Recommendation: The Associate Administrator of the Office of Entrepreneurial Development should reevaluate the SBDC funding application requirements, including reexamining the funding estimate SBDCs are required to use and considering other changes that could reduce administrative burdens on SBDCs. (Recommendation 1)

Agency: Small Business Administration
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The U.S. Commissioner of the IBWC should work with the Mexican Commissioner to formalize a binational rapid response team to address sewage infrastructure failures along the U.S.-Mexico border, including the Nogales and South Bay wastewater treatment plants. (Recommendation 1)

Agency: International Boundary and Water Commission, United States and Mexico
Status: Open

Comments: In July 2020, USIBWC stated that two teams have been established with members, one in the Nogales, Arizona and Nogales, Sonora region and one in the San Diego and Tijuana region. IBWC continues to take actions to formalize the binational rapid response teams. We will review the final documents for each team when they are completed and available.

Recommendation: The U.S. Commissioner of the IBWC should direct USIBWC staff to conduct long-term capital planning for the Santa Cruz River Basin and Tijuana River Valley watersheds, following the principles in OMB Circular A-11. (Recommendation 2)

Agency: International Boundary and Water Commission, United States and Mexico
Status: Open

Comments: In July 2020, the U.S. Commissioner of the IBWC stated that it had conducted long-term capital planning for the facilities for which it is responsible. They noted the 5-year plan that USIBWC had developed for the South Bay plant and the 10-year plan that it had developed for the Nogales plant. We noted these plans in our original report and stated that they needed to be broadened to identify needs in the Santa Cruz River Basin and Tijuana River Valley watersheds. The agency only partially concurred with our recommendation in the report and noted that to the extent our report envisions USIBWC undertaking long-term capital planning for (1) nonfederal infrastructure; (2) infrastructure that does not yet exist; and/or (3) infrastructure that the USIBWC is not yet authorized to construct or maintain, it does not concur. The agency is a key player in managing water quality on the border and has the infrastructure and organization that will be part of the solution. Without the information that USIBWC would generate by comprehensively assessing its long-term needs, such as through long-term capital planning efforts, Congress cannot authorize specific work that needs to be done. We recommended that the agency conduct long-term planning, including for infrastructure that does not exist and for infrastructure that is not yet authorized specifically to address this problem. We continue to believe that USIBWC should recognize its role along the border and start planning for it, including by undertaking long-term capital planning for existing and potential future infrastructure and identifying alternatives to address the long-standing water quality problems.

Recommendation: The Secretary of the Army should develop targeted strategies for using its recruitment, training, and retention programs collectively to address key military physician gaps in a coordinated manner, and metrics that would monitor the effectiveness of its programs collectively in reducing gaps. (Recommendation 1)

Agency: Department of Defense
Status: Open

Comments: Army concurred with this recommendation. In October 2019, the Army reported that several steps have been taken, including creating a 6-year health professions officer retention bonus for critically short physician specialties; increased the number of Health Professions Scholarship Program scholarships to help decrease the overall physician shortfalls; and added a recruiting mission using Financial Assistance Program (FAP) scholarships to help decrease the physician shortfall in critical specialties. The FAP mission is to begin in fiscal year 2020. While the steps Army reported demonstrate progress toward fully implementing our recommendation, we believe that this recommendation should remain open until more progress is made.

Recommendation: The Secretary of the Navy should develop targeted strategies for using its recruitment, training, and retention programs collectively to address key military physician gaps in a coordinated manner, and metrics that would monitor the effectiveness of its programs collectively in reducing gaps. (Recommendation 2)

Agency: Department of Defense
Status: Open

Comments: Navy concurred with this recommendation. In October 2019, Navy officials stated that several steps have been taken, including exploring policy changes that would assist in meeting requirements. According to Navy officials, a working group has been formed which will address recruitment and retention of all critical specialties and plan to issue an end product by June 2020.

Recommendation: The Secretary of the Air Force should develop targeted strategies for using its recruitment, training, and retention programs collectively to address key military physician gaps in a coordinated manner, and metrics that would monitor the effectiveness of its programs collectively in reducing gaps. (Recommendation 3)

Agency: Department of Defense
Status: Open

Comments: Air Force concurred with our recommendation. In October 2019, the Air Force reported that several steps have been taken; including developing a sustainable process for improved marketing of key specialties to students and increasing the number of Health Professions Scholarship Program scholarships. While the steps Air Force reported demonstrate progress toward fully implementing our recommendation, we believe that this recommendation should remain open until more progress is made.

Recommendation: The Secretary of the Navy should track complete, accurate, and accessible information on the qualifications, performance, and progress of Navy AFHPSP medical students. (Recommendation 5)

Agency: Department of Defense
Status: Open

Comments: Navy concurred with this recommendation. In November 2018, the Navy changed its Navy Standard Integrated Personnel System (NSIPS) to allow tracking of qualification data fields. As of October 2019, the Navy reported it is taking steps to update NSIPS to track the complete performance and progress of AFHPSP medical students. While the steps Navy reported demonstrate progress toward fully implementing our recommendation, we believe that this recommendation should remain open until more progress is made.

Recommendation: The Secretary of the Air Force should track complete, accurate, and accessible information on the qualifications, performance, and progress of Air Force AFHPSP medical students. (Recommendation 6)

Agency: Department of Defense
Status: Open

Comments: Air Force concurred with this recommendation. In August 2018, the Air Force updated guidance to emphasize the requirement for accurate and complete reporting of qualification data of AFHPSP medical students. As of October 2019, the Air Force reported that it is partnering with the Army and Navy to secure a tri-service database to track students' performance across the continuum of learning. While the steps Air Force reported demonstrate progress toward fully implementing our recommendation, we believe that this recommendation should remain open until more progress is made.

Recommendation: The President of Uniformed Services University of the Health Sciences (USUHS) should track complete, accurate, and accessible information on the performance and progress of USUHS medical students. (Recommendation 7)

Agency: Department of Defense
Status: Open

Comments: Uniformed Services University of the Health Sciences concurred with our recommendation. In October 2019, the University reported that issues relevant to tracking its students continue to be researched and have offered to collaborate with the military departments. While the steps the University reported demonstrate progress toward fully implementing our recommendation, we believe that this recommendation should remain open until more progress is made.

Recommendation: The Secretary of the Navy should use information on medical student performance to evaluate Navy accession programs. (Recommendation 8)

Agency: Department of Defense
Status: Open

Comments: Navy concurred with this recommendation. In October 2019, the Navy reported that the Navy Standard Integrated Personnel System (NSIPS) now contains qualification data of AFHPSP medical students and also has some performance data of these students as they compete their post graduate training. NPSIS is capable of being queried and this data, according to the Navy, can be used to evaluate its accession programs. While the steps Navy reported demonstrate progress toward fully implementing our recommendation, we believe that this recommendation should remain open until more progress is made.

Recommendation: The Secretary of the Air Force should use information on medical student performance to evaluate Air Force accession programs. (Recommendation 9)

Agency: Department of Defense
Status: Open

Comments: Air Force concurred with our recommendation. In October 2019, the Air Force reported it plans to annually track and analyze information regarding its AFHPSP medical students and it is in the process of performing its annual review. While the steps Air Force reported demonstrate progress toward fully implementing our recommendation, we believe that this recommendation should remain open until more progress is made.

Recommendation: To improve the transparency and accountability of HHS's section 1115 Medicaid demonstration approval process, and to ensure that federal Medicaid funds for the demonstrations do not duplicate other federal funds, the Secretary of Health and Human Services should issue criteria for assessing whether section 1115 expenditure authorities are likely to promote Medicaid objectives.

Agency: Department of Health and Human Services
Status: Open

Comments: The Department of Health and Human Services (HHS) partially concurred with this recommendation and has taken some steps to address the problems GAO identified. Initially, in August 2015, HHS posted on its website general criteria for assessing whether Medicaid section 1115 demonstration expenditure authorities are likely to promote Medicaid objectives, but GAO found the general criteria were not sufficiently specific. HHS later removed these criteria from its website and replaced them with six broad areas of reform that HHS encourages states to consider. As of January 2020, HHS does not have specific criteria for approving section 1115 expenditure authorities, but officials noted that the agency had begun including in approval letters the agency's rationale for approving specific expenditure authorities. GAO considers this a positive step towards improving the transparency of HHS's approval decisions, and if implemented consistently would address the intent of GAO's recommendation. HHS officials indicated that this step would be included in written protocols the agency is drafting but did not have a date for their completion. If these protocols are completed and consistently implemented, HHS's bases for its approvals of expenditure authorities, which can amount to billions of dollars in federal spending, will be more transparent. We will continue to monitor HHS's actions in response to this recommendation.

Recommendation: To improve the transparency and accountability of HHS's section 1115 Medicaid demonstration approval process, and to ensure that federal Medicaid funds for the demonstrations do not duplicate other federal funds, the Secretary of Health and Human Services should ensure the application of these criteria is documented in all HHS's approvals of section 1115 demonstrations, including those approving new or extending or modifying existing expenditure authorities, to inform internal and external stakeholders, including states, the public, and Congress, of the basis for the agency's determinations that approved expenditure authorities are likely to promote Medicaid objectives.

Agency: Department of Health and Human Services
Status: Open

Comments: HHS agreed with this recommendation and, as of January 2020, had taken some steps to ensure that the bases for its approval decisions are documented in all approvals of section 1115 demonstrations. In December 2017, HHS's Centers for Medicare & Medicaid Services (CMS) issued a letter to state Medicaid officials, stating it had begun requesting additional documentation of the demonstration purposes being served by certain types of previously approved funding in demonstration proposals. Additionally, the agency noted it was taking certain steps to ensure that only allowable costs were matched by federal Medicaid funds. In April 2018, CMS officials stated that the agency had begun addressing in approval documents how each intervention proposed by the state was determined to be likely to promote Medicaid objectives. Officials reported that this step would be included in formal written protocols that outline the agency's procedures for application review and preparation of approval documents for section 1115 demonstrations, but as of January 2020, the agency did not have time frames for the completion of these protocols. If CMS completes and implements the written protocols, stakeholders should be able to more easily and consistently assess the agency's decisions. We will continue to monitor CMS's efforts in this area.

Recommendation: To improve compliance with shareholder basis rules, Congress may wish to require S corporations to calculate and report shareholder's stock and debt basis as completely as possible. S corporations would report the calculation on the Schedule K-1 and send it to shareholders as well as IRS. If Congress judges that stock purchase price information that is currently only available to shareholders should not be transmitted to the S corporation due to privacy concerns, an alternative is to require that S corporations report less complete basis calculations using information already available to the S corporation.

Agency: Congress
Status: Open

Comments: As of January 2020, Congress had not enacted legislation to require S corporations--a federal business type that provides certain tax benefits like passing income and losses to shareholders' individual returns-- to calculate and report shareholder's stock and debt basis as completely as possible and report the calculation to shareholders and IRS, as GAO suggested in December 2009.

Recommendation: To enhance the transparency of CMS oversight and clarify and communicate the types of allowable state financing arrangements, the Administrator of CMS should provide each state CMS reviews under its initiative with specific and written explanations regarding agency determinations on the allowability of various arrangements for financing the nonfederal share of Medicaid payments and make these determinations available to all states and interested parties.

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open

Comments: CMS has taken steps to provide states with specific and written explanations regarding agency determinations on whether various arrangements for financing the nonfederal share of Medicaid payments are allowable and making those determinations available to states and interested parties. In November 2019, CMS issued a proposed rule that the agency said would promote state accountability, improve federal oversight, and strengthen fiscal integrity of the Medicaid program. The proposed rule would establish new policies and codify existing policies related to the sources of funds that states use to finance the nonfederal share of Medicaid payments. For example, the rule is intended to provide CMS and states with better information and guidance to identify existing and emerging state financing issues, provide more clarity on allowable financing arrangements and promote state accountability. GAO will continue to monitor the status of the proposed rule, as well as review a final rule, if one is issued, to determine the extent to which it addresses the recommendation.