Major Management Challenges at the Department of Health and Human Services

The Department of Health and Human Services (HHS), with a $548 billion budget and a workforce of more than 65,000 people, presents one of the more massive and complex management challenges in the federal government. Overall, HHS has made some progress in addressing some of the management challenges GAO identified in 2003, but significant work remains to address others.

The department's largest program in terms of federal expenditures—Medicare—retains the high-risk status designated by GAO in 1990 due, in part, to its sheer size and complexity. With estimated outlays of $297 billion in fiscal year 2004, Medicare continues to be a target for exploitation. The Centers for Medicare & Medicaid Services (CMS), tasked with safeguarding the integrity of the Medicare program, estimated that the program had made net improper payments of $19.9 billion in fiscal year 2004. CMS reported focusing recent Medicare program integrity efforts on identifying fraud “hot spots,” where program fraud occurs systematically, and stated, for example, that from January 2003 through June 2004, these efforts resulted in avoiding over $260 million in improper payments by fraudulent entities billing for home health services. Nevertheless, certain program safeguard challenges GAO noted in January 2003—overseeing the claims payment work of Medicare's contractors and monitoring Medicare managed care plans for their adherence to program rules—remained issues over the following 2 years. For example, in 2004, GAO reported that it took 6 years for CMS to implement reforms after Medicare contractors reviewing claims made by power wheelchair suppliers had identified potential billing abuses. Although CMS began to address the problems in 2003, the delay cost Medicare millions of dollars in overpayments. In a 2004 report about private health plans in a Medicare demonstration program, GAO found that CMS allowed plans to exclude coverage for some Medicare-covered services, such as skilled nursing and home health care, when Medicare enrollees obtained these services from providers outside of the plans' networks. This exclusion was contrary to federal law, which requires private plans in the demonstration to allow Medicare enrollees to receive covered services from any provider that is legally authorized to provide Medicare services and accepts the plans' terms for payment. On GAO's recommendation, CMS agreed to instruct the Medicare preferred provider organization (PPO) demonstration plans accordingly and stated that it is working to ensure that the plans come into compliance with the provisions that govern their Medicare participation. Additional information on Medicare can be found in High-Risk Series: An Update ( GAO-05-207 ).

The design and administration of Medicare's multiple payment systems continues to be a challenge for CMS, as paying appropriately for Medicare services requires frequent and carefully targeted refinements. When Medicare sets payment rates that exceed market prices, taxpayer dollars are spent needlessly and beneficiaries are penalized through excessive copayments. Conversely, if Medicare rates were to be set too low, beneficiaries' access to providers could be compromised. As CMS seeks to control aggregate Medicare payments, it must refine payment rates to ensure that they reflect cost differences across providers and services and monitor beneficiaries' use of services to assess the impact of any changes on access . Such refinement and monitoring of payments requires that timely and accurate data be available. In reports issued over the past 2 years, regarding payments for home health and ambulance services, GAO found that payments to providers may have been adequate in the aggregate but needed targeted adjustments; regarding payments for hospital outpatient, hospice, and other services, GAO found that data weaknesses hindered CMS from assessing the adequacy of payments for these services. GAO has made recommendations for CMS to refine and adjust payment systems appropriately, in part, by collecting the most accurate and current data possible.

Medicaid, a program that CMS administers jointly with the states, was added to GAO's list of high-risk programs in 2003 and remains there due to its size, growth, diversity, and fiscal management weaknesses. In 2003, total Medicaid outlays were about $274 billion, of which the federal share was about $160 billion. CMS has taken steps to improve its fiscal and management oversight of Medicaid, but its efforts fall short of what is needed to prevent excessive federal spending. For example, states have continued to operate financing schemes that allow them to obtain excessive federal matching funds, despite steps CMS has taken to curb inappropriate practices. Regarding improper payments made to Medicaid providers, CMS has activities to support states' program integrity efforts but conducts little oversight of states' program integrity operations. For example, CMS began a project to share claims information between the Medicaid and Medicare programs and has reported that this effort achieved a 21-to-1 return on investment in its first year in one large state. Since then, CMS expanded this effort to eight additional states. At the same time, however, CMS reviews fewer than one in five states' program integrity operations in a given year, and these reviews are limited in scope. Moreover, despite GAO recommendations to the contrary, the Secretary of Health and Human Services (HHS) has continued to approve waivers allowing states to operate demonstration programs that expand Medicaid coverage to new populations, even when those programs could increase the federal government's financial liability substantially beyond what it would have been without the waivers. Additional information on Medicaid can be found in High-Risk Series: An Update ( GAO-05-207 ).

Weaknesses remain despite CMS's efforts to improve the oversight of care provided to Medicare and Medicaid beneficiaries . In general, CMS defines standards that nursing homes, hospitals, kidney dialysis facilities, and other providers must meet to participate in the Medicare and Medicaid programs and contracts with states to assess whether these standards are met through periodic inspections, complaint investigations, and oversight surveys. CMS has instituted annual assessments of each state's compliance with federal oversight requirements for some providers, but in 2003, GAO reported that these assessments could be strengthened by making greater use of available data and ensuring greater CMS regional office consistency in conducting such reviews. Although under development for nearly 7 years, CMS has not implemented an improved nursing home survey methodology, which is intended to better ensure that surveyors do not overlook serious care problems. Our review of the Arkansas state survey agency's investigation of nursing home deaths found that serious care problems were frequently overlooked, a problem consistent with shortcomings in CMS's survey methodology. Moreover, CMS was conducting only about 5 percent of the statutorily required federal fire safety oversight surveys. CMS said that to accomplish additional fire safety oversight surveys for fiscal year 2005, it planned to redirect funds from a contract being used to increase the number of nursing home federal oversight surveys, an increase that had been recommended by GAO. CMS acknowledged that the number of hospital oversight surveys, which had dropped from 5 percent per year to 1 percent, was insufficient and stated that it planned an increase in such surveys. Kidney dialysis facilities, unlike nursing homes and hospitals, are not subject to federally required oversight surveys. Although some such surveys are conducted by CMS regional offices, GAO found that the number declined from fiscal years 2001 through 2002. GAO also found that states had either received no feedback on oversight survey results or had conducted no oversight surveys. CMS has not specified the number of oversight surveys that its regional offices should conduct nor has it committed to ensuring more consistent oversight of dialysis facilities.

Ensuring that every community—and the approximately 2,900 state and local public health agencies across the nation—meets a basic standard of preparedness for a global influenza pandemic, a bioterrorist attack, or other public health emergencies is another significant HHS challenge. Over the past 2 years, GAO found that efforts to develop public health infrastructure and coordinate responsible entities needed attention. As GAO reported in 2003, the 2001 anthrax incidents made local and state officials aware of gaps in the preparedness of their public health workforce, clinical laboratories, and coordination among responders. The anthrax incidents also strained the Centers for Disease Control and Prevention's (CDC) information management and communication resources and highlighted shortcomings in the availability of vaccines and drugs and in relevant training for clinicians. CDC has taken steps to address some of these issues, including creating the Office of Terrorism Preparedness and Emergency Response. In 2004, GAO noted that states had improved their disease surveillance systems, laboratory capacity, communication systems, and workforces, but regional planning among the states and the capacity to treat a sudden, large influx of patients within many states were lacking. In 2004, GAO also found that challenges persisted in ensuring an adequate and timely flu vaccine supply, owing to manufacturing and distribution system problems and the absence of a system to ensure that individuals at greatest risk receive vaccinations first when there are shortages. CDC has taken steps to influence distribution patterns to help providers obtain vaccine for their high-risk patients, but HHS's draft plan for addressing pandemic influenza—although comprehensive in scope—leaves decisions about the purchase, distribution, and administration of vaccines for the states to make individually.

In its oversight of medical product safety and efficacy , the Food and Drug Administration (FDA) has taken actions to prohibit the marketing of dietary supplements with significant health risks. For example, FDA banned the sale of dietary supplements containing ephedra, the first time it has withdrawn a dietary supplement from marketing. This action followed a 2003 congressional hearing at which GAO testified that (1) the serious adverse events reported to a manufacturer of ephedra products—heart attacks, seizures, and strokes—were consistent with the known physiological effects of ephedra; (2) FDA had received 15 times more adverse event reports about epehdra than the next most commonly reported supplement; and (3) FDA had previously prohibited the marketing of over-the-counter drugs with ingredients similar to those in dietary supplements containing ephedra. However, FDA continues to face challenges in obtaining the data needed to assess agency oversight activities. For example, in 2003, GAO reported that FDA did not obtain sufficient information about the racial identifications of children participating in clinical drug trials to ensure that the studies included adequate numbers of children from racial and ethnic minorities. In 2004, GAO also reported that FDA did not have the data necessary to determine if the agency was meeting its mandated time frames for reviewing applications for the marketing of new medical devices.

HHS has taken steps to improve its oversight of states' social service programs designed to enhance the economic independence and well-being of children and families, but challenges remain in this area as well. For example, in partnership with states, HHS has worked to improve child welfare information systems, initiated efforts to better assess whether key welfare and social services programs are at risk of improper payments, and disseminate research findings on program effectiveness. At the same time, HHS continues to face challenges in conducting rigorous research on program effectiveness and in facilitating states' efforts to implement information systems and provide reliable program data. For example, in 2004, GAO reported that HHS lacked adequate information to assess the extent to which family assistance and child care programs were at risk of improper payments. With regard to health insurance coverage, a key component to economic independence and well-being, HHS also faces challenges in ensuring that states coordinate eligibility for Medicaid and State Children's Health Insurance Program (SCHIP) programs in a manner that safeguards federal resources and ensures that eligible individuals have access to coverage.

HHS has made some progress in improving its financial management processes, systems, and controls . For the past 6 years, the department has earned an unqualified, or “clean,” opinion on its financial audit. In addition, the department has made progress in identifying strategies for estimating, reducing, and recovering improper payments in several of its programs. Despite this progress, challenges remain in identifying cost-effective and cost-efficient approaches for estimating improper payments in its family assistance and child care programs. The department also continues to rely on systems and processes that do not routinely generate financial information that is timely or reliable. Efforts to develop and implement a new, integrated financial management system have been ongoing for several years, but HHS has not followed key disciplined processes necessary to reduce the risks associated with implementing its new financial management system to acceptable levels. Problems in key systems development and implementation areas—compounded by incomplete information technology management practices, information security weaknesses, and problematic human capital practices—significantly increase the risks that the new system will not fully meet one or more of its cost, schedule, and performance objectives. Further, the department remains unable to ensure that it can protect the confidentiality of sensitive information from unauthorized access or its systems from service disruption.

Related Products

Medicare Program Integrity Safeguards

Medicare: Accuracy of Responses from the 1-800-MEDICARE Help Line Should Be Improved . GAO-05-130 . Washington, D.C.: December 8, 2004.

Medicare: CMS's Program Safeguards Did Not Deter Growth in Spending for Power Wheelchairs. GAO-05-43 . Washington, D.C.: November 17, 2004.

Medicare: Incomplete Plan to Transfer Appeals Workload from SSA to HHS Threatens Service to Appellants. GAO-05-45 . Washington, D.C.: October 4, 2004.

Medicare Demonstration PPOs: Financial and Other Advantages for Plans, Few Advantages for Beneficiaries .  GAO-04-960 . Washington, D.C.: September 27, 2004.

Comprehensive Outpatient Rehabilitation Facilities: High Medicare Payments in Florida Raise Program Integrity Concerns . GAO-04-709 . Washington, D.C.: August 12, 2004.

Medicare: Call Centers Need to Improve Responses to Policy-Oriented Questions from Providers .  GAO-04-669 . Washington, D.C.: July 16, 2004.

Financial Management: Status of the Governmentwide Efforts to Address Improper Payment Problems.   GAO-04-99 . Washington, D.C.: October 17, 2003.

Medicare Appeals: Disparity between Requirements and Responsible Agencies' Capabilities .  GAO-03-841 . Washington, D.C.: September 29, 2003.

Federal Budget: Opportunities for Oversight and Improved Use of Taxpayer Funds .  GAO-03-1029T . Washington, D.C.: July 16, 2003.

Financial Management: Effective Implementation of the Improper Payments Information Act of 2002 Is Key to Reducing the Government's Improper Payments .  GAO-03-991T . Washington, D.C.: July 14, 2003.

Financial Management Systems: Core Financial Systems at the 24 Chief Financial Officers Act Agencies .  GAO-03-903R . Washington, D.C.: June 27, 2003.

Financial Management: Challenges Remain in Addressing the Government's Improper Payments .  GAO-03-750T . Washington, D.C.: May 13, 2003.

Medicare Provider Enrollment: Opportunities to Enhance Program Integrity Efforts .   GAO-03-185 . Washington, D.C.: March 17, 2003.

Medicare Program Design and Administration

Medicare Chemotherapy Payments: New Drug and Administration Fees Are Closer to Providers' Costs. GAO-05-142R . Washington, D.C.: December 1, 2004.

Medicare Hospice Care: Modifications to Payment Methodology May Be Warranted . GAO-05-42 . Washington, D.C.: October 15, 2004.

Medicare: Appropriate Dispensing Fee Needed for Suppliers of Inhalation Therapy Drugs. GAO-05-72 . Washington, D.C.: October 12, 2004.

Medicare Physician Payments: Concerns about Spending Target System Prompt Interest in Considering Reforms . GAO-05-85 . Washington, D.C.: October 8, 2004.

Medicare: Information Needed to Assess Adequacy of Rate-Setting Methodology for Payments for Hospital Outpatient Services. GAO-04-772 . Washington, D.C.: September 17, 2004.

Medicare: Past Experience Can Guide Future Competitive Bidding for Medical Equipment and Supplies. GAO-04-765 . Washington, D.C.: September 7, 2004.

Comptroller General David M. Walker. Viewpoint: We Must Repair Our Ailing Healthcare System. AAMC Reporter. September 2004. http://www.aamc.org/newsroom/reporter/sept04/viewpoint.htm .

Health Care: Unsustainable Trends Necessitate Comprehensive and Fundamental Reforms to Control Spending and Improve Value. GAO-04-793SP . Washington, D.C.: May 2004.

Department of Health and Human Services, Office of Inspector General. Medicare Payments for Power Wheelchairs. OEI-03-02-00600 . Washington, D.C.: April 2004.

Health Care System Crisis: Growing Challenges Point to Need for Fundamental Reform. Presented to the participants of the GAO Health Care Forum, held on January 13, 2004. Last updated April 16, 2004. http://www.gao.gov/cghome/healthcare/

Medicare Home Health: Payments to Most Freestanding Home Health Agencies More Than Covered Their Costs .  GAO-04-359 . Washington, D.C.: February 27, 2004.

Medicare: Discrepancy in Hospital Outpatient Prospective Payment System Methodology Leads to Inaccurate Beneficiary Copayments and Medicate Payments .  GAO-04-103R . Washington, D.C.: October 6, 2003.

Medicare: Modifying Payments for Certain Pathology Services Is Warranted .  GAO-03-1056 . Washington, D.C.: September 30, 2003.

Ambulance Services: Medicare Payments Can Be Better Targeted to Trips in Less Densely Populated Rural Areas. GAO-03-986 . Washington, D.C.: September 19, 2003.

Medicare: Most Beneficiaries Receive Some but Not All Recommended Preventive Services .  GAO-03-958 . Washington, D.C.: September 8, 2003 .

Medicare Home Health Payment: Nonroutine Medical Supply Data Needed to Assess Payment Adjustments .  GAO-03-878 . Washington, D.C.: August 15, 2003.

Opportunities For Oversight And Improved Use Of Taxpayer Funds: Examples from Selected GAO Work .  GAO-03-1006 . Washington, D.C.: August 1, 2003.

Federal Budget: Opportunities for Oversight and Improved Use of Taxpayer Funds .  GAO-03-1030T . Washington, D.C.: July 17, 2003.

Medicare: Divided Authority for Policies on Coverage of Procedures and Devices Results in Inequities .  GAO-03-175 . Washington, D.C.: April 11, 2003.

Medicare: Financial Challenges and Considerations for Reform .  GAO-03-577T . Washington, D.C.: April 10, 2003.

Medicare: Observations on Program Sustainability and Strategies to Control Spending on Any Proposed Drug Benefit .  GAO-03-650T . Washington, D.C.: April 9, 2003.

Medicare: Payment for Blood Clotting Factor Exceeds Providers' Acquisition Cost .  GAO-03-184 . Washington, D.C.: January 10, 2003.

Fiscal and Management Oversight of Medicaid

Medicaid Program Integrity: State and Federal Efforts to Prevent and Detect Improper Payments . GAO-04-707 . Washington, D.C.: July 16, 2004.

Medicaid Waivers: HHS Approvals of Pharmacy Plus Demonstrations Raise Continuing Cost and Oversight Concerns . GAO-04-480 . Washington, D.C.: June 30, 2004.

Medicaid: Intergovernmental Transfers Have Facilitated State Financing Schemes .  GAO-04-574T . Washington, D.C.: March 18, 2004.

Medicaid: Improved Federal Oversight of State Financing Schemes Is Needed .  GAO-04-228 . Washington, D.C.: February 13, 2004.

SCHIP: HHS Continues to Approve Waivers That Are Inconsistent with Program Goals .  GAO-04-166R .   Washington, D.C.: January 5, 2004

Financial Management: Status of the Government Efforts to Address Improper Payment Problems.   GAO-04-99 . Washington, D.C.: October 17, 2003.

Medicaid and SCHIP: Recent HHS Approvals of Demonstration Waiver Projects Raise Concerns . GAO-02-817. Washington, D.C.: July 12, 2002.

Medicaid Financial Management: Better Oversight of State Claims for Federal Reimbursement Needed . GAO-02-300. Washington, D.C.: February 8, 2002.

Medicare and Medicaid Care Oversight

Nursing Home Deaths: Arkansas Coroner Referrals Confirm Weaknesses in State and Federal Oversight of Quality of Care. GAO-05-78 . Washington, D.C.: November 12, 2004 .

Medicare: CMS Needs Additional Authority to Adequately Oversee Patient Safety in Hospitals . GAO-04-850 . Washington, D.C.: July 20, 2004.

Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in Federal Standards and Oversight . GAO-04-660 . Washington, D.C.: July 16, 2004.

Dialysis Facilities: Problems Remain in Ensuring Compliance with Medicare Quality Standards . GAO-04-63 . Washington, D.C.: October 8, 2003.

Nursing Home Quality: Prevalence of Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight . GAO-03-561 . Washington, D.C.: July 15, 2003 .

Preparedness for Public Health Emergencies, Including Bioterrorism

Flu Vaccine: Recent Supply Shortages Underscore Ongoing Challenges .  GAO-05-177T .  Washington, D.C.: November 18, 2004.

Emerging Infectious Diseases: Review of State and Federal Disease Surveillance Efforts . GAO-04-877 . Washington, D.C.: September 30, 2004.

Infectious Disease Preparedness: Federal Challenges in Responding to Influenza Outbreaks .  GAO-04-1100T . Washington, D.C.: September 28, 2004.

September 11: Health Effects in the Aftermath of the World Trade Center Attack .  GAO-04-1068T . Washington, D.C.: September 8, 2004.

Public Health Preparedness: Response Capacity Improving, but Much Remains to Be Accomplished .  GAO-04-458T . Washington, D.C.: February 12, 2004.

HHS Bioterrorism Preparedness Programs: States Reported Progress but Fell Short of Program Goals for 2002 .  GAO-04-360R . Washington, D.C.: February 10, 2004.

Infectious Diseases: Gaps Remain in Surveillance Capabilities of State and Local Agencies . GAO-03-1176T . Washington, D.C.: September 24, 2003.

Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but Lack Certain Capacities for Bioterrorism Response . GAO-03-924 . Washington, D.C.: August 6, 2003.

Severe Acute Respiratory Syndrome: Established Infectious Disease Control Measures Helped Contain Spread, but a Large-Scale Resurgence May Pose Challenges . GAO-03-1058T . Washington, D.C.: July 30, 2003.

Bioterrorism: Information Technology Strategy Could Strengthen Federal Agencies' Abilities to Respond to Public Health Emergencies . GAO-03-139 . Washington, D.C.: May 30, 2003.

SARS Outbreak: Improvements to Public Health Capacity Are Needed for Responding to Bioterrorism and Emerging Infectious Diseases . GAO-03-769T . Washington, D.C.: May 7, 2003.

Smallpox Vaccination: Implementation of National Program Faces Challenges . GAO-03-578 . Washington, D.C.: April 30, 2003.

Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have Improved Public Health Response Capacity, but Gaps Remain . GAO-03-654T . Washington, D.C.: April 9, 2003.

Bioterrorism: Preparedness Varied across State and Local Jurisdictions . GAO-03-373 . Washington, D.C.: April 7, 2003.

Hospital Emergency Departments: Crowded Conditions Vary among Hospitals and Communities . GAO-03-460 . Washington, D.C.: March 14, 2003.

Medical Product Safety and Efficacy

Food and Drug Administration: Data to Measure the Timeliness of Reviews of Medical Device Applications Are Limited . GAO-04-1022 . Washington, D.C.: August 30, 2004.

Internet Pharmacies: Some Pose Safety Risks for Consumers . GAO-04-820 . Washington, D.C.: June 17, 2004.

Pediatric Drug Research: Food and Drug Administration Should More Efficiently Monitor Inclusion of Minority Children . GAO-03-950 . Washington, D.C.: September 26, 2003.

Dietary Supplements Containing Ephedra: Health Risks and FDA's Oversight . GAO-03-1042T . Washington, D.C.: July 23, 2003.

Dietary Supplements: Review of Health-Related Call Records for Users of Metabolife 356 . GAO-03-494 . Washington, D.C.: March 31, 2003.

Prescription Drugs: FDA Oversight of Direct-to-Consumer Advertising Has Limitations . GAO-03-177 . Washington, D.C.: October 28, 2002.

Economic Independence and Well-being of Children and Families

Foster Youth: HHS Actions Could Improve Coordination of Services and Monitoring of States' Independent Living Programs. GAO-05-25 . Washington, D.C.: November 18, 2004.

Financial Management Systems: HHS Faces Many Challenges in Implementing Its Unified Financial Management System .  GAO-04-1089T . Washington, D.C.: September 30, 2004.

D.C. Child and Family Services Agency: More Focus Needed on Human Capital Management Issues for Caseworkers and Foster Parent Recruitment and Retention. GAO-04-1017 . Washington, D.C.: September 24, 2004.

Food Stamp Program: Farm Bill Options Ease Administrative Burden, but Opportunities Exist to Streamline Participant Reporting Rules among Programs .  GAO-04-916 .  Washington, D.C.: September 16, 2004.

TANF and SSI: Opportunities Exist to Help People with Impairments Become More Self-Sufficient .  GAO-04-878 .  Washington, D.C.: September 15, 2004.

Welfare Reform: Rural TANF Programs Have Developed Many Strategies to Address Rural Challenges .  GAO-04-921 .  Washington, D.C.: September 10, 2004.

Child Care: State Efforts to Enforce Safety and Health Requirements. GAO-04-786 . Washington, D.C.: September 9, 2004.

Prekindergarten: Four Selected States Expanded Access by Relying on Schools and Existing Providers of Early Education and Care to Provide Services .  GAO-04-852 . Washington, D.C.: September 9, 2004.

TANF and Child Care Programs: HHS Lacks Adequate Information to Assess Risk and Assist States in Managing Improper Payments .  GAO-04-723 .  Washington, D.C.: June 18, 2004.

Child and Family Services Reviews: States and HHS Face Challenges in Assessing and Improving State Performance .  GAO-04-781T .  Washington, D.C.: May 13, 2004.

D.C. Family Court: Operations and Case Management Have Improved, but Critical Issues Remain. GAO-04-685T . Washington, D.C.: April 23, 2004.

Child and Family Services Reviews: Better Use of Data and Improved Guidance Could Enhance HHS's Oversight of State Performance .  GAO-04-333 .  Washington, D.C.: April 20, 2004.

District of Columbia: Status of Reforms to the District's Mental Health System. GAO-04-387 . Washington, D.C.: March 31, 2004.

Medicaid and SCHIP: States' Premium and Cost Sharing Requirements for Beneficiaries .  GAO-04-491 . Washington, D.C.: March 31, 2004. 

Child Support Enforcement: Better Data and More Information on Undistributed Collections Are Needed . GAO-04-377 . Washington, D.C.: March 19, 2004.

Food Stamp Program: Steps Have Been Taken to Increase Participation of Working Families, but Better Tracking of Efforts Is Needed.  GAO-04-346 .  Washington, D.C.: March 5, 2004.

Transportation-Disadvantaged Populations: Federal Agencies Are Taking Steps to Assist States and Local Agencies in Coordinating Transportation Services .  GAO-04-420R .  Washington, D.C.: February 24, 2004.

Child Welfare: Improved Federal Oversight Could Assist States in Overcoming Key Challenges . GAO-04-418T . Washington, D.C.: January 28, 2004.

Supports for Low-Income Families: States Serve a Broad Range of Families through a Complex and Changing System .  GAO-04-256 .  Washington, D.C.: January 26, 2004.

D.C. Family Court: Progress Has Been Made in Implementing Its Transition. GAO-04-234 . Washington, D.C.: January 6, 2004.

SCHIP: HHS Continues to Approve Waivers That Are Inconsistent with Program Goals .  GAO-04-166R . Washington, D.C.: January 5, 2004.

Head Start: Better Data and Processes Needed to Monitor Underenrollment . GAO-04-17 . Washington, D.C.: December 4, 2003.

Child Welfare: States Face Challenges in Developing Information Systems and Reporting Reliable Child Welfare Data . GAO-04-267T . Washington, D.C.: November 19, 2003.

Head Start: Increased Percentage of Teachers Nationwide Have Required Degrees, but Better Information on Classroom Teachers' Qualifications Needed . GAO-04-5 . Washington, D.C.: October 1, 2003.

Head Start: Curriculum Use and Individual Child Assessment in Cognitive and Language Development . GAO-03-1049 . Washington, D.C.: September 12, 2003.

Child Welfare: Enhanced Federal Oversight of Title IV-B Could Provide States Additional Information to Improve Services . GAO-03-956 . Washington, D.C.: September 12, 2003.

Welfare Reform: Information on TANF Balances .  GAO-03-1094 .  Washington, D.C.: September 8, 2003.

Child Welfare: Most States Are Developing Statewide Information Systems, but the Reliability of Child Welfare Data Could Be Improved . GAO-03-809 . Washington, D.C.: July 31, 2003.

Education and Care: Head Start Key Among Array of Early Childhood Programs, but National Research on Effectiveness Not Completed .  GAO-03-840T .  Washington, D.C.: July 22, 2003.

Child Welfare and Juvenile Justice: Several Factors Influence the Placement of Children Solely to Obtain Mental Health Services . GAO-03-865T . Washington, D.C.: July 17, 2003.

Welfare Reform: Information on Changing Labor Market and State Fiscal Conditions .  GAO-03-977 . Washington, D.C.: July 15, 2003.

Medicaid Formula: Differences in Funding Ability among States Often Are Widened .  GAO-03-620 .  Washington, D.C.: July 10, 2003.   

Health Care: Approaches to Address Racial and Ethnic Disparities .  GAO-03-862R .  Washington, D.C.: July 8, 2003.  

Transportation-Disadvantaged Populations: Some Coordination Efforts Among Programs Providing Transportation Services, but Obstacles Persist .  GAO-03-697 . Washington, D.C.: June 30, 2003.

Medicaid and Ticket to Work: States' Early Efforts to Cover Working Individuals with Disabilities .  GAO-03-587 .  Washington, D.C.: June 13, 2003.

D.C. Child and Family Services: Better Policy Implementation and Documentation of Related Activities Would Help Improve Performance. GAO-03-646 . Washington, D.C.: May 27, 2003.

D.C. Child and Family Services: Key Issues Affecting the Management of Its Foster Care Cases. GAO-03-758T . Washington, D.C.: May 16, 2003.

Child Care: Recent State Policy Changes Affecting the Availability of Assistance for Low-Income Families .  GAO-03-588 . Washington, D.C.: May 5, 2003.

Program Evaluation: An Evaluation Culture and Collaborative Partnerships Help Build Agency Capacity . GAO-03-454 . Washington, D.C.: May 2, 2003.

Transportation-Disadvantaged Populations: Many Federal Programs Fund Transportation Services, but Obstacles to Coordination Persist .  GAO-03-698T .  Washington, D.C.: May 1, 2003.

Child Welfare and Juvenile Justice: Federal Agencies Could Play a Stronger Role in Helping States Reduce the Number of Children Placed Solely to Obtain Mental Health Services . GAO-03-397 . Washington, D.C.: April 21, 2003.

Multiple Employment and Training Programs: Funding and Performance Measures for Major Programs .  GAO-03-589 .  Washington, D.C.: April 18, 2003.

Foster Care: States Focusing on Finding Permanent Homes for Children, but Long-Standing Barriers Remain .  GAO-03-626T . Washington, D.C.: April 8, 2003.

District of Columbia: Issues Associated with the Child and Family Services Agency's Performance and Policies. GAO-03-611T . Washington, D.C.: April 2, 2003 .

Child Welfare: HHS Could Play a Greater Role in Helping Child Welfare Agencies Recruit and Retain Staff . GAO-03-357 . Washington, D.C.: March 31, 2003.

Workforce Training: Employed Worker Programs Focus on Business Needs, but Revised Performance Measures Could Improve Access for Some Workers .  GAO-03-353 .  Washington, D.C.: February 14, 2003.

Managing for Results: Efforts to Strengthen the Link Between Resources and Results at the Administration for Children and Families .  GAO-03-9 . Washington, D.C.: December 10, 2002.

Welfare Reform: Former TANF Recipients with Impairments Less Likely to Be Employed and More Likely to Receive Federal Supports .  GAO-03-210 .  Washington, D.C.: December 6, 2002.

Financial Management

Financial Management Systems: HHS Faces Many Challenges in Implementing Its Unified Financial Management System .  GAO-04-1089T .  Washington, D.C.: September 30, 2004.

Medicaid Financial Management: Better Oversight of State Claims for Federal Reimbursement Needed . GAO-02-300. Washington, D.C.: February 28, 2002.