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



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

Report 1: This report provides background information and issues for Congress on the Aegis ballistic missile defense (BMD) program, which is carried out by the Missile Defense Agency (MDA) and the Navy, and gives Navy Aegis cruisers and destroyers a capability for conducting BMD operations  The issue for Congress is whether to approve, reject, or modify Department of Defense (DOD) acquisition strategies and proposed funding levels for the Aegis BMD program  Congress's decisions on the Aegis BMD program could significantly affect U S  BMD capabilities and funding requirements, and the BMD-related industrial base  For an overview of the strategic and budgetary context in which the Aegis BMD program may be considered, see CRS Report RL32665, Navy Force Structure and Shipbuilding Plans: Background and Issues for Congress , by Ronald O'Rourke  Most of the Navy's cruisers and destroyers are called Aegis ships because they are equipped with the Aegis ship combat system—an integrated collection of sensors, computers, software, displays, weapon launchers, and weapons named for the mythological shield that defended Zeus  The Aegis system was originally developed in the 1970s for defending ships against aircraft, anti-ship cruise missiles (ASCMs), surface threats, and subsurface threats  The system was first deployed by the Navy in 1983, and it has been updated many times since  The Navy's Aegis ships include Ticonderoga (CG-47) class cruisers and Arleigh Burke (DDG-51) class destroyers  A total of 27 CG-47s (CGs 47 through 73) were procured for the Navy between FY1978 and FY1988; the ships entered service between 1983 and 1994  The first five ships in the class (CGs 47 through 51), which were built to an earlier technical standard in certain respects, were judged by the Navy to be too expensive to modernize and were removed from service in 2004-2005, leaving 22 ships in operation (CGs 52 through 73)  A total of 62 DDG-51s were procured for the Navy between FY1985 and FY2005; the first entered service in 1991 and the 62 nd entered service in FY2012  The first 28 ships are known as Flight I/II DDG-51s  The next 34 ships, known as Flight IIA DDG-51s, incorporate some design changes, including the addition of a helicopter hangar  No DDG-51s were procured in FY2006-FY2009  The Navy during this period instead procured three Zumwalt (DDG-1000) class destroyers  The DDG-1000 design does not use the Aegis system and does not include a capability for conducting BMD operations  Navy plans do not call for modifying the three DDG-1000s to make them BMD-capable  Procurement of DDG-51s resumed in FY2010, following procurement of the three DDG-1000s  A total of 20 DDG-51s were procured in FY2010-FY2019  DDG-51s procured in FY2017 and subsequent years are being built to a new version of the DDG-51 design called the Flight III version  The Flight III version is to be equipped with a new radar, called the Air and Missile Defense Radar (AMDR) or the SPY-6 radar, that is more capable than the SPY-1 radar installed on all previous Aegis cruisers and destroyers  Sales of the Aegis system to allied countries began in the late 1980s  Allied countries that now operate, are building, or are planning to build Aegis-equipped ships include Japan, South Korea, Australia, Spain, and Norway  Most of Japan's Aegis-equipped ships are currently BMD-capable, and Japan plans to make all of them BMD-capable in coming years  The Aegis-equipped ships operated by South Korea, Australia, Spain, and Norway are not BMD-capable  Aegis ships are given a capability for conducting BMD operations by incorporating changes to the Aegis system's computers and software, and by arming the ships with BMD interceptor missiles  In-service Aegis ships can be modified to become BMD-capable ships, and DDG-51s procured in FY2010 and subsequent years are being built from the start with a BMD capability  The Aegis BMD system exists in several variants  Listed in order of increasing capability, these include (but are not necessarily limited to) 3 6 X variant, the 4 0 3 variant, the 4 1 variant (also known as the Aegis Baseline [BL] 5 4 variant), the 5 0 CU (Capability Upgrade) variant (also known as the BL 9 1 variant), the 5 1 variant (also known as the BL 9 2 variant), and the 6 X variant (also known as the BL 10 variant)  Figure 1 summarizes the capabilities of some of these variants (using their designations as of 2016) and correlates them with the phases of the European Phased Adaptive Approach (or EPAA; see discussion below) for European BMD operations  As shown in Figure 1 , the Aegis BMD system was originally designed primarily to intercept theater-range ballistic missiles, meaning short-, medium-, and intermediate-range ballistic missiles (SRBMs, MRBMs, and IRBMs, respectively)  In addition to its capability for intercepting theater-range ballistic missiles, detection and tracking data collected by the Aegis BMD system's radar might be passed to other U S  BMD systems that are designed to intercept intercontinental ballistic missiles (ICBMs), which might support intercepts of ICBMs that are conducted by those other U S  BMD systems  With the advent of the Aegis BMD system's new SM-3 Block IIA interceptor (which is discussed further in the next section), DOD is now evaluating the potential for the Aegis BMD system to intercept certain ICBMs  Section 1680 of the FY2018 National Defense Authorization Act ( H R  2810 / P L  115-91 of December 12, 2017) directed DOD to "conduct a test to evaluate and demonstrate, if technologically feasible, the capability to defeat a simple intercontinental ballistic missile threat using the standard missile 3 block IIA missile interceptor " DOD's January 2019 missile defense review report states the following: The SM-3 Blk IIA interceptor is intended as part of the regional missile defense architecture, but also has the potential to provide an important "underlay" to existing GBIs [ground-based interceptors] for added protection against ICBM threats to the homeland  This interceptor has the potential to offer an additional defensive capability to ease the burden on the GBI system and provide continuing protection for the U S  homeland against evolving rogue states' long-range missile capabilities  Congress has directed DoD to examine the feasibility of the SM-3 Blk IIA against an ICBM-class target  MDA will test this SM-3 Blk IIA capability in 2020  Due to the mobility of sea-based assets, this new underlay capability will be surged in a crisis or conflict to further thicken defensive capabilities for the U S  homeland  Land-based sites in the United States with this SM-3 Blk IIA missile could also be pursued  A March 18, 2019, press report states: The Pentagon plans a "first-of-its-kind" test of an unprecedented weapons capability to intercept and destroy an enemy Intercontinental Ballistic Missile "ICBM" -- from a Navy ship at sea using a Standard Missile-3 Block IIA  The concept, as articulated by Pentagon officials and cited briefly in this years' DoD "Missile Defense Review," would be to use an advanced SM-3 IIA to "underlay" and assist existing Ground-Based Interceptors (GBI), adding new dimensions to the current US missile defense posture … The testing, Pentagon officials tell Warrior, is slated for as soon as next year  The effectiveness and promise of the Raytheon-built SM-3 IIA shown in recent testing have inspired Pentagon weapons developers to envision an even broader role for the weapon  The missile is now "proven out," US weapons developers say…  "The SM-3 IIA was not designed to take out ICBMs, but is showing great promise  This would be in the upper range of its capability -- so we are going to try," the Pentagon official told Warrior…  The SM-3 IIA's size, range, speed and sensor technology, the thinking suggests, will enable it to collide with and destroy enemy ICBMs toward the beginning or end of their flight through space, where they are closer to the boundary of the earth's atmosphere  "The SM-3 IIA would not be able to hit an ICBM at a high altitude, but it can go outside the earth's atmosphere," the Pentagon official said  "You want to hit it as far away as possible because a nuke could go off " A March 26, 2018, press report states the following: [MDA] Director Lt  Gen  Sam Greaves said MDA "is evaluating the technical feasibility of the capability of the SM-3 Block IIA missile, currently under development, against an ICBM-class target " "If proven to be effective against an ICBM, this missile could add a layer of protection, augmenting the currently deployed GMD [ground-based missile defense] system," Greaves said in written testimony submitted March 22 to the Senate Armed Services strategic forces subcommittee  [Greaves] said MDA will conduct a demonstration of the SM-3 Block IIA against an ICBM-like target by the end of 2020 " The BMD interceptor missiles used by Aegis ships are the Standard Missile-3 (SM-3), the SM-2 Block IV, and the SM-6  The SM-3 is designed to intercept ballistic missiles above the atmosphere (i e , exo-atmospheric intercept), in the midcourse phase of an enemy ballistic missile's flight  It is equipped with a "hit-to-kill" warhead, called a kinetic vehicle, that is designed to destroy a ballistic missile's warhead by colliding with it  MDA and Navy plans call for fielding increasingly capable versions of the SM-3 in coming years  The current versions, called the SM-3 Block IA and SM-3 Block IB, are to be supplemented in coming years by SM-3 Block IIA  Compared to the Block IA version, the Block IB version has an improved (two-color) target seeker, an advanced signal processor, and an improved divert/attitude control system for adjusting its course  Compared to the Block IA and 1B versions, which have a 21-inch-diameter booster stage at the bottom but are 13 5 inches in diameter along the remainder of their lengths, the Block IIA version has a 21-inch diameter along its entire length  The increase in diameter to a uniform 21 inches provides more room for rocket fuel, permitting the Block IIA version to have a burnout velocity (a maximum velocity, reached at the time the propulsion stack burns out) that is greater than that of the Block IA and IB versions, as well as a larger-diameter kinetic warhead  The United States and Japan have cooperated in developing certain technologies for the Block IIA version, with Japan funding a significant share of the effort  The SM-2 Block IV is designed to intercept ballistic missiles inside the atmosphere (i e , endo-atmospheric intercept), during the terminal phase of an enemy ballistic missile's flight  It is equipped with a blast fragmentation warhead  The existing inventory of SM-2 Block IVs—72 as of February 2012—was created by modifying SM-2s that were originally built to intercept aircraft and ASCMs  A total of 75 SM-2 Block IVs were modified, and at least 3 were used in BMD flight tests  MDA and the Navy are now procuring a more capable terminal-phase (endo-atmospheric intercept) BMD interceptor based on the SM-6 air defense missile (the successor to the SM-2 air defense missile)  The SM-6 is a dual-capability missile that can be used for either air defense (i e , countering aircraft and anti-ship cruise missiles) or ballistic missile defense  A July 23, 2018, press report states the following: The Defense Department has launched a prototype project that aims to dramatically increase the speed and range of the Navy's Standard Missile-6 by adding a larger rocket motor to the ship-launched weapon, a move that aims to improve both the offensive and defensive reach of the Raytheon-built system  On Jan  17, the Navy approved plans to develop a Dual Thrust Rocket Motor with a 21-inch diameter for the SM-6, which is currently fielded with a 13 5-inch propulsion package  The new rocket motor would sit atop the current 21-inch booster, producing a new variant of the missile: the SM-6 Block IB  On September 17, 2009, the Obama Administration announced a new approach for regional BMD operations called the Phased Adaptive Approach (PAA)  The first application of the approach is in Europe, and is called the European Phased Adaptive Approach (EPAA)  EPAA calls for using BMD-capable Aegis ships, a land-based radar in Europe, and two Aegis Ashore sites in Romania and Poland to defend Europe against ballistic missile threats from countries such as Iran  Phase I of EPAA involved deploying Aegis BMD ships and a land-based radar in Europe by the end of 2011  Phase II involved establishing the Aegis Ashore site in Romania with SM-3 IB interceptors in 2016  Phase 3 involves establishing the Aegis Ashore site in Poland with SM-3 IIA interceptors by perhaps FY2020  The completion of construction of the Poland site has been delayed by at least a year, MDA says, due to contractor performance issues  Each Aegis Ashore site in the EPAA is to include a structure housing an Aegis system similar to the deckhouse on an Aegis ship and 24 SM-3 missiles launched from a relocatable Vertical Launch System (VLS) based on the VLS that is installed in Navy Aegis ships  Although BMD-capable Aegis ships were deployed to European waters before 2011, the first BMD-capable Aegis ship officially deployed to European waters as part of the EPAA departed its home port of Norfolk, VA, on March 7, 2011, for a deployment to the Mediterranean that lasted several months  Under the FY2020 budget submission, the number of BMD-capable Navy Aegis ships is projected to increase from 38 at the end of FY2018 to 59 at the end of FY2024  During the period FY2018-FY2024, the portion of the force equipped with earlier Aegis variants is to decrease, and the number equipped with later variants is to increase  On October 5, 2011, the United States, Spain, and NATO jointly announced that, as part of the EPAA, four BMD-capable Aegis ships were to be forward-homeported (i e , based) at the naval base at Rota, Spain  The four ships were transferred to Rota in FY2014 and FY2015  Navy officials have said that the four Rota-based ships can provide a level of level of presence in the Mediterranean for performing BMD patrols and other missions equivalent to what could be provided by about 10 BMD-capable Aegis ships that are homeported on the U S  east coast  The Rota homeporting arrangement thus effectively releases about six U S  Navy BMD-capable Aegis ships for performing BMD patrols or other missions elsewhere  The Aegis BMD development effort, including Aegis BMD flight tests, has been described as following a development philosophy long held within the Aegis program office of "build a little, test a little, learn a lot," meaning that development is done in manageable steps, then tested and validated before moving on to the next step  For a summary of Aegis BMD flight tests since 2002, see Appendix A   Japan is modifying all six of its Aegis destroyers to include the Aegis BMD capability  As of August 2017, four of the six ships reportedly had been modified, and Japan planned to modify a fifth by March 2018, or perhaps sooner than that  In November 2013, Japan announced plans to procure two additional Aegis destroyers and equip them as well with the Aegis BMD capability, which will produce an eventual Japanese force of eight BMD-capable Aegis destroyers  The two additional ships are expected to enter service in 2020 and 2021  Japanese BMD-capable Aegis ships have participated in some of the flight tests of the Aegis BMD system using the SM-3 interceptor (see Table A-1 in Appendix A )  Japan cooperated with the United States on development the SM-3 Block IIA missile  Japan developed certain technologies for the missile, and paid for the development of those technologies, reducing the missile's development costs for the United States  Japan plans to procure and operate two Aegis Ashore systems that reportedly are to be located at Ground Self-Defense Force (GSDF) facilities in Akita Prefecture in eastern Japan and Yamaguchi Prefecture in western Japan, and would be operated mainly by the GSDF (i e , Japan's army)  The two systems reportedly will be equipped with a new Lockheed-made radar called the Long Range Discrimination Radar (LRDR) rather than the Raytheon-made SPY-6 AMDR that is being installed on U S  Navy Flight III DDG-51s, and reportedly will go into operation by 2023  A July 6, 2018, press report states that "The U S  and Japan are looking to jointly develop next-generation radar technology that would use Japanese semiconductors to more than double the detection range of the Aegis missile defense system " An October 12, 2018, press report states that "the South Korean military has decided to buy ship-based SM-3 interceptors to thwart potential ballistic missile attacks from North Korea, a top commander of the Joint Chiefs of Staff revealed Oct  12  Other countries that MDA views as potential naval BMD operators (using either the Aegis BMD system or some other system of their own design) include the United Kingdom, the Netherlands, Spain, Germany, Denmark, and Australia  Spain, South Korea, and Australia either operate, are building, or are planning to build Aegis ships  The other countries operate destroyers and frigates with different combat systems that may have potential for contributing to BMD operations  The Aegis BMD program is funded mostly through MDA's budget  The Navy's budget provides additional funding for BMD-related efforts  Table 1 shows MDA procurement and research and development funding for the Aegis BMD program  Research and development funding for the land-based SM-3 is funding for Aegis Ashore sites  MDA's budget also includes additional funding not shown in the table for operations and maintenance (O&M) and military construction (MilCon) for the Aegis BMD program  One issue for Congress is whether to approve, reject, or modify MDA's FY2019 procurement and research and development funding requests for the program  In considering this issue, Congress may consider various factors, including whether the work that MDA is proposing to fund for FY2019 is properly scheduled for FY2019, and whether this work is accurately priced  Another potential issue for Congress concerns required numbers of BMD-capable Aegis ships versus available numbers of BMD-capable Aegis ships  Some observers are concerned about the potential operational implications of a shortfall in the available number of BMD-capable relative to the required number  Regarding the required number of BMD-capable Aegis ships, an August 15, 2018, Navy information paper states the following: The [Navy's] 2016 Force Structure Assessment [FSA] sets the requirement [for BMD-capable ships] at 54 BMD-capable ships, as part of the 104 large surface combatant requirement, to meet Navy unique requirements to support defense of the sea base and limited expeditionary land base sites…  The minimum requirement for 54 BMD ships is based on the Navy unique requirement as follows  It accepts risk in the sourcing of combatant commander (CCDR) requests for defense of land  - 30 to meet CVN escort demand for rotational deployment of the carrier strike groups - 11 INCONUS for independent BMD deployment demand - 9 in forward deployed naval forces (FDNF) Japan to meet operational timelines in USINDOPACOM - 4 in FDNF Europe for rotational deployment in EUCOM  A related potential issue for Congress is the burden that BMD operations may be placing on the Navy's fleet of Aegis ships, particularly since performing BMD patrols requires those ships to operate in geographic locations that may be unsuitable for performing other U S  Navy missions, and whether there are alternative ways to perform BMD missions now performed by U S  Navy Aegis ships, such as establishing more Aegis Ashore sites  A June 16, 2018, press report states the following: The U S  Navy's top officer wants to end standing ballistic missile defense patrols and transfer the mission to shore-based assets  Chief of Naval Operations Adm  John Richardson said in no uncertain terms on June 12 that he wants the Navy off the tether of ballistic missile defense patrols, a mission that has put a growing strain on the Navy's hard-worn surface combatants, and the duty shifted towards more shore-based infrastructure  "Right now, as we speak, I have six multi-mission, very sophisticated, dynamic cruisers and destroyers―six of them are on ballistic missile defense duty at sea," Richardson said during his address at the U S


Report 2:  Naval War College's Current Strategy Forum  "And if you know a little bit about this business you know that geometry is a tyrant  "You have to be in a tiny little box to have a chance at intercepting that incoming missile  So, we have six ships that could go anywhere in the world, at flank speed, in a tiny little box, defending land " Richardson continued, saying the Navy could be used in emergencies but that in the long term the problem demands a different solution  "It's a pretty good capability and if there is an emergent need to provide ballistic missile defense, we're there," he said  "But 10 years down the road, it's time to build something on land to defend the land  Whether that's AEGIS ashore or whatever, I want to get out of the long-term missile defense business and move to dynamic missile defense " The unusually direct comments from the CNO come amid growing frustration among the surface warfare community that the mission, which requires ships to stay in a steaming box doing figure-eights for weeks on end, is eating up assets and operational availability that could be better used confronting growing high-end threats from China and Russia  The BMD mission was also a factor in degraded readiness in the surface fleet  Amid the nuclear threat from North Korea, the BMD mission began eating more and more of the readiness generated in the Japan-based U S  7th Fleet, which created a pressurized situation that caused leaders in the Pacific to cut corners and sacrifice training time for their crews, an environment described in the Navy's comprehensive review into the two collisions that claimed the lives of 17 sailors in the disastrous summer of 2017  Richardson said that as potential enemies double down on anti-access technologies designed to keep the U S  Navy at bay, the Navy needed to focus on missile defense for its own assets  "We're going to need missile defense at sea as we kind of fight our way now into the battle spaces we need to get into," he said  "And so restoring dynamic maneuver has something to do with missile defense  A June 23, 2018, press report states the following: The threats from a resurgent Russia and rising China―which is cranking out ships like it's preparing for war―have put enormous pressure on the now-aging [U S  Navy Aegis destroyer] fleet  Standing requirements for BMD patrols have put increasing strain on the U S  Navy's surface ships  The Navy now stands at a crossroads  BMD, while a burden, has also been a cash cow that has pushed the capabilities of the fleet exponentially forward over the past decade  The game-changing SPY-6 air and missile defense radar destined for DDG Flight III, for example, is a direct response to the need for more advanced BMD shooters  But a smaller fleet, needed for everything from anti-submarine patrols to freedom-of-navigation missions in the South China Sea, routinely has a large chunk tethered to BMD missions  "Right now, as we speak, I have six multimission, very sophisticated, dynamic cruisers and destroyers―six of them are on ballistic missile defense duty at sea," Chief of Naval Operations Adm  John Richardson said during an address at the recent U S  Naval War College's Current Strategy Forum  "You have to be in a tiny little box to have a chance at intercepting that incoming missile  So we have six ships that could go anywhere in the world, at flank speed, in a tiny little box, defending land " And for every six ships the Navy has deployed in a standing mission, it means 18 ships are in various stages of the deployment cycle preparing to relieve them  The Pentagon, led by Defense Secretary Jim Mattis, wants the Navy to be more flexible and less predictable―"dynamic" is the buzzword of moment in Navy circles  What Richardson is proposing is moving standing requirements for BMD patrols away from ships underway and all the associated costs that incurs, and toward fixed, shore-based sites, and also surging the Navy's at-sea BMD capabilities when there is an active threat     In a follow-up response to questions posed on the CNO's comments, Navy spokesman Cmdr  William Speaks said the Navy's position is that BMD is an integral part of the service's mission, but where long-term threats exist, the Navy should "consider a more persistent, land-based solution as an option " "This idea is not about the nation's or the Navy's commitment to BMD for the U S  and our allies and partners―the Navy's commitment to ballistic missile defense is rock-solid," Speaks said  "In fact, the Navy will grow the number of BMD-capable ships from 38 to 60 by 2023, in response to the growing demand for this capability  "The idea is about how to best meet that commitment  In alignment with our national strategic documents, we have shifted our focus in an era of great power competition―this calls us to think innovatively about how best to meet the demands of this mission and optimize the power of the joint force "    While the idea of saving money by having fixed BMD sites and freeing up multimission ships is sensible, it may have unintended consequences, said Bryan McGrath, a retired destroyer skipper and owner of the defense consultancy The FerryBridge Group  "The BMD mission is part of what creates the force structure requirement for large surface combatants," McGrath said on Twitter after Defense News reported the CNO's comments  "Absent it, the number of CG's and DDG's would necessarily decline  This may in fact be desirable, depending on the emerging fleet architecture and the roles and missions debate underway  Perhaps we need more smaller, multi-mission ships than larger, more expensive ones  "But it cannot be forgotten that while the mission is somewhat wasteful of a capable, multi-mission ship, the fact that we have built the ships that (among other things) do this mission is an incredibly good thing  If there is a penalty to be paid in peacetime sub-optimization in order to have wartime capacity--should this not be considered a positive thing?" McGrath went on to say that the suite of combat systems that have been built into Aegis have been in response to the BMD threat  And indeed, the crown jewels of the surface fleet―Aegis Baseline 9 software, which allows a ship to do both air defense and BMD simultaneously; the Aegis common-source library; the forthcoming SPY-6; cooperative engagement―have come about either in part or entirely driven by the BMD mission     A Navy official who spoke on condition of anonymity, to discuss the Navy's shifting language on BMD, acknowledged the tone had shifted since the 2000s when the Navy latched onto the mission  But the official added that the situation more than a decade later has dramatically shifted  "The strategic environment has changed significantly since the early 2000s―particularly in the western Pacific  We have never before faced multiple peer rivals in a world as interconnected and interdependent as we do today," the official said  "Nor have we ever seen technologies that could alter the character of war as dramatically as those we see emerging around us  China and Russia have observed our way of war and are on the move to reshape the environment to their favor " In response to the threat and Defense Secretary Jim Mattis' desire to use the force more dynamically, the Navy is looking at its options, the official said  "This includes taking a look at how we employ BMD ships through the lens of great power competition to compete, deter and win against those who threaten us " A January 29, 2019, press report states the following: The Navy is looking to get out of the missile defense business, the service's top admiral said today, and the Pentagon's new missile defense review might give the service the off-ramp it has been looking for to stop sailing in circles waiting for ground-based missile launches  This wasn't the first time Adm  John Richardson bristled in public over his ships sailing in "small boxes" at sea tasked with protecting land, when they could be out performing other missions challenging Chinese and Russian adventurism in the South China Sea and the North Atlantic…  "We've got exquisite capability, but we've had ships protecting some pretty static assets on land for a decade," Richardson said at the Brookings Institute  "If that [stationary] asset is going to be a long-term protected asset, then let's build something on land and protect that and liberate these ships from this mission " Japan is already moving down the path of building up a more robust ground-based sensor and shooter layer, while also getting its own ships out to sea armed with the Aegis radar and missile defense system, both of which would free up American hulls from what Richardson on Monday called "the small [geographic] boxes where they have to stay for ballistic missile defense " Another related potential issue for Congress concerns burden sharing—how allied contributions to regional BMD capabilities and operations compare to U S  naval contributions to overseas regional BMD capabilities and operations, particularly in light of constraints on U S  defense spending, worldwide operational demands for U S  Navy Aegis ships, and calls by some U S  observers for increased allied defense efforts  The issue can arise in connection with both U S  allies in Europe and U S  allies in Asia  Regarding U S  allies in Asia, a December 12, 2018, press report states the following: In June, US Navy Chief of Naval Operations (CNO) Admiral John Richardson said during a speech at the US Naval War College that the US Navy should terminate its current practice of dedicating several US Navy warships solely for Ballistic Missile Defense (BMD)  Richardson wanted US warships to halt BMD patrols off Japan and Europe as they are limiting, restrictive missions that could be better accomplished by existing land-based BMD systems such as Patriot anti-missile batteries, the US Terminal High Altitude Area Defense (THAAD) anti-missile system and the Aegis Ashore anti-missile system  In the months since dropping his bombshell, Richardson—and much of the debate—has gone quiet  "My guess is the CNO got snapped back by the Pentagon for exceeding where the debate actually stood," one expert on US naval affairs told Asia Times  But others agree with him  Air Force Lt Gen Samuel A Greaves, the director of the US Missile Defense Agency (MDA), acknowledges Richardson's attempts to highlight how these BMD patrols were placing unwelcome "strain on the (US Navy's) crews and equipment " But there are complications  While it may free US Navy warships for sea-control, rather than land defense, there is a concern that next- generation hypersonic cruise missiles could defeat land-based BMD systems, such as Aegis Ashore, while the US Navy's Aegis-equipped warships offer the advantages of high-speed mobility and stealth, resulting in greater survivability overall  As Japan prepares to acquire its first Aegis Ashore BMD system – and perhaps other systems such as the THAAD system which has been deployed previously in Romania and South Korea – the possibility that the US Navy will end its important BMD role represents abrupt change…  Japan's decision to deploy Aegis Ashore can fill in any gap created by a possible US Navy cessation of BMD patrols  "The land-based option is more reliable, less logistically draining, and despite being horrendously expensive, could be effective in the sense that it provides a degree of reassurance to the Japanese people and US government, and introduces an element of doubt of missile efficacy into [North Korean] calculations," said [Garren Mulloy, Associate Professor of International Relations at Daito Bunka University in Saitama, Japan], adding, however, that these systems could not cover Okinawa  "Fixed sites in Japan could be vulnerable, and the Aegis vessels provide a flexible forward-defense, before anything enters Japanese airspace, but with obviously limited reactions times," Mulloy said  "Aegis Ashore gives more reaction time – but over Japanese airspace "… The silence about this sudden possible shift in the US defense posture in the western Pacific is understandable: it is a sensitive topic in Washington and Tokyo  However, the Trump administration has urged its allies to pay more for their own defense needs and to support US troops deployed overseas  Meanwhile, Tokyo needs to proceed cautiously given the likelihood that neighbors might view a move on BMD as evidence that Tokyo is adopting an increasingly aggressive defense posture in the region  But for them, it is a no-win situation  If the US does ditch the BMD patrol mission, China and North Korea might view the shift as equally menacing given that it greatly enhances the US Navy's maritime warfare capabilities  Another potential issue for Congress is whether to convert the Aegis test facility in Hawaii into an operational land-based Aegis BMD site  DOD's January 2019 missile defense review report states, in a section on improving or adapting existing BMD systems, that Another repurposing option is to operationalize, either temporarily or permanently, the Aegis Ashore Missile Defense Test Center in Kauai, Hawaii, to strengthen the defense of Hawaii against North Korean missile capabilities  DoD will study this possibility to further evaluate it as a viable near-term option to enhance the defense of Hawaii  The United States will augment the defense of Hawaii in order to stay ahead of any possible North Korean missile threat  MDA and the Navy will evaluate the viability of this option and develop an Emergency Activation Plan that would enable the Secretary of Defense to operationalize the Aegis Ashore test site in Kauai within 30 days of the Secretary's decision to do so, the steps that would need to be taken, associated costs, and personnel requirements  This plan will be delivered to USDA&S, USDR&E, and USDP within six months of the release of the MDR  A January 25, 2019, press report states the following: The Defense Department will examine the funding breakdown between the Navy and the Missile Defense Agency should the government make Hawaii's Aegis Ashore Missile Defense Test Center into an operational resource, according to the agency's director  "Today, it involves both Navy resources for the operational crews -- that man that site -- as well as funds that come to MDA for research, development and test production and sustainment," Lt  Gen  Sam Greaves said of the test center when asked how the funding would shake out between the Navy and MDA should the Pentagon move forward with the recommendation  Another potential issue for Congress concerns the potential for ship-based lasers, electromagnetic railguns (EMRGs), and gun-launched guided projectiles (GLGPs, previously known as hypervelocity projectiles [HVPs]) to contribute in coming years to Navy terminal-phase BMD operations and the impact this might eventually have on required numbers of ship-based BMD interceptor missiles  Another CRS report discusses the potential value of ship-based lasers, EMRGs, and GLGPs for performing various missions, including, potentially, terminal-phase BMD operations  Another potential oversight issue for Congress is technical risk and test and evaluation issues in the Aegis BMD program  Regarding this issue, a December 2018 report from DOD's Director, Operational Test and Evaluation (DOT&E)—DOT&E's annual report for FY2018—stated the following in its section on the Aegis BMD program: Assessment • Results from flight testing, high-fidelity M&S, HWIL, and distributed ground testing demonstrate that Aegis BMD can intercept non-separating, simple-separating, and complex-separating ballistic missiles in the midcourse phase  However, flight testing and M&S did not address all expected threat types, ground ranges, and raid sizes  • FTM-45 successfully and fully demonstrated the Aegis BL 9 2 organic engagement capability and corrective action for the previous FTM-29 missile failure  FTM-29 was only partially able to demonstrate EOR capability given the in-flight missile failure  In FTM-29, the Aegis Weapon System supported the SM-3 Block IIA missile and demonstrated bi-directional communication between the SM-3 Block IIA guidance section and the KW until loss of signal at horizon  However, the weapon system did not exercise all aspects of communication after KW eject  DOT&E considers the FTM-29 failure to be an example of a shortfall in conducting ground testing in an operationally representative way, and an example of a deficiency found in OT that DT should have discovered  • The MDA implemented process improvements to better identify, report, and fi x common failures and anomalies identified during SM-3 ground testing prior to flight testing  • SM CTV-03 demonstrated the capability of the Aegis BMD 4 1 upgrade to fi re an SM-6 Dual I missile  The BMD 4 1 build incorporates BL 9 C1 capabilities into the BMD 4 0 baseline  • FS-17 demonstrated the Aegis BMD 4 0 3 capability to interoperate with NATO partners over operational communication architectures during cruise missile and ballistic missile engagements, and to use remote data provided by NATO partners to prosecute remote engagements  JFTM-05 Event 2 demonstrated inter-ship communication between U S  and Japanese destroyers using a realistic communications architecture while prosecuting ballistic missile engagements  Pacific Dragon demonstrated interoperability between U S  Aegis BMD assets, Japanese destroyers, and Republic of Korea naval assets  • Aegis BMD has exercised rudimentary engagement coordination with Terminal High-Altitude Area Defense firing units, but not with Patriot  The MDA plans to include Patriot in FTO-03  MDA ground tests have routinely demonstrated that inter-element coordination and interoperability need improvement to increase situational awareness and improve engagement efficiency  • The MDA has been collaborating with DOT&E and the Under Secretary of Defense (Research and Engineering) to establish an affordable ground testing approach to support assessments of reliability  DOT&E cannot assess SM-3 missile reliability with confidence until the MDA is able to provide additional ground test data that simulates the in-flight environment  DOT&E is working with the MDA to determine if existing ground test venues are able to provide the needed missile reliability data  Recommendations The MDA should: 1  Ensure that ground tests of all SM-3 missile components, sections, and all-up rounds use the same configuration as will be flown in flight tests (i e , "test as you fly")  2  Determine how to properly score acceptance ground test data for production missiles to enable their use in estimating SM-3 reliability  3  Fund and execute high-fidelity M&S RFRs for Aegis BL 9 2 SM-3 Block IIA and SM-6 Dual II scenarios that span the engagement battlespace  Regarding the SM-6 missile, the January 2018 DOT&E report also stated the following: Assessment • As reported in the DOT&E FY18 SM-6 BLK I FOT&E Report, the SM-6 remains effective and suitable with the exception of the classified deficiency identified in the FY13 IOT&E Report  The SM-6 Block 1 satisfactorily demonstrated compatibility with Aegis Weapon System Baseline 9 Integrated Fire Control capability  • In FY17-18, the Navy developed and tested specific software improvements to SM-6 BLK I to mitigate the classified performance problems discovered during IOT&E  As previously reported, testing conducted by the Navy demonstrated the software improvements perform as intended, but did not eliminate them  Recommendation 1  The Navy should continue to improve software based on IOT&E results and verify corrective actions with flight tests  Table 2 summarizes congressional action on the FY2020 request for MDA procurement and research and development funding for the Aegis BMD program  Appendix A  Aegis BMD Flight Tests Table A-1 presents a summary of Aegis BMD flight tests since January 2002  As shown in the table, since January 2002, the Aegis BMD system has achieved 33 successful exo-atmospheric intercepts in 42 attempts using the SM-3 missile (including 4 successful intercepts in 5 attempts by Japanese Aegis ships, and 2 successful intercepts in 3 attempts attempt using the Aegis Ashore system), and 7 successful endo-atmospheric intercepts in 7 attempts using the SM-2 Block IV and SM-6 missiles, making for a combined total of 40 successful intercepts in 49 attempts  In addition, on February 20, 2008, a BMD-capable Aegis cruiser operating northwest of Hawaii used a modified version of the Aegis BMD system with the SM-3 missile to shoot down an inoperable U S  surveillance satellite that was in a deteriorating orbit  Including this intercept in the count increases the totals to 34 successful exo-atmospheric intercepts in 43 attempts using the SM-3 missile, and 41 successful exo- and endo-atmospheric intercepts in 50 attempts using SM-3, SM-2 Block IV, and SM-6 missiles 

ground_truth: Under CAPTA, states perform a range of prevention activities, including addressing the needs of infants born with prenatal drug exposure. The number of children under the age of 1 entering foster care increased by about 15 percent from fiscal years 2012 through 2015. Child welfare professionals attribute the increase to the opioid epidemic. GAO was asked to examine the steps states are taking to implement CAPTA requirements on substance-affected infants and related amendments enacted in 2016. This report examines (1) the extent to which states have adopted policies and procedures to notify CPS of substance-affected infants; (2) state efforts to develop plans of safe care, and associated challenges; and (3) steps HHS has taken to help states implement the provisions. To obtain this information, GAO surveyed state CPS directors in all 50 states and the District of Columbia and reached a 100 percent response rate. GAO also visited 3 states (Kentucky, Massachusetts, and Pennsylvania); reviewed relevant documents such as federal laws and regulations, and HHS guidance; and interviewed HHS officials. GAO did not assess states' compliance with CAPTA requirements. All states reported adopting, to varying degrees, policies and procedures regarding health care providers notifying child protective services (CPS) about infants affected by opioids or other substances. Under the Child Abuse Prevention and Treatment Act (CAPTA), as amended, governors are required to provide assurances that the states have laws or programs that include policies and procedures to address the needs of infants affected by prenatal substance use. This is to include health care providers notifying CPS of substance-affected infants. In response to GAO's survey, 42 states reported having policies and procedures that require health care providers to notify CPS about substance-affected infants and 8 states reported having policies that encourage notification. The remaining 1 state has a policy requiring health care providers to assess the needs of mothers and infants and if they conclude that infants are at risk for abuse or neglect, CPS is notified. In response to GAO's survey, 49 states reported that their CPS agency has policies to develop a plan of safe care; 2 reported not having such a requirement. Under CAPTA, states are required to develop a plan of safe care for substance-affected infants. Although not defined in law, a plan of safe care generally entails an assessment of the family's situation and a plan for connecting families to appropriate services to stabilize the family and ensure the child's safety and well-being. States reported that plans typically address the infant's safety needs, immediate medical needs, and the caregiver's substance use treatment needs. However, officials in the 3 states GAO visited noted challenges, including uncertainty about what to include in plans and the level of intervention needed for infants at low risk of abuse or neglect. The Department of Health and Human Services (HHS) has provided technical assistance and guidance to states to implement these CAPTA requirements. Most states reported in GAO's survey that additional guidance and assistance would be very or extremely helpful for addressing their challenges. Nevertheless, HHS officials told GAO that the agency does not anticipate issuing additional written guidance, but that states can access technical assistance through their regional offices and the National Center on Substance Abuse and Child Welfare—a resource center funded by HHS. However, of the 37 states that reported on the helpfulness of the assistance they have received, 19 said it was only moderately helpful to not helpful. States offered suggestions for improving the assistance, such as developing substance abuse training materials for staff and holding video conferences with other states to share information. In October 2017, HHS officials explained that some states have submitted plans that include details on how they are addressing the CAPTA requirements. HHS officials reported that some of the plans submitted to date indicated that states are not meeting the requirements and those states have been asked to develop program improvement plans. Without more specific guidance and assistance to enhance states' understanding of CAPTA requirements and better address known challenges such as the ones described in this report, states may miss an opportunity to provide more effective protections and services for the children and families most in need. GAO recommends that HHS provide additional guidance and technical assistance to states to address known challenges and enhance their understanding of requirements. HHS did not concur with the recommendation. As discussed in the report, GAO continues to believe that added guidance would benefit states.

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



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

Report 1: CAPTA, originally enacted in 1974, provides formula grants to states to improve child protective service systems  ACF administers the CAPTA state grant program and provides guidance and oversight to states  In fiscal year 2017, Congress provided about $25 million for the program  As part of the CAPTA state grant program, states are required to submit to the Secretary of HHS plans outlining how they intend to use CAPTA funds to improve their child protective service systems, among other things  State plans remain in effect for the duration of states’ participation in the grant program; if modifications are needed, these must be submitted  In addition to state plans, states are required to submit to HHS an annual data report providing information on agency decisions made in response to referrals of child abuse and neglect, as well as preventive services provided to families, among other things  CAPTA requires state governors to provide a series of assurances in their state plans  Since 2003, governors have had to provide an assurance that states have in effect and are enforcing a state law or program that includes policies and procedures to address the needs of infants affected by prenatal substance abuse or displaying withdrawal symptoms at birth  Under states’ policies and procedures, health care providers are required to notify CPS of such infants  Governors must also assure that a plan of safe care is developed for these infants  Although CAPTA does not define “plans of safe care,” for the purposes of this report we define them as plans to ensure the safety and well-being of infants who are born substance-affected  The Comprehensive Addiction and Recovery Act of 2016 (CARA) amended certain provisions of CAPTA that relate to substance-affected infants (see table 1)  In addition to provisions related to substance-affected infants, CAPTA also requires governors to provide an assurance to the Secretary of HHS that they have provisions or procedures for certain individuals to report known and suspected instances of child abuse and neglect, which are generally referred to as mandated reporter laws  All states have statutes identifying persons who are required to report suspected child maltreatment to an appropriate agency, such as child protective services, a law enforcement agency, or a state’s toll-free child abuse reporting hotline, according to a 2016 HHS report  Mandatory reporters often include social workers; teachers, principals, and other school personnel; physicians, nurses, and other health care workers; and counselors, therapists, and other mental health professionals  The circumstances under which a mandatory reporter must make a report vary from state to state, according to HHS  Typically, a report must be made when the reporter, in his or her official capacity, suspects or has reason to believe that a child has been abused or neglected  State laws require mandatory reporters to report the facts and circumstances that led them to suspect that a child has been abused or neglected; they do not have the burden of providing proof that abuse or neglect has occurred  CPS, a division within state and local social services, is generally the agency that conducts an initial assessment or investigation of reports of child abuse and neglect  It also offers services to families and children where maltreatment has occurred or is likely to occur  Typically, when CPS agencies receive a notification about suspected child abuse, including a substance-affected infant, social workers review the referral to determine if it should be accepted for investigation  During an investigation, social workers determine, among other things, the nature, extent, and cause of abuse or neglect, and identify the person responsible for the maltreatment  An investigation may include the following: a visit to the hospital and/or infant’s home; observation of the infant; risk and safety assessments; evaluation of the home environment; background checks, including criminal record checks of adults that reside with the family; as well as mental health evaluations  If social workers determine that there is enough evidence to suggest that an infant is at risk for harm or neglect, or that abuse or neglect occurred, the case is substantiated  Once a case is substantiated, CPS develops a case plan with the family outlining objectives and tasks for the family  Among other things, CPS may refer the family to services in the community, such as early intervention services, parenting classes, and substance abuse treatment  Generally, CPS attempts to strengthen the family and alleviate the problems which led to maltreatment  If the case is not substantiated, but there is genuine concern about the child’s situation and the family may benefit from services in the community, the case may be closed and/or the family may be referred for voluntary services (see figure 1)  Prenatal maternal opioid use has increased considerably in recent years  This increase has contributed to a significant rise in the rate of NAS  According to a recent study, the rate of NAS has increased from 1 2 per 1,000 hospital births in 2000 to 5 8 per 1,000 hospital births in 2012, reaching a total of 21,732 infants diagnosed with NAS  NAS occurs with considerable variability  According to a recent HHS report, various studies indicate that anywhere from 55 to 94 percent of infants exposed to opioids in-utero exhibit some degree of symptoms  Typically, infants with NAS develop symptoms within 72 hours of birth, but may develop symptoms within the first 2 weeks of life, including after hospital discharge  For the purpose of this report, infants exposed to opioids ingested by mothers in utero are considered substance-exposed, and those born negatively affected by exposure or experiencing withdrawal symptoms are considered substance-affected  According to experts, NAS is considered an expected and treatable result of women’s prenatal opioid use  Opioid exposure during pregnancy may occur for the following reasons: Women receiving pain medication with a prescription under the care of a physician  Medications can include fentanyl and oxycodone  Women under the care of a physician and undergoing treatment for an opioid use disorder with medications, such as methadone or buprenorphine  This type of treatment is generally referred to as medication-assisted treatment (MAT)  Women misusing opioid pain medications with or without a prescription (such as using without a prescription, using a different dosage than prescribed, or continuing to use a drug when no longer needed for pain)  Women using or abusing illicit opioid, such as heroin  In response to our survey, 42 states reported that state policies and procedures require health care providers to notify CPS about substance- affected infants  Some states reported that they explicitly require health care providers to notify CPS of substance-affected infants  For example, Wisconsin reported that under its state law if tests indicate that infants have controlled substances or controlled substance analogs in their bodily fluids, the health care provider shall report the occurrence of that condition to CPS  Others reported that the requirement is met by their states’ mandated reporter law—whereby people in certain positions, including health care providers, are required to notify CPS about substance-affected infants, similar to the manner in which other mandatory reporters, like school teachers, day care personnel, and social workers are required to report other instances of child abuse and neglect  For example, Kentucky statute requires that “any person who knows or has reasonable cause to believe that a child is dependent, neglected, or abused shall immediately” make a report to the police or CPS  The statutory definition for an abused or neglected child in Kentucky includes situations where a child’s health or welfare is harmed or threatened with harm because of parental incapacity due to alcohol and other drug abuse  Of the 42 states that require health care providers to notify CPS of substance-affected infants, 21 reported that notification is required for infants affected by both illegal and legal use of opioids  For example, in Massachusetts health care providers are required to notify CPS orally and, in writing within 48 hours, about substance-affected infants physically dependent on drugs, even if the drugs were legally obtained and the mother is under the care of a prescribing medical professional  Sixteen of the 42 states reported that health care providers are required to notify CPS of infants affected only by the illegal use of opioids, and five of the 42 states reported that they did not know if health care providers were required to notify CPS of infants affected by the illegal and legal use of opioids  The other eight states reported that although they did not have policies and procedures that require health care providers to notify CPS about substance-affected infants, they have laws or policies that encourage notification  Specifically, in written responses to our survey: Two states reported that under their state mandated reporter laws health care providers are encouraged, but not required, to notify CPS about substance-affected infants  Four states reported that they are working to amend their states’ policies and procedures to require that health care providers refer substance-affected infants to CPS  Another state reported that it encourages the notification from health care providers, but has not sought legislation to require health care providers to report substance-affected infants to CPS because of concerns that any laws that criminalize prenatal substance use would further deter substance-using pregnant women from seeking prenatal care  The state’s law requires all hospital personnel who suspect abuse and neglect or observe conditions that are likely to result in abuse or neglect to notify CPS  One state reported that all persons, including health care providers, are required to report child abuse and neglect, but reporting depends on whether a hospital’s policy indicates substance abuse is child abuse or neglect  Further, the state CPS director reported collaboration with the health care community on reporting substance exposed infants to its child abuse hotline  Although one state reported in our survey that it does not require or encourage health care providers to notify CPS about substance-affected infants, in an interview, state officials explained that its policy requires that health care providers notify CPS if, through an assessment, they conclude that infants are at risk for abuse and neglect  Under the state’s law, health care providers in each county are required to assess the needs of mothers and substance-affected infants using a protocol established by county health departments, CPS agencies, and hospitals  State officials told us that under the state’s law, the birth of a substance- affected infant is not in and of itself a sufficient basis for reporting child abuse or neglect  In addition to having policies and procedures regarding the reporting of substance-affected infants, in written responses to our survey some states reported providing training and guidance to support the efforts of health care providers to notify CPS about these infants  Three states reported that they offer mandatory reporter training to inform health care providers that they are obligated to notify CPS about substance-affected infants  Another state reported that its Department of Human Services developed a guide for mandated reporters that discusses what needs to be reported and where to make reports  Also, one state reported that it sent a formal letter to its state hospital association about how to report substance-affected infants to CPS  This state also sent a memo to its CPS county directors instructing them to contact their local health care providers on the importance of reporting substance-affected infants to CPS and the process for doing so  In addition, during our Massachusetts site visit, officials shared with us a memo that was sent to mandated reporters, community partners, and other stakeholders that offered guidance on when to file a report about substance-exposed infants  Further, local CPS staff at one Massachusetts field office told us that upon request they provide mandated reporter training to health care providers  Despite these policies, procedures, and guidance, in written responses to our survey, a few states reported concerns about requiring health care providers to notify CPS about substance-affected infants and the definition of substance-affected  All of the hospitals that we visited have policies consistent with their state’s law that require that health care providers, primarily hospital social workers, to notify CPS about substance-affected infants  However, one state reported that some medical personnel have been reluctant to report some infants that are positive for illegal and legal substances due to fears of mothers being arrested  Another state reported that stakeholders are concerned that having to notify CPS about substance-affected infants will have a chilling effect on the willingness of pregnant women who use substances to be honest with providers and seek the help and support they need and deserve  According to one state, there is often an inherent resistance to contacting CPS in these cases as health care providers tend to view child welfare involvement as punitive rather than a potential resource for the family  In addition, three states reported in written responses to our survey challenges understanding how to define terms, such as substance- affected, under CAPTA  For example, the Pennsylvania CPS director expressed concerns during our site visit, suggesting that CAPTA raises many unanswered questions, such as (1) if “affected by substances” means at-risk of being or physically affected by substances, (2) what policies relating to substance-affected infants should look like and include, and (3) whether “affected by substances” should include women who are under the care of health care or treatment providers and taking their medications as prescribed  A Kentucky public health official told us that a drug test, or whether the infant is affected by legal or illegal substances, should not be the sole factor in determining CPS’ involvement with a family  Rather, a holistic view of the family, whether the substance prohibits the mother’s ability to care for her child, and any risk factors present that places the infant at risk should also be considered  According to officials, an infant that is exposed to substances, but has not been affected by the substance, can still be at risk for child abuse and neglect  In response to our survey, 46 states reported that they have policies and procedures for deciding which notifications about substance-affected infants are accepted for investigation  Seventeen of those states reported that all notifications of substance-affected infants are accepted for investigation, regardless of the circumstances  The remaining 29 states reported that they apply specific criteria to determine if children who present as substance-affected are accepted for investigation by CPS  Several states reported in written responses to our survey that they base their criteria for accepting notifications on the infant’s safety  For these states, drug exposure does not by itself indicate that an infant’s safety is at risk  For example, one state explained that in determining a child’s safety risk, staff evaluate a number of factors including the history of the family; the family’s presentation at the birthing hospital (appearance of chaotic behavior, suspected intoxication of adults, lack of appropriate concern or bonding with the infant); the presentation of the infant’s physical condition; the results of any testing of parent or child (blood, urine, etc ); discrepancies identified in the parent’s representation of their substance use or substance use treatment; and any other concerns noted by the reporting source  Other states reported that their criteria for accepting notifications for investigation are based on the degree or type of drug exposure in question  For example, one state reported that its policy directs CPS agencies to accept notifications for investigation when a parent has used illegal substances or non-medical use of prescribed medication during the last trimester of pregnancy  Another state reported that it will accept notifications for investigation if the infant is born with a positive toxicology or is experiencing drug withdrawal, or if the mother tests positive for substances  A few states reported using both risk to the safety of infants as well as degree or type of drug as their criteria for accepting notifications  For example, one state reported that it considers factors, such as the type of drug, the parent’s ability to care for the child, addiction history, and the parent’s readiness and preparation to care for the infant  In follow-up correspondences with states that reported that they do not have policies and procedures to decide whether to accept for investigation notices about substance-affected infants, one state reported that decisions are made on a case-by-case basis  A few states reported that after receiving notifications about substance- affected infants, CPS agencies may decide to opt out of investigating some families, referred to as “screening out” families  For example, in Massachusetts, CPS can “screen out” referrals of mothers if the only substance affecting the infants was used by the mothers as prescribed by their physician  In these instances, when CPS in Massachusetts is notified by the hospital about an infant, the screener gathers information from the caller and consults with a supervisor to determine whether the referral should be accepted for investigation or screened out  If the mother is on methadone, for example, but is involved with services and is in a treatment plan, CPS verifies with medical or other qualified providers that the mother used the drug as part of substance abuse or medical treatment as authorized  Additionally, CPS confirms that there are no other concerns of child abuse and/or neglect  If CPS officials in Massachusetts are unable to collect all the information that they need to screen out families, for example when a mother does not sign a release allowing CPS officials to speak with her health care providers, notifications about substance-affected infants are accepted for investigation  In response to our survey, 49 states reported that their CPS agency has policies to develop a plan to ensure the safety and well-being of substance-affected infants who meet the state’s criteria for investigation  Two states reported that CPS staff are not required to develop such a plan, even if a notification is accepted for an investigation or an assessment  For purposes of this report, we are defining a plan of safe care as a plan to ensure the safety and well-being of the infant  States’ approaches to identifying children and families who will receive a plan of safe care generally fall into two categories: 38 states reported that CPS is required to develop a plan of safe care for all notifications of substance-affected infants that are accepted for investigation, including those that are not substantiated  11 states reported that CPS staff are required to develop a plan of safe care only in those instances where an investigation substantiates the notification or uncovers an unmet need or present or emerging danger  For example, local Pennsylvania CPS officials told us that they only develop plans when there is a safety threat or other concern about the infant  Most states reported that after a notification of a substance-affected infant is accepted for investigation, CPS always conducts a needs assessment for the infant and caregivers  For example, one local CPS office that we visited told us that social workers assess risk to and safety of infants, their function (development, age appropriate behavior, etc ), and environment  In addition, workers assess the caregiver’s ability to parent and employment status, as well as housing  The assessments conducted as part of the investigation inform the development of plans of safe care, as well as decisions about the removal of infants from the home  Among the 49 states that reported that plans of safe care are developed for all or some substance-affected infants, 47 reported that these plans either always or sometimes address infants’ safety needs  Plans also address other needs, such as infants’ immediate medical and longer-term developmental needs, as well as caregiver’s substance use treatment needs  See figure 2 for the number of states whose plans of safe care address various issues facing the infant and parent  In written responses to our survey and during our site visits, officials reported that plans of safe care and referrals for services included in the plans are individualized based on the infant and family’s needs  For example, Massachusetts state CPS officials told us that plans of safe care are developed for each family based on the information that staff collect from the safety, risk, and family assessments, as well as information collected from individuals who may have knowledge that would inform the family assessments, such as medical and treatment providers, and family members  Kentucky state CPS officials told us that the local organizations and service providers that they collaborate with to develop the plan of safe care also vary based on the family’s needs  For example, Kentucky will only collaborate with substance use treatment providers to develop the plan of safe care when families have substance use disorders  Similarly, during our site visits, officials from two states told us that the decision to place an infant in foster care is based on the individualized needs of the infant and caregiver  For example, Massachusetts state officials told us that their decision to remove a baby from the home depends on a myriad of factors and is determined on a case-by-case basis  Officials explained that if a mother is discharged from the hospital and begins using drugs again and does not have adequate supports in place to care for her baby, CPS may decide to place the infant in foster care  However, if a mother has existing support systems in place to mitigate safety risks, CPS may decide to keep the baby in the home  In our survey, all 51 states reported that their agencies either always or sometimes refer parents or caregivers to substance use treatment programs, and most states reported that they always or sometimes refer parents or caregivers to parenting classes or programs (49), and other supportive services (49)  CPS officials in each of the three states that we visited told us that their plans of safe care include referrals to address not only the immediate needs of the infants, but also the needs of the parent or caregiver  For example, officials from a local Kentucky CPS agency told us that staff refer mothers of substance-exposed infants to a program called Sobriety Treatment and Recovery Team (START)  START is comprised of a social worker and a peer support mentor who has at least 3 years of sobriety, previous involvement with CPS, and was successfully able to regain or keep custody of her own children  According to officials, the START program has been able to provide participants with quick access to substance use disorder treatment  Officials from a Massachusetts local CPS agency told us that one of the services that they provide to parents of substance-affected infants is a parent aide who can help monitor how the parent is caring for the infant, such as administering the infant’s medications appropriately and ensuring the parent is not abusing the infant’s drugs  In addition, a parent aide can provide emotional support and help parents adjust after the infant is discharged from the hospital  Kentucky officials noted the effect that a healthy caregiver has on the outcome of the infant and emphasized that a baby cannot be healthy if the mother is not  Kentucky CPS officials said that they have found that the earlier caregivers enter treatment, the better the outcomes are for mothers and babies  According to Kentucky officials, parents who participate in the START program are less likely to have their child placed in foster care  Officials from the states that we visited told us that developing and monitoring plans of safe care under CAPTA’s new requirements for infants affected by their mother’s legal use of prescribed medications, as well as plans for these infants’ caregivers, present challenges  Specifically, officials reported concerns about increased caseloads, particularly if they are required to provide plans and services for infants at low risk of abuse or neglect, the content of plans, and confidentiality restrictions  Thirty-one of 50 states reported on our survey that staffing or resource limitations was very or extremely challenging, and CPS officials across the 3 states we visited said that the opioid epidemic has directly contributed to increased caseloads  According to a local Kentucky CPS office, the number of babies that met criteria for being accepted for investigation has increased about 55 percent from 2011 to 2016, while the number of staff has remained the same  Similarly, hospitals reported being impacted by this challenge  For example, staff at four hospitals we visited told us that they have delayed discharging infants from the hospital because CPS social workers did not identify caregivers to whom infants may be released or make plans for infants in a timely manner  In addition, staff from three hospitals told us that some CPS workers are difficult to contact and not especially responsive to their questions  One hospital social worker told us that she is concerned that the changes to CAPTA that require notifying CPS of all substance-affected newborns will inundate the agencies with cases  Officials from two of the three states we visited anticipated that providing services to infants affected by the legal use of prescribed medications, but not likely to be at risk for child abuse and neglect, will result in an increase in the number of families referred to CPS  This, in turn, will require a plan of safe care and further strain limited resources  Twenty- five states reported in our survey that the plan they develop for substance-affected infants is the same as for other children in CPS care, suggesting that states devote the same level of resources to these infants as other cases  The states we visited interpret CAPTA to require that plans of safe care be developed for all substance-affected infants who are referred to CPS, including those who may not meet usual criteria to be accepted for an investigation  Some state officials we interviewed questioned whether the new CAPTA requirements would allow for the best use of limited resources  For example, one senior state CPS official questioned whether it would be a good use of resources to develop plans of safe care for mothers in substance use disorder treatment or mothers using opioid medications due to chronic pain  A local CPS official we interviewed stated that drug exposure, in and of itself, is not necessarily a safety risk, and CPS should not intervene with families who are not at risk for child abuse or neglect  Instead, hospitals or treatment providers should intervene and refer families who do not meet criteria for CPS involvement, but could benefit from additional supports, to voluntary services  Kentucky public health officials told us that the period after a woman gives birth is a critical time for families as mothers may be stressed, sleep-deprived, exhausted, and may have other children in the home  This period may be especially challenging for mothers with substance use disorders, if adequate supports are not in place  According to officials women are typically covered for substance use treatment during pregnancy; however, this coverage ends roughly 60 days after the baby is born  In written responses to our survey, some states reported that they would rely on other agencies to develop plans of safe care  Similarly, in order to manage limited CPS resources, officials from two of the three states that we visited said they are considering having hospitals or other agencies assume responsibility for developing plans of safe care when there is no evidence of abuse or neglect and there appears to be minimal risk to the safety and well-being of the infant  Kentucky officials told us that they envision that CPS will be responsible for developing a plan of safe care for notifications that are accepted for investigation, while hospitals, or another agency, will be responsible for developing plans of safe care for referrals that are screened out by CPS  According to CPS state officials, the plan of safe care for the infant and the family can be part of the discharge plan prior to the family leaving the hospital  However, officials reported that obtaining cooperation from other agencies may be difficult  Some state officials reported being concerned that other agencies may not feel obligated to develop these plans, in part, because CAPTA provides funding to child welfare, and other agencies may therefore believe that child welfare should be responsible for developing the plan of safe care  CPS officials we interviewed in two of our site visit states, as well as one state we followed up with, told us that they were unsure of whether their current plans will meet new CAPTA requirements because CAPTA does not define a plan of safe care  For example, Massachusetts officials said that their plans include everything that a family might need to ensure the safety of the child, including resources to ensure stabilization and reunification of a family, but they are not sure whether the plans meet new CAPTA requirements, in part because they are not familiar with the term “plan of safe care ” An official in another state was also unsure about whether his state’s “safety plans” would meet CAPTA requirements  According to the official, safety plans may include a treatment plan for mothers, and referral services, such as early intervention for the child  In practice, plans of safe care generally address gaps that place an infant at risk for harm or neglect  However, state officials we interviewed reported being unsure about what a plan of safe care should look like for families where these gaps do not exist  Also, in a written response to our survey, one state expressed uncertainty about CPS’ role if required to work with infants who do not typically receive CPS services  For example, a Pennsylvania official said that it is unclear what types of interventions child welfare should conduct with families of infants exposed to legal substances, such as medications prescribed by doctors, when the caregivers are taking their medications correctly  Similarly, officials also questioned whether a plan would be necessary, and what the plan would entail, for caregivers who are already addressing their substance use disorder and taking steps to ensure their infant’s safety  Officials from a local Kentucky CPS office described a case in which a mother was participating in medication-assisted treatment, had attended counseling three times per week throughout her pregnancy, and was continuing treatment in the postpartum period  Through CPS’ investigation, the agency found that the case was not substantiated, in part, because there were no additional services that CPS could connect her with that she was not already receiving  Officials across the three states we visited also said that state and federal drug and alcohol confidentiality restrictions may challenge their ability to monitor plans of safe care  To monitor plans of safe care, CPS staff may need access to confidential information in order to know how caregivers are progressing in treatment, particularly now that these plans must address the substance use disorder needs of the caregiver  However, federal law restricts the disclosure and use of alcohol and drug patient records maintained in connection with the performance of any federal- assisted alcohol and drug abuse program  Generally, confidential information may be disclosed in accordance with the prior written consent of the patient  State and local CPS staff we interviewed said that strict confidentiality requirements make it challenging for drug and alcohol treatment providers to share information about mothers and infants  A CPS state director from Pennsylvania said that treatment providers are often reluctant to provide CPS case workers with information or updates on a mother’s treatment, which prevents child welfare workers from fully understanding how mothers are progressing with their treatment and the extent to which those in treatment are adhering to prescribed directions as outlined by treatment providers  In addition, one official from a state we visited said state statutes regarding sharing of drug and alcohol treatment information may be more restrictive than the federal statute  Some states have developed ways to obtain confidential information about mothers in substance use disorder treatment  For example, officials from one local CPS office told us that in instances when they have to develop a long-term plan of safe care for families, they have mothers sign a release of information form in order to obtain updates about her treatment adherence from the medication- assisted treatment provider  Similarly, a local Massachusetts CPS office told us that typically staff obtain releases from mothers so that they can verify whether mothers are actively participating in their treatment and that there are no records of relapse  In HHS’ role to assist states in the delivery of child welfare services, two agencies—ACF and the Substance Abuse and Mental Health Services Administration (SAMHSA)—provided technical assistance to states through the National Center on Substance Abuse and Child Welfare (NCSACW)  In addition, in ACF’s role to administer and monitor states’ implementation of CAPTA, the agency has provided some guidance to states on the provisions pertaining to substance-affected infants and has begun its monitoring responsibilities  ACF and SAMHSA, which leads public health efforts to reduce the impact of substance abuse and mental illness, established the NCSACW in 2002  The NCSACW provides technical assistance to states, and has issued publications and hosted forums to help states develop policies and procedures around issues affecting substance-affected infants  The technical assistance has focused on a broad range of issues, including collaboration among service providers, and plans of safe care  With respect to collaboration, NCSACW has issued several studies that identify opportunities for strengthening interagency efforts to prevent, intervene, identify, and treat prenatal substance exposure  The NCSACW collaboration guides encourage states to involve CPS agencies with medical providers in an interagency collaborative setting, thereby facilitating the process for CPS agencies to be notified of substance- affected infants  Regarding plans of safe care, NCSACW has provided technical assistance and best practices to states around development of these plans  For example, in one state it has facilitated discussion groups to help the state develop a model plan  From calendar year 2011 to 2016, NCSACW processed approximately 600 requests from state CPS agencies for short-term technical assistance related to improving care for substance-affected infants and their families  This short-term technical assistance included activities such as responding to telephone inquiries, mailing information, identifying needed resources, and making referrals  The NCSACW has also provided in- depth assistance to 16 states to strengthen collaboration and linkages across child welfare, addiction treatment, medical communities, early care and education systems, and family courts to improve outcomes for substance-affected infants and their families  Through this in-depth assistance, NCSACW identified areas for improvement in states, including a lack of clarity regarding compliance with CAPTA requirements (such as identification, notification, and developing plans of safe care) and the need for state models to comply with CAPTA requirements to develop plans of safe care  In one state, the project overview report indicated that a next step for the in-depth technical assistance is to continue development of the plan of safe care model and ensure practices and protocols are in place across systems to meet CAPTA requirements  The report indicated that this will include ongoing work with hospitals to ensure consistent identification of infants with prenatal exposure and notifications to CPS  Although18 states reported in our survey that technical assistance from the NCSACW was very or extremely helpful, 11 reported that it was moderately helpful, 7 reported that it was slightly helpful, and 1 reported that it was not at all helpful  Eleven states reported that they were not familiar with this assistance  Since July 2016, when the most recent amendments to CAPTA were enacted, ACF has issued one information memorandum and two program instructions to states about provisions relating to substance-affected infants  According to an ACF official, information memoranda share information with states, while program instructions provide interpretations of the law and inform states of actions they must take  ACF issued an August 2016 information memorandum informing states of the 2016 amendments to CAPTA  The August 2016 information memorandum also provided states with best practices, drawing on an NCSACW guide on collaboration for developing multi-systemic approaches to assist child welfare, medical, substance use disorder treatment, and other systems to support families affected by opioid use disorders  In January 2017, ACF issued a program instruction which provided guidance to states on implementing the 2016 amendments to CAPTA made by CARA and informed states of the flexibilities that they have under the law  Particularly, the guidance noted that: “CAPTA does not define ‘substance abuse’ or ‘withdrawal symptoms resulting from prenatal drug exposure ’ We recognize that by deleting the term ‘illegal’ as applied to substance abuse affecting infants, the amendment potentially expands the population of infants and families subject to the provision [that states have policies and procedures in place to address their needs]  States have flexibility to define the phrase, ‘infants born and identified as being affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure,’ so long as the state’s policies and procedures address the needs of infants born affected by both legal (e g , prescribed drugs) and illegal substance abuse ” “While CAPTA does not specifically define a ‘plan of safe care,’ CARA amended the CAPTA state plan requirement       to require that a plan of safe care address the health and substance use disorder treatment needs of the infant and affected family or caregiver ” “CAPTA does not specify which agency or entity must develop the plan of safe care; therefore the state may determine which agency will develop the plans  We understand that in most instances the state already has identified the responsible agency in its procedures  When the state reviews and modifies its policies and procedures to incorporate the new safe care plan requirements in CARA, the state may wish to revisit its procedures regarding which agency develops the plan of safe care, including any role for agencies collaborating with CPS in caring for the infant and family ” In addition, in April 2017, ACF issued a program instruction on reporting requirements, including changes in those requirements brought about by the 2016 amendments to CAPTA  ACF conducted limited monitoring of states prior to the amendments passed in 2016  According to ACF officials, if presented with evidence of potential deficiencies, the agency would attempt to learn more about the state’s activities  In one instance, ACF reviewed South Carolina’s policies and found them to not be in compliance with the notification and safe care plan requirements of CAPTA  It directed the state to develop a program improvement plan to bring it into full compliance, which South Carolina submitted in April 2016  In a recent progress report (February–April 2017), South Carolina reported that it was focused on updating statutes, developing policies and procedures, training child protective service workers, and building relations with health care providers  In response to the 2016 amendments to CAPTA that added the requirement for HHS to monitor state policies and procedures to address the needs of substance-affected infants, ACF officials told us that staff in regional offices will review states’ annual reports, submitted in June 2017  In its program instruction describing the reporting requirements, ACF asked each state to submit a new Governor’s Assurance, as well as a narrative explaining what they have done in response to the amendments  Specifically, ACF asked states to provide information on any changes that were made in state laws, policies, or procedures related to identifying and referring infants affected by substance abuse to CPS as a result of prenatal drug exposure  It also requested updates on states’ policies and procedures regarding the development of plans of safe care; a description of how states have developed systems to monitor plans of safe care; and a description of any outreach or coordination efforts the states have taken to implement the amendments, among other things  According to ACF officials, as of October 1, 2017, some states have provided information and a Governor’s Assurance demonstrating compliance with the amended provisions and some states have been placed on Program Improvement Plans, but the agency does not yet have information on the status of all states  An ACF official explained that, in their annual reports, some states either acknowledged that they are trying to get legislation enacted to bring them into compliance with the law and it has failed, or that they are not in compliance, for example, because they were limiting their policies to those infants affected only by illegal substances  In addition, in May 2017, ACF issued a technical bulletin informing states of the new data collection requirements that resulted from the 2016 amendments to CAPTA  ACF stated that it intends to collect data required by the amendments to CAPTA through the National Child Abuse and Neglect Data System, beginning with states’ submission of fiscal year 2018 data  This system is maintained by ACF and contains data from states about children who have been abused or neglected  ACF issued a Federal Register notice about the proposed data elements and requested comments on the accuracy and quality of the proposed data collection, among other things; the comment period closed in July 2017  In the Federal Register notice, ACF notes that the 2016 amendments to CAPTA require it to collect information from state CPS agencies on the number of notifications from health care providers that are accepted for investigation or screened out  Further, of those infants screened in, ACF is required to collect data on the number of safe care plans developed for substance- affected infants as well as the number of infants for whom a referral was made for appropriate services, including services for the affected family or caregiver  In the Federal Register notice, ACF proposed to collect this information using a combination of existing and new data from states  Thirty-two states reported in our survey that they already collect data on the incidence of substance-affected and/or substance-exposed infants; 15 of those 32 states also collect data on the incidence of NAS  Further, 18 states reported that they collect data on the number of notifications health care providers make to CPS  Of those states, 8 reported that they collect specific data on notifications related to infants diagnosed with NAS  Most states reported in our survey that additional guidance and assistance would be extremely or very helpful (see figure 3)  For example, 38 states reported that additional guidance on requirements for health care providers to notify CPS of substance-affected infants would be extremely or very helpful  Similarly, 37 states reported that additional guidance on developing, implementing, and monitoring plans to ensure the safety and well-being of substance-affected infants would be extremely or very helpful  In written responses to our survey, states suggested ideas for additional guidance, training, and technical assistance to help them address the needs of substance-affected infants  States’ suggestions ranged from assisting in the development of substance abuse training curriculum for staff to video conferences with other states to share information about implementing CAPTA  A few states suggested that the guidance ACF has provided to date is not clear and reported grappling with the meaning of terms such as “affected” and “legal vs  illegal” substances, and two states requested “concrete guidance” and “specificity ” A few other states suggested that it would be helpful to obtain additional information about meeting the requirements of plans of safe care within the constraints of state and federal confidentiality laws, technical assistance on what plans of safe care look like, and a format for a plan of safe care  ACF officials told us that states have flexibility with implementing the law and the agency does not anticipate issuing additional written guidance on the amendments to CAPTA made by CARA  ACF officials explained, in October 2017, that they were finalizing their review of the plans that states were required to submit  These plans are expected to include details on how the states are addressing the CAPTA requirements  While ACF could not provide the number, officials reported that some of the state plans submitted to date did not meet the requirements and those states have been asked to develop program improvement plans  They expect states to work with the ACF regional offices, which will provide or facilitate technical assistance to states on their implementation of the provisions, as needed  In addition to the review of state plans, ACF officials explained that regional officials may learn about states’ needs for technical assistance through meetings or informational exchanges  Finally, the NCSACW is expected to review and prepare a summary of CAPTA state plans, current state statutes and policies and procedures relating to amended CAPTA requirements  In addition, according to ACF, NCSACW will continue to offer technical assistance on the development and implementation of plans of safe care to states  Technical assistance may include responding to requests for information, disseminating written materials and resources, and conducting webinars/conference calls  Further, ACF reported that some states will receive more in-depth technical assistance, albeit in some instances on a time-limited basis  Undertaking these actions can enhance states’ understanding of CAPTA requirements and better address known challenges such as the ones described in this report  However, more specific guidance from HHS on the issues which states have expressed confusion can assist them in better understanding CAPTA requirements and providing more effective protections and services for the children and families most in need  The opioid epidemic has generated a significant increase in the number of substance-affected infants born and diagnosed with NAS  These vulnerable infants may be at risk for child abuse and neglect if adequate supports and services are not available to ensure their safety  CAPTA requires states to have policies and procedures to address the needs of these infants and their families, including mothers with a substance use disorder  However, states have experienced challenges implementing new CAPTA requirements  Many states reported in our survey that they are not completely adhering to the law  This is reflected in ACF’s review of state plans, some of which are resulting in program improvement plans  States cite challenges that stem, in part, from ACF’s lack of specificity in providing guidance on implementing CAPTA requirements  Specifically, states report that ACF has not provided clear guidance about which substance-affected infants health care providers are required to notify CPS about, as well what a plan of safe care is and for whom it should be developed  Given the challenges that states reported facing in implementing the provisions, a majority reported wanting more help from ACF, such as trainings and teleconferences with other states, to help overcome their challenges  Additional guidance and assistance from HHS would help states better understand what they need to do to develop policies and procedures that meet the needs of children and families affected by substance use  The Secretary of HHS should direct ACF to provide additional guidance and technical assistance to states to address known challenges and enhance their understanding of CAPTA requirements, including the requirements for health care providers to notify CPS of substance- affected infants and the development of a plan of safe care for these infants  We provided a draft of this report to HHS for review and comment  HHS’s comments are reproduced in appendix I  HHS also provided technical comments, which we incorporated into our report where appropriate  HHS did not concur with our recommendation  HHS stated that: in January 2017, ACF clarified in guidance several of the issues raised in the report, including the population of infants and families covered by the provision and the state flexibility inherent in determining which infants are “affected by” substance abuse, and the terminology used in the federal law of what a “plan of safe care” is; ACF believes it is necessary to allow states the flexibility to meet the requirements in the context of their state CPS program; several of the challenges that the GAO notes are not specific to CAPTA compliance with the safe care plan and notification requirements; and it does see the value in continuing to provide technical assistance to states to address known challenges and to enhance their understanding of CAPTA requirements  With respect to HHS’ January 2017 guidance, state officials reported in our survey and during site visits that they found some terms unclear and were uncertain about what is required of them  In written responses to our survey, states reported challenges understanding how to define substance-affected under CAPTA  In addition, as we note in our report, the guidance about plans of safe care described the following: “While CAPTA does not specifically define a ‘plan of safe care,’ CARA amended the CAPTA state plan requirement       to require that a plan of safe care address the health and substance use disorder treatment needs of the infant and affected family or caregiver ” States reported in our survey and in follow-up discussions that this lack of specificity remained an ongoing challenge for them  For example, as we discuss in our report, one state that we followed up with in August 2017 was still unsure about whether its safety plans would meet CAPTA requirements for plans of safe care  In addition, as of October 2017, HHS confirmed that some state plans did not meet CAPTA requirements and that the states were asked to develop program improvement plans  Accordingly, a key ongoing challenge was not addressed by the January guidance  Regarding allowing states flexibility to meet CAPTA requirements, we acknowledge in our report that HHS said that states have flexibility  However, in our survey and site visits, states indicated that they would find it helpful for HHS to provide them with greater specificity around terms, including the degree of flexibility they are allowed  States added that this would include parameters within which they can develop policies and procedures that meet CAPTA requirements  We continue to believe that additional guidance addressing these concerns would benefit states and could be provided without imposing additional mandates  Concerning HHS’ third point that some of the issues raised in the report are not specific to CAPTA, the states we visited interpret CAPTA to require that plans of safe care be developed for all substance-affected infants who are referred to CPS  During our discussions with states and in responses to our survey, state officials did not delineate which federal requirement impacted their approach to serving children and families  As stated in our conclusion, vulnerable infants may be at risk for child abuse and neglect if adequate supports and services are not available to ensure their safety  Lastly, HHS indicated that it will continue to provide technical assistance to states and fund demonstration sites to establish or enhance collaboration across community agencies and courts  Although continuing to provide technical assistance to states should be beneficial, our findings demonstrate that additional guidance is also needed  For example, 38 states reported that additional guidance on requirements for health care providers to notify CPS of substance-affected infants would be extremely or very helpful  Similarly, 37 states reported that additional guidance on developing, implementing, and monitoring plans to ensure the safety and well-being of substance-affected infants would be extremely or very helpful  Overall, given the results of our review, we continue to believe our recommendation is warranted  Effective implementation of our recommendation should help states better implement protections for children  As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date  At that time, we will send copies of this report to the appropriate congressional committees and the Secretary of Health and Human Services  In addition, the report is available at no charge on the GAO website at http://www gao gov  If you or your staff have any questions about this report, please contact me at (202) 512-7215 or larink@gao gov  Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report  GAO staff who made key contributions to this report are listed in appendix II  Kathryn A  Larin, (202) 512-7215 or larink@gao gov  In addition to the contact above, Sara Schibanoff Kelly (Assistant Director), Ramona L  Burton (Analyst-in-Charge), Kay E  Brown, Hannah Dodd, Ada Nwadugbo, and Srinidhi Vijaykumar made key contributions to this report  Also contributing to this report were Sandra L  Baxter, James Bennett, Gina Hoover, Jessica Orr, Rhiannon Patterson, Jean McSween, and James Rebbe 


Report 2: T he Public Safety Officers' Benefits (PSOB) program provides cash benefits to federal, state, and local law enforcement officers; firefighters; employees of emergency management agencies; and members of emergency medical services agencies who are killed or permanently and totally disabled as the result of personal injuries sustained in the line of duty  The Public Safety Officers' Educational Assistance (PSOEA) program, a component of the PSOB program, provides higher-education assistance to the children and spouses of public safety officers killed or permanently disabled in the line of duty  Both programs are administered by the PSOB Office of the Department of Justice (DOJ), Bureau of Justice Assistance (BJA)  Congress appropriates funds for these programs in the annual Departments of Commerce and Justice, Science, and Related Agencies Appropriations Act  For FY2019, the one-time lump-sum PSOB benefit is $359,316 and the monthly full-time attendance PSOEA assistance is $1,224  The PSOB and PSOEA benefit amounts are indexed to reflect changes in the cost of living  Table 1 shows PSOB and PSOEA claims and approvals as reported by DOJ  To be eligible for PSOB benefits for death or disability, a person must have served in one of the following categories of public safety officers: law enforcement officer, firefighter, or chaplain in a public agency; FEMA employee or a state, local, or tribal emergency management agency employee; or emergency medical services member  There is no minimum amount of time a person must have served to be eligible for benefits  To be eligible for PSOB benefits as a law enforcement officer, firefighter, or chaplain, a person must have served in a "public agency" in an official capacity, with or without compensation  For the purposes of PSOB eligibility, a public agency is defined as the federal government and any department, agency, or instrumentality of the federal government; and any state government, the District of Columbia government, and any U S  territory or possession; and any local government, department, agency, or instrumentality of a state, the District of Columbia, or any U S  territory or possession  For the purposes of PSOB eligibility, a law enforcement officer is defined as "an individual involved in crime and juvenile delinquency control or reduction, or enforcement of the criminal laws (including juvenile delinquency), including, but not limited to, police, corrections, probation, parole, and judicial officers " For the purposes of PSOB eligibility, the definition of firefighter includes both professional firefighters and persons serving as an "officially recognized or designated member of a legally organized volunteer fire department " A chaplain is eligible for PSOB benefits (1) if he or she is either an "officially recognized or designated member of a legally organized volunteer fire department or legally organized police department" or public employee of a police or fire department and (2) only if he or she was performing the duties of a chaplain in an official capacity while responding to a police, fire, or rescue emergency  Employees of the Federal Emergency Management Agency (FEMA) and state, local, or tribal emergency management agencies may be eligible for PSOB benefits under certain conditions provided in statute  A FEMA employee or an employee of a state, local, or tribal emergency management agency working with FEMA is eligible for PSOB benefits if he or she is performing official duties that are related to a major disaster or an emergency declared under the Robert T  Stafford Disaster Relief and Emergency Assistance Act (Stafford Act) and that are considered hazardous by the FEMA Administrator or the head of the state, local, or tribal agency  A member, including a volunteer member, of a rescue squad or "ambulance crew" who is authorized or licensed by law and the applicable agency and is engaging in rescue services or providing emergency medical services may be eligible for PSOB benefits  The rescue squad or ambulance service may provide ground or air ambulance services and may be either a public agency or a nonprofit entity authorized to provide rescue or emergency medical services  By PSOB regulation, eligible emergency medical services workers include rescue workers, ambulance drivers, paramedics, health care responders, emergency medical technicians, or others who are trained in rescue activity or emergency medical services and have the legal authority and responsibility to provide such services  The PSOB program pays benefits if a public safety officer becomes permanently and totally disabled or dies "as the direct and proximate result of a personal injury sustained in the line of duty " To qualify for coverage under the PSOB program, a public safety officer's disability or death must have been the result of a personal injury  The PSOB regulation defines an injury for the purposes of benefit eligibility as a traumatic physical wound (or a traumatized physical condition of the body) directly and proximately caused by external force (such as bullets, explosives, sharp instruments, blunt objects, or physical blows), chemicals, electricity, climatic conditions, infectious disease, radiation, virii, or bacteria     The regulation also provides that the definition of an injury does not include an occupational disease or a condition of the body caused by stress or strain, including psychological conditions such as post-traumatic stress disorder  However, the PSOB statute specifically provides for deaths caused by certain cardiovascular conditions  The death of a public safety officer due to a heart attack, stroke, or vascular rupture shall be presumed to be a death from a personal injury for the purposes of PSOB eligibility if the officer engaged in nonroutine stressful or strenuous physical activity as part of an emergency response or training exercise; and if the condition began during the physical activity, while the officer remained on duty after the physical activity, or within 24 hours of the physical activity  The PSOB program covers a public safety officer's death or disability if it occurred as the result of an injury incurred in the line of duty  The PSOB regulations provide that an injury occurs in the line of duty if it (1) is the result of the public safety officer's authorized activities while on duty, (2) occurs while responding to an emergency or request for assistance, or (3) occurs while commuting to or from duty in an authorized department or personal vehicle  In addition, if there is convincing evidence that the injury was the result of the individual's status as a public safety officer, that injury is covered by the PSOB program  The lump-sum PSOB death and disability benefit for FY2019 is $359,316  The benefit amount is adjusted annually to reflect changes in the cost of living using the annual percentage change in the Consumer Price Index for Urban Consumers (CPI-U) for the one-year period ending in the previous June  If a public safety officer receives a disability benefit and later dies from the same injury, the officer's survivors may not receive a PSOB death benefit  The payable benefit amount is based on the date of the public safety officer's death or the date of the injury that caused the disability, rather than on the date of application for benefits or disability determination  Thus, if a benefit increase occurs while an application is pending, the benefit is payable at the previous, lower, benefit level  Death and disability benefits are not subject to the federal income tax  In general, PSOB death and disability benefits are paid in addition to any other workers' compensation, life insurance, or other benefits paid for the death of a public safety officer  However, the PSOB death benefit is offset by the following benefits: benefits under the Federal Employees' Compensation Act (FECA) payable to state and local law enforcement officers injured or killed while enforcing federal law; benefits under the D C  Retirement and Disability Act of 1916 for certain police officers and firefighters in the District of Columbia; and payments from the September 11 th Victim Compensation Fund (VCF)  PSOB death benefits are payable to the eligible spouse and children of a public safety officer  A spouse is the person to whom the officer is legally married, even if physically separated, under the marriage laws of the jurisdiction where the marriage took place  Pursuant to regulations issued after the Supreme Court struck down the federal Defense of Marriage Act in United States v  Windsor , the legally married spouse of a public safety office may be of the same sex as the officer  A child is defined as any "natural, illegitimate, adopted, or posthumous child or stepchild" of the public safety officer who, at the time of the public safety officer's fatal or catastrophic injury, is 18 years of age or under; between 18 and 23 years of age and a full-time student in high school or undergraduate higher education; or over 18 years of age and incapable of self-support because of physical or mental disability  PSOB death benefits are paid to eligible survivors in the following order: 1  if the officer is survived by only a spouse, 100% of the death benefits are payable to the spouse; 2  if the officer is survived by a spouse and children, 50% of the death benefits are payable to the spouse and the remaining 50% is distributed equally among the officer's children; 3  if the officer is survived by only children, the death benefits are equally distributed among the officer's children; 4  if the officer has no surviving spouse or children, the death benefits are paid to the individual or individuals designated by the officer in the most recently executed designation of beneficiary on file at the time of the officer's death; or if the officer does not have a designation of beneficiary on file, the benefits are paid to the individual or individuals designated by the officer in the most recently executed life insurance policy on file at the time of the officer's death; 5  if the officer has no surviving spouse or eligible children, and the officer does not have a life insurance policy, the death benefits are equally distributed between the officer's surviving parents; or 6  if the officer has no surviving spouse, eligible children, or parents, and the officer did not have a designation of beneficiary or a life insurance policy on file at the time of his or her death, the death benefits are payable to surviving adult, nondependent, children of the officer  PSOB disability benefits are paid only in cases of permanent and total disability  There are no benefits payable for partial or short-term disabilities  A disability is considered permanent for the purposes of PSOB eligibility if, given the current state of medicine in the United States, there is a degree of medical certainty that the condition will remain constant or deteriorate over the person's lifetime or that the public safety officer has reached maximum medical improvement  A public safety officer is considered to be totally disabled for the purposes of PSOB eligibility if given the current state of medicine in the United States, there is a degree of medical certainty that the officer is unable to perform any gainful work  PSOB regulation defines gainful work as "full- or part-time activity that is compensated or commonly compensated " Applications for PSOB death and disability benefits are filed with the PSOB office, which determines benefit eligibility and commences benefit payment  Unless extended for good cause, application deadlines must be met  Complete benefit applications must be filed no later than for death benefits: three years after the death; one year after the determination of the officer's employing agency to award or deny death benefits payable by that agency; or one year after certification by the officer's employing agency that the agency is not authorized to pay any death benefits; and for disability benefits: three years after the date of the injury; one year after the determination of the officer's employing agency to award or deny workers' compensation or disability benefits payable by that agency; or one year after certification by the officer's employing agency that the agency is not authorized to pay any workers' compensation or disability benefits  A lump-sum interim payment of up to $3,000 may be made if a PSOB death benefit will "probably be paid " The interim payment amount reduces the final PSOB payment amount  If the ultimate decision is to deny death benefits, the interim payment must be returned to the federal government, unless this repayment is waived because it would create a hardship for the beneficiary  Section 611 of the Uniting and Strengthening America by Providing Appropriate Tools Required to Intercept and Obstruct Terrorism Act of 2001 (USA PATRIOT Act; P L  107-56 ) provides for expedited payment of PSOB death and disability benefits if the officer's injury occurred "in connection with prevention, investigation, rescue, or recovery efforts related to a terrorist attack " In such cases, PSOB benefits must be paid within 30 days of certification from the officer's employing agency that the officer's death or disability was related to terrorism  The Public Safety Officers' Education Assistance (PSOEA) program provides financial assistance with costs associated with higher education to the spouse or children of a public safety officer who is eligible for PSOB death or disability benefits  The spouse or child of a public safety officer who is eligible for PSOB death or disability benefits may be eligible for PSOEA benefits  To be eligible for PSOEA benefits, a spouse must have been married to an eligible public safety officer at the time of the officer's death or injury  A child is eligible for PSOEA benefits until the age of 27  This age limit can be extended by the Attorney General in extraordinary circumstances, or, pursuant to Section 3 of the Public Safety Officers' Benefits Improvement Act of 2017 ( P L  115-36 ), if there is a delay of more than one year in approving PSOB or PSOEA benefits  In addition, to be eligible for PSOEA benefits, the spouse or child must be enrolled at an eligible educational institution  For the purposes of PSOEA eligibility, an eligible education institution is one that meets the definition of an "institution of higher education" as provided by Section 102 of the Higher Education Act of 1965 and that is eligible for federal student aid  PSOEA benefits are payable to the claimant and may be used only to defray costs associated with higher education attendance, including tuition, room, board, book and supplies, and education-related fees  The monthly PSOEA benefit amount is equal to the monthly benefit amount payable under the GI Bill Survivors' and Dependents' Educational Assistance (DEA) program, which is administered by the Department of Veterans Affairs (VA) for spouses and dependents of veterans with disabilities or who died as a result of service-connected conditions  The PSOEA benefit amounts are adjusted annually to reflect changes in the cost of living in accordance with changes to the GI Bill DEA benefit amounts  For FY2019, the PSOEA monthly benefit for a student attending an educational institution full-time is $1,224  The PSOEA benefit rates are prorated for less than full-time attendance  The maximum duration of PSOEA benefits for any person is 45 months of full-time education or a proportionate duration of part-time education  A person is ineligible for PSOEA if he or she is in default on a federal student loan or is ineligible for federal benefits due to a drug trafficking or drug possession conviction  In addition, the Attorney General may discontinue PSOEA benefits for a student that fails to make satisfactory progress in his or her course of study as defined by Section 484(c) of the Higher Education Act of 1965  A claimant who is dissatisfied with a PSOB disability benefit denial may request a reconsideration  There is no reconsideration offered for denials of PSOB death or PSOEA benefits  A claimant who is dissatisfied with a PSOB or PSOEA benefit denial may request a de novo hearing before a hearing officer assigned by the director of the DOJ PSOB Office  The determination of a hearing officer may be appealed to the PSOB Office director  The director's determination is considered the final agency determination and is not subject to any further agency administrative review or appeal  However, provided all administrative appeals remedies have been exhausted, the PSOB Office director's determination may be appealed to the United States Court of Appeals for the Federal Circuit  The PSOB statute authorizes the BJA to prescribe the maximum fee that an attorney or other representative may charge a claimant for services rendered in connection with a claim, with attorney fees generally limited to between 3% and 6% of the total benefit paid, depending on the level in the administrative appeals process the claim is approved  Program regulation prohibits stipulated-fee and contingency-fee arrangements for PSOB representation  Congress provides funding for PSOB and PSOE benefits and associated administrative expenses in the annual Departments of Commerce and Justice, Science, and Related Agencies Appropriations Act  Funding for PSOB death benefits and associated administrative expenses is considered mandatory spending and Congress appropriates "such sums as may be necessary" for the payment of these benefits  Funding for PSOB disability and PSOEA benefits is considered discretionary and is subject to specific congressional appropriations  Annual appropriations language grants the Attorney General the authority to transfer from any available appropriations to the DOJ the funds necessary to respond to emergent circumstances that require additional funding for PSOB disability benefits and PSOEA benefits  

ground_truth: The Public Safety Officers' Benefits (PSOB) program provides cash benefits to federal, state, and local law enforcement officers; firefighters; employees of emergency management agencies; and members of emergency medical services agencies who are killed or permanently and totally disabled as the result of personal injuries sustained in the line of duty. The Public Safety Officers' Educational Assistance (PSOEA) program, a component of the PSOB program, provides higher-education assistance to the children and spouses of public safety officers killed or permanently disabled in the line of duty. The PSOB and PSOEA programs are administered by the Department of Justice (DOJ), Bureau of Justice Assistance (BJA). However, claimants dissatisfied with denials of benefits may pursue administrative appeals within DOJ and may seek judicial review before the United States Court of Appeals for the Federal Circuit. Each year, Congress appropriates funding for PSOB death benefits, which is considered mandatory spending, and for PSOB disability benefits and PSOEA benefits, which is subject to annual appropriations. For FY2019, the one-time lump-sum PSOB death and disability benefit is $359,316 and the PSOEA monthly benefit for a student attending an educational institution full-time is $1,224. In FY2017, the DOJ approved 399 claims for PSOB death benefits, 82 claims for PSOB disability benefits, and 601 claims for PSOEA benefits.