposed that the overseas contingency operations (OCO) designation, which had been applied since 2009 to war-related Defense appropriations, including to DOD assistance programs such as ISFF, ASFF and CERP, be extended to include "extraordinary, but temporary, costs of the Department of State and USAID in the front line states of Iraq, Afghanistan and Pakistan " Congress not only adopted the OCO designation in the FY2012 SFOPS appropriations legislation, but expanded it to include funding for additional accounts and countries  In every fiscal year since, a portion of certain foreign assistance accounts—primarily ESF, FMF, IDA, MRA and INCLE—has been appropriated with the OCO designation  The OCO designation is significant because the Budget Control Act of 2011 (BCA), which set annual caps on discretionary funding from FY2013 through FY2021, specified that funds designated as OCO do not count toward the discretionary spending limits established by the act  OCO designation makes it possible to prevent war-related funding from crowding out core international affairs activities within the budget allocation  The OCO approach is reminiscent of the use of supplemental international affairs appropriations for the first decade after the September 11, 2001, terrorist attacks  Congress appropriated significant emergency supplemental funds for foreign operations and Defense assistance programs every year from FY2002 through FY2010 for activities in Iraq, Afghanistan, and elsewhere, which were not counted toward subcommittee budget allocations  Since the OCO designation was first applied to foreign operations in FY2012, supplemental appropriations for foreign aid have declined significantly  In the FY2019 and FY2020 budget requests, the Trump Administration did not request OCO funding within the international affairs budget, but did request OCO funding for the Department of Defense, including for DOD aid accounts  Congress used the OCO designation for both DOD and State/USAID accounts in the FY2019 appropriation, P L  116-6 , but a smaller portion of aid was designated as OCO compared to FY2018  It remains to be seen whether this is the beginning of a downward trend in OCO use for foreign aid  Congress historically sought to enhance the domestic benefits of foreign aid by requiring that most U S  foreign aid be used to procure U S  goods and services  The conditioning of aid on the procurement of goods and services from the donor-country is sometimes called "tied aid," and while quite common for much of the history of modern foreign assistance, has become increasingly disfavored in the international community  Studies have shown that tying aid increases the costs of goods and services by 15%-30% on average, and up to 40% for food aid, reducing the overall effectiveness of aid flows  The United States joined other donor nations in committing to reduce tied aid in the Paris Declaration on Aid Effectiveness in March 2005, and the portion of tied aid from all donors fell from 70% of total bilateral development assistance in 1985 to an average of 12% in 2016  However, an estimated 32% of U S  bilateral development assistance was tied in 2016, the highest percentage among major donors, perhaps reflecting the perception of policymakers that maintaining public and political support for foreign aid programs requires ensuring direct economic benefit to the United States  About 67% of U S  foreign assistance funds in FY2017 were obligated to U S -based entities  A considerable amount of U S  foreign assistance funds remain in the United States, through domestic procurement or the use of U S  implementers, but the portion differs by program and is hard to identify with any accuracy  For some types of aid, the legislative requirements or program design make it relatively easy to determine how much aid is spent on U S  goods or services, while for others, this is more difficult to determine  USAID  Most USAID funding (Development Assistance, Global Health, Economic Support Fund) is implemented through contracts, grants, and cooperative agreements with implementing partners  While many implementing partner organizations are based in the United States and employ U S  citizens, there is little information available about what portion of the funds used for program implementation are used for goods and services provided by American firms  Procurement reform efforts initiated by USAID in 2010 have aimed to increase procurement and implementation by host country entities as a means to enhance country ownership, build local capacity, and improve sustainability of aid programs  Food assistance commodities, until recently, were purchased wholly in the United States, and generally required by law to be shipped by U S  carriers, suggesting that the vast majority of food aid expenditures are made in the United States  Starting in FY2009, a small portion of food assistance was authorized to be purchased locally and regionally to meet urgent food needs more quickly  Successive Administrations and several Members of Congress have proposed greater flexibility in the food aid program, potentially increasing aid efficiency but reducing the portion of funds flowing to U S  farmers and shippers  To date, these proposals have been largely unsuccessful  Foreign Military Financing , with the exception of certain assistance allocated to Israel, is used exclusively to procure U S  military equipment and training  Millennium Challenge Corporation  The MCC bases its procurement regulations on those established by the World Bank, which calls for an open and competitive process, with no preference given to donor country suppliers  Between FY2011 and FY2017, the MCC awarded roughly 15% of the value of compact contracts to U S  firms  Multilateral development aid  Multilateral aid funds are mixed with funds from other nations and the bulk of the program is financed with borrowed funds rather than direct government contributions  Information on the U S  share of procurement financed by MDBs is unavailable  In addition to the direct benefits derived from aid dollars used for American goods and services, many argue that the foreign aid program brings significant indirect financial benefits to the United States  For example, analysts maintain that provision of military equipment through the military assistance program and food commodities through the Food for Peace program helps to develop future, strictly commercial, markets for those products  More broadly, as countries develop economically, they are in a position to purchase more goods from abroad and the United States benefits as a trade partner  Since an increasing majority of global consumers are outside of the United States, some business leaders assert that establishing strong economic and trade ties in the developing world, using foreign assistance as a tool, is key to U S  economic and job growth  Since World War II, with the exception of several years between 1989 and 2001, during which Japan ranked first among aid donors, the United States has led the developed countries in net disbursements of economic aid, or "Official Development Assistance (ODA)" as defined by the Organization for Economic Cooperation and Development's (OECD) Development Assistance Committee (DAC)  In 2017, the most recent year for which data are available, the United States disbursed $34 12 billion in ODA, or about 24% of the $144 71 billion in total net ODA disbursements by DAC donors that year  Germany ranked second at $24 16 billion, the United Kingdom followed at $18 59 billion, Japan ranked fourth at $11 85 billion, and France rounded out the top donors with $11 03 billion in 2017 (see Figure 8 )  While the top five donors have not varied for more than a decade, there have been shifts lower down the ranking  For example, Turkey has become a much more prominent ODA donor in recent years (ranked 6 th in 2017, with $9 08 billion in ODA, compared to 21 st in 2006), reflecting large amounts of humanitarian aid to assist Syrian refugees  Even as it leads in dollar amounts of aid flows to developing countries, the United States often ranks low when aid is calculated as a percentage of gross national income (GNI)  This calculation is often cited in the context of international donor forums, as a level of 0 7% GNI was established as a target for donors in the 2000 U N  Millennium Development Goals  In 2017, the United States ranked at the bottom among major donors at 0 18% of GNI, slightly lower than Portugal and Spain (0 18% and 0 19%, respectively)  The United Arab Emirates, which has significantly increased its reported ODA in recent years, ranked first among top donors at 1 03% of GNI, followed by Sweden at 1 02% and Luxembourg at 1 00%  There has also been an increase in ODA from non-DAC countries  Between 2000 and 2014, China spent $81 1 billion in ODA, more than tripling its ODA commitments during this period  While reported Chinese ODA is still relatively small compared to that of major donor countries, policymakers are paying increasing attention to growing Chinese investments in developing countries that do not meet the ODA definition  China has touted its "Belt and Road" initiative as an effort to boost development and connectivity across as many as 125 countries to create "strategic propellers" for its own development  However, China has provided little official aggregate information on the initiative, including on the number of projects, countries involved, the terms of financing, and metrics for success  Numerous congressional authorizing committees and appropriations subcommittees maintain responsibility for U S  foreign assistance  Several committees have responsibility for authorizing legislation establishing programs and policy and for conducting oversight of foreign aid programs  In the Senate, the Committee on Foreign Relations, and in the House, the Committee on Foreign Affairs, have primary jurisdiction over bilateral development assistance, political/strategic and other economic security assistance, military assistance, and international organizations  Food aid, primarily the responsibility of the Agriculture Committees in both bodies, is periodically shared with the Foreign Affairs Committee in the House  U S  contributions to multilateral development banks are within the jurisdiction of the Senate Foreign Relations Committee and the House Financial Services Committee  The large nontraditional aid programs funded by DOD, such as Nunn-Lugar Cooperative Threat Reduction programs and the military aid programs in Afghanistan and Iraq, come under the jurisdiction of the Armed Services Committees  Some global health assistance, such as research and other activities done by the Centers for Disease Control and Prevention, may fall under the jurisdiction of the House Energy and Commerce and Senate HELP committees  Traditionally, most foreign aid appropriations fall under the jurisdiction of the SFOPS Subcommittees, with food assistance appropriated by the Agriculture Subcommittees  As noted earlier, however, certain military, global health, and other activities that have been reported as foreign aid have been appropriated through other subcommittees in recent years, including the Defense and the Labor, Health and Human Services, Education and Related Agencies subcommittees  (For current information on SFOPS Appropriations legislation, see CRS Report R45168, Department of State, Foreign Operations and Related Programs: FY2019 Budget and Appropriations , by Susan B  Epstein, Marian L  Lawson, and Cory R  Gill ) The most significant permanent foreign aid authorization laws are the Foreign Assistance Act of 1961, covering most bilateral economic and security assistance programs (P L  87-195; 22 U S C  2151); the Arms Export Control Act (1976), authorizing military sales and financing (P L  90-629; 22 U S C  2751); the Agricultural Trade Development and Assistance Act of 1954 (P L  480), covering food aid (P L  83-480; 7 U S C  1691); and the Bretton Woods Agreement Act (1945), authorizing U S  participation in multilateral development banks (P L  79-171; 22 U S C  286)  In the past, Congress usually scheduled debates every two years on omnibus foreign aid legislation that amended these permanent authorization measures  Congress has not enacted into law a comprehensive foreign assistance authorization measure since 1985, although foreign aid authorizing bills have passed the House or Senate, or both, on numerous occasions  Foreign aid bills have frequently stalled at some point in the debate because of controversial issues, a tight legislative calendar, or executive-legislative foreign policy disputes  In contrast, DOD assistance is authorized in annual National Defense Authorization legislation  In lieu of approving a broad State Department/USAID authorization bill, Congress has on occasion authorized major foreign assistance initiatives for specific regions, countries, or aid sectors in stand-alone legislation or within an appropriation bill  Among these are the SEED Act of 1989 ( P L  101-179 ; 22 U S C  5401); the FREEDOM Support Act of 1992 ( P L  102-511 ; 22 U S C  5801); the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 ( P L  108-25 ; 22 U S C  7601); the Tom Lantos and Henry J  Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 ( P L  110-293 ); the Millennium Challenge Act of 2003 (Division D, Title VI of P L  108-199 ); the Enhanced Partnership With Pakistan Act of 2009 ( P L  111-73 ; 22 U S C  8401); the Global Food Security Act of 2016 ( P L  114-195 ; 22 U S C  9306), and the BUILD Act ( P L  115-254 )  In the absence of regular enactment of foreign aid authorization bills, appropriation measures considered annually within the SFOPS spending bill have assumed greater significance for Congress in influencing U S  foreign aid policy  Not only do appropriations bills set spending levels each year for nearly every foreign assistance account, SFOPS appropriations also incorporate new policy initiatives that would otherwise be debated and enacted as part of authorizing legislation  Appendix A  Data Table Appendix B  Common Foreign Assistance Abbreviations


Report 2:  Effective beginning March 2016, VA issued a contract modification that eliminated the requirement that community providers must submit medical documentation as a condition of receiving payment for their claims  Data from one TPA showed a reduction in non-clean claims following the implementation of this contract modification  For example, starting in April 2016, after this modification was executed, almost 100 percent of claims submitted to TriWest were classified as clean claims, as opposed to 49 percent of claims submitted in March 2016  However, when the modification first went into effect in March 2016, TriWest and Health Net officials stated that they processed a large amount of claims from community providers that had previously been pended or denied because they lacked medical documentation and, in turn, submitted a large number of invoices to VA for reimbursement  As previously discussed, to help address the increased number of TPA invoices, VA issued lump-sum payments to the TPAs during this time period  Modification of timely filing requirement  In February and May 2018, VA issued waivers that gave TPAs the authority to allow providers to resubmit rejected or denied claims more than 180 days after the end of the episode of care if the original claims were submitted timely—that is, within 180 days of the end of the episode of care  VA officials stated that the waivers were intended to reduce the number of rejected and denied claims by giving community providers the ability to resubmit previously rejected or denied claims for which the date of service occurred more than 180 days ago  VA’s waivers were implemented as follows: In February 2018, VA issued a waiver that allowed community providers to resubmit certain claims rejected or denied for specific reasons when the provider or TPA could verify that the provider made an effort to submit the claim prior to the claims submission deadline  In May 2018, VA issued a second waiver that removed the 180 day timeliness requirement for all Choice Program claims  The waiver also provided instructions to the TPAs on informing providers that they may resubmit claims rejected or denied for specific reasons and how the TPAs are to process the resubmitted claims  In regards to the first waiver, TPA officials stated that the processing of those resubmitted claims adversely affected the timeliness of the TPAs’ payments to community providers because the waiver resulted in a large influx of older claims  As the second waiver was in the process of being implemented by the two TPAs at the time we conducted our work, we were unable to determine if the second waiver affected the TPAs’ provider payment timeliness  Changes to authorization of care requirement  VA issued a contract modification in January 2017 to expand the time period for which authorizations for community providers to provide care to veterans under the Choice Program are valid  In addition, in May 2017, VA expanded the scope of the services covered by authorizations, allowing them to encompass an overall course of treatment, rather than a specific service or set of services  According to VA officials, the changes VA made related to the authorization of care requirement were also intended to reduce the need for secondary authorization requests (SAR)  Community providers request SARs when veterans need health care services that exceed the period or scope of the original authorizations  Community providers are required to submit SARs to their TPA, which, in turn, submits the SARs to the authorizing VA medical facility for review and approval  Both Health Net and TriWest officials told us that since VA changed the time frame and scope of authorizations, the number of SARs has decreased  Despite efforts to decrease the number of SARs, payment delays or claim denials are likely to continue if SARs are needed  We found that VA is not ensuring that VA medical facilities are reviewing and approving SARs within required time frames  VA policy states that VA medical facilities are to review and make SAR approval decisions within 5 business days of receipt  However, officials from one of the TPAs and 7 of the 15 providers we interviewed stated that VA medical facilities are not reviewing and approving SARs in a timely manner  According to TriWest officials, as of May 2018, VA medical facilities in their regions were taking an average of 11 days to review and make approval decisions on SARs, with four facilities taking over 30 days for this process  According to an official from VA’s Office of Community Care, VA does not currently collect reliable national data to track the extent of nonadherence to the VA policy to review and make SAR approval decisions within 5 business days  The official told us that instead, VA relies on employees assigned to each Veterans Integrated Service Network to monitor data on VA medical facilities’ timeliness in making these SAR approval decisions  If a VA medical facility is found not to be in adherence with the SAR policy, the official told us that staff assigned to the Veterans Integrated Service Network attempt to identify the reasons for nonadherence, and perform certain corrective actions, including providing education to the facility  Despite these actions, the official told us that there are still VA medical facilities not in adherence with VA’s SAR approval policy  According to a VA official, VA is in the process of piloting software for managing authorizations that will allow VA to better track SAR approval time frames across VA medical facilities in the future  However, even after this planned software is implemented, if VA does not use the data to monitor and assess SAR approval decision time frames VA will be unable to ensure that all VA medical facilities are adhering to the policy  Standards for internal control in the Federal Government state that management should establish and operate monitoring activities to evaluate whether a specific function or process is operating effectively and take corrective actions as necessary  Furthermore, monitoring such data will allow VA to identify and take actions as needed to address any identified challenges VA medical facilities are encountering in meeting the required approval decision time frames  Without monitoring data to ensure that all VA medical facilities are adhering to the SAR approval time frames as outlined in VA policy, community providers may delay care until the SARs are approved or provide care without SAR approval  This in turn increases the likelihood that the community providers’ claims will be denied  Further, continued nonadherence to VA’s SAR policy raises concerns about VA’s ability to ensure timely approval of SARs when VA medical facilities assume more responsibilities for ensuring veterans’ access to care under the forthcoming Veterans Community Care Program  We found that VA and its TPAs have taken steps to educate community providers in order to help prevent claims processing issues that have contributed to the length of time TPAs have taken to pay these providers  Despite these efforts, 9 of the 15 providers we interviewed reported poor customer service when attempting to resolve claims payment issues  While VA’s contracts with the TPAs do not include requirements for educating and training providers on the Choice Program, both TPAs have taken steps to educate community providers on how to successfully submit claims under the Choice Program  Specifically, TriWest and Health Net officials told us that they have taken various steps to educate community providers on submitting claims correctly, including sending monthly newsletters, emails, and faxes to communicate changes to the Choice Program; updating their websites with claims processing information; and holding meetings with some providers monthly or quarterly to resolve claims processing issues  Officials from both TPAs also told us that they provided one-on-one training to some providers on the claims submission process to help reduce errors when submitting claims  In addition, VA’s RFP for the Veterans Community Care Program contracts includes requirements to provide an annual training program curriculum and an initial on-boarding and ongoing outreach and education program for community providers, which includes training on the claims submission and payment processes and TPA points of contact  VA and the TPAs have also made efforts to help providers resolve claims processing issues and outstanding payments  For example, VA launched its “top 20 provider initiative” in January 2018 to work directly with community providers with high dollar amounts of unpaid claims and resolve ongoing claims payment issues  This initiative included creating rapid response teams to work with community providers to settle unpaid claim balances within 90 days and working with both TPAs to increase the number of clean claims paid in less than 30 days  In addition, VA has developed webinars on VA’s community care programs and—in conjunction with trade organizations and health care systems—has delivered provider education on filing claims properly  TriWest officials stated that it has educated the customer service staff at its claims processing sub-contractor, who field community provider calls regarding claims processing issues, to help ensure that the staff are familiar with Choice Program changes and can effectively assist community providers and resolve claims processing issues  Internal TriWest data show that providers’ average wait time to speak to a customer service representative about claims processing issues decreased from as high as 18 minutes in 2016 to as low as 2 5 minutes in 2018  Health Net officials were unable to provide data, but stated that since the fourth quarter of 2017, Health Net has decreased the time it takes for a community provider to speak with a customer service representative by adding additional staff and extending the hours in which providers can call with questions  In addition, Health Net officials stated that they have required customer service staff to undergo additional training related to resolving claims processing issues  Despite these efforts, 7 of the 10 providers that participate in the Health Net network and 2 of the 7 providers that participate in the TriWest network we interviewed between April and June 2018 told us that when they contact the TPAs’ customer service staff to address claim processing questions, such as how to resolve claim rejections or denials, they experience lengthy hold times, sometimes exceeding one hour  In addition, 7 of the 15 providers we spoke with told us they typically reach employees who are unable to answer their questions  According to these providers, this experience frustrated them, as they often did not understand why a claim had been denied or rejected, and they required assistance correcting the claim so it could be resubmitted  One community provider stated that their common practice to resolve questions or concerns was to call customer service enough times until they received the same answer twice from a TPA representative  In addition, 5 of the 10 Health Net providers we interviewed stated that they have significant outstanding claim balances owed to them  One of these providers—who reported over $3 million in outstanding claims—stressed the importance of being able to effectively resolve claims issues with TPA customer service staff, as the administrative burden of following up on outstanding claim balances takes time away from caring for patients  The issues concerning customer service wait times and TPA staff inability to resolve some claims processing issues reported by community providers appear to be inconsistent with VA contractual requirements  VA’s current Choice Program contracts require the TPAs to establish a customer call center to respond to calls from veterans and non-VA providers  The contract requires specified levels of service for telephone inquiries at the call center  For example, VA requires TPA representatives to answer customer service calls within an average speed of 30 seconds or less and requires 85 percent of all inquiries to be fully and completely answered during the initial telephone call  However, VA officials explained that VA does not enforce the contractual requirement for responding to calls from community providers  Furthermore, according to these officials, VA allows the TPAs to prioritize calls from veterans  Officials from VA’s Office of General Counsel, Procurement Law Group, confirmed that this requirement does apply to the TPAs’ handling of calls from community providers  Because VA does not enforce the customer service requirement for providers, VA has not collected data on or monitored the TPAs’ compliance with these requirements for providers’ calls  As previously stated, standards for internal control in the Federal Government state that management should establish and operate monitoring activities to evaluate whether a specific function or process is operating effectively and take corrective actions as necessary  Without collecting data and monitoring customer service requirements for provider calls, VA does not have information on the extent to which community providers face challenges when contacting the TPAs about claims payment issues that could contribute to the amount of time it takes to successfully file claims and receive reimbursement for services under the Choice Program  This, in turn, poses a risk to the Choice Program to the extent that community providers who face these challenges decide not to serve veterans under the Choice Program  Looking forward, VA has included customer service requirements in its RFP for the Veterans Community Care Program contracts, and VA officials have told us that these requirements are applicable to provider calls  For example, the RFP includes a requirement for its future TPAs to establish and maintain call centers to address inquiries from community providers and has established customer service performance metrics to monitor call center performance  Monitoring data on provider calls under the contracts will be important as Veterans Community Care Program TPAs will continue to be responsible for building provider networks, processing claims, and resolving claims processing issues  The Choice Program relies on community providers to deliver care to eligible veterans when VA is unable to provide timely and accessible care at its own facilities  Although VA has taken steps to improve the timeliness of TPA claim payments to providers, VA is not collecting data or monitoring compliance with two Choice Program requirements, and this could adversely affect the timeliness with which community providers are paid under the Choice Program  First, VA does not have complete data allowing it to effectively monitor adherence with its policy for VA medical facilities to review SARs within 5 days of receipt, which impacts its ability to meet the requirement  To the extent that VA medical facilities delay these reviews and approvals, community providers may have to delay care or deliver care that is not authorized, which in turn increases the likelihood that the providers’ claims will be denied and the providers will not be paid  Second, VA requires the TPAs to establish a customer call center to respond to calls from veterans and non-VA providers  However, VA does not enforce the contractual requirement for responding to calls from community providers and allows the TPAs to prioritize calls from veterans  Consequently, VA is not collecting data, monitoring, or enforcing compliance with its contractual requirements for the TPAs to provide timely customer service to providers  As a result, VA does not have information on the extent to which community providers face challenges when contacting the TPAs about claims payment issues, which could contribute to the amount of time it takes to receive reimbursement for services  To the extent that these issues make community providers less willing to continue participating in the Choice Program and the forthcoming Veterans Community Care Program, they pose a risk to VA’s ability to successfully implement these programs and ensure veterans’ timely access to care  We are making the following two recommendations to VA: Once VA’s new software for managing authorizations has been fully implemented, the Undersecretary for Health should monitor data on SAR approval decision time frames to ensure VA medical facilities are in adherence with VA policy, assess the reasons for nonadherence with the policy, and take corrective actions as necessary  (Recommendation 1) The Undersecretary for Health should collect data and monitor compliance with the Choice Program contractual requirements pertaining to customer service for community providers, and take corrective actions as necessary  (Recommendation 2) We provided a draft of this report to VA for review and comment  In its written comments, reproduced in appendix I, VA concurred with our two recommendations and said it is taking steps to address them  For example, VA plans to implement software in spring 2019 that will automate the SAR process and allow for streamlined reporting and monitoring of SAR timeliness to ensure ongoing compliance  Additionally, VA has included provider customer service performance requirements and metrics in its Veterans Community Care Program RFP, and will require future contractors to provide a monthly report to VA on their call center operations and will implement quarterly provider satisfaction surveys  We are sending copies of this report to the Secretary of Veterans Affairs, the Under Secretary for Health, appropriate congressional committees, and other interested parties  This report is also available at no charge on the GAO Web site at http://www gao gov  If you or your staff have any questions about this report, please contact Sharon M  Silas at (202) 512-7114 or silass@gao gov  Contact points for our Offices of Congressional Relations and Public Affairs are on the last page of this report  GAO staff who made major contributions to this report are listed in appendix II  In addition to the contact named above, Marcia A  Mann (Assistant Director), Michael Zose (Analyst-in-Charge), and Kate Tussey made major contributions to this report  Also contributing were Krister Friday, Jacquelyn Hamilton, and Vikki Porter 

ground_truth: SNAP is the largest federally funded nutrition assistance program. In fiscal year 2017, it provided about $63 billion in benefits. USDA and the states jointly administer SNAP and partner to address issues that affect program integrity, including improper payments and fraud. GAO has previously reported on various aspects of SNAP, including state SNAP E&T programs, improper payment rates, recipient fraud, and retailer trafficking. This testimony discusses GAO's prior and ongoing work on (1) SNAP E&T programs, including program participants, design, and USDA oversight, and (2) USDA's efforts to address SNAP program integrity, including improper payments, as well as recipient and retailer fraud. As part of its ongoing work on SNAP E&T programs, GAO analyzed E&T expenditures and participation data from fiscal years 2007 through 2016, the most recent data available; reviewed relevant research from USDA; and interviewed USDA and selected state and local officials. The prior work discussed in this testimony is based on four GAO products on E&T programs (GAO-03-388), improper payments (GAO-16-708T), recipient fraud (GAO-14-641), and retailer trafficking (GAO-07-53). Information on the scope and methodology of our prior work is available in each product. Overseen by the U.S. Department of Agriculture (USDA) and administered by states, Supplemental Nutrition Assistance Program (SNAP) Employment and Training (E&T) programs served about 0.5 percent of the approximately 43.5 million SNAP recipients in an average month of fiscal year 2016, according to the most recent USDA data available. These programs are generally designed to help SNAP recipients increase their ability to obtain regular employment through services such as job search and training. Some recipients may be required to participate. According to USDA, about 14 percent of SNAP recipients were subject to work requirements in an average month of fiscal year 2016, while others, such as children and the elderly, were generally exempt from these requirements. States have flexibility in how they design their E&T programs. Over the last several years, states have 1) increasingly moved away from programs that mandate participation, 2) focused on serving able-bodied adults without dependents whose benefits are generally time-limited unless they comply with work requirements, and 3) partnered with state and local organizations to deliver services. USDA has taken steps to increase support and oversight of SNAP E&T since 2014, including collecting new data on participant outcomes from states. GAO has ongoing work reviewing SNAP E&T programs, including USDA oversight. USDA and the states partner to address issues that affect program integrity, including improper payments and fraud, and USDA has taken some steps to address challenges in these areas, but issues remain. Improper Payments. In 2016, GAO reviewed SNAP improper payment rates and found that states' adoption of program flexibilities and changes in federal SNAP policy in the previous decade, as well as improper payment rate calculation methods, likely affected these rates. Although USDA reported improper payment estimates for SNAP in previous years, USDA did not report an estimate for benefits paid in fiscal years 2015 or 2016 due to data quality issues in some states. USDA has since been working with the states to improve improper payment estimates for the fiscal year 2017 review. Recipient Fraud. In 2014, GAO made recommendations to USDA to address challenges states faced in combatting recipient fraud. For example, GAO found that USDA's guidance on the use of transaction data to uncover potential trafficking lacked specificity and recommended USDA develop additional guidance. Since then, USDA has provided technical assistance to some states, including on the use of data analytics. GAO has ongoing work reviewing states' use of data analytics to identify SNAP recipient fraud. Retailer Trafficking. In 2006, GAO identified several ways in which SNAP was vulnerable to retailer trafficking—a practice involving the exchange of benefits for cash or non-food items. For example, USDA had not conducted analyses to identify high-risk retailers and target its resources. Since then, USDA has established risk levels for retailers based on various factors. GAO has ongoing work assessing how USDA prevents, detects, and responds to retailer trafficking and reviewing the usefulness of USDA's estimates of the extent of SNAP retailer trafficking. GAO is not making new recommendations. USDA generally concurred with GAO's prior recommendations.