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



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

Report 1: In accordance with the Improper Payments Information Act of 2002 (IPIA), as amended, and OMB guidance, CMS developed the PERM to estimate the national Medicaid improper payment rate  CMS has other mechanisms to review and assess program integrity risks in state Medicaid managed care programs, and it uses information from the PERM to target its program integrity activities and oversight of states’ Medicaid programs  IPIA requires federal executive branch agencies to, among other things, (1) identify programs and activities that may be susceptible to significant improper payments; and (2), on an annual basis, estimate the amount of improper payments for susceptible programs and activities  Agency heads must produce a statistically valid estimate or an estimate that is otherwise appropriate, using an OMB-approved alternate methodology  Those agencies with programs identified by OMB as being high priority for additional oversight and review are required to submit annual reports to their Inspectors General detailing the actions the agency plans to take to recover improper payments and prevent future improper payments  The Inspector General of each agency submitting such a report is required to review the quality of the improper payment estimates and methodology, among other things  OMB designated Medicaid as a high priority program  In addition, the Improper Payments Elimination and Recovery Act of 2010 requires the Inspector General of each agency to conduct a compliance review to report on the agency’s compliance with several criteria, one of which is that an agency has reported an improper payment rate of less than 10 percent for each program and activity  IPIA also directed OMB to issue guidance for agencies in implementing the IPIA improper payments requirements  Among other things, the OMB guidance requires that agencies review payments made at the point that federal funds are transferred to nonfederal entities and report on the root causes of identified improper payments  To calculate the Medicaid improper payment rate through the PERM, CMS computes an annual rolling average of improper payment rates across all states based on a 17-state, 3-year rotation cycle  In accordance with IPIA, as amended, OMB approved CMS’s PERM methodology, and the HHS-OIG conducts annual compliance reviews  Beginning with its annual improper payment compliance review for fiscal year 2014, the HHS-OIG established a rotating approach to reviewing the estimation methodology for high-priority programs, including Medicaid, that OMB deemed susceptible to improper payments  Due to the number and complexity of the programs, the HHS-OIG methodology reviews are scheduled to be performed over a 4-year period; the PERM estimation methodology will be reviewed as a part of its fiscal year 2017 compliance review  Each of the three components of the Medicaid PERM—FFS, managed care, and eligibility—is estimated differently: The FFS component of the PERM measures errors in a sample of FFS claims, which are records of services provided and the amount the Medicaid program paid for these services  For the majority of sampled FFS claims, the PERM review contractor performs a medical review, which includes a review of the medical documentation to determine errors that do not meet federal and state policies, such as medically unnecessary services, diagnosis coding errors, and policy violations  Any FFS claims that were paid for services that should have been covered under a managed care plan’s capitated payment are also considered errors  The managed care component of the PERM measures errors that occur in the capitated payments that state Medicaid agencies make to managed care organizations (MCO) on behalf of enrollees  Capitated payments are periodic payments approved by CMS that state Medicaid agencies make to contracted MCOs to cover the provision of medical services to enrollees, as well as the MCOs’ administrative expenses and their profits or earnings  The PERM assesses whether any payments made to the MCOs were in amounts different than those the state agency is contractually required to pay, which are approved by CMS  In contrast to the FFS component, the managed care component of the PERM neither includes a medical review of services delivered to enrollees, nor reviews of MCO records or data  The eligibility component of the PERM measures errors in state determinations of whether enrollees meet categorical and financial criteria for receipt of benefits under the Medicaid program  The eligibility component assesses determinations for both FFS and managed care enrollees  This component has not been calculated since 2014; instead, CMS piloted different approaches to update the methodologies used to assess enrollee eligibility, as the Patient Protection and Affordable Care Act changed income eligibility requirements for nonelderly, nonpregnant individuals who qualify for Medicaid  Beginning in the 2019 reporting year, eligibility reviews under the PERM will resume and will be conducted by a federal contractor  Medicaid program integrity consists of efforts to ensure that federal and state expenditures are used to deliver quality, necessary care to eligible enrollees, and efforts to prevent fraud, waste, and abuse  We have found in prior work that CMS’s and states’ program integrity efforts focused primarily on payments and services delivered under FFS and did not closely examine program integrity in Medicaid managed care  For Medicaid managed care, CMS has largely delegated program integrity oversight of MCOs to the states  States, in turn, generally oversee MCOs and the providers under contract to MCOs through their contracts with the MCOs and reporting requirements  Some program integrity risks for managed care are similar to those in FFS, including payments made for nonenrolled, ineligible, or deceased individuals; payments to ineligible, excluded, or deceased providers; and payments to providers for improper or false claims, such as payments for services that are not medically necessary  Other program integrity risks are more unique to managed care  For example, capitated payments generally reflect the average cost to provide covered services to enrollees, rather than a specific service  Federal law requires capitation rates to be actuarially sound, meaning that, among other things, they must be reasonably calculated for the populations expected to be covered and for the services expected to be furnished under contract  In order to receive federal funds for its managed care program, a state is required to submit the rates it pays MCOs and the methodology it uses to set those rates to CMS for review and approval  Additionally, federal and state oversight of Medicaid managed care can include ensuring that MCOs fulfill contractual provisions within their managed care contracts  In some cases, these provisions relate directly to program integrity activities, including plans and procedures for identifying, recovering, and reporting on overpayments made to providers  The managed care component of the PERM measures the accuracy of the capitated payments state Medicaid agencies make to MCOs  Specifically, a CMS contractor examines whether the state agency made capitated payments only for eligible enrollees, made capitated payments for the correct amount based on the contract and coverage requirements (time period and geographic location), made capitated payments based on the correct rate for enrollees, and did not make any duplicate payments for enrollees  CMS officials noted that the agency established capitated payments as the level of review, because the capitation rate is the transaction used to determine the federal match in managed care  In general, the federal government matches most state expenditures for Medicaid services on the basis of a statutory formula  In FFS, the federal match is provided for the amount the state pays a health care provider for delivering services to enrollees  With managed care, the federal match is provided for the amount of the capitation rate the state pays the MCO  Capitated payments do not directly relate to the provision of a specific service, but reflect the average cost to provide covered services to enrollees  As a result, CMS officials maintain that the capitated payment is the lowest transaction level at which the agency can clearly identify federal funds without making significant assumptions  Because the managed care component of the PERM review is limited to measuring capitated payments, it does not account for other program integrity risks—such as overpayments to providers and unallowable MCO costs  In addition to errors in capitated payments included in PERM reviews, CMS regulations state that overpayments in managed care include any payment made to an MCO or provider under contract to an MCO to which the MCO or provider is not entitled under Medicaid  Such overpayments included payments for services that were not provided or medically necessary; or to ineligible, excluded, or deceased providers, which are not measured by the PERM  Unallowable MCO costs refers to operating costs that MCOs cannot claim under their managed care contracts, such as certain marketing costs, or that the MCO reported incorrectly  Among the 27 audits and investigations of Medicaid managed care programs we reviewed, 10 identified about $68 million in MCO overpayments to providers and unallowable MCO costs that were not accounted for in PERM estimates  In addition, one investigation of an MCO operating in nine states resulted in a $137 5 million settlement to resolve allegations of false claims  (See app  I for a complete list of the audits and investigations we identified ) However, the full extent of these overpayments and unallowable costs is unknown, because these audits and investigations were conducted over more than 5 years and involved a small fraction of the more than 270 MCOs operating nationwide as of September 2017  Specifically, 24 of the audits and investigations represented reviews in 10 states and, in many cases, focused on individual providers or MCOs; there were about 90 MCOs operating in the 10 states as of September 2017, according to the Kaiser Family Foundation  Some examples of the audits and investigations that identified overpayments and unallowable costs include the following: The Washington State Auditor’s Office found that two MCOs made $17 5 million in overpayments to providers in 2010, which may have increased the state’s 2013 capitation rates  The New York State Comptroller found that two MCOs paid over $6 6 million to excluded and deceased providers from 2011 through 2014  The Massachusetts State Auditor found that one MCO paid $420,000 for health care services and unauthorized prescriptions from excluded providers in 2013 and 2014  The Department of Justice alleged that an MCO operating in several states submitted inflated expenditure information to the state Medicaid agencies, falsified encounter data, and manipulated claims costs and service provision costs in nine states  The MCO agreed to pay over $137 5 million to resolve these claims  The Texas State Auditor’s Office found that an MCO reported $3 8 million in unallowable costs for advertising, company events, gifts, and stock options, along with $34 million in other questionable costs in 2015  The New York State Comptroller also found that an MCO claimed over $260,000 in unallowable administrative expenses, which contributed to an increase in capitation rates across the state  To the extent that the state does not identify or know of MCO overpayments to providers or unallowable MCO costs, the overpayments and unallowable costs could inflate future capitation rates, as the Washington State Auditor and New York State Comptroller noted in their findings  The PERM assesses the accuracy of capitated payments that states make to MCOs  States set capitation rates based on cost data— historical utilization and spending—that MCOs submit to the state Medicaid agencies, but the PERM does not consider these data  Unless removed from these cost data, unidentified overpayments and unallowable costs would likely inflate the MCO cost data that states use to set capitation rates  (See fig  1 ) As a result, future capitation rates would also be inflated, resulting in higher state and federal spending  In fiscal year 2017, the Medicaid managed care improper payment rate was 0 3 percent, while the FFS improper payment rate was 12 9 percent, leading to an assumption that the estimated risks in managed care are less significant than those estimated in FFS  However, the managed care component of the PERM does not determine whether MCO payments to providers were for services that were medically necessary, actually provided, accurately billed and delivered by eligible providers, or whether the MCO costs were allowable and appropriate  As a result, the PERM improper payment estimate potentially understates the extent of program integrity risks in Medicaid managed care  Moreover, this potential understatement in the PERM’s improper payment rate estimate may curtail investigations into the appropriateness of MCO spending  We previously reported that CMS and state program integrity efforts did not closely examine program integrity in Medicaid managed care, focusing primarily on payments and services delivered under FFS  Our current review of the 27 audits we identified encompassed a 5-year period, suggesting that reviews of managed care continue to be limited  An official from a state auditor’s office we spoke with suggested that some states may not audit services delivered under managed care, because of a low improper payment rate  In addition, he noted that his state Medicaid agency used the relatively low payment error rate in managed care as an indicator of few program integrity problems  As noted, CMS has increased its focus on and worked with states to improve oversight of Medicaid managed care; however, these efforts and the oversight efforts of states do not ensure the identification and reporting of overpayments and unallowable costs  In recent years, the agency has sought to strengthen oversight of managed care programs through updated regulations; reviews of states’ managed care programs (Focused Program Integrity Reviews) and collaborative audits, which are conducted jointly by federal program integrity contractors and states; and state monitoring of overpayments  Regulations  In May 2016, CMS updated its regulations for managed care programs in order to strengthen oversight  The updated regulations require a number of additional program integrity activities, such as those listed below  If fully implemented, these updated regulations may help with the identification and removal of overpayments and unallowable costs from data used to set future capitation rates  Under these regulations States must arrange for an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by MCOs, at least once every 3 years  Through contracts with MCOs, states must require MCOs to have a mechanism through which providers report and return overpayments to the MCOs  States must also require MCOs to promptly report any identified or recovered overpayments—specifying those that are potentially fraudulent—and submit an annual report on recovered overpayments to their state  States must use this information when setting actuarially sound capitation rates  Through contracts with MCOs, states must also require MCOs to report specific data, information, and documentation  In addition, the MCO’s chief executive officer or authorized representative must certify the accuracy and completeness of the reported data, information, and documentation  States must enroll MCO providers that are not otherwise enrolled with the state to provide services to enrollees in Medicaid FFS, and revalidate the enrollment at least once every 5 years  Initially this requirement was to start for MCO contracts beginning on July 1, 2018  Subsequently enacted legislation codified this requirement in statute and moved the implementation to January 1, 2018  It is too early to know if these regulations will assure better oversight of MCO payments to providers and the data used to set future capitation rates  The above program integrity requirements only went into effect recently—for contracts starting on or after July 1, 2017, and January 1, 2018  In addition, CMS issued a notice in June 2017 stating that the agency will use its enforcement discretion to assist states that are unable to implement new requirements by the required compliance date  Also, CMS has delayed issuance of implementing guidance for certain provisions until the agency completes its review, a step that may further delay states’ implementation  The agency has designated Medicaid managed care for “deregulatory action” and plans to propose a new rule, but has not indicated which of these provisions, if any, would be revised  Focused Program Integrity Reviews  In fiscal year 2014, CMS implemented its Focused Program Integrity Reviews in order to target high-risk program integrity areas in each state, including managed care  As we previously reported, these focused reviews are narrower in scope than the prior reviews conducted by CMS, but they still involve on-site visits to states  In its focused reviews of managed care, CMS found that several states had incomplete oversight of MCO payments to providers, even though the agency relies on states to verify reported MCO overpayments and to ensure the overpayments are excluded from the data used to set capitation rates  In the 27 focused reviews of managed care from 2014 to 2017, CMS found that MCOs in 17 states reported fewer overpayments to their state Medicaid agencies than CMS would expect  For example, MCOs in at least 5 states reported that overpayments were less than 0 1 percent of their total managed care expenditures; while CMS noted in 1 focused review that overpayments typically equal 1 to 10 percent of total expenditures in managed care  CMS also found that 5 of the 27 states did not verify that MCOs excluded overpayments from these data, and 1 state did not exclude overpayments from the capitation rate setting  This is consistent with our March 2017 report in which we noted that CMS commonly found that MCOs reported low amounts of recovered overpayments and conducted few reviews to identify overpayments  Also, officials from three of the five states we interviewed for that report said the focused reviews gave them leverage in dealing with MCOs or led MCOs to focus more on program integrity  We also reported that CMS officials recommended states take steps to improve their oversight of MCOs, based on the focused review findings  The findings from CMS’s focused reviews of managed care also highlight the need for greater federal oversight of states  Without these reviews, it is unclear if states would independently identify MCOs’ reporting of overpayments or work to strengthen MCO reporting  Yet, CMS has not yet published the focused reviews of managed care in 13 states, and it may only conduct a focused review in a state once every three or more years  Given CMS’s timeline for the focused reviews, it may take years to determine if corrective actions result in improved program integrity in services delivered through managed care  Collaborative audits  CMS has expanded the federal-state collaborative audits beyond FFS, and has begun to engage states to participate in collaborative audits of MCOs and providers under contract to MCOs  As a part of the collaborative audit process, the state volunteers to jointly develop the audit processes the federal contractors follow  CMS officials told us that federal contractors have completed 14 collaborative audits of providers under contract to MCOs in three states—Arizona, the District of Columbia, and Tennessee  Only the audit of Trusted Healthcare, an MCO in the District of Columbia, has been published  That audit identified $129,000 in overpayments in a sample of MCO payments to providers, which, if generalized to all of the MCO’s payments over 6 months, would equate to over $4 million in overpayments  According to CMS, three additional states—Louisiana, Nebraska, and New Hampshire—have shown interest in collaborative audits of their MCOs, although such audits require states to prepare data files for the federal contractor and commit staff time  In our March 2017 report, we found that states’ participation in FFS collaborative audits varied and some states reported barriers to their participation  Expanding collaborative audits in managed care will require commitment from and coordination with states  State monitoring of overpayments in managed care  States are required to report overpayments they have identified and recouped along with state expenditures on a quarterly basis  However, based on the responses of the program integrity officials in 13 of the 16 states we contacted, most officials were unable to define the magnitude of overpayments in their managed care programs, which may signify a need for greater federal oversight or coordination  Specifically, officials in 7 of the 13 states could not or did not identify the share of total reported Medicaid overpayments that occurred in managed care  In 11 of the 13 states, officials responded that they did not directly monitor MCO payments to providers  Of those 11 states, officials in 4 said they depend on MCOs to report overpayments and exclude the overpayments from the data used to set capitation rates  As long as states are not taking action to identify overpayments in managed care, they cannot be assured that they are accurately paying MCOs for medically necessary services provided to enrollees  Federal internal control standards call for agency management to identify, analyze, and respond to risks  CMS has taken some steps to identify, analyze, and respond to risks through its regulations, Focused Program Integrity Reviews, and collaborative audits  However, key CMS and state oversight efforts fall short of mitigating the limitations of the PERM estimates of improper payments for managed care, because they do not ensure the identification and reporting of overpayments to providers and unallowable MCO costs  Without addressing these key risks, CMS and states cannot ensure the integrity of Medicaid managed care programs  The 0 3 percent improper payment rate for Medicaid managed care, as measured by the PERM, is significantly lower than the improper payment rate of 12 9 percent for Medicaid FFS  However, this difference does not signal better oversight; rather, it represents differences in the review criteria between FFS and managed care, which result in a less complete accounting for the program integrity risks in managed care  The PERM does not account for key program integrity risks in Medicaid managed care: specifically, unidentified overpayments and unallowable costs  One federal investigation of an MCO operating in nine states resulted in a settlement of $137 5 million to resolve allegations of false claims that were not captured in the national Medicaid improper payment rate estimate  Further, CMS found that MCOs and states do not provide sufficient oversight in Medicaid managed care to address the risks that are not accounted for in the PERM, findings that are reinforced by our reports on Medicaid managed care program integrity  CMS has taken steps to improve its oversight of Medicaid managed care, yet these efforts fall short of ensuring that the agency and states will be able to identify and address overpayments to providers and unallowable MCO costs  Without better measurement of program risks—particularly as expenditures for Medicaid managed care continue to grow—CMS cannot be certain that the low improper payment rate for managed care, as measured by the PERM, accurately reflects lower risks in managed care  The Administrator of CMS should consider and take steps to mitigate the program risks that are not measured in the PERM, such as overpayments and unallowable costs; such an effort could include actions such as revising the PERM methodology or focusing additional audit resources on managed care  (Recommendation 1) We provided a draft of this report to the Department of Health and Human Services (HHS) for comment  In its written comments, HHS concurred with our recommendation, and indicated that it will review regulatory authority and audit resources to determine the best way to account for Medicaid program risks that are not accounted for in the PERM  However, HHS stated that the PERM is not intended to measure all Medicaid program integrity risks, and utilizing the PERM measurement in that way would be a misunderstanding and misuse of the reported rate  HHS also commented that a review of payments from MCOs to providers is outside the scope of IPIA  In addition, HHS asserted that including such a review would diminish the value of PERM reporting—because it would require significant assumptions about the amount of federal share in MCO payments to providers  Further, HHS maintained that such a review also would result in a measurement that was not comparable to other programs or agencies, which would diminish the value of government- wide improper payment rate reporting  We acknowledge that the current PERM methodology has been approved by OMB  However, we maintain that the PERM likely underestimates program integrity risks in Medicaid managed care  To ensure the appropriate targeting of program integrity activities, CMS needs better information about these risks  Given the size of the Medicaid program, its vulnerability to improper payments, and the growth in managed care, it is critical to have a full accounting of program integrity risks in managed care in order to best ensure the integrity of the whole Medicaid program  In its written comments, HHS also summarized several activities it uses to oversee and support states’ Medicaid program integrity efforts, including state program integrity reviews; collaborative audits conducted by federal contractors; Medicaid Integrity Institute training for state employees; and the Medicaid Provider Enrollment Compendium  HHS also provided technical comments, which we incorporated as appropriate  HHS’s comments are reprinted in appendix II  As agreed with your offices, 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 to the Secretary of Health and Human Services, the Administrator of CMS, appropriate congressional committees, and other interested parties  In addition, the report will be available at no charge on the GAO website at http://www gao gov  If you or your staff members have any questions about this report, please contact me at (202) 512-7114 or at yocomc@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 that made key contributions to this report are listed in appendix III  We reviewed 16 federal and state audits and 11 notices of investigations of Medicaid managed care organizations (MCO) and providers issued from January 2012 to September 2017  As the findings below show, the audits and investigations represent a limited number of reviews that, in many cases, focused on individual states and individual providers or MCOs within that state  Given the limited scope and number of states reviewed, the amount of the overpayments and unallowable costs occurring nationwide is unknown  These audits and investigations show cases of MCO overpayments to providers or unallowable costs, which are not accounted for by the Centers for Medicare & Medicaid Services’ Payment Error Rate Measurement (PERM) ; errors in capitated payments (e g , capitated payments made for deceased individuals), which are accounted for in the PERM; and gaps in managed care oversight  When reporting overpayments and unallowable costs identified in the audits and investigations, we only include amounts specifically attributed to MCOs in our total  This total does not include the following: overpayments and unallowable costs identified in those audits and investigations that did not distinguish between the amounts attributable to MCOs, Medicaid fee-for-service, or Medicare; overpayments and unallowable costs identified in criminal proceedings that are not yet resolved; and errors in capitated payments, as those payments would be reviewed by the PERM  As a result, the total amount of overpayments and unallowable costs and capitated payment errors in this appendix exceed what we report  In addition to the contact named above, Leslie V  Gordon (Assistant Director), Pauline Adams (Analyst-in-Charge), Erika Huber, and Drew Long made key contributions to this report  Also contributing were Muriel Brown and Jennifer Whitworth 


Report 2: According to international and U S  government sources, climate change poses serious risks to many of the physical and ecological systems upon which society depends, although the exact details of these impacts are uncertain  Climate change may intensify slow-onset disasters, such as drought, crop failure, and sea level rise  Climate change is also increasing the frequency and intensity of extreme weather events, including sudden- onset disasters, such as floods, according to key scientific assessments  These effects of climate change may alter existing migration trends across the globe, according to IOM  (See appendix II for further discussion of climate change as a driver of migration in seven geographic regions ) For example, sea level rise, a slow-onset disaster, may result in the salinization of soil and drinking water, thereby undermining a country or community’s ability to sustain livelihoods and maintain critical services, which could cause some people to migrate  Sudden-onset disasters may also contribute to migration as people flee natural disasters, in most cases leading to temporary displacement  For example, people may either voluntarily migrate, or be forced to migrate, to earn money needed to rebuild damaged homes after flooding, especially as extreme weather events increase in intensity and number  If unable or unwilling to migrate, people may find themselves trapped or choosing to stay in deteriorating conditions  Sources agree that the effects of climate change generally impact internal migration, while migration across international borders due to climate change is less common  In deciding whether to migrate, people weigh multiple factors including economic and political factors, social or personal motives, or demographic pressures  The effects of climate change add another layer of complexity to this decision, but there is debate about the role climate change plays in migration  Figure 1 depicts how climate change may influence other factors that drive the decision to migrate or stay  There are limitations to reliably estimating the number of people displaced by climate change because there are no reliable global estimates for those migrating due to slow-onset disasters, and estimates for those migrating due to sudden-onset disasters are based on limited data, according to IOM  The lack of reliable data is due in part to the multi- causal nature of migration  Further, IOM notes that forecasts for the number of environmental migrants by 2050 vary from 25 million to 1 billion  They and others have questioned the methodologies used to arrive at even these broad estimates  Migration, potentially driven by climate change, may contribute to instability and result in national security challenges, according to some international organizations and national governments  For example, an influx of migrants to a city may put pressure on existing resources, resulting in tensions between new migrants and residents, or between the population and its government  The U S  Global Change Research Program has also stated that migration, such as displacement resulting from extreme weather events, is a potential national security issue  At different times, the United Nations General Assembly and, in 2014, DOD have deemed climate change to be a threat multiplier, as the effects of climate change could increase competition for resources, reduce government capacity, and threaten livelihoods, thereby causing instability and migration  Further, the U S  intelligence community considers climate change to increase the risks of humanitarian disasters, conflict, and migration  Identifying the cause of a conflict, however, is complicated, and experts debate the connections linking climate, migration, and national security  For example, IOM has reported that existing evidence on climate migration and instability must be considered with caution  Further, some studies stress that other factors can mitigate the effects of climate change on migration and stability, including governance and community resilience, as the World Bank has reported  State, USAID, and DOD are among the U S  government agencies with a role in responding to issues related to climate change, including as a driver of migration  State interacts with foreign governments and international organizations focused on climate change and migration primarily through the Bureau of Oceans and International Environmental and Scientific Affairs (State/OES) and the Bureau of Population, Refugees, and Migration (State/PRM)  USAID supports a range of development programs that help to mitigate the effects of climate change through the Bureaus for Economic Growth, Education and Environment; Democracy, Conflict and Humanitarian Assistance; Food Security; Asia; and Africa; and individual USAID missions  Additionally, USAID’s Offices of U S  Foreign Disaster Assistance (USAID/OFDA) and Food for Peace (USAID/FFP) lead and coordinate the U S  government’s emergency responses to sudden- and slow-onset disasters, and complex emergencies overseas  DOD assists in the United States’ humanitarian response to sudden- onset disasters abroad through its six geographic combatant commands, with support from the Assistant Secretary of Defense for Special Operations and Low Intensity Conflict and the Joint Staff’s Office of Humanitarian Engagement  Climate change as a driver of migration was not a focus of the policy documents we reviewed for either the current or previous administrations during fiscal years 2014 through 2018  Our review of executive actions, budget requests, and executive branch strategies that affected State, USAID, and DOD found only brief mentions of climate change as a driver of migration  None of the documents we reviewed reflected a priority for assessing or addressing climate change as a driver of migration, although these documents reflect a shift in administrations’ climate change priorities more generally  The previous administration issued two executive orders and a presidential memorandum related to climate change  These executive actions had a policy of improving climate preparedness and resilience, factoring climate-resilience considerations into agencies’ international development decisions, and creating forums for interagency coordination  In March 2017, the current administration issued a subsequent executive order revoking some of the previous executive actions related to climate change  See figure 2 for a timeline of these executive actions  The previous administration issued three executive actions related to climate change, which included requirements focused on agencies’ considerations of the impacts of climate change and established forums for interagency coordination  The current administration issued an executive action related to energy independence and climate change  Executive Order 13653: Preparing the United States for the Impacts of Climate Change  Executive Order 13653 stated that agencies—including State, USAID, and DOD—shall, among other things, develop, implement, and update comprehensive Agency Adaptation Plans that integrate consideration of climate change into agency operations and overall mission objectives  Executive Order 13653 also established the Council on Climate Preparedness and Resilience  Executive Order 13677: Climate-Resilient International Development  Executive Order 13677 requires State, USAID, and other U S  government agencies with direct international development programs and investments to incorporate climate-resilience considerations into decision making by assessing climate-related risks to agency strategies, and to adjust relevant strategies as appropriate, among other things  Executive Order 13677 also established the Working Group on Climate-Resilient International Development as part of the Council on Climate Preparedness and Resilience  2016 Presidential Memorandum on Climate Change and National Security  The 2016 presidential memorandum required, among other things, that agencies, including State, USAID, and DOD, develop an agency-specific approach to address climate-related threats to national security  It also required agencies to develop implementation plans that would describe how they would identify the potential impact of climate change on human mobility, including migration and displacement, and the resulting impacts on national security, among other requirements, and stated that the effects of climate change can lead to population migration within and across international borders, spur crises, and amplify or accelerate conflict in countries or regions already facing instability  The 2016 memorandum also established the Climate and National Security Working Group  Executive Order 13783, Promoting Energy Independence and Economic Growth  Executive Order 13783 revoked Executive Order 13653 and the 2016 presidential memorandum, among other things, as seen in figure 2  Priorities related to climate change shifted between the past two administrations as reflected in a recent budget request that reduced some climate change funding affecting U S  foreign assistance  2017 Presidential Budget Request  The previous administration stated in its fiscal year 2017 budget request that “the challenge of climate change will define the contours of this century more dramatically than any other” and that “it is imperative for the United States to couple action on climate change at home with leadership internationally ” The fiscal year 2017 budget request sought $1 3 billion in discretionary funding to advance the goals of the Global Climate Change Initiative, which was established in 2010 and aimed to promote resilient, low-emission development, and integrate climate change considerations into U S  foreign assistance  The $1 3 billion in requested funding included $750 million in U S  funding for the Green Climate Fund, a multilateral trust fund designed to foster resilient low-emission development in developing countries  2018 Presidential Budget Request  The current administration, in its fiscal year 2018 budget request, did not include any funding for the Global Climate Change Initiative  In addition, the current administration’s budget request stated that it “Eliminate the Global Climate Change Initiative and fulfill the President’s pledge to cease payments to United Nations’ (UN) climate change programs by eliminating U S  funding related to the Green Climate Fund     ” Some strategies from the current and previous administrations that affect State, USAID, and DOD, among other agencies, reflect a shift in priorities related to climate change  For example, the previous administration cited climate change as a “top strategic risk” in its 2015 National Security Strategy and stated that climate change is an urgent and growing threat to U S  national security, contributing to increased natural disasters, refugee flows, and conflicts over basic resources like food and water  The current administration does not discuss climate change in its 2017 National Security Strategy  Additionally, State and USAID have a Joint Strategic Plan to help the agencies achieve the objectives of the National Security Strategy  The previous State-USAID Joint Strategic Plan included a strategic goal on “promoting the transition to a low-emission, climate-resilient world” that proposed leading international actions to combat climate change  The current State-USAID Joint Strategic Plan does not have a climate change goal  State, USAID, and DOD were required by executive orders to assess climate change-related risks to their missions and, for State and USAID, to their strategies, among other things  In response to Executive Order 13653, which has since been revoked, the agencies completed adaptation plans that integrated considerations of climate change into agency operations and overall mission objectives  In response to Executive Order 13677, which has not been revoked, State and USAID developed processes for climate change risk assessments for their country and regional planning documents  Although these executive orders did not require a specific assessment of climate change as a driver of migration, all three agencies have discussed the effects of climate change on migration in their adaptation plans and risk assessments  However, State lacks clear guidance on its process for assessing climate change-related risks to its integrated country strategies  State, USAID, and DOD each completed adaptation plans in 2014 that included limited discussions of migration as one potential effect of climate change  Executive Order 13653 directed the agencies to develop or continue to develop, implement, and update comprehensive Agency Adaptation Plans that integrate consideration of climate change into agency operations and overall mission objectives  Each adaptation plan was to include, among other things, a description of how the agency would consider the need to improve climate adaptation and resilience  State  In its 2014 adaptation plan, State included a brief discussion of climate change as one of multiple factors that potentially will drive migration and impact its mission  State reported that the specific impacts of climate change on the ability of the department to promote peace and stability in regions of vital interest to the United States were unknown  For example, according to the plan, an increase in heavy precipitation events around the world could damage the electric grid and transportation and energy water infrastructure, upon which State depends, making it difficult to maintain operations and diplomatic relations  In its plan, State reported that climate change impacts may threaten international peace, civil stability, and economic growth through aggravating existing problems related to poverty and environmental degradation  Further, environmental and poverty- related issues and regional instability could stress relationships with some foreign governments  However, the plan noted that specific impacts of climate change on conflict, migration, terrorism, and complex disasters were still unknown  USAID  In its 2014 adaptation plan, USAID included a brief discussion of migration as one potential effect of climate change that could also impact security  USAID stated that the impact of climate change on its programs and operations, if left unaddressed, could compromise the agency’s ability to achieve its mission  Further, USAID’s plan referred to increased migration as a potential risk of climate change  Flooding and other extreme climate events can result in increased migration, among other impacts, that could affect existing and planned USAID programming  In particular, programs in areas like agriculture and food security, global health, water and sanitation, infrastructure, and disaster readiness and humanitarian response are vulnerable to climate change, according to USAID  In the infrastructure area, climate change may necessitate new protective measures for coastal homes and infrastructure, and in some cases even mass evacuations or permanent migration  USAID stated that climate change could further reduce or alter the distribution of already limited resources like food and water, or force temporary or permanent migration of communities  According to the plan, in areas with high risk factors for conflict, climate change stresses can aggravate tensions and contribute to conflict  DOD  In its 2014 adaptation roadmap, DOD included a brief discussion of migration as one of multiple potential effects of climate change that could impact national security  DOD referred to climate change as a threat multiplier that can aggravate other risks around the world, with migration being one effect that could increase requests for DOD to provide assistance  The roadmap stated that as climate change affects the availability of food and water, human migration, and competition for natural resources, the department’s unique capability to provide logistical, material, and security assistance on a massive scale or in rapid fashion may be called upon with increasing frequency  Furthermore, DOD stated that the impacts of climate change may cause instability in other countries by, among other things, impairing access to food and water, damaging infrastructure, uprooting and displacing large numbers of people, and compelling mass migration  These developments, according to the department, could undermine already fragile governments that are unable to respond effectively, or challenge currently stable governments, as well as increase competition and tension between countries vying for limited resources  In response to Executive Order 13677, State and USAID developed processes for climate change risk assessments for their country and regional planning documents  Though these assessments are not specific to migration, a few of the assessments identified the nexus of climate change and migration  State  State required climate change risk assessments for all new integrated country strategies drafted in 2016 or later  We reviewed 10 integrated country strategies from the two regions that were the first to implement the climate change risk assessment requirement— Africa, and East Asia and the Pacific  All 10 of the strategies included climate change risk assessments, one of which—Cambodia— identified migration as a risk for the country  The Cambodia strategy states that internal migration due to climate change hinders access to health care and the prevention of infectious diseases like malaria  We also reviewed 10 strategies from State’s functional and regional bureaus for assessments of climate-related risks, including 3 functional bureau strategies (State/PRM, State/OES, and State’s Bureau of International Organization Affairs) and 7 regional bureau strategies  All of the functional bureau strategies we reviewed identified climate change as a risk and State/PRM cited the impact of climate change on migration  Of the regional bureau strategies we reviewed, we found that one, the Bureau for East Asian and Pacific Affairs, identified climate change as a driver of migration as a challenge or risk in its region  For example, the strategy states that climate change is becoming increasingly disruptive, potentially increasing migration due to rising sea levels  None of the other six regional bureau strategies we reviewed identified the nexus of climate change and migration as a risk or challenge  However, five regional bureaus identified climate change as a risk or challenge and one identified migration as a risk or challenge  USAID  USAID also requires the integration of climate risk management into all country or regional development cooperation strategies drafted since October 1, 2015  Missions must document in a climate change appendix to the strategy any climate risks they identified and how they considered climate change in their strategy  As of August 2018, USAID had completed five country or regional development cooperation strategy updates initiated since October 1, 2015—Uganda, Tunisia, East Africa, Sri Lanka, and Zimbabwe—and all five included the required appendix  Of the five updated strategies, three—Uganda, Tunisia, and East Africa—discuss the indirect effect of climate change on migration, among other issues  For example, Uganda’s 2016-2021 country strategy states that increased frequency and duration of droughts is likely to be the most significant climate‐related change in Uganda  The strategy also notes that droughts have affected, and will continue to affect, water resources, hydroelectricity production, and agriculture, among other sectors  As agriculture, forestry, and fisheries decline in Uganda, the strategy asserts that people will migrate to urban areas, leading to the formation of slums  We also reviewed USAID’s nine regional development cooperation strategies, one of which—East Africa—had been updated since the requirement to include climate risk management  Of the other eight strategies that have yet to be updated, seven identified climate change as a challenge or risk and three identified climate change as a driver of migration as a challenge or risk  For example, the Southern Africa regional development cooperation strategy states that water scarcity, natural disasters, and other climate change related events will most likely increase migration throughout the region  Additionally, the Asia regional development cooperation strategy discusses the risks of climate change in urban areas  In Asia, the number of migrants seeking economic opportunities in urban centers is likely to increase  According to the strategy, migrants are moving into hazard-prone areas located along coastlines, flood plains, and other low-lying areas in many Asian primary and secondary cities—areas that experts predict will experience more frequent and intense storm surges, floods, and coastal erosion as a result of climate change  The requirement in Executive Order 13677 to assess climate change- related risks to agency strategies remains unchanged; however, State now lacks clear guidance on its process for assessing climate change- related risks to its integrated country strategies  Specifically, State’s 2016 guidance for developing integrated country strategies stated that all missions should assess the risk of climate change on their strategies’ goals and objectives and included reference to the climate risk screening tool—a method that missions could use to assess climate change risks  State issued new guidance to its missions in 2018, but this guidance does not include information on the process for assessing climate change-related risks to agency strategies  According to State officials, the 2018 guidance for integrated country strategies does not reference climate change risk assessments because, in September 2017, State decided that the strategies should not single out climate change risks in a separate appendix  State officials said this decision resulted, in part, from the new administration’s shift in priorities on climate change  Officials also said that this decision reflects a new approach to risk management by State and that the missions could choose to include climate change and other potential risks in the general risk discussion section of their strategies  Officials from State’s Office of U S  Foreign Assistance Resources said that it is now up to each mission to decide whether a strategic objective may have a climate challenge  However, those missions that choose to include an assessment of climate change risks are not provided guidance on the process for doing so and there is no reference to the climate risk screening tool—or to climate change at all—in the 2018 guidance  Executive Order 13677 directed State to incorporate climate-resilience considerations into decision making by assessing climate-related risks to agency strategies, among other things  Subsequently, a State cable from September 2016 further explained that State would implement the executive order’s requirement by screening for climate risks as part of the process for drafting all new integrated country strategies  Additionally, the Standards for Internal Control in the Federal Government state that documentation is a necessary part of an effective internal control system  If management determines that a principle is not relevant, management must support that determination with documentation that includes the rationale of how, in the absence of that principle, the associated component could be designed, implemented, and operated effectively  Because State lacks clear guidance on its process for assessing climate change-related risks to its integrated country strategies, it is less likely that the current round of strategies will include the assessment of climate- related risks  It is also possible that those missions that choose to conduct climate change risk assessments will not do so in a consistent manner  Such assessments might identify climate change as a driver of migration, as at least one previous assessment did under the 2016 guidance  Thus, without clear guidance, missions may not examine climate change as a risk to their strategic objectives and could miss opportunities to improve the climate resilience of foreign assistance activities  For fiscal years 2014 through 2017, State, USAID, and DOD had some activities that could potentially address climate change as a driver of migration, although none of these activities specifically focused on the issue  For example, USAID has climate change adaptation activities, but to date migration has not been a focus of this programming  With the shift in priorities related to climate change in fiscal year 2017, agencies have reduced some of these activities  State’s offices that are focused on the issues of climate change (State/OES) and migration (State/PRM) have participated in multilateral activities related to climate change as a driver of migration and funded adaptation and other activities related to the issue  State officials said that the agency does not, however, have any activities that specifically address migration due to climate change or environmental factors  State has participated in multilateral activities related to climate change and migration  With the shift in priorities related to climate change in fiscal year 2017, the United States has disengaged from some of these multilateral activities (see table 1)  In addition to State’s participation in the multilateral activities described in table 2, State has provided funding for activities related to climate change and capacity building that address natural disasters  These activities may involve efforts potentially related to migration  For example, according to State: State provided about $2 million per year, between fiscal years 2014 and 2016, to the Intergovernmental Panel on Climate Change, which analyzed the impacts of climate change on migration in its most recent assessment report  State/PRM provided about $4 million, between fiscal years 2014 through 2018, for IOM’s Migrants in Countries in Crisis Initiative, which provides guidelines to protect migrants in countries experiencing conflict or natural disasters  IOM provides training to countries on these guidelines  State/PRM officials said that this initiative is not specifically related to climate change and does not focus on specific types of disasters but does mention sudden-onset disasters  Officials also said that IOM tries to promote a climate change perspective in its trainings  State/OES provided about $78 million in adaptation funding from the Global Climate Change Initiative to eight projects during fiscal years 2014 through 2017  (See appendix III for a description of all eight projects ) State/OES officials said that these projects help countries prepare for the impacts of climate change, potentially reducing the pressure to migrate  However, to these officials’ knowledge, none of these projects directly supported activities related to migration  For example, State/OES provided a $4 million grant to the National Adaptation Plans Global Network  This network focuses on increasing the capacity of governments to identify and assess climate risks, integrate these risks in planning, develop a pipeline of projects to address these risks, identify and secure funding for projects, and track progress toward resilience targets  Adaptation activities occurred in over 35 countries  With the shift in priorities related to climate change in fiscal year 2017, State discontinued some of these efforts  For example, funding for the Global Climate Change Initiative was not included in the President’s budget request for fiscal year 2018  State/OES officials said that the agency does not plan to fund additional adaptation activities and has not requested additional funding for the activities  According to a State official, PRM had been in discussion with IOM to develop a project proposal that would have assisted the governments of Small Island Developing States in adapting their migration policies to account for challenges and opportunities associated with environmental degradation, ecosystem loss, climate change impacts, and natural disasters  State/PRM stopped further development of the proposal following the change in administrations  Additionally, according to a State official, the department made some efforts at the end of the previous administration to develop a formal position on the topic of climate change as a driver of migration  For example, State drafted an internal document to help clarify its role in responding to the humanitarian aspects of sudden-onset and slow-onset climate events  This initial work stopped under the current administration  USAID officials said that, with respect to the agency’s climate-related programming, its climate change adaptation programming was the most likely to include activities related to migration or displacement, although a broad swath of USAID development programming has the potential to build host country resilience  Officials stated that, to date, migration has not been a primary motivation for the agency’s climate-related or disaster assistance programming  However, officials said that, in a humanitarian crisis or under some economic conditions, development programming can reduce displacement or the pressure to migrate—such as by fostering greater resilience to drought or other adverse conditions—and that this is also true of climate-related programming  USAID also provides humanitarian assistance in response to natural disasters that displace people  Officials said that USAID recognizes the links between displacement and natural disasters, but that the agency does not have specific programs linking disaster assistance, migration, and climate change  USAID identified about 250 activities that received adaptation funding from the Global Climate Change Initiative during fiscal years 2014 through 2016  Our analysis of the descriptions of these activities determined that none directly mentioned any efforts specifically related to migration  Officials emphasized that the connection between climate change and migration tends to be indirect and shaped by other more immediate factors  USAID’s data on activities that received adaptation funding identified 38 beneficiary countries, as well as activities described generally as implemented at the regional or global level  For activities where USAID’s data identified a specific region, most activities were located in Africa followed by Asia and Latin America and the Caribbean  Examples of the types of activities that received adaptation funding from the Global Climate Change Initiative during fiscal years 2014 through 2016 include: The Mali Climate Change Adaptation Activity, which aims to build resilience to current climate variability and increase resilience to longer-term climate change effects  This activity is also working to strengthen the capacity of Mali’s meteorological agency to provide improved climate information as well as to incorporate climate considerations into local-level planning  The total estimated cost is about $13 million over 5 years  The activity for Climate-Resilient Ecosystems and Livelihoods, which ended in September 2018, aimed to increase Bangladesh’s resilience to natural hazards by working with community-based organizations, government ministries, and technical agencies  This activity provided technical assistance to the Government of Bangladesh and local communities to improve ecosystem conservation and resilience capacity  The total estimated cost was about $33 million in funding over 6 years  The activity for Pastoralist Areas Resilience Improvement through Market Expansion, which aims to support pastoralists in Ethiopia via expansion of markets and long-term behavior change (see fig  3)  USAID officials cited this activity as an example of adaptation efforts that indirectly address the issue of climate change as a driver of migration  The activity has three interrelated objectives: increasing household incomes, enhancing resilience, and bolstering adaptive capacity to climate change among pastoral people in Ethiopia  An evaluation of the activity found that migration is a coping strategy for dealing with climate shocks, although participants said that drought is becoming more frequent, placing a severe strain on traditional coping mechanisms, such as migration and selling cattle, and that permanent migration is not a preferred strategy  The total estimated cost is about $60 million in funding over 6 years  With the shift in priorities related to climate change, funding for USAID’s climate change adaptation activities has decreased  Missions may continue to fund their adaptation activities with discretionary funds or other earmarked, sector funding, provided the activities further the funding source’s objective, according to USAID  For example, in some cases, missions are using Water sector funding to continue some of their adaptation work  USAID also said that among the agency’s goals are to increase the resilience of USAID partner countries to recurrent crises, including climate variability and change  In addition to USAID’s climate change adaptation programming, USAID/OFDA and USAID/FFP provide emergency humanitarian assistance to people affected by sudden-onset disasters—such as hurricanes and floods—and slow-onset and extended disasters, including droughts and conflicts  Some of this assistance helps people who have been displaced by disaster  USAID officials stated that although disasters cause mainly temporary displacement, the relationship among humanitarian assistance, climate change, and migration is very complex and depends on both climatic and non-climatic factors  USAID/OFDA responded to 267 disasters from fiscal year 2014 through June 2018, according to agency data  For example, USAID/OFDA responded to the effects of Hurricane Matthew in Haiti in October 2016, as seen in figure 4, including helping temporarily displaced people  DOD assists in the U S  government response to overseas disasters, including helping people displaced by such disasters, regardless of the cause of the disaster  These efforts are not specific to climate change as a driver of migration  For example, officials from DOD’s geographic combatant commands said that, to the extent they address climate change, migration is not a focus of those efforts and they view migration as caused by security and economic issues  Between fiscal years 2014 and 2018, Congress has appropriated to DOD between $103 and $130 million per year for Overseas Humanitarian, Disaster, and Civic Aid  Officials said that the geographic combatant commands use most of this funding for steady state humanitarian assistance related to health, education, basic infrastructure, and disaster preparedness with a smaller amount set aside for immediate disaster assistance although that varies based on emergency requirements  DOD officials said that they have not seen any changes to this funding or associated activities with the change of administrations in fiscal year 2017  DOD officials we spoke with also emphasized that USAID/OFDA is the lead agency for the U S  government’s response to disasters overseas  USAID/OFDA formally requested DOD support on about 10 percent of the foreign disaster assistance provided by USAID/OFDA, according to USAID data for fiscal year 2014 through June 2018 and DOD officials  DOD assistance is typically provided for the largest, most complex disasters, according to agency officials  According to a July 2015 assessment conducted by the geographic combatant commands, while their activities vary, each command works with partner nations to increase their abilities to reduce the risks and effects from environmental impacts and climate-related events, including severe weather and other hazards  For example, in the report, U S  Southern Command stated that it had requested funding to pre-position assets for when a severe storm threatens Haiti to be able to respond immediately to a potential disaster  U S  Southern Command officials said that they work with partner nations to encourage residents experiencing extreme weather to remain where they are because it is easier to provide help to people who stay in one place  Officials from U S  Southern Command and U S  Africa Command also said that the major factors driving migration in their regions are security and economic issues  State, USAID, and DOD have participated in interagency forums regarding climate change, which may have addressed its effects on migration  With changes to priorities regarding climate change in fiscal year 2017, these forums have been disbanded or are not meeting  The Council on Climate Preparedness and Resilience  The Council on Climate Preparedness and Resilience, of which State, USAID, and DOD were members, was established to facilitate the integration of climate science in policies and planning of government agencies, including by promoting the development of climate change related information, data, and tools, among other things  Additionally, the council was to develop, recommend, and coordinate interagency efforts on priority federal government actions related to climate preparedness and resilience  According to State officials, the council began working with the National Security Council and other agencies to facilitate greater interagency cooperation on adaptation  In addition, a task force on the council was discussing the federal role in addressing displacement related to climate change  The council was disbanded when Executive Order 13783 revoked Executive Order 13653, which had established the council  The Working Group on Climate-Resilient International Development  The Working Group on Climate-Resilient International Development, of which State and USAID were members, was established by Executive Order 13677 and placed under the Council on Climate Preparedness and Resilience  The working group’s mission includes developing guidelines for integrating considerations of climate-change risks and climate resilience into agency strategies, plans, programs, projects, investments, and related funding decisions, among other things  Additionally, the working group was tasked with facilitating the exchange of knowledge and lessons learned in assessing climate risks to agency strategies, among other things  USAID officials said that the working group had not discussed climate change as a driver of migration  While the working group has not been formally disbanded, it has not met since at least November 2017 according to USAID  The Climate and National Security Working Group  The Climate and National Security Working Group, of which State, USAID, and DOD were members, was established by the 2016 presidential memorandum  The chairs of the working group were to coordinate the development of a strategic approach to identify, assess, and share information on current and projected climate-related impacts on national security interests and to inform the development of national security doctrine, policies, and plans, among other things  According to the memorandum, the working group was to provide a venue for enhancing the understanding of the links between climate change- related impacts and national security interests and for discussing opportunities for climate mitigation and adaptation activities to address national security issues  This working group was disbanded when Executive Order 13783 revoked the 2016 presidential memorandum, which had established the working group  State, USAID, and DOD assessments and activities have not focused specifically on the nexus of climate change and migration  State did identify migration as a risk of climate change in at least one of its climate change risk assessments for the department’s country strategies  However, State now lacks clear guidance on its process for assessing climate change-related risks to its integrated country strategies  State’s current guidance for these country strategies no longer mentions a climate change risk assessment and does not provide missions with information about the climate risk screening tool that can be used to conduct such an assessment  As such, missions are less likely to examine climate change as a risk to their strategic objectives, or to do so in a consistent manner, and thus may not have the information they would need to identify migration as a risk of climate change  By clearly documenting and providing guidance on how to assess the risk of climate change, State would ensure that the department examines the potential risks of climate change on its foreign assistance activities  We are making the following recommendation to State: The Secretary of State should ensure that the Director of the Office of U S  Foreign Assistance Resources provides missions with guidance that clearly documents the department’s process for climate change risk assessments for integrated country strategies  (Recommendation 1) We provided a draft of this product to State, USAID, and DOD for review and comment  State provided written comments, which we have reprinted in appendix IV  In its comments, State did not oppose the recommendation and noted that the agency will update its integrated country strategy guidance by June 30, 2019 to inform missions that they have the option to include an annex on climate resilience, as well as other topics  However, State also indicated that the agency will begin working with stakeholders to consider whether to recommend that the Secretary of State ask the President to rescind Executive Order 13677: Climate- Resilient International Development  USAID also provided written comments, which we have reprinted in appendix V  In its letter, USAID provided some additional information about its programs and its proposed transformation effort  USAID and DOD provided technical comments, which we incorporated as appropriate  We are sending copies of this report to the appropriate congressional requesters, Secretary of State, the Administrator of USAID, and the Secretary of Defense  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 David Gootnick at (202) 512-3149 or gootnickd@gao gov, or Brian J  Lepore at (202) 512-4523 or leporeb@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 VI  This report (1) describes executive branch actions related to climate change and migration from fiscal years 2014 through 2018; (2) examines the extent to which the Department of State (State), the U S  Agency for International Development (USAID), and the Department of Defense (DOD) have discussed the potential effects of climate change on migration in their plans and risk assessments; and (3) describes State, USAID, and DOD activities, if any, that are related to climate change and global migration  We chose fiscal years 2014 through 2018 as our time frame based on our review of recent executive orders related to climate change  We selected State, USAID, and DOD because the agencies’ missions of diplomacy, development, and defense provide the foundation for promoting and protecting U S  interests abroad  To describe executive branch actions related to climate change and migration from fiscal years 2014 through 2018, we reviewed documents that reflect priorities of the previous and current administrations  Specifically, we reviewed budget requests and enacted appropriations between fiscal years 2014 through 2018 for funding priorities related to climate change and U S  foreign assistance  In addition, we reviewed executive actions and executive branch strategies that applied to State, USAID, and DOD between fiscal years 2014 through 2018 for executive and national security priorities related to climate change  For example, we reviewed the current and previous national security strategies  strategies and seven regional bureau strategies  For USAID, we examined the five country and regional strategies that were required to include a climate risk assessment at the time of our review: Uganda, Tunisia, East Africa, Sri Lanka, and Zimbabwe  We also reviewed all nine USAID regional strategies  For both State and USAID, we reviewed the selected strategies by searching for information related to migration and climate change  To determine whether State clearly documents the department’s current climate risk assessment process for integrated country strategies, we compared State’s 2018 guidance for developing integrated country strategies with standards related to documentation in Standards for Internal Control in the Federal Government and previous State guidance issued in 2016, which was created in response to Executive Order 13677’s requirements to assess climate change risks to strategies, among other things  to these issues  The agency then provided us with data for about 250 activities from its annual operational plans for fiscal years 2014 through 2016, the 3 years during the period we reviewed in which it received adaptation funding  USAID identified these activities based on whether the agency had tagged them in its plans as having an “adaptation key issue ” USAID excluded projects that had planned attributions to the adaptation key issue of less than $250,000 in a given fiscal year, as well as certain other activities such as those that focused on project support  We then conducted an automated review of the activity description fields provided by USAID for terms related to migration and other descriptive information such as locations of activities  Because no USAID adaptation activities specifically mentioned migration, for the purposes of this report we chose illustrative examples to provide context for the types of activities the agency has funded  DOD officials we met with did not identify any specific activities related to climate change as a driver of migration  DOD officials from the Assistant Secretary of Defense for Special Operations and Low Intensity Conflict and the geographic combatant commands generally discussed DOD activities related to humanitarian assistance and disaster response as most relevant to our inquiry  Because DOD works in coordination with USAID’s Office of U S  Foreign Disaster Assistance on disaster assistance we also reviewed USAID data on its disaster response activities during this period  We determined that the USAID and State adaptation project data and USAID disaster assistance data were sufficiently reliable for the purposes of describing these efforts  State, USAID, and DOD to obtain information on whether changes in government priorities related to climate change affected their activities  We conducted this performance audit from October 2017 to January 2019 in accordance with generally accepted government auditing standards  Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives  We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives  This appendix provides a review by region of observed and projected climate change effects, migration trends, and challenges in stability and security  Multiple sources we used for this overview make a connection between climate change and such events as rising sea levels, higher temperatures, and an increase in the number and severity of extreme weather events  The following regions are discussed: Asia, South America, the Arctic, Sub-Saharan Africa, the Middle East and North Africa, Oceania, and Central America and the Caribbean  We have provided an overview for each region and a focus on one country or territory in the region  international and regional organizations, including a variety of organizations within the United Nations, the World Bank, regional development banks, the European Union, and others  Third, we reviewed relevant public documents from U S  government agencies, including the Department of Defense, the U S  Agency for International Development (USAID), and the United States Institute of Peace (USIP)  Fourth, we reviewed academic sources, research institutions, and documents from the relevant country’s national government  population  Economic conditions may be a factor for people deciding whether to migrate or stay in their country of origin  Remittances as Percent of GDP: The money international migrants transfer to recipients in their country of origin, expressed as a percentage of the origin country’s GDP  Sources agree that remittances support resilience in origin countries  Agriculture, Fishing, Forestry as Percent of GDP: A measure of the value added to an economy from the agricultural sector, which includes forestry, hunting, fishing, and the cultivation of crops and livestock, expressed as a percentage of the country’s GDP  Countries that depend on the agricultural sector may be vulnerable to the effects of climate change, according to the World Bank  Percent of Population in Cities: The population living in areas classified as urban according to criteria each country uses  Today, more than half of the global population lives in cities  Migration, in some cases due to climate change, is an important driver of urban growth, according to IOM  Cities are also expected to face increasing risks from rising sea levels, flooding, storms, and other climate change effects  Net Migration Rate: A measure of the number of people leaving a country compared to the number of people entering a country, expressed as a number per 1,000 people  The effects of climate change in Asia may impact migration and stability according to the Intergovernmental Panel on Climate Change (IPCC) and the Asian Development Bank (ADB)  In coastal areas, effects of climate change include rising sea levels, storm surges, and others  Receding glaciers in mountanous areas may also cause flooding, and monsoons in a warmer climate may be more severe  Heat extremes and more rainfall are a particular concern in Southeast Asia  Changes in precipitation and drought in Asia may exacerbate food security challenges, and contribute to people deciding to migrate  Increases in migration, partly stemming from the effects of climate change in surrounding rural areas, may put pressure on existing urban infrastructure  Rural migrants may settle in informal communities on the outskirts of cities, areas that have little resilience to natural disasters  Although the World Bank and others agree that climate change largely causes internal migration, some evidence shows that the impact of climate change contributes to cross-border migration in Asia  Large numbers of migrants, along with other destabilizing factors, may contribute to instability and conflict, according to the IPCC  The effects of climate change on livelihoods, for example, could increase migration, strain governance, and contribute to conflict as a result  Bangladesh is one example where decreased yields from agriculture and fisheries have contributed to migration to the country’s coastal cities, which face their own climate change challenges  Bangladesh’s high population density and geography make the country susceptible to the effects of climate change, according to the World Bank, and others  Bangladesh’s coasts and river banks are vulnerable to sudden-onset events such as tropical cyclones and flooding  Cyclone Aila in 2009, for example, caused widespread flooding in the southern coastal areas of Bangladesh and impacted millions of people  The storm washed away embankments that protected coastlines and caused severe damage to crops and livelihoods  Tropical Cyclone Mora in 2017 damaged thousands of homes and displaced an estimated 200,000 people  Increases in the number and intensity of tropical cyclones, which some predict will occur in a warmer climate, could have severe impacts on homes, livelihoods, and food security  Bangladesh also experiences many slow-onset climate change events, such as rising sea levels and increasingly severe droughts, which are projected to intensify with climate change  Bangladesh would lose an estimated 17 5 percent of its land if the sea level rose 1 meter, as the International Organization for Migration (IOM) has reported  Projected changes in precipitation levels could cause drought and food insecurity in the northwest and salt-water intrusion could reduce crop yields in the southwest  Migration is a common adaptation strategy to climate change in Bangladesh, according to the ADB  For example, some farmers have adapted to salt water intrusion and destroyed crops by switching to salt- tolerant rice production or shrimp cultivation  Others have migrated, often to Bangladesh’s cities to find work less dependent on agriculture  Many new migrants to Bangladesh’s cities live in informal settlements that lack the resilience to withstand sudden-onset climate events  The capital city, Dhaka, is a common destination for migrants displaced by salt-water intrusion, flooding, and river erosion, according to IOM  Dhaka, like many coastal cities in South Asia, is located on a low-lying riverbank and faces increasing risks of extreme flooding  For example, past floods in Dhaka have destroyed homes and contaminated drinking water, creating significant health hazards  In some cases, individuals migrate to cities temporarily for work and return home after the agricultural off season ends  Bangladeshis also provide a significant number of labor migrants to the Gulf States and Malaysia  Remittances from international migrants represent 5 4 percent of the country’s GDP, and may help to support resilience to climate change, according to IOM, and others  These migration trends may intensify in the future  One study estimates 9

ground_truth: The improper payment rate is a sentinel measure of program integrity risks for the Medicaid program. CMS and the states oversee Medicaid, whose size, structure, and diversity make it vulnerable to improper payments. CMS estimates the Medicaid improper payment rate annually through its PERM, which includes an estimate for Medicaid managed care, in which states contract with MCOs to provide services to Medicaid enrollees. GAO was asked to study the PERM methodology for managed care. In this report, GAO examined the extent to which the PERM accounts for program integrity risks in Medicaid managed care, including CMS's and states' oversight. GAO identified program integrity risks reported in 27 federal and state audits and investigations issued between January 2012 and September 2017; reviewed federal regulations and guidance on the PERM and CMS's Focused Program Integrity Reviews; and contacted program integrity officials in the 16 states with a majority of 2016 Medicaid spending for managed care, as well as CMS officials and program integrity experts. The Centers for Medicare & Medicaid Services' (CMS) estimate of improper payments for Medicaid managed care has limitations that are not mitigated by the agency's and states' current oversight efforts. One component of the Payment Error Rate Measurement (PERM) measures the accuracy of capitated payments, which are periodic payments that state Medicaid agencies make to managed care organizations (MCO) to provide services to enrollees and to cover other allowable costs, such as administrative expenses. However, the managed care component of the PERM neither includes a medical review of services delivered to enrollees, nor reviews of MCO records or data. Further, GAO's review of the 27 federal and state audits and investigations identified key program risks. Ten of the 27 federal and state audits and investigations identified about $68 million in overpayments and unallowable MCO costs that were not accounted for by PERM estimates; another of these investigations resulted in a $137.5 million settlement. These audits and investigations were conducted over more than 5 years and involved a small fraction of the more than 270 MCOs operating nationwide as of September 2017. To the extent that overpayments and unallowable costs are unidentified and not removed from the cost data used to set capitation rates, they may allow inflated MCO payments and minimize the appearance of program risks in Medicaid managed care. CMS and states have taken steps to improve oversight of Medicaid managed care through updated regulations, focused reviews of states' managed care programs, and federal program integrity contractors' audits of managed care services. However, some of these efforts went into effect only recently, and others are unlikely to address the risks in managed care across all states. Furthermore, these efforts do not ensure the identification and reporting of overpayments to providers and unallowable costs by MCOs. Federal internal control standards call for agency management to identify and respond to risks. Without addressing key risks, such as the extent of overpayments and unallowable costs, CMS cannot be certain that its estimated improper payment rate for managed care (0.3 percent compared with 12.9 percent in Medicaid fee-for-service) accurately reflects program risks. The Administrator of CMS should consider and take steps to mitigate the program risks that are not measured in the PERM, such as overpayments and unallowable costs; such an effort could include actions such as revising the PERM methodology or focusing additional audit resources on managed care. HHS concurred with this recommendation. HHS also provided technical comments, which were incorporated as appropriate.

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



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



Report 2: 6 million people will migrate from 2011 to 2050 due to the effects of climate change  Challenges in Stability and Security Migration due to climate change is cited as a potential destabilizing factor in Bangladesh by ADB, and others  The low-income population in Bangladesh is dependent on agriculture, making the effects of climate change—including impacts on food security—a particular concern  By 2030, these effects on livelihoods and food security could increase the poverty rate in Bangladesh by 15 percent, as the IPCC has reported  Given the proximity of Bangladesh to India, some individuals may also choose to cross the border  Increased migration to India is a potential concern, according to some sources, as India may not have the resources to absorb large numbers of Bangladeshi migrants  The CNA Corporation, National Security and the Threat of Climate Change (Alexandria, VA: 2007); and Population Council, “Effects of Future Climate Change on Cross-Border Migration in North Africa and India,” Population and Development Review, Vol  36, No  2 (2010)  The effects of climate change in South America vary by region, according to the the Intergovernmental Panel on Climate Change (IPCC) and International Organization for Migration (IOM), as well as potentially impacting migration and stability  On the coast, risks include sea level rise, depletion of fisheries, and coral reef bleaching, according to IOM  Coastal cities with growing populations are particularly vulnerable  Melting glaciers in the Andean mountain region, and increased rainfall are expected to change the distribution of water resources, and impact food production as global demand for food is growing  Desertification and land degradation, complicated by the effects of climate change, are contributing to migration from rural areas to cities in South America, as IOM has reported  An estimated 77 percent of people living in high risk areas in South America are located in cities, according to IOM  IOM predicts that as these people feel the effects of sea level rise and water scarcity, they will migrate from the large coastal cities to smaller urban areas  While South America has experienced economic growth in the last decade, poverty rates remain high, and the effects of climate change, including possible migration, may exacerbate inequalities, putting further pressure on cities to meet the needs of their populations  Water security in particular is expected to disproportionaly impact low-income communities, according to the IPCC  For example, in Brazil, drought in the northeast may increase migration to southern cities that are facing rising sea levels and landslides, with consequences for food, water, and energy security  Observed and Projected Effects of Climate Change Brazil’s cities and rural regions may encounter a range of climate change effects, according to the IPCC and IOM  Rural areas, particularly in the northeast, could experience significant impacts from climate change partly due to poverty rates, and historical vulnerability to drought  Higher temperatures are expected to affect crop yields and household incomes, especially for low-income communities  In northeastern Brazil, temperatures are expected to increase and rainfall to decrease  The northeast could see a 22 percent reduction in precipitation by 2100, according to IPCC projections  Brazil’s coastal areas, including cities, are also vulnerable to rising sea levels, heavy precipitation, flooding, and landslides  The vast majority of Brazil’s population, about 86 percent, lives in cities, many in coastal areas, according to the United Nations Development Program  As their populations have grown, urban areas have extended out  This urban growth in Brazil’s megacities has caused further increases in temperature, rainfall, and landslides  For example, current levels of urbanization in the metropolitan area of Sao Paulo may already be responsible for the 2°C warming observed in the city over the last 50 years, as well as the rise in extreme rainfall, according to the IPCC  The metropolitan area is expected to extend its area 38 percent by 2030  Multiple studies of the effects of urbanization on Sao Paulo’s climate suggest higher temperatures affect convective rainfall, which occurs when warm air rises, condenses to form clouds, and produces extreme rain  Other concerns are the depletion of coral reefs and mangrove forests on Brazil’s coastlines, and decreases in biodiversity  Migration from drought in northeastern Brazil to cities has increased urban populations, putting more people at risk of displacement from flooding and landslides  Migration from the northeast is a historical trend in Brazil, as economic migrants have sought seasonal jobs in more productive agricultural regions, or moved permanently to southern cities  Projected declines in rainfall have led some to predict further increases in migration in northeastern Brazil, as the IPCC has reported  However, remittances from family members who leave Brazil’s northeast support resilience for those who remain and may help to reduce migration  Already environmental factors contribute to migration to cities, including to favelas, informal settlements often constructed in hilly areas and floodplains outside of Brazilian cities  A significant number of the favela residents in Rio de Janeiro are migrants from northeastern Brazil, according to IOM  These new migrants may be at risk of further displacement if heavy rainfall, flooding, and other climate change effects destroy their vulnerable homes  For example, heavy rainfall in April 2010 resulted in landslides across Rio de Janeiro, displacing an estimated 5,000 people, according to a report from the World Bank  Brazil is also a destination for migrants from other countries in the region  Migrants from Venezuela searching for jobs and improved food security have come in growing numbers in recent years, as have migrants from Haiti fleeing a series of natural disasters, as IOM has reported  Challenges in Stability and Security Although Brazil ranks 106th out of 178 countries on the Fragile States Index, the effects of climate change may contribute to challenges with water, food, and energy access according to the IPCC  Decreased rainfall could decrease agricultural productivity, with potential health impacts for poor populations  These conditions are of particular concern in northeastern Brazil, as extreme weather and low crop yields are associated with more violence, according to the IPCC  Brazil also receives about 70 percent of its electricity from hydroelectric power, according the United Nations Environment Programme, and recent droughts caused power cuts across many major cities  Although not linked to the effects of climate change, absorbing a growing number of migrants fleeing political and economic instability in Venezuela may impact the broader region, according to the U S  Department of Defense and the National Intelligence Council  Neighboring countries, including Brazil, may struggle to absorb the influx of migrants  On average, 800 Venezuelans are crossing the border to Brazil every day in need of urgent humanitarian assistance, according to the UNHCR, the UN Refugee Agency  The effects of climate change in the Arctic, including higher temperatures and melting ice, have contributed to shifts in migration across the Arctic, and may have security implications  Increasing temperatures may have a variety of impacts in the Arctic, according to the Intergovernmental Panel on Climate Change (IPCC)  The effects of rising temperatures are disrupting livelihoods and food security, especially for indigenous communities, and opening up untapped natural resources to extraction  Both trends have impacted migration flows in the Arctic  Rising temperatures and melting ice have opened up previously inaccessible waterways in the Arctic, with implications for national security, according to the Department of Defense and others  Greenland, located in the Arctic and considered part of Kingdom of Denmark, exhibits many of these trends  Greenland is experiencing the effects of climate change, including glacial and ice melt, shifts in wildlife distribution, and newly available oil and mineral deposits, among others  The Greenland Ice Sheet covers approximately 80 percent of Greenland’s land mass  The ice sheet’s melting rate is slow, but uncertain  Increases in temperature greater than 1°C may result in the near loss of the entire ice sheet over a millennium and significant sea level rise, according to the IPCC  In the short term, predicting the ice sheet’s melting rate is a challenge as predictions vary in the scientific community  Accurate predictions would support mitigation and adaptation efforts in vulnerable areas  Rising temperatures and shrinking ice cover have shifted the distribution and migration patterns of marine mammals and fish, and impacted food security according to the IPCC and the Arctic Council, an intergovernmental forum for Arctic states  For example, the economy in Paamiut, Greenland, depended primarily on cod fisheries until changing climate conditions caused cod to disappear, and the town was slow to adapt to newly available shrimp  Similarly, fisheries in Disko Bay, Greenland, have struggled to adapt to new conditions  Rising temperatures and the resulting reduction in ice cover have required a shift to fishing from boats in open water instead of hunting and fishing over ice cover  Lastly, warming and ice melt may make significant oil and mineral deposits accessible for extraction in the future  The potential expansion of extraction industries makes environmental sustainability another possible concern  For example, an estimated 31 billion barrels of oil and gas may exist off the coast of Northeast Greenland, according to the Kingdom of Denmark’s 2011-2020 Arctic Strategy  The strategy stresses the importance of assessing and reducing risks to the environment resulting from the exploration and extraction of oil and gas  The effects of climate change are predicted to contribute to internal and external migration in Greenland  For example, young people are increasingly leaving indigenous communities in rural areas for cities in Greenland in search of work, as traditional livelihoods become unsustainable  Greenland is home to a majority indigenous population, primarily Inuit, whose traditional hunting and fishing practices require travel across ice  In the past, people adapted to seasonal changes to support livelihoods by migrating, and the practice was embedded into indigenous social structures  With reduced ice cover, however, migrating to hunt, fish, and maintain connections to community is more dangerous or restricted  Government policies promoting centralized services, such as health care and education, have also played a role in the shift away from migration as a way of life  As a result, indigenous livelihoods are more difficult to maintain, and young people often migrate to towns and cities in Greenland, or to Denmark, for education  At the same time, warmer temperatures have made mineral extraction feasible  As the extraction industry grows, new jobs may draw migrants from outside the Arctic region  In 2011 companies spent $100 million on the exploration of minerals in the Artic, and the estimated number of new mines is expected to require more workers than now live in the region 17 79Currently, more people leave than migrate to Greenland  The local Inuit population in Uummannaq, Greenland relies heavily on ice coverage for fishing and travel by traditional dog-sled  Brookings-LSE Project on Internal Displacement, A Complex Constellation: Displacement, Climate Change and Arctic Peoples (January 30, 2013)  Brookings-LSE Project on Internal Displacement  The effects of climate change on Sub-Saharan Africa vary depending on the region and have impacts on migration and security, according to the International Organization for Migration (IOM)  Coastal areas, for example, in West and East Africa are at risk from sea level rise that could affect major cities  Drought and the risk of desertification in the Sahel is cited as a concern, as is increased rainfall in parts of Central Africa accompanied by lower agricultural yields  As desertification threatens the livelihoods of farmers and herders, and drought makes fishing more challenging, rural dwellers may be more likely to migrate to cities, according to the United Nations Environment Programme (UNEP)  Urbanization and population growth across Sub-Saharan Africa is already making densely populated cities vulnerable to flooding, storms, and erosion, increasing the number of people at risk of displacement by sudden-onset disasters  Climate change effects and changing migration flows across Sub-Saharan Africa may impact access to natural resources and contribute to existing tensions and conflicts, according to UNEP and the Intergovernmental Panel on Climate Change (IPCC)  In Nigeria, the effects of climate change may effect a variety of livelihoods and increase migration south, while also exacerbating existing conflicts  The effects of climate change on Nigeria may impact the country’s agriculture and economy, according to the United States Institute of Peace (USIP)  Higher temperatures and decreased rainfall have contributed to drought in northern Nigeria  Desertification is also a concern  Some regions in northern Nigeria have less than 10 inches of rain a year, an amount that has decreased by 25 percent since the 1980’s, according to USIP  In other areas across Nigeria flooding has resulted in major crop losses, according to UNEP  Rising sea level, water inundation, and erosion are concerns in Nigeria’s coastal areas  Rising sea level is predicted to pose medium to very high risks to Africa’s coastal areas by 2100, according to the IPCC  Future sea level rise could result in the inundation of over 70 percent of the Nigerian coast  A rise of 0 2 meters in sea level could risk billions of dollars in assets, including oil wells near the coast  Even without a rapid rise in sea level, Nigeria’s coastal areas could experience erosion and significant land loss by 2100, as the IPCC has reported  The effects of climate change on livelihoods in northern Nigeria may contribute to migration to the south according to UNEP, while conflict in the north drives separate migration trends  As the effects of climate change make farming and fishing more challenging elsewhere in Nigeria, migration to southern coastal cities may increase  Traditionally, farmers, herders, and fishery workers migrated for temporary employment during the off season, including migration to Nigeria’s cities to work in the oil industry  Permanent migration south as well as to cities may become more common if land suitable for farming decreases  As fish habitats like Lake Chad dry up, fishery workers may also migrate  Larger urban populations on the coast will put more people at risk of sea level rise, water inundation, and erosion, according to the IPCC  A rise in sea level of 1 meter could put over 3 million people at risk of displacement as the IPCC has reported  Herders have also moved further south due to increased drought in northern Nigeria, as UNEP and USIP have reported  A 2010 survey of herdsmen in Nigeria, for example, found that nearly one-third of them had migrated southeast as a result of changes in the natural environment, according to the UNEP  The ongoing conflict with Boko Haram, while not caused by climate change, has further resulted in millions of displaced people across the Lake Chad region, including many Nigerians who have fled to Cameroon, Chad, and Niger  Nigerian refugees at the Minawao camp in Cameroon  Challenges in Stability and Security The effects of climate change, migration, and conflict are interconnected in Nigeria, as USIP has reported  The country is ranked 14th of 178 countries on the Fragile States Index  Events in northwest Africa, including Boko Haram’s attacks in Nigeria, have underscored concerns about the region’s vulnerability to the spread of violent extremism  The effects of climate change may exacerbate these concerns, according to USIP  Nigerians fleeing attacks from Boko Haram in the north have gone to communities in neighboring Chad, Cameroon, and Niger that are already experiencing food shortages due in part to climate change  These neighboring countries as a result have fewer resources to support both their own residents and the newer refugees  Non-state actors may also take advantage of government inaction on the effects of climate change  Boko Haram, for example, has justified its acts of violence by pointing to government failures, according to the USIP  Separately, increased drought in the north may aggravate historic tensions over land and water use between farmers in the south and herders migrating from the north, according to UNEP  Nigeria’s oil fields on the coast, which represent a significant part of the economy, are also at risk from sea level rise  Potential losses in oil revenue could impact Nigeria’s ability to respond to humanitarian crises and conflict at home  Increased violence within its borders could also affect Nigeria’s ability to support regional peacekeeping missions, such as the United Nations Mission in Liberia from 2003 to 2018, where Nigerian troops worked to restore security after a civil war  The effects of climate change in the Middle East and North Africa, including on its desert regions, may impact water access and compound migration and stability challenges, according to the United Nations Environmental Programme (UNEP)  Over 60 percent of the population already experiences high or very high water stress, according to the World Bank  Coupled with unsustainable water use, climate change may further exacerbate challenges with water security  The region continues to experience rising temperatures and declining annual rainfall, trends that contribute to the severity and length of drought, land degradation, and desertification  Decreased water security affects the livelihood and quality of life of farmers in the region, contributing to an increase in their migration to the cities and more urbanization, according to the World Bank  In contrast, many people are expected to migrate away from coastal cities as a result of sea level rise, according to UNEP  These potential migrations would be taking place in a region that already hosts large numbers of migrants such as those displaced by conflict and violence, including 18 percent of the world’s refugees, according to the International Organization for Migration  Challenges in water security may put greater pressure on unstable governments in the region, by intensifying existing tensions and conflicts between populations and their governments as well as between countries that share sources of water  The conflict in Syria illustrates the complex nature of climate change, migration, and conflict in the region, and the challenges to accurately assessing the links among the three, as noted in a technical paper commissioned by the U S  Agency for International Development (USAID)  Rising temperatures and declining rainfall have contributed to recent droughts in Syria, a trend that may continue  The country underwent an extended drought from about 2006 until 2011  During the drought an estimated 60 percent of Syria experienced severe crop failure, and accompanying impacts on food security  Some studies have linked the length and severity of the drought in Syria to climate change, as USAID has reported  Others, however, have pointed to government land and water use policies, combined with the effects of climate change, as responsible for the severity of the drought  Agricultural policies, for example, encouraged farmers to grow water intensive crops like wheat, and supported inefficient irrigation practices, policies which further depleted ground water and made the region more vulnerable to decreases in rainfall linked to climate change  Across the Middle East, the rising temperatures and declining rainfalls of recent decades may worsen, according to the World Bank  If these trends continue, countries in the Middle East, including Syria, could continue to experience periods of severe drought and reduced crop yields  Migration Trends The ongoing conflict in Syria, in which migration due to climate change may have been a contributing factor, has caused large-scale migration to neighboring countries in the Middle East and to Europe  Leading up to the civil war, prolonged drought, among other factors, had increased migration to Syrian cities  Because of the drought, in 2009, over 800,000 Syrians lost their livelihoods in the agricultural sector, while nearly 1 million experienced food insecurity  In 2010, an estimated 200,000 people migrated from farms in rural areas to cities, according to a UN report  The conflict in Syria, which began in 2011, has further displaced large numbers of people within the country and across the Middle East, as we have previously reported At the beginning of the conflict, Syrians, as well as Iraqi and Palestinian refugees who had been residing in Syria, fled mainly to Jordan, Lebanon, and Turkey  As the conflict persisted, refugees fled in larger numbers to Turkey, with the UNHCR reporting that nearly 1 million Syrians sought protection in that country in 2015  Starting that year, a growing number of Syrians risked dangerous sea voyages to reach countries in Europe, such as Greece, Germany, and Sweden  As of June 2017, more than 5 million registered Syrian refugees were living in neighboring countries, including more than 3 million in Turkey, and more than 1 million in Lebanon  Challenges in Stability and Security Sources agree that the Syrian conflict is a significant security challenge that has resulted in large scale migration across the Middle East and to Europe  Yet the link between prolonged drought, rural to urban migration, and the current conflict in Syria is uncertain  Some academic sources argue that the increased strain on urban infrastructure and resources due to the rural to urban migration played a role in Syria’s growing instability  Others highlight the complex nature of the Syrian conflict, pointing to broader political factors that exacerbated resource scarcity and inequality  For example, as the drought intensified, the Syrian government downplayed the severity of the humanitarian crisis, as described in research cited in a technical report commissioned by USAID result, appeals to the international community for emergency aid received minimal support  Combined with existing sectarian divisions, ongoing revolutions across the Middle East, and other factors, the government’s response to the drought may have contributed to the current conflict  Migration and displacement are a concern in the region, according to the Department of Defense and others  The U S  government has provided significant humanitarian assistance for Syrian refugees in the Middle East, including in Lebanon and Jordan, as we have previously reported However, a technical report commissioned by USAID has cautioned that the ongoing conflict in Syria makes it difficult to conduct research and draw conclusions related to climate, migration and conflict  As a The effects of climate change on Oceania, particularly rising seas, may significantly impact coastal populations and increase migration in the future, as the Asian Development Bank (ADB) and the Intergovernmental Panel on Climate Change (IPCC) have reported  Rising temperatures and declining rainfall may also contribute to lower yields from fisheries and agriculture, and a significant decrease in coral reef cover  Extreme weather events, including higher temperatures, wind, and rainfall, have already increased in number and intensity across the region  In the majority of Pacific island nations, of those who migrate, more people leave than come, according to the African, Caribbean, and Pacific Observatory on Migration  The majority of migration in the region is economically driven  In the future, climate change may further impact these migration patterns across the region, according to the IPCC  Climate change has already exacerbated challenges that aid-dependent nations in the region face, restricting livelihoods and resources and contributing to pressures to migrate  The costs of climate change, including a decline in crop yields, a rise in energy demands, and a loss of coastal land, are predicted to be significant  The ADB estimates these costs will reach 12 7 percent of the Pacific regions’ GDP by 2100  Increased migration may also impact political stability and play a role in geopolitical rivalries within the region, according to the IPCC  The effects of climate change, especially rising sea levels, may result in forced migration from the Republic of the Marshall Islands (the Marshall Islands) and have additional impacts on the U S  defense infrastructure on the islands  Observed and Projected Effects of Climate Change Rising sea levels are a grave threat to the Marshall Islands The country consists of islands, low-lying atolls—coral caps sitting on top of submerged volcanoes—making it particularly vulnerable to rising sea levels  On average, the Marshall Islands are 2 meters above sea level  In Majuro, the country’s most populous atoll, observed rates of sea level rise are already twice as fast as the global average  Population centers experience significant flooding, with damage to roads, houses, and infrastructure, especially during La Niña years, which are significantly wetter and more prone to extreme rainfall  Flooding is expected to worsen with rising sea levels, with consequences for the availabity of drinking water  On Roi-Namur island, for example, a 0 4 meter rise in sea level combined with wave-driven flooding is predicted to make groundwater undrinkable year round as early as 2055  This salt water inundation may contaminate already limited groundwater across the Marshall Islands  Lastly, during the 1940s and 1950s, the Marshall Islands was the site of 67 U S  nuclear weapons tests on or near Bikini and Enewetak Atolls  Projected increases in frequency of flooding may negatively impact efforts to contain radioactive material stored on Runit Island  A number of factors have increased migration from the Marshall Islands, including to the United States  In 1986, the United States entered into a compact of free association with the country that allowed its citizens to migrate to the United States, as we have previously reported  As a result, more than 20,000 Marshallese now live in the United States People are more likely to migrate abroad as the effects of climate change on the Marshall Islands—including rising sea levels—increasingly impact livelihoods The threat of mass displacement and forced migration is also a concern, as the International Organization for Migration has reported  However, Marshallese culture has a strong connection to the land, which means that many view migration as a last resort  For people still living in the Marshall Islands, they face overpopulation in urban centers and displacement by sudden-onset disasters like cyclones and flooding  Factors influencing people deciding to move abroad include displacement, lack of economic opportunity—sometimes exacerbated by climate change—and limited access to health care  Climate change is likely to increase risks to public health in the country Increased rainfall, for instance, may expand mosquito breeding grounds, raising the risk of diseases like dengue fever  The country’s limited health care system may further contribute to migration from the islands  Challenges in Stability and Security In the future, the Marshall Islands may become uninhabitable  This prospect threatens the existence of the Marshall Islands as a sovereign state, as well as the United States defense facilities located on the islands  The total loss of land could result in the Marshall Islands being uninhabitable, which raises problems of migration, resettlement, cultural survival, and sovereignty  Relocation of the population of the Marshall Islands, and of other Pacific Island nations at risk of rising seas, could cause significant geopolitical challenges The Marshall Islands are also of strategic importance for the United States  Under the Compact of Free Association, the United States has permission to use several islands— including Kwajalein Atoll, the location of the Ronald Reagan Ballistic Missile Defense Test Range—until 2066  The country’s proximity to the equator makes the Marshall Islands ideal for missile defense and space work  Yet the island’s defense infrastructure and operations are at significant risk due to rising sea levels, flooding, and diminishing supplies of potable water  As the Department of Defense has noted, climate change will have serious implications for the department’s ability to maintain its infrastructure and ensure military readiness in the future  DOD, 2014 Climate Change Adaptation Roadmap (Alexandria, VA: June 2014)  The effects of climate change on Central America and the Caribbean may increase migration and exacerbate poverty rates, as the National Intelligence Council has reported  The climate in Central America and the Caribbean is predicted to be warmer and dryer  The Caribbean’s extensive coastlines and low-lying areas are vulnerable to sea level rise and an increase in sudden-onset disasters, including hurricanes and storm surges  Drought is a particular concern in Central America, where declines in rainfall have reduced crop yields and threatened livelihoods in recent years  Some evidence shows that drought in parts of Central America has contributed to migration north, including to the United States  Population growth, especially in coastal cities, has increased the number of people at risk during hurricane season, and the number and intensity of hurricanes have grown in recent years  Some attribute the increase in intensity to higher sea surface temperatures caused by climate change  However, there remains debate about long term hurricane trends  Recent hurricanes have caused displacement, and significant losses and damages—including to infrastructure—across the region  The depletion of coral reefs and mangrove trees, natural barriers to coastal erosion and flooding, has exacerbated vulnerability to storms in coastal areas  Climate change is likely to have negative impacts on tourism in the Caribbean, where the industry is an important part of the economy, according to Inter-American Development Bank  Climate change impacts on the economy may make it increasingly difficult for governments to reduce poverty and move towards environmental sustainability  Haiti’s geography, location, and high poverty rates make the country especially vulnerable  Haiti is highly vulnerable to climate change effects, partly due to its long coastline Hurricanes routinely make landfall in the country, and increases in rainfall and wind speeds associated with hurricanes are likely  Severe hurricanes, including Hurricane Matthew in September 2016, have hit Haiti in recent years  Hurricane Matthew was the first category 4 storm in Haiti since 1964  Damage from severe flooding and severe winds during the hurricane affected over 2 million people and created significant food security and public health challenges  Significant deforestation has further exacerbated Haiti’s vulnerability to hurricanes, as trees previously provided a natural barrier to the erosion that strong winds and more rainfall can cause  Rising temperature and highly variable rainfall have led to extreme drought and flash flooding, according to the U S  Agency for International Development (USAID) 32 2 These trends decrease crop yields, affecting the livelihoods of farmers, and threaten water access  Projected increase in temperature and decreases in rainfall are likely to intensify drought in Haiti’s interior  USAID, Haiti: Environment and Climate Change Fact Sheet (January 2016)  Migration Trends Slow-onset climate events, such as drought, and rising sea levels, and sudden-onset events, including earthquakes, affect Haiti, according to the International Organization for Migration (IOM)  Haiti is also particularly exposed to extreme weather events, such as hurricanes, which can lead to displacement  In January 2010, a catastrophic earthquake in Haiti killed an estimated 230,000 people and left close to 1 5 million people homeless  According to IOM, the recurrence of environmental disruptions increases risks and vulnerabilities  When Hurricane Sandy struck Haiti in October 2012, the country had still not recovered from the 2010 earthquake  The worsening of climate change effects around the world, particularly in low-income countries, may increase the number of people wanting to immigrate to the United States, where approximately 700,000 Haitians live today Remittances from family members living outside Haiti make up a significant portion of the economy, at 24 7 percent of GDP  The majority of these remittances come from the United States, as we have previously reported 34 4Remittances may support resilience to climate change effects as migrants send money home for disaster recovery and adaptation  Challenges in Stability and Security Haiti, the poorest country in the western hemisphere, has experienced political instability for most of its history, and ranks 12th of 178 on the Fragile States Index  The government has a low capacity to respond to additional challenges like those related to climate change, according to USAID  The Ministry of Environment, for example, is a relatively new organization within the Haitian government, and local and regional governments have a limited ability to enforce environmental laws and regulations  The United States has provided substantial aid to Haiti, both in disaster response and broader development projects  Official development assistance for Haiti in 2015, for instance, totaled slightly more than $1 billion  According to a January 2018 UN report, 2 8 million people were still in need of humanitarian assistance  GAO, Remittances To Fragile Countries: Treasury Should Assess Risks from Shifts to Non-Banking Channels, GAO-18-313 (Washington, D C , March 8, 2018)  The Department of State’s Bureau of Oceans and International Environmental and Scientific Affairs (State/OES) provided about $78 million in adaptation funding from the Global Climate Change Initiative for eight projects for fiscal years 2014 through 2017 (see table 2)  The Global Climate Change Initiative was established in 2010 to promote resilient, low- emission development, and integrate climate change considerations into U S  foreign assistance and was divided into three main programmatic initiatives: (1) Adaptation assistance, (2) Clean Energy assistance, and (3) Sustainable Landscapes assistance  The primary purpose of these contributions to the LDCF was to address the adaptation needs of the least developed countries, which are especially vulnerable to the adverse impacts of climate change  The LDCF financed the preparation and implementation of National Adaptation Programs of Action, which identify a country’s priorities for adaptation actions  Initial grant to the National Adaptation Plans Global Network  The network is focused on increasing the capacity of national and subnational governments to identify and assess climate risks, integrate these risk considerations in sector planning, develop a pipeline of projects to address risks, identify and secure funding for projects, and track progress toward resilience targets  Colombia, East Caribbean (Guyana, Saint Lucia, Saint Vincent and the Grenadines), Ethiopia, Peru, South Africa, Uganda, West Africa (Côte d’Ivoire, Ghana, Guinea, Sierra Leone, Togo) and, under current consideration, East Caribbean (Dominica, Suriname), and Pacific (Fiji, Kiribati, Tuvalu) The cost amendment intensified the technical support on National Adaptation Plans to select countries dependent upon specific country adaption needs  In addition, the cost amendment continued the learning and progress from the initial grant  Implemented through the Department of Treasury, this funding supported a Treasury grant to the Pacific Catastrophe Risk Assessment and Financing Initiative Multi Donor Trust Fund at the World Bank  This activity established the Pacific Catastrophe Risk Insurance Foundation and the Pacific Catastrophe Risk Insurance Company, among other things  The goal of PIER is to increase private sector investment in resilience to climate change in eight developing countries  The first phase of the project will assess and identify opportunities for private investment in resilience, as well as build public and private capacity for climate risk assessment in all the countries  In the second phase, public and private sector partners will develop and pilot climate risk-reduction investment models in four of the countries  The third phase will publicize the piloted investment models and lessons learned among the eight countries  Implemented through the National Oceanic and Atmospheric Administration, this activity aims to implement a capacity-building partnership with India to promote effective climate resilient decision making at national, state, and local levels  In addition to the contacts named above, the following individuals made key contributions to this report: Miriam Carroll Fenton (Assistant Director), Kristy Williams (Assistant Director), Rachel Girshick (Analyst-in-Charge), Nancy Santucci, Miranda Cohen, Aldo Salerno, Neil Doherty, and Judith Williams  Alexander Welsh, Justin Fisher, and Joseph Thompson provided technical and other support  Climate Change Adaptation: DOD Needs to Better Incorporate Adaptation into Planning and Collaboration at Overseas Installations  GAO-18-206  Washington, D C : November 13, 2017  Compacts Of Free Association: Actions Needed to Prepare for The Transition of Micronesia and the Marshall Islands to Trust Fund Income  GAO-18-415  Washington, D C : May 17, 2018  Remittances to Fragile Countries: Treasury Should Assess Risks from Shifts to Non-Banking Channels  GAO-18-313  Washington, D C : March 8, 2018  Syrian Refugees: U S  Agencies Conduct Financial Oversight Activities for Humanitarian Assistance but Should Strengthen Monitoring  GAO-18-58  Washington, D C : October 31, 2017  International Food Assistance: Agencies Should Ensure Timely Documentation of Required Market Analyses and Assess Local Markets for Program Effects  GAO-17-640  Washington, D C : July 13, 2017  High-Risk Series: Progress on Many High-Risk Areas, While Substantial Efforts Needed on Others  GAO-17-317  Washington, D C : February 15, 2017  Federal Disaster Assistance: Federal Departments and Agencies Obligated at Least $277 6 Billion during Fiscal Years 2005 through 2014  GAO-16-797  Washington, D C : September 22, 2016  Coast Guard: Arctic Strategy Is Underway, but Agency Could Better Assess How Its Actions Mitigate Known Arctic Capability Gaps  GAO-16-453  Washington, D C : July 12, 2016  Climate Information: A National System Could Help Federal, State, Local, and Private Sector Decision Makers Use Climate Information  GAO-16-37  Washington, D C : November 23, 2015  Hurricane Sandy: An Investment Strategy Could Help the Federal Government Enhance National Resilience for Future Disasters  GAO-15-515  Washington, D C : July 30, 2015  High-Risk Series: An Update  GAO-15-290  Washington, D C : February 11, 2015  Standards for Internal Control in the Federal Government  GAO-14-704G  Washington, D C : September 10, 2014  Combating Terrorism: U S  Efforts in Northwest Africa Would Be Strengthened by Enhanced Program Management  GAO-14-518  Washington, D C : June 24, 2014  Climate Change Adaptation: DOD Can Improve Infrastructure Planning and Processes to Better Account for Potential Impacts  GAO-14-446  Washington, D C : May 30, 2014  Extreme Weather Events: Limiting Federal Fiscal Exposure and Increasing the Nation’s Resilience  GAO-14-364T  Washington, D C : February 12, 2014  Climate Change: State Should Further Improve Its Reporting on Financial Support to Developing Countries to Meet Future Requirements and Guidelines  GAO-13-829  Washington, D C : September 19, 2013  High-Risk Series: An Update  GAO-13-283  Washington, D C : February 14, 2013  International Climate Change Assessments: Federal Agencies Should Improve Reporting and Oversight of U S  Funding  GAO-12-43  Washington, D C : November 17, 2011  Climate Change Adaptation: Federal Efforts to Provide Information Could Help Government Decision Making  GAO-12-238T  Washington, D C : November 16, 2011  Foreign Relation: Kwajalein Atoll Is the Key U S  Defense Interest in Two Micronesian Nations, GAO-02-119  Washington D C : January 22, 2002 
Report 2:  OMB issues guidance for agencies to implement various requirements of the improper payment laws  Specifically, OMB is required by IPERIA to issue guidance to set standards for agencies to follow in determining the underlying validity of sampled payments to ensure that amounts being billed, paid, or obligated for payment are proper  Although existing OMB guidance addresses requirements for sampling, it does not address how agencies test to identify improper payments, such as using a risk-based approach to help ensure that key risks of improper payments, like eligibility, are addressed through testing processes  Without such guidance, there is increased risk that agencies’ processes may not address key risks of improper payments in their programs—for example, the cases of DOD Military Pay and OPM Retirement described above—calling into question the improper payment estimates for such programs and their usefulness for developing effective corrective actions  According to OMB guidance, when an agency’s review is unable to determine whether a payment was proper because of insufficient or lack of documentation, the payment must be considered an improper payment  Among the six agencies and 10 programs we reviewed, treatment of insufficient documentation varied by program, as did the classification of these issues for root cause reporting in the AFRs  HHS’s programs were the only ones we reviewed that reported improper payments in the insufficient documentation root cause category for fiscal years 2016 or 2017, as shown in table 6  Some agencies stated that they report insufficient documentation in other root cause categories that they consider more appropriate  For example, Education officials stated that for the Direct Loan program, payments that lack sufficient supporting documentation may be placed in the “Administrative or Process Error Made by Other Party” root cause category  In these cases, a third party—such as a loan servicer—is unable to provide sufficient documentation supporting that the sampled payment was proper  OMB guidance states that in cases where the agency believes that more than one root cause category might be suitable, the agency should determine which category it believes to be the most appropriate  Additionally, some agencies stated that the “insufficient documentation” category was not always relevant when they recreated sampled cases to estimate a program’s improper payments  For example, according to officials, to complete an OASDI stewardship review of a sampled case, a Social Security Administration (SSA) quality reviewer reviews the documentation related to the original determination and then independently re-develops all factors of the payment and interviews the associated beneficiary  According to agency officials, insufficient documentation would not apply as all improper payments identified in the stewardship sample are supported by documentation and payment has been verified in all reviewed cases  As noted previously, the processes for estimating DOD Military Pay and OPM Retirement improper payments were limited, and these limitations may have an impact on the agencies’ ability to identify improper payments related to insufficient documentation  Treatment of cases of nonresponse  Some agencies contact outside entities—such as payees or beneficiaries—as part of their improper payment testing processes  Among the six agencies we reviewed, treatment of cases of nonresponse differed  For example: SSA officials stated that in cases where quality reviewers do not receive responses from OASDI beneficiaries they contact, they exclude the cases from review (unless the reviewer identifies an improper payment in the initial review that is completed prior to reaching out to the beneficiary)  For EITC improper payment estimation purposes, the Internal Revenue Service (IRS) stated that the agency does not consider the sampled payment associated with a nonresponse case to be proper or improper  It sets the sampling weight of nonresponse cases to zero and adjusts the sampling weights of respondents upward to account for the nonresponse cases  IRS’s methodology assumes nonresponse and response cases have an equal likelihood of improper payment  For Medicare Fee-for-Service and Medicaid, HHS’s policies and procedures consider payments associated with nonresponse cases to be improper  OMB guidance states that when an agency’s review is unable to discern whether a payment was proper as a result of insufficient or lack of documentation, this payment must be considered an improper payment  However, it does not specifically address the appropriate treatment of nonresponse cases for improper payment estimation purposes  As a result, without clearer guidance there is increased risk that agencies’ improper payment estimates may be understated and that estimates for similar programs may not be comparable  When agencies identify improper payments, they must determine the amount of the payment that was improperly made  The six agencies we reviewed generally reported using the definition of improper payment in relevant laws and OMB guidance to determine the amount of improper payments identified  OMB guidance provides agencies with instructions on how to calculate the amount of improper payments  However, when developing its improper payment estimate for EITC, IRS subtracted overpayments that were paid out and later recovered  By subtracting recovered overpayments, IRS excluded them from the EITC improper payment estimate  For 2013—the tax year used to produce the fiscal year 2017 improper payment estimate—IRS estimated that $1 2 billion in EITC overpayments would be recovered  IPERIA directed OMB to provide guidance that requires agencies to include all improper payments in their improper payment estimates, regardless of whether they have been or are being recovered  Although the OMB guidance was revised in October 2014 to implement this requirement, IRS has not updated its estimation methodology for EITC  By not updating its guidance and continuing to remove EITC overpayments that may be subsequently recovered, IRS is understating its improper payment estimate and potentially limits its ability to address these types of improper payments before they occur  Improper payments are a long-standing, significant problem in the federal government  Estimation of improper payments is key to understanding the extent of the problem and to developing effective corrective actions to address it  Among the six agencies we reviewed, processes to estimate improper payments in their programs varied, and certain differences in these processes may affect the quality of the resulting estimates and consequently these agencies’ efforts to reduce improper payments  Specifically, policies and procedures for DOD’s Military Pay and OPM’s Retirement programs’ improper payment estimation methodologies do not address certain key risks, like eligibility, in part because these agencies have not fully assessed their processes  Further, although OMB guidance addresses requirements for sampling, it does not address how agencies test to identify improper payments  Without such assessments and guidance, there is increased risk that agencies’ processes may not address key risks of improper payments in their programs, calling into question the improper payment estimates for such programs and their usefulness for developing effective corrective actions  Additionally, for agencies we reviewed that contact outside entities as part of their improper payment estimation processes, the treatment of cases of nonresponse varied  OMB guidance does not specifically address the appropriate treatment of nonresponse cases for improper payment estimation purposes  Without clearer guidance there is increased risk that agencies’ improper payment estimates may be understated and that estimates for similar programs may not be comparable  Finally, although IPERIA directed OMB to provide guidance that requires agencies to include all improper payments in their improper payment estimates, regardless of whether they have been or are being recovered, IRS has not updated its processes to reflect the change  By not updating its guidance and continuing to remove EITC overpayments that may be subsequently recovered, IRS is understating its improper payment estimate and potentially limits its ability to address these types of improper payments before they occur  We are making two recommendations to the Director of OMB that have government-wide implications and specific recommendations to DOD, OPM, and IRS regarding their programs included in this review  The Director of OMB should develop guidance on how agencies test to identify improper payments, such as using a risk-based approach to help ensure that key risks of improper payments, such as eligibility, are addressed through testing processes  (Recommendation 1) The Director of OMB should develop guidance clarifying the appropriate treatment of nonresponse cases during improper payment testing  (Recommendation 2) The Under Secretary of Defense (Comptroller) should assess the processes for estimating Military Pay improper payments to determine whether they effectively address key risks of improper payments— including eligibility for different types of pay and allowances—and take steps to update the processes to incorporate key risks that are not currently addressed  (Recommendation 3) The Director of OPM should assess the processes to estimate Retirement improper payments to determine whether they effectively address key risks of improper payments—including eligibility and whether older claims face different risks of improper payments than new claims—and take steps to update the processes to incorporate key risks that are not currently addressed  (Recommendation 4) The Commissioner of IRS should update IRS’s improper payment estimation methodology to not exclude recovered overpayments from its EITC improper payment estimate  (Recommendation 5) We provided a draft of this report for comment to OMB, DOD, Education, HHS, Treasury, OPM, SSA, and USDA  OMB provided oral comments, which are summarized below  OPM, DOD, and IRS provided written comments, which are reproduced in appendixes II through IV, respectively  Education, HHS, SSA, and USDA did not provide written comments on the draft report  In addition, HHS, IRS, OMB, OPM, and SSA provided technical comments, which we have incorporated, as appropriate  In oral comments provided on April 30, 2018, a Senior Policy Advisor in OMB’s Office of Federal Financial Management stated that OMB partially agreed with our first recommendation and agreed with our second recommendation  Regarding the first recommendation, the Senior Policy Advisor stated that OMB should not have to develop more specific guidance as each program and activity has its own risks  Instead, inspectors general are better equipped and positioned to review the sampling and estimation plans as part of their annual IPERA compliance audits and that agencies, their statisticians, and inspectors general should work out the best testing procedures for their agencies  OMB could provide suggestions during OMB’s annual town hall meeting related to improper payments for areas that inspectors general may consider  Although we agree that programs and activities may face different risks of improper payment, we continue to believe that guidance from OMB on how agencies test to identify improper payments—such as directing agencies to take a risk-based approach in developing their testing procedures—could help ensure that agencies address the specific risks they identify when developing improper payment estimates  Further, such guidance could also help ensure that testing processes are designed to address an agency’s identified risks before the estimate is developed, whereas an inspector general’s review—as well as related recommendations for improvement—would generally occur after the agency’s improper payment estimate had been developed and reported  Regarding the second recommendation, the Senior Policy Advisor noted that OMB plans to update its guidance to direct agencies to treat nonresponse cases as improper payments and to include a new category for tracking such cases  In its written comments, OPM partially concurred with our recommendation to assess the processes to estimate Retirement improper payments to determine whether they effectively address the key risks of improper payments  OPM agreed to conduct an audit of older claims to determine if they face different risks than new claims  However, OPM did not agree with the part of the recommendation to assess the risk of improper payments related to eligibility in the estimation process  OPM stated that eligibility is determined before annuity or survivor benefits are fully adjudicated  However, the objective of an improper payment estimate is to determine whether payments were made properly  To do so, an agency should determine whether the payee was eligible for the payment that was made, among other things  As such, we continue to believe that the recommendation—including the assessment of the risk of improper payments related to eligibility—is warranted  In their written comments, DOD and IRS both agreed with our recommendations directed to them and described the steps they plan to take to implement them  We are sending copies of this report to the appropriate congressional committees; the Secretaries of Agriculture, Defense, Education, Health and Human Services, and the Treasury; the Director of the Office of Personnel Management; the Administrator of the Social Security Administration; the Director of the Office of Management and Budget; and other interested parties  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) 512-2623 or davisbh@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 V  Table 7 lists the fiscal year 2017 improper payment estimates by agency and program, as reported by agencies in their fiscal year 2017 agency financial reports and compiled on the Office of Management and Budget’s payment integrity website, paymentaccuracy gov  In addition to the contact named above, Phillip McIntyre (Assistant Director), James M  Healy (Auditor in Charge), Daniel Flavin, and Fabiola Torres made key contributions to this report 

ground_truth: The effects of climate change, combined with other factors, may alter human migration trends across the globe, according to the International Organization for Migration. For example, climate change can increase the frequency and intensity of natural disasters, causing populations to move from an area. Climate change can also intensify slow-onset disasters, such as drought, crop failure, or sea level rise, potentially altering longer-term migration trends. GAO was asked to review how U.S. agencies address climate change as a potential driver of global migration. For State, USAID, and DOD, this report (1) describes executive branch actions related to climate change and migration from fiscal years 2014 through 2018; (2) examines the extent to which the agencies discussed the potential effects of climate change on migration in their plans and risk assessments; and (3) describes agency activities on the issue. GAO analyzed documents on administration priorities; reviewed agency plans, risk assessments, and documentation of agency activities; and interviewed agency officials. From fiscal years 2014 through 2018, a variety of executive branch actions related to climate change—such as executive orders and strategies—affected the Department of State (State), the U.S. Agency for International Development (USAID), and the Department of Defense (DOD), including their activities that could potentially address the nexus of climate change and migration. For example, a fiscal year 2016 presidential memorandum—rescinded in 2017—required agencies to develop implementation plans to identify the potential impact of climate change on human mobility, among other things. In general, however, climate change as a driver of migration was not a focus of the executive branch actions. For example, a fiscal year 2014 executive order—also rescinded in 2017—requiring agencies to prepare for the impacts of climate change did not highlight migration as a particular concern. State, USAID, and DOD have discussed the potential effects of climate change on migration in agency plans and risk assessments. For example, State and USAID required climate change risk assessments when developing country and regional strategies, and a few of the strategies reviewed by GAO identified the nexus of climate change and migration as a risk. However, State changed its approach in 2017, no longer providing missions with guidance on whether and how to include climate change risks in their integrated country strategies. In doing so, State did not include in its 2018 guidance to the missions any information on how to include climate change risks, should the missions choose to do so. Without clear guidance, State may miss opportunities to identify and address issues related to climate change as a potential driver of migration. The three agencies have been involved in climate change related activities but none were specifically focused on the nexus with global migration. For example, USAID officials said that the agency's adaptation efforts, such as its Pastoralist Areas Resilience Improvement through Market Expansion project in Ethiopia, were the most likely to include activities, such as enhancing resilience, that can indirectly address the issue of climate change as a driver of migration. GAO recommends that State provide missions with guidance that clearly documents its process for climate change risk assessments for country strategies. In commenting on a draft of this report, State indicated that it would update its integrated country strategy guidance and will specifically note that missions have the option to provide additional information on climate resilience and related topics.