Recommendation: The Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare & Medicaid Services to take steps to ensure that state-based marketplace annual sustainability plans, to the extent possible, have complete 5-year budget forecasts. (Recommendation 1)

Agency: Department of Health and Human Services
Status: Open

Comments: HHS did not concur with our recommendation and stated that it had updated its requirement to request 2-year budget forecasts instead of 5-year budget forecasts. In its December 2017 statement of actions, HHS stated that it was working to streamline and simplify its data collection effort as part of the annual sustainability plan. In April 2018, HHS provided a revised 2-year budget forecast template as well as related state marketplace training documentation. As of April 2020, HHS had not provided further documented evidence of its streamlined process using the 2-year budget forecast template or justification that a 5-year budget is not necessary for assessing long-term financial sustainability and state marketplace sustainability risks.

Recommendation: The Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare & Medicaid Services to take steps to ensure that all state-based marketplaces provide required annual financial audit reports which are in accordance with generally accepted government auditing standards. (Recommendation 2)

Agency: Department of Health and Human Services
Status: Open

Comments: HHS concurred with our recommendation and stated in its December 2017 update that it continued to provide technical assistance such as webinars and other trainings on independent financial and programmatic audit submission requirements. In April 2018, HHS provided evidence that it had taken some steps to ensure that state-based marketplaces provide required annual financial audit reports, including draft financial audit procedures, documentation of related training provided to states, and a revised HHS state officer annual review checklist emphasizing financial audit reporting. However as of April 2020, the department had not provided evidence of finalized procedures, examples of checklist usage, or of states providing annual financial audit reports. Further, HHS training documentation stated that state-based marketplaces could provide alternate financial audit reports, such as a state-wide financial audit report, in lieu of a marketplace specific report. It is not clear from the provided evidence that the department has ensured that state-based marketplaces are in compliance with financial audit reporting requirements. We will continue to monitor the department's progress in implementing the recommendation and provide updates when the agency takes further action.

Recommendation: The Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare & Medicaid Services to take steps to ensure that marketplace IT self-sustainability risk assessments are based on fully defined measurable terms, a clear categorization process, and a defined response to high risks. (Recommendation 3)

Agency: Department of Health and Human Services
Status: Open

Comments: HHS concurred with our recommendation and stated in its December 2017 update that it would refine its marketplace self-sustainability risk assessment process to provide greater insight into the state marketplace sustainability efforts and to identify areas where states may need assistance. In April 2018, HHS provided evidence that it had taken some steps to base its risk assessments on fully defined processes. CMS provided documentation of clearly defined and measurable terms used for state marketplace budget analysis. However, HHS did not provide evidence that these defined terms were incorporated into analyses or risk assessments. As of April 2020, CMS has not provided evidence that it took steps to develop a clear categorization process or a defined response to high risks. We will continue to monitor the department's progress in implementing the recommendation and provide updates when the agency takes action.

Recommendation: The Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare & Medicaid Services to take steps to ensure that states develop, update, and follow performance measurement plans that allow the states to continuously identify and assess the most important IT metrics for their state marketplaces. (Recommendation 4)

Agency: Department of Health and Human Services
Status: Open

Comments: HHS partially concurred with our recommendation and stated in its December 2017 update that though each marketplace was accountable for managing and reporting its own IT metrics in accordance with federal and state law, HHS would work with states on the improvement of their management and operations through technical assistance and oversight and accountability measures. As of April 2020, the agency had not yet provided sufficient evidence that it has implemented the recommendation. We will continue to monitor the department's progress in implementing the recommendation and provide updates when the agency takes action.

Recommendation: The Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare & Medicaid Services to take steps to conduct operational analysis reviews and systematically monitor the performance of states' marketplace IT systems using key performance indicators. (Recommendation 5)

Agency: Department of Health and Human Services
Status: Open

Comments: HHS did not concur with our recommendation and stated that it conducted Open Enrollment Readiness Reviews to assess marketplace key performance indicators, which according to CMS officials, are similar to operational analysis reviews. However, as of October 2018, HHS had not provided evidence that the Open Enrollment Readiness Reviewed systematically and comprehensively reported on the key performance indicators or include discussion of other key elements identified in best practices for operational analysis reviews, such as how objectives could be better met, or costs could be saved. As of April 2020, the agency had not yet provided sufficient evidence that it has implemented the recommendation.

Recommendation: The Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare & Medicaid Services to take steps to ensure that metrics collected from states to monitor marketplaces' operational performance link to performance goals and include baselines and targets to monitor progress. (Recommendation 6)

Agency: Department of Health and Human Services
Status: Open

Comments: HHS partially concurred with our recommendation and stated in its December 2017 update that states were responsible for monitoring their own performance measures but HHS would continue to review IT metrics of state marketplaces in the implementation phase of their systems through technical assistance activities and oversight and accountability measures. As of April 2020, the agency had not yet provided sufficient evidence that it has implemented the recommendation. We will continue to monitor the department's progress in implementing the recommendation and provide updates when the agency takes action.

Recommendation: To help ensure that the pilot programs for disconnected youth can be effectively implemented over the lifetime of the initiative, the Director of OMB should coordinate with relevant federal agencies to identify and estimate expected annual financial and staff resource contributions from each agency, including during the implementation and evaluation phases of the pilots.

Agency: Executive Office of the President: Office of Management and Budget
Status: Open

Comments: As of May 2020, the Office of Management and Budget (OMB) and relevant federal agencies described steps they have taken that could address the intent of this recommendation. However, they have not yet shared documentation so that we can independently verify those actions. Since we issued our report in April 2017, federal agencies discontinued contributing financial resources to support joint pilot program activities, such as start-up grants, general technical assistance, or evaluations. According to OMB staff and officials at several agencies in August 2018, that change in contributions began with the fiscal year 2018 pilots. At that time, they all told us that relevant agencies would continue to provide staff support to the pilots, as needed. In April 2020, officials from the Department of Education (Education)-the lead agency for overall performance partnership efforts-informed us that six pilots remain active, through September 2020, and were able to provide information about staff resource contributions. For example, Education officials told us that two of the department's employees devote less than 10 percent of their time to support those six pilots. We have requested additional information from Education to better understand staff resource commitments and contributions from other agencies involved in those six pilots.

Recommendation: To ensure that federal agencies involved in the disconnected youth pilots are able to evaluate pilot outcomes and ultimately communicate to Congress whether and to what extent the flexibilities tested by the pilots should be integrated into broader efforts, the Director of OMB should coordinate with relevant federal agencies to identify criteria or standards for assessing scalability, and collect data needed to address those criteria or standards.

Agency: Executive Office of the President: Office of Management and Budget
Status: Open

Comments: As of May 2020, the Office of Management and Budget (OMB) and relevant federal agencies described steps they have taken that could address this recommendation. However, they have not yet shared documentation so that we can independently verify those actions. In August 2018, OMB staff told us that they were coordinating relevant work with the Department of Health and Human Services (HHS) and the Department of Labor (DOL), which is leading the national evaluation for the disconnected youth pilot programs. OMB staff told us this group was studying specific criteria or standards that could be used for assessing the scalability of the disconnected youth pilot programs. In April 2020, DOL officials told us that the department was examining issues related to scalability in products it is developing as part of the national evaluation. For example, the officials informed us that DOL plans to publish a report in summer 2020 that examines the effects of flexibilities tested by individual pilot programs, and their potential to be scaled. Furthermore, DOL officials told us that the department, in coordination with OMB, HHS, and other relevant agencies, had drafted, but not yet finalized, a memorandum that identifies criteria for assessing scalability. We have requested copies of relevant DOL evaluation products and the memorandum. When provided, we will assess the extent to which they address our recommendation.

Recommendation: To improve consistency in CMS oversight of federal spending under section 1115 demonstrations, the Secretary of Health and Human Services should require the Administrator of CMS to develop and document standard operating procedures for monitoring spending under demonstrations that (1) require setting reporting requirements for states that provide CMS the data elements needed for CMS to assess compliance with demonstration spending limits; (2) require consistent enforcement of states' compliance with financial reporting requirements; and (3) require consistent tracking of the amount of unspent funds under demonstration spending limits.

Agency: Department of Health and Human Services
Status: Open

Comments: The Department of Health and Human Services (HHS) has taken steps to improve the consistency of oversight of federal spending under section 1115 demonstrations. In November 2018, HHS officials reported that they have developed draft guidance, including a standard reporting tool for states, to better ensure consistent reporting of the elements needed to assess compliance with demonstration spending limits and was in the process of testing the tool with two states. In addition, the agency is developing standard operating procedures for agency staff to require consistent tracking of unspent funds under the spending limit. As of November 2019, HHS has not provided any updates. GAO will continue to monitor HHS's actions and once procedures are in place, GAO will assess whether they address our recommendation.

Recommendation: To promote consistency in the distribution of supplemental payments among states and with CMS policy, the Administrator of CMS should issue written guidance clarifying its policy that requires a link between the distribution of supplemental payments and the provision of Medicaid-covered services.

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

Comments: CMS issued a proposed rule in November 2019 that may address this issue. According to the agency, the rule will promote state accountability, improve federal oversight, and strengthen the fiscal integrity of Medicaid. Specifically, the agency said the rule would require states to report to CMS a comprehensive description of the methodology used to calculate the amount and distribution of supplemental payments and the provider metrics used to calculate payment amounts, such as Medicaid utilization or costs. We will assess the extent to which the final rule addresses our recommendation when it is issued.

Recommendation: To promote consistency in the distribution of supplemental payments among states and with CMS policy, the Administrator of CMS should issue written guidance clarifying its policy that payments should not be made contingent on the availability of local funding.

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

Comments: CMS issued a proposed rule in November 2019 that may address this issue. According to the agency, the rule will promote state accountability, improve federal oversight, and strengthen the fiscal integrity of Medicaid. Specifically, the proposed rule clarifies the agency policy that Medicaid payments may not be contingent on the availability of local funding, according to agency officials. We will assess the extent to which the final rule addresses our recommendation when it is issued.

Recommendation: To ensure that resources are being efficiently applied to meet the National Guard counterdrug program's objectives, the Secretary of Defense should direct the National Guard Bureau in consultation with the Deputy Assistant Secretary of Defense for Counternarcotics and Global Threats to subsequently collect and use performance information to help inform funding distribution decisions to state programs and to conduct oversight of the training offered by the counterdrug schools.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with our recommendation and stated that it would collect and use performance information to evaluate the effectiveness of each state program to provide support and to meet its objectives. DOD also stated that it would take steps to assist states with any needed corrective-action plans. While the National Guard counterdrug program has begun collecting performance information in its annual assessments of state programs and counterdrug schools, it has not yet incorporated the information into its funding distribution decisions. In January 2020, DOD officials indicated that responsibility for implementing this recommendation was assigned to the Counterdrug Advisory Counsel and Threat Based Resourcing Model Target Team for action. They estimated a completion date of December 2020.

Recommendation: To ensure that federal funding efficiently and effectively responds to the countercyclical nature of the Medicaid program, Congress may wish to consider enacting an FMAP formula that is targeted for variable state Medicaid needs and provides automatic, timely, and temporary increased FMAP assistance in response to national economic downturns.

Agency: Congress
Status: Open

Comments: As of September 2020, no legislation had been enacted. GAO has testified on at least one bill that had been introduced in the Congress that would implement this Matter for Congressional Consideration. On February 10, 2016, GAO testified on considerations related to the Medicaid funding formula. See Medicaid: Changes to Funding Formula Could Improve Allocation of Funds to States GAO-16-377T January 26, 2016. We also cited this report in our discussion on Medicaid funding during economic downturns in Medicaid: Key Policy and Data Considerations for Designing a Per Capita Cap on Federal Funding (GAO-16-726). We cited this Matter in Opportunities to Improve the Federal Recovery and Response Efforts (GAO-20-625) and in COVID-19: Brief Update on Initial Federal Response to the Pandemic (GAO-20-708).

Recommendation: To establish accountability for meeting the programs' goal of increasing the participation of traditionally underrepresented groups in the highway construction workforce, the Secretary of Transportation should direct the FHWA Administrator to create and implement an oversight mechanism that (1) holds states accountable for meeting federal training criteria and (2) clearly stipulates how FHWA will assess state program effectiveness, including what type of program achievement data states are to submit and how such data will be used. This oversight mechanism should include assessing the effectiveness of its division offices in overseeing state activities.

Agency: Department of Transportation
Status: Open

Comments: FHWA has taken initial steps to implement a mechanism for state oversight, which includes collecting program implementation information from each state. FHWA plans to convene a working group to review this information and provide feedback to states on their programs. FHWA officials then anticipate sharing best practices and essential requirements for the program through webinars and other technical assistance. As of August 2019, FHWA has gathered information from states and is in the early stages of implementing this oversight mechanism.

Recommendation: To the extent that the CDBG program continues to be the primary vehicle used to provide post-disaster assistance for permanent housing, Congress may wish to consider providing more specific direction regarding the distribution of disaster-related CDBG assistance that states are to provide for homeowners and renters. If Congress wishes to change the proportion of assistance directed to homeowners and rental property owners in future recovery efforts, Congress could, for example, require states to demonstrate to HUD that they are adequately addressing the needs of both homeowners and renters with their CDBG allocation and other resources as a condition for receiving funds. Alternatively, Congress could direct HUD to develop a formula that accounts for the housing needs of both homeowners and renters. Such a formula could be used by states to determine the proportions of their disaster CDBG funds that should be used for housing, specifically rental housing. Further, the formula could also reflect the anticipated production levels of other programs that provide permanent housing assistance, such as the Low-Income Housing Tax Credit program.

Agency: Congress
Status: Open

Comments: Since 1993, Congress has appropriated Community Development Block-Disaster Recovery (CDBG-DR) funding in the wake of numerous presidentially-declared disasters, including, most recently, $2.431 billion in Public Law 116-20, the majority of which amount is for disasters that occurred in 2018 and 2019. Similar to previous CDBG-DR appropriations, the CDBG-DR appropriation in Public Law 116-20, enacted June 6, 2019, neither requires states to demonstrate to HUD that they adequately addressed the needs of both homeowners and renters nor, alternatively, directs HUD to develop a formula that accounts for the housing needs of both homeowners and renters. A bill introduced and reported out of committee in the 115th Congress, HR 4557, required HUD to disapprove a state action plan that detailed a grantee's use of funds if, among other reasons, the plan did not provide an equitable allocation of resources among homeowners, renters, and persons experiencing homelessness. A draft bill, whose provisions were essentially identical to HR 4557, was the focus of a hearing during the 116th Congress.

Recommendation: In order to put the Emergency Relief program on a sound financial footing, Congress may wish to consider the expected future demands on the program and reexamine the appropriate level and sources of funding--including whether to increase the $100 million annual authorized funding and whether the Highway Trust Fund, the General Fund, or some combination would allow the program to accomplish its purpose in a fiscally sustainable manner.

Agency: Congress
Status: Open

Comments: As of November 2019, Congress has not yet taken action on this recommendation. The Emergency Relief Program is due to be reauthorized in 2020.

Recommendation: Congress may also wish to consider tightening the eligibility criteria for Emergency Relief funding, either through amending the purpose of the Emergency Relief program, or by directing FHWA to revise its program regulations. Revised criteria could include limitations on the use of Emergency Relief funds to fully finance projects with scope and costs that have grown as a result of environmental and community concerns.

Agency: Congress
Status: Open

Comments: As of November 2019, Congress has not yet taken action on this recommendation. The Emergency Relief Program is due to be reauthorized in 2020.