Poverty in America: Economic Research Shows Adverse Impacts on Health Status and Other Social Conditions as well as the Economic Growth Rate
Published: 2007-01-24T00:00:00

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Highlights:
section_title: Why GAO Did This Study
paragraphs: In 2005, 37 million people, approximately 13 percent of the total population, lived below the poverty line, as defined by the Census Bureau. Poverty imposes costs on the nation in terms of both programmatic outlays and productivity losses that can affect the economy as a whole. To better understand the potential range of effects of poverty, GAO was asked to examine (1) what the economic research tells us about the relationship between poverty and adverse social conditions, such as poor health outcomes, crime, and labor force attachment, and (2) what links economic research has found between poverty and economic growth. To answer these questions, GAO reviewed the economic literature by academic experts, think tanks, and government agencies, and reviewed additional literature by searching various databases for peer- reviewed economic journals, specialty journals, and books. We also provided our draft report for review by experts on this topic.
section_title: What GAO Found
paragraphs: Economic research suggests that individuals living in poverty face an increased risk of adverse outcomes, such as poor health and criminal activity, both of which may lead to reduced participation in the labor market. While the mechanisms by which poverty affects health are complex, some research suggests that adverse health outcomes can be due, in part, to limited access to health care as well as greater exposure to environmental hazards and engaging in risky behaviors. For example, some research has shown that increased availability of health insurance such as Medicaid for low-income mothers led to a decrease in infant mortality. Additionally, exposure to higher levels of air pollution from living in urban areas close to highways can lead to acute health conditions. Data suggest that engaging in risky behaviors, such as tobacco and alcohol use, a sedentary life-style, and a low consumption of nutritional foods, can account for some health disparities between lower and upper income groups. The economic research we reviewed also points to links between poverty and crime. For example, one study indicated that higher levels of unemployment are associated with higher levels of property crime. The relationship between poverty and adverse outcomes for individuals is complex, in part because most variables, like health status, can be both a cause and a result of poverty. These adverse outcomes affect individuals in many ways, including limiting their development of the skills, abilities, knowledge, and habits necessary to fully participate in the labor force. Research shows that poverty can negatively affect economic growth by affecting the accumulation of human capital and rates of crime and social unrest. Economic theory has long suggested that human capital--that is, the education, work experience, training, and health of the workforce--is considered one of the fundamental drivers of economic growth. The conditions associated with poverty can work against this human capital development by limiting individuals' ability to remain healthy and develop skills, in turn decreasing the potential to contribute talents, ideas, and even labor to the economy. An educated labor force, for example, is better at learning, creating and implementing new technologies. Economic theory suggests that when poverty affects a significant portion of the population, these effects can extend to the society at large and produce slower rates of growth. Although historically research has focused mainly on the extent to which economic growth alleviates poverty, some recent empirical studies have begun to demonstrate that higher rates of poverty are associated with lower rates of growth in the economy as a whole. For example, areas with higher poverty rates experience, on average, slower per capita income growth rates than low-poverty areas.

section_title: Letter
paragraphs: According to the Census Bureau, approximately 37 million people in the  United States—nearly 13 percent of the total population—lived below the  poverty line in 2005. This percentage was significantly larger for particular  population groups, specifically children, minorities, and those living in  certain geographic areas such as inner cities. The federal government  spends billions of dollars on programs to assist low-income individuals  and families. These programs included Medicaid, food stamps, Temporary  Assistance for Needy Families (TANF), and the Earned Income Tax Credit  (EITC), to name some of the largest. While some have taken issue with  Census’ official poverty measure and proposed alternative measures, it is  generally recognized that poverty imposes costs on the nation as a whole,  not merely in terms of programmatic outlays but also through lost  productivity that can affect the overall economy.
A substantial body of economic research has looked at the effects of  poverty and you asked us to discuss (1) what the economic research tells  us about the relationship between poverty and adverse social conditions,  such as poor health outcomes, crime, and labor force attachment; and (2)  what links economic research has found between poverty and economic  growth.
To answer these questions, we reviewed the economic literature by  academic experts, think tanks, and government agencies, which we  collected from searches of various databases, peer-reviewed economic  journals, specialty journals, and books. We also provided our draft report  to four external reviewers. They are recognized experts who have  conducted research and published on the topic of poverty and economic  growth and whose work has recommended a variety of approaches and  strategies to policymakers. We limited the scope of our work by looking at  recent studies published since 1996, excluding anything older, with  exceptions made for work that was considered seminal. Thus, our results  are not an exhaustive or historical treatment of the topic. Our review was  primarily driven by the economic literature focused on the United States  either exclusively or including other developed nations; studies from other  disciplines were excluded unless they were captured in either the  economic study under review or its bibliography. When we refer to  poverty in the report, we are using an absolute measure, not a relative one.  This means that, for the most part, the studies we reviewed typically used  the official poverty line published by the Census Bureau as its benchmark.  A few of the studies we reviewed used relative measures such as the  poorest 10 percent of the population.
Our work was conducted between October 2006 and January 2007  according to generally accepted government auditing standards. Because  we did not evaluate the policies, operations, or programs of any federal  agency to develop the information presented in this report, and because  we are not making any recommendations, we did not seek agency  comments. However, we met with agency officials from the Departments  of Commerce, Health and Human Services, Justice, and Labor to obtain  information on research they or others had conducted related to our work  objectives.
subsections: section_title: Background
paragraphs: Economic growth is one of the indicators by which the well-being of the  nation is typically measured, although recent discussions have focused on  a broader set of indicators, such as poverty. Poverty in the United States is  officially measured by the Census Bureau, which calculates the number of  persons or households living below an established level of income deemed  minimally adequate to support them. The federal government has a long- standing history of assisting individuals and families living in poverty by  providing services and income transfers through numerous and various  types of programs.
subsections: section_title: Measuring the Nation’s Well-Being: Economic Growth and Other Indicators
paragraphs: Economic growth is typically defined as the increase in the value of goods  and services produced by an economy; traditionally this growth has been  measured by the percentage rate of increase in a country’s gross domestic  product, or GDP. The growth in GDP is a key measure by which policy- makers estimate how well the economy is doing. However, it provides  little information about how well individuals and households are faring.
Recently there has been a substantial amount of activity in the United  States and elsewhere to develop a comprehensive set of key indicators for  communities, states, and the nation that go beyond traditional economic  measures. Many believe that such a system would better inform  individuals, groups, and institutions on the nation as a whole. Poverty is  one of these key indicators. Poverty, both narrowly and more broadly  defined, is a characteristic of society that is frequently monitored and  defined and measured in a number of ways.
section_title: How Is Poverty Defined in the United States.?
paragraphs: The Census Bureau is responsible for establishing a poverty threshold  amount each year; persons or families having income below this amount  are, for statistical purposes, considered to be living in poverty. The  threshold reflects estimates of the amount of money individuals and  families of various sizes need to purchase goods and services deemed  minimally adequate based on 1960s living standards, and is adjusted each  year using the consumer price index. The poverty rate is the percentage of  individuals in total or as part of various subgroups in the United States  who are living on income below the threshold amounts.
Over the years, experts have debated whether or not the way in which the  poverty threshold is calculated should be changed. Currently the  calculation only accounts for pretax income and does not include noncash  benefits and tax transfers, which, especially in recent years, have  comprised larger portions of the assistance package to those who are low- income. For example, food stamps and the Earned Income Tax Credit  could provide a combined amount of assistance worth an estimated $5,000  for working adults with children who earn approximately $12,000 a year.If noncash benefits were included in a calculation of the poverty  threshold, the number and percentage of individuals at or below the  poverty line could change. In 1995, a National Academy of Sciences (NAS)  panel recommended that changes be made to the threshold to count  noncash benefits, tax credits, and taxes; deduct certain expenses from  income such as child care and transportation; and adjust income levels  according to an area’s cost of living. In response, the Census Bureau  published an experimental poverty measure in 1999 using the NAS  recommendations in addition to its traditional measure but, to date,  Census has not changed the official measure.
section_title: U.S. Poverty Rates
paragraphs: In 2005, close to 13 percent of the total U.S. population—about 37 million  people—were counted as living below the poverty line, a number that  essentially remained unchanged from 2004. Poverty rates differ, however,  by age, gender, race, and ethnicity and other factors. For example,
Children: In 2005, 12.3 million children, or 17.1 percent of children  under the age of 18, were counted as living in poverty. Children of color  were at least three times more likely to be in poverty than those who  were white: 3.7 million, or 34.2 percent of, children who were African-  American and 4 million, or 27.7 percent of, children who were Hispanic  lived below the poverty line compared to 4 million, or 9.5 percent of,  children who were white.
Racial and ethnic minorities: African-Americans and Hispanics have  significantly higher rates of poverty than whites. In 2005, 24.9 percent  of African-Americans (9.2 million) and 22 percent of Hispanics (9.4  million) lived in poverty, compared to 8.3 percent for whites (16.2  million).
Elderly: The elderly have lower rates of poverty than other groups. For  example, 10.1 percent of adults (3.6 million) aged 65 or older lived in  poverty.
Poverty rates also differ depending on geographical location and for urban  and nonurban areas. Poverty rates for urban areas were double those in  suburbs, 17 percent compared to 9.3 percent. Poverty rates in the South  were the highest at 14 percent; the West had a rate of 12.6 percent,  followed by the Midwest with 11.4 percent and the Northeast at 11.3  percent.
section_title: The Role of the Federal Government
paragraphs: The U.S. government has a long history of efforts to improve the  conditions of those living with severely limited resources and income.  Presidents, Congress, and other policymakers have actively sought to help  citizens who were poor, beginning as early as the 1850s through the more  recent efforts established through welfare reform initiatives enacted in  1996.
Over the years, the policy approaches used to help low-income individuals  and families have varied. For example, in the1960s federal programs  focused on increasing the education and training of those living in poverty.  In the 1970s, policy reflected a more income-oriented approach with the  introduction of several comprehensive federal assistance plans. More  recently, welfare reform efforts have emphasized the role of individual  responsibility and behaviors in areas such as family formation and work to  assist people in becoming self-sufficient. Although alleviating poverty and  the conditions associated with it has long been a federal priority,  approaches to developing effective interventions have sometimes been  controversial, as evidenced by the diversity of federal programs in  existence and the ways in which they have evolved over time.
Currently, the federal government, often in partnership with the states, has  created an array of programs to assist low-income individuals and families.  According to a recent study by the Congressional Research Service (CRS),  the federal government spent over $400 billion on 84 programs in 2004 that  provided cash and noncash benefits to individuals and families with  limited income. These programs cover a broad array of services: Examples  include income supports or transfers such as the Earned Income Tax  Credit and TANF; work supports such as subsidized child care and job  training; health supports and insurance through programs like the State  Children’s Health Insurance Program (SCHIP) and Medicaid; and other  social services such as food, housing, and utility assistance. Table 1  provides a list of examples of selected programs.
section_title: Economic Research Links Poverty with Adverse Outcomes for Individuals Such as Poor Health and Crime
paragraphs: Economic research suggests that individuals living in poverty face an  increased risk for adverse outcomes, such as poor health, criminal activity,  and low participation in the workforce. The adverse outcomes that are  associated with poverty tend to limit the development of skills and  abilities individuals need to contribute productively to the economy  through work, and this in turn, results in low incomes. The relationship  between poverty and outcomes for individuals is complex, in part because  most variables, like health status, can be both a cause and a result of  poverty. The direction of the causality can have important policy  implications. To the extent that poor health causes poverty, and not the  other way around, then alleviating poverty may not improve health.
subsections: section_title: Individuals Living in Poverty Experience Higher Rates of Adverse Health Outcomes, in Part because of Limited Access to Health Care, Environmental Hazards, and Risky Behaviors
paragraphs: Health outcomes are worse for individuals with low incomes than for their  more affluent counterparts. Lower-income individuals experience higher  rates of chronic illness, disease, and disabilities, and also die younger than  those who have higher incomes. As reported by the National Center on  Health Statistics, individuals living in poverty are more likely than their  affluent counterparts to experience fair or poor health, or suffer from  conditions that limit their everyday activities (fig.1). They also report  higher rates of chronic conditions such as hypertension, high blood  pressure, and elevated serum cholesterol, which can be predictors of more  acute conditions in the future. Life expectancies for individuals in poor  families as compared to nonpoor families also differ significantly. One  study showed that individuals with low incomes had life expectancies 25  percent lower than those with higher incomes. Other research suggests  that an individual’s household wealth predicts the amount of functionality  of that individual in retirement.
Research suggests that part of the reason that those in poverty have poor  health outcomes is that they have less access to health insurance and thus  less access to health care, particularly preventive care, than others who  are nonpoor. Very low-income individuals were three times as likely not to  have health insurance than those with higher incomes, which may lead to  reduced access to and utilization of health care (fig. 2).
Data show that those who are poor with no health insurance access the  health system less often than those who are either insured or wealthier  when measured by one indicator of health care access: visits to the doctor.  For example, data from the National Center on Health Statistics show that  children in families with income below the poverty line who were  continuously without health insurance were three to four times more  likely to have not visited a doctor in the last 12 months than children in  similar economic circumstances who were insured (fig. 3). Research also  suggests that a link between income and health exists independent of  health insurance coverage. Figure 3 also shows that while children who  are uninsured but in wealthier families visit the doctor fewer times than  those who are insured, they still go more often than children who are  uninsured but living in poverty.
Some research examining government health insurance suggests that  increased health insurance availability improves health outcomes.  Economists have studied the expansion of Medicaid, which provides  health insurance to those with low income. They found that Medicaid’s  expansion of coverage, which occurred between 1979 and 1992, increased  the availability of insurance and improved children’s health outcomes. For  example, one study found that a 30 percentage point increase in eligibility  for mothers aged 15-44 translated into a decrease in infant mortality of 8.5  percent. Another study looked at the impact of health insurance coverage  through Medicare and its effects on the health of the elderly and also  found a statistically significant though modest impact. There is some  evidence that variations in health insurance coverage do not explain all the  differences in health outcomes. A study done in Canada found  improvements in children’s health with increases in income, even though  Canada offers universal health insurance coverage for hospital services,  indicating that health insurance is only part of the story.
Although there is a connection among poverty, having health insurance,  and health outcomes, having health insurance is often associated with  other attributes of an individual, thus making it difficult to isolate the  direct effect of health insurance alone. Most individuals in the United  States are either self-insured or insured through their employer. If those  who are uninsured have lower levels of education, as do individuals with  low income, differences in health between the insured and uninsured  might be due to level or quality of education, and not necessarily  insurance.
Another reason that individuals living in poverty may have more negative  health outcomes is because they live and work in areas that expose them  to environmental hazards such as pollution or substandard housing. Some  researchers have found that because poorer neighborhoods may be  located closer to industrial areas or highways than more affluent  neighborhoods, there tend to be higher levels of pollution in lower-income  neighborhoods. The Institute of Medicine concluded that minority and  low-income communities had disproportionately higher exposure to  environmental hazards than the general population, and because of their  impoverished conditions were less able to effectively change these  conditions.
The link between poverty and health outcomes may also be explained by  lifestyle issues associated with poverty. Sedentary life-style: the use of  alcohol and drugs; as well as lower consumption of fiber, fresh fruits, and  vegetables are some of the behaviors that have been associated with lower  socioeconomic status. Cigarette smoking is also more common among  adults who live below the poverty line than among those above it, about 30  percent compared to 21 percent. Similarly, problems with being  overweight and obese are common among those with low family incomes,  although most prevalent in women: Women with incomes below 130  percent of the poverty line were 50 percent more likely to be obese than  those with incomes above this amount. Figure 4 shows that people living  in poverty are less likely to engage in regular, leisure-time physical activity  than others and are somewhat more likely to be obese, and children in  poverty are somewhat more likely to be overweight than children living  above the poverty line. In addition, there is also evidence to suggest a link  among poverty, stress, and adverse health outcomes, such as  compromised immune systems.
While evidence shows how poverty could result in poor health, the  opposite could also be true. For example, a health condition could result,  over time, in restricting an individual’s employment, resulting in lower  income. Additionally, the relationship between poverty and health  outcomes could also vary by demographic group. Failing health, for  example, can be more directly associated with household income for  middle-aged and older individuals than with children, since adults are  typically the ones who work.
section_title: Economic Research Shows an Association Between Poverty and Crime
paragraphs: Just as research has established a link between poverty and adverse health  outcomes, evidence suggests a link between poverty and crime. Economic  theory predicts that low wages or unemployment makes crime more  attractive, even with the risks of arrest and incarceration, because of  lower returns to an individual through legal activities. While more mixed,  empirical research provides support for this. For example, one study  shows that higher levels of unemployment are associated with higher  levels of property crime, but is less conclusive in predicting violent crime.Another study has shown that both wages and unemployment affect crime,  but that wages play a larger role.
Research has found that peer influence and neighborhood effects may also  lead to increased criminal behavior by residents. Having many peers that  engage in negative behavior may reduce social stigma surrounding that  behavior. In addition, increased crime in an area may decrease the  chances that any particular criminal activity will result in an arrest. Other  research suggests that the neighborhood itself, independent of the  characteristics of the individuals who live in it, affects criminal behavior.One study found that arrest rates were lower among young people from  low-income families who were given a voucher to live in a low-poverty  neighborhood, as opposed to their peers who stayed in high-poverty  neighborhoods. The most notable decrease was in arrests for violent  crimes; the results for property crimes, however, were mixed, with arrest  rates increasing for males and decreasing for females.
section_title: Adverse Outcomes, Such as Poor Health and Low Educational Attainment, Lead to Reduced Participation in the Labor Market
paragraphs: Regardless of whether poverty is a cause or an effect, the conditions  associated with poverty limit the ability of low-income individuals to  develop the skills, abilities, knowledge, and habits necessary to fully  participate in the labor force, in turn, leads to lower incomes. According to  2000 Census data, people aged 20-64 with income above the poverty line in  1999 were almost twice as likely to be employed as compared to those  with incomes below it. Some of the reasons for these outcomes include  educational attainment and health status.
Poverty is associated with lower educational quality and attainment, both  of which can affect labor market outcomes. Research has consistently  demonstrated that the quality and level of education attained by lower- income children is substantially below those for children from middle- or  upper-income families. Moreover, high school dropout rates in 2004 were  four times higher for students from low-income families than those in  high-income families. Those with less than a high school degree have  unemployment rates almost three times greater than those with a college  degree, 7.6 percent compared to 2.6 percent in 2005. And the percentage of  low-income students who attend college immediately after high school is  significantly lower than for their wealthier counterparts: 49 percent  compared to 78 percent.
A significant body of economic research directly links adverse health  outcomes, which are also associated with low incomes, with the quality  and quantity of labor that the individual is able to offer to the workforce.  Many studies that have examined the relationship among individual adult  health and wages, labor force participation, and job choice have  documented positive empirical relationships among health and wages,  earnings, and hours of work. Although there is no consensus about the  exact magnitude of the effects, the empirical literature suggests that poor  health reduces the capacity to work and has substantive effects on wages,  labor force participation, and job choice, meaning that poor health is  associated with low income.
Research also demonstrates that poor childhood health has substantial  effects on children’s future outcomes as adults. Some research, for  example, shows that low birth weight is correlated with a low health  status later in life. Research also suggests that poor childhood health is  associated with reduced educational attainment and reduced cognitive  development. Reduced educational attainment may in turn have a causal  effect not only on future wages as discussed above but also on adult health  if the more educated are better able to process health information or make  more informed choices about their health care or if education makes  people more “future oriented” by helping them think about the  consequences of their choices. In addition, some research shows that poor  childhood health is predictive of poor adult health and poor adult  economic status in middle age, even after controlling for educational  attainment.
section_title: Economic Research Suggests a Negative Association between Poverty and Economic Growth
paragraphs: The economic literature suggests that poverty not only affects individuals  but can also create larger challenges for economic growth. Traditionally,  research has focused on the importance of economic growth for  generating rising living standards and alleviating poverty, but more  recently it has examined the reverse, the impact of poverty on economic  growth. In the United States, poverty can impact economic growth by  affecting the accumulation of human capital and rates of crime and social  unrest. While the empirical research is limited, it points to the negative  association between poverty and economic growth consistent with the  theoretical literature’s conclusion that higher rates of poverty can result in  lower rates of growth.
Research has shown that accumulation of human capital is one of the  fundamental drivers of economic growth. Human capital consists of the  skills, abilities, talents, and knowledge of individuals as used in  employment. The accumulation of human capital is generally held to be a  function of the education level, work experience, training, and healthiness  of the workforce. Therefore, schooling at the secondary and higher levels  is a key component for building an educated labor force that is better at  learning, creating, and implementing new technologies. Health is also an  important component of human capital, as it can enhance workers’  productivity by increasing their physical capacities, such as strength and  endurance, as well as mental capacities, such as cognitive functioning and  reasoning ability. Improved health increases workforce productivity by  reducing incapacity, disability, and the number of days lost to sick leave,  and increasing the opportunities to accumulate work experience. Further,  good health helps improve education by increasing levels of schooling and  scholastic performance.
The accumulation of human capital can be diminished when significant  portions of the population have experienced long periods of poverty, or  were living in poverty at a critical developmental juncture. For example,  recent research has found that the distinct slowdown in some measures of  human capital development is most heavily concentrated among youth  from impoverished backgrounds. When individuals who have experienced  poverty enter the workforce, their contributions may be restricted or  minimal, while others may not enter the workforce in a significant way.  Not only is the productive capability of some citizens lost, but their  purchasing power and savings, which could be channeled into productive  investments, is forgone as well.
In addition to the effects of poverty on human capital, some economic  literature suggests that poverty can affect economic growth to the extent  that it is associated with crime, violence, and social unrest. According to  some theories, when citizens engage in unproductive criminal activities  they deter others from making productive investments or their actions  force others to divert resources toward defensive activities and  expenditures. The increased risk due to insecurity can unfavorably affect  investment decisions—and hence economic growth—in areas afflicted by  concentrated poverty. Although such theories link poverty to human  capital deficiencies and criminal activity, the magnitude of their impact on  economic growth for an economy such as the United States is unclear at  this time. In addition, people living in impoverished conditions generate  budgetary costs for the federal government, which spends billions of  dollars on programs to assist low-income individuals and families.  Alleviating these conditions would allow the federal government to  redirect these resources toward other purposes.
While economic theory provides a guide to understanding how poverty  might compromise economic growth, empirical researchers have not as  extensively studied poverty as a determinant of growth in the United  States. Empirical evidence on the United States and other rich nations is  quite limited, but some recent studies support a negative association  between poverty and economic growth. For example, some research finds  that economic growth is slower in U.S. metropolitan areas characterized  by higher rates of poverty than those with lower rates of poverty. Another  study, using data from 21 wealthy countries, has found a similar negative  relationship between poverty and economic growth.
section_title: Concluding Observations
paragraphs: Maintaining and enhancing economic growth is a national priority that  touches on all aspects of federal decision making. As the nation moves  forward in thinking about how to address the major challenges it will face  in the twenty-first century, the impact of specific policies on economic  growth will factor into decisions on topics as far ranging as taxes, support  for scientific and technical innovation, retirement and disability, health  care, education and employment. To the extent that empirical research  can shed light on the factors that affect economic growth, this information  can guide policymakers in allocating resources, setting priorities, and  planning strategically for our nation’s future.
Economists have long recognized the strong association between poverty  and a range of adverse outcomes for individuals, and empirical research,  while limited, has also begun to help us better understand the impact of  poverty on a nation’s economic growth. The interrelationships between  poverty and various adverse social outcomes are complex, and our  understanding of these relationships can lead to vastly different  conclusions regarding appropriate interventions to address each specific  outcome. Furthermore, any such interventions could take years, or even a  generation, to yield significant and lasting results, as the greatest impacts  are likely to be seen among children. Nevertheless, whatever the  underlying causes of poverty may be, economic research suggests that  improvements in the health, neighborhoods, education, and skills of those  living in poverty could have impacts far beyond individuals and families,  potentially improving the economic well-being of the nation as a whole.
section_title: Reviewer Comments
paragraphs: We provided the draft report to four outside reviewers with expertise in  the areas of poverty and economic growth.  The reviewers generally  acknowledged that our report covers a substantial body of recent  economic research on the topic and did not dispute the validity of the  specific studies included in our review.  However, they expressed some  disagreement over our presentation of this research.
Some reviewers felt that the evidence directly linking poverty to adverse  outcomes is more robust than implied by our summary and directed us to  additional research that bolsters the link between poverty and poor health  and crime. We did not incorporate this additional research into our  findings, but we reviewed it and found it consistent with the evidence  already incorporated in our summary.  Other reviewers felt that our report  implied a stronger relationship between poverty and adverse outcomes  than is supported by the research.  They felt that the report did not provide  adequate information on the causes of poverty and external factors that  could be responsible for both poverty and adverse outcomes. In response  to these comments, we made several revisions to the text to ensure that  the information we presented was balanced.  The reviewers also provided  technical comments that we incorporated as appropriate.
Copies of this report are being sent to the Departments of Commerce,  Health and Human Services, Justice, and Labor; appropriate congressional  committees; and other interested parties. Copies will be made available to  others upon request. The report is also available at no charge on the GAO  Web site at http://www.gao.gov.
If you or your staff have any questions about matters discussed in this  report, please contact me at (202) 512-7215 or at nilsens@gao.gov. Other  contact and staff acknowledgments are listed in appendix II.
section_title: Appendix I: Bibliography
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section_title: Appendix II: Contacts and Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: Kathy Larin, Assistant Director, and Janet Mascia, Analyst-in-Charge,  managed this assignment. Lawrance Evans, Ben Bolitzer , Ken Bombara,  Amanda Seese, and Rhiannon Patterson made significant contributions  throughout the assignment. Charles Willson, Susannah Compton, and  Patrick DiBattista helped develop the report’s message.
In addition, Doug Besharov, Dr. Maria Cancian, Dr. Sheldon Danziger, and  Dr. Lawrence Mead reviewed and provided comments on the report.