You are given two reports by the government agency.  

Report 1:
Created in 1968, the SFSP is authorized under the Richard B. Russell National School Lunch Act and generally provides free meals to children age 18 and under in low-income areas during certain periods when school is not in session. Specifically, the SFSP operates during school summer vacation periods between May through September, vacation periods in any month for programs operating on a continuous school calendar, and certain other times for areas affected by an unanticipated school closure, such as for a natural disaster. However, the majority of SFSP meals are served to children during the summer months. In fiscal years 2007 through 2016, federal expenditures on SFSP increased, according to FNS data, though there was a slight decrease between fiscal years 2015 and 2016 (see fig. 1). The SFSP is administered at the federal level by FNS through its national and regional offices. FNS is responsible for issuing regulations, instructions, and guidance; reviewing states’ program management and administration plans; overseeing program administration; and reimbursing states for meals served that meet program requirements. At the state level, the program is administered by state agencies and locally operated by state-approved sponsors, such as school districts, local government entities, or private nonprofit organizations. State agencies are responsible for approving, providing training to, and inspecting and monitoring sponsors and meal sites. Sponsors, in turn, are responsible for monitoring their SFSP meal sites, managing the meal service, and providing training to administrative staff and site operators. A sponsor may operate one site or multiple sites. Sites are physical locations in the community where children receive and consume meals in a supervised setting. According to FNS guidance, sites may be located in a variety of settings, including schools, parks, community centers, health clinics, hospitals, apartment complexes, churches, and migrant camps. States may approve different types of SFSP meal sites, including open sites, closed enrolled sites, and camps. Open sites operate in an area where at least half of the children are eligible for free or reduced-price school meals (referred to as “area eligible”), according to data from entities such as schools or the U.S. Census Bureau. Children are generally eligible for free or reduced-price school meals if their households have incomes at or below 185 percent of federal poverty guidelines. At open sites, meals are made available to all children in the area, and all meals served that meet program requirements are reimbursable. Closed enrolled sites, on the other hand, are open only to enrolled children, as opposed to the community at large. At closed enrolled sites, meals served to all children in attendance are reimbursable as long as at least half of the enrolled children are eligible for free or reduced-price school lunch. Unlike other types of sites, camps are reimbursed only for meals served to children who have been individually determined to be eligible for free or reduced-price school meals. SFSP meals must meet certain requirements in order to be eligible for federal reimbursement; for example, the meals must be served and consumed on-site at an approved site. Federal reimbursements for summer meals are provided for each breakfast, lunch, supper, or snack served to an eligible child at an eligible site that also meets federal requirements for menu components, scheduled meal times, and nutrition. For example, to meet nutritional requirements, a lunch or a supper must, at a minimum, include four components: 2 ounces of meat or a comparable serving of a meat alternate, 3/4 cup of fruits and/or vegetables (at least two kinds), a slice of bread or a comparable serving of another grain, and a cup of milk. In 2017, the federal reimbursement rate was $3.83 or $3.77 for each eligible SFSP lunch or supper served, depending on the type of meal site. Each site may serve up to two meals or one meal and one snack per day. Some flexibilities are available to FNS in implementing the SFSP program, under its waiver and demonstration authorities. Specifically, the National School Lunch Act authorizes the Secretary of Agriculture to waive, upon request of a state or eligible service provider, certain program requirements established under the National School Lunch Act or the Child Nutrition Act of 1966, as amended, including some for the SFSP. In order to grant a waiver request, the Secretary must determine that the waiver would facilitate the state or service provider’s ability to carry out the purpose of the program, and that the waiver will not increase the overall cost of the program to the federal government, among other things. In the event a waiver request is submitted, the Secretary is required to act promptly and state in writing whether the waiver request is granted or denied, and why. The Secretary is also required to periodically review the performance of waiver recipients, and submit an annual report to Congress summarizing the use of waivers and their effectiveness, among other details. In addition to this waiver authority, the Secretary is also authorized to carry out demonstration projects to develop and test methods of providing access to summer meals for low-income children in urban and rural areas, to reduce or eliminate the food insecurity and hunger of low-income children and improve their nutritional status. The Secretary is required to provide for an independent evaluation of the demonstration projects carried out under this authority, and submit an annual report to Congress on the status of each project and the results of the evaluations. The total number of SFSP meals served nationwide during the summer— one indicator of program participation—increased from 113 million meals in fiscal year 2007 to 149 million meals in fiscal year 2016, or by 32 percent, according to our analysis of FNS data. The number of SFSP meals served has generally increased from year to year over this 10-year period. Most recently, meals decreased by 6 percent from 156 million meals in summer 2015 to 149 million meals in summer 2016, according to our analysis of FNS data (see fig. 2). Factors that may have affected year-to-year fluctuations include changes in funding for summer programs, sponsor participation, weather, and the number of weekdays available for sites to serve meals within a given summer, according to FNS and state agency officials we interviewed. For example, state agency officials in one of the three selected states we visited said they believe that reductions in state and local funding for summer programs that also provide meals, and turnover of sponsors, including losing one of the state’s largest sponsors in a recent summer, affected the total number of SFSP meals served in their state in 2016. According to our analysis of FNS data, SFSP lunches served in the summer months increased by over 17 million from fiscal year 2007 through fiscal year 2016, accounting for almost half of the total increase in the number of SFSP meals served in that period. However, when comparing across each of the meal types, supper and breakfast had the largest percentage increases over the 10-year period, 50 and 48 percent, respectively (see table 1). In comparison, the number of SFSP lunches served increased by 26 percent from fiscal years 2007 through fiscal year 2016. From fiscal year 2007 through fiscal year 2016, there were increases in the numbers of meals served in both SFSP and NSLP, the largest child nutrition assistance program. Specifically, SFSP lunches served in July increased from 32 million to 40 million, or 24 percent, from fiscal year 2007 to 2016, and NSLP lunches served in March increased from 328 million to 376 million meals, or 15 percent, according to our analysis of FNS data. Although the programs generally serve similar populations, different factors likely affected the number of meals served by each program, in part because NSLP serves children in schools during the school year and SFSP serves children in a variety of settings during the summer months. Although states report the actual number of SFSP meals served to FNS, they estimate the number of children participating in SFSP, and information obtained from our state survey and FNS indicate that these participation estimates have been calculated inconsistently. FNS instructs state agencies on how to calculate a statewide estimate of children’s participation in the SFSP, referred to as average daily attendance (ADA), using sponsor-reported information on the number of meals served and days of operation in July of each year. However, states’ methods for calculating ADA have differed from state to state and from year to year, according to our review of states’ survey responses and FNS documents. For example, although FNS directed states to include the number of meals served in each site’s primary meal service— which may or may not be lunch—some states, according to our survey and FNS data, were calculating ADA using only meals served at lunch. FNS officials told us that these states were therefore not following the agency’s instructions. Further, some states have changed their methods for calculating ADA over time—five states reported in our survey that the method they used to calculate ADA in fiscal year 2016 differed from the one they used previously. While FNS clarified its instructions in May 2017 to help improve the consistency of states’ ADA calculations moving forward, ADA remains an unreliable estimate of children’s daily participation in SFSP for at least two reasons, according to our analysis. (See sidebar for the revised ADA calculation instructions.) First, ADA is based on summary data that does not account for existing variation in site days of operation, and second, it is based on July data, which does not reflect the month with the greatest number of meals served in every state. According to our analysis, ADA is an unreliable estimate of children’s participation in SFSP because it currently does not account for existing variation in the number of days that each site serves meals to children. Specifically, because FNS’s instructions indicate that sites’ ADAs are to be combined to provide a statewide ADA estimate, differences in the number of days of meal service are disregarded. As a result, ADA does not reflect the average number of children served SFSP meals daily throughout the month. Our analysis of site-level data from one of the selected states illustrates this limitation. In this state, multiple sites reported an ADA of 60 for July, yet two of those sites served meals to children on only 1 day of the month and another site served meals to children on 20 days. Although 120 children were served SFSP meals only 1 day in July across two of these sites, the combined ADA across all three sites, which we calculated following FNS’s instructions, inaccurately suggests an average of 180 children were participating in SFSP at these sites on a daily basis in July. According to our analysis, ADA is also an unreliable estimate of children’s participation in SFSP because it currently does not account for state variation in the month with the greatest number of SFSP meals served, potentially leading to an underestimate. According to FNS officials, the agency instructs states to calculate ADA for July because officials identified this as the month with the largest number of meals served nationwide. However, because of reasons such as state variations in school calendars, July is not the month with the largest number of meals served in every state. In one of the selected states, Arizona, using July to calculate ADA cuts the estimate almost in half. Specifically, we followed FNS’s instructions and calculated that Arizona’s ADA was 14,987 in July 2016 compared to 26,772 in June 2016. Nationwide, in summer 2016, 26 states served more SFSP meals in June or August than in July, according to our analysis of FNS data. However, without site level data on meals served and operating days, the extent to which these states had higher ADAs in June or August as compared to July is unknown. In its May 2017 memo to states revising the ADA calculation instructions, FNS said that it is critical that the agency’s means of estimating children’s participation in the SFSP is as accurate as possible because it helps inform program implementation at the national level and facilitates strategic planning and outreach to areas with low participation. In addition, Standards for Internal Control in the Federal Government state that agencies should maintain quality data and process it into quality information that is shared with stakeholders to help achieve agency goals. Although FNS has also collected information on other data that states collect on the SFSP, the agency has not yet used this information to help improve its estimate of children’s participation in the program. In 2015, FNS published a Request for Information, asking whether states or sponsors collect any SFSP data that are not reported to FNS. While FNS received responses from only 15 states, these responses suggest that some states collect additional data, such as site-level data that may allow for an improved estimate of children’s SFSP participation, potentially addressing the issues we found in our analysis. In response to the information FNS received, they followed up with up to 9 of the 15 states in 2016 and 2017 to explore the feasibility of collecting additional data and improving estimates of children’s participation. Although they took these steps, FNS officials told us they are cognizant of the burden on states and site operators that would be associated with additional reporting requirements. At this time, the agency has not taken further action to improve the estimate, such as addressing the reliability issues caused by variation in the number of operating days of meal sites and in the months with the greatest number of meals served by state. As a result, FNS’s understanding of children’s participation in the SFSP remains limited, which impairs its ability to both inform program implementation and facilitate strategic planning and outreach to areas with low participation. Other federal programs that operate solely in the summer, as well as those operating year-round, help feed low-income children in the summer months. These programs include the NSLP Seamless Summer Option, which provides nutrition assistance benefits solely in the summer, and several federal programs that operate year-round. In July 2016, in addition to the 70 million meals provided through the SFSP, 26 million meals were provided to low-income children through school food authorities participating in the NSLP’s Seamless Summer Option, according to FNS data. The Seamless Summer Option was established in 2004, and according to FNS, streamlines administrative requirements to encourage school food authorities providing free or reduced-price meals during the school year under the NSLP and SBP to continue providing meals to low-income children when school is not in session. For example, officials from a national organization involved in summer meals told us the Seamless Summer Option makes it easier for school food authorities to provide summer meals because they continue working with the same state agency, reporting the same information to the state, and operating without having to transition to a separate program. Nonetheless, school food authorities can choose to provide free summer meals to children through either the SFSP or Seamless Summer Option, and the majority of states (34) reported in our survey that a greater proportion of school food authorities participated in the SFSP than the Seamless Summer Option in summer 2016. According to FNS and selected state officials, this may be related to the generally lower meal reimbursement rates school food authorities participating in the Seamless Summer Option receive compared to the rates received by those participating in the SFSP. In summer 2016, the Seamless Summer Option added to the geographic availability of summer meal sites in two of the three states we visited as part of our review. School food authorities provided summer meals through the Seamless Summer Option in Arizona and Illinois, but not in Massachusetts, based on our analysis of data provided by these states. In Arizona and Illinois, school food authorities participating in the Seamless Summer Option added 643 and 298 summer meal sites, respectively, in the month with the largest number of SFSP meals served in each state (see fig. 3). In addition, some of the Seamless Summer Option sites in these two states provided meals to children in areas where there were no SFSP sites. For example, Seamless Summer Option sites provided meals in areas near the northeastern and southwestern corners of Arizona that lacked nearby SFSP sites. In addition to the SFSP and the Seamless Summer Option, the Summer Electronic Benefit Transfer for Children (Summer EBT) demonstration provided nutrition assistance benefits to 209,000 low-income children in summer 2016 in select areas across 6 states and 2 Indian Tribal Organizations, according to FNS officials. Since the summer of 2011, Summer EBT benefits have been provided to eligible households on an electronic benefits transfer card, which households use to purchase eligible foods at authorized retailers. Specifically, the demonstration has provided monthly benefits of $30 or $60 per eligible child to households with children in areas with a perceived high level of need, based on the demonstration grantees’ assessments of the percentage of children eligible for free or reduced-price school meals and the availability of the SFSP. Consistent with this, three of the states that participated in Summer EBT in 2016 reported through our survey that these benefits helped children who were unable to access summer meals through the SFSP or the Seamless Summer Option. Further, according to an FNS- funded evaluation, Summer EBT improved food security among low- income children who participated in the demonstration. Specifically, the evaluation found the receipt of these benefits reduced the number of children in the demonstration experiencing very low food security between 2011 and 2013 by one-third. Some low-income children also receive nutrition assistance in the summer through federal programs that operate year-round. According to FNS data, in June 2016, 5.8 million infants and children participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and 3 million children participated in the Child and Adult Care Food Program (CACFP). In addition, an average of 19.2 million children participated each month in the Supplemental Nutrition Assistance Program (SNAP) in fiscal year 2016, according to FNS data. These benefits are provided year-round, including when school is in session and children may also be eligible to receive school meals. In our previous work on federal domestic food assistance programs, we reported that no one program alone is intended to meet a household’s full nutritional needs. At that time, several officials and providers told us that the variety of food assistance programs offers eligible individuals and households different types of assistance and can help households fill the gaps and address the specific needs of individual members. For example, a mother with two children may rely on SNAP for her household’s basic groceries, the NSLP to feed a school-age child during the school year, and WIC to obtain supplemental foods for herself and an infant. Some low-income children also receive summer meals through nonfederal programs, according to our state survey and interviews with organizations involved in summer meals. Twenty-seven states reported in our survey that they were aware of other state- or non-state-funded programs that provided children of low-income households with meals in their states during the summer months. According to our analysis of state survey responses, local faith-based organizations and foodbanks were the most common types of entities operating these types of programs. Similarly, officials from FNS and two regional organizations we interviewed said they were aware of children receiving summer meals through nonfederal programs operated by faith- based and other community organizations. In addition, SFSP site operators at 6 of the 30 meal sites we visited in the selected states told us nearby foodbanks and faith-based organizations may also be providing children with free meals to some extent. For example, one of the meal sites we visited was operated by a foodbank that, in addition to the SFSP, provided food boxes to those in need and distributed food to other local community organizations to provide to persons in need of immediate assistance, including families with children. Although FNS and the majority of states do not collect data on nonfederal programs, results from our state survey and interviews with SFSP providers and organizations involved in summer meals indicate the reach of nonfederal programs is limited. In our survey, states reported that the geographic coverage of these nonfederal programs varied by state, with 11 states indicating that they operated in some portions of the state—the most common state response. In addition, 16 states reported that they were not aware of any nonfederal programs providing summer meals to children in their state (see fig. 4). Similarly, SFSP site operators at 24 of the 30 meal sites we visited were unaware of nonfederal programs providing meals to children in the areas in which they operated. In addition, officials from several national organizations involved in summer meals told us children have very few options for receiving summer meals beyond the federal summer meals programs. Specifically, officials from one national organization explained that food is often a significant part of the cost of a summer activity program for children and suggested that is one reason why organizations choose to participate in the SFSP. Although the SFSP provides for federal reimbursement of eligible meals and certain administrative and operating costs, nonfederal programs that provide children with summer meals may choose not to participate in the SFSP for several reasons, according to officials we interviewed from several organizations involved in summer meals. For example, some nonfederal program providers may not participate in the SFSP because they are unaware the program exists. Additionally, some nonfederal program providers may be aware of the SFSP, but choose not to participate because they do not want to follow certain program requirements, such as the nutrition or meal pattern standards. In addition, some providers may not participate in the program because they do not think they can handle certain aspects of the administrative workload associated with the SFSP. For example, a state official we interviewed told us the administrative workload associated with the SFSP can be particularly challenging, especially for smaller sponsors. Similarly, officials from a regional organization involved in summer meals told us one of the providers they work with who operated 10 meal sites chose to leave the SFSP because the paperwork required to operate the sites was too administratively burdensome for their volunteer site operators. States and SFSP providers reported challenges with meal sites, participation, and administration, though federal, state, and local entities have taken steps to improve these areas. Half or more of states reported in our survey that SFSP issues related to meal site availability, such as in rural areas, increasing children’s participation, and program administration were moderately to extremely challenging (see fig. 5). Overall, 41 states reported facing at least one challenge with the SFSP, while 9 reported facing none. Availability of transportation, low population density, and limited meal sites pose challenges for SFSP in rural areas, according to states we surveyed, selected national organizations, and state and local officials in the three selected states we visited. More than two-thirds of states in our survey reported they faced a moderate to extreme challenge with limited options in rural areas to transport children to summer meal sites (37), as well as with the distance to summer meal sites in rural areas resulting in low child turnout that affects the financial viability of site sponsorship (36). As officials from one national organization explained, it may not be cost- effective for sponsors to operate in remote or rural areas if there are not enough meal sites or children participating in the program. Similarly, a sponsor in one of the selected states indicated that there are large parts of the state where the distances between meal sites are substantial, and travel between them takes several hours. An official from one of the selected states said transportation challenges can lead to underserved rural areas, including Indian reservations. Of the three states we reviewed, each had rural areas with few or no federally funded meal sites in summer 2016. However, a majority of the children in some of those areas were eligible for free or reduced price school meals, according to Census data provided by FNS, and would therefore be “area eligible” for the purposes of SFSP. For example, as shown in figure 6, “area eligible” locations in rural western parts of Arizona did not have any SFSP or Seamless Summer Option meals sites in June 2016, the month with the greatest number of summer meals served in that state. States and SFSP providers have responded to challenges with meal sites in rural areas by using other meal delivery approaches—efforts that FNS has supported through information sharing and grants. For example, according to one national organization involved in summer meals, some SFSP providers offer vans or buses to transport children to meal sites or partner with local bus authorities to give children free rides to meal sites. Instead of transporting children to sites, other sponsors transport meals to children through mobile meal delivery, an alternative summer meal model used in 48 states according to our survey. In this model, sponsors deliver meals by bus, using a route with state-approved stops in a community, and children consume the meal at the stop under a supervised setting. According to FNS officials and representatives from national organizations, this approach can be particularly helpful for providing summer meals to children in rural areas. State officials in two selected states told us they use mobile meal delivery to help fill gaps in meal service and help children overcome the lack of transportation or resources in their community. To serve children in very remote areas with limited resources, a sponsor in one of the selected states reported piloting a model involving delivering frozen meals every other week to such areas and supplying equipment, such as freezers and microwaves, to support meal service. To help sponsors address challenges related to meal sites in rural areas, FNS has shared information on alternative delivery models through its SFSP toolkit and webinars and has also provided related grant funding. For example, in summer 2011 and 2012, FNS funded the Meal Delivery demonstration project to provide meals to children in rural areas where low population density, long distances, and transportation issues made it difficult for children to get to SFSP sites, making site and sponsor operation financially unsustainable. The demonstration project funded meals to children in rural areas of Delaware, Massachusetts, and New York, providing food delivery to homes or drop-off sites near homes of eligible children. More than half the states (30) in our survey reported they faced a moderate to extreme challenge reaching low-income children in communities that are not area eligible. Areas in which fewer than 50 percent of children qualify for free or reduced-price meals during the school year are not eligible to have open summer meal sites at which all children who come to the site can receive a free meal. As a result, some children who are eligible for free and reduced-price meals during the school year do not have open summer meal sites located in close proximity to their residences, according to several national organization officials and SFSP providers. Eligible children in these areas may instead be limited to other types of SFSP sites, such as closed enrolled summer meal sites, or nonfederal programs providing meals, if available. For example, in one of the selected states, a sponsor of SFSP sites funded meals without federal support at one site that they operated as an open site in order to serve low-income children residing in low-income housing. These children did not otherwise have access to a federally funded summer meals site, according to these officials, because the broader area was part of a school district that had a greater than 50 percent proportion of children from higher-income families. Recognizing that some children may reside in an area that is not area eligible but is immediately adjacent to such an area, FNS has allowed additional flexibility in establishing area eligibility for open meal sites. Specifically, in 2014 and 2016 policy memos, FNS expanded the ways in which states and sponsors can use Census data to establish area eligibility. For example, FNS has allowed states and sponsors to average Census data across adjacent geographic areas to determine area eligibility. FNS noted that these additional flexibilities help ensure meal sites can be located in more areas in which poor economic conditions exist. Nearly all states (50) reported in our survey that the availability of meal sites throughout the summer months was a factor critical to the success of the SFSP, yet more than half the states (27) also reported they faced a moderate to extreme challenge with limited meal site days of operation. Nineteen of the 40 states that provided information about site days of operation reported 1 day as the shortest length of operation for SFSP sites in their state in fiscal year 2016. Limited meal site days of operation was a significant challenge in one of the three selected states we visited, as almost one-quarter of sites operated for only 1 to 2 weeks across a 2-month period in summer 2016, and an additional half of sites operated for 3 to 4 weeks across that same period, according to our analysis of state data. In contrast, in the other two selected states, the majority of sites (64 and 76 percent, respectively) operated for 5 or more weeks during a 2-month period. SFSP sites may have limited days of operation for various reasons, such as constraints with program administration and costs, according to interviews with a national organization official and a sponsor in one of the selected states. Some SFSP providers and national organizations involved in summer meals have responded to these challenges by working to extend the days of operation of meal sites—efforts that FNS has supported through related grant funding. Officials from one meal site located at a school in one of the selected states told us that 2017 was the first year the site stayed open an additional 4 weeks after summer school classes ended in an effort to expand participation, an extension made possible through support from an experienced sponsor. In addition, officials from a national organization involved in sponsoring summer meals told us they encourage their local sites to operate in August—a month where there are generally fewer summer meal service offerings—to meet children’s needs. At the federal level, under its demonstration authority, FNS funded the Extending Length of Operation Incentive project, a grant which provided an additional 50-cent reimbursement for all lunch meals served at sites in Arkansas in 2010 that offered meals for 40 or more days. Two-thirds of states (34) reported through our survey that they also faced a moderate to extreme challenge with a lack of awareness of summer meal sites among children and families, a challenge also mentioned by SFSP providers in the selected states. Meal site operators in one selected state noted that making families aware that all children may receive a meal for free at open sites can be a challenge. For example, one sponsor operating a meal site in a school said the perception among some is that the meal program is only for children attending summer school, and not for others in the community. Although that site had outside banners and advertising to help address that misperception, another SFSP provider explained that having sufficient funds to market the SFSP and increase awareness among families is also a challenge. To address these challenges, state agencies, some SFSP providers, and FNS have taken steps to help promote awareness of the SFSP. For example, nearly all states (47) reported in our survey that they have increased their outreach efforts for the SFSP in the last 5 years. More than half of states (36) also reported increases in overall SFSP participation during that time, which they believe were related to their outreach efforts. The majority of states in our survey reported conducting outreach on the SFSP to groups including children, parents and guardians, and schools, among others, using methods such as flyers, email, newspapers, and social media (see fig. 7). Further, state agency officials and sponsors in the selected states reported that they have developed partnerships with state and local advocacy groups and community leaders, among others, to promote the SFSP. For example, one state agency official said they partner with local advocacy organizations to field calls from parents seeking information about summer meal sites through their hunger hotline. FNS has promoted the use of such partnerships, as well as traditional and social media, to raise awareness of the SFSP. In addition, FNS developed the Summer Meals Site Finder, an online mapping tool that provides information on summer meal sites nationwide. Attracting children of all ages to SFSP meal sites can also be a challenge, according to states and SFSP providers. More than half of the states (31) reported in our survey that they faced a moderate to extreme challenge with limited youth and teen participation at summer meal sites, and an official from a national organization involved in the SFSP explained that it is difficult to attract children to a meal site when the site is focused solely on food. Similarly, 46 states in our survey reported that providing age- appropriate programming and enrichment activities for children at summer meal sites is a factor critical to the success of the SFSP. However, some meal sites may lack the resources to add activities, according to some SFSP providers in the selected states as well as FNS and national organization officials. Attracting teens can be particularly challenging, in part because of meal service time periods, a lack of age- appropriate activities, and stigma, according to national organizations and providers we interviewed. For example, early morning meal sites generally attract younger kids as teens may be apt to sleep later in the summer, and teens may also perceive a stigma in participating in a free meal program and may face peer pressure not to eat. In addition, meal offerings at SFSP sites may also present challenges to teen participation. Specifically, because FNS bases minimum portion size requirements for meals on the needs of younger children, meals are not always adequate to meet the nutritional needs of teens, according to one sponsor we interviewed. Across the 30 meal sites in the 3 states we visited in summer 2016, we observed variety in the meals served during different meal services. (see fig. 8.) States and SFSP providers have collaborated with others and sought specific types of sites to help provide enrichment activities and attract certain age groups—efforts that FNS has supported through information sharing and related grant funding. Sponsors in the selected states said they have focused on partnerships with groups such as those focused on youth development, churches, libraries, and police or fire departments, to offer age-appropriate activities for children (see fig. 9). For example, programs with local police departments, such as Cops N Kids in one selected state, or libraries in two selected states, provided meal services in combination with youth development or other enrichment activities. (See sidebar for highlights on the Cops N Kids program.) One national organization official said activities at SFSP sites can help take away the stigma around the program because children are not just there for the meal. Efforts to rebrand the SFSP as a community event where entire families can participate at the meal site also can have this effect, which is why some sponsors in the selected states said they partnered with foodbanks to donate meals for adults. In addition, a sponsor in one selected state told us they adjusted their meal offerings to match the needs of children of different age groups, for example, by serving meals to younger children earlier in the day and meals to teens later in the day. To support participation from children of all ages, FNS has shared information on age-appropriate activities through its SFSP toolkit and provided related grant funding. For example, in 2010, FNS funded the Activity Incentive demonstration project, in which sponsors in Mississippi were provided with mini-grants to increase enrichment and recreational activities, such as education, tutoring, sports and games, arts and other activities, to draw children to meal sites. More than half the states reported in our survey that they faced a moderate to extreme challenge with limited state agency staffing (27), a limited amount of federal funding for SFSP administration (27), as well as ensuring sponsor participation to meet needs (28). In addition, 28 states reported in our survey that they faced a moderate to extreme challenge with sponsors not following program requirements. Limited staffing can affect a state agency’s ability to conduct efforts aimed at increasing participation, identifying potential sponsors, and reviewing and monitoring sponsors, according to national organization and state officials we interviewed. For example, increases in sponsors and sites requires additional staff and time to conduct pre-approval visits, sponsor and site reviews, vendor reviews, and technical assistance visits, which directly affects the amount of funding needed to support staff salaries and travel reimbursement, according to one state in our survey. However, because the SFSP administrative funds FNS provides to states are based on the number of meals served in the previous year, increasing the number of staff to help increase SFSP participation is difficult, according to a national organization official we interviewed. States reported a moderate to extreme challenge with the following issues related to ensuring sponsor participation: a lack of sponsors to meet summer meal needs, a lack of awareness of the summer meal program among potential sponsors or sites, completing federal requirements for monitoring of SFSP sponsors, and identifying potential sponsors. State agencies responsible for administering the SFSP reported relying on other resources and partners to help with program administration— strategies that FNS has supported through information sharing and its online tools. As discussed earlier, all three selected state agencies we interviewed told us they partner with advocacy groups to help expand and conduct outreach on the SFSP. Additionally, more than half the states in our survey reported several factors—which may ease the administrative burden on states—as critical to the success of the SFSP, including partnerships with SFSP sponsors (49) and retaining sponsors and sites over multiple summers (51). To support states’ use of alternative funding sources to help administer the SFSP, FNS has shared information on federal, state, and private funding and grant opportunities. FNS also developed the online Capacity Builder tool, which 35 states reported in our survey was moderately to extremely useful in identifying or confirming meal site eligibility in fiscal year 2017. Seventeen states reported in our survey that ensuring summer meal sites are in safe locations was moderately to very challenging, a challenge that some states and SFSP providers have taken steps to help address. State officials and SFSP providers in the selected states reported that when crime has occurred near a site, there are concerns about ensuring children’s safety while they are consuming meals at the site, as well as the safety of site staff delivering meals. Some sponsors noted, in particular, parents’ concerns for the safety of their children at meal sites in light of criminal activities in the surrounding area. To ensure children continue to have access to meals, some sponsors noted that in the event of an immediate threat at an outdoor meal site, site staff are sometimes able to bring children to a nearby indoor space instead. States and SFSP provider officials in two selected states told us they have also used other strategies, including partnerships with local law enforcement agencies, to help address safety concerns during the meal service and ensure children have access to meals. For example, national organizations involved in summer meals and sponsor officials in the selected states said they encourage partnerships with local police departments to use police escorts at meal sites or to follow mobile meal routes in situations where safety at the meal site is a concern. When violence or crime has occurred near a site, some states and SFSP sponsors have also sought flexibility from FNS with respect to the federal requirement that children consume summer meals on site, according to state and local officials. FNS has used its available authorities to grant some states and sponsors flexibility with respect to the requirement that children consume summer meals on site, such as when safety at the site is a concern; however, FNS has not clearly communicated to all states and sponsors the circumstances it considers when deciding whether to grant this flexibility. According to our review of letters FNS sent to multiple states approving their requests for this type of flexibility, the agency identified a consistent set of circumstances that needed to be met for it to grant this flexibility. These circumstances were described in the letters the agency sent to states and generally included verification that violent crime activities occurred within both a 6-block radius of the meal site and 72 hours prior to the meal service. FNS’s letters to states indicate that when documentation was provided to the agency showing that these circumstances existed at a summer meals site on a particular day or days, meals consumed by children off site on those days were eligible for federal reimbursement. Although FNS has issued guidance on the general processes for requesting flexibility from program requirements under its waiver and demonstration authorities, these guidance documents do not detail the specific circumstances that the agency considers when deciding whether to grant flexibility from the on-site requirement due to safety concerns. FNS has communicated this information only in its responses to specific state and sponsor requests, and it has not communicated these circumstances more broadly to all states and sponsors. FNS officials explained that they review state and sponsor requests for flexibility due to safety concerns on a case-by-case basis. However, they also acknowledged that the set of circumstances used for approval of state and sponsor requests for flexibility, which we identified in their letters to states, has been used repeatedly. Further, states and sponsors reported challenges obtaining the specific data needed for approval of a site for this type of flexibility, hampering some providers’ efforts to ensure safe delivery of meals. For example, state agency and sponsor officials in one selected state said obtaining the crime data needed to qualify for the flexibility can be an administrative burden on sponsors, and these data are not consistently available in a timely manner. According to state agency and sponsor officials in one of the selected states, daily crime statistics are not available in all areas, and while a sponsor can sometimes access current data on crime in a city, the most recent available data on crime in suburban areas are sometimes one year old. FNS is aware of state and local challenges obtaining the necessary crime data, according to our discussions with FNS officials. FNS officials acknowledged that while they have granted some state and sponsor requests to allow children to consume meals off site in certain areas where violence or crime has occurred, some sponsors were unable to implement the flexibility because they could not obtain the necessary crime data. To help achieve agency objectives and address related risks, the Standards for Internal Control in the Federal Government state that agencies should communicate key information to their internal and external stakeholders. Although FNS officials told us they do not have one set of circumstances under which they approve these requests, our review found only one set of circumstances under which this type of flexibility has been approved. However, FNS has not broadly communicated the circumstances it considers in deciding whether to approve requests for flexibility with respect to the requirement that children consume summer meals on site in areas with violence or crime. Unless FNS shares this information with all states and sponsors, states and sponsors will likely continue to be challenged to use this flexibility, hindering its usefulness in ensuring safe summer meal delivery to children. In addition, FNS has issued reports to Congress evaluating some of its demonstration projects, as required under its statutory authorities, but the agency has not issued any such reports to Congress specifically on the use of flexibilities with respect to the on-site requirement in areas where safety is a concern. As previously discussed, the agency is required to annually submit certain reports to Congress regarding the use of waivers and evaluations of projects carried out under its demonstration authority. Furthermore, Standards for Internal Control in the Federal Government state that management should use quality information to make informed decisions and evaluate the entity’s performance in achieving key objectives and addressing risks. Yet, FNS has not evaluated nor reported on the use of waivers and demonstration projects in cases where safety was a concern. Although FNS requests reports from state agencies or sponsors that have received flexibility with summer meals delivery under FNS’s demonstration and waiver authorities, FNS officials told us they have not assessed whether their use of these flexibilities to address safety issues has been effective in ensuring safe meal delivery. FNS officials told us that they have not evaluated or reported on these flexibilities, in part, because they have limited information on their outcomes. Without understanding the impact of its use of these flexibilities, neither FNS nor Congress knows whether these flexibilities are helping provide meals to children. In addition to the challenges with safety at meal sites, sponsors also sometimes face administrative challenges when participating in multiple child nutrition programs that are operated by different state agencies or divisions within the same agency, according to officials from national and regional organizations and sponsors we interviewed. For example, officials from national organizations involved in summer meals told us the management of each child nutrition program and processes related to applications, funding, and oversight are fragmented in many states. For example, a sponsor in one of the selected states told us aspects of the SFSP and CACFP sponsor applications are highly duplicative and estimated it took 42 hours last year to complete duplicative paperwork. Another sponsor that provides school meals during the school year told us they had to fill out 60 additional pages of paperwork to provide summer meals, which coupled with having a state contact for the SFSP that was different from the one they worked with for the NSLP, was a significant burden for them. Officials from one national organization told us a lack of interoperability of some state agencies’ data systems has caused challenges and administrative burden for some sponsors. For example, in some states, different agencies oversee child nutrition programs, yet are unable to share data on sponsor approval, and therefore, sponsors are required to submit similar information to both, according to these officials. Duplicative paperwork can be particularly burdensome for some SFSP providers, as national organization officials and SFSP providers in the selected states said completing SFSP application paperwork can be especially challenging when a sponsor has staff shortages or no dedicated SFSP staff. Some selected states have worked with SFSP sponsors to help minimize the administrative burden. For example, state agency officials from one of the selected states said they have connected less-experienced sponsors to more-experienced sponsors in the community to help them with program administration. In one case, an experienced SFSP sponsor partnered with a small sponsor new to the program to help with SFSP administration, including helping them understand program rules and paperwork requirements. One SFSP sponsor also noted that their state agency took additional steps to ease administrative burden, such as making the forms for the CACFP more consistent with those for the SFSP and streamlining certain requirements for large and experienced sponsors, which the sponsor found helpful. At the federal level, FNS has established program and policy simplifications to help lessen the administrative burden on sponsors participating in multiple child nutrition programs, though the persistence of these challenges indicate that information about these simplifications has not reached all relevant state agencies. While FNS officials told us that some of the duplicative requirements may be a function of differences in statute, FNS provided guidance to states in 2011 and 2014 on simplified application procedures for institutions participating in CACFP that also wish to apply for SFSP. FNS noted in its guidance that in states where CACFP and SFSP are administered by different state agencies, state agencies are encouraged to work together to share information and streamline the application and agreement process as much as possible. FNS also addressed these simplifications in a state agency meeting in November 2017. Additionally, FNS provided guidance to states in 2012 on simplified application and review procedures for school food authorities participating in the NSLP that wish to also participate in the SFSP. Although FNS has shared this information with states in an attempt to make them aware of streamlining options, FNS officials noted that some states may choose not to implement them. Standards for Internal Control in the Federal Government state that management should externally communicate the necessary quality information to achieve the entity’s objectives, as well as periodically evaluate the methods of communication to ensure communication is effective and appropriate. FNS’s existing guidance addresses options for streamlining administrative requirements for sponsors participating in multiple child nutrition programs. However, information on program and policy simplifications available for sponsors participating in both NSLP and SFSP has not been shared with states recently, and challenges in this area persist, indicating this information has not reached all relevant state agencies. Without further efforts from FNS to disseminate information on current options for streamlining administrative requirements across child nutrition programs, overlapping and duplicative administrative requirements may limit children’s access to meals by discouraging sponsor participation in child nutrition programs. The purpose of the SFSP is to continue to provide children in low-income areas with nutritious meals over the summer when school is no longer in session, and to that end, the program provided 149 million SFSP meals to children in fiscal year 2016. Although meals served are one indicator of participation, FNS’s current estimates of children participating in SFSP are unreliable. Without additional understanding of children’s participation in the SFSP, FNS lacks information critical for informing program implementation, strategic planning, and outreach. The majority of states nationwide and SFSP providers in the three states we visited reported experiencing a number of challenges with the SFSP, and FNS has taken important steps to address these challenges. Two key challenges identified by officials in the selected states and national organizations we interviewed are ensuring summer meal sites are in safe locations, and meeting administrative requirements when participating in multiple child nutrition programs. FNS has taken steps to address these challenges by providing flexibilities in how meals are delivered to children and streamlining options for those providers participating in more than one child nutrition program. However, a lack of clarity concerning the circumstances under which FNS grants flexibilities in areas of violence and crime, and a lack of information on its use of these flexibilities and their impact on program administration, hinder efforts to ensure program goals are met. Furthermore, absent a reminder to states regarding existing options for streamlining administration across multiple nutrition programs, some providers may continue to be discouraged from participating in these programs due to duplicative and burdensome administrative requirements, which may ultimately limit the provision of nutritious meals to children. We are making the following four recommendations to FNS: The Administrator of FNS should improve its estimate of children’s participation in the SFSP by focusing on addressing, at a minimum, data reliability issues caused by variations in the number of operating days of meal sites and in the months in which states see the greatest number of meals served. (Recommendation 1) The Administrator of FNS should communicate to all SFSP stakeholders the circumstances it considers in approving requests for flexibility with respect to the requirement that children consume SFSP meals on-site in areas that have experienced crime and violence, taking into account the feasibility of accessing data needed for approval, to ensure safe delivery of meals to children. (Recommendation 2) The Administrator of FNS should evaluate and annually report to Congress, as required by statute, on its use of waivers and demonstration projects to grant states and sponsors flexibility with respect to the requirement that children consume SFSP meals on-site in areas experiencing crime or violence, to improve its understanding of the use and impact of granting these flexibilities on meeting program goals. (Recommendation 3) The Administrator of FNS should disseminate information about existing flexibilities available to state agencies to streamline administrative requirements for sponsors participating in the SFSP and other child nutrition programs to help lessen the administrative burden. For example, FNS could re-distribute existing guidance to state agencies that explains available flexibilities and encourage information sharing. (Recommendation 4) We provided a draft of this report to the Secretary of the USDA for review and comment. FNS officials provided technical comments, which we incorporated as appropriate. In addition, in oral comments, FNS officials, including the Deputy Administrator for Child Nutrition Programs, generally agreed with the recommendations in the report. As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies to the Secretary of the USDA and interested congressional committees. The report will also be available at no charge on the GAO website at www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7215 or larink@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix IV. This appendix discusses in detail our methodology for addressing three research objectives: (1) What is known about participation in the Summer Food Service Program (SFSP) and how has it changed in the last 10 years? (2) What other programs help feed low-income children over the summer? and (3) What challenges exist, if any, in providing summer meals to children, and to what extent does the U.S. Department of Agriculture’s (USDA) Food and Nutrition Service (FNS) provide assistance to states and sponsors to address these challenges? In addition to the methods we discuss below, to address all three research objectives, we reviewed relevant federal laws, regulations, and guidance; interviewed FNS officials in its headquarters and seven regional offices; and interviewed a broad range of regional and nationwide organizations involved in the SFSP. In addition, we coordinated with officials in USDA’s Office of Inspector General on their ongoing work in this area. To address our first objective about participation in the SFSP, we analyzed FNS data on meals served for fiscal years 2007 through 2016. Specifically, we analyzed the total number of meals served nationwide through the SFSP from fiscal year 2007 through fiscal year 2016. Each month, states report to FNS the number of meals served by meal type (breakfast, lunch, snack, and supper) and the number of meals served by meal and sponsor type (e.g., government, nonprofit, etc.) using the FNS- 418 form. To add context on these trends, we also analyzed and compared the number of SFSP lunches served in July with the number of free and reduced-price lunches served to children in March through the National School Lunch Program (NSLP), the largest child nutrition assistance program, from fiscal year 2007 through fiscal year 2016. Each month, states report to FNS the number of meals served through the NSLP using the FNS-10 form. To assess the reliability of SFSP and NSLP data, we (1) performed electronic testing of relevant data elements, (2) reviewed existing information about the data and the system that produced them, and (3) interviewed agency officials knowledgeable about the data. Electronic testing included, but was not limited to, checks for missing data elements, duplicative records, and values outside a designated range or valid time period. We determined that these data were sufficiently reliable to identify the number of SFSP meals served and assess change over time. To further examine what is known about participation in the SFSP, we also reviewed FNS’s data on estimates of children’s participation in the program and determined that these estimates have been calculated inconsistently and are unreliable. To assess the reliability of these data, we reviewed documentation about the estimates, interviewed FNS officials, and asked states about the estimate calculation in our survey. As described in our findings, FNS does not collect data on the number of children participating in the SFSP. Instead, FNS relies on states’ estimates of children’s participation, which are based on other data reported by sponsors, such as the number of meals served and meal service days in July. To address our second objective about other programs that help feed children in the summer, we reviewed FNS’s estimate of the number of meals served through the NSLP’s Seamless Summer Option in fiscal year 2016. FNS does not collect data on the number of meals served through the Seamless Summer Option. Instead, FNS annually estimates the number of Seamless Summer Option meals served nationally by aggregating the number of free and reduced-price breakfasts, lunches, and snacks served through the School Breakfast Program (SBP) and NSLP in July. As previously noted, states report these data monthly to FNS. Although FNS does not know the actual number of meals served through the Seamless Summer Option, agency officials told us they believe the number of summer meals provided through the NSLP is small relative to the number of meals served through the Seamless Summer Option during the summer months. They noted that their use of July NSLP data to estimate the Seamless Summer Option meals likely overestimates the number of these meals for July and underestimates the number of these meals for the entire summer. To assess the reliability of the July NSLP data, we (1) performed electronic testing of relevant data elements, (2) reviewed existing information about the data and the system that produced them, and (3) interviewed agency officials knowledgeable about the data. Electronic testing included, but was not limited to, checking for missing data and data that fell outside of a reasonable range or date for the specific time period (July). We determined that these data were sufficiently reliable to describe the number of meals served. In addition to the data FNS requires states to report, some states collect summer meals data at the meal site level and we used such data from the three selected states to address all three objectives. For objective one, to examine the number of meals served and days of operation at each summer meals site, we analyzed site-level data for 2 months from summer 2016, including the month with the largest number of SFSP meals served in each selected state: Arizona (June and July 2016), Illinois (July and August 2016), and Massachusetts (July and August 2016). Each state also provided us with data on the number and types of meals served at each SFSP site, the site location, and the duration of time each site operated over the summer. Using the data provided by the states, we calculated the average daily attendance (ADA) for each meal site based on FNS’s instructions and examined the variation in ADA across sites and months. For our second objective on other programs, these selected states provided similar site level data for the state’s Seamless Summer Option sites, if applicable. We assessed the reliability of these data by (1) performing electronic testing of relevant data elements, (2) reviewing existing information about the data and the system that produced them, and (3) interviewing agency officials knowledgeable about the data. We determined that the data were sufficiently reliable for the purposes of this report. For both our second objective on other programs and third objective about challenges in providing summer meals to children, we also examined meal site availability in the three selected states by mapping the locations of meal sites. On the maps, we included fiscal year 2016 area eligibility data from FNS’s Capacity Builder mapping tool, as provided by FNS. The site area eligibility data from FNS’s Capacity Builder is based on the U.S. Census Bureau’s 5-Year American Community Survey (ACS) estimates of children ages 0-12 and 0-18 eligible for free and reduced-price meals by Census block group and tract. According to FNS officials, FNS obtains 5-Year ACS estimates annually from the U.S. Census Bureau and updates its site area eligibility in the Capacity Builder accordingly. For fiscal year 2016, FNS used 2009- 2013 ACS data to identify and include site area eligibility in its Capacity Builder. To help inform all of our research objectives, we conducted a survey of the state agencies that oversee the SFSP in the 50 states and the District of Columbia. We administered our web-based survey between August and October 2017 and received 100 percent response rate. The survey included questions about participation in the SFSP, factors critical to the overall success of the SFSP, outreach efforts, federal technical assistance, barriers and challenges in providing summer meals, alternative summer feeding models, the NSLP’s Seamless Summer Option and the federal Summer Electronic Benefit Transfer for Children demonstration, and nonfederal programs that provide children of low- income households with meals during the summer months. The survey also requested data on SFSP sites participating in the program in fiscal year 2016 and the method state agencies used to calculate ADA in SFSP on the FNS-418 form in fiscal year 2016. Because this was not a sample survey, there are no sampling errors. However, the practical difficulties of conducting any survey may introduce nonsampling errors, such as variations in how respondents interpret questions and their willingness to offer accurate responses. We took steps to minimize nonsampling errors, including pretesting draft instruments and using a web-based administration system. Specifically, during survey development, we pretested draft instruments with SFSP staff from four states (Michigan, New Mexico, North Carolina, and South Dakota) in May 2017. We selected the pretest states based on information provided by officials from FNS’s regional offices and national organizations involved in summer meals about state administration of summer meals programs, with the goal of selecting a group of states with varied experiences. In the pretests, we were generally interested in the clarity, precision, and objectivity of the questions, as well as the flow and layout of the survey. For example, we wanted to ensure definitions used in the surveys were clear and known to the respondents, categories provided in close-ended questions were complete and exclusive, and the ordering of survey sections and the questions within each section were appropriate. We revised the final survey based on pretest results. Another step we took to minimize nonsampling errors was using a web-based survey. Allowing respondents to enter their responses directly into an electronic instrument created a record for each respondent in a data file and eliminated the need for and the errors associated with a manual data entry process. We did not fully validate specific information that states reported through our survey. To help inform all of our objectives and gather information about the SFSP directly at the local-level, we conducted 30 site visits in three states: Arizona (12 sites), Illinois (8 sites), and Massachusetts (10 sites) between June and July 2017, and interviewed organizations involved with the SFSP in each site visit state. We used U.S. Census Bureau data to select states and local areas within those states based on a high proportion of children in poverty, a mix of urban and rural locations, as well as a mix of sponsor and site type and diverse locations. We visited a wide variety of site locations including, but not limited to, schools, parks, community recreation areas, and libraries. At each SFSP site, we gathered information on local level factors related to SFSP participation and administration by interviewing the organization sponsoring the site, the site operators and staff, and those participating at the site using semi-structured questions. While interviewing SFSP sponsor organizations, we collected information on the sponsors’ roles in the SFSP, characteristics of the sites the organizations sponsored, outreach efforts, any challenges or barriers to SFSP administration and any efforts to address such challenges, relationships with the state agencies that administer the SFSP, relationships with FNS (national and regional offices), and the availability of nonfederally funded programs that provide meals to low-income children over the summer. During the interviews with site operators and staff, we collected information about site operation (e.g., site operating days, meals offered, etc.), any challenges to providing SFSP meals to children and any efforts to address such challenges, outreach efforts, and the proximity of the next closest meal site. The information we collected from those participating at the sites included their perspectives on the SFSP food, site food consumption habits, ease of travel to the site, and access to other SFSP sites. At each site, we made observations as to how the food was provided to the children, food consumption and waste, the approximate age range of the children being served, and availability of programs or activities (e.g., recreational sports). Using semi-structured questions, we also interviewed the state agencies responsible for administering the SFSP in the site visit states to gather further information on how the SFSP is administered in each state, statewide participation in the program, related data collection activities, any challenges to administering the program and any efforts to address such challenges, related outreach efforts, alternative meal delivery models being employed by SFSP sponsors, FNS guidance or technical assistance, and the availability of nonfederally funded programs that provide meals to low-income children over the summer. For states that indicated there were other challenge(s), we provided an open-ended question that requested a description of the challenge(s) and 14 states provided descriptions of other challenges, not shown here. For states that indicated there were other challenge(s), we provided an open-ended question that requested a description of the challenge(s) and 8 states provided descriptions of other challenges, not shown here. In addition to the contact named above, Rachel Frisk (Assistant Director), Claudine Pauselli (Analyst-in-Charge), Melissa Jaynes, and Matthew Nattinger made key contributions to this report. Also contributing to this report were Susan Aschoff, Sarah Cornetto, Ying Long, Jean McSween, Mimi Nguyen, Almeta Spencer, and Ashanta Williams.

 

 Report 2:
Medicare is one of four principal health-insurance programs administered by CMS; it provides health insurance for persons aged 65 and over, certain individuals with disabilities, and individuals with end-stage renal disease. See table 1 for information about Medicare’s component programs. Medicare is the largest CMS program, at $702 billion in fiscal year 2017. As discussed earlier, according to CBO, Medicare outlays are projected to rise to $1.5 trillion in 2028 (see fig. 1). Fraud involves obtaining something of value through willful misrepresentation. There are no reliable estimates of the extent of fraud in the Medicare program, or in the health-care industry as a whole. By its very nature, fraud is difficult to detect, as those involved are engaged in intentional deception. Further, potential fraud cases must be identified, investigated, prosecuted, and adjudicated—resulting in a conviction— before fraud can be established. As I mentioned earlier, we designated Medicare as a high-risk program in 1990 because its size, scope, and complexity make it vulnerable to fraud, waste, and abuse. Similarly, the Office of Management and Budget (OMB) designated all parts of Medicare a “high priority” program because they each report $750 million or more in improper payments in a given year. We also highlighted challenges associated with duplicative payments in Medicare in our annual report on duplication and opportunities for cost savings in federal programs. Improper payments are a significant risk to the Medicare program and may include payments made as a result of fraud. However, I would note that improper payments are not a proxy for the amount of fraud or extent of fraud risk in a particular program as improper payment measurement does not specifically identify or estimate such payments due to fraud. Improper payments are those that are either made in an incorrect amount (overpayments and underpayments) or those that should not have been made at all. Our December 2017 report found that CMS manages its fraud risks as part of a broader program-integrity approach working with a broad array of stakeholders. CMS’s program-integrity approach includes efforts to address waste, abuse, and improper payments as well as fraud across its four principal programs. In Medicare, CMS collaborates with contractors, health-insurance plans, and law-enforcement and other agencies to carry out its program-integrity responsibilities. According to CMS officials, this broader program-integrity approach can help the agency develop control activities to address multiple sources of improper payments, including fraud. According to federal standards and guidance, executive-branch agency managers are responsible for managing fraud risks and implementing practices for combating those risks. Federal internal control standards call for agency management officials to assess the internal and external risks their entities face as they seek to achieve their objectives. The standards state that as part of this overall assessment, management should consider the potential for fraud when identifying, analyzing, and responding to risks. Risk management is a formal and disciplined practice for addressing risk and reducing it to an acceptable level. In July 2015, GAO issued the Fraud Risk Framework, which provides a comprehensive set of key components and leading practices that serve as a guide for agency managers to use when developing efforts to combat fraud in a strategic, risk-based way. The Fraud Risk Framework describes leading practices in four components: commit, assess, design and implement, and evaluate and adapt, as depicted in figure 2. The Fraud Reduction and Data Analytics Act of 2015, enacted in June 2016, requires OMB to establish guidelines for federal agencies to create controls to identify and assess fraud risks and design and implement antifraud control activities. The act further requires OMB to incorporate the leading practices from the Fraud Risk Framework in the guidelines. In July 2016, OMB published guidance about enterprise risk management and internal controls in federal executive departments and agencies. Among other things, this guidance affirms that managers should adhere to the leading practices identified in the Fraud Risk Framework. Further, the act requires federal agencies to submit to Congress a progress report each year for 3 consecutive years on the implementation of the controls established under OMB guidelines, among other things. CMS’s antifraud efforts partially aligned with the Fraud Risk Framework. Consistent with the framework, CMS has demonstrated commitment to combating fraud by creating a dedicated entity to lead antifraud efforts. It has also taken steps to establish a culture conducive to fraud risk management, although it could expand its antifraud training to include all employees. CMS has taken some steps to identify fraud risks in Medicare; however, it has not conducted a fraud risk assessment or developed a risk-based antifraud strategy for Medicare as defined in the Fraud Risk Framework. CMS has established monitoring and evaluation mechanisms for its program-integrity control activities that, if aligned with a risk-based antifraud strategy, could enhance the effectiveness of fraud risk management in Medicare. The commit component of the Fraud Risk Framework calls for an agency to commit to combating fraud by creating an organizational culture and structure conducive to fraud risk management. This component includes establishing a dedicated entity to lead fraud risk management activities. Within CMS, the Center for Program Integrity (CPI) serves as the dedicated entity for fraud, waste, and abuse issues in Medicare, which is consistent with the Fraud Risk Framework. CPI was established in 2010, in response to a November 2009 Executive Order on reducing improper payments and eliminating waste in federal programs. This formalized role, according to CMS officials, elevated the status of program-integrity efforts, which previously were carried out by other parts of CMS. As an executive-level Center—on the same level with five other executive-level Centers at CMS, such as the Center for Medicare—CPI has a direct reporting line to executive-level management at CMS. The Fraud Risk Framework identifies a direct reporting line to senior-level managers within the agency as a leading practice. According to CMS officials, this elevated organizational status offers CPI heightened visibility across CMS, attention by CMS executive leadership, and involvement in executive-level conversations. The commit component of the Fraud Risk Framework also includes creating an organizational culture to combat fraud at all levels of the agency. Consistent with the Fraud Risk Framework, CMS has promoted an antifraud culture by, for example, coordinating with internal and external stakeholders. Consistent with leading practices in the Fraud Risk Framework to involve all levels of the agency in setting an antifraud tone, CPI has worked collaboratively with other CMS Centers. In addition to engaging executive-level officials of other CMS Centers through the Program Integrity Board, CPI has worked collaboratively with other Centers within CMS to incorporate antifraud features into new program design or policy development and established regular communication at the staff level. For example: Center for Medicare and Medicaid Innovation (CMMI). When developing the Medicare Diabetes Prevention Program, CMMI officials told us they worked with CPI’s Provider Enrollment and Oversight Group and Governance Management Group to develop risk-based screening procedures for entities that would enroll in Medicare to provide diabetes-prevention services, among other activities. The program was expanded nationally in 2016, and CMS determined that an entity may enroll in Medicare as a program supplier if it satisfies enrollment requirements, including that the supplier must pass existing high categorical risk-level screening requirements. Center for Medicare (CM). In addition to building safeguards into programs and developing policies, CM officials told us that there are several standing meetings, on monthly, biweekly, and weekly bases, between groups within CM and CPI that discuss issues related to provider enrollment, FFS operations, and contractor management. A senior CM official also told us that there are ad hoc meetings taking place between CM and CPI: “We interact multiple times daily at different levels of the organization. Working closely is just a regular part of our business.” CMS has also demonstrated its commitment to addressing fraud, waste, and abuse to its stakeholders. Representatives of CMS’s extensive stakeholder network whom we interviewed—contractors and officials from public and private entities—generally recognized the agency’s commitment to combating fraud. In our interviews with stakeholders, officials observed CMS’s increased commitment over time to address fraud, waste, and abuse and cited examples of specific CMS actions. CMS contractors told us that CMS’s commitment to combating fraud is incorporated into contractual requirements, such as requiring (1) data analysis for potential fraud leads and (2) fraud-awareness training for providers. Officials from entities that are members of the Healthcare Fraud Prevention Partnership (HFPP), specifically, a health-insurance plan and the National Health Care Anti-Fraud Association, added that CMS’s effort to establish the HFPP and its ongoing collaboration and information sharing reflect CMS’s commitment to combat fraud in Medicare. The Fraud Risk Framework identifies training as one way of demonstrating an agency’s commitment to combating fraud. Training and education intended to increase fraud awareness among stakeholders, managers, and employees serve as a preventive measure to help create a culture of integrity and compliance within the agency. The Fraud Risk Framework discusses requiring all employees to attend training upon hiring and on an ongoing basis thereafter. To increase awareness of fraud risks in Medicare, CMS offers and requires training for stakeholder groups such as providers, beneficiaries, and health-insurance plans. Specifically, through its National Training Program and Medicare Learning Network, CMS makes available training materials on combating Medicare fraud, waste, and abuse. These materials help to identify and report fraud, waste, and abuse in CMS programs and are geared toward providers, beneficiaries, as well as trainers and other stakeholders. Separately, CMS requires health- insurance plans working with CMS to provide annual fraud, waste, and abuse training to their employees. However, CMS does not offer or require similar fraud-awareness training for the majority of its workforce. For a relatively small portion of its overall workforce—specifically, contracting officer representatives who are responsible for certain aspects of the acquisition function—CMS requires completion of fraud and abuse prevention training every 2 years. According to CMS, 638 of its contracting officer representatives (or about 10 percent of its overall workforce) completed such training in 2016 and 2017. Although CMS offers fraud-awareness training to others, the agency does not require fraud-awareness training for new hires or on a regular basis for all employees because the agency has focused on providing process-based internal controls training for its employees. While fraud-awareness training for contracting officer representatives is an important step in helping to promote fraud risk management, fraud- awareness training specific to CMS programs would be beneficial for all employees. Such training would not only be consistent with what CMS offers to or requires of its stakeholders and some of its employees, but would also help to keep the agency’s entire workforce continuously aware of fraud risks and examples of known fraud schemes, such as those identified in successful HHS OIG investigations. Such training would also keep employees informed as they administer CMS programs or develop agency policies and procedures. Considering the vulnerability of Medicare and Medicaid programs to fraud, waste, and abuse, without regular required training CMS cannot be assured that its workforce of over 6,000 employees is continuously aware of risks facing its programs. In our December 2017 report, we recommended that the Administrator of CMS provide fraud-awareness training relevant to risks facing CMS programs and require new hires to undergo such training and all employees to undergo training on a recurring basis. In its March 2018 letter to GAO, HHS stated that CMS is in the process of developing Fraud, Waste, and Abuse Training for all new employees, to be presented at CMS New Employee Orientations. Additionally, CMS is also developing training to be completed by current CMS employees on an annual basis. As of July 2018, this recommendation remains open. The assess component of the Fraud Risk Framework calls for federal managers to plan regular fraud risk assessments and to assess risks to determine a fraud risk profile. Identifying fraud risks is one of the steps included in the Fraud Risk Framework for assessing risks to determine a fraud risk profile. In our December 2017 report, we discussed several examples of steps CMS has taken to identify fraud risks as well as control activities that target areas the agency has designated as higher risk within Medicare, including specific provider types and specific geographic locations. These examples include data analytics to assist investigations in Medicare FFS, including Medicare’s Fraud Prevention System (FPS ), prior authorization for Medicare FFS services or supplies, revised provider screening and enrollment processes for Medicare FFS, and temporary provider enrollment moratoriums for certain providers and geographic areas for Medicare FFS. CMS officials told us that CPI initially focused on developing control activities for Medicare FFS and consider these activities to be the most mature of all CPI efforts to address fraud risks. CMS Has Not Conducted a Fraud Risk Assessment for Medicare The assess component of the Fraud Risk Framework calls for federal managers to plan regular fraud risk assessments and assess risks to determine a fraud risk profile. Furthermore, federal internal control standards call for agency management to assess the internal and external risks their entities face as they seek to achieve their objectives. The standards state that, as part of this overall assessment, management should consider the potential for fraud when identifying, analyzing, and responding to risks. The Fraud Risk Framework states that, in planning the fraud risk assessment, effective managers tailor the fraud risk assessment to the program by, among other things, identifying appropriate tools, methods, and sources for gathering information about fraud risks and involving relevant stakeholders in the assessment process. Fraud risk assessments that align with the Fraud Risk Framework involve (1) identifying inherent fraud risks affecting the program, (2) assessing the likelihood and impact of those fraud risks, (3) determining fraud risk tolerance, (4) examining the suitability of existing fraud controls and prioritizing residual fraud risks, and (5) documenting the results (see fig. 3). Although CMS had identified some fraud risks posed by providers in Medicare FFS, the agency had not conducted a fraud risk assessment for the Medicare program as a whole. Such a risk assessment would provide the detailed information and insights needed to create a fraud risk profile, which, in turn, is the basis for creating an antifraud strategy. According to CMS officials, CMS had not conducted a fraud risk assessment for Medicare because, within CPI’s broader approach of preventing and eliminating improper payments, its focus has been on addressing specific vulnerabilities among provider groups that have shown themselves particularly prone to fraud, waste, and abuse. With this approach, however, it is unlikely that CMS will be able to design and implement the most-appropriate control activities to respond to the full portfolio of fraud risks. A fraud risk assessment consists of discrete activities that build upon each other. Specifically: Identifying inherent fraud risks affecting the program. As discussed earlier, CMS took steps to identify fraud risks. However, CMS has not used a process to identify inherent fraud risks from the universe of potential vulnerabilities facing Medicare, including threats from various sources. According to CPI officials, most of the agency’s fraud control activities are focused on fraud risks posed by providers. The Fraud Risk Framework discusses fully considering inherent fraud risks from internal and external sources in light of fraud risk factors such as incentives, opportunities, and rationalization to commit fraud. For example, according to CMS officials, the inherent design of the Medicare Part C program may pose fraud risks that are challenging to detect. A fraud risk assessment would help CMS identify all sources of fraudulent behaviors, beyond threats posed by providers, such as those posed by health-insurance plans, contractors, or employees. Assessing the likelihood and impact of fraud risks and determining fraud risk tolerance. CMS has taken steps to prioritize fraud risks in some areas, but it had not assessed the likelihood or impact of fraud risks or determined fraud risk tolerance across all parts of Medicare. Assessing the likelihood and impact of inherent fraud risks would involve consideration of the impact of fraud risks on program finances, reputation, and compliance. Without assessing the likelihood and impact of risks in Medicare or internally determining which fraud risks may fall under the tolerance threshold, CMS cannot be certain that it is aware of the most-significant fraud risks facing this program and what risks it is willing to tolerate based on the program’s size and complexity. Examining the suitability of existing fraud controls and prioritizing residual fraud risks. CMS had not assessed existing control activities or prioritized residual fraud risks. According to the Fraud Risk Framework, managers may consider the extent to which existing control activities—whether focused on prevention, detection, or response—mitigate the likelihood and impact of inherent risks and whether the remaining risks exceed managers’ tolerance. This analysis would help CMS to prioritize residual risks and to determine mitigation approaches. For example, CMS had not established preventive fraud control activities in Medicare Part C. Using a fraud risk assessment for Medicare Part C and closely examining existing fraud control activities and residual risks, CMS could be better positioned to address fraud risks facing this growing program and develop preventive control activities. Furthermore, without assessing existing fraud control activities and prioritizing residual fraud risks, CMS cannot be assured that its current control activities are addressing the most-significant risks. Such analysis would also help CMS determine whether additional, preferably preventive, fraud controls are needed to mitigate residual risks, make adjustments to existing control activities, and potentially scale back or remove control activities that are addressing tolerable fraud risks. Documenting the risk-assessment results in a fraud risk profile. CMS had not developed a fraud risk profile that documents key findings and conclusions of the fraud risk assessment. According to the Fraud Risk Framework, the risk profile can also help agencies decide how to allocate resources to respond to residual fraud risks. Given the large size and complexity of Medicare, a documented fraud risk profile could support CMS’s resource-allocation decisions as well as facilitate the transfer of knowledge and continuity across CMS staff and changing administrations. Senior CPI officials told us that the agency plans to start a fraud risk assessment for Medicare after it completes a separate fraud risk assessment of the federally facilitated marketplace. This fraud risk assessment for the federally facilitated marketplace eligibility and enrollment process is being conducted in response to a recommendation we made in February 2016. In April 2017, CPI officials told us that this fraud risk assessment was largely completed, although in September 2017 CPI officials told us that the assessment was undergoing agency review. CPI officials told us that they have informed CM officials that there will be future fraud risk assessments for Medicare; however, they could not provide estimated timelines or plans for conducting such assessments, such as the order or programmatic scope of the assessments. Once completed, CMS could use the federally facilitated marketplace fraud risk assessment and apply any lessons learned when planning for and designing fraud risk assessments for Medicare. According to the Fraud Risk Framework, factors such as size, resources, maturity of the agency or program, and experience in managing risks can influence how the entity plans the fraud risk assessment. Additionally, effective managers tailor the fraud risk assessment to the program when planning for it. The large scale and complexity of Medicare as well as time and resources involved in conducting a fraud risk assessment underscore the importance of a well-planned and tailored approach to identifying the assessment’s programmatic scope. Planning and tailoring may involve decisions to conduct a fraud risk assessment for Medicare as a whole or divided into several subassessments to reflect their various component parts (e.g., Medicare Part C). CMS’s existing fraud risk identification efforts as well as communication channels with stakeholders could serve as a foundation for developing a fraud risk assessment for Medicare. The leading practices identified in the Fraud Risk Framework discuss the importance of identifying appropriate tools, methods, and sources for gathering information about fraud risks and involving relevant stakeholders in the assessment process. CMS’s fraud risk identification efforts discussed earlier could provide key information about fraud risks and their likelihood and impact. Furthermore, existing relationships and communication channels across CMS and its extensive network of stakeholders could support building a comprehensive understanding of known and potential fraud risks for the purposes of a fraud risk assessment. For example, the fraud vulnerabilities identified through data analysis and information sharing with health-insurance plans, law-enforcement organizations, and contractors could inform a fraud risk assessment. CPI’s Command Center missions—facilitated collaboration sessions that bring together experts from various disciplines to improve the processes for fraud prevention in Medicare—could bring together experts to identify potential or emerging fraud vulnerabilities or to brainstorm approaches to mitigate residual fraud risks. As CMS makes plans to move forward with a fraud risk assessment for Medicare, it will be important to consider the frequency with which the fraud risk assessment would need to be updated. While, according to the Fraud Risk Framework, the time intervals between updates can vary based on the programmatic and operating environment, assessing fraud risks on an ongoing basis is important to ensure that control activities are continuously addressing fraud risks. The constantly evolving fraud schemes, the size of the programs in terms of beneficiaries and expenditures, as well as continual changes in Medicare—such as development of innovative payment models and increasing managed- care enrollment—call for constant vigilance and regular updates to the fraud risk assessment. In our December 2017 report we recommended that the Administrator of CMS conduct fraud risk assessments for Medicare and Medicaid to include respective fraud risk profiles and plans for regularly updating the assessments and profiles. In its March 2018 letter to GAO, HHS stated that it is currently evaluating its options with regards to implementing this recommendation. As of July 2018, the recommendation remains open. The design and implement component of the Fraud Risk Framework calls for federal managers to design and implement a strategy with specific control activities to mitigate assessed fraud risks and collaborate to help ensure effective implementation. According to the Fraud Risk Framework, effective managers develop and document an antifraud strategy that describes the program’s approach for addressing the prioritized fraud risks identified during the fraud risk assessment, also referred to as a risk-based antifraud strategy. A risk- based antifraud strategy describes existing fraud control activities as well as any new fraud control activities a program may adopt to address residual fraud risks. In developing a strategy and antifraud control activities, effective managers focus on fraud prevention over detection, develop a plan for responding to identified instances of fraud, establish collaborative relationships with stakeholders, and create incentives to help effectively implement the strategy. Additionally, as part of a documented strategy, management identifies roles and responsibilities of those involved in fraud risk management activities; describes control activities as well as plans for monitoring and evaluation; creates timelines; and communicates the antifraud strategy to employees and stakeholders, among other things. As discussed earlier, CMS had some control activities in place to identify fraud risk in Medicare, particularly in the FFS program. However, CMS had not developed and documented a risk-based antifraud strategy to guide its design and implementation of new antifraud activities and to better align and coordinate its existing activities to ensure it is targeting and mitigating the most-significant fraud risks. Antifraud strategy. CMS officials told us that CPI does not have a documented risk-based antifraud strategy. Although CMS has developed several documents that describe efforts to address fraud, the agency had not developed a risk-based antifraud strategy for Medicare because, as discussed earlier, it had not conducted a fraud risk assessment that would serve as a foundation for such strategy. In 2016, CPI identified five strategic objectives for program integrity, which include antifraud elements and an emphasis on prevention. However, according to CMS officials, these objectives were identified from discussions with CMS leadership and various stakeholders and not through a fraud risk assessment process to identify inherent fraud risks from the universe of potential vulnerabilities, as described earlier and called for in the leading practices. These strategic objectives were presented at an antifraud conference in 2016, but were not announced publicly until the release of the Annual Report to Congress on the Medicare and Medicaid Integrity Programs for Fiscal Year 2015 in June 2017. Stakeholder relationships and communication. CMS has established relationships and communicated with stakeholders, but, without an antifraud strategy, stakeholders we spoke with lacked a common understanding of CMS’s strategic approach. Prior work on practices that can help federal agencies collaborate effectively calls for a strategy that is shared with stakeholders to promote trust and understanding. Once an antifraud strategy is developed, the Fraud Risk Framework calls for managers to collaborate to ensure effective implementation. Although some CMS stakeholders were able to describe various CMS program- integrity priorities and activities, such as home health being a fraud risk priority, the stakeholders could not communicate, articulate, or cite a common CMS strategic approach to address fraud risks in its programs. Incentives. The Fraud Risk Framework discusses creating incentives to help ensure effective implementation of the antifraud strategy once it is developed. Currently, some incentives within stakeholder relationships may complicate CMS’s antifraud efforts. Among contractors, CMS encourages information sharing through conferences and workshops; however, competition for CMS business among contractors can be a disincentive to information sharing. CMS officials acknowledged this concern and said that they expect contractors to share information related to fraud schemes, outcomes of investigations, and tips for addressing fraud, but not proprietary information such as algorithms to risk-score providers. Without developing and documenting an antifraud strategy based on a fraud risk assessment, as called for in the design and implement component of the Fraud Risk Framework, CMS cannot ensure that it has a coordinated approach to address the range of fraud risks and to appropriately target and allocate resources for the most-significant risks. Considering fraud risks to which Medicare is most vulnerable, in light of the malicious intent of those who aim to exploit the programs, would help CMS to examine its current control activities and potentially design new ones with recognition of fraudulent behavior it aims to prevent. This focus on fraud is distinct from a broader view of program integrity and improper payments by considering the intentions and incentives of those who aim to deceive rather than well-intentioned providers who make mistakes. Also, continued growth of the program, such as growth of Medicare Part C, calls for consideration of preventive fraud control activities across the entire network of entities involved. Furthermore, considering the large size and complexity of Medicare and the extensive stakeholder network involved in managing fraud in the program, a strategic approach to managing fraud risks within the programs is essential to ensure that a number of existing control activities and numerous stakeholder relationships and incentives are being aligned to produce desired results. Once developed, an antifraud strategy that is clearly articulated to various CMS stakeholders would help CMS to address fraud risks in a more coordinated and deliberate fashion. Thinking strategically about existing control activities, resources, tools, and information systems could help CMS to leverage resources while continuing to integrate Medicare program-integrity efforts along functional lines. A strategic approach grounded in a comprehensive assessment of fraud risks could also help CMS to identify future enhancements for existing control activities, such as new preventive capabilities for its Fraud Prevention System (FPS) or additional fraud factors in provider enrollment and revalidation, such as provider risk-scoring, to stay in step with evolving fraud risks. CMS Has Established Monitoring and Evaluation Mechanisms That Could Inform a Risk-Based Antifraud Strategy for Medicare The evaluate and adapt component of the Fraud Risk Framework calls for federal managers to evaluate outcomes using a risk-based approach and adapt activities to improve fraud risk management. Furthermore, according to federal internal control standards, managers should establish and operate monitoring activities to monitor the internal control system and evaluate the results, which may be compared against an established baseline. Ongoing monitoring and periodic evaluations provide assurances to managers that they are effectively preventing, detecting, and responding to potential fraud. CMS has established monitoring and evaluation mechanisms for its program-integrity activities that it could incorporate into an antifraud strategy. As described in the Fraud Risk Framework, agencies can gather information on the short-term or intermediate outcomes of some antifraud initiatives, which may be more readily measured. For example, CMS has developed some performance measures to provide a basis for monitoring its progress towards meeting the program-integrity goals set in the HHS Strategic Plan and Annual Performance Plan. Specifically, CMS measures whether it is meeting its goal of “increasing the percentage of Medicare FFS providers and suppliers identified as high risk that receive an administrative action.” CMS does not set specific antifraud goals for other parts of Medicare; other CMS performance measures relate to measuring or reducing improper payments in the various parts of Medicare. CMS uses return-on-investment and savings estimates to measure the effectiveness of its Medicare program-integrity activities and FPS. For example, CMS uses return-on-investment to measure the effectiveness of FPS and, in response to a recommendation we made in 2012, CMS developed outcome-based performance targets and milestones for FPS. CMS has also conducted individual evaluations of its program-integrity activities, such as an interim evaluation of the prior-authorization demonstration for power mobility devices that began in 2012 and is currently implemented in 19 states. Commensurate with greater maturity of control activities in Medicare FFS compared to other parts of Medicare and Medicaid, monitoring and evaluation activities for Medicare Parts C and D and Medicaid are more limited. For example, CMS calculates savings for its program-integrity activities in Medicare Parts C and D, but not a full return-on-investment. CMS officials told us that calculating costs for specific activities is challenging because of overlapping activities among contractors. CMS officials said they continue to refine methods and develop new savings estimates for additional program-integrity activities. According to the Fraud Risk Framework, effective managers develop a strategy and evaluate outcomes using a risk-based approach. In developing an effective strategy and antifraud activities, managers consider the benefits and costs of control activities. Ongoing monitoring and periodic evaluations provide reasonable assurance to managers that they are effectively preventing, detecting, and responding to potential fraud. Monitoring and evaluation activities can also support managers’ decisions about allocating resources, and help them to demonstrate their continued commitment to effectively managing fraud risks. As CMS takes steps to develop an antifraud strategy, it could include plans for refining and building on existing methods such as return-on- investment or savings measures, and setting appropriate targets to evaluate the effectiveness of all of CMS’s antifraud efforts. Such a strategy would help CMS to efficiently allocate program-integrity resources and to ensure that the agency is effectively preventing, detecting, and responding to potential fraud. For example, while doing so would involve challenges, CMS’s strategy could detail plans to advance efforts to measure a potential fraud rate through baseline and periodic measures. Fraud-rate measurement efforts could also inform risk assessment activities, identify currently unknown fraud risks, align resources to priority risks, and develop effective outcome metrics for antifraud controls. Such a strategy would also help CMS ensure that it has effective performance measures in place to assess its antifraud efforts beyond those related to providers in Medicare FFS, and establish appropriate targets to measure the agency’s progress in addressing fraud risks. In our December 2017 report we recommended that the Administrator of CMS should, using the results of the fraud risk assessments for Medicare, create, document, implement, and communicate an antifraud strategy that is aligned with and responsive to regularly assessed fraud risks. This strategy should include an approach for monitoring and evaluation. In its March 2018 letter to GAO, HHS stated that it is currently evaluating its options with regards to implementing this recommendation. As of July 2018, the recommendation remains open. Chairman Jenkins and Ranking Member Lewis, this concludes my prepared statement. I look forward to the subcommittee’s questions. If you or your staff have any questions concerning this testimony, please contact Seto J. Bagdoyan, who may be reached at (202) 512-6722 or bagdoyans@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement. Other individuals who made key contributions to this testimony include Tonita Gillich (Assistant Director), Irina Carnevale (Analyst-in- Charge), Colin Fallon, Scott Hiromoto, and Maria McMullen. Improper Payments: Actions and Guidance Could Help Address Issues and Inconsistencies in Estimation Processes. GAO-18-377. Washington, D.C.: May 31, 2018. Medicare: CMS Should Take Actions to Continue Prior Authorization Efforts to Reduce Spending. GAO-18-341. Washington, D.C.: April 20, 2018. Medicare and Medicaid: CMS Needs to Fully Align Its Antifraud Efforts with the Fraud Risk Framework. GAO-18-88. Washington, D.C.: December 5, 2017. Medicare: CMS Fraud Prevention System Uses Claims Analysis to Address Fraud. GAO-17-710. Washington, D.C.: August 30, 2017. Medicare Advantage Program Integrity: CMS’s Efforts to Ensure Proper Payments and Identify and Recover Improper Payments. GAO-17-761T. Washington, D.C.: July 19, 2017. Medicare Provider Education: Oversight of Efforts to Reduce Improper Billing Needs Improvement. GAO-17-290. Washington, D.C.: March 10, 2017. High-Risk Series: Progress on Many High-Risk Areas, While Substantial Efforts Needed on Others. GAO-17-317. Washington, D.C.: February 15, 2017. Medicare Advantage: Limited Progress Made to Validate Encounter Data Used to Ensure Proper Payments. GAO-17-223. Washington, D.C.: January 17, 2017. Medicare: Initial Results of Revised Process to Screen Providers and Suppliers, and Need for Objectives and Performance Measures. GAO-17-42. Washington, D.C.: November 15, 2016. Medicare: Claim Review Programs Could Be Improved with Additional Prepayment Reviews and Better Data. GAO-16-394. Washington, D.C.: April 13, 2016. Medicare Advantage: Fundamental Improvements Needed in CMS’s Effort to Recover Substantial Amounts of Improper Payments. GAO-16- 76. Washington, D.C.: April 8, 2016. Health Care Fraud: Information on Most Common Schemes and the Likely Effect of Smart Cards. GAO-16-216. Washington, D.C.: January 22, 2016. A Framework for Managing Fraud Risks in Federal Programs. GAO-15-593SP. Washington, D.C.: July 28, 2015. Medicare Program Integrity: Increased Oversight and Guidance Could Improve Effectiveness and Efficiency of Postpayment Claims Reviews. GAO-14-474. Washington, D.C.: July 18, 2014. Medicare Fraud Prevention: CMS Has Implemented a Predictive Analytics System, but Needs to Define Measures to Determine Its Effectiveness. GAO-13-104. Washington, D.C.: October 15, 2012. This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.

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

Answer: The SFSP, a federal nutrition assistance program, is intended to provide food to children in low-income areas during periods when area schools are closed for vacation. In the last decade, federal expenditures for SFSP have increased as the program has expanded, according to USDA data. GAO was asked to review the SFSP. This report examines (1) what is known about SFSP participation, (2) other programs that help feed low-income children over the summer, and (3) challenges, if any, in providing summer meals to children and the extent to which USDA provides assistance to address these challenges. GAO reviewed relevant federal laws, regulations, and guidance; analyzed USDA's SFSP data for fiscal years 2007 through 2016; surveyed state agencies responsible for administering the SFSP in 50 states and the District of Columbia; visited a nongeneralizable group of 3 states and 30 meal sites, selected based on Census data on child poverty rates and urban and rural locations; analyzed meal site data from the 3 states; and interviewed USDA, state and national organization officials, and SFSP providers, including sponsors and site operators. Nationwide, the total number of meals served to children in low-income areas through the Summer Food Service Program (SFSP) increased from 113 to 149 million (about 32 percent) from fiscal year 2007 through 2016. The U.S. Department of Agriculture (USDA) directs states to use the number of meals served, along with other data, to estimate the number of children participating in the SFSP. However, participation estimates have been calculated inconsistently from state to state and year to year. In 2017, USDA took steps to improve the consistency of participation estimates, noting they are critical for informing program implementation and strategic planning. However, GAO determined that the method USDA directs states to use will continue to provide unreliable estimates of participation, hindering USDA's ability to use them for these purposes. Other federal and nonfederal programs help feed low-income children over the summer to some extent, according to states GAO surveyed and SFSP providers and others GAO interviewed. For example, in July 2016, USDA data indicate about 26 million meals were served through a separate federal program that allows school meal providers to serve summer meals. Some children also received summer meals through nonfederal programs operated by faith-based organizations and foodbanks, though GAO's state survey and interviews with providers and national organizations indicate the reach of such efforts is limited. States and SFSP providers reported challenges with meal sites, participation, and program administration; USDA has taken steps to address these areas. Specifically, in GAO's survey, a majority of states reported challenges with availability and awareness of meal sites, as well as limited program participation and administrative capacity. National, state, and local officials have taken steps to address these issues, such as increasing outreach and offering activities to attract participation. In addition, 17 states in GAO's survey and providers in the states GAO visited reported a challenge with ensuring meal sites are in safe locations. To address this safety issue, USDA has granted some states and sponsors flexibility from the requirement that children consume meals on-site. However, USDA has not broadly communicated the circumstances it considers when granting this flexibility. Further, some states and sponsors that have requested this flexibility reported difficulty obtaining data to show these circumstances exist, hampering their ability to ensure safe meal delivery. GAO is making four recommendations, including that USDA improve estimates of children's participation in SFSP and communicate the circumstances it considers when granting flexibilities to ensure safe meal delivery. USDA generally agreed with GAO's recommendations.