What GAO Found In fiscal year 2023, GAO's work yielded $70.4 billion in financial benefits, a return of about $84 for every dollar invested in GAO. Our average return on investment for the past 6 years is $133 to $1. In 2023 we also identified 1,220 other benefits that led to improved services to the American people, strengthened public safety, and spurred improvements across the government. GAO's High Risk Series this past year resulted in $32.9 billion in financial benefits and 468 program and operational improvements. GAO is also helping advance agencies' efforts and related Congressional oversight to prevent, detect, and respond to fraud, waste, and abuse. For instance, in FY 2023 we estimated that the amount of unemployment insurance fraud during the COVID-19 pandemic was likely between $100 billion and $135 billion. For our fiscal year 2025 budget, GAO is requesting $916.0 million in appropriated funds and $59.8 million in offsets and supplemental appropriations. This will maintain 3,600 full-time equivalents (FTE). These resources will enable GAO to continue to meet the priority needs of the Congress including five key areas of importance to the nation and Congress: National Security Enterprise. GAO evaluates an array of national security efforts in areas such as military readiness, space programs, and the U.S. nuclear complex. Fraud Prevention. We examine government efforts to safeguard programs from fraud by focusing agencies more on prevention. Science and Technology. GAO's growing portfolio of ongoing and future work includes many aspects of artificial intelligence, medical research and applications, critical minerals recovery, and quantum computing. Cybersecurity. GAO assesses the development and execution of a comprehensive national cybersecurity strategy, the cybersecurity of 16 critical infrastructure sectors across the U.S., and the security of federal information systems. Health Care Costs. GAO examines the sustainability and integrity of the Medicare and Medicaid programs, Veterans Affairs, DOD, and Indian Health Service health care services. Our fiscal year 2025 budget request also supports GAO's IT modernization and space optimization efforts. We will transition processes to Cloud Services and enhance cybersecurity. This will allow GAO to grow in agility and better engage IT Modernization strategies. In addition, we will advance space optimization projects to increase leasable space in headquarters and decrease leased space in the field. We will also continue addressing a maintenance backlog at the headquarters building. Why GAO Did This Study GAO’s mission is to support Congress in meeting its constitutional responsibilities and to help improve the performance and ensure the accountability of the federal government for the benefit of the American people. We provide nonpartisan, objective, professional and reliable information to Congress, federal agencies, and to the public. GAO recommends hundreds of improvements across the full breadth and scope of the federal government’s responsibilities. In fiscal year 2023 alone, GAO issued 671 products, and 1,345 new recommendations. Congress used our work extensively to inform its decisions on key fiscal year 2023 and 2024 legislation. Since fiscal year 2002, GAO’s work has resulted in over: $1.38 trillion dollars in financial benefits; and Over 28,000 program and operational benefits that helped to change laws, improve public safety, and promote sound management throughout government. As a non-partisan, fact-based service organization, GAO is committed to providing program and technical expertise to support Congress. This includes crafting legislation; overseeing the executive branch; evaluating government programs, operations, and spending priorities; and assessing information from outside parties. For more information, contact A. Nicole Clowers at (202) 512-4400 or clowersa@gao.gov.

What GAO Found Federal law defines the quality standards that hospices must meet to participate in the Medicare program. The Centers for Medicare & Medicaid Services (CMS) monitors compliance with these standards through inspections—referred to as standard surveys—to be carried out at least every 3 years. Serious quality deficiencies cited on a survey indicate the hospice may not have the capacity to furnish adequate care or may adversely affect the health and safety of patients. CMS has fully implemented five and partially implemented three of the eight provisions related to hospice oversight required through the Consolidated Appropriations Act, 2021 (CAA). For example, CMS has not issued planned internal guidance that would enable consistent use of new enforcement tools for hospices not complying with quality standards. Implementing these provisions would help ensure CMS meets its statutory obligations for hospice oversight. GAO also found that about 15 percent of hospices that had at least one standard survey in each 3-year reporting cycle between 2017 and 2022 were cited with serious quality deficiencies, and most were cited with multiple such deficiencies. CMS policy requires that these hospices undergo additional monitoring and face termination from the Medicare program without timely resolution; according to CMS officials, 18 hospices were terminated between 2017 and 2022. As of May 2023, about 10 percent of hospices participating in Medicare for 36 months or more were overdue for a survey. Of the hospices with overdue surveys, over one quarter had not had a standard survey in at least 5 years. In addition, 17 percent had at least one previous serious quality deficiency, and about 11 percent had a previous complaint that was severe and substantiated. CMS defines survey priorities each year, but does not provide any direction to prioritize among overdue surveys. CMS has noted that funding and staffing issues at state agencies, which conduct the surveys, as well as the COVID-19 public health emergency, have constrained the timely completion of surveys. Prioritizing among overdue standard surveys for hospices based on potential risk factors, such as previous quality issues, could help target such hospices. Hospices with Overdue Surveys, by the Length of Time Overdue, as of May 2023 Why GAO Did This Study In fiscal year 2022, over 1.7 million Medicare beneficiaries received hospice care. GAO and the Department of Health and Human Services' (HHS) Office of Inspector General have reported on the need to strengthen oversight to protect Medicare beneficiaries receiving hospice services. The CAA included a provision for GAO to report on hospice quality of care and CMS's oversight of such care. This report addresses, among other things, CMS's implementation of hospice-related CAA provisions; the extent to which hospices were cited for serious quality deficiencies from 2017 through 2022; and the number of hospices with overdue surveys, and CMS's efforts to prioritize survey administration. GAO reviewed CMS documentation and interviewed CMS officials, provider and consumer groups, and surveyors. GAO also analyzed CMS data on hospice surveys from 2017 through 2022 for hospices that had at least one standard survey in each of the two 3-year reporting cycles during this time. To count the number of hospices with overdue surveys, GAO reviewed data provided by CMS as of May 2023.

What GAO Found The U.S. Coast Guard manages its major shipbuilding programs—generally those with cost estimates of $1 billion or greater—using the Department of Homeland Security's (DHS) acquisition framework. GAO's prior work found that the Coast Guard continues to face challenges in its highest priority shipbuilding acquisition programs—the Offshore Patrol Cutter and the Polar Security Cutter. Design instability. The shipbuilders have yet to stabilize their designs, which has contributed to schedule delays and cost growth for both programs. For example, the Offshore Patrol Cutter program began ship construction without a matured critical technology, which led to redesign of portions of the ship and contributed to delays of the lead ship by almost 4 years. GAO recommended in June 2023 that the program mature this same critical technology before moving forward through design on the next set of ships. DHS did not concur. GAO closed this recommendation in April 2024 after the Coast Guard approved a design review without maturing the critical technology. However, GAO stands by the intent of the recommendation to minimize risk to the program. Program oversight. Both programs lack key milestones in their acquisition program baselines—a document that sets the program's cost, schedule, and performance goals—to ensure adequate program oversight and accountability. For example, the Coast Guard did not include the delivery date of the last Polar Security Cutter in its acquisition program baseline. If included as a key event, failure to meet this date would trigger a formal assessment by DHS. In July 2023, GAO recommended that DHS and the Coast Guard include this delivery date in the acquisition program baseline, and the department concurred. Coast Guard officials told GAO they plan to include ship delivery dates in its revised baseline. The Coast Guard's Offshore Patrol Cutter and Polar Security Cutter In May 2024, GAO identified leading practices in ship design, such as using iterative design to accelerate design maturity and employing robust in-house ship design capabilities and tools. These practices build on previous leading practices that GAO identified in product development and shipbuilding. Over the past decade, GAO has recommended numerous actions to the Coast Guard and DHS reflecting those practices—such as attaining design stability and developing solid business cases—to achieve successful shipbuilding outcomes. Why GAO Did This Study The Coast Guard, a component of DHS, employs a variety of ships that conduct many missions, including drug interdiction, migrant interdiction, search and rescue, and ice operations. The Coast Guard plans to invest billions of dollars in two of its highest priority programs—acquiring three heavy icebreakers, known as Polar Security Cutters, and a fleet of 25 Offshore Patrol Cutters, to replace its older ships. This statement addresses (1) how the Coast Guard acquires and oversees its shipbuilding programs, including its highest priority ones, (2) the primary challenges the Coast Guard has faced in acquiring and overseeing its highest priority shipbuilding programs and the resulting outcomes, and (3) recent GAO work on leading practices for acquiring new ships. This statement is based on information from GAO-24-106573, GAO-23-105805, GAO-23-105949, and GAO-24-105503 , among other work. Information about the scope and methodology of prior work on which this statement is based can be found in those products.

What GAO Found In August 2023, GAO identified two priority recommendations for the Federal Deposit Insurance Corporation (FDIC). These recommendations call for the following: Developing a coordination mechanism with other federal financial regulators to identify and address blockchain risks. Collaborating with other financial regulators to communicate with banks that have third-party relationships with financial technology lenders about using alternative data in underwriting. As of May 2024, FDIC had not implemented these priority recommendations. We are not adding any new priority recommendations this year. Fully implementing these open recommendations could significantly improve FDIC's efforts to oversee more effectively the safety and soundness of the U.S. banking system and risks to consumers. Why GAO Did This Study Priority open recommendations are the GAO recommendations that warrant priority attention from heads of key departments or agencies because their implementation could save large amounts of money; improve congressional and/or executive branch decision-making on major issues; eliminate mismanagement, fraud, and abuse; or ensure that programs comply with laws and funds are legally spent, among other benefits. Since 2015, GAO has sent letters to selected agencies to highlight the importance of implementing such recommendations. For more information, contact Daniel Garcia-Diaz at (202) 512-8678 or GarciaDiazD@gao.gov.

What GAO Found In August 2023, GAO identified two priority recommendations for the Office of the Comptroller of the Currency (OCC). The recommendations call for the following: Developing a coordination mechanism with other federal financial regulators to identify and address blockchain risks. Collaborating with other financial regulators to communicate with banks that have third-party relationships with financial technology lenders about using alternative data in underwriting. As of May 2024, OCC had not implemented these priority recommendations. We are not adding any new priority recommendations this year. Fully implementing these open recommendations could significantly improve OCC's efforts to supervise and examine the operations of its chartered banks Why GAO Did This Study Priority open recommendations are the GAO recommendations that warrant priority attention from heads of key departments or agencies because their implementation could save large amounts of money; improve congressional and/or executive branch decision-making on major issues; eliminate mismanagement, fraud, and abuse; or ensure that programs comply with laws and funds are legally spent, among other benefits. Since 2015, GAO has sent letters to selected agencies to highlight the importance of implementing such recommendations. For more information, contact Daniel Garcia-Diaz at (202) 512-8678 or garciadiazd@gao.gov.

What GAO Found In 2021, the Department of Defense (DOD) required the military services to establish career paths in military justice that would allow military attorneys, known as judge advocates, to specialize as litigators (e.g., trial counsel, defense counsel, and military judges). The Navy has had such a program in place since 2007, and by 2022 the Army, the Marine Corps, and the Air Force had submitted plans for their own career paths. However, GAO identified issues that may hinder the success of these judge advocate career reforms. Specifically, the services: Do not have a communication strategy. The Army, Marine Corps, and Air Force have begun to promote their newly established career paths. However, judge advocates interviewed during this review told GAO that, in general, litigators at these three services do not trust that it will result in department-wide cultural change. Developing and implementing a strategy to communicate the establishment of and leadership support for the career paths may help attract judge advocates and increase litigator experience levels. Have not assessed the need for tailored experience standards for supervisory litigators and defense counsel. All four services have developed general professional experience requirements—called experience standards—judge advocates must obtain to serve as litigators. The services have also developed specific experience standards for a limited number of positions, such as military judges and victims' counsel. However, they have not assessed the need for tailored experience standards for other key positions, including supervisory litigators and defense counsel. Without assessing the need for tailored experience standards for other litigation positions, and implementing any recommendations from the assessment, the services lack reasonable assurance that they are placing the right judge advocates into potentially critical positions. Lack an approach for evaluating career path effectiveness. Multiple issues will limit the military services' ability to determine the effectiveness of these paths once fully implemented. First, the services do not collect key data to assess the effectiveness of the career paths, including litigator retention rates, reasons litigators separate from military service, and the number of litigator positions the services have filled. Second, DOD lacks a framework for assessing the effectiveness of the career path that includes performance measures and an evaluation plan. Collecting quality data on the military justice career path, developing a standardized suite of performance measures, and an evaluation plan would help the services measure progress towards achieving their goals and objectives as well as identify and address any challenges. Without addressing these issues, DOD risks falling short of achieving the objective of its judge advocate career reforms—increasing the experience and competence of military justice litigators. Why GAO Did This Study The military justice system depends on skilled and experienced litigators to try cases involving military personnel. However, DOD and a congressional committee have recently raised concerns about litigators' skills, qualifications, and career management, and whether they are sufficient to handle highly complex cases, such as sexual assault cases. House Report 117-397 includes a provision for GAO to review the military services' military justice communities, including their structure, experience requirements, and the use of military justice career paths. This report examines the extent to which the services have (1) implemented military justice career paths, (2) established experience standards for litigation positions, and (3) established mechanisms to determine the effectiveness of the career paths. GAO reviewed guidance, analyzed program documentation, and interviewed service officials as well as litigators at a nongeneralizable sample of four military installations.

What GAO Found The Strategic National Stockpile (SNS) is a multibillion dollar inventory of drugs, vaccines, supplies, and other medical countermeasures that can be provided to jurisdictions—states, localities, territories—and Tribes during emergencies. The Department of Health and Human Services (HHS) provided four primary types of resources ahead of recent public health emergencies—COVID-19 and mpox—to help jurisdictions access and use SNS assets. This included guidance, recurring communication, trainings and exercises, and an inventory management system. The 62 jurisdictions we surveyed reported challenges during the COVID-19 and mpox responses related to understanding the SNS inventory and coordinating on requesting and receiving SNS assets. HHS has taken steps to address some of these challenges by creating a new office focused on external coordination and developing a new system to track SNS requests. Jurisdictions also reported challenges related to understanding federal agencies' roles and navigating outdated guidance. These challenges led to jurisdictional confusion during response efforts. While HHS has taken some actions, challenges still exist regarding the lack of (1) clearly defined roles for HHS agencies that work with SNS assets; and (2) procedures for updating SNS's main guidance document. For example, the main guidance document for SNS assets has not been updated since 2014 and does not reflect the agency currently responsible for the SNS. By defining and sharing SNS roles and developing procedures for updating guidance, HHS would help jurisdictions navigate SNS processes improving response efforts. GAO Survey Results About Strategic National Stockpile Written Guidance Jurisdiction and tribal officials identified other coordination issues that may affect future responses. This included jurisdiction officials not seeing, or being unaware of, HHS response plans including those specific to the SNS, and federal efforts needed to help jurisdictions manage stockpiles that expanded after the COVID-19 pandemic. HHS officials said they plan to coordinate with jurisdictions on these issues by creating and sharing information about response planning and stockpile management. Also, GAO found that Tribes experienced various concerns with requesting and receiving SNS assets. In response, an HHS working group is focused on clarifying the ways Tribes can request SNS assets. However, HHS has not assessed the unique challenges—such as geography and infrastructure—that could affect Tribes' ability to receive SNS assets. By engaging with Tribes to do such an assessment, HHS and Tribes would be better equipped to deliver and receive assets, respectively, collectively strengthening preparedness and response efforts to future incidents. Why GAO Did This Study Recent public health emergencies have highlighted the importance of coordination across all levels of government. One key component of the nation's medical response is the SNS. In January 2022, GAO placed HHS's leadership and coordination of public health emergencies on its High Risk List, in part due to coordination issues with the SNS. The CARES Act includes a provision for GAO to report on the federal response to the COVID-19 pandemic. This report examines (1) SNS resources provided to jurisdictions; (2) challenges jurisdictions faced in accessing SNS assets during two recent emergencies; and (3) jurisdictional and tribal SNS coordination issues that might affect future responses. For this work, GAO surveyed public health officials from all 62 jurisdictions nationwide and received a 100 percent response rate. GAO also interviewed officials in nine jurisdictions which were selected to obtain variation in governance structure and tribal presence, among other criteria. GAO also reviewed guidance, presentations, strategic plans, and other documentation; compared HHS actions to leading practices for collaboration and federal internal controls; and interviewed HHS and tribal officials.

Why This Matters Changing maritime threats are pushing the U.S. Navy to increase its pace for designing and delivering new ships. Since 2009, GAO has used leading practices in commercial shipbuilding to evaluate the plans and execution of Navy shipbuilding programs. GAO’s numerous recommendations have spurred Navy action to improve acquisition practices and the use of taxpayer dollars. Yet, the Navy has continued to face persistent challenges in its ability to design and deliver timely, affordable new ships that perform as expected. Computing power and digital design capabilities have rapidly changed in the 15 years since GAO first identified leading ship design practices. As a result, GAO’s examination of commercial industry’s current practices helps ensure that the activities and performance of the Navy’s shipbuilding programs are evaluated against cutting-edge practices used to design new ships efficiently and effectively. Key Takeaways GAO found that leading commercial ship buyers and builders prioritize shorter, predictable periods for design and construction, which result in delivering timely ships that meet current user needs. In contrast, the Navy's approach often results in significantly longer design and construction cycle times for its shipbuilding programs' lead ships. Comparison of Design and Construction Cycles for Selected Commercial and Navy Ships Note: For commercial ships, the range of months indicates the shortest and longest typical periods for companies to deliver a ship after contract award. For Navy ships, the range of months for different ship types indicates the shortest and longest periods for the Navy to provide selected lead ships to the fleet since 2007. For Navy programs with a contract prior to the detail design and construction award, the earlier award date represents the start of the cycle. Key differences between commercial companies' and the Navy's ship design practices contribute to the slower pace and less predictable cost, schedule, and performance outcomes for Navy shipbuilding programs. Leading design practices involve effective management of a ship's business case—a reflection of the balance of customer needs and the resources needed to develop and produce the ship; and focus on efficiently maturing new ship designs to better inform decisions on schedule, cost, and performance. This includes using consistent, meaningful design maturity measures to determine readiness to move from design to construction. GAO Comparison of Leading Ship Design Practices for Commercial Companies and U.S. Navy How GAO Did This Study A conference report directed GAO to examine ship design practices. This report assesses (1) the leading design practices used by commercial ship buyers and builders to inform their understanding of design maturity and readiness for construction, and (2) how the Navy’s ship design practices compare to the leading practices in commercial ship design. To address these objectives. GAO interviewed and reviewed documentation from four commercial ship buyers and five shipbuilders—builders generally also design the ships. GAO selected these companies using criteria reflective of commercial success in designing, building, and buying ships relatable to Navy ships. GAO also reviewed its prior work on leading practices for shipbuilding and product development. In addition, GAO reviewed documentation and interviewed representatives from the Navy and selected Navy shipbuilders, as well as reviewed prior work on Navy shipbuilding program efforts. Based on the results of these activities, GAO compared the ship design practices used by the Navy with leading commercial practices.