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



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

Report 1: The House of Representatives has standing rules that govern how bills and resolutions are to be taken up and considered on the floor  However, to expedite legislation receiving floor action, the House may temporarily set aside these rules for measures that are not otherwise privileged for consideration  This can be done by agreeing to a special order of business resolution (special rule) or by adopting a motion to suspend the rules and pass the underlying measure  In general, special rules enable the consideration of complex or contentious legislation, such as major appropriations or reauthorizations, while the suspension of the rules procedure is usually applied to broadly supported legislation that can be approved without floor amendments or extensive debate in the chamber  Most bills and resolutions that receive floor action in the House are called up and considered under suspension of the rules  The suspension procedure allows nonprivileged measures to be raised without a special rule, waives points of order, limits debate, and prohibits floor amendments  Motions to suspend the rules and pass the measure require a two-thirds vote, so the procedure is typically reserved for bills and resolutions that can meet a supermajority threshold  Decisions to schedule bills for consideration under suspension are generally based on how widely supported the measures are, how long Members wish to debate them, and whether they want to propose floor amendments  These decisions are not necessarily related to the subject matter of the measure  Accordingly, measures brought up under suspension cover a wide range of policy areas but most often address government operations, such as the designation of federal facilities  This report describes the suspension procedure, which is defined in clause 1 of House Rule XV, and provides an analysis of measures considered under suspension during the 114 th Congress (2015-2016)  Figures 1- 8 display statistical data, including the prevalence and form of suspension measures, sponsors of measures, committee consideration, length of floor debate, voting, and resolution of differences between the chambers  Table 1 summarizes the final legislative status of measures initially considered in the House under the suspension of the rules  Finally, Figure A-1 depicts the use of the suspension procedure from the 110 th through the 114 th Congresses (2007-2016)  The suspension of the rules procedure is established by clause 1 of House Rule XV  Bills, resolutions, House amendments to Senate bills, amendments to the Constitution, conference reports, and other types of business may be considered under suspension, even those "that would otherwise be subject to a point of order … [or have] not been reported or referred to any calendar or previously introduced " Suspension motions are in order on designated days  As Rule XV states, "the Speaker may not entertain a motion that the House suspend the rules except on Mondays, Tuesdays, and Wednesdays and during the last six days of a session of Congress " Suspension measures, however, may be considered on other days by unanimous consent or under the terms of a special order of business (special rule) reported by the Committee on Rules and agreed to by the House  A motion to suspend the rules is a compound motion to suspend the House rules and pass a bill or agree to a resolution  When considering such a motion, the House is voting on the two questions simultaneously  Once recognized, the Member making the motion will say, "Mr  [or Madam] Speaker, I move to suspend the rules and pass___ " The House rules that are suspended under this procedure include those that "would impede an immediate vote on passage of a measure … such as ordering the previous question, third reading, recommittal, or division of the question " A measure considered under the suspension procedure is not subject to floor amendment  The motion to suspend and pass the measure, though, may provide for passage of the measure in an amended form  That is, the text to be approved may be presented in a form altered by committee amendments or by informal negotiations  Suspension measures that are passed with changes incorporated into the text are passed "as amended " There are no separate votes on the floor approving such amendments  Suspension motions are "debatable for 40 minutes, one-half in favor of the motion and one-half in opposition thereto " However, in most instances, a true opponent never claims half the time, and most speakers come to the floor to express support for the measure  Debate time is controlled by two floor managers, one from each party, who sit on a committee of jurisdiction  Each manager makes an opening statement and may yield increments of the 20 minutes they control to other Members to debate the measure  Once debate has concluded, a single vote is held on the motion to suspend the rules and pass the measure  The motion requires approval by "two-thirds of the Members voting, a quorum being present " Should the vote fall short of the two-thirds required for passage (290, if all Members vote), the measure is not permanently rejected  Before the end of the Congress, the House may consider the measure again under suspension, or the Committee on Rules may report a special rule that provides for floor consideration of the measure  As illustrated in Figure 1 , the majority of measures considered on the House floor during the 114 th Congress were called up under the suspension of the rules procedure  Sixty-two percent of all measures that received floor action were considered under suspension (743 out of the 1,200), compared to those under the terms of a special rule (14%), unanimous consent (7%), or privileged business (16%)  Figure 2 displays the form of suspension measures  Most of the measures considered under suspension during the 114 th Congress (94%) were bills  House bills made up 83% of the suspension total, Senate bills 11%  As represented in Figure 3 , most suspension measures were sponsored by members of the majority party during the 114 th Congress  House or Senate majority-party members sponsored 69% of all bills and resolutions initially considered in the House under suspension, while House majority-party members sponsored 467 (71%) of the 660 House-originated measures (designated with an H R , H Res , H Con Res  or H J Res  prefix)  Suspension is, however, the most common procedure used to consider minority-sponsored legislation in the House by a wide margin  In the 114 th Congress, 85% of the minority-sponsored measures that were considered on the House floor were raised under the suspension procedure  Members of the House or Senate minority parties sponsored 31% of all suspension measures originating in either chamber, compared to 9% of legislation subject to different procedures, including privileged business (17 measures), unanimous consent (21 measures), and special rules (one Senate bill)  Minority-party House Members sponsored 193 (29%) of the 660 House measures considered under suspension  No minority-party House Member sponsored a House-originated measure that was considered under a special rule  Most suspension measures are referred to at least one House committee before their consideration on the chamber floor  In the 114 th Congress, 710 out of the 743 suspension measures considered (96%) were previously referred to a House committee  Of the 33 measures that were considered without a referral, 31 were Senate bills that were "held at the desk," and two were House resolutions that provided concurrence to Senate amendments  Measures may be referred to multiple House committees before receiving floor action  When a bill or resolution is referred to more than one House committee, the Speaker will designate one committee as primary, meaning it is the committee exercising jurisdiction over the largest part of the measure  Generally, the chair of the committee of primary jurisdiction works with majority party leadership to determine if and when a measure should be considered under suspension  Figure 4 shows the number and percentage of measures brought up under suspension from each House committee of primary jurisdiction  The House Committee on Oversight and Government Reform (now Oversight and Reform) was the committee of primary jurisdiction for the plurality of measures considered under suspension in the 114 th Congress: 106, or 14%, of the total number of suspension measures considered  Many of these bills designated names for post offices or other federal properties  For most House committees, the majority of their referred measures that reached the floor were raised under the suspension procedure  In the 114 th Congress, the four exceptions were the Committee on House Administration—which had several measures considered by unanimous consent—and the Committees on Appropriations, the Budget, and Armed Services, which had at least half of their measures considered pursuant to special rules  For the other committees, suspension measures ranged from 57% to 100% of the total number of the committee's measures receiving floor action ( Figure 5 )  Since suspension motions require a two-thirds majority for passage, House committees that handle less contentious subjects tend to have more of their measures considered under the suspension procedure in comparison to other committees  In the 114 th Congress, high-suspension committees included Small Business (100% of measures receiving floor action) and Veterans' Affairs (92%)  The Small Business Committee's measures sought to authorize new business development programs  Veterans' Affairs measures included authorizations, reauthorizations, and bills designating federal facilities  While suspension measures are not subject to floor amendments, committees may recommend amendments to legislative texts during markup meetings or through informal negotiations  The motion to suspend the rules can include these proposed changes when a Member moves to suspend the rules and pass the measure "as amended " In the 114 th Congress, 396 suspension measures (53% of the total) were considered "as amended," meaning that the text to be approved differed from the measure's introduced text  Clause 2 of House Rule XIII requires that measures reported by House committees must be accompanied by a written report  Otherwise, they are not placed on a calendar of measures eligible for floor consideration  However, the written report requirement is among those rules suspended under the suspension procedure  Thus, measures may be called up on the floor under suspension of the rules even if a committee never ordered them to be reported or wrote an accompanying committee report


Report 2:  Instead, the motion to suspend the rules discharges the committee and moves the legislation directly to the House floor  In the 114 th Congress, 517 (70%) suspension measures were ordered to be reported by a House committee  Of this number, 398 were reported with an accompanying House committee report  Twenty measures that did not have a House report did have a Senate report, while 325 measures had no written report from either chamber (43% of the total number of suspension measures)  Pursuant to Rule XV, motions to suspend the rules are regularly in order on Mondays, Tuesdays, and Wednesdays or on the last six days of a session of Congress  However, suspension motions may be considered on other days by unanimous consent or under the terms of a special rule reported by the Committee on Rules and agreed to by the House  As displayed in Figure 6 , in the 114 th Congress, the plurality of suspension measures were considered on Tuesdays (312, 42% of the total number considered), followed by Mondays (291, 39%) and Wednesdays (114, 15%)  In addition, 25 suspension measures were considered on Thursdays and one on a Friday  Of these, one was considered by unanimous consent, while 25 were called up under suspension pursuant to permission included in a special rule reported by the Rules Committee and agreed to by the full House  Such special rules included a provision stating, "It shall be in order at any time on the legislative day of ___ for the Speaker to entertain motions that the House suspend the rules as though under clause 1 of rule XV " Pursuant to Rule XV, suspension measures are "debatable for 40 minutes, one-half in favor of the motion and one-half in opposition thereto " In practice, there is rarely a true opponent to a motion to suspend the rules, and the time is divided between two floor managers, usually one from each party, who both favor the motion  The floor managers each control 20 minutes of debate  The managers may be their parties' sole representative for or against the motion, or they may yield increments of the 20-minute allotment to other Members  Typically, the relevant committee chairs and ranking members select the majority and minority floor managers for particular bills and resolutions  These managers may be the measure's sponsor, the chair or ranking member of the measure's committee of primary jurisdiction, or another committee member  In the 114 th Congress, the measure's sponsor served as the majority manager on 26% of the suspension measures receiving floor action  The committee chair managed 29% of the measures  The minority manager was the measure's sponsor for 11% of the measures and the committee's ranking member for 26% of the measures considered  Occasionally, floor managers controlling time on a motion to suspend the rules ceded their control to other Members during debate  In two identified cases, both the majority and minority floor managers favored the measure, and another Member claimed the time in true opposition during the initial floor consideration of the measure  In at least one other instance, the minority manager asked unanimous consent to yield managerial control to another Member  A majority floor manager makes the motion to suspend the rules by stating, "Mr  [Madam] Speaker, I move to suspend the rules and pass the bill [or resolution] ____ " The Speaker [or Speaker pro tempore] responds, "Pursuant to the rule, the gentleman[woman] from [state] and the gentleman[woman] from [state] each will control twenty minutes " The majority and minority managers then, in turn, make opening statements regarding the measure using the 20 minutes each controls  If the majority and minority managers have secured additional speakers, the speakers generally alternate between the parties within the 40-minute limit  During the 114 th Congress, on a motion to suspend the rules, the average number of speakers in addition to the floor managers was fewer than two  On 83% of the measures (620) considered, there were one or two additional speakers  On 27% of the measures (199) considered, there were no additional speakers, and in 16% of the measures (120) considered, there were 3 to 12 additional speakers  Three measures had 20, 21, and 25 additional speakers, respectively  At the start of the debate period, the majority manager may request "unanimous consent that all Members may have five legislative days in which to revise and extend their remarks and add extraneous materials on this bill [resolution] " This request enables general leave statements to be inserted into the Congressional Record   In 29% of the suspension measures considered in the 114 th Congress, a written general leave statement appeared in the Record following in-person remarks, indicating that the remarks were submitted on the day the legislation was considered  General leave statements submitted on a day other than the day of consideration appear in the Extension of Remarks section of the Congressional Record   Suspension measures are limited to a maximum of 40 minutes of debate under Rule XV  However, if there are time gaps between speakers or procedural interruptions, such as a vote on a motion to adjourn, the time period between the start of the first speaker's remarks and the conclusion of debate may exceed 40 minutes  The statistics displayed in Figure 7 show the length of consideration of suspension measures as documented in Congress gov, not the accumulated length of statements, as kept by official timekeepers in the chamber  In the 114 th Congress, the average length of consideration on a motion to suspend the rules was 13 minutes and 10 seconds, and half of the measures considered had a debate period of 10 minutes or less  Thus, while overall debate is limited to 40 minutes under the rule, on most suspension measures, only a fraction of that time was actually expended during consideration  Seventeen measures, however, had consideration periods that exceeded 40 minutes due to procedural delays or, in the case of one measure, a request for unanimous consent to extend debate by 10 minutes to each side  House leaders generally choose measures for suspension that are likely to achieve the two-thirds majority threshold for passage  Thus, almost all suspension measures were passed by the House in the 114 th Congress  The full House approved all House resolutions (28), concurrent resolutions (12), joint resolutions (2), and Senate bills (82) that were considered under suspension  The House also passed, via motions to suspend the rules, 612 of the 619 House bills that were initially considered under suspension  Seven bills did not receive the requisite supermajority  Two of these bills were later considered and approved under the terms of a special rule  The remaining five bills did not return to the floor and therefore did not pass the House  Most suspension motions are agreed to in the House by voice vote, which is the chamber's default method of voting on most questions  In 2015 and 2016, this method of voting led to the final approval of 72% (531) of the motions to suspend the rules and pass the measures (see Figure 8 )  After the initial voice vote, Members triggered an eventual record vote (often called a roll call vote) on 212 (28%) of the suspension measures considered in the 114 th Congress  This was done by demanding the "yeas and nays," objecting to the vote "on the grounds that a quorum is not present," or, in one case, demanding a recorded vote  In most instances, the chair elected to postpone the vote to a later period, within two additional legislative days, pursuant to clause 8 of House Rule XX  Of the 212 record votes, 3 immediately followed debate on the measure  The remaining 209 votes were postponed to another time on the legislative schedule, usually later the same day  In the 114 th Congress, 205 suspension motions were adopted by record vote, and 7 motions to suspend the rules were defeated by record votes  The defeat of a motion to suspend the rules, however, does not necessarily kill the legislation  The Speaker may choose to recognize a Member at a later time to make another motion to suspend the rules and pass the bill, or the House may consider the measure pursuant to a special rule reported by the Committee on Rules  Accordingly, two of the initially unsuccessful measures were later called up and passed under the terms of a special rule  Five measures were not considered again, via any House floor procedure, before the end of the 114 th Congress  Although suspension measures generally receive broad support, measures that receive the requisite two-thirds majority in the House are not guaranteed passage in the Senate  As noted in Table 1 , in the 114 th Congress, the Senate passed 197 of the 619 House bills initially considered under suspension (32%)  Additionally, the Senate agreed to 1 of the 2 House joint resolutions and 5 of the 11 House concurrent resolutions considered under suspension of the rules  Of the number of suspension measures that passed the House and Senate, 60 required a resolution of differences between the chambers  Forty-four House measures and 15 Senate bills were subject to an amendment exchange process, and on one occasion, a conference committee was used to resolve the differences between the House and Senate versions of a House bill  The Senate passed three House bills, initially approved in the House under suspension, that did not become public law because the House did not agree to the final bill text, as amended by the Senate  In those instances, the House did not reconsider the bills once the Senate returned the Senate-amended versions to the House chamber  Thus, 194 House bills were presented to the President for signature  Of the measures initially considered under suspension during the 114 th Congress, President Obama was presented with 194 House bills, 82 Senate bills, and 1 House joint resolution for signature or veto  The President vetoed H R  1777 (Presidential Allowance Modernization Act of 2016) and S  2040 (Justice Against Sponsors of Terrorism Act)  The House chose not to attempt a veto override on H R  1777 , so the measure did not become public law  Both the Senate and House voted to override the veto of S  2040 , enabling it to become law without the President's signature ( P L  114-222 )  Thus, of the 703 law-making measures (bills and joint resolutions) initially considered under suspension of the rules, 193 House bills, 82 Senate bills, and 1 House joint resolution became public law (see Table 1 ) 

ground_truth: This report provides an overview and analysis of FY2019 appropriations for the Department of Homeland Security (DHS). The primary focus of this report is on congressional direction and funding provided to DHS through the appropriations process. It includes an Appendix with definitions of key budget terms used throughout the suite of Congressional Research Service reports on homeland security appropriations. It also directs the reader to other reports providing context for specific component appropriations. As part of an overall DHS budget that the Office of Management and Budget (OMB) estimated to be $74.88 billion, the Trump Administration requested $47.43 billion in adjusted net discretionary budget authority through the appropriations process for DHS for FY2018. The request amounted to a $0.29 billion (0.6%) decrease from the $47.72 billion in annual appropriations enacted for FY2018 through the Department of Homeland Security Appropriations Act, 2018 (P.L. 115-141, Division F). The Administration also requested discretionary funding for DHS components that does not count against discretionary spending limits and is not reflected in the adjusted net discretionary budget authority total. The Administration requested an additional $6.65 billion for the Federal Emergency Management Agency (FEMA) in disaster relief funding, as defined by the Budget Control Act (P.L. 112-25; BCA), and in the budget request for the Department of Defense (DOD), $165 million in Overseas Contingency Operations designated funding (OCO) from the Operations and Maintenance budget of the U.S. Navy. On June 21, 2018, the Senate Committee on Appropriations reported out S. 3109, the Department of Homeland Security Appropriations Act, 2019, accompanied by S.Rept. 115-283. Committee-reported S. 3109 included $48.33 billion in adjusted net discretionary budget authority for FY2019. This was $901 million (1.9%) above the level requested by the Administration, and $611 million (1.3%) above the enacted level for FY2018. The Senate committee-reported bill included the Administration-requested levels for disaster relief funding, and included the OCO funding in an appropriation to the Coast Guard, rather than as a transfer from the U.S. Navy. On July 26, 2018, the House Appropriations Committee marked up H.R. 6776, its version of the Department of Homeland Security Appropriations Act, 2019. H.Rept. 115-948 was filed September 12, 2018. Committee-reported H.R. 6776 included $51.44 billion in adjusted net discretionary budget authority. The House committee-reported bill included the Administration-requested levels for disaster relief funding, but unlike S. 3109, did not include the OCO funding for the Coast Guard. As some of the annual appropriations for FY2019 remained unfinished, a consolidated appropriations bill that included a continuing resolution was passed by Congress and signed into law on September 28, 2018. The resolution, which covered DHS along with several other departments and agencies, continued funding at a rate of operations equal to FY2018 with some exceptions. This continuing resolution was extended through December 21, 2018, after which point annual appropriations lapsed. A partial government shutdown ensued for 35 days until continuing appropriations were resumed January 25, 2019, by P.L. 116-5. P.L. 116-6, the Consolidated Appropriations Act, 2019, was passed by Congress on February 14, 2019, and signed into law the following day. Division A of the act included the Homeland Security Appropriations Act, 2019, which included $49.41 billion in adjusted net discretionary budget authority, $12 billion designated for the costs of major disasters, and $165 million in OCO funding for the Coast Guard. This report will be updated in the event of FY2019 supplemental appropriations actions.

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



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

Report 1: This report describes and analyzes annual appropriations for the Department of Homeland Security (DHS) for FY2019  It compares the enacted FY2018 appropriations for DHS, the Donald J  Trump Administration's FY2019 budget request, and the appropriations measures developed and considered by Congress in response to it  This report identifies additional informational resources, reports, and products on DHS appropriations that provide context for the discussion, and it provides a list of Congressional Research Service (CRS) policy experts with whom clients may consult on specific topics  The suite of CRS reports on homeland security appropriations tracks legislative action and congressional issues related to DHS appropriations, with particular attention paid to discretionary funding amounts  These reports do not provide in-depth analysis of specific issues related to mandatory funding—such as retirement pay—nor do they systematically follow other legislation related to the authorizing or amending of DHS programs, activities, or fee revenues  Discussion of appropriations legislation involves a variety of specialized budgetary concepts  The Appendix to this report explains several of these concepts, including budget authority, obligations, outlays, discretionary and mandatory spending, offsetting collections, allocations, and adjustments to the discretionary spending caps under the Budget Control Act (BCA; P L  112-25 )  A more complete discussion of those terms and the appropriations process in general can be found in CRS Report R42388, The Congressional Appropriations Process: An Introduction , coordinated by James V  Saturno, and the Government Accountability Office's A Glossary of Terms Used in the Federal Budget Process   All amounts contained in the suite of CRS reports on homeland security appropriations represent budget authority  For precision in percentages and totals, all calculations in these reports used unrounded data, which are presented in each report's tables  However, amounts in narrative discussions are rounded to the nearest million (or 10 million, in the case of numbers larger than 1 billion), unless noted otherwise  Data used in this report for FY2018 amounts are derived from the explanatory statement accompanying P L  115-141 , the Consolidated Appropriations Act, 2017—Division F of which is the Department of Homeland Security Appropriations Act, 2018  The explanatory statement also includes data on FY2018 supplemental appropriations for DHS enacted prior to the development of the consolidated appropriations act for FY2018  Data for the FY2019 requested levels and enacted levels are drawn from H Rept  116-9 , the explanatory statement accompanying P L  116-6   Data on the Senate Appropriations Committee recommendation are drawn from S Rept  115-283 , and data for the House Appropriations Committee recommendation are drawn from H Rept  115-948   Scoring methodology is consistent across this report, relying on data provided by the Appropriations Committees that has been developed with Congressional Budget Office (CBO) methodology  CRS does not attempt to compare this data with Office of Management and Budget (OMB) data because technical scoring differences do not allow precise comparisons  This section provides an overview of the process of enactment of appropriations for the Department of Homeland Security for FY2019, from the Administration's initial request, through committee action in the House and Senate, continuing appropriations (and their lapse), and enactment of the consolidated appropriations bill that contained DHS annual appropriation  On February 12, 2018, the Trump Administration released its budget request for FY2019  The enactment of the Bipartisan Budget Act of 2018 ( P L  115-123 ) three days before had established discretionary spending limits for FY2018 and FY2019, replacing the limits prescribed by the Budget Control Act of 2011 ( P L  112-25 )  The Administration chose to submit an addendum to their request in a letter accompanying the formal request documentation, which included additional requests for resources for DHS and several other departments and agencies  The Trump Administration requested $47 43 billion in adjusted net discretionary budget authority for DHS for FY2019, as part of an overall budget that the Office of Management and Budget estimated to be $74 88 billion (including fees, trust funds, and other funding that is not annually appropriated or does not score against discretionary budget limits)  The request amounted to a $0 29 billion (0 6%) decrease from the $47 72 billion in annual appropriations enacted for FY2018 through the Department of Homeland Security Appropriations Act, 2018 ( P L  115-141 , Division F)  The Trump Administration also requested discretionary funding for DHS components that does not count against discretionary spending limits set by the Budget Control Act (BCA; P L  112-25 ) and is not reflected in the above totals  The Administration requested an additional $6 65 billion for the Federal Emergency Management Agency (FEMA) in disaster relief funding, as defined by the BCA, and in the budget request for the Department of Defense, $165 million in Overseas Contingency Operations/Global War on Terror designated funding (OCO), to be transferred to the Coast Guard  On June 21, 2018, the Senate Appropriations Committee reported out S  3109 , the Department of Homeland Security Appropriations Act, 2019, accompanied by S Rept  115-283   Committee-reported S  3109 included $48 33 billion in adjusted net discretionary budget authority for FY2019  This was $901 million (1 9%) above the level requested by the Administration, and $611 million (1 3%) above the enacted level for FY2018  The Senate committee-reported bill also included the Administration-requested levels for disaster relief funding, and $163 million in OCO-designated funding directly for the Coast Guard, as had been done in FY2018, rather than as a transfer, as had been requested by the Administration  This bill was never taken up for action on the Senate floor  On July 26, 2018, the House Appropriations Committee marked up H R  6776 , its version of the Department of Homeland Security Appropriations Act, 2019  H Rept  115-948 was filed September 12, 2018  Committee-reported H R  6776 included $51 44 billion in adjusted net discretionary budget authority  The House committee-reported bill included the Administration-requested levels for disaster relief funding, but unlike S  3109 , did not include the OCO funding for the Coast Guard  This bill did not see action on the House floor  As some of the annual appropriations for FY2019 remained unfinished, a consolidated appropriations bill that included a continuing resolution was passed by Congress and signed into law on September 28, 2018, as P L  115-245   The continuing resolution (Division C) continued funding for DHS at a rate of operations equal to that of the Department of Homeland Security Appropriations Act, 2018, with some exceptions  The continuing resolution was extended through December 21, 2018, at which point it expired, and annual appropriations for DHS lapsed, resulting in a partial shutdown of DHS for 35 days  Continuing appropriations were restored at the FY2018 rate of operations with the enactment of P L  116-4 on January 25, 2019  On February 14, 2019, the House took up H J Res  31 , a consolidated appropriations bill that included eight annual appropriations bills  Division A, the Department of Homeland Security Appropriations Act, 2019, included $49 41 billion in adjusted net discretionary budget authority, $1 69 billion (3 5%) more than had been provided for FY2018, and $2 04 billion more than had been requested by the Administration in February 2018  In addition to that total, the bill included $12 billion designated for the costs of major disasters—$5 35 billion (80 4%) more than had been requested, and the requested $165 million in OCO funding appropriated for the Coast Guard operating budget, rather than a transfer from the Navy  The bill passed the House by a vote of 300-128, and the Senate that same day by a vote of 83-16  The President signed it into law the next day  Generally, the homeland security appropriations bill includes all annual appropriations provided for DHS, allocating resources to every departmental component  Discretionary appropriations provide roughly two-thirds to three-fourths of the annual funding for DHS operations, depending how one accounts for disaster relief spending and funding for overseas contingency operations  The remainder of the budget is a mix of fee revenues, trust funds, and mandatory spending  Appropriations measures for DHS typically have been organized into five titles  The first four are thematic groupings of components, while the fifth provides general direction to the department, and sometimes includes provisions providing additional budget authority  Prior to the FY2017 act, the legislative language of many appropriations included directions to components or specific conditions on how the budget authority it provided could be used  Similarly, general provisions provided directions or conditions to one or more components  In the FY2017 act, a number of these provisions within appropriations and component-specific general provisions were grouped at the ends of the titles where their targeted components are funded, and identified as "administrative provisions " This practice has continued in subsequent years  When DHS was established in 2003, components of other agencies were brought together over a matter of months, in the midst of ongoing budget cycles  Rather than developing a new structure of appropriations for the entire department, Congress and the Administration continued to provide resources through existing account structures when possible  At the direction of Congress, in 2014 DHS began to work on a new Common Appropriations Structure (CAS), which would standardize the format of DHS appropriations across components  In an interim report in 2015, DHS noted that operating with "over 70 different appropriations and over 100 Programs, Projects, and Activities     has contributed to a lack of transparency, inhibited comparisons between programs, and complicated spending decisions and other managerial decision-making " After several years of work and negotiations with Congress, DHS made its first budget request in the CAS for FY2017, and implemented it while operating under the continuing resolutions funding the department in October 2016  For FY2017 and FY2018, all DHS components requested appropriations under the CAS except for the Coast Guard, due to constraints of its financial management system  For FY2019, all the components' requests generally conformed to the CAS  A visual representation of the FY2019 requested funding in this new structure follows in Figure 1   On the left, CAS appropriations categories are listed next to a black bar representing the total FY2018 funding levels requested for DHS for each category  A catch-all "other" category is included for budget authority associated with the legislation that does not fit the CAS categories  Colored lines flow to the DHS components listed on the right, showing how the amount of funding for each appropriations category is distributed across DHS components  Wider lines indicate greater funding levels, so it is possible to understand how components may be funded differently  For example, while Customs and Border Protection (CBP) gets most of its funding from Operations and Support appropriations, the Federal Emergency Management Agency (FEMA) receives most of its discretionary funding from the Disaster Relief Fund appropriation  The following sections present textual and tabular comparisons among FY2018 enacted appropriations, FY2019 requested appropriations, the FY2019 appropriations bills developed by the appropriations committees, and the final enacted annual appropriation in Division A of the FY2019 Consolidated Appropriations Act ( P L  116-6 )  The structure of the appropriations reflects the organization outlined in the detail table of the explanatory statement accompanying the act ( H Rept  116-9 )  The tables summarize enacted appropriations for FY2018, and those requested by the Administration, and proposed in appropriations committee-developed legislation under development for FY2019  Only the formal request for FY2019 annual appropriations is reflected in the "Request" column  The tables include data on enacted annual and supplemental appropriations  Instances where appropriations are provided for a title's components in other parts of the bill (such as in general provisions or by transfer) are shown separately  Supplemental appropriations provided with an emergency designation for a given component in FY2018 are displayed after the subtotal of annual appropriations  Following the methodology used by the appropriations committees, totals of "appropriations" do not include resources provided by transfer or under adjustments to discretionary spending limits (i e , for emergency requirements, overseas contingency operations for the Coast Guard or the cost of major disasters under the Stafford Act for the Federal Emergency Management Agency)  Amounts covered by adjustments are included with discretionary appropriations in a separate total for "discretionary funding " A subtotal for each component of total estimated budgetary resources that would be available under the legislation and from other sources (such as fees, mandatory spending, and trust funds) for the given fiscal year is also provided at the end of each component section  Totals at the bottom of each table indicate the total net discretionary appropriation for the title on its own, the total net discretionary funding from the annual appropriations bill and any supplemental appropriations (when such were provided), and the projected total estimated budgetary resources for each phase in the appropriations process shown in the table  Title I, Departmental Management and Operations, the smallest of the component-specific titles, contains appropriations for the Office of the Secretary and Executive Management, the Management Directorate, Analysis and Operations (A&O), and the Office of the Inspector General (OIG)  For FY2018, these components received $1 36 billion in net discretionary funding through the appropriations process, including $25 million in FY2018 supplemental appropriations  The Trump Administration requested $1 60 billion in FY2019 net discretionary funding for components included in this title  In addition, $24 million was requested as a transfer from the FY2019 appropriation for the Disaster Relief Fund to the OIG  Not including the transfer, the appropriations request was $241 million (17 7%) more than the amount provided for FY2018  Senate Appropriations Committee-reported S  3109 included $1 47 billion in FY2019 net discretionary funding for the components funded in this title  This was $137 million (8 6%) less than requested by the Trump Administration and $103 million (7 6%) more than the amount provided for FY2018  S  3109 included $72 million in discretionary budget authority drawn from unobligated prior-year balances from the DRF, but did not include the proposed transfer of FY2019 DRF resources to the OIG  As a result, the gross budgetary resources provided to components funded in Title I was $89 million (5 5%) less than the request, and $176 million (12 9%) more than provided in FY2018  House Appropriations Committee-reported H R  6776 included $1 48 billion in FY2019 net discretionary funding for the components funded in this title  This was $119 million (7 4%) less than requested by the Trump Administration and $122 million (8 9%) more than the amount provided for FY2018  H R  6776 , like the Senate committee-reported bill, did not include the proposed transfer of FY2019 DRF resources to the OIG  As a result, the gross budgetary resources provided to components funded in Title I were $143 million (8 8%) less than the request, and $122 million (8 9%) more than provided in FY2018  P L  116-6 included a total of $1 88 billion in FY2019 net discretionary funding for the components funded in this title  This included $51 million in a general provision for financial systems modernization, controlled by the management directorate  The total was $513 million (37 7%) more than was provided in FY2018, and $248 million (15 2%) more than was requested by the Administration, if one included the Administration's proposed transfer of $24 million from the Disaster Relief Fund to the Office of the Inspector General  Table 1 shows these comparisons in greater detail  As resources were requested or provided for the Management Directorate and Office of the Inspector General in some cases from outside Title I, separate lines are included for each of those components showing a total for what is provided solely within Title I, then the individual items funded outside the title, followed by the total annual appropriation for the components  Title II, Security, Enforcement, and Investigations, contains appropriations for U S  Customs and Border Protection (CBP), Immigration and Customs Enforcement (ICE), the Transportation Security Administration (TSA), the Coast Guard (USCG), and the U S  Secret Service (USSS)  Title II funding represents the majority of DHS's budget, comprising roughly three-quarters of the funding appropriated annually for the department  For FY2018, these components received $39 52 billion in net discretionary funding, as part of $47 13 billion in projected total budget authority  This included $1 06 billion in supplemental appropriations  The Trump Administration formally requested $38 41 billion in FY2019 net discretionary funding for components included in this title, as part of a total budget request for these components of $47 08 billion for FY2019  The funding request was $45 million (0 1%) less than the amount provided for FY2018, setting aside FY2018 supplemental appropriations  Again setting aside FY2018 supplemental appropriations, the total resources proposed for FY2019 was $1 01 billion (2 2%) more than projected for FY2018  The Administration reportedly sought additional funding in this title for construction of border barriers, above the formally requested level  In January 2019, the acting director of the Office of Management and Budget sent a letter to congressional leaders officially seeking an additional $4 1 billion  Those amounts are not included in these comparative calculations or in the table below  Senate Appropriations Committee-reported S  3109 included $38 68 billion in FY2019 net discretionary funding for the components funded in this title  This was $271 million (0 7%) more than formally requested by the Trump Administration and $227 million (0 6%) more than the amount provided for FY2018, setting aside FY2018 supplemental appropriations  The total budgetary resources projected under S  3109 were $614 million (1 3%) less than the Administration's request (largely due to rejection of a proposed TSA fee increase), but $391 million (0 8%) more than projected for FY2018, again setting aside FY2018 supplemental appropriations  House Appropriations Committee-reported H R  6776 included $41 28 billion in FY2019 net discretionary funding for the components funded in this title  This was $2 87 billion (7 5%) more than formally requested by the Trump Administration and $2 82 billion (7 3%) more than the amount provided for FY2018, setting aside FY2018 supplemental appropriations  The total budgetary resources projected under H R  6776 were $2 08 billion (4 4%) more than formally requested by the Administration and $3 12 billion (6 8%) more than projected for FY2018, again setting aside FY2018 supplemental appropriations  H R  6776 would have provided $2 59 billion (6 7%) more than S  3019 , largely due to the House Appropriations Committee recommending $3 35 billion more than its Senate counterpart for CBP's Border Security Assets and Infrastructure activity  P L  116-6 included $40 00 billion in net discretionary funding for the components funded in this title  The enacted annual appropriations were $1 59 billion (4 1%) more than requested, and $486 million (1 2%) more than the amount provided in FY2018  Setting aside FY2018 supplemental funding, FY2019 enacted net discretionary funding exceeded FY2018 levels by $1 55 billion (4 0%)  The total budgetary resources projected for components funded in this title were $47 82 billion, $704 million (1 5%) more than was formally requested by the Administration, and $1 75 billion (3 8%) more than was provided in FY2018, setting aside the FY2018 supplemental funding  Table 2 shows these comparisons in greater detail  Title III, Protection, Preparedness, Response, and Recovery, contains appropriations for the Cybersecurity and Infrastructure Security Agency (CISA), the Office of Health Affairs (OHA), and the Federal Emergency Management Agency (FEMA)  It is the second largest of the component-specific titles  For FY2018, these components received $7 22 billion in net discretionary appropriations and $7 37 billion in specially designated funding for disaster relief through the annual appropriations process  In addition to that annual funding, $58 23 billion was provided for FEMA in emergency supplemental appropriations in FY2018  Incorporating all these elements, the total net discretionary funding level for all Title III components was $72 61 billion for FY2018  The Trump Administration requested $6 19 billion in FY2019 net discretionary appropriations for components included in this title, and $6 65 billion in specially designated funding for disaster relief as part of a total net discretionary funding level for these components of $12 84 billion for FY2019  Setting aside the $58 23 billion in FY2018 supplemental appropriations, the appropriations request was $1 54 billion (10 7%) less than the amount provided for FY2018 in net discretionary funding  Senate Appropriations Committee-reported S  3109 included $13 54 billion in FY2019 net discretionary funding for the components funded in this title  This was $694 million (5 4%) more than requested by the Trump Administration and $847 million (5 9%) less than the amount provided for FY2018, setting aside supplemental funding  The total budgetary resources projected would be $718 million (3 8%) more than the Administration's request, but $1 29 billion (6 2%) less than projected for FY2018, setting aside supplemental funding  The Senate committee-reported bill included within these totals the requested disaster relief funding of $6 65 billion, and offset $228 million in its Federal Assistance appropriation from unobligated DRF balances  House Appropriations Committee-reported H R  6776 included $13 70 billion in FY2019 net discretionary funding for the components funded in this title  This was $861 million (6 7%) more than requested by the Trump Administration and $681 million (4 7%) less than the amount provided for FY2018, setting aside supplemental funding  The total budgetary resources projected would be $885 million (4 7%) more than the Administration's request, but $1 13 billion (5 4%) less than projected for FY2018, setting aside supplemental funding  The House committee-reported bill included within these totals the requested disaster relief funding of $6 65 billion  P L  116-6 included $18 27 billion in FY2019 net discretionary funding for the components funded in this title  The enacted discretionary funding level was $5 43 billion (42 3%) more than requested, and $3 89 billion (27 1%) more than the amount provided for FY2018, setting aside the historically high level of supplemental appropriations  The total budgetary resources projected for FY2019 was $5 46 billion (29 0%) more than was requested, and $3 44 billion (16 5%) more than was projected for FY2018, setting aside FY2018 supplemental funding  Table 3 shows these comparisons in greater detail  As some annually appropriated resources were provided for FEMA from outside Title III in FY2018, a separate line is included for FEMA showing a total for what is provided solely within Title III, then the non-Title III appropriation, followed by the total annual appropriation for FEMA  Title IV, Research and Development, Training, and Services, the second smallest of the component-specific titles, contains appropriations for the U S  Citizenship and Immigration Services (USCIS), the Federal Law Enforcement Training Center (FLETC), the Science and Technology Directorate (S&T), and the Domestic Nuclear Detection Office (DNDO)  In FY2018, these components received $1 57 billion in net discretionary funding, as part of a projected total budget of $5 92 billion  This included $10 million in supplemental appropriations for FLETC  The Trump Administration requested $1 53 billion in FY2019 net discretionary funding for components included in this title, as part of a total budget for these components of $6 11 billion for FY2018  The funding request was $36 million (2 3%) less than the amount provided for FY2018, setting aside supplemental appropriations, although the overall budget request was $201 million (3 3%) higher than the annual budget projected for FY2018 (again, setting aside supplemental funding)  This is due to changes in anticipated fee collections for USCIS and reorganization of most of the Office of Health Affairs and DNDO into the new CWMD component reflected in the request  Senate Appropriations Committee-reported S  3109 included $1 53 billion in net discretionary funding for components included in this title, as part of a projected total budget of $6 23 billion  This was $115 million (7 5%) more than requested, and $79 million (5 0%) less than the amount provided for FY2018, not including supplemental funding  The total budgetary resources projected under S  3109 would have been $115 million (1 9%) more than the Administration's request, and $316 million (5 3%) more than projected for FY2018, setting aside supplemental funding  House Appropriations Committee-reported H R  6776 included $1 64 billion in net discretionary funding for components included in this title, as part of a projected total budget of $6 21 billion  This was $97 million (6 3%) more than requested, and $60 million (3 9%) more than the amount provided for FY2018, not including supplemental funding  The total budgetary resources projected under H R  6776 would have been $97 million (1 6%) more than the Administration's request, and $297 million (5 0%) more than projected for FY2018, setting aside supplemental funding  P L  116-6 included $1 62 billion in FY2019 net discretionary funding for the components funded in this title  Enacted FY2019 appropriations were $199 million (3 3%) more than was requested by the Administration, and $163 million (10 4%) more than was provided in FY2018, setting aside FY2018 supplemental funding  Total budgetary resources projected for FY2019 are $199 million (3 3%) more than were requested by the Administration, and $400 million (6 8%) more than was projected for FY2018, setting aside FY2018 supplemental funding  Table 4 shows these comparisons in greater detail  As noted above, the fifth title of the FY2019 DHS appropriations act contains general provisions, the impact of which may reach across the entire department, affect multiple components, or focus on a single activity  Rescissions of prior-year appropriations—cancellations of budget authority that reduce the net funding level in the bill—are found in this title  For FY2018, Division F of P L  115-141 included $489 million in rescissions  For FY2019, the Administration proposed rescinding $300 million in prior-year funding from the DRF  S  3109 included $137 million in rescissions from other appropriations, but specifically directed the $300 million the Administration had proposed rescinding from the DRF to other activities within DHS  H R  6776 did not include any rescissions, although an amendment from Representative Palazzo was passed in full committee markup on a voice vote redirecting unobligated balances from the Science and Technology Directorate to the Coast Guard  Division A of P L  116-6 included $303 million in rescissions, and a provision directing that $300 million of DRF unobligated balances be used to offset new DRF appropriations  In FY2018, funding was also included in Title V for the Financial Systems Modernization initiative and a grant program for Presidential Residence Protection costs, which are reflected in the tables for Title I and Title III, respectively, as those titles fund the components that manage these resources  For FY2019, Title V of S  3109 only funded the Financial Systems Modernization initiative, and Title V of H R  6776 only funded Presidential Residence Protection costs  Title V of P L  116-6 , Division A, included funding for both the Financial Systems Modernization initiative and Presidential Residence Protection costs  The detail table in the back of H Rept  115-948 also notes the discretionary cost of several policy changes in H R  6776   Four amendments adopted in House Appropriations Committee markup resulted in a net $13 million increase in the score of the bill, which is reflected in the detail table, but not in the tables of this report  No such costs are reflected in the detail table of H Rept  116-9   For additional perspectives on FY2019 DHS appropriations, see the following: CRS Report R44604, Trends in the Timing and Size of DHS Appropriations: In Brief ; CRS Report R44052, DHS Budget v  DHS Appropriations: Fact Sheet ; and CRS Report R45262, Comparing DHS Component Funding, FY2019: In Brief   Congressional clients also may wish to consult CRS's experts directly  The following table lists CRS analysts and specialists who have expertise in policy areas linked to DHS appropriations  Budget Authority, Obligations, and Outlays Federal government spending involves a multistep process that begins with the enactment of budget authority by Congress  Federal agencies then obligate funds from enacted budget authority to pay for their activities  Finally, payments are made to liquidate those obligations; the actual payment amounts are reflected in the budget as outlays  Budget authority is established through appropriations acts or direct spending legislation and determines the amounts that are available for federal agencies to spend  The Antideficiency Act prohibits federal agencies from obligating more funds than the budget authority enacted by Congress  Budget authority also may be indefinite in amount, as when Congress enacts language providing "such sums as may be necessary" to complete a project or purpose  Budget authority may be available on a one-year, multiyear, or no-year basis  One-year budget authority is available for obligation only during a specific fiscal year; any unobligated funds at the end of that year are no longer available for spending  Multiyear budget authority specifies a range of time during which funds may be obligated for spending, and no-year budget authority is available for obligation for an indefinite period of time  Obligations are incurred when federal agencies employ personnel, enter into contracts, receive services, and engage in similar transactions in a given fiscal year—which create a legal requirement for the government to pay  Outlays are the funds that are actually spent during the fiscal year  Because multiyear and no-year budget authorities may be obligated over a number of years, outlays do not always match the budget authority enacted in a given year  Additionally, budget authority may be obligated in one fiscal year but spent in a future fiscal year, especially with certain contracts  In sum, budget authority allows federal agencies to incur obligations and authorizes payments, or outlays, to be made from the Treasury  Discretionary funded agencies and programs, and appropriated entitlement programs, are funded each year in appropriations acts  Discretionary and Mandatory Spending Gross budget authority , or the total funds available for spending by a federal agency, may be composed of discretionary and mandatory spending  Discretionary spending is not mandated by existing law and is thus appropriated yearly by Congress through appropriations acts  The Budget Enforcement Act of 1990 defines discretionary appropriations as budget authority provided in annual appropriations acts and the outlays derived from that authority, but it excludes appropriations for entitlements  Mandatory spending , also known as direct spending , consists of budget authority and resulting outlays provided in laws other than appropriations acts and is typically not appropriated each year  Some mandatory entitlement programs, however, must be appropriated each year and are included in appropriations acts  Within DHS, Coast Guard retirement pay is an example of appropriated mandatory spending  Offsetting Collections Offsetting funds are collected by the federal government, either from government accounts or the public, as part of a business-type transaction such as collection of a fee  These funds are not considered federal revenue  Instead, they are counted as negative outlays  DHS net discretionary budget authority , or the total funds appropriated by Congress each year, is composed of discretionary spending minus any fee or fund collections that offset discretionary spending  Some collections offset a portion of an agency's discretionary budget authority  Other collections offset an agency's mandatory spending  These mandatory spending elements are typically entitlement programs under which individuals, businesses, or units of government that meet the requirements or qualifications established by law are entitled to receive certain payments if they establish eligibility  The DHS budget features two mandatory entitlement programs: the Secret Service and the Coast Guard retired pay accounts (pensions)  Some entitlements are funded by permanent appropriations, and others are funded by annual appropriations  Secret Service retirement pay is a permanent appropriation and, as such, is not annually appropriated  In contrast, Coast Guard retirement pay is annually appropriated  In addition to these entitlements, the DHS budget contains offsetting Trust and Public Enterprise Funds  These funds are not appropriated by Congress  They are available for obligation and included in the President's budget to calculate the gross budget authority  302(a) and 302(b) Allocations In general practice, the maximum budget authority for annual appropriations (including DHS) is determined through a two-stage congressional budget process  In the first stage, Congress sets overall spending totals in the annual concurrent resolution on the budget  Subsequently, these totals are allocated among the appropriations committees, usually through the statement of managers for the conference report on the budget resolution  These amounts are known as the 302(a) allocations   They include discretionary totals available to the House and Senate Committees on Appropriations for enactment in annual appropriations bills through the subcommittees responsible for the development of the bills  In the second stage of the process, the appropriations committees allocate the 302(a) discretionary funds among their subcommittees for each of the appropriations bills  These amounts are known as the 302(b) allocations   These allocations must add up to no more than the 302(a) discretionary allocation and form the basis for enforcing budget discipline, since any bill reported with a total above the ceiling is subject to a point of order  The 302(b) allocations may be adjusted during the year by the respective appropriations committee issuing a report delineating the revised suballocations as the various appropriations bills progress toward final enactment  No subcommittee allocations are developed for conference reports or enacted appropriations bills  Table A-1 shows comparable figures for the 302(b) allocation for FY2018, based on the adjusted net discretionary budget authority included in Division F of P L  115-141 , the President's request for FY2019, and the House and Senate subcommittee allocations for the Homeland Security appropriations bills for FY2019  The Budget Control Act, Discretionary Spending Caps, and Adjustments The Budget Control Act established enforceable discretionary limits, or caps, for defense and nondefense spending for each fiscal year from FY2012 through FY2021  Subsequent legislation, including the Bipartisan Budget Act of 2013, amended those caps  Most of the budget for DHS is considered nondefense spending  In addition, the Budget Control Act allows for adjustments that would raise the statutory caps to cover funding for overseas contingency operations/Global War on Terror, emergency spending, and, to a limited extent, disaster relief and appropriations for continuing disability reviews and control of health care fraud and abuse  Three of the four justifications outlined in the Budget Control Act for adjusting the caps on discretionary budget authority have played a role in DHS's appropriations process  Two of these—emergency spending and overseas contingency operations/Global War on Terror—are not limited  The third justification—disaster relief—is limited  Under the Budget Control Act, the allowable adjustment for disaster relief was determined by the Office of Management and Budget (OMB), using the following formula until FY2019: Limit on disaster relief cap adjustment for the fiscal year = Rolling average of the disaster relief spending over the last ten fiscal years (throwing out the high and low years) + the unused amount of the potential adjustment for disaster relief from the previous fiscal year  The Bipartisan Budget Act of 2018 amended the above formula, increasing the allowable size of the adjustment by adding 5% of the amount of emergency-designated funding for major disasters under the Stafford Act, calculated by OMB as $6 296 billion  The act also extended the availability of unused adjustment capacity  In August 2018, OMB released a sequestration update report for FY2019 that provided a preview estimate of the allowable adjustment for FY2019 of $14 965 billion —the second-largest allowable adjustment for disaster relief in the history of the mechanism  $12 billion of that adjustment was exercised in P L  116-6 , Division A, in appropriations for the Disaster Relief Fund  No other annual appropriations used the disaster relief adjustment for FY2019  


Report 2: We found that from October 2013 through March 2017, the five selected VA medical centers required reviews of a total of 148 providers’ clinical care after concerns were raised about their care, but officials at these medical centers could not provide documentation to show that almost half of these reviews were conducted  We found that all five VA medical centers lacked at least some documentation of the reviews they told us they conducted, and in some cases, we found that the required reviews were not conducted at all  Specifically, across the five VA medical centers, we found the following: The medical centers lacked documentation showing that one type of review—focused professional practice evaluations (FPPE) for cause—had been conducted for 26 providers after concerns had been raised about their care  FPPEs for cause are reviews of providers’ care over a specified period of time, during which the provider continues to see patients and has the opportunity to demonstrate improvement  Documentation of these reviews is explicitly required under VHA policy  Additionally, VA medical center officials confirmed that FPPEs for cause that were required for another 21 providers were never conducted  The medical centers lacked documentation showing that retrospective reviews—which assess the care previously delivered by a provider during a specific period of time— had been conducted for 8 providers after concerns had been raised about their clinical care  One medical center lacked documentation showing that reviews had been conducted for another 12 providers after concerns had been raised about their care  In the absence of any documentation, we were unable to identify the types of reviews, if any, that were conducted for these 12 providers  We also found that the five selected VA medical centers did not always conduct reviews of providers’ clinical care in a timely manner  Specifically, of the 148 providers, the VA medical centers did not initiate reviews of 16 providers for 3 months, and in some cases, for multiple years, after concerns had been raised about the providers’ care  In a few of these cases, additional concerns about the providers’ clinical care were raised before the reviews began  We found that two factors were largely responsible for the inadequate documentation and untimely reviews of providers’ clinical care we identified at the selected VA medical centers  First, VHA policy does not require VA medical centers to document all types of reviews of providers’ clinical care, including retrospective reviews, and VHA has not established a timeliness requirement for initiating reviews of providers’ clinical care  Second, VHA’s oversight of the reviews of providers’ clinical care is inadequate  Under VHA policy, networks are responsible for overseeing the credentialing and privileging processes at their respective VA medical centers  While reviews of providers’ clinical care after concerns are raised are a component of credentialing and privileging, we found that none of the network officials we spoke with described any routine oversight of such reviews  This may be in part because the standardized tool that VHA requires the networks to use during their routine audits does not direct network officials to ensure that all reviews of providers’ clinical care have been conducted and documented  Further, some of the VISN officials we interviewed told us they were not using the standardized audit tool as required  Without adequate documentation and timely completion of reviews of providers’ clinical care, VA medical center officials lack the information they need to make decisions about providers’ privileges, including whether or not to take adverse privileging actions against providers  Furthermore, because of its inadequate oversight, VHA lacks reasonable assurance that VA medical center officials are reviewing all providers about whom clinical care concerns have been raised and are taking adverse privileging actions against the providers when appropriate  To address these shortcomings, we recommended that VHA 1) require documentation of all reviews of providers’ clinical care after concerns have been raised, 2) establish a timeliness requirement for initiating such reviews, and 3) strengthen its oversight by requiring networks to oversee VA medical centers to ensure that such reviews are documented and initiated in a timely manner  VA concurred with these recommendations and described plans for VHA to revise existing policy and update the standardized audit tool used by the networks to include more comprehensive oversight of VA medical centers’ reviews of providers’ clinical care after concerns have been raised  We found that from October 2013 through March 2017, the five VA medical centers we reviewed had only reported one of nine providers required to be reported to the NPDB under VHA policy  These nine providers either had adverse privileging actions taken against them or resigned or retired while under investigation before an adverse privileging action could be taken  None of these nine providers were reported to state licensing boards as required by VHA policy  The VA medical centers documented that these nine providers had significant clinical deficiencies that sometimes resulted in adverse outcomes for veterans  For example, the documentation shows that one provider’s surgical incompetence resulted in numerous repeat surgeries for veterans  Another provider’s opportunity to improve through an FPPE for cause had to be halted and the provider was removed from providing care after only a week due to concerns that continuing the review would potentially harm patients  In addition to these nine providers, one VA medical center terminated the services of four contract providers based on deficiencies in the providers’ clinical performance, but the facility did not follow any of the required steps for reporting providers to the NPDB or relevant state licensing boards  This is concerning, given that the VA medical center documented that one of these providers was terminated for cause related to patient abuse after only 2 weeks of work at the facility  Two of the five VA medical centers we reviewed each reported one provider to the state licensing boards for failing to meet generally accepted standards of clinical practice to the point that it raised concerns for the safety of veterans  However, we found that the medical centers’ reporting to the state licensing board took over 500 days to complete in both cases, which was significantly longer than the 100 days suggested in VHA policy  Across the five VA medical centers, we found that providers were not reported to the NPDB and state licensing boards as required for two reasons  First, VA medical center officials were generally not familiar with or misinterpreted VHA policies related to NPDB and state licensing board reporting  For example, at one VA medical center, we found that officials failed to report six providers to the NPDB because they were unaware that they had been delegated responsibility for NPDB reporting  Officials at two other VA medical centers incorrectly told us that VHA cannot report contract providers to the NDPB  At another VA medical facility, officials did not report a provider to the NPDB or to any of the state licensing boards where the provider held a medical license because medical center officials learned that one state licensing board had already found out about the issue independently  Therefore, VA officials did not believe that they needed to report the provider  This misinterpretation of VHA policy meant that the NPDB and the state licensing boards in other states where the provider held licenses were not alerted to concerns about the provider’s clinical practice  Second, VHA policy does not require the networks to oversee whether VA medical centers are reporting providers to the NPDB or state licensing boards when warranted  We found, for example, that network officials were unaware of situations in which VA medical center officials failed to report providers to the NPDB  We concluded that VHA lacks reasonable assurance that all providers who should be reported to these entities are reported  VHA’s failure to report providers to the NPDB and state licensing boards as required facilitates providers who provide substandard care at one facility obtaining privileges at another VA medical center or at hospitals outside of VA’s health care system  We found several cases of this occurring among the providers who were not reported to the NPDB or state licensing boards by the five VA medical centers we reviewed  For example, we found that two of the four contract providers whose contracts were terminated for clinical deficiencies remained eligible to provide care to veterans outside of that VA medical center  At the time of our review, one of these providers held privileges at another VA medical center, and another participated in the network of providers that can provide care for veterans in the community  We also found that a provider who was not reported as required to the NPDB during the period we reviewed had their privileges revoked 2 years later by a non-VA hospital in the same city for the same reason the provider was under investigation at the VA medical center  Officials at this VA medical center did not report this provider following a settlement agreement under which the provider agreed to resign  A committee within the VA medical center had recommended that the provider’s privileges be revoked prior to the agreement  There was no documentation of the reasons why this provider was not reported to the NPDB under VHA policy  To improve VA medical centers’ reporting of providers to the NPDB and state licensing boards and VHA oversight of these processes, we recommended that VHA require its networks to establish a process for overseeing VA medical centers to ensure they are reporting to the NPDB and to state licensing boards and to ensure that this reporting is timely  VA concurred with this recommendation and told us that it plans to include oversight of timely reporting to the NPDB and state licensing boards as part of the standard audit tool used by the networks  If you or your staff members have any questions concerning this testimony, please contact me at (202) 512-7114 (williamsonr@gao gov)  Contact points for our Office of Congressional Relations and Public Affairs may be found on the last page of this statement  Other individuals who made key contributions to this testimony include Marcia A  Mann (Assistant Director), Kaitlin M  McConnell (Analyst-in-Charge), Summar C  Corley, Krister Friday, and Jacquelyn Hamilton  This is a work of the U S  government and is not subject to copyright protection in the United States  The published product may be reproduced and distributed in its entirety without further permission from GAO  However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately 

ground_truth: This testimony summarizes the information contained in GAO's November 2017 report, entitled VA Health Care: Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns ( GAO-18-63 ). Department of Veterans Affairs (VA) medical center (VAMC) officials are responsible for reviewing the clinical care delivered by their privileged providers—physicians and dentists who are approved to independently perform specific services—after concerns are raised. The five VAMCs GAO selected for review collectively required review of 148 providers from October 2013 through March 2017 after concerns were raised about their clinical care. GAO found that these reviews were not always documented or conducted in a timely manner. GAO identified these providers by reviewing meeting minutes from the committee responsible for requiring these types of reviews at the respective VAMCs, and through interviews with VAMC officials. The selected VAMCs were unable to provide documentation of these reviews for almost half of the 148 providers. Additionally, the VAMCs did not start the reviews of 16 providers for 3 months to multiple years after the concerns were identified. GAO found that VHA policies do not require documentation of all types of clinical care reviews and do not establish timeliness requirements. GAO also found that the Veterans Health Administration (VHA) does not adequately oversee these reviews at VAMCs through its Veterans Integrated Service Networks (VISN), which are responsible for overseeing the VAMCs. Without documentation and timely reviews of providers' clinical care, VAMC officials may lack information needed to reasonably ensure that VA providers are competent to provide safe, high quality care to veterans and to make appropriate decisions about these providers' privileges. GAO also found that from October 2013 through March 2017, the five selected VAMCs did not report most of the providers who should have been reported to the National Practitioner Data Bank (NPDB) or state licensing boards (SLB) in accordance with VHA policy. The NPDB is an electronic repository for critical information about the professional conduct and competence of providers. GAO found that selected VAMCs did not report to the NPDB eight of nine providers who had adverse privileging actions taken against them or who resigned during an investigation related to professional competence or conduct, as required by VHA policy, and none of these nine providers had been reported to SLBs. GAO found that officials at the selected VAMCs misinterpreted or were not aware of VHA policies and guidance related to NPDB and SLB reporting processes resulting in providers not being reported. GAO also found that VHA and the VISNs do not conduct adequate oversight of NPDB and SLB reporting practices and cannot reasonably ensure appropriate reporting of providers. As a result, VHA's ability to provide safe, high quality care to veterans is hindered because other VAMCs, as well as non-VA health care entities, will be unaware of serious concerns raised about a provider's care. For example, GAO found that after one VAMC failed to report to the NPDB or SLBs a provider who resigned to avoid an adverse privileging action, a non-VA hospital in the same city took an adverse privileging action against that same provider for the same reason 2 years later.