Government Accountability Office Research Articles

The Effect of the COVID-19 Pandemic on Risk of Corruption

AbstractThis paper estimates the effect of the COVID-19 pandemic on risk of corruption in Mexico. To calculate the pandemic’s impact on risk of corruption, this study uses monthly administrative data of 378,000 public acquisitions through 64 institutions from the Mexican Federal Government during the 2018–2020 period. These institutions account for approximately 75% of all allocations of public acquisitions made by the Mexican Federal Government. The risk of corruption is measured through the Discrete-Contracts-Value-to-Budget (DCVB) ratio, which represents the ratio of the value of contracts assigned through discretionary non-competitive mechanisms to the total value of contracts per institution. The empirical strategy consists of a difference-in-differences methodology and an event-study design. The analysis is conducted over all institutions as well as by healthcare and non-healthcare institutions. The results show the following: (1) the pandemic increased the DCVB ratio by 17%; (2) the DCVB ratio increased during six months and then it returned to pre-pandemic levels (inverted U-shape form); and (3) surprisingly, the rise in the risk of corruption is mainly driven by non-healthcare institutions. From a policy perspective, Mexico’s Government Accountability Office, although counterintuitive, should focus on non-healthcare institutions when conducting audits targeting public acquisitions made during the pandemic, even though much of the political debate remains centered around the risk of corruption in healthcare institutions.

Good Governance and the Partisan Wars: The Effects of Divided Government on Administrative Problem Solving and Oversight Agenda Setting in Congress

Abstract Congress’s constitutional responsibility to oversee and investigate the executive branch of government demands that instances of waste, fraud, and abuse in the administrative state be checked via both legislation and nonlegislative committee hearings. In this article, I establish an oversight agenda for Congress using the nonpartisan Government Accountability Office's (GAO) biennial identification of the most vulnerable federal agencies and programs. I then assess whether and how government-wide partisanship affects Congress’s ability to address this slate of issues. I find that, when government is divided, Congress is more legislatively productive on high-risk issues, and the House of Representatives is more likely to prioritize investigative hearings on high-risk issues. My results suggest a silver lining to the reality of partisan agenda control: preexisting administrative problems identified by well-positioned and well-informed observers at GAO may get more attention when there is a partisan incentive for the legislature to investigate an opposition-controlled government.

DEFINING ‘OUTBREAK’: ADMINISTRATORS’ EXPERIENCES MANAGING COVID-19 AT US NURSING HOMES

Abstract The CDC defines a COVID-19 outbreak as starting with a single positive case of a staff member or resident in a facility and ending after there have been no new cases for 14 days. According to a report from the U.S. Government Accountability Office, 94% of nursing homes in the U.S. experienced multiple COVID-19 outbreaks, resulting in a reported 1.66 million residents and 1.64 million staff members with confirmed COVID-19 as of July 2023. Research has shown that COVID-19 outbreaks froze new admissions and caused significant financial strain. This qualitative study aimed to examine how COVID-19 outbreaks were managed in U.S. nursing homes. 156 interviews were conducted with nursing home administrators from 40 facilities across the U.S. between July 2020-December 2021. Two major themes emerged from thematic analysis: 1) the definition of “outbreak” as a single individual testing positive with COVID-19 was inconsistently communicated to nursing home administrators at the start of the pandemic; and 2) administrator self-reports of COVID-19 outbreaks at their facilities indicated that many endured multiple outbreaks which were long-lasting (greater than 1 month). As policy makers and industry experts review policies around managing nursing home viral outbreaks, they should consider the emerging infection control strategies from the pandemic which successfully prevented the spread of COVID-19 and update the response to an ‘outbreak’ such that infection control mitigation measures are effective without causing restrictions that are detrimental to resident well being or nursing home financial hardship.

Outcomes of the 340B Drug Pricing Program

The 340B Drug Pricing Program requires manufacturers to offer discounted drug prices to support safety net hospitals and clinics (covered entities) providing care to low-income populations. Amid expansion, the program has received criticism and calls for reform. To assess the literature on the foundations of and outcomes associated with the 340B program. The databases searched in this scoping review included PubMed, Embase, EconLit, National Bureau of Economic Research (NBER), Westlaw, the Department of Health and Human Services Office of the Inspector General (HHS-OIG) website, the Government Accountability Office (GAO) website, and Google in February 2023 for peer-reviewed literature, legal publications, opinion pieces, and government agency and committee reports related to the 340B program. Among a collected 900 documents, 289 met inclusion criteria: 83 articles from PubMed, 12 articles from Embase, 2 articles from EconLit, 1 article from NBER, 28 articles from Westlaw, 23 legislative history documents, 103 documents from Google, 11 GAO reports, and 26 HHS-OIG reports. Included literature pertained to 4 stakeholders in the 340B program: covered entities, pharmacies, pharmaceutical manufacturers, and patients. This literature showed that hospitals, clinics, and pharmacies generated revenue and manufacturers have forgone revenue from 340B discounted drugs. Audits of covered entities found low rates of compliance with 340B program requirements, whereas mixed evidence was uncovered on how covered entities used their 340B revenue, with some studies suggesting use to expand health care services for low-income populations and others to acquire physician practices and open sites in higher-income neighborhoods. These studies were hampered by a lack of transparency and reporting on the use of 340B revenue. Studies revealed patient benefits from access to expanded health care services, but there was mixed evidence on patient cost savings. Although the review identified considerable research on 340B hospitals, pharmacies, and patients, less research was found evaluating the 340B program's effect on nonhospital covered entities, drug pricing, and racial and ethnic minority groups. In this scoping review of the 340B program, we found that the 340B program was associated with financial benefits for hospitals, clinics, and pharmacies; improved access to health care services for patients; and substantial costs to manufacturers. Increased transparency regarding the use of 340B program revenue and strengthened rulemaking and enforcement authority for the Health Resources and Services Administration would support compliance and help ensure the 340B program achieves its intended purposes.

Navigating obstacles impacting the sustainability of Medicare-funded wound care pricing.

With more effective oversight, Medicare costs can be reduced, while stabilising a portion of its trust fund, disincentivising non-compliance and improving outcomes for the growing population of US beneficiaries with hard-to-heal wounds.

Medicare Advantage: Growth Amidst Mounting Scrutiny.

The Medicare Advantage Program, home to nearly half of the eligible Medicare population, has recently come under increased scrutiny. The Government Accountability Office called on the Centers for Medicare & Medicaid Services to monitor "disenrollment of MA beneficiaries in the last year of life, validate MA-provided encounter data, and strengthen audits used to identify and recover improper payments to MA plans." The House Subcommittee on Oversight and Investigations of the Committee on Energy & Commerce, dedicated a hearing to "Protecting America's Seniors: Oversight of Private Sector Medicare Advantage Plans." In addition, a recently conducted audit of the Office of the Inspector General of the Department of Health and Human Services raised concerns over "denials of prior authorization requests" and "beneficiary access to medically necessary care." In this article we consider the backdrop for the growing scrutiny of the MA program and the implications thereof to its future trajectory.

A Century of Progress: U.S. Government Accountability Office Procedures, Reports, and Performance Measures

SYNOPSIS In 2021, the U.S. Government Accountability Office (GAO) celebrated its 100th anniversary, and its mission has never been more critical. This study documents the 100-year history of GAO, examining how Congressional law changes and leadership influences of the Comptroller General of the United States have shaped GAO’s role, services, and products. GAO has transformed from focusing on providing oversight through its audits of federal government expenditures during its early years (e.g., to assess legality) to emerging as a leader in providing insights to Congress through program evaluation audits and, more recently, to providing Congress the foresight necessary to confront the challenges and opportunities that lie ahead.

Critiquing the U.S. characterization, attribution and retaliation laws and policies for cyberattacks

This paper critiques the U.S. characterization, attribution, and retaliation laws and policies for cyberattacks. Characterization, attribution, and retaliation are part of the most important aspects of responding to cyberattacks. The U.S. does not have a clearly defined characterization process, other than the Government Accountability Office (GAO), Cybersecurity and Infrastructure Security Agency (CISA) and the Department of Homeland Security (DHS)’s Threat Table which characterizes the different motivations for carrying out cyberattacks by cyber threat actors. This Threat Table has hardly changed since 2005, yet, cyber threat actors continually develop their tactics, techniques, and procedures (TTPs) and conceal their real motivations for carrying out cyberattacks. Like characterization, the U.S. does not have a known attribution procedure, nor is a single agency tasked with the function of attribution. Different agencies – the Department of Justice (DoJ), the Federal Bureau of Investigation (FBI), the National Cyber Investigative Joint Task Force (NCIJTF), and the Office of the Director of National Intelligence (ODNI) – and even private sectors companies, participate in the attribution process. This invites potential contradiction and interference with the attribution process. Though, unlike characterization and attribution, the U.S. retaliation policies are contained in different documents, none has the preciseness required to be effective. This paper thus, makes recommendations for each of these aspects of cyberattack response.

Always Watchful: Political Context and Congressional Oversight through the Government Accountability Office

Oversight of the executive branch is one of Congress’s most critical functions. It is meant to ensure accountability, consistency, and fairness in the implementation of programs by the federal bureaucracy. Much previous scholarship has argued that oversight is more common when Congress and the White House are controlled by different parties. However, much of this research has focused principally on committee hearings, and other tools of oversight have received less attention. One such tool is the Government Accountability Office (GAO). I test competing theories of GAO usage: one which argues that GAO reports are simply another tool of oversight, like hearings, and tend to follow similar patterns and thus are more common in conditions of divided government. The other theory argues that the GAO, because of its commitment to providing useful, nonpartisan information, is more likely to be used when legislative and presidential priorities are aligned. Leveraging reports from the GAO between 1995 and 2022, I find support for the latter proposition, at least in the modern Congress. There is evidence that Congress changes its methods of oversight in response to political incentives, but oversight continues regardless.

Protest Denied: A Qualitative Meta-Analysis of Failed Challenges to Government Contracting

Firms interested in doing business with the US federal government, one of the biggest spenders in the world, may have reasons to believe they have been denied fair opportunities to compete for federal government contracts. The US Government Accountability Office (GAO) provides an expeditious forum where interested parties can challenge government procurement decisions. In this meta-summary, the authors qualitatively analyzed 17 denied bid protests filed against the US Army Corps of Engineers to identify quasi-legal bases that the GAO most frequently took in its denial of bid protests. The findings were abstracted into 12 themes with corresponding frequency effect sizes. Finally, three recent denied bid protests were reviewed in light of the themes to validate the effectiveness of the findings. This study contributes to the growing body of knowledge about one aspect of the US government acquisition practice, i.e., denying bid protests, and presents findings that can limitedly assist small businesses as defined by the relevant regulations to test the validity of their cases in advance.

Private Equity and Nursing Home Care: What Policies Can Be Adopted to Address the Growing Problems?

Private equity (PE) firms are private entities that recruit investors, such as pension funds and insurance companies, as limited partners (Batt and Appelbaum, 2021). PE firms have been investing in health care for over 20 years (Government Accountability Office [GAO], 2010). By 2020, health care was the second major sector for PE investment, with $750 billion in health investment deals made between 2010 and 2020 (Scheffler et al., 2021). PE has invested in hospitals, nursing homes (NHs), clinical and outpatient services, medical groups, pharmaceuticals, hospices, home health, and others (Scheffler et al., 2021). PE investors have been widely criticized for loading companies with excessive debt, selling off assets and real estate of acquired companies, failing to provide financial transparency, taking advantage of tax loopholes, and charging high management fees (Batt and Appelbaum, 2021). Moreover, PE companies have consolidated healthcare markets, reduced competition, aggressively focused on revenues, increased overall costs, and reduced quality (Scheffler et al., 2021). PE firms generally are oriented to short-term investment with predetermined expiration dates, typically 4 to 7 years. Investors are promised high earnings, which incentivizes financial engineering strategies (Scheffler et al., 2021).

Effect of the COVID-19 Pandemic on Maternal Health in the United States.

The COVID-19 pandemic is responsible for over 1 million deaths in the United States. More than 500 of those deaths were among pregnant and postpartum women. The recent United States Government Accounting Office report on the effects the pandemic on maternal health is summarized. While the efforts in reporting these data in detail are appreciated, it is past time for taking action to prevent preventable maternal deaths in the United States including the racial and ethnic disparities these deaths represent rather than gathering information about them each year.

Paying for Nursing Home Quality: An Elusive But Important Goal.

Paying for Nursing Home Quality: An Elusive But Important Goal.

Social Justice Suite

Social Justice Suite (SJS) is a collection of five HeinOnline databases in the areas of historical slavery, civil and human rights, and gun regulation and legislation. The databases were added between 2016 and 2022. The majority of the databases include Supreme Court briefs. Other databases include hearings, legislative histories, and Congressional Research Service (CRS) and Government Accountability Office (GAO) reports. Databases can be searched individually or at once. Scholarly articles are available only to HeinOnline Core subscribers. The databases are complimentary for Core subscribers and free to interested organizations (requires registration). SJS benefits from a clean and uncluttered interface, and the top navigational menu and search components are the same across databases.

On Who Should Pay When Orbital Debris “Trickles-Down” in a Tragedy of the Low Earth Orbit Commons

In March 2023, NASA released the most rigorous and wide-reaching orbital debris analysis in the space law literature that provides a cost-benefit analysis of removing orbital debris from low Earth orbit (LEO), a region of the Earth’s environment with no environmental regulation. NASA contextualized the motivation in releasing this report as rooted in the exponential growth of the commercial satellite industry, noting that “the number of tracked and untracked debris in LEO is projected to grow . . . even if no new satellites are launched into space, yet launch traffic is likely to increase in the coming decade compared to recent history.” Similarly, in a May 2023 Congressional Budget Office (CBO) report, the CBO argued that the “number of satellites operating in LEO has increased significantly in recent years, driven in large part by commercial [satellite] constellations,” which are networks of identical satellites whose orbits and positions are coordinated to accomplish a given mission, such as providing global broadband internet. Underscoring the dangers of launching thousands of satellites into a finite orbital space with no environmental regulation, SpaceX, who operates the world’s largest constellation, Starlink, reported that from December 2022 to May 2023, Starlink had to perform 25,299 collision avoidance maneuvers in LEO. This number of collision avoidance maneuvers is double the number of maneuvers reported by SpaceX during the previous six-month period, which is alarming to industry experts. Concerning the risks that satellite constellations pose to the sustainability of LEO, experts note that the global space market grew by 8% to $424 billion in 2022 and is expected to be valued at more than $737 billion by 2030, which is a market that will certainly be impacted if LEO is enshrouded in an impenetrable maelstrom of orbital debris moving at speeds seven times faster than a bullet. Cross-referencing the most current orbital debris numbers from the European Space Agency with NASA’s estimated costs of $300 per debris removed with ground-based lasers, and $6,000 per debris removed with space-based lasers, the total estimated cost to remove the 1,036,500 trackable pieces of orbital debris from LEO is from $310 million to $6.2 billion. On the other hand, the cost to remove the estimated 130 million pieces of currently untraceable orbital debris from LEO is from $39 to $780 billion, all of which is a sizeable liability for the United States (U.S.) government to allocate to the U.S. taxpayer. Indeed, under both the Outer Space Treaty and the Proposed ORBITS Act of 2023, which is a bipartisan bill recently unanimously passed by the U.S. Senate, the U.S. taxpayer will be left with footing the bill for remediating the debris left behind by U.S.-authorized commercial satellite operators. Describing the LEO environment as a classical “tragedy of the commons” and drawing from studies conducted by NASA, the Government Accountability Office, the CBO, United Nations, and others, the purpose of this article is to tackle the question of who should pay when orbital debris “trickles down” in a manner that compromises Earth’s satellite-reliant infrastructure and otherwise causes damage to Earth’s environment, persons, and property. This article then recommends specific language to amend Title III of the Communications Act of 1934, which created and charged the Federal Communications Commission (FCC) with regulating commercial satellite systems, to establish a satellite constellation “orbital use fee” (OUF), which the FCC will levy as a requirement for receiving a license to operate in LEO. This OUF will then fund orbital debris remediation projects, related research, and remediation of the environmental impacts of satellite constellations. Given that the U.S. leads the world in the total number of satellites in space per country, and SpaceX will own more satellites than each country in the world combined once it fully deploys Starlink, this article concludes by arguing that the U.S. is uniquely positioned to engage its allies in forging the foundation of customary international space law. First, through passing into law the types of model legislation provided in this article, which will then form the basis of bilateral and multilateral treaty negotiations with both current and potential space-faring nations. This legislative and diplomatic strategy will help to operationalize the 1967 Outer Space Treaty (OST) proclamation establishing space as the “province of all mankind,” and promote its peaceful use and exploration for the “benefit and in the interests of all countries.”

Bus Rapid Transit: A Viable Alternative?

Bus Rapid Transit (BRT) presents a significant opportunity for the public transit industry to enhance the set of transportation investment options that can be brought to bear on the mobility problems experienced by urban areas across the country. As new Census data are released, the picture of strong population growth in dispersed patterns, growing congestion levels, and stubbornly modest transit use levels emerges. This paints a compelling picture that merits serious consideration by transportation planners with regard to the full range of transportation investment options available for urban areas.This article addresses several specific characteristics of BRT that differentiate it from other public transit modes and supports the explicit consideration of BRT as an alternative in Major Investment Studies (MIS). Clearly, the high cost of rail transit limits the possible role it can play in urban mobility even under radical changes in modal spending priorities. The pursuit of more moderate costing infrastructure transit options increases the chances of public transit being able to make more meaningful contributions to urban mobility. A key characteristic of BRT is the prospect that it can offer a lower-cost method of providing better performing public transit service (not yet fully verified) that is able to both retain current and attract new customers as well as garner political and taxpayer support. Evidence provided by the Government Accounting Office (GAO) in its recent report on BRT indicated that the BRTprojects reviewed cost less to build than the light rail transit (LRT) projects reviewed, on a per-mile basis. In addition, the GAO also points out that ridership was comparable between the BRT and LRT systems reviewed and that five of the six BRT projects had higher overall system operating speeds than the LRT projects.This article also addresses the definition of BRT and the implications of the various definitions on branding of the mode. An interesting perspective on the BRT branding is offered by looking at it from the perspective of various user groups. In addition, the article explores the prospects of BRT becoming attractive to the public transit industry and with customers, decision-makers, and taxpayers. It continues by addressing certain aspects of BRT that differentiate it from LRT and the comparative impacts on land use by BRT and LRT. The article concludes by offering thoughts regarding the opportunities presented by BRT concept.

2-step process recycles mixed plastics

A two-stage process that combines the power of chemistry and biology can convert mixtures of common waste plastics into single products, potentially overcoming a major obstacle in recycling ( Science 2022, DOI: 10.1126/science.abo4626 ). Plastic waste contains a mélange of materials , so it typically goes through a laborious sorting process to separate certain types of plastic for mechanical recycling. For example, polyethylene terephthalate (PET) and high-density polyethylene (HDPE) can be chopped up and used to make new products. But most other plastics cannot be recycled in this way, including composite materials that are difficult to tease apart. Overall, the US recycles less than 10% of its plastic waste, with the remainder landfilled, incinerated, or dumped, according to the US Government Accountability Office. Although a growing number of chemical processes are able to break down polymers into their constituent monomers, which can then be turned into fresh plastics, very few

Assessment of the mass burning rate of LNG pool fires by a validated CFD model

Liquefied natural gas (LNG) is widely used, because it provides an easy and economic solution to the transport and storage of natural gas (NG), especially on long distances or when transport by pipeline is not viable. The LNG pool fire is one major process safety accident at the LNG facilities according to the report of the U.S. Government Accountability Office. Moreover, due to the high surface emissive power of LNG compared to other hydrocarbon fuels, LNG pool fires have a high potential in causing domino effects and cascading events in process industry. Previous studies developed Computational Fluid Dynamics (CFD) models of LNG pool fires, but the mass burning rate was fixed manually as a model input, not considering that the mass burning rate is determined by the fuel’s physical properties and heat input vaporizing the fuel. In this study, a model of LNG pool fire controlled by material physical properties was developed using fire dynamics simulator (FDS), and was validated against LNG pool fire experiments carried out by Mary Kay O’Connor Process Safety Center (MKOPSC). Statistical performance measurement shows that the model is superior to the semi-empirical approaches in predicting the mass burning rate of LNG pool fire under different pool sizes. A flame geometry analysis software was developed comparing different algorithms, and the centroid method was selected. The results show that the fire model (200 kW/m3 as flame contour) can accurately predict the flame geometry observed in the experimental runs. The influence of wind velocity and dike height on the mass burning rate was also investigated. The results show that the height of the concrete dike is negatively correlated with the mass burning rate of LNG pool fire. The effect of wind velocity on LNG mass burning rate is twofold. The forced convective boundary layer at lower wind velocity promotes LNG combustion and increases the mass burning rate, while higher wind velocities reduce the mass burning rate due to the reduction of the thermal radiation feedback. The findings in this study will contribute to an accurate risk assessment of LNG pool fire accidents in the process industry.

Failing Grade: The Pandemic Legacy of HHS

On January 27, 2022, the Government Accountability Office (GAO) issued its ninth report on the efforts of the federal government to respond to and recover from the coronavirus disease 2019 (COVID-19) pandemic.1 The GAO report reaches as far back as January 2020 to encompass both the Trump and Biden Administrations. Turning its attention to HHS (home to agencies such as the Food and Drug Administration and the Centers for Disease Control and Prevention [CDC]), the GAO found persistent deficiencies in the preparedness and response efforts in several areas.

Variations in Medical Necessity Determinations Across Commercial Insurance Carriers for Prostate Cancer Procedures

Variation in commercial insurance coverage may lead to disparity in access to quality cancer care. We evaluated commercial insurance coverage determinations to assess the degree of variation across a national sample. We identified the predominant carrier of commercial insurance in each state based on the 2020 US Government Accounting Office (GAO-21-34) report on insurance. For each state, publicly available medical policies from January 1, 2021 to January 31, 2021 were analyzed for coverage of 3 widely accepted procedures: hydrogel spacer, fluciclovine- positron emission tomography (PET), and intensity modulated radiation in low volume metastatic prostate cancer. We analyzed 83 commercial medical policies across 51 states and District of Columbia. There was widespread variation in coverage policy. Hydrogel spacer was determined medically necessary in 9 states, mixed coverage in 8, not medically necessary in 22, and no available public policy in 12. Use of fluciclovine-PET required a minimum prostate specific antigen level of 2 ng/mL in 9 states, 1 ng/mL in 17, any minimum prostate specific antigen in 7, mixed coverage in 12, and no publicly available policy in 6. Intensity modulated radiation in low volume metastatic prostate cancer was medically necessary in 17 states, not necessary in 7, and not stated in 27. Insurance carriers often used external utilization management companies such as AIM-Healthcare and Evicore Healthcare. These determinations were more restrictive than carriers which did not use utilization management. Commercial medical policies vary widely in medical necessity determinations for novel prostate cancer treatment procedures that are Food and Drug-approved and covered by Medicare. These data suggest a need for more consistent methodology for medical necessity determination to mitigate the current state where patients have unequal access to cancer procedures due to the location of residence and age.