Energy Employees Compensation: Case-Processing Bottlenecks Delay Payment of Claims
Published: 2003-12-06T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Department of Energy (Energy) and its predecessor agencies and contractors have employed thousands of workers in the nuclear weapons production complex. Some employees were exposed to toxic substances, including radioactive and hazardous materials, during this work and many subsequently developed illnesses. Subtitle D of the Energy Employees Occupational Illness Compensation Program Act of 2000 allows Energy to help its contractor employees file state workers' compensation claims for illnesses determined by a panel of physicians to be caused by exposure to toxic substances in the course of employment at an Energy facility. Energy began accepting applications under this program in July 2001, but did not begin processing them until its final regulations became effective on September 13, 2002. The Congress mandated that GAO study the effectiveness of the benefit program under Subtitle D of this Act. This testimony is based on GAO's ongoing work on this issue and focuses on three key areas: (1) the number, status, and characteristics of claims filed with Energy; (2) the extent to which there will be a "willing payer" of workers' compensation benefits, that is, an insurer who--by order from, or agreement with Energy--will not contest these claims; and (3) the extent to which Energy policies and procedures help employees file timely claims for these state benefits.
section_title: What GAO Found
paragraphs: As of June 30, 2003, Energy had completely processed only about 6 percent of the nearly 19,000 cases it had received. More than three-quarters of all cases were associated with facilities in nine states. Processing had not begun on over half of the cases and, of the remaining 40 percent of cases that were in processing, almost all were in the initial case development stage. While the majority of cases (86 percent) associated with major Energy facilities in nine states potentially have a willing payer of workers' compensation benefits, actual compensation is not certain. This figure is based primarily on the method of workers' compensation coverage used by Energy contractor employers and is not an estimate of the number of cases that will ultimately be paid. Since no claimants to date have received compensation as a result of their cases filed with Energy, there is no actual experience about how contractors and state programs treat such claims. Claimants have been delayed in filing for state worker's compensation benefits because of two bottlenecks in Energy's claims process. First, the case development process has not always produced sufficient cases to allow the panels of physicians who determine whether the worker's illness was caused by exposure to toxic substances to operate at full capacity. While additional resources may allow Energy to move sufficient cases through its case development process, the physician panel process will continue to be a second, more important, bottleneck. The number of panels, constrained by the scarcity of physicians qualified to serve on panels, will limit Energy's capacity to decide cases more quickly, using its current procedures. Energy officials are exploring ways that the panel process could be more efficient.

section_title: Letter
paragraphs: I am pleased to be here today to discuss our work regarding the  effectiveness of the benefit program under Subtitle D of the Energy  Employees Occupational Illness Compensation Program Act of 2000  (EEOICPA) in assisting contractor employees in obtaining compensation  for occupational illnesses. Congress mandated that we study this issue and  report to the Senate Committees on Energy and Natural Resources and  Appropriations and the House Committees on Energy and Commerce and  Appropriations.
For the last several decades, the Department of Energy (Energy), and its  predecessor agencies and contractors have employed thousands of  individuals in secret and dangerous work in the nuclear weapons  production complex. Over the years, employees were unknowingly  exposed to toxic substances, including radioactive and hazardous  materials, and studies have shown that many of these employees  subsequently developed illnesses. The Energy Employees Occupational  Illness Compensation Program provides for compensation to these  employees who developed occupational illnesses and, where applicable, to  their survivors. Congressional Committees, as well as individual Members  of Congress, claimants, and advocates have raised concerns regarding  Energy’s processing of claims and the availability of benefits once claims  have been decided.
As title XXXVI of the Floyd D. Spence National Defense Authorization Act  for Fiscal Year 2001, which was signed into law on October 30, 2000, this  legislation has two major components. Subtitle B provides eligible  workers who were exposed to radiation or other toxic substances and  who subsequently developed illnesses such as cancer and lung disease a  one-time payment of up to $150,000 and covers future medical expenses  related to the illness. The Department of Labor administers these benefits,  payable from a compensation fund established by the same legislation.  Subtitle D allows Energy to help its contractor employees file state  workers’ compensation (WC) claims for illnesses determined by a panel of  physicians to be caused by exposure to toxic substances in the course of  employment at an Energy facility. The legislation did not set aside funding  for payment of benefits under Subtitle D.
My testimony today reflects our ongoing review of the effectiveness of  Energy’s implementation of Subtitle D. We focused our work on three key  areas: (1) the number, status, and characteristics of claims filed with  Energy; (2) the extent to which there will be a “willing payer” of workers’  compensation benefits; that is, an insurer who—by order from, or  agreement with Energy—will not contest these claims; and (3) the extent  to which Energy policies and procedures help employees file timely claims  for state workers’ compensation benefits.
In summary, as of June 30, 2003, Energy had fully processed about  6 percent of the nearly 19,000 cases received, and more than three-quarters  of all cases were associated with facilities in nine states. Energy had not  begun processing over half of the cases received. While some other case  characteristics can be determined, such as illness claimed, systems  limitations prevent reporting on other case characteristics, such as the  reasons for ineligibility or basic demographics. While the majority of cases  (86 percent) associated with major Energy facilities in nine states  potentially have a willing payer of workers’ compensation benefits, actual  compensation is not certain. In certain states such as Ohio and Iowa, there  are likely to be many cases that lack willing payers, and in some instances  may be less likely to receive compensation than a comparable case with a  willing payer in a different state. The 86 percent figure reflects the number  of cases for which contractors and their insurers are likely to not contest a  workers’ compensation claim, rather than the number of cases that will  ultimately be paid. For all claimants, actual compensation is not certain  because of additional factors such as variations in state workers’  compensation programs or contractors’ uncertainty on how to compute  the benefit. Claims for workers’ compensation have been delayed by two  bottlenecks in Energy’s claims process. First, Energy’s case development  process has not always produced sufficient cases to keep physician panels  operating at full capacity. While additional resources may allow Energy to  move a sufficient number of cases through its case development process,  the physician panel process will continue to be a second and more  important bottleneck. The number of panels, constrained by the scarcity  of physicians qualified to serve on panels, will limit Energy’s capacity to  decide cases more quickly, using its current procedures. Energy officials  are exploring ways that the panel process could be made more efficient.
To perform our review, we analyzed data extracted from Energy’s Subtitle  D case management system for applications filed through June 30, 2003.
We also reviewed the provisions of, and interviewed officials with, the  workers’ compensation programs in nine states accounting for more than  three-quarters of Subtitle D cases filed, and we interviewed the  contractors operating the major facilities in these states. In addition, we  conducted site visits to three Energy facilities in Oak Ridge, Tennessee,  the state with facilities accounting for the greatest number of Subtitle D  claims. We also interviewed key program officials and other experts. We  conducted our review from April 2003 through October 2003 in  accordance with generally accepted government auditing standards.
subsections: section_title: Background
paragraphs: Energy oversees a nationwide network of 40 contractor-operated  industrial sites and research laboratories that have historically employed  more than 600,000 workers in the production and testing of nuclear  weapons. In implementing EEOICPA, the President acknowledged that it  had been Energy’s past policy to encourage and assist its contractors in  opposing workers’ claims for state workers’ compensation benefits based  on illnesses said to be caused by exposure to toxic substances at Energy  facilities. Under the new law, workers or their survivors could apply for  assistance from Energy in pursuing state workers’ compensation benefits,  and if they received a positive determination from Energy, the agency  would direct its contractors to not contest the workers’ compensation  claims or awards. Energy’s rules to implement the new program became  effective in September 2002, and the agency began to process the  applications it had been accepting since July 2001, when the law took  effect.
Energy’s claims process has several steps, as shown in Figure 1. First,  claimants file applications and provide all available medical evidence.  Energy then develops the claims by requesting records of employment,  medical treatment, and exposure to toxic substances from the Energy  facilities at which the workers were employed. If Energy determines that  the worker was not employed by one of its facilities or did not have an  illness that could be caused by exposure to toxic substances, the agency  finds the claimant ineligible. For all others, once development is complete,  a panel of three physicians reviews the case and decides whether  exposure to a toxic substance during employment at an Energy facility  was at least as likely as not to have caused, contributed to, or aggravated  the claimed medical condition. The panel physicians are appointed by the  National Institute for Occupational Safety and Health (NIOSH) but paid by  Energy for this work. Claimants receiving positive determinations are  advised that they may wish to file claims for state workers’ compensation  benefits. Claimants found ineligible or receiving negative determinations  may appeal to Energy’s Office of Hearings and Appeals.
Each of the 50 states and the District of Columbia has its own workers’  compensation program to provide benefits to workers who are injured on  the job or contract a work-related illness. Benefits include medical  treatment and cash payments that partially replace lost wages.  Collectively, these state programs paid more than $46 billion in cash and  medical benefits in 2001. In general, employers finance workers’  compensation programs. Depending on state law, employers finance these  programs through one of three methods: (1) they pay insurance premiums  to a private insurance carrier, (2) they contribute to a state workers’  compensation fund, or (3) they set funds aside for this purpose as self­ insurance. Although state workers’ compensation laws were enacted in  part as an attempt to avoid litigation over workplace accidents, the  workers’ compensation process is still generally adversarial, with  employers and their insurers tending to challenge aspects of claims that  they consider not valid.
State workers’ compensation programs vary as to the level of benefits,  length of payments, and time limits for filing. For example, in 1999, the  maximum weekly benefit for a total disability in New Mexico was less than  $400, while in Iowa it was approximately $950. In addition, in Idaho, the  weekly benefit for total disability would be reduced after 52 weeks, while  in Iowa benefits would continue at the original rate for the duration of the  disability. Further, in Tennessee, a claim must be filed within 1 year of the  beginning of incapacity or death. However, in Kentucky a claim must be  filed within 3 years of exposure to more substances, but within 20 years of  exposure to radiation or asbestos.
section_title: Energy Has Fully Processed Few Cases, and Systems Limitations Complicate Program Management
paragraphs: As of June 30, 2003, Energy had completely processed about 6 percent of  the nearly 19,000 cases that had been filed, and the majority of all cases  filed were associated with facilities in nine states. Forty percent of cases  were in processing, but more than 50 percent remained unprocessed.  While some case characteristics can be determined, such as illness  claimed, systems limitations prevent reporting on other case  characteristics, such as the reasons for ineligibility or basic demographics.
subsections: section_title: About 6 Percent of Cases Have Been Fully Processed
paragraphs: During the first 2 years of the program ending June 30 2003, Energy had  fully processed about 6 percent of the nearly 19,000 claims it received. The  majority of these claims had been found ineligible due to either a lack of  employment at an eligible facility or an illness related to toxic exposure.  Of the cases that had been fully processed, 42 cases—less than one third  of one percent of the nearly 19,000 cases filed—had a final determination  from a physician panel. More than two thirds of these determinations (30  cases) were positive. At the time of our study, Energy had not yet begun  processing more than half of the cases, and an additional 40 percent of  cases were in processing (see fig. 2). The majority of cases being  processed were in the case development stage, where Energy requests  information from the facility at which the claimant was employed. Fewer  than 1 percent of cases in process were ready for physician panel review  and an additional 1 percent were under panel review.
A majority of cases were filed early during program implementation, but  new cases continue to be filed. Nearly two-thirds of cases were filed  within the first year of the program, between July 2001 and June 2002.  However, in the second year of the program—between July 2002 and June  30, 2003—Energy continued to receive more than 500 cases per month.  Energy officials report that they currently receive approximately 100 new  cases per week.
section_title: Energy Facilities in Nine States Account for More than 75 percent of Cases
paragraphs: While cases filed are associated with facilities in 38 states or territories,  the majority of cases are associated with Energy facilities in nine states  (see fig. 3). Facilities in Colorado, Idaho, Iowa, Kentucky, New Mexico,  Ohio, South Carolina, Tennessee, and Washington account for more than  75 percent of cases received by June 30, 2003. The largest group of cases is  associated with facilities in Tennessee.
Workers filed the majority of cases, and cancer is the most frequently  reported illness. Workers filed about 60 percent of cases, and survivors of  deceased workers filed about 36 percent of cases. In about 1 percent of  cases, a worker filed a claim that was subsequently taken up by a survivor.  Cancer is the illness reported in more than half of the cases. Diseases  affecting the lungs accounted for an additional 14 percent of cases.  Specifically, chronic beryllium disease is reported in 1 percent of cases,  and beryllium sensitivity, which may develop into chronic beryllium  disease, is reported in an additional 5 percent. About 7 percent of cases  report asbestosis, and less than 1 percent claimed silicosis.
section_title: Systems Limitations Complicate Program Management
paragraphs: Systems limitations prevent Energy officials from aggregating certain  information important for program management. For example, the case  management system does not collect information on the reasons that  claimants had been declared ineligible or whether claimants have  appealed decisions. Systematic tracking of the reasons for ineligibility  would make it possible to identify other cases affected by appeal decisions  that result in policy changes. While Energy officials report that during the  major systems changes that occurred in July 2003, fields were added to the  system to track appeals information, no information is yet available  regarding ineligibility decisions. In addition, basic demographic data such  as age and gender of claimants are not available. Gender information was  not collected for the majority of cases. Further, insufficient edit controls—  for example, error checking that would prevent claimants’ dates of birth  from being entered if the date was in the future—prevent accurate  reporting on claimants’ ages.
Insufficient strategic planning regarding data collection and tracking have  made it difficult for Energy officials to completely track case progress and  determine whether they are meeting the goals they have established for  case processing. For example, Energy established a goal of completing  case development within 120 days of case assignment to a case manager.  However, the data system developed by contractors to aid in case  management was developed without detailed specifications from Energy  and did not originally collect sufficient information to track Energy’s  progress in meeting this 120-day goal. Furthermore, status tracking has  been complicated by changes to the system and failure to consistently  update status as cases progress. While Energy reports that changes made  as of July 2003 should allow for improved tracking of case status, it is  unclear whether these changes will be applied retroactively to status data  already in the system. If they are not, Energy will still lack complete data  regarding case processing milestones achieved prior to these changes.
section_title: While A Majority of Cases Potentially Have A Willing Payer, Actual Compensation Is Not Certain
paragraphs: Our analysis shows that a majority of cases associated with major Energy  facilities in nine stateswill potentially have a willing payer of worker’s  compensation benefits. This finding reflects the number of cases for which  contractors and their insurers are likely to not contest a workers’  compensation claim, rather than the number of cases that will ultimately  be paid. The contractors considered to be willing payers are those that  have an order from, or agreement with, Energy to not contest claims.  However, there are likely to be many claimants who will not have a willing  payer in certain states, such as Ohio and Iowa. For all claimants,  additional factors such as state workers’ compensation provisions or  contractors’ uncertainty on how to compute the benefit may affect  whether or how much compensation is paid.
subsections: section_title: A Majority of Cases in Nine States Potentially Have a Willing Payer
paragraphs: A majority of cases in nine states will potentially have a willing payer of  workers’ compensation benefits, assuming that for all cases there has been  a positive physician panel determination and the claimant can  demonstrate a loss from the worker’s illness that has not previously been  compensated. Specifically, based on our analysis of worker’s  compensation programs and the different types of workers compensation  coverage used by the major contractors, it appears that approximately 86  percent of these cases will potentially have a willing payer—that is,  contractors and their insurers who will not contest the claims for benefits.  It was necessary to assume that all cases filed would receive a positive  determination by a physician panel because sufficient data are not  available to project the outcomes of the physician panel process. More  specifically, there are indications that the few cases that have received  determinations from physician panels may not be representative of all  cases filed, and sufficient details on workers’ medical conditions were not  available to enable us to independently judge the potential outcomes. In  addition, we assumed that all workers experienced a loss that was not  previously compensated because sufficient data were not available to  enable us to make more detailed projects on this issue.
As shown in table 1, most of the contractors for the major facilities in  these states are self-insured, which enables Energy to direct them to not  contest claims that receive a positive medical determination. In addition,  the contractor in Colorado, which is not self-insured but has a commercial  policy, took the initiative to enter into an agreement with Energy to not  contest claims. The contractor viewed this action as being in its best  interest to help the program run smoothly. However, it is unclear whether  the arrangement will be effective because no cases in Colorado have yet  received compensation. In such situations where there is a willing payer,  the contractor’s action to pay the compensation consistent with Energy’s  order to not contest a claim will override state workers’ compensation  provisions that might otherwise result in denial of a claim, such as failure  to file a claim within a specified period of time. However, since no  claimants to date have received compensation as a result of their cases  filed with Energy, there is no actual experience about how contractors and  state workers’ compensation programs treat such cases.
About 14 percent of cases in the nine states we analyzed may not have a  willing payer. Therefore, in some instances these cases may be less likely  to receive compensation than a comparable case for which there is a  willing payer, unless the claimant is able to overcome challenges to the  claim. Specifically, these cases that lack willing payers involve contractors  that (1) have a commercial insurance policy, (2) use a state fund to pay  workers’ compensation claims, or (3) do not have a current contract with  Energy. In each of these situations, Energy maintains that it lacks the  authority to make or enforce an order to not contest claims. For instance,  an Ohio Bureau of Workers’ Compensation official said that the state  would not automatically approve a case, but would evaluate each workers’  compensation case carefully to ensure that it was valid, and thereby  protect its state fund.
Concerns about the extent to which there will be willing payers of benefits  have led to various proposals for addressing this issue. For example, the  state of Ohio proposed that Energy designate the state as a contractor to  provide a mechanism for reimbursing the state for paying the workers’  compensation claims. However, Energy rejected this proposal on the  grounds that EEOICPA does not authorize the agency to establish such an  arrangement. In a more wide-ranging proposal, legislation introduced in  this Congress proposes to establish Subtitle D as a federal program with  uniform benefits administered by the Department of Labor.
section_title: Multiple Factors Make Compensation Not Certain
paragraphs: In contrast to Subtitle B provisions that provide for a uniform federal  benefit that is not affected by the degree of disability, various factors may  affect whether a Subtitle D claimant is paid under the state workers’  compensation program, or how much compensation will be paid. Beyond  the differences in the state programs that may result in varying amounts  and length of payments, these factors include the demonstration of a loss  resulting from the illness and contractors’ uncertainty on how to compute  compensation.
Even with a positive determination from a physician panel and a willing  payer, claimants who cannot demonstrate a loss, such as loss of wages or  medical expenses, may not qualify for compensation. On the other hand,  claimants with positive determinations but not a willing payer may still  qualify for compensation under the state program if they show a loss and  can overcome all challenges to the claim raised by the employer or the  insurer.
Contractors’ uncertainty on how to compute compensation may also cause  variation in whether or how much a claimant will receive in compensation.  While contractors with self-insurance told us that they plan to comply with  Energy’s directives to not contest cases with positive determinations,  some contractors were unclear about how to actually determine the  amount of compensation that a claimant will receive. For example, one  contractor raised a concern that no guidance exists to inform them about  whether they can negotiate the degree of disability, a factor that could  affect the amount of the workers’ compensation benefit. Other contractors  will likely experience similar situations, as Energy has not issued guidance  on how to consistently compute compensation amounts.
While not directly affecting compensation amounts, a related issue  involves how contractors will be reimbursed for claims they pay. Energy  uses several different types of contracts to carry out its mission, such as  operations or cleanup, and these different types of contracts impact how  workers’ compensation claims will be paid. For example, a contractor  responsible for managing and operating an Energy facility was told to pay  the workers’ compensation claims from its operating budget. The  contractor said that this procedure may compromise its ability to conduct  its primary responsibilities. On the other hand, a contractor cleaning up an  Energy facility was told by Energy officials that its workers’ compensation  claims would be reimbursed under its contract, and therefore paying  claims would not affect its ability to perform cleanup of the site.
section_title: Bottlenecks In Energy’s Claims Process Delay Filing Of Workers Compensation Claims
paragraphs: As a result of Energy’s policies and procedures for processing claims,  claimants have experienced lengthy delays in receiving the determinations  they need to file workers’ compensation claims. In particular, the number  of cases developed during initial case processing has not always been  sufficient to allow the physician panels to operate at full capacity.  Moreover, even if these panels were operating at full capacity, the small  pool of physicians qualified to serve on the panels would limit the agency’s  ability to produce more timely determinations. Energy has recently  allocated more funds for staffing for case processing, but is still exploring  methods for improving the efficiency of its physician panel process.
subsections: section_title: Sufficient Cases Have Not Always Been Available for Physician Panel Review
paragraphs: Energy’s case development process has not consistently produced enough  cases to ensure that the physician panels are functioning at full capacity.  To make efficient use of physician panel resources, it is important to  ensure that a sufficient supply of cases is ready for physician panel review.  Energy officials established a goal of completing the development of 100  cases per week by August 2003 to keep the panels fully engaged. However,  as of September 2003, Energy officials stated that the agency was  completing development on only about 40 cases a week. Further, while  agency officials indicated that they typically assigned 3 cases at a time to  be reviewed within 30 days, several panel physicians indicated that they  received fewer cases, some receiving a total of only 7 or 8 during their first  year as a panelist.
Energy was slow to implement its case development operation. Initially,  agency officials did not have a plan to hire a specific number of employees  for case development, but they expected to hire additional staff as they  were needed. When Energy first began developing cases, in the fall of  2002, the case development process had a staff of about 14 case managers  and assistants. With modest staffing increases, the program quickly  outgrew the office space used for this function. Though Energy officials  acknowledged the need for more personnel by spring 2003, they delayed  hiring until additional space could be secured in August. As of August  2003, Energy had more than tripled the number of employees dedicated to  case development to a about 50, and Energy officials believe that they will  now be able to achieve their goal of completing development of 100 cases  a week that will be ready for physician panel review. Energy officials cited  a substantial increase in the number of cases ready for physician panel  review during October 2003, and reported preparing more than a hundred  cases for panel review in the first week of November 2003.
Energy shifted nearly $10 million from other Energy accounts into this  program in fiscal year 2003, and plans to shift an additional $33 million  into the program in fiscal year 2004, to quadruple its case-processing  operation. With additional resources, Energy plans to complete the  development of all pending cases as quickly as possible and have them  ready for the physician panels. However, this would create a large backlog  of cases awaiting review by physician panels. Because most claims filed so  far are from workers whose medical conditions are likely to change over  time, creation of such a backlog could further slow the decision process  by making it necessary to update medical records before panel review.
section_title: The Ability to Produce More Timely Decisions May Be Limited By Small Pool Of Qualified Physicians and Gaps in Information They Need to Quickly Decide Cases
paragraphs: Even if additional resources allow Energy to speed initial case  development, the limited pool of qualified physicians for panels will likely  prevent significant improvements in processing time. Currently,  approximately 100 physicians are assigned to panels of 3 physicians. In an  effort to improve overall processing time, Energy has requested that  NIOSH appoint an additional 500 physicians to staff the panels. NIOSH has  indicated that the pool of physicians with the appropriate credentials and  experience (including those already appointed) may be limited to about  200. Even if Energy were able to increase the number of panel physicians  to 200, with each panel reviewing 3 cases a month, the panels would not  be able to review more than 200 cases in any 30-day period given current  procedures. Thus, even with double the number of physicians currently  serving on panels, it would take more than 7 years to process all cases  pending as of June 30, 2003, without consideration of the hundreds of new  cases the agency is receiving each month.
Energy officials are exploring ways that the panel process could be made  more efficient. For example, the agency is currently planning to establish  permanent physician panels in Washington, DC. Physicians who are  willing to serve full-time for a 2 or 3-week period would staff these panels.  In addition, the agency is considering reducing the number of physicians  serving on each panel—for example, initially using one physician to review  a case, assigning a second physician only if the first reaches a negative  determination, and assigning a third physician if needed to break a tie.  Energy staff are currently evaluating whether such a change would require  a change in their regulations.
Agency officials have also recommended additional sources from which  NIOSH might recruit qualified physicians and are exploring other potential  sources. For example, the physicians in the military services might be used  on a part-time basis. In addition, physicians from the Public Health Service  serve on temporary full-time details as panel physicians.
Panel physicians have also suggested methods to Energy for improving the  efficiency of the panels. For example, some physicians have stated that  more complete profiles of the types and locations of specific toxic  substances at each facility would speed their ability to decide cases. In  addition, one panel physician told us that one of the cases he reviewed  received a negative determination because specific documentation of  toxic substances at the worker’s location was lacking. While Energy  officials reported that they have completed facility overviews for about  half the major sites, specific data are available for only a few sites. Agency  officials said that the scarcity of records related to toxic substances and a  lack of sufficient resources constrain their ability to pursue building-by­ building profiles for each facility.
Mr. Chairman, this completes my prepared statement. I would be happy to  respond to any questions you or other Members of the Committee may  have at this time.
section_title: Contacts and Acknowledgments
paragraphs: For information regarding this testimony, please contact Robert E.  Robertson, Director, or Andrew Sherrill, Assistant Director, Education,  Workforce, and Income Security at (202) 512-7215. Individuals making  contributions to this testimony include Amy E. Buck, Melinda L. Cordero,  Beverly Crawford, Patrick DiBattista, Corinna A. Nicolaou, Mary Nugent,  and Rosemary Torres Lerma.
This is a work of the U.S. government and is not subject to copyright protection in the  United States. It 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.