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



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

Report 1: NAS is a withdrawal condition within infants that can result from the prenatal use of opioids by pregnant women  Prenatal opioid use occurs when a woman, during the course of her pregnancy, uses an opioid- based medication or substance  Prenatal opioid use can take various forms, including (1) the use of prescriptions for pain management, such as fentanyl and oxycodone; (2) medication-assisted treatment for opioid addiction, such as methadone and buprenorphine; (3) prescription drug misuse or use disorder (such as using an opioid without a prescription, using a different dosage than prescribed, or continuing to use an opioid when it is no longer needed for pain); and (4) illicit opioid use, such as heroin use  These types of prenatal opioid use are not mutually exclusive  A 2014 study found that almost 22 percent of pregnant Medicaid beneficiaries filled a prescription for an opioid during their pregnancy  Medication-assisted treatment—an approach that combines the use of certain medications and behavioral therapy—is generally considered by HHS and medical specialty societies to be the standard of care for treating pregnant women with opioid use disorders, depending on the individual and her circumstances  SAMHSA and several medical specialty societies, including the American College of Obstetricians and Gynecologists and the American Society of Addiction Medicine, have noted that providing medication-assisted treatment during pregnancy prevents complications associated with illicit opioid use, encourages prenatal care, and reduces the risk of obstetric complications  Further, women may use multiple substances in addition to opioids during pregnancy—known as maternal polysubstance use—such as tobacco, alcohol, or anti-depressants, among others  GAO reported in 2015 that the gaps in efforts to address prenatal opioid use and NAS most commonly cited by federal agency officials and experts were related to the treatment of prenatal opioid use and NAS  Agency officials and experts said that there has not been adequate research comparing different types of treatment approaches and that research is needed on how best to treat a pregnant woman with an opioid use disorder so that the treatment is most effective for the woman while offering minimal risk to the fetus  See GAO-15-203  For more information on factors that can affect access to medication- assisted treatment, see GAO, Opioid Addiction: Laws, Regulations, and Other Factors Can Affect Medication-Assisted Treatment Access, GAO-16-833 (Washington, D C : Sept  2016)  respiratory distress  There is currently no national standard of care for screening or treating NAS  There have been a few scoring tools developed to screen the infant to determine the appropriate course of treatment  Health care providers predominantly diagnose NAS using the Finnegan Neonatal Abstinence Scoring Tool, which calculates a score based on a variety of central nervous, metabolic, respiratory, and gastro-intestinal symptoms that might be observed  The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend that infants with NAS should not be initially treated with medication, known as pharmacologic treatment  Instead, these organizations recommend starting with non-pharmacologic treatment, which includes placing the infant in a dark and quiet environment, swaddling, breastfeeding, rooming-in with the mother, and providing high-calorie nutrition, among other things  For example, rooming-in—allowing the mother to reside with the infant during the infant’s treatment—may have benefits, such as helping to develop a bond between the mother and infant and to reduce the severity of the infant’s NAS symptoms  Pharmacologic treatment, such as using methadone or morphine, may be necessary only for the relief of moderate to severe signs of NAS  See figure 1 for more information on non-pharmacologic and pharmacologic treatment  HHS has published several guidance and educational resources related to NAS and prenatal opioid use  These documents serve as tools to help stakeholders, including state entities and health care providers, who work with this population  For example, SAMHSA published a clinical report for health care providers in 2016 that provides recommendations to help them when making decisions regarding the evaluation, care, and treatment of women with opioid use disorders and infants with NAS  As of July 2017, SAMHSA is in the process of producing a clinical guide based on this report and expects to publish an updated report later this year  In another example, SAMHSA published a guidance document in 2016 that aims to support the efforts of states, tribes, and local communities in addressing the needs of pregnant women with opioid use disorders and their infants  Among other things, the document includes strategies and guidance to promote care coordination among stakeholders, including child welfare agencies and medical professionals, when treating infants with NAS  (See app  II for a list of federal educational resources related to NAS and prenatal opioid use published by HHS ) As we previously noted, more than 80 percent of NAS cases are paid for by Medicaid, which is a federal-state health care program that finances health care coverage for low-income and medically needy populations, including children and aged or disabled adults  States administer their Medicaid programs within broad federal requirements and according to a state plan approved by CMS, the federal agency within HHS that oversees Medicaid  The Medicaid program allows states to design and implement their programs within certain federal parameters, resulting in more than 50 distinct state-based programs  For example, states generally determine the type and scope of services to cover, set payment rates that different health care providers will receive for various covered services, and pay these providers for claims submitted for services rendered  In addition, states vary in the extent to which they enroll beneficiaries in managed care versus delivering care through the more traditional fee-for-service model  Under a managed care delivery model, states typically contract with managed care plans to provide a specific set of Medicaid-covered services to beneficiaries and pay them a set amount per beneficiary—referred to as capitation payments—to provide those services  Under fee-for-service, Medicaid pays health care providers a fee for each service provided to a Medicaid beneficiary  Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment benefit, which states are required to provide, covers comprehensive health screenings, preventive health services, and all medically necessary treatment and services—for Medicaid eligible-children under the age of 21—to correct or ameliorate health conditions discovered through screenings  According to the literature we reviewed, most infants with NAS in the United States are treated in a hospital setting, often in the neonatal intensive care unit (NICU), which has a relatively high daily cost of care  Stakeholders we interviewed told us that these infants may also be treated in other hospital settings  According to state and perinatal collaborative officials in the four selected states we reviewed, infants diagnosed with NAS begin—and most complete—treatment for the condition in various hospital settings which provide different levels of care: a well newborn nursery (level I), special care nursery (level II), or NICU (level III or IV)  For example, according to these officials, most infants with NAS in Vermont are treated in well newborn nurseries, while most infants with NAS in Kentucky and Wisconsin are treated in NICUs  West Virginia perinatal collaborative officials told us that about a third of infants with NAS are treated in well newborn nurseries, while two-thirds receive treatment in either a special care nursery or NICU  According to perinatal collaborative officials and hospital providers in the four selected states, the severity of the infant’s NAS symptoms or the hospital’s capability to treat NAS can determine whether the infant receives care in a nursery or NICU  Health care providers in the four selected states described the general clinical approach for treating infants with NAS  According to these providers, they generally start with non-pharmacologic treatment—for example, swaddling or placing the infant in a quiet, dark room  Health care providers may continue to monitor and assess the severity of the infant’s NAS symptoms using one of the available scoring tools for NAS  If the infant’s symptoms meet or exceed a certain threshold, these providers may initiate pharmacologic treatment by administering morphine or methadone, for example  Some perinatal collaborative officials that we interviewed in the four selected states told us that not all hospitals may have the capability to provide pharmacologic treatment  For example, these officials told us that level I hospitals—hospitals with only well newborn nurseries—in Kentucky and Wisconsin may not provide pharmacologic treatment to infants with NAS because these hospitals may not have the staff expertise to administer the needed medication and monitor the infants who receive it  Instead, these hospitals may transfer infants with NAS who require pharmacologic treatment to hospitals with higher levels of care, such as those with a NICU  Table 1 provides information on the eight selected hospitals in our review that provide NAS services  According to a 2015 study we reviewed, nationwide, infants with NAS who require pharmacologic treatment generally have longer average hospital stays (23 days) compared with infants with NAS who do not require such medication (17 days)  Health care providers from our selected hospitals also indicated a similar trend—the average length of hospital stay in calendar year 2016 for infants with NAS who received pharmacologic treatment ranged from 7 to 30 days, while the stays for infants who did not require such medication ranged from 3 to 7 days  Medicaid generally pays for NAS treatment services in our four selected states using a diagnosis-related group (DRG) based payment system, in which hospitals receive a fixed amount for a bundle of services  In general, the DRG-based system used in Medicaid pays for the medical services necessary for treating infants with NAS, such as medication, bed space, and nursing staff, according to CMS officials  CMS officials said that the DRG-based system generally does not pay for professional services, such as physician visits; instead, these services are typically paid under a fee-for-service payment schedule, in which states or contracted managed care plans pay health care providers directly for their services  Officials in our selected states said information on total Medicaid payments for hospital-based NAS services was not readily available  Several DRGs are typically used to bill Medicaid for services provided to infants  However, these codes alone cannot provide an accurate estimate of Medicaid payments for NAS treatment services because the codes are not used exclusively for NAS  For example, according to some health care providers we interviewed, two DRG codes that may be used to bill Medicaid and other payers for NAS treatment services are 791 (prematurity with major problems) and 793 (full term neonate with major problems)  However, these codes could be used to bill for over 2,000 diagnoses—for example, pneumonia or measles  One state official said that while they could provide us with information on Medicaid payments for these infants, they could not parse out the costs by diagnosis codes, such as those related to NAS  Thus, estimates of total Medicaid payments based only on DRG codes likely overstate the amount paid for NAS hospital-based services  Officials from two of the four selected states told us that their state has a public health surveillance system that tracks the incidence of infants diagnosed with NAS; however, the surveillance systems do not capture financial information, including Medicaid payments for NAS  At our request, one of the states cross-referenced their surveillance and Medicaid data and estimated that in 2016, their state Medicaid program spent over $22 million to treat 1,565 infants with NAS  While selected states generally could not provide information on total Medicaid payments for infants with NAS, some hospitals in our selected states were able to generate this information at our request using diagnosis codes that they identified as related to NAS from hospital claims data  Six of our selected eight hospitals reported that in calendar year 2016, the average Medicaid payment for treating infants with NAS ranged from about $1,500 to about $20,200 per infant per stay  The wide range in Medicaid payment averages may be because the averages included both infants who did and did not require pharmacologic treatment and because these hospitals treated infants in various settings, such as a nursery or a NICU  The literature we reviewed also had limited information on Medicaid payments for NAS treatment services provided in hospitals  A recent study reported that from 2009 through 2012—the most recent data available at the time of the study—Medicaid payments to hospitals for NAS treatment services increased from about $564 million to $1 2 billion nationwide  While most infants with NAS typically complete treatment in a hospital setting, stakeholders told us that some of these infants may be transferred to a non-hospital setting to complete pharmacologic treatment and continue non-pharmacologic treatment  HHS officials told us that there is not a comprehensive list of facilities that may treat infants with NAS outside of the hospital  Based on information from the stakeholders we interviewed and the literature we reviewed, we identified two types of non-hospital settings available in certain states that treat infants with NAS: (1) outpatient clinics and programs and (2) neonatal withdrawal centers  For the purposes of this report, we defined neonatal withdrawal centers as facilities that can treat infants who are prenatally exposed to drugs, including infants with NAS, within the facility  Outpatient clinics and programs to treat NAS Through stakeholder interviews and the literature we reviewed, we identified examples of outpatient clinics and programs in certain states where infants with NAS can continue pharmacologic treatment after their discharge from the hospital  For example, some stakeholders we interviewed told us about a Neonatal Medical Follow-Up Clinic in Vermont used to follow-up with infants with NAS who have been discharged from the hospital and are being weaned off methadone on an outpatient basis  Hospital providers train the infant’s family on how to administer the infant’s medication at home and provide a referral to the clinic  After hospital discharge, the infant and family have follow-up visits in the clinic every 1 to 2 weeks, during which the family discusses with health care providers the weaning schedule and demonstrate how they administer the infant’s medication  Health care providers told us that they also encourage the family to continue providing non-pharmacologic treatment to the infant  After weaning is complete, the infant continues to follow-up at the clinic every 1 to 2 months until the infant reaches 12 to 18 months of age  Literature we reviewed indicated that other outpatient treatment clinics or programs such as the one in Vermont have been established or considered in other states  Specifically, four studies we reviewed described instances in which infants began their treatment in the hospital but completed their treatment through a dedicated outpatient program in Florida, Ohio, and Pennsylvania  Each study noted that the inpatient-to- outpatient approach can result in a shorter hospital length of stay  For example, one 2015 study found that infants who began treatment in a hospital and completed their treatment in an outpatient setting stayed in the hospital an average of 11 days, compared to infants who completed treatment in the hospital, where the stays averaged about 25 days  However, the studies also noted that the inpatient-to-outpatient approach resulted in a longer overall treatment duration across the two settings  Neonatal withdrawal centers to treat NAS Some stakeholders we interviewed, including health care providers, described examples of neonatal withdrawal centers in two states, where infants with NAS can continue pharmacologic treatment after their discharge from the hospital  Health care providers in these facilities told us that in Washington and West Virginia, some infants with NAS who began treatment in a hospital may be referred to these facilities, where they reside until they complete treatment and are discharged from the facility  These providers explained that in these facilities, the infants are placed in nursery rooms, where health care providers can monitor them and administer and adjust their medication as needed  In addition, nursing staff or other caregivers are responsible for providing continuous non-pharmacologic treatment, and mothers are encouraged to visit and continue this care  For example, health care providers told us that in Washington, two to three infants may share a nursery room where trained caregivers provide them with non-pharmacologic treatment  In West Virginia, health care providers said infants are typically placed in individual nursery rooms where nurses provide them with non- pharmacologic treatment  The rooms in the West Virginia facility are also equipped with a rocking chair to encourage mothers to visit and provide this care as well  Health care providers told us that the facility currently offers one nursery room equipped with a bed to help prepare mothers on what to expect after discharge; they also said that they encourage mothers to spend the night prior to the infant’s discharge from the facility  (See text box below)  Treating infants with neonatal abstinence syndrome (NAS) in a neonatal withdrawal center One health care provider from a neonatal withdrawal center told us that the practice of rooming-in helps to facilitate the bond between the mother and infant  He also said that rooming-in allows health care providers to model care for the mothers and for mothers to learn how to care for their infants with NAS  Health care providers told us that the facility currently offers one nursery room equipped with a bed to help prepare mothers on what to expect after discharge and that they encourage mothers to spend the night prior to the infant’s discharge from the facility  One health care provider told us that one mother, after staying overnight with her infant, realized that she was not prepared to take care of her infant and consequently gave up custody of the infant  Because of rooming-in, health care providers were able to ensure that the infant was safe because the mother came to this realization at the facility, rather than alone at home  Although the lack of physical space at the facility currently makes it difficult to accommodate rooming-in for the entire course of the infant’s treatment, these providers noted the importance of this practice and that they are committed to parental involvement when treating infants with NAS at their facility  Figure 2 depicts nursery rooms in the neonatal withdrawal center in West Virginia  Efforts are also underway to open a neonatal withdrawal center in Arizona and Ohio, according to stakeholders we interviewed  Stakeholders we interviewed and the literature we reviewed suggest some limitations as well as benefits of treating infants with NAS in non- hospital settings, including factors to consider in these settings  Health care providers from one of the hospitals we visited in Vermont told us that their hospital is the only one in the state that allows infants with NAS to complete pharmacologic treatment through the Vermont outpatient clinic because they have established the necessary infrastructure to ensure families’ compliance and safe practices at home  These providers said that they worked with one local pharmacy to ensure proper dispensing of the medication  Additionally, these providers measured the amount of medication left over at each follow- up visit with the families  Some state and perinatal collaborative officials told us that neonatal withdrawal centers may not be the best environment to treat infants with NAS because these settings may limit a mother’s access to her infant, since she may not always be allowed to reside with the infant  Such limits, according to officials, do not facilitate bonding between mother and infant  Another state perinatal collaborative official, as well as health care providers and staff, told us that neonatal withdrawal centers may be better for treating infants with NAS because the environment is quieter and less stimulating than hospital settings, such as NICUs  Several studies we reviewed also emphasized that the inpatient-to- outpatient approach requires ongoing coordination, communication, and commitment from multidisciplinary providers, as well as the families  These studies highlighted instances in which these approaches reduced the length of the infants’ stay in a hospital, though the studies emphasized that more work needs to be done to determine whether these are the optimal approaches for infants with NAS, as well as the potential long-term benefits of such approaches  Medicaid pays for NAS treatment services provided in the non-hospital settings we identified in certain states, according to CMS officials and other stakeholders we spoke with, but generally pays for these services separately, in contrast with the single bundled payment paid to hospitals  State officials and health care providers in the non-hospital settings we examined described various ways in which Medicaid covered services they provided to treat infants with NAS  For example: Outpatient follow-up clinic in Vermont  State officials and staff at this facility told us that the Vermont Medicaid program pays for an infant’s outpatient physician visits using a fee-for-service payment schedule  They added that the Vermont Medicaid program also pays for the infant’s medication used in pharmacologic treatment and explained that the pharmacy that dispenses the medication bills Medicaid for these services  Neonatal withdrawal center in Washington  Health care providers at this facility told us that the Washington Medicaid program or their contracted managed care plans pay for physician visits using a fee- for-service payment schedule, noting that the facility decided to stop billing Medicaid for medical supplies because of the low reimbursement  Additionally, these providers suggested that because the facility does not meet the Medicaid standards required for receiving payment for hospital inpatient, nursing, or other covered facility services, the facility is ineligible to receive Medicaid payment for the costs of room and board  These providers said that they receive funding for the cost of these services through state appropriations, foster care payments, city contracts, grants, and private donations  Neonatal withdrawal center in West Virginia  State officials and health care providers at this facility told us that West Virginia pays for NAS services through two mechanisms, depending on whether the infant is in foster care  Specifically, if the infant is in foster care, the facility receives a bundled payment from the state Medicaid program and the Bureau of Children and Families  However, if the infant is not in foster care, the state Medicaid program pays for physician visits using a fee-for-service schedule  Additionally, the facility can receive payment under a per diem rate that is negotiated with state Medicaid managed care plans  The health care providers said that they also receive funding through grants and private donations to help cover the costs of NAS services  Stakeholders we interviewed and literature we reviewed suggest that the costs of treating infants with NAS in non-hospital settings were lower than treating them in hospital settings  However, supporting data and research of the costs in different settings are anecdotal or otherwise limited  For example: Health care providers from the neonatal withdrawal center in Washington told us that their facility could treat infants at a lower average cost per day than could hospitals—at about $700 per infant per day compared to an average cost of about $1,500-2,500 per infant per day in a hospital  These providers said that this cost savings is in part due to their limited staffing of nurses and their ability to leverage specially trained caregivers to provide infants with non-pharmacologic treatment and hands-on care, such as feeding and bathing  These providers also said they use volunteers to help with household duties, such as laundry and replenishing supplies  A health care provider from the neonatal withdrawal center in West Virginia conducted a study that found that the average daily charges per infant were about $400 in their facility, compared to about $2,600 in a special care nursery and $4,000 in a NICU  Two studies we reviewed found that inpatient-to-outpatient treatment approaches reduced hospital costs for NAS treatment; however, these studies were not generalizable and did not account for the duration of treatment across the two settings  Specifically, one study found that an inpatient-to-outpatient treatment approach reduced hospital length of stay by 55 percent—estimated to save hospitals $396 million annually—compared with treatment provided solely in a hospital  The second study found that infants who received care for NAS through an inpatient-to-outpatient treatment approach had an average length of stay of 13 days and cost about $14,000, while an inpatient- only approach had an average length of stay of 25 days and cost about $28,000  The 32 stakeholders we interviewed and the literature we reviewed identified several recommended practices for addressing NAS—that is, treating women with opioid use disorders during pregnancy or treating infants diagnosed with NAS after birth  The most frequently recommended practices were (1) prioritizing non-pharmacologic treatment, such as allowing the mother to reside with the infant during treatment, to facilitate the mother-infant bond; (2) educating mothers on prenatal care, treatment for NAS, and available resources for after an infant’s discharge; (3) educating health care providers on the stigma faced by women who use opioids during pregnancy and on how to screen for and treat NAS; and (4) using a protocol in a hospital or non-hospital setting for screening and treating infants with NAS  These recommended practices are described in more detail below  Volunteer programs to provide non- pharmacologic treatment for neonatal abstinence syndrome (NAS) Some stakeholders told us that some hospitals have established volunteer cuddler programs that train volunteers to help provide some of these non-pharmacologic treatments—-namely, swaddling, feeding, soothing, and coddling infants  However, health care providers at some facilities noted that volunteers are not necessarily available during late shifts  indicated that non-pharmacologic treatment may (1) facilitate the mother- infant bond, (2) reduce the severity of NAS symptoms, (3) reduce the need for pharmacologic treatment, and (4) reduce the length of an infant’s hospital stay  For example, two of the articles we reviewed noted that rooming-in has been shown to help decrease the need for pharmacologic treatment, the number of admissions to the NICU, and the length of an infant’s hospital stay  Additionally, 17 of the stakeholders we interviewed and nine articles we reviewed recommended that mothers be allowed to breastfeed while their infants are treated for NAS, as it helps to build a bond between the mother and infant  Most of these articles also noted that breastfeeding has been shown to reduce the severity of NAS  Educating mothers on prenatal care, treatment for NAS, and resources for after an infant’s hospital discharge  Most stakeholders we interviewed and several of the literature articles we reviewed recommended providing comprehensive, ongoing education to mothers on prenatal care and treatment for NAS and on the resources that are available after an infant’s discharge  (See text box below)  The stakeholders and literature indicated that this education may (1) facilitate a non-combative relationship between the mother and health care providers; (2) help to reassure and support the mother, who may feel responsible for the infant’s suffering, in addition to facilitating treatment of NAS; and (3) help the mother understand her infant’s behavior and develop greater confidence in her parenting skills  For example, one article noted that an infant’s withdrawal behavior, such as fisting, back arching, and jaw clenching, may be misinterpreted by the mother as dislike of touch, and that educating mothers on these behaviors can help alleviate feelings of guilt  Education for mothers on prenatal care, treatment for neonatal abstinence syndrome (NAS), and resources for after an infant’s hospital discharge Explaining to the mother during the prenatal period what she can expect when the infant is born to help ensure she understands the effects of and treatment for NAS; Informing the mother about non-pharmacologic treatment techniques that can help reduce the severity of the infant’s NAS symptoms; Modeling good parenting skills, such as demonstrating how to comfort an infant who may be crying inconsolably for hours because of withdrawal; and Informing the mother about contraception for preventing future pregnancies  Educating health care providers on the stigma faced by women who use opioids during pregnancy, and how to screen for and treat NAS  Most stakeholders we interviewed and several of the literature articles we reviewed recommended educating health care providers, including providers who are not addiction specialists, on both the stigma faced by women who use opioids during pregnancy as well as on how to screen for and treat infants with NAS  The stakeholders and literature indicated that this education may: (1) improve care so that mothers with opioid use disorders feel more comfortable seeking and obtaining prenatal care, (2) help health care providers know how to recognize NAS symptoms to help ensure infants receive appropriate treatment, and (3) allow for more consistency among these providers in NAS screening and treatment  For example, 26 stakeholders told us that educating health care providers about stigma is important because provider attitudes affect how and if pregnant women obtain prenatal care and treatment for their opioid use disorders, which can affect the severity of NAS  Additionally, several articles we reviewed noted the importance of educating and training clinicians on how to administer the screening tools used to identify infants with NAS, which helps ensure infants are identified and receive optimal care  Using a protocol for screening and treating infants with NAS  While there is no single national standard of care for screening and treating NAS, most stakeholders we interviewed and several of the literature articles we reviewed recommended that hospital and non-hospital settings use a protocol to screen for and treat infants with NAS  The stakeholders and literature indicated that having a protocol can help: (1) identify infants at risk for NAS, (2) ensure that care is provided consistently, and (3) reduce the length of stay for infants receiving pharmacologic treatment  For example, the stakeholders we interviewed explained that a standard protocol also helps health care providers understand the tools used to assess the severity of NAS; know the types of medication used in treatment, including amounts and duration; and learn how to wean the infant off these medications  Similarly, one article we reviewed noted that infants who were treated at facilities that adopted standard treatment protocols experienced shorter durations of pharmacologic treatment compared with infants who were treated at facilities that did not use a standard protocol  Stakeholders we interviewed and literature we reviewed identified several challenges health care providers face in their efforts to address NAS  The most frequently cited challenges included (1) the use of multiple substances by pregnant women, which can exacerbate NAS; (2) the stigma faced by women who use opioids during pregnancy, which may affect whether they seek prenatal care to address NAS, among other things; (3) hospital staff burden and limited physical capacity to care for infants with NAS; (4) limited coordination of care for mothers and infants with NAS; and (5) gaps in research and data on NAS  These challenges are described in more detail below  The use of multiple substances by pregnant women, which can exacerbate NAS  Most stakeholders we interviewed and some of the literature we reviewed noted that the use of multiple substances by pregnant women, including opioids—referred to as maternal polysubstance use—can be a challenge, and some stated that the use of these substances can exacerbate NAS symptoms  According to the stakeholders, the substances can include methamphetamines, nicotine, alcohol, cocaine, marijuana, benzodiazepines, and Gabapentin  The stakeholders and literature indicated that maternal polysubstance use can lead to multiple conditions in the infant—such as prematurity or Hepatitis C—that can exacerbate NAS symptoms and prolong the length of an infant’s hospital stay  For example, one expert noted that many women with opioid use disorders are also heavy cigarette smokers, and the nicotine typically exacerbates NAS withdrawal symptoms  Additionally, officials from a hospital and non-hospital setting we visited told us that they had developed a separate protocol for treating infants exposed to multiple substances that includes the use of several medications to address the more severe NAS withdrawal symptoms  Stigma faced by women who use opioids which may affect whether they seek prenatal care to mitigate the severity of NAS, among other things  Most stakeholders we interviewed and several of the literature articles we reviewed noted that the stigma faced by pregnant women with opioid use disorders is a challenge in addressing NAS  The stakeholders and literature indicated that stigma may: (1) prevent pregnant women from seeking substance use treatment or prenatal care; (2) prevent them from disclosing their drug use to health care providers during pregnancy; or (3) cause the women to fear punitive effects, such as losing custody of their children, being detained, or losing their jobs  For example, officials from one perinatal quality collaborative told us that these women may fail to seek care because of stigma, which can ultimately make it more difficult for health care providers to build relationships with these women and identify infants at risk for NAS  Hospital staff burden and limited physical capacity to care for infants with NAS  According to most stakeholders we interviewed and some literature we reviewed, staff burden and a limited physical capacity at facilities can pose challenges for addressing NAS  The stakeholders and literature indicated that there is increased burden on staff to care for these infants because they require frequent, personal attention  For example, the stakeholders explained that a hospital may have to increase the number of nurses on duty in order to provide the care the infants need  Health care providers at one hospital said that nurses still struggle to care for infants with NAS, even with additional staff, because these infants are overstimulated, cry, and do not eat or sleep well  As a result, they require much time and one-on-one attention—including cuddling— from nurses  With respect to physical capacity, some stakeholders told us that limited physical capacity can make it difficult to (1) find space in the facility where the infants can be protected from high levels of stimulation and (2) facilitate the mother-infant bond  For example, some stakeholders told us that hospitals may not have a dedicated space for rooming-in, making it more difficult to facilitate bonding between mothers and infants  Limited coordination of care for mothers and infants with NAS  Most stakeholders we interviewed explained that the lack of coordination among health care providers and others for the mother and infant with NAS during the prenatal period, after the infant is born, and following the infant’s discharge can be a challenge  This coordination includes organizing patient care activities and sharing information among health care providers, social workers, and all other participants concerned with the mother and infant’s care  The stakeholders indicated that this lack of coordination can make it difficult for families to get the resources or support they need  (See text box below)  For example, some stakeholders told us that women may miss health care visits because of a lack of access to enabling services such as transportation or child care  Limited coordination of care for mothers and infants with neonatal abstinence syndrome (NAS) One expert told us that there is a disproportionate number of infants with NAS born in rural areas  Infants in these areas may be discharged from the hospital without many follow-up services, such as transportation and care coordination  Gaps in research and data on NAS  Some stakeholders we interviewed noted that gaps in research and data on NAS make it challenging to conduct research on the affected population and fully understand the magnitude of the problem  The stakeholders indicated that there are gaps in adequate research and data on (1) the different types of treatment approaches for NAS; (2) the extent and effects of maternal polysubstance use among pregnant women; (3) the long-term effects of prenatal drug exposure, including the effects seen in childhood and adolescence; and (4) the efforts to ensure more consistent provider diagnosis and screening, such as through an improved screening tool  For example, the stakeholders told us that gaps in research and data may contribute to a lack of a national standard of care for screening and treating infants with NAS  According to some stakeholders, this may result in missed opportunities for identifying and treating infants with NAS  Some stakeholders also told us that because of gaps in research on the long- term effects of prenatal drug exposure, there is limited information on the types of services that infants with NAS may need in early childhood  Additionally, some stakeholders noted they found that because NAS was not consistently diagnosed and coded in medical records using diagnosis codes, the condition may be under-reported, and researchers may be limited in their ability to track these infants  In May 2017, HHS published the Protecting Our Infants Act: Report to Congress, which—among other things—presents a strategy that identifies key recommendations related to addressing NAS  Specifically, HHS’s strategy—known as the Protecting Our Infants Act: Final Strategy—made 39 recommendations related to the prevention, treatment, and related services for NAS and prenatal opioid use  Of the 39 recommendations HHS made in its report, we found that 28 of them directly relate to the recommended practices or challenges that we describe above  For example, the Strategy recommends the following: promoting non-pharmacologic treatment, such as rooming-in; providing continuing medical education to health care providers for managing and treating infants with NAS, such as on NAS treatment protocols; conducting research on the long-term effects of prenatal drug exposure so that appropriate services can be developed for infants with NAS; and establishing clear definitions of NAS and standardizing the use of diagnosis codes to collect more meaningful and actionable data on NAS  According to the Strategy, the recommendations will be used to inform planning and policy across HHS  However, HHS does not include any information in the Strategy on how the department and other stakeholders will implement the recommendations  Specifically, HHS does not include in its Strategy the following: the explicit priorities among the numerous recommendations and associated efforts the department has initiated related to NAS; timeframes for partial or full implementation of these recommendations; clear roles and responsibilities for the recommendations, such as the extent to which HHS will need to rely on the medical community and federal and public stakeholders for implementation; and the methods that will be used to assess the department’s progress in implementing any of these recommendations  HHS officials told us that they expect to develop a separate plan to guide implementation of the recommendations and that efforts to develop this plan were likely to begin in July 2017  However, as of September 2017, HHS could not provide any documentation that it had started to develop this implementation plan or establish a timeline for completing the plan; nor was HHS able to provide any information on what the plan may include  Having such a plan in place is important to ensure priorities are known and responsibilities are clear so that agencies and stakeholders can take appropriate action  Federal internal control standards call for agencies to have defined objectives clearly as part of their objective- setting process and to assign roles and responsibilities for achieving these objectives  Objectives defined in specific and measurable terms allow for the assessment of performance toward achieving objectives  Furthermore, leading principles on sound planning we have identified in our prior work call for developing robust plans to achieve agency goals  Until HHS finalizes an implementation plan that includes specific priorities, timeframes, responsibilities, and methods for evaluating progress, it is at risk of not being able to provide reasonable assurance that it can successfully implement these recommendations in a timely manner and assess the effectiveness of its efforts  The rising opioid crisis has caused a significant increase in the number of infants born and diagnosed with NAS, a condition that affects infants and their families, hospitals, and other health care providers who are treating them  The increase in infants born with NAS also increases medical and other treatment costs experienced by the federal government and states  HHS recently published a strategy with key recommendations that have the potential to address some of the challenges related to treating NAS  However, HHS lacks a sound plan for implementing these recommendations  The absence of such planning raises questions about whether and when HHS will be able to implement these recommendations in a timely manner and be able to assess its progress  The Secretary of HHS should expeditiously develop a plan—that includes priorities, timeframes, clear roles and responsibilities, and methods for assessing progress—to effectively implement the NAS-related recommendations identified in the Protecting Our Infants Act: Final Strategy  (Recommendation 1) We provided a draft of this report to HHS for review, and HHS provided written comments, which are reprinted in appendix III  HHS also provided technical comments, which we incorporated as appropriate  In its written comments, HHS concurred with our recommendation to expeditiously take steps to address NAS and re-stated that its Strategy will be used to inform planning and policy across HHS  Specifically, HHS said that as part of its broader initiative to address the opioid crisis, the department will develop and implement a plan—that will include priorities, timeframes, roles and responsibilities, and methods for assessing progress—to address as appropriate and possible, the NAS-related recommendations in its Strategy  HHS also stated that full implementation would be contingent on funding, though it provided no information on how much funding was needed or how the funding would be used  Developing a plan to guide implementation can help the department determine what resources, if any, are needed to implement the recommendations in its Strategy  We are sending copies of this report to the appropriate congressional addressees, the Secretary of Health and Human Services, and other interested parties  In addition, the report will be available at no charge on GAO’s website at http://www gao gov  If you or your staff have any questions about this report, please contact me at (202) 512-7114 or at iritanik@gao gov  Contact points for our Office of Congressional Relations and Office of Public Affairs can be found on the last page of this report  GAO staff who made major contributions to this report are listed in appendix IV  To address our first three audit objectives to describe care settings for treating infants with neonatal abstinence syndrome (NAS), Medicaid payment for NAS treatment, and the recommended practices and challenges for addressing NAS, we selected 32 stakeholders based on their relevant experience to cover a range of perspectives on NAS  Specifically, these stakeholders included those from site visits we conducted to four states—Kentucky, Vermont, West Virginia, and Wisconsin  We selected these states because they met the following criteria: 1  the state had one of the top 10 highest incidence rates of NAS, according to data from the Centers for Disease Control and Prevention (CDC) for 2013, the most recent year of publicly available data; 2  the state provided variation in United States geographic regions with high rates of NAS, as of 2012; 3  more than 40 percent of births in the state were financed by Medicaid, according to a 2016 Kaiser Family Foundation Medicaid Budget Survey; and 4  the state has a perinatal quality collaborative—a state or multi-state network of teams working to improve health outcomes for mothers and infants—with work related to NAS, which we identified through the American College of Obstetricians and Gynecologists  As part of these site visits, we interviewed (1) officials from each of the four states, including Medicaid officials, Maternal and Child Health Directors, and Women’s Services Coordinators; (2) representatives from the four state perinatal collaboratives; (3) health care providers (including physicians or nurses) from eight hospitals of varying levels of care (two hospitals in each state), which were selected based on recommendations from the state perinatal collaboratives because of the hospitals’ experience treating NAS; and (4) officials from a residential treatment facility in each of the four states that provide prenatal and postpartum care to mothers, which were also selected based on recommendations from the state perinatal collaboratives regarding the facilities’ experience with pregnant women with opioid use disorders and their infants with NAS  In addition to our site visits, we selected 12 additional stakeholders that included health care providers or administrators in non-hospital settings across the United States; officials from medical specialty societies; and experts  Specifically, we spoke with (1) health care providers (including physicians or nurses) or administrators from four non-hospital settings in Arizona, Ohio, Washington, and West Virginia, which were selected based on recommendations from stakeholders we interviewed and on the availability of such settings and their experience treating NAS; (2) health care providers from five medical specialty societies, including the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Society of Addiction Medicine, MedNAX (a network of physicians that specialize in neonatal care, including NAS treatment), and the National Association of Neonatal Nurses; and (3) three experts, including the authors of published literature we reviewed  We interviewed each of these 32 stakeholders and requested information from stakeholders about treating infants with NAS, including the utilization of available hospital and non-hospital care settings and associated costs of treatment services  For example, we requested protocols for screening and treating infants with NAS from hospital and non-hospital care settings  We reviewed available protocols provided by hospitals and a non-hospital care setting  We also reviewed available information reported by state officials, hospital and non-hospital providers, and state perinatal collaboratives on the utilization of hospital and non-hospital care settings, the facilities’ cost of treating NAS in hospital and non-hospital settings, the lengths of stay for treating infants with NAS, or the amount of Medicaid payments for treating infants with NAS  We discussed the information provided by stakeholders and examined the information for obvious errors  The information obtained from these stakeholders is not generalizable to other states or other hospital and non-hospital settings  In addition, in some cases, stakeholders used different methods to collect the information they reported, including information on Medicaid payments; as a result, the information reported by stakeholders is not directly comparable  Additionally, we interviewed officials from HHS, including those from the Centers for Medicare & Medicaid Services (CMS) and HHS’s Behavioral Health Coordinating Council—which includes officials from the Substance Abuse and Mental Health Services Administration (SAMHSA), the Indian Health Service, the Centers for Disease Control and Prevention (CDC), and the Food and Drug Administration, among others—concerning NAS treatment services, settings of care, Medicaid payment, and recommended practices and challenges related to addressing NAS  We also conducted a comprehensive literature review to identify relevant studies on NAS published in peer-reviewed journals from January 2013 to December 2016  We searched more than 40 databases for research published in relevant peer-reviewed journals, including BIOSIS Previews®, Embase®, Gale Group Health Periodicals Database, MEDLINE®, and New England Journal of Medicine  Key search terms included “neonatal abstinence syndrome,” “neonatal opioid withdrawal syndrome,” and “newborn infants ” After excluding duplicates, we identified and reviewed 325 abstracts  For those abstracts we found relevant, we obtained and reviewed the full study and selected 40 that were relevant to (1) hospital and non-hospital settings and related treatment services for infants with NAS; (2) the costs associated with treating infants with NAS, including Medicaid payments for services in these care settings; or (3) recommended practices and challenges for addressing NAS  We examined the methodologies for each of these studies and interviewed some of their authors  We determined that the studies were sufficiently reliable for our audit objectives  For a complete list of the studies we reviewed, see below  To examine our last audit objective on HHS’s strategy related to addressing NAS, we interviewed agency officials and reviewed agency documents on the agency’s efforts to develop a strategy  Specifically, we interviewed relevant officials from CMS and HHS’s Behavioral Health Coordinating Council concerning their efforts to develop a strategy related to addressing NAS  In reviewing relevant HHS documents, we focused on HHS’s Protecting Our Infants Act Report to Congress, which includes a strategy to address identified gaps, challenges, and recommendations related to NAS and prenatal opioid use  In addition, we reviewed the relevant standards for internal control in the federal government and the relevant criteria from GAO’s body of work on effectively managing performance under the Government Performance and Results Act (GPRA) of 1993 and the GPRA Modernization Act of 2010  Allocco, E , M  Melker, F  Rojas-Miguez, C  Bradley, K  A  Hahn, and E  M  Wachman  “Comparison of Neonatal Abstinence Syndrome Manifestations in Preterm Versus Term Opioid-Exposed Infants ” Advances in Neonatal Care, vol  16, no 5 (2016)  Artigas, V  “Management of Neonatal Abstinence Syndrome in the Newborn Nursery ” Nursing for Women’s Health, vol  18, issue 6 (Dec  2014/Jan  2015)  Asti, L , J  S  Magers, E  Keels, J  Wispe, and R  E  McLead  “A Quality Improvement Project to Reduce Length of Stay for Neonatal Abstinence Syndrome ” Pediatrics, vol  135, no  6 (2015)  Busch, D  W  “Clinical management of the Breast-Feeding Mother-Infant Dyad in Recovery from Opioid Dependence ” Journal of Addictions Nursery, vol  27, no  2 (2016)  Casper, T  and M  Arbour  “Evidence-Based Nurse-Driven Interventions for the Care of Newborns with Neonatal Abstinence Syndrome ” Advances in Neonatal Care, vol  14, no  6 (2014)  Chau, K  T , J  Nguyen, B  Miladinovic, C  M  Lilly, T  L  Ashmeade, and M  Balakrishnan  “Outpatient Management of Neonatal Abstinence Syndrome: A Quality Improvement Project ” The Joint Commission Journal on Quality and Patient Safety, vol  42, no  11 (2016)  Cirillo, C  and K  Francis  “Does Breast Milk Affect Neonatal Abstinence Syndrome Severity, the Need for Pharmacologic Therapy, and Length of Stay for Infants of Mothers on Opioid Maintenance Therapy During Pregnancy?” Advances in Neonatal Care, vol  16, no 5 (2016)  Clark, L  and A  Rohan  “Identifying and Assessing the Substance- Exposed Infant ” MCN in Advance (2015)  Demirci, J  R , D  L  Bogen, and Y  Klionsky  “Breastfeeding and Methadone Therapy: The Maternal Experience ” Substance Abuse, vol  36, no  2 (2015)  Edwards, L  and L  F  Brown  “Nonpharmacologic Management of Neonatal Abstinence Syndrome: An Integrative Review ” Neonatal Network, vol  35, no  5 (2016)  Gregory, K  E  “Caring for the Infant with neonatal Abstinence Syndrome in a Community-Based Setting ” The Journal of Perinatal & Neonatal Nursing, (2014)  Grim, K , T  E  Harrison, and R  T  Wilder  “Management of Neonatal Abstinence Syndrome from Opioids ” Clinics in Perinatology, (2013)  Hahn, J , A  Lengerich, R  Byrd, R  Stoltz, J  Hench, S  Byrd, and C  Ford  “Neonatal Abstinence Syndrome: The Experience of Infant Massage ” Creative Nursing, vol  22, issue 1 (2016)  Hall, E  S , S  L  Wexelblatt, M  Crowley, J  L  Grow, L  R  Jasin, M  A  Klebanoff, R  E  McClead, J  Meinzen-Derr, V  K  Mohan, H  Stein, and M  C  Walsh  “A Multicenter Cohort Study of Treatments and Hospital Outcomes in Neonatal Abstinence Syndrome ” Pediatrics, vol  134, no  2 (2014)  Hall, E  S , S  L  Wexelblatt, M  Crowley, J  L  Grow, L  R  Jasin, M  A  Klebanoff, R  E  McClead, J  Meinzen-Derr, V  k  Mohan, H  Stein, and M  C  Walsh  “Implementation of a Neonatal Abstinence Syndrome Weaning Protocol: A Multicenter Cohort Study ” Pediatrics, vol  136, no  4 (2015)  Holmes, A  V , E  C  Atwood, B  Whalen, J  Beliveau, J  D  Jarvis, J  C  Matulis, and S  L  Ralston  “Rooming-In to Treat Neonatal Abstinence Syndrome: Improved Family-Centered Care at Lower Cost ” Pediatrics, vol  137, no  6 (2016)  Jones, H  E , K  Deppen, M  L  Hudak, L  Leffert, C  McClelland, L  Sahin, J  Starer, M  Terplan, J  M  Throrp Jr , J  Walsh, and A  A  Creanga  “Clinical Care for Opioid-Using Pregnant and Postpartum Women: The Role of Obstetric Providers ” American Journal of Obstetrics & Gynecology, vol  210, issue 4 (2014)  Jones, H E , C  Seashore, E  Johnson, E  Horton, K E  O’Grady, K  Andringa, M  R  Grossman, B  Whalen, and A V  Holmes  “Brief Report: Psychometric Assessment of the Neonatal Abstinence Scoring System and the MOTHER NAS Scale ” American Journal on Addictions, (2016)  Kraft, W K , M  W  Stover, and J  M  Davis  “Neonatal Abstinence Syndrome: Pharmacologic Strategies for the Mother and Infant ” Seminars in Perinatology, vol  40, issue 3 (2016)  Krans, E  E , G  Cochran, and D  L  Bogen  “Caring for Opioid Dependent Pregnant Women: Prenatal and Postpartum Care Considerations ” Clinical Obstetrics and Gynecology, vol  58, no  2 (2015)  Lee, J , S  Hulman, M  Musci Jr , and E  Stang  “Neonatal Abstinence Syndrome: Influence of a Combined Inpatient/Outpatient Methadone Treatment Regimen on the Average Length of Stay of a Medicaid NICU Population ” Population Health Management, vol  18, no 5 (2015)  MacMullen, N  J , L  A  Dulski, and P  Blobaum  “Evidence-Based Interventions for Neonatal Abstinence Syndrome ” Pediatric Nursing, vol  40, no  4 (2014)  Maguire, D  J , “Mothers on Methadone: Care in the NICU ” Neonatal Network, vol  32, no  6 (2013)  Marcellus, L  “Supporting Women with Substance Use Issues: Trauma- Informed Care as a Foundation for Practice in the NICU ” Neonatal Network, vol  33, no 6 (2014)  McKeever, A  E , S  Spaeth-Brayton, and S  Sheerin  “The Role of Nurses in Comprehensive Care Management of Pregnant Women with Drug Addiction ” Nursing for Women’s Health, vol  18, no 4 (2014)  Meyer, M  and J  Phillips  “Caring for Pregnant Opioid Abusers in Vermont: A Potential Model for Non-Urban Areas ” Preventive Medicine, vol  80 (2015)  Newnam, K  M  “The Right Tool at the Right Time: Examining the Evidence Surrounding Measurement of Neonatal Abstinence Syndrome ” Advances in Neonatal Care, vol  14, no 3 (2014)  Orlando, S  “An Overview of Clinical Tools Used to Assess Neonatal Abstinence Syndrome ” Journal of Perinatal and Neonatal Nursing, vol  28, no 3 (2014)  Patrick, S W , M M  Davis, C U  Lehman, and W O  Cooper  “Increasing Incidence and Geographic Distribution of Neonatal Abstinence Syndrome: United States 2009 to 2012 ” Journal of Perinatology, vol  35 (2015)  Patrick, S W , H C  Kaplan, M  Passarella, M M  Davis, and S A  Lorch  “Variation in Treatment of Neonatal Abstinence Syndrome in U S  Children’s Hospitals, 2004-2011 ” Journal of Perinatology, vol  34, no  11 (2014)  Patrick, S W , J  Dudley, P R  Martin, F E  Harrell, M D  Warren, K E  Hartmann, E W  Ely, C G  Grijalva, and W O  Cooper  “Prescription Opioid Epidemic and Infant Outcomes ” Pediatrics, vol  135, no 5 (2015)  Patrick, S W , R  E  Schumacher, J  D  Horbar, M  E  Buus-Frank, E  M  Edwards, K  A  Morrow, K  R  Ferrelli, A  P  Picarillo, M  Gupta, and R  F  Soll  “Improving Care for Neonatal Abstinence Syndrome ” Pediatrics, vol  137, no  5 (2016)  Reece-Stremtan, S , and K  A  Marinelli  “ABM Clinical Protocol #21: Guidelines for Breastfeeding and the Drug-Dependent Woman, Revised 2015 ” Breastfeeding Medicine, vol  10, no 3 (2015)  Shaw, M  R , C  Lederhos, M  Haberman, D  Howell, S  Fleming, and J  Roll  “Nurses Perceptions of Caring for Childbearing Women Who Misuse Opioids ” The American Journal of Maternal-Child Nursing, vol  41, no  1 (2016)  Sublett, J  “Neonatal Abstinence Syndrome: Therapeutic Interventions ” The American Journal of Maternal-Child Nursing, vol  38, no  2 (2013)  Sutter, M  B , L  Leeman, and A  Hsi  “Neonatal Opioid Withdrawal Syndrome ” Obstetrics and Gynecology Clinics of North America, vol  41, issue 2 (2014)  Teague, A  H , A  J  Jnah, and D  Newberry  “Intraprofessional Excellence in Nursing: Collaborative Strategies for Neonatal Abstinence Syndrome ” Neonatal Network, vol  34, no 6 (2015)  Terplan, M , A  Kennedy-Hendricks, and M  S  Chisolm  “Prenatal Substance Use: Exploring Assumptions of Maternal Unfitness ” Substance Abuse: Research and Treatment (2015)  Tolia, V  N , S  W  Patrick, M  M  Bennett, K  Murthy, J  Sousa, P  B  Smith, R  H  Clark, and A  R  Spitzer  “Increasing Incidence of the Neonatal Abstinence Syndrome in U S  Neonatal ICUs ” The New England Journal of Medicine, vol  372, no  22 (2015)  Wiles, J  R , B  Isemann, L  P  Ward, A  A  Vinks, and H  Akinbi  “Current Management of Neonatal Abstinence Syndrome Secondary to Intrauterine Opioid Exposure ” Journal of Pediatrics, vol  165, no  3 (2014)  The Department of Health and Human Services (HHS) has published several guidance and educational resources related to neonatal abstinence syndrome and prenatal opioid use  According to HHS, these documents serve as tools to help stakeholders, including state entities and health care providers, and policymakers  Examples of these resources are listed below  Centers for Disease Control and Prevention (CDC), Pregnancy and Opioid Medications Factsheet, accessed June 8, 2017, https://www cdc gov/drugoverdose/pdf/pregnancy_opioid_pain_factsheet- a pdf  CDC Public Health Grand Rounds, Primary Prevention and Public Strategies to Prevent Neonatal Abstinence Syndrome (Atlanta, GA: CDC, last updated August 18, 2016), accessed July 19, 2017, https://www cdc gov/cdcgrandrounds/archives/2016/August2016 htm  CDC, Treating for Two: Safer Medication Use in Pregnancy Initiative (Atlanta, GA: CDC, last updated May 5, 2016), accessed June 8, 2017, https://www cdc gov/pregnancy/meds/treatingfortwo  Department of Health and Human Services, Opioids: The Prescription Drug & Heroin Overdose Epidemic (Washington, D C , last reviewed March 24, 2016), accessed June 8, 2017, https://www hhs gov/opioids/index html  Department of Health and Human Services, National Center for Substance Abuse and Child Welfare, Resources & Topics on Neonatal Abstinence Syndrome, accessed June 8, 2017, https://www ncsacw samhsa gov/resources/opioid-use-disorders-and-me dication-assisted-treatment/neonatal-abstinence-syndrome aspx  Jean Y  Ko  et al , “CDC Grand Rounds: Public Health Strategies to Prevent Neonatal Abstinence Syndrome,” Morbidity and Mortality Weekly Report (Centers for Disease Control and Prevention, March 10, 2017), accessed June 8, 2017, https://www cdc gov/mmwr/volumes/66/wr/mm6609a2 htm  National Institute on Drug Abuse, Principles of Substance Abuse Prevention for Early Childhood: A Research Based Guide (last updated March 2016), accessed June 8, 2017, https://www drugabuse gov/publications/principles-substance-abuse-prev ention-early-childhood/principles-substance-abuse-prevention-early-child hood  National Institute on Drug Abuse, Substance Use in Women (last updated September 2016), accessed June 8, 2017, https://www drugabuse gov/publications/research-reports/substance-use-i n-women/summary  Reddy, Uma M  J  M  Davis, Z  Ren, and M  F  Greene, “Opioid Use in Pregnancy, Neonatal Abstinence Syndrome, and Childhood Outcomes: Executive Summary of a Joint Workshop ” Obstetrics and Gynecology, vol  130, issue 1 (July 2017)  Substance Abuse and Mental Health Services Administration, A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders  HHS Publications No  (SMA) 16-4978  Rockville, MD: Substance Abuse and Mental Health Services Administration, 2016  Substance Abuse and Mental Health Services Administration, “Advancing the Care of Pregnant and Parenting Women With Opioid Use Disorder and Their Infants: A Foundation for Clinical Guidance,” Rockville, MD: Substance Abuse and Mental Health Services Administration, 2016  Substance Abuse and Mental Health Services Administration, “Methadone Treatment for Pregnant Women ” HHS Publication No  (SMA) 14-4124 (Rockville, MD: Substance Abuse and Mental Health Services Administration, revised 2014)  In addition to the contact named above, Rashmi Agarwal, Assistant Director; Amy Leone, Analyst-in-Charge; Melissa Duong; Krister Friday; Jacquelyn Hamilton; Giao N  Nguyen; and Laurie Pachter made key contributions to this report  Drug Control Policy: Information on Status of Federal Efforts and Key Issues for Preventing Illicit Drug Use  GAO-17-766T  Washington, D C : July 26, 2017  Medicaid Expansion: Behavioral Health Treatment Use in Selected States in 2014  GAO-17-529  Washington, D C : July 21, 2017  VA Health Care: Actions Needed to Ensure Medical Facility Controlled Substance Inspection Programs Meet Agency Requirements  GAO-17-242  Washington, D C : February 15, 2017  Highlights of a Forum: Preventing Illicit Drug Use  GAO-17-146SP  Washington, D C : November 14, 2016  Opioid Addiction: Laws, Regulations, and Other Factors Can Affect Medication-Assisted Treatment Access  GAO-16-833  Washington, D C : September 27, 2016  Drug Enforcement Administration: Additional Actions Needed to Address Prior GAO Recommendations  GAO-16-737T  Washington, D C : June 22, 2016  Office of National Drug Control Policy: Progress toward Some National Drug Control Strategy Goals, but None Have Been Fully Achieved  GAO-16-660T  Washington, D C : May 17, 2016  Veterans Justice Outreach Program: VA Could Improve Management by Establishing Performance Measures and Fully Assessing Risks  GAO-16-393  Washington, D C : April 28, 2016  State Marijuana Legalization: DOJ Should Document Its Approach to Monitoring the Effects of Legalization  GAO-16-1  Washington, D C : December 30, 2015  Prescription Drugs: More DEA Information about Registrants’ Controlled Substances Roles Could Improve Their Understanding and Help Ensure Access  GAO-15-471  Washington, D C : June 25, 2015  Mental Health: Better Documentation Needed to Oversee Substance Abuse and Mental Health Services Administration Grantees  GAO-15-405  Washington, D C : May 12, 2015  Prenatal Drug Use and Newborn Health: Federal Efforts Need Better Planning and Coordination  GAO-15-203  Washington, D C : February 10, 2015  Medicare Program Integrity: CMS Pursues Many Practices to Address Prescription Drug Fraud, Waste, and Abuse  GAO-15-66  Washington, D C : October 24, 2014  Office of National Drug Control Policy: Office Could Better Identify Opportunities to Increase Program Coordination  GAO-13-333  Washington D C : March 26, 2013  Child Welfare: States Use Flexible Federal Funds, But Struggle to Meet Service Needs  GAO-13-170  Washington, D C : January 30, 2013 


Report 2:  Depending on how much of the costs are shifted, the additional costs could increase the challenge for retirees to ensure their accumulated resources last throughout retirement, or for postal employees to save for retirement  Further, as we have reported, rising health care costs can increase the overall amount individuals may need to save to ensure they have an adequate income once they retire  Change the federal contribution to a fixed subsidy: As some companies and state governments have done, postal retiree health benefits could be shifted to a structure with a fixed amount subsidizing the benefit  This amount could be adjusted over time; any adjustments might or might not keep up with costs  Depending on the initial size of the fixed subsidy and any adjustments over time, this approach could reduce the expenses of the RHB Fund and USPS’s required payments  RHB Fund expenses could be reduced over time if the fixed subsidy increases less than postal retiree health premiums  This approach would require changes to current law and regulations that prescribe the federal government’s financial contribution to FEHBP  For example, CBO recently identified one option to change FEHBP’s statutory structure from a premium-sharing structure that is required by law to fixed subsidies for health benefits  Under this option, the fixed subsidies would grow at the rate of inflation rather than at the average rate of growth for FEHBP premiums; CBO stated this change would be expected to slow the growth of federal contributions to FEHBP  A fixed subsidy for retiree health benefits could increase incentives for retirees to make less costly decisions with respect to health care  However, this approach could result in greater cost exposure for retirees, who may face difficult decisions regarding their health care, particularly if their financial resources are limited  As we have reported, individuals face the risk that rising and unpredictable health care or long-term care costs may lead them to draw down their retirement savings faster than expected  Establish a non-federal voluntary employees’ beneficiary association (VEBA) for postal retiree health benefits: As some companies have done to provide retiree health benefits separately from the employer, a VEBA outside the federal government could be established to manage postal retiree health benefits  This approach means that postal retiree health benefits would be provided through the VEBA instead of through the OPM-administered FEHBP  The non-federal VEBA would administer the postal retiree health benefits program, including determining the specific benefits that would be provided and the level of contributions from the VEBA members—who could include retirees and employees—and the investing of its assets  Such an approach would require determining the VEBA’s governance structure, funding sources, level of funding, type of investments, and associated market risks  One issue could be determining the source and level of initial funding for a new VEBA for postal retiree health benefits, such as whether initial funding would come from the RHB Fund, the Treasury, or both  Other issues could be what funds would be provided to the VEBA going forward, including the source(s) and level of funding, and what the benefit levels would be  If the entire RHB Fund were transferred into a VEBA, the current level of benefits would ultimately not be sustainable unless further funding is provided from one or more sources, such as from USPS, retirees, active employees, or the federal government  Thus, trade-offs would involve what level of benefits would be provided, who would bear the costs, and what might happen if VEBA assets decline or become depleted  Reduce the required level of prefunding: Proposed legislation includes an 80 percent funding target for postal retiree health benefits instead of the 100 percent target established by current law  This would reduce USPS’s required payments to the RHB Fund but could increase costs for future postal ratepayers and increase the risk that USPS may not be able to pay for these costs  As previously discussed in this report, state governments either do not prefund their retiree health benefits or generally have a low level of prefunding  We have expressed concern about a proposed 80 percent funding target for postal retiree health benefits that would have the effect of carrying a permanent unfunded liability equal to roughly 20 percent of USPS’s liability, which could be a significant amount  As we previously reported, an alternative could be to build in a schedule to achieve 100 percent funding in a later time period after the 80 percent level is achieved  Although USPS payments with an 80 percent funding target would reduce USPS’s required payments, fully funded benefits protect against an inability to make payments later, make promised benefits less vulnerable to cuts, and protect USPS’s long-term viability  Further, reducing the funding target is unlikely to have any effect as long as USPS continues to make no payments to the RHB Fund, as discussed earlier  We continue to believe that as long as USPS is required by law to pay its share of retiree health benefits premiums, it is important for USPS to prefund its retiree health benefit liability to the maximum extent that its finances permit  We recognize that multiple options exist to prefund benefits and amortize unfunded liability and that no prefunding approach will be viable unless USPS can make the payments and maintain liquidity  As we have reported, making affordable prefunding payments would protect the viability of USPS by not saddling it with bills later on, when employees are already retired and no longer helping it to generate revenue; making payments can also make the promised benefits more secure  We also have reported that deferring payments can pass costs from current to future postal ratepayers  To the extent prefunding is postponed by using a lower funding target, larger payments will be required later, when they likely would be supported by lower levels of profitable First-Class Mail volume  Outside investment: Proposed legislation would initially require 25 percent of the RHB Fund to be invested in index funds modeled after those used for federal Thrift Savings Plan investments  The objective of investing RHB Fund assets outside of U S  Treasury securities would be to seek a greater rate of return on these assets in an attempt to reduce unfunded liabilities and the amount of required prefunding payments  Such outside investment would require legislation because current law limits RHB Fund assets to U S  Treasury securities that are backed by the full faith and credit of the federal government  A higher rate of return on RHB Fund assets could reduce long-term funding needs  However, there are other considerations  For example, we have reported that if fund assets were invested in non-Treasury securities, the fund may experience losses in a market downturn and would thus have reduced assets available for health care  Assuming there would be no explicit federal guarantee of the value of the invested assets, we stated that USPS is not well positioned to deal with a potentially significant decline in their value, given its significant operating losses and continuing decline in mail volume  We also reported that the impact of any asset losses could be magnified because a market downturn that negatively affects asset value could be associated with a more general economic downturn that negatively affects USPS mail volume and revenues  About a half million postal retirees receive retiree health benefits  Postal retirees have provided a vital service to the nation, and resolving a key aspect of their future situation warrants congressional action  Failure to address the poor financial outlook of the RHB Fund could pose serious consequences for these retirees as well as USPS, postal customers, and other stakeholders, including the federal government  It is reasonable to believe that USPS will not be able to fill the financial gap once the RHB fund is depleted—a situation that could occur in as little as 12 years under the status quo  There is no certainty on what actions should be taken to address this problem  However, we have identified multiple approaches that could be used, individually or in combination, that Congress could consider to help address the financial shortfall in this area  All of these approaches have different potential effects, and it is up to Congress to consider the merits of the approaches and determine the most appropriate action to take  It would be preferable to take action when careful consideration is possible, rather than wait until lack of adequate funding could disrupt postal retiree health benefits  Congress should consider passing legislation to put postal retiree health benefits on a more sustainable financial footing  We provided a draft of this report to OPM and USPS for their review and comment  OPM provided technical comments, which we incorporated as appropriate  USPS provided a written response, which is reproduced in appendix II of this report  In its written response, USPS stated that it concurred with our matter for congressional consideration that congressional action is necessary to achieve a financially sustainable Postal Service Retiree Health Benefits Fund (RHB Fund)  However, USPS said our discussion of potential policy approaches for postal retiree health benefits would benefit from additional context and balance  USPS also put forth additional information for three of the potential policy approaches highlighted in our report  Our report presents a high-level overview of eight potential policy approaches  It was not designed to be a comprehensive catalog of possible options with an analysis of the various considerations relevant to each  With regard to the Medicare integration approach, USPS stated that increased Medicare participation by postal retirees is not limited to the “full Medicare integration option,” as represented in our report and identified variations of such an approach  USPS said readers would benefit from a fuller picture of Medicare integration practices, stating that among employers that continue to provide retiree health benefits, full Medicare integration is a uniform best practice  USPS cited a 2014 report that said Medicare integration is the most common arrangement for employer-provided retiree health benefits, adding that retiree health benefits for Medicare-eligible employees are assumed to be merely supplemental to Medicare as a matter of course  Our report discussed Medicare integration by state governments, but did not present recent data on the percentage of private companies that coordinate their retiree health benefits with Medicare because such data are not publicly available  Additionally, USPS said our report framed the issue of Medicare integration as “solely” a tradeoff between USPS and Medicare costs while there are other factors to consider, such as the relative benefits to USPS compared to the overall cost for the Medicare program  As we noted in our report, the eight potential policy approaches were not designed to be mutually exclusive, nor an exhaustive list of possible approaches  Additionally, we recognize there are various factors related to this approach, but that the primary one is whether to increase postal retirees’ use of Medicare which would lead to further increasing Medicare costs  Second, USPS said it believed our statements about approaches for changing the level of prefunding for retiree health benefits below the 100 percent level were misplaced, citing “universally accepted practices” for other entities to “pay-as-you-go” (i e , not prefund at all), or to prefund at much lower levels  We have reported on such funding levels in the past as well  However, a proposed 80 percent funding target for postal retiree health benefits would have the effect of carrying a permanent unfunded liability equal to roughly 20 percent of USPS’s liability, which could be a significant amount  As we previously reported, an alternative could be to build in a schedule to achieve 100 percent funding in a later time period after the 80 percent level is achieved  As our report also explained, although USPS payments with an 80 percent funding target would reduce USPS’s required payments, fully funded benefits protect against an inability to make payments later, make promised benefits less vulnerable to cuts, and protect USPS’s long-term viability  Finally, USPS said that our statements about potential risks associated with investment of assets outside the U S  Treasury seem disproportionate given USPS’s view that diversification of assets set aside for retiree health benefits is “universally accepted” as a best practice  We recognize that a higher rate of return on RHB Fund assets could reduce long-term funding needs for the RHB Fund  However, there are considerations specific to USPS  For example, assuming there would be no explicit federal guarantee of the value of the invested assets, we stated that USPS is not well positioned to deal with a potentially significant decline in their value, given its significant operating losses and continuing decline in mail volume  We also noted that, as we have previously reported, the impact of any asset losses could be magnified because a market downturn that negatively affects asset value could be associated with a more general economic downturn that also negatively affects USPS mail volume and revenues  In summary, we believe our report presents a balanced description of a wide range of possible policy options; it does not endorse or recommend any particular option for Congress  As we concluded, all of these approaches have different potential effects, and the information we present, as well as the additional views presented by USPS, provide critical information for congressional decision-makers to assess as they consider the merits of the approaches and determine the most appropriate action to take  As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date  At that time, we will send copies to the appropriate congressional committees; the Postmaster General; and the Director of the Office of Personnel Management  In addition, the report will be available at no charge on the GAO website at http://www gao gov  If you or your staff have any questions concerning this report, please contact me at (202) 512-2834 or rectanusl@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  End of year net funded status (unfunded) (55 0) Missed USPS payments to the fund (53 5) (52 0) (48 6) (46 2) (47 8) (48 3) (48 9) (54 8) (52 1) payments due on Sept  30, 2017, of $955 million for the amortization of USPS’s unfunded liability for postal retiree health benefits, and $3 3 billion for the “normal costs” of retiree health benefits  The “normal cost” is the annual expected growth in liability attributable to an additional year of employees’ service  In addition to the individual named above, Derrick Collins (Assistant Director); Kenneth John (Analyst-in-Charge); Amy Abramowitz; Taiyshawna Battle; William Colwell; Swati Deo; John Dicken; Leia Dickerson; William Hadley; James Leonard; Emei Li; Thanh Lu; Sara Ann Moessbauer; Joshua Parr; Malika Rice; Matthew Rosenberg; Amy Rosewarne; Frank Todisco; and Crystal Wesco made key contributions to this report 

ground_truth: As the opioid crisis has increased in recent years, so has the number of pregnant women who use opioids, which can result in NAS. A recent peer-reviewed study found that cases of NAS have grown nearly five-fold between 2000 and 2012 and that most infants with NAS are covered under Medicaid. The Comprehensive Addiction and Recovery Act of 2016 includes a provision for GAO to examine NAS in the United States and related treatment services covered under Medicaid. This report 1) describes the hospital and non-hospital settings for treating infants with NAS and how Medicaid pays for services, 2) describes recommended practices and challenges for addressing NAS, and 3) examines HHS's strategy for addressing NAS. GAO reviewed HHS documentation and interviewed HHS officials. GAO also conducted site visits to four states—Kentucky, Vermont, West Virginia, and Wisconsin—selected based on several factors, including incidence rates of NAS and geographic variation. GAO interviewed stakeholders from 32 organizations, including health care providers and state officials in the selected states. The prenatal use of opioids or other drugs can produce a withdrawal condition in newborns known as neonatal abstinence syndrome (NAS). Health care providers, state officials, and other stakeholders told GAO that most infants with NAS are treated in the hospital—such as in a neonatal intensive care unit—though some may be referred to a non-hospital setting—such as a neonatal withdrawal center with nursery rooms—to complete their treatment. The table below provides more information on settings for treating infants with NAS and on how Medicaid pays for services in these settings. According to stakeholders GAO interviewed and literature reviewed, there are several recommended practices and challenges associated with addressing NAS. The most frequently recommended practices included prioritizing non-pharmacologic treatment to infants—treatment that does not involve medications—such as allowing the mother to reside with the infant during treatment; educating mothers and health care providers on treatment of NAS, among other things; and using a protocol in the hospital or non-hospital setting for screening and treating infants with NAS. The most frequently cited challenges included the maternal use of multiple drugs—or polysubstance use—as it can exacerbate NAS symptoms; stigma faced by pregnant women who use opioids; hospital staff burden and limited physical capacity to care for infants with NAS; limited coordination of care for mothers and infants with NAS; and gaps in research and data on NAS, such as research on the long-term effects of the condition. In May 2017, the Department of Health and Human Services (HHS) published a strategy document that makes key recommendations to address NAS. The Strategy recommends, for example, that health care providers receive continuing education on managing and treating infants with NAS and promote non-pharmacologic treatment. According to HHS officials, these recommendations will inform planning and policy across the department. However, HHS has yet to determine how and when the recommendations will be implemented, including establishing priorities; the roles and responsibilities of other federal, state, and public stakeholders; implementation timeframes; and methods for assessing progress. HHS officials told GAO that they expect to develop an implementation plan sometime in 2017 but had no timeline for doing so. Without a plan that clearly specifies how HHS will implement the Strategy and assess its progress, the department increases the risk that its recommendations for addressing NAS will not be implemented. HHS should expeditiously develop a plan for implementing the recommendations included in its strategy related to addressing NAS. HHS concurred that it should expeditiously address NAS, but noted implementation of the strategy is contingent on funding.

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



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



Report 2: Our simulations suggest that the sector will likely continue to face a difference between revenue and spending during the next 50 years  This long-term outlook is measured by the operating balance—a measure of the sector’s ability to cover its current expenditures out of current receipts  While both expenditures and revenues are projected to increase as a percentage of gross domestic product (GDP) during the simulation period, a difference between the two is projected to persist because expenditures are generally expected to grow at a faster rate than revenues  (see figure 1)  Absent any policy changes by state and local governments, revenues are likely to be insufficient to maintain the sector’s capacity to provide services at levels consistent with current policies during the next 50 years  Our simulations suggest that state and local governments will need to make policy changes to avoid fiscal imbalances before then and assure that revenues are at least equal to expenditures  We simulated the state and local government sector’s operating balance (the difference between the sector’s operating revenues and operating expenditures) in order to understand the sector’s long-term fiscal outlook  The sector’s operating expenditures were 15 1 percent of GDP in 2017  As shown in figure 2, these state and local government sector operating expenditures are comprised of employee compensation, social benefit payments, interest payments, capital outlays, and other expenditures  The sector’s operating revenues were 13 8 percent of GDP in 2017  As shown in figure 3, these state and local government sector operating revenues are comprised of taxes, transfer receipts, and other types of revenues  One way of measuring the long-term fiscal challenges faced by the state and local government sector is through an indicator known as the “fiscal gap ” The fiscal gap is an estimate of actions—such as revenue increases or expenditure reductions—that must be taken today and maintained for each year going forward to achieve fiscal balance during the simulation period  While we measured the gap as the amount of reductions in expenditures needed to prevent negative operating balances, increases in revenues, reductions in expenditures, or a combination of the two of sufficient magnitude would allow the sector to close the fiscal gap  Our simulations suggest that the fiscal gap is about 14 7 percent of total expenditures or about 2 4 percent of GDP  That is, assuming no change in projected total revenues, eliminating the difference between the sector’s expenditures and revenues during the 50-year simulation period would likely require action to be taken today, and maintained for each year equivalent to a 14 7 percent reduction in the sector’s total expenditures (see figure 4)  Alternatively, assuming no change in projected total expenditures, closing the fiscal gap by increasing revenue would also likely require actions of similar magnitude  More likely, eliminating the difference between expenditures and revenues would involve some combination of spending reductions and revenue increases  Our simulations suggest that growth in the sector’s overall spending is largely driven by health care expenditures  As shown in figure 5, these expenditures are projected to increase from about 4 1 percent of GDP in 2018 to 6 3 percent of GDP in 2067  Two types of health care expenditures—Medicaid spending and spending on health benefits for state and local government employees and retirees—will likely constitute a growing expenditure for state and local governments during the simulation period  Medicaid expenditures are expected to rise, on average, by 1 percentage point more than GDP each year  According to CBO, growth in Medicaid spending reflects growth in both the number of people receiving Medicaid benefits and the cost of Medicaid benefits each person receives  Specifically, CBO reported that between 2019 and 2028, Medicaid spending is projected to grow at an average rate of 5 5 percent per year—nearly 5 percentage points of this growth is due to an increase in per capita costs and about 1 percentage point of this growth is due to an increase in enrollment  Data from CBO and the Centers for Medicare & Medicaid Services (CMS) also suggest that growth in Medicaid spending per capita is generally expected to outpace GDP growth in the future—referred to as excess cost growth  Our estimates of Medicaid excess cost growth using CMS data suggest that Medicaid spending per capita will grow, on average, about 0 5 percent faster than GDP per capita for the period from 2018 through 2067  Our simulations also suggest that health benefits for state and local government employees and retirees—a type of employee compensation spending—are likely to rise, on average, by 0 9 percentage points more than GDP each year  Growth in these health benefits also reflects growth in the projected number of employees and retirees and growth in the projected amount of health benefits for each employee and retiree  Growth in spending by states and local governments on health care per capita, which includes spending on employee and retiree health benefits, is generally expected to outpace GDP per capita  Data from CMS suggest that national health expenditures per capita are likely to grow on average about 0 8 percent faster than GDP per capita each year during the simulation period from 2018 through 2067  If employee and retiree health benefits follow trends in overall national health spending, they will likely make up an increasingly large share of total employee compensation going forward (see figure 6)  While state and local government contributions to employee pension plans—another type of employee compensation spending—will likely decline as a percentage of GDP, as shown in figure 6, our simulations nonetheless suggest that state and local governments may need to take steps to manage their pension obligations in the future  From 1998 through 2007, state and local governments’ pension contributions amounted to about 8 percent of wages and salaries on average  In addition, for the period from 2008 through 2017, pension contributions amounted to about 12 3 percent of wages and salaries on average  Our simulations suggest that those pension contributions will need to be about 12 9 percent of wages and salaries for state and local governments to meet their long-term pension obligations  This is the case even though pension asset values have increased in recent years, from about $2 4 trillion in 2008 to about $4 2 trillion in 2017 (adjusted for inflation and measured in 2012 dollars)  This suggests that state and local governments may need to take additional steps to manage their pension obligations by reducing benefits or increasing employees’ contributions  Along with pension contributions, other types of state and local government expenditures are projected to grow more slowly than GDP  For example, in 2017, wages and salaries of state and local government employees constituted a large expenditure for the sector  However, these expenditures are projected to decline as a percentage of GDP during the simulation period  Our simulations also suggest that state and local governments’ capital outlays—which include spending on infrastructure, such as buildings, highways and streets, sewer systems, and water systems, as well as equipment and land— will grow more slowly than GDP if state and local governments continue to provide current levels of capital per resident  Our simulations suggest that federal grants overall will increase as a share of GDP, while Medicaid grants will likely grow more quickly than other types of federal grants (see figure 7)  Thus, Medicaid grants will likely make up an increasing share of revenues in the future  Since Medicaid is a matching formula grant program, the projected increase in federal Medicaid grants, therefore, reflects expected increased Medicaid expenditures that will be shared by state governments  Our simulations also suggest that federal investment grants (i e , grants intended to finance capital infrastructure investments) and other federal grants unrelated to Medicaid (i e , grants intended to finance education, social services, housing, and community investment) are likely to decline as a share of GDP  Further, our simulations suggest that if historical relationships between state and local governments’ tax revenues and tax bases persist, total tax revenues for the state and local government sector will increase from 8 8 percent of GDP in 2018 to 9 4 percent of GDP by the end of the simulation period  This increase is driven largely by the growth in personal income taxes, as shown in figure 8  Specifically, our simulations suggest that personal income tax revenues will increase as a share of GDP by about 1 percentage point during the simulation period  Sales taxes and property taxes, on the other hand, are projected to remain relatively constant as a share of GDP during the simulation period through 2067  While our long-term simulations do not account for pending or future federal policy changes that will result in changes to expenditures and revenues, an understanding of several recent federal policy changes related to taxes and health care are important to note because they present sources of uncertainty for the state and local government sector’s long-term fiscal outlook  In addition, as is the case in any model that is reliant on historical data to simulate a long-term outlook, other considerations, such as economic growth and rates of return on pension assets, could shift future fiscal outcomes  These policy changes and uncertainties are discussed below and may help federal policy makers and state and local governments consider how these changes could affect the long-term outlook  Recently enacted legislation, such as Public Law 115-97, commonly referred to by the President and administrative documents as the Tax Cuts and Jobs Act (TCJA), could affect the sector’s revenues over the long-term  Enacted in December 2017, TCJA included significant changes to corporate and individual tax law, with implications for state and local government tax collections  In particular, for individual taxpayers, for tax years 2018 through 2025, tax rates were lowered for nearly all income levels, some deductions from taxable income were changed (personal exemptions were eliminated, while the standard deduction was increased), and certain credits, such as the child tax credit, were expanded  The effect of TCJA on the long-term state and local fiscal outlook is still evolving, and will likely depend on how states incorporate the law’s changes into their state income tax rules  That is, because some states link their state income taxes to federal income tax rules, states must decide whether to let the changes from TCJA flow through to their state income tax systems, or establish new state income tax rules  For example, some states have adopted the federal definition of taxable income as a starting point for state tax calculations, while other states use the federal definition of adjusted gross income as a starting point  The choices states make to continue to link to these definitions could have long-term implications for their state tax revenues  In addition, under TCJA, the amount of the federal itemized deductions allowed for all state and local income, sales, and property taxes (commonly referred to as the state and local tax (SALT) deduction) is now capped at $10,000 for tax years 2018 to 2025  The magnitude or net effect of these changes is uncertain in that states are still working to understand the impact of the tax laws on their revenues  It remains to be seen whether and how states will see changes in their revenues in the future  Moreover, a recent U S  Supreme Court decision involving state sales taxes could have implications for states’ ability to collect revenue  Specifically, the court’s ruling in June 2018 in South Dakota v  Wayfair, Inc  held that states could require out-of-state sellers to collect and remit sales taxes on purchases made from those out-of-state sellers, even if the seller does not have a substantial physical presence in the taxing state  Prior to this ruling, a seller that did not have a substantial physical presence in a state could not be required to collect and remit a sales tax on goods sold into the state  Instead, a purchaser may have been required to pay a use tax (i e , a tax levied on the consumer for the privilege of use, ownership, or possession of taxable goods and services) in the same amount to his or her state government  In 2017, we reported that states could realize between an estimated $8 5 billion and $13 4 billion in additional state sales tax revenue across all states if all sellers were required to collect taxes on all remote sales at current rates  The extent to which states realize changes in sales tax revenue will likely depend on how they revise their state laws and enforcement efforts in response to this June 2018 ruling  Enacted health care legislation could also affect the long-term fiscal position of state and local governments  As we have reported in prior work, the effect of the Patient Protection and Affordable Care Act (PPACA) on the long-term state and local fiscal outlook could depend on how states implement PPACA, and on future rates of health care cost growth  For example, consider the states that have opted, under PPACA, to expand Medicaid program coverage to millions of lower income adults  While the federal government is expected to cover a large share of the costs of the Medicaid expansion, these states are ultimately expected to bear some of the costs  Specifically, the federal government reimbursed 100 percent of the costs of the expanded population beginning in 2014  This reimbursement rate will decline from the 2018 reimbursement rate of 94 percent to 90 percent by 2020  As such, the reduced federal reimbursement rate may affect those states that expanded their Medicaid populations in recent years  As discussed earlier in this report, our simulations suggest that Medicaid spending will make up an increasing share of the state and local government sector’s operating expenditures in the future  A weakening of the economy could add to the fiscal pressures states face in funding these Medicaid obligations  As our prior work has shown, past recessions in 2001 and 2007 hampered states’ ability to fund increased Medicaid enrollment and maintain their existing services  Specifically, Medicaid enrollment increased during these recessions, in part due to increased unemployment, which led more individuals to become eligible for the program  We have also reported on the use of Medicaid demonstrations, which allow states to test new approaches to coverage to improve quality and access, or generate savings or efficiencies  Specifically, CMS may waive certain Medicaid requirements and approve new types of expenditures that would not otherwise be eligible for federal Medicaid matching funds  For example, under demonstrations, states have extended coverage to certain populations, provided services not otherwise eligible for Medicaid, and made payments to providers to incentivize delivery system improvements  We previously reported that, as of November 2016, nearly three-quarters of states have CMS- approved demonstrations  In fiscal year 2015, federal spending under demonstrations represented a third of all Medicaid spending nationwide  We also reported that in 10 states, federal spending on demonstrations represented 75 percent or more of all federal spending on Medicaid  Joint financing of Medicaid is a fixture of this federal-state partnership  Demonstration waivers hold the potential for changing state Medicaid spending  However, as we have reported, these demonstrations are required, under HHS policy, to achieve budget neutrality and not raise costs for the federal government  In addition to federal tax- and health-related policy changes, a number of other factors could affect the state and local government sector’s long- term fiscal outlook  Specifically, we developed simulations using alternative assumptions of the growth of key model variables—which include economic growth, health care excess cost growth, and the rate of return on pension assets  We determined that changes in the growth projections of these key variables could affect the operating balance of state and local governments, thereby shifting future fiscal outcomes for the sector  Future trends in GDP growth could affect the state and local government sector’s fiscal outlook  Data from CBO and the Board of Trustees of the Federal Old-Age and Survivors Insurance and Federal Disability Insurance Trust Funds (OASDI Trustees) project real GDP to grow by 1 9 percent per year on average from 2018 through 2028, and by 2 1 percent per year on average after 2028, respectively  Using these projections, our simulations suggest that maintaining current policies would cause the sector’s expenditures to exceed its revenues and that the difference between revenues and expenditures would become increasingly negative during the next several decades  However, simulations we developed using the OASDI Trustees’ alternative projections of real GDP growth suggest that the difference between revenues and expenditures would expand before narrowing toward the end of the simulation period if real GDP were to grow at a faster rate—2 8 percent per year on average—as shown in figure 9  Our simulations also show that if GDP were to grow at a slower rate—1 5 percent per year on average—the difference between revenues and expenditures would expand  This would result in an increasingly negative operating balance during the simulation period  As discussed earlier in this report, excess cost growth in health care is another key determinant of the sector’s fiscal balance  Data from CBO project Medicaid spending per capita to grow about 1 5 percent faster than GDP per capita on average for the period from 2019 through 2028  Data from CMS project Medicaid spending per capita to grow about 0 6 percent faster on average for the period from 2029 through 2067  Data from CMS also project national health expenditures per capita to grow about 0 8 percent faster than GDP per capita for the period from 2018 through 2067  Using these projections, our simulations suggest that maintaining current policies will cause the sector’s expenditures to exceed its revenues, and that the difference between revenues and expenditures will become increasingly negative during the next several decades  However, simulations developed using alternative projections of excess cost growth in Medicaid and national health expenditures suggest that the difference between revenues and expenditures may be reduced but not eliminated within the simulation period if excess cost growth in health care is zero  In the scenario where excess cost growth rises faster—0 7 percent on average for Medicaid for the period from 2029 through 2067 and 1 percent for national health expenditures for the period from 2018 through 2067—our simulations show that the difference between revenues and expenditures will persist for the remainder of the simulation period (see figure 10)  The rate of return on pension assets could also affect the state and local government sector’s fiscal outlook  Based on an inflation-adjusted rate of return on pension assets of 5 percent, our simulations suggest that state and local governments will need to make pension contributions equivalent to about 12 9 percent of their wages and salaries to meet their long-term pension obligations  However, this estimate is sensitive to the rate of return on state and local governments’ pension assets  Simulations we developed using a higher rate of return—7 5 percent—suggest that pension contributions needed to meet pension obligations would be about 3 percent of state and local government employees’ wages and salaries  In addition, under this scenario, our simulations suggest that the difference between revenues and expenditures will be reduced, but not eliminated within the simulation period  Alternatively, we estimated that if the rate of return on pension assets is relatively low—at 2 5 percent— required pension contributions would need to be about 23 percent of state and local government employees’ wages and salaries during the simulation period  Under this scenario, our simulations show that the sector’s negative operating balance will continue to grow larger throughout the simulation period  It follows therefore, that high rates of return on pension assets are associated with an improved outlook for state and local governments, and vice versa (see figure 11)  This report was prepared under the direction of Michelle A  Sager, Director, Strategic Issues, who can be reached at (202) 512-6806 or sagerm@gao gov, and Oliver M  Richard, Director, Center for Economics, who can be reached at (202) 512-8424 or richardo@gao gov if there are any questions  GAO staff who made key contributions to this report are listed in appendix IV  To simulate measures of fiscal balance for the state and local government sector for the long term, we used aggregate data on the state and local government sector and national data on other variables from the following sources: Agency for Healthcare Research and Quality; Board of Governors of the Federal Reserve System; Board of Trustees of the Federal Old-Age and Survivors Insurance and Federal Disability Insurance Trust Funds (OASDI Trustees); Bureau of Economic Analysis (BEA); Bureau of Labor Statistics; Centers for Medicare & Medicaid Services (CMS); Congressional Budget Office (CBO); and Federal Reserve Bank of St  Louis  Our approach generally follows the approach used in GAO-08-317 and in subsequent updates of that report  Specifically, we developed a model that projects the levels of receipts and expenditures of the state and local government sector (henceforth, the sector) in future years based on current and historical spending and revenue patterns  We use table 3 3 of the National Income and Product Accounts (NIPA)—State and Local Government Current Receipts and Expenditures—prepared by BEA at the U S  Department of Commerce as an organizing framework for developing our model of the sector’s revenues and expenditures (see table 1)  In this table, current revenues are grouped in five main categories  Current tax receipts  These receipts are tax payments made by persons or businesses to state and local governments  They include income taxes, general sales taxes, property taxes, and excise taxes  Current taxes also include fees for motor vehicle licenses, drivers’ licenses, and business licenses  Social insurance contributions  These contributions finance the provision of certain social benefits to qualified persons, and include contributions from employers and employees for temporary disability insurance, worker’s compensation insurance, and other programs  Income receipts from government assets  These receipts include interest, dividends, and rental income, such as royalties paid on drilling on the outer continental shelf  Also, state and local governments earn interest and dividend income on financial assets  Current transfer receipts  Transfer receipts are receipts for which state and local governments provide nothing of value in return  Current transfer receipts include federal grants, fines, fees, donations, and tobacco settlements  Also included are net insurance settlements, certain penalty taxes, court fees, and other miscellaneous transfers  Current surplus of government enterprises  This surplus is a profit- type measure for state and local government enterprises, such as water, sewer, gas, and electricity providers; toll providers; liquor stores; air and water terminals; public transit; and state lotteries  Some types of enterprises, such as state lotteries, consistently earn surpluses which are used to fund general government activities  In contrast, many enterprises run deficits, which, in turn, reduce receipts  State and local governments also receive income from the sale of goods and services, such as school tuition  In the NIPAs, this income is treated as an offset against expenditures, not revenue  This income comes from voluntary purchases that might have been made from a private sector provider of such services  In addition to current receipts, state and local governments receive capital transfer receipts  These receipts include estate and gift taxes, and federal government investment grants for capital such as highways, transit, air transportation, and water treatment plants  State and local government current expenditures are grouped into four main categories  Consumption expenditures  Generally, spending for which some value is provided in return  State and local government consumption spending is the sum of inputs used to provide goods and services, including compensation of general government employees, consumption of general government fixed capital (depreciation), and intermediate goods and services purchased, less sales to other sectors and own-account investment  Current transfer payments  Payments for which nothing of value is provided in return  For state and local governments, current transfer payments consist primarily of social benefits, which are payments to persons to provide for needs that arise from circumstances such as sickness, unemployment, retirement, and poverty  There are two kinds of social benefits—benefits from social insurance funds, such as temporary disability insurance and workers’ compensation, and other social benefits, such as medical benefits from Medicaid and the state Children’s Health Insurance Program (CHIP), family assistance from Temporary Assistance to Needy Families, education assistance, and other public assistance programs  While NIPA table 3 3 also includes other current transfer payments to the rest of the world as part of current transfer payments, these amounts are generally equal to zero  Interest payments  These include actual and imputed interest and represent the cost of borrowing by state and local governments to finance their capital and operational costs  Subsidies  State and local government subsidies are largely payments to railroads  State and local government spending also includes gross investment, capital transfer payments, and net purchases of nonproduced assets  Gross investment is spending on capital goods like structures, equipment, and intellectual property—items that are called fixed assets or capital because of their repeated or continuous use in providing government services for more than 1 year  Structures include residential and commercial buildings, highways and streets, sewer systems, and water systems  State and local government capital transfer payments include disaster-related insurance benefits paid to the U S  territories and the Commonwealths of Puerto Rico and Northern Mariana Islands  Net purchases of nonproduced assets are composed of net purchases of land less oil bonuses (payments to states for the long-term rights to extract oil)  Our main indicator of the sector’s fiscal balance is its operating balance net of funds for capital expenditures (henceforth, operating balance), which is a measure of the sector’s ability to cover its current expenditures out of current revenues  The operating balance is defined as total receipts minus (1) capital outlays not financed by medium- and long-term debt issuance, (2) total current expenditures less depreciation, (3) current surplus of state and local government enterprises, and (4) net social insurance fund balance  Alternative indicators of fiscal balance include net saving and net lending or borrowing  Net saving is the difference between current receipts and current expenditures  Since current expenditures exclude capital investment but include a depreciation measure, net saving can be thought of as a measure of the extent to which governments are covering their current operations from current receipts  Net lending or borrowing is the difference between total receipts and total expenditures, and is analogous to the federal unified surplus or deficit  Total receipts differ from current receipts because they include capital transfer receipts  Total expenditures differ from current expenditures because they include capital investment, capital transfer payments, and net purchases of nonproduced assets  However, they exclude fixed capital consumption  The former three categories are cash expenditures, while the latter is a noncash charge  Net lending or net borrowing represents the governments’ cash surplus or borrowing requirement  This measure is normally negative because governments borrow to finance their capital investment (and sometimes to finance current operations as well)  The following equations describe how we simulated state and local government receipts and expenditures, as well as the intermediate variables used in those simulations  For this update, we started with historical data for 2017, or the most recent year available, and then simulated each variable for each year from 2018 through 2092 (the simulation period)  To simulate state and local government receipts and expenditures, we use simulations of various national-level demographic, macroeconomic, and health care variables derived from projections produced by CBO, CMS, and the OASDI Trustees, and otherwise derived using our own assumptions (see table 2)  This approach is similar to the approach we have used in prior model updates  To simulate state and local government spending on defined benefit pensions, we first estimate the contribution rate (as a fraction of state and local government general government wages and salaries) that state and local governments would need to make each year going forward to ensure that their pension systems are fully funded on an ongoing basis  Our goal is to estimate the financial commitments to employees that have been and are likely to continue to be made by the state and local sector to better understand the full fiscal outlook for the sector  As such, our analysis projects the liabilities that the sector is likely to continue to incur in the future based on simulations of future numbers of retirees receiving pension benefits and their benefit amounts; future numbers of employees, their wages and salaries, and their pension contributions; and assets in state and local government defined benefit pension funds  Although we are only interested in applying contribution rates over the simulation time frame, we actually have to derive the contribution rate for a longer time frame in order to find the steady-state level of necessary contributions  This longer time frame is required because the estimated contribution rate increases as the projection horizon increases and eventually converges to a steady state  If the projection period is of insufficient length, the steady-state level of contribution is not attained, and the necessary contribution rate is understated  We simulated variables used to estimate the pension contribution rate using the approach summarized in table 3  This approach is similar to the approach we have used in prior model updates  Future growth in the number of state and local government retirees— many of whom will be entitled to pension and health care benefits—is largely driven by the size of the workforce in earlier years  We simulated the number of state and local government retirees by assuming that the growth rate in the number of retirees is a weighted average of the growth rates in lagged general government and government enterprise employment  We estimated the weights using a regression of the percent change in the number of retirees on the percent change in employment 1, 6, 11, 16, 21, 26, 31, 36, and 41 years in the past  The coefficients on the past percentage changes in employment were constrained to be non- negative and to sum to 1  For this regression, we removed cyclical swings in employment using the Hodrick-Prescott filter  Similarly, future changes in the real amount of pension benefits will be a function of past changes in real wages and salaries  As indicated in table 3, we used a weighted average of past values of the state and local government employment cost index to simulate the employment cost index for state and local government retirees  We chose the weights to reflect changes in the share and average real benefit level of three subsets of the retiree population over time: (1) new retirees entering the beneficiary pool, (2) deceased retirees leaving the pool, and (3) continuing retirees from the previous year  We simulated the weight for new retirees in a year as the number of retirees less the number of continuing retirees divided by the number of retirees  We simulated the weight for deceased retirees as the mortality rate multiplied by last year’s retirees divided by this year’s retirees  We simulated the weight for continuing retirees as last year’s retirees divided by this year’s retirees  Finally, we simulated the employment cost index for state and local government retirees as the sum of the weight on new retirees multiplied by the state and local government employment cost index and the weight on continuing retirees multiplied by the state and local government employment cost index 8 years prior, less the weight on deceased retirees multiplied by the state and local government employment cost index 21 years prior  As discussed above, we started with historical data for 2017, or the most recent year available, simulated all of the variables in table 3 over the long run, and then used the consumer price index (CPI) and the real return on pension assets to calculate the total present value of wages and salaries for state and local government general government and government enterprise employees, the total present value of real pension benefits paid to state and local government retirees, and the total present value of state and local government employees’ pension contributions  Then, we calculated the total present value of state and local governments’ pension liabilities as the total present value of real pension benefits paid to state and local government retirees less the total present value of state and local government employees’ pension contributions, and the value of assets in state and local government defined benefit pension funds in 2017  Finally, we estimated state and local governments’ pension contribution rate as the ratio of the total present value of their pension liabilities to the total present value of wages and salaries for state and local government employees  Table 4 summarizes the approach we used to simulate interest rates on state and local government financial assets and liabilities  This approach is similar to the approach we have used in prior model updates  Table 5 summarizes our approach to simulating state and local government receipts  This approach is similar to the approach we have used in prior model updates  These variables track state and local government receipts in table 1 above as follows: State and local government personal income tax revenue is the sum of state personal income tax revenue and local personal income tax revenue; State and local government personal tax revenue is the sum of personal income tax revenue and other personal tax revenue; State and local government revenue from taxes on production and imports is the sum of general sales tax revenue, excise tax revenue, property tax revenue, and revenue from other taxes on production and imports; State and local government current tax revenue is the sum of personal tax revenue, revenue from taxes on production and imports, and corporate income tax revenue; State and local government current transfer receipts are equal to federal Medicaid grants minus Medicare Part D payments to the federal government, plus other federal grants (excluding investment grants), transfer receipts from businesses, and transfer receipts from persons; State and local government current receipts are the sum of current tax revenue, current transfer receipts, income on assets, social insurance contributions, and government enterprise surplus; State and local government capital transfer receipts are the sum of federal investment grants and estate and gift tax revenue; and State and local government total receipts are the sum of current receipts and capital transfer receipts  Our general approach to simulating state and local government expenditures is to assume that state and local governments maintain the current level of public goods and services provision per capita (see table 6)  Thus, we generally assume that expenditures keep up with U S  population growth and some measure of inflation, where the relevant rate of inflation varies depending on the specific type of expenditure  However, we use alternative approaches—described below—to simulate depreciation, interest payments, and social benefits for health care  This approach is similar to the approach we have used in prior model updates  These variables correspond to state and local government expenditures in table 1 as follows: Employee compensation is the sum of wages and salaries, pension contributions, health benefits for current employees, health benefits for retirees, and other compensation, for state and local government general government employees  Consumption expenditures are the sum of employee compensation, general government fixed capital consumption, and other general government consumption expenditures  Social benefit payments are the sum of Medicaid benefits, non- Medicaid health benefits, and non-health social benefits  Current expenditures are the sum of consumption expenditures, social benefit payments, interest payments, and subsidy payments  Total expenditures are the sum of current expenditures, gross investment, capital transfer payments, and purchases of nonproduced assets, minus general government and government enterprise fixed capital consumption  Table 7 summarizes our approach for simulating state and local government financial assets and liabilities  This approach is similar to the approach we have used in prior model updates  Our method for simulating the sectors’ short-term debt outstanding leverages the fact that for any entity, there is a direct relationship between budget outcomes and changes in financial position  Specifically, if expenditures exceed receipts, the gap needs to be financed by some combination of changes in financial assets and changes in financial liabilities  If governments spend more than they take in, they must pay for it by issuing debt, cashing in assets, or some combination of the two  Conversely, if receipts exceed expenditures and the sector is a net lender, its net financial investment (the net change in financial assets minus the net change in financial liabilities) must equal the budget surplus  The relationship between budget outcomes and the sector’s financial position is shown in the following accounting identity: total receipts – total expenditures = change in financial assets – change in financial liabilities  The sector’s financial liabilities include short-, medium-, and long-term debt; trade payables; and loans from the federal government, so the accounting identity can be rewritten as follows: total receipts – total expenditures = change in financial assets – change in medium- and long-term debt – change in trade payables – change in federal government loans – change in short term debt  For a given difference between total receipts and total expenditures, various combinations of changes in financial assets and changes in financial liabilities can satisfy this identity  However, we assumed that financial assets grow at the same rate as U S  GDP, that medium- and long-term debt outstanding is determined using the historical relationship described in table 7, that federal government loans to state and local governments are determined using the historical relationship described in table 7, and that trade payables grow at the same rate as other state and local government consumption spending  If the first four terms on the right hand side of the identity are already determined, then only the fifth term— the change in short-term debt—is free to satisfy this identity  As discussed above, our indicators of fiscal balance are operating balance, net saving, and net lending or borrowing  This approach is similar to the approach we have used in prior model updates  Recall that we defined operating balance as follows: operating balance = total receipts – (gross investment + capital transfer payments + net purchases of nonproduced assets – medium- and long-term debt issuance) – (current expenditures – consumption of general government fixed assets) – current surplus of state and local government enterprises – net social insurance fund balance  By substituting for total receipts and current expenditures using the relationships described above and rearranging terms, we can also calculate operating balance using a formula that more easily identifies its revenue components—the items in the first set of parentheses—and expenditure components—the items in the second set of parentheses: operating balance = (current tax revenues + estate and gift tax revenues + social insurance fund contributions + income receipts from assets + current transfers + federal investment grants + medium- and long-term debt issuance) – (compensation of general government employees + social benefit payments + interest payments + gross investment + capital transfer payments + net purchases of nonproduced assets + other general government consumption expenditures + subsidy payments + net social insurance fund balance)  Some of our simulations are based on estimated historical relationships between pairs of variables: Elasticity of real personal consumption expenditures less food and services with respect to real wages and salaries; Elasticity of the real U S  market value of real estate with respect to Relationship between effective interest rates on financial assets and Relationship between state and local government bond yields and 10- year Treasury rates; Relationship between effective interest rates on long-term state and local government debt and federal government loans and state and local government bond yields; Elasticity of real state personal income tax revenue with respect to Elasticity of real state and local government excise tax revenue with respect to real wages and salaries; Relationship between long-term debt issuance as a fraction of gross investment and nonproduced asset purchases in excess of federal investment grants and the change in state and local government bond yields; and Relationship between real federal government lending to state and local governments and real U S  GDP  To estimate each of these historical relationships, we used the following approach: first, we assessed the order of integration of both variables using unit root tests of the levels and the first differences, where a variable is integrated of order 0 (I(0) or stationary) if we rejected the null hypothesis of a unit root in the levels at standard significance levels, and is integrated of order 1 (I(1) or first-order nonstationary) if we could not reject the null hypothesis of a unit root in the levels but we could do so for the first differences  For relationships between variables that were both stationary, we estimated an autoregressive distributed lag model, where y is the dependent variable, x is the independent variable, and ε is an independent, identically distributed error term  The long-run impact on y of a one unit change in x is given by ∑   We initially chose the number of lags based on the Bayesian Information Criteria and then added additional lags of the dependent variable, if needed, until the residuals were consistent with a white noise process at standard significance levels  For relationships between variables that were both first-order nonstationary, we used the same approach but also used the Pesaran, Shin, and Smith bounds test for the existence of a cointegrating (long-run equilibrium) relationship  We concluded that the variables were cointegrated if we rejected the null hypothesis of no relationship at standard significance levels  Tables 8 and 9 summarize the estimated regression models as well as the results of the unit root, white noise, and cointegration tests  We simulated the model for the 75-year period from 2018 through 2092, and we used the results to calculate the operating balance for the state and local government sector as a percentage of U S  GDP  Our results suggest that if the sector maintains current policy and continues to provide current per capita levels of public goods and services, then its operating balance will decline from about -1 percent of U S  GDP to about -3 percent of U S  GDP over the next 50 years  To shed light on how maintaining the operating balance at or above zero would affect the state and local government sector, we used the model to simulate the level of total expenditures that would keep the operating balance greater than or equal to zero  We then calculated the difference between the present value of total expenditures simulated assuming the sector maintains balance, and the present value of total expenditures simulated assuming the sector maintains current policies, both as a percentage of the present value of total expenditures assuming the sector maintains current policies, and as a percentage of the present value of U S  GDP  We calculated all of the present values for the 50-year period from 2018 through 2067, and we used a discount rate equal to the average of the 3-month Treasury rate and the 10-year Treasury rate for each year  Our results suggest that the difference between the present value of total expenditures that maintain balance and the present value of total expenditures that maintain current policies is about -14 7 percent of the present value of total expenditures that maintain current policies, or about -2 4 percent of the present value of U S  GDP  That is, our simulations suggest that maintaining balance would require the sector to spend about 14 7 percent less than it would spend each year to maintain current policies  We note that a similar exercise based on simulating total revenues required to maintain the operating balance at or above zero would generate a similar result  Our approach has a number of limitations and the results should be interpreted with caution: The state and local government fiscal model is not designed for certain types of analyses  The simulations are not intended to provide precise predictions  Even though we know that these governments regularly make changes to tax laws and expenditures, the model essentially holds current policy in place and analyzes the fiscal future for the sector as if those policies were maintained because it would be highly speculative to make any assumptions about future policy adjustments  Fiscal outcomes, as related to the state and local government sector’s financial position and solvency, may not reflect all aspects of the sector’s fiscal health  Other indicators include economic indicators that go beyond the sector’s financial position to include economic growth, income, or distributional equity, as well as indicators of the quality of services provided by the sector, including education, health care, infrastructure, and other public goods and services  Our unit of analysis is the state and local government sector as a whole, so our results provide an assessment of the sector’s fiscal outlook  However, individual state and local governments likely exhibit significant heterogeneity in their expenditure and revenue patterns, so their fiscal outlooks will likely differ from that for the sector  Nevertheless, it is informative to assess the overall fiscal outlook of the sector because doing so reveals the outlook for the average state or local government  In addition, aggregate data on the sector are available on a more timely basis than data for individual state and local governments  This allows for a better assessment of the sector’s current fiscal outlook  Our results for the sector also provide a baseline from which to view the experiences of individual state and local governments  Finally, assessing the fiscal outlook of the sector as a whole can help mitigate the tendency to extrapolate from the most visible, but potentially not representative, experiences of individual states or localities  Our baseline approach to simulating the fiscal outlook for the state and local government sector is described in appendix I  As part of our simulation approach, we used five variables with values for the simulation period—the period from 2018 through 2092—that are projected outside the model and that do not rely on maintaining historical relationships: U S  population, real U S  gross domestic product (GDP) growth, national health care excess cost growth, Medicaid excess cost growth, and the real rate of return on pension assets  U S  population  For our baseline simulations, we used the Board of Trustees of the Federal Old-Age and Survivors Insurance and Federal Disability Insurance Trust Funds’ (OASDI Trustees) intermediate population projections  Real U S  GDP  For our baseline simulations, we projected real U S  GDP to grow at the same rate as Congressional Budget Office (CBO) projections for the period from 2018 through 2028 and to grow at the same rate as the OASDI Trustees’ intermediate projections of real U S  GDP growth for the period from 2029 through 2092  National health expenditures excess cost growth  For our baseline simulations, we used Centers for Medicare & Medicaid Services’ (CMS) baseline projection of national health expenditures excess cost growth  Medicaid excess cost growth  For our baseline simulations, for the period from 2029 through 2092, we used Medicaid excess cost growth derived from CMS’s baseline projections  Real rate of return on state and local government pension assets  For our baseline simulations, we assumed a 5 percent real rate of return on state and local government pension assets  To assess the sensitivity of our results to changes in these baseline projections, we selected two alternative projections of each of these variables, one associated with a faster growth rate or rate of return and one associated with a slower growth rate or rate of return  U S  population  For our alternative simulations, we used the OASDI Trustees’ high cost and low cost population projections  Real U S  GDP  For our alternative simulations, we used the OASDI Trustees’ high cost and low cost projections of real U S  GDP growth  National health expenditures excess cost growth  For our alternative simulations, we used CMS’s alternative projection of national health expenditures excess cost growth  As another alternative, we simulated the model assuming excess cost growth for national health expenditures is zero  Medicaid excess cost growth  For our alternative simulations, for the period from 2029 through 2092, we used Medicaid excess cost growth derived from CMS’s alternative projections for the period from 2029 through 2092  As another alternative, we simulated the model assuming Medicaid excess cost growth is zero for the period from 2029 through 2092  Real rate of return on state and local government pension assets  For our sensitivity analysis, we used real rates of return of 2 5 percent and 7 5 percent  Table 10 shows the average annual growth rate or rate of return associated with the baseline and alternative projections of each variable for the simulation period  For our simulations based on alternative assumptions about U S  population growth and real U S  GDP growth, as well as simulations based on alternative assumptions about real pension asset returns, we simulated the model changing one variable at a time and leaving the others fixed at their baseline values  For example, for one simulation we used the slower assumption for real U S  GDP growth and the baseline assumptions for all other variables  For our simulations based on alternative assumptions about excess cost growth for national health expenditures and for Medicaid, we changed both variables in the same direction and left the others fixed at their baseline values  For example, for one simulation we used zero excess cost growth for both national health expenditures and for Medicaid, and made the baseline assumption for the other variables  Thus, our sensitivity analysis is in the spirit of a partial equilibrium comparative statics analysis that sheds light on how each of the individual variables may affect the state and local government sector’s fiscal outlook  However, these variables are likely to be correlated so future changes in one would likely be associated with changes in others  State and Local Governments’ Fiscal Outlook: December 2016 Update, GAO-17-213SP  Washington, D C : Dec  8, 2016  State and Local Governments’ Fiscal Outlook: December 2015 Update, GAO-16-260SP  Washington, D C : Dec  16, 2015  State and Local Governments’ Fiscal Outlook: December 2014 Update, GAO-15-224SP  Washington, D C : Dec  17, 2014  State and Local Governments’ Fiscal Outlook: April 2013 Update, GAO-13-546SP  Washington, D C : Apr  29, 2013  State and Local Governments’ Fiscal Outlook: April 2012 Update, GAO-12-523SP  Washington, D C : Apr  5, 2012  State and Local Government Pension Plans: Economic Downturn Spurs Efforts to Address Costs and Sustainability, GAO-12-322  Washington, D C : Mar  2, 2012  State and Local Governments’ Fiscal Outlook: April 2011 Update, GAO-11-495SP  Washington, D C : Apr  6, 2011  State and Local Governments: Knowledge of Past Recessions Can Inform Future Federal Fiscal Assistance, GAO-11-401  Washington, D C : Mar  31, 2011  State and Local Governments: Fiscal Pressures Could Have Implications for Future Delivery of Intergovernmental Programs, GAO-10-899  Washington, D C : July 30, 2010  State and Local Governments’ Fiscal Outlook: March 2010 Update, GAO-10-358  Washington, D C : Mar  2, 2010  Update of State and Local Government Fiscal Pressures, GAO-09-320R  Washington, D C : Jan  26, 2009  State and Local Fiscal Challenges: Rising Health Care Costs Drive Long- term and Immediate Pressures, GAO-09-210T  Washington, D C : Nov  19, 2008  State and Local Governments: Growing Fiscal Challenges Will Emerge during the Next 10 Years, GAO-08-317  Washington, D C : Jan  22, 2008  Our Nation’s Long-Term Fiscal Challenge: State and Local Governments Will Likely Face Persistent Fiscal Challenges in the Next Decade, GAO-07-1113CG  Washington, D C : July 18, 2007  State and Local Governments: Persistent Fiscal Challenges Will Likely Emerge within the Next Decade, GAO-07-1080SP  Washington, D C : July 18, 2007  In addition to the contacts listed above, Brenda Rabinowitz and Courtney LaFountain (Assistant Directors), David Aja, Brett Caloia, Ann Czapiewski, Joe Silvestri, Stewart Small, Andrew J  Stephens, Frank Todisco, Walter Vance, and Chris Woika made significant contributions to this report 
Report 2:  Depending on how much of the costs are shifted, the additional costs could increase the challenge for retirees to ensure their accumulated resources last throughout retirement, or for postal employees to save for retirement  Further, as we have reported, rising health care costs can increase the overall amount individuals may need to save to ensure they have an adequate income once they retire  Change the federal contribution to a fixed subsidy: As some companies and state governments have done, postal retiree health benefits could be shifted to a structure with a fixed amount subsidizing the benefit  This amount could be adjusted over time; any adjustments might or might not keep up with costs  Depending on the initial size of the fixed subsidy and any adjustments over time, this approach could reduce the expenses of the RHB Fund and USPS’s required payments  RHB Fund expenses could be reduced over time if the fixed subsidy increases less than postal retiree health premiums  This approach would require changes to current law and regulations that prescribe the federal government’s financial contribution to FEHBP  For example, CBO recently identified one option to change FEHBP’s statutory structure from a premium-sharing structure that is required by law to fixed subsidies for health benefits  Under this option, the fixed subsidies would grow at the rate of inflation rather than at the average rate of growth for FEHBP premiums; CBO stated this change would be expected to slow the growth of federal contributions to FEHBP  A fixed subsidy for retiree health benefits could increase incentives for retirees to make less costly decisions with respect to health care  However, this approach could result in greater cost exposure for retirees, who may face difficult decisions regarding their health care, particularly if their financial resources are limited  As we have reported, individuals face the risk that rising and unpredictable health care or long-term care costs may lead them to draw down their retirement savings faster than expected  Establish a non-federal voluntary employees’ beneficiary association (VEBA) for postal retiree health benefits: As some companies have done to provide retiree health benefits separately from the employer, a VEBA outside the federal government could be established to manage postal retiree health benefits  This approach means that postal retiree health benefits would be provided through the VEBA instead of through the OPM-administered FEHBP  The non-federal VEBA would administer the postal retiree health benefits program, including determining the specific benefits that would be provided and the level of contributions from the VEBA members—who could include retirees and employees—and the investing of its assets  Such an approach would require determining the VEBA’s governance structure, funding sources, level of funding, type of investments, and associated market risks  One issue could be determining the source and level of initial funding for a new VEBA for postal retiree health benefits, such as whether initial funding would come from the RHB Fund, the Treasury, or both  Other issues could be what funds would be provided to the VEBA going forward, including the source(s) and level of funding, and what the benefit levels would be  If the entire RHB Fund were transferred into a VEBA, the current level of benefits would ultimately not be sustainable unless further funding is provided from one or more sources, such as from USPS, retirees, active employees, or the federal government  Thus, trade-offs would involve what level of benefits would be provided, who would bear the costs, and what might happen if VEBA assets decline or become depleted  Reduce the required level of prefunding: Proposed legislation includes an 80 percent funding target for postal retiree health benefits instead of the 100 percent target established by current law  This would reduce USPS’s required payments to the RHB Fund but could increase costs for future postal ratepayers and increase the risk that USPS may not be able to pay for these costs  As previously discussed in this report, state governments either do not prefund their retiree health benefits or generally have a low level of prefunding  We have expressed concern about a proposed 80 percent funding target for postal retiree health benefits that would have the effect of carrying a permanent unfunded liability equal to roughly 20 percent of USPS’s liability, which could be a significant amount  As we previously reported, an alternative could be to build in a schedule to achieve 100 percent funding in a later time period after the 80 percent level is achieved  Although USPS payments with an 80 percent funding target would reduce USPS’s required payments, fully funded benefits protect against an inability to make payments later, make promised benefits less vulnerable to cuts, and protect USPS’s long-term viability  Further, reducing the funding target is unlikely to have any effect as long as USPS continues to make no payments to the RHB Fund, as discussed earlier  We continue to believe that as long as USPS is required by law to pay its share of retiree health benefits premiums, it is important for USPS to prefund its retiree health benefit liability to the maximum extent that its finances permit  We recognize that multiple options exist to prefund benefits and amortize unfunded liability and that no prefunding approach will be viable unless USPS can make the payments and maintain liquidity  As we have reported, making affordable prefunding payments would protect the viability of USPS by not saddling it with bills later on, when employees are already retired and no longer helping it to generate revenue; making payments can also make the promised benefits more secure  We also have reported that deferring payments can pass costs from current to future postal ratepayers  To the extent prefunding is postponed by using a lower funding target, larger payments will be required later, when they likely would be supported by lower levels of profitable First-Class Mail volume  Outside investment: Proposed legislation would initially require 25 percent of the RHB Fund to be invested in index funds modeled after those used for federal Thrift Savings Plan investments  The objective of investing RHB Fund assets outside of U S  Treasury securities would be to seek a greater rate of return on these assets in an attempt to reduce unfunded liabilities and the amount of required prefunding payments  Such outside investment would require legislation because current law limits RHB Fund assets to U S  Treasury securities that are backed by the full faith and credit of the federal government  A higher rate of return on RHB Fund assets could reduce long-term funding needs  However, there are other considerations  For example, we have reported that if fund assets were invested in non-Treasury securities, the fund may experience losses in a market downturn and would thus have reduced assets available for health care  Assuming there would be no explicit federal guarantee of the value of the invested assets, we stated that USPS is not well positioned to deal with a potentially significant decline in their value, given its significant operating losses and continuing decline in mail volume  We also reported that the impact of any asset losses could be magnified because a market downturn that negatively affects asset value could be associated with a more general economic downturn that negatively affects USPS mail volume and revenues  About a half million postal retirees receive retiree health benefits  Postal retirees have provided a vital service to the nation, and resolving a key aspect of their future situation warrants congressional action  Failure to address the poor financial outlook of the RHB Fund could pose serious consequences for these retirees as well as USPS, postal customers, and other stakeholders, including the federal government  It is reasonable to believe that USPS will not be able to fill the financial gap once the RHB fund is depleted—a situation that could occur in as little as 12 years under the status quo  There is no certainty on what actions should be taken to address this problem  However, we have identified multiple approaches that could be used, individually or in combination, that Congress could consider to help address the financial shortfall in this area  All of these approaches have different potential effects, and it is up to Congress to consider the merits of the approaches and determine the most appropriate action to take  It would be preferable to take action when careful consideration is possible, rather than wait until lack of adequate funding could disrupt postal retiree health benefits  Congress should consider passing legislation to put postal retiree health benefits on a more sustainable financial footing  We provided a draft of this report to OPM and USPS for their review and comment  OPM provided technical comments, which we incorporated as appropriate  USPS provided a written response, which is reproduced in appendix II of this report  In its written response, USPS stated that it concurred with our matter for congressional consideration that congressional action is necessary to achieve a financially sustainable Postal Service Retiree Health Benefits Fund (RHB Fund)  However, USPS said our discussion of potential policy approaches for postal retiree health benefits would benefit from additional context and balance  USPS also put forth additional information for three of the potential policy approaches highlighted in our report  Our report presents a high-level overview of eight potential policy approaches  It was not designed to be a comprehensive catalog of possible options with an analysis of the various considerations relevant to each  With regard to the Medicare integration approach, USPS stated that increased Medicare participation by postal retirees is not limited to the “full Medicare integration option,” as represented in our report and identified variations of such an approach  USPS said readers would benefit from a fuller picture of Medicare integration practices, stating that among employers that continue to provide retiree health benefits, full Medicare integration is a uniform best practice  USPS cited a 2014 report that said Medicare integration is the most common arrangement for employer-provided retiree health benefits, adding that retiree health benefits for Medicare-eligible employees are assumed to be merely supplemental to Medicare as a matter of course  Our report discussed Medicare integration by state governments, but did not present recent data on the percentage of private companies that coordinate their retiree health benefits with Medicare because such data are not publicly available  Additionally, USPS said our report framed the issue of Medicare integration as “solely” a tradeoff between USPS and Medicare costs while there are other factors to consider, such as the relative benefits to USPS compared to the overall cost for the Medicare program  As we noted in our report, the eight potential policy approaches were not designed to be mutually exclusive, nor an exhaustive list of possible approaches  Additionally, we recognize there are various factors related to this approach, but that the primary one is whether to increase postal retirees’ use of Medicare which would lead to further increasing Medicare costs  Second, USPS said it believed our statements about approaches for changing the level of prefunding for retiree health benefits below the 100 percent level were misplaced, citing “universally accepted practices” for other entities to “pay-as-you-go” (i e , not prefund at all), or to prefund at much lower levels  We have reported on such funding levels in the past as well  However, a proposed 80 percent funding target for postal retiree health benefits would have the effect of carrying a permanent unfunded liability equal to roughly 20 percent of USPS’s liability, which could be a significant amount  As we previously reported, an alternative could be to build in a schedule to achieve 100 percent funding in a later time period after the 80 percent level is achieved  As our report also explained, although USPS payments with an 80 percent funding target would reduce USPS’s required payments, fully funded benefits protect against an inability to make payments later, make promised benefits less vulnerable to cuts, and protect USPS’s long-term viability  Finally, USPS said that our statements about potential risks associated with investment of assets outside the U S  Treasury seem disproportionate given USPS’s view that diversification of assets set aside for retiree health benefits is “universally accepted” as a best practice  We recognize that a higher rate of return on RHB Fund assets could reduce long-term funding needs for the RHB Fund  However, there are considerations specific to USPS  For example, assuming there would be no explicit federal guarantee of the value of the invested assets, we stated that USPS is not well positioned to deal with a potentially significant decline in their value, given its significant operating losses and continuing decline in mail volume  We also noted that, as we have previously reported, the impact of any asset losses could be magnified because a market downturn that negatively affects asset value could be associated with a more general economic downturn that also negatively affects USPS mail volume and revenues  In summary, we believe our report presents a balanced description of a wide range of possible policy options; it does not endorse or recommend any particular option for Congress  As we concluded, all of these approaches have different potential effects, and the information we present, as well as the additional views presented by USPS, provide critical information for congressional decision-makers to assess as they consider the merits of the approaches and determine the most appropriate action to take  As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date  At that time, we will send copies to the appropriate congressional committees; the Postmaster General; and the Director of the Office of Personnel Management  In addition, the report will be available at no charge on the GAO website at http://www gao gov  If you or your staff have any questions concerning this report, please contact me at (202) 512-2834 or rectanusl@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  End of year net funded status (unfunded) (55 0) Missed USPS payments to the fund (53 5) (52 0) (48 6) (46 2) (47 8) (48 3) (48 9) (54 8) (52 1) payments due on Sept  30, 2017, of $955 million for the amortization of USPS’s unfunded liability for postal retiree health benefits, and $3 3 billion for the “normal costs” of retiree health benefits  The “normal cost” is the annual expected growth in liability attributable to an additional year of employees’ service  In addition to the individual named above, Derrick Collins (Assistant Director); Kenneth John (Analyst-in-Charge); Amy Abramowitz; Taiyshawna Battle; William Colwell; Swati Deo; John Dicken; Leia Dickerson; William Hadley; James Leonard; Emei Li; Thanh Lu; Sara Ann Moessbauer; Joshua Parr; Malika Rice; Matthew Rosenberg; Amy Rosewarne; Frank Todisco; and Crystal Wesco made key contributions to this report 

ground_truth: Fiscal sustainability presents a national challenge shared by all levels of government. Since 2007, GAO has published simulations of long-term fiscal trends in the state and local government sector, which have consistently shown that the sector faces long-term fiscal pressures. While most states have requirements related to balancing their budgets, deficits can arise because the planned annual revenues are not generated at the expected rate, demand for services exceeds planned expenditures, or both, resulting in a near-term operating deficit. This report updates GAO's state and local fiscal model to simulate the fiscal outlook for the state and local government sector. This includes identifying the components of state and local expenditures likely to contribute to the sector's fiscal pressures. In addition, this report identifies considerations related to federal policy and other factors that could contribute to uncertainties in the state and local government sector's long-term fiscal outlook. GAO's model uses the Bureau of Economic Analysis's National Income and Product Accounts as the primary data source and presents the results in the aggregate for the state and local sector as a whole. The model shows the level of receipts and expenditures for the sector until 2067, based on current and historical spending and revenue patterns. In addition, the model assumes that the current set of policies in place across state and local government remains constant to show a simulated long-term outlook. GAO's simulations suggest that the state and local government sector will likely face an increasing difference between revenues and expenditures during the next 50 years as reflected by the operating balance--a measure of the sector's ability to cover its current expenditures out of its current receipts. While both expenditures and revenues are projected to increase as a percentage of gross domestic product (GDP), a difference between the two is projected to persist because expenditures are expected to grow faster than revenues throughout the simulation period. GAO's simulations also suggest that growth in the sector's overall spending is largely driven by health care expenditures--in particular, Medicaid spending and spending on health benefits for state and local government employees and retirees. These expenditures are projected to grow as a share of GDP during the simulation period. GAO's simulations also suggest that revenues from personal income taxes and federal grants to states and localities will increase during the simulation period. However, revenues will grow more slowly than expenditures such that the sector faces a declining fiscal outlook. GAO also identified federal policy changes that could affect the state and local government sector's fiscal outlook. For example, the effects of the recently-enacted Tax Cuts and Jobs Act will likely depend on how states incorporate the Act into their state income tax rules. In addition, other factors, such as economic growth and rates of return on pension assets, could shift future fiscal outcomes for the sector.