What GAO Found The Coast Guard and U.S. Customs and Border Protection (CBP) employ assets—including aircraft and vessels—and personnel, to ensure maritime security and safety. Coast Guard and CBP also coordinate with the Department of Defense on the allocation of assets and specialized personnel in their efforts to counter the flow of illicit drugs. GAO previously identified challenges Coast Guard and CBP face in managing maritime security assets. This includes determining the appropriate allocation of assets across geographic locations and in response to catastrophic events or emergencies, such as hurricanes, oil spills, and humanitarian events. For example, in September 2020, GAO found that the Department of Homeland Security's (DHS) ability to assess the costs and benefits of consolidating Coast Guard and CBP operating locations was limited, in part due to the lack of a standard cost measure between the components. GAO recommended DHS develop and implement a way to compare costs. In September 2021, DHS implemented a standardized methodology for costs. Coast Guard Personnel Conducting a Drug Interdiction Operation The Coast Guard and CBP have taken steps to assess workforce needs. In February 2020, GAO found that the Coast Guard had assessed a small portion of its workforce needs and recommended that Coast Guard update its workforce plan with timeframes and milestones to meet its workforce assessment goals. As of March 2023, the Coast Guard reported that it had revised this plan and submitted it to Congress, as required. GAO is continuing to evaluate the plan. In June 2018, GAO found that CBP faced challenges meeting target hiring and retention levels, such as for law enforcement personnel. CBP implemented an agency-wide exit survey and uses data to inform retention efforts. Why GAO Did This Study Securing the nation's borders against unlawful movement of people, illegal drugs and other contraband, and terrorist activities is a key part of the DHS's mission. With increased attention to overland routes in recent years, such as along the southwest border, criminal organizations use maritime routes to smuggle people, drugs, and weapons into the U.S. Within DHS, the Coast Guard and CBP share responsibility for securing the nation's maritime borders. This statement discusses: (1) Coast Guard and CBP resources for maritime security and related federal coordination, (2) challenges these agencies have faced managing assets, and (3) related workforce challenges. This statement is based on GAO's prior work on a variety of asset and workforce issues. For that work, GAO analyzed Coast Guard and CBP documentation and data and interviewed officials. For this statement, GAO also obtained updates on actions DHS has taken to address GAO's recommendations as of March 2023. For a full list of the reports, see Related GAO Products at the conclusion of this statement.

What GAO Found The William M. (Mac) Thornberry National Defense Authorization Act for Fiscal Year 2021 expanded and added responsibilities for Sector Risk Management Agencies (SRMAs). These agencies engage with their public and private sector partners to promote security and resilience within their designated critical infrastructure sectors. Some officials from these agencies described to GAO new activities to address the responsibilities set forth in the act, and many reported having already conducted related activities. For example, the act added risk assessment and emergency preparedness as responsibilities not previously included in a key directive for SRMAs. New activities officials described to address these responsibilities included developing a communications risk register and developing emergency preparedness exercises. The Department of Homeland Security's (DHS) Cybersecurity and Infrastructure Security Agency (CISA) has identified and undertaken efforts to help SRMAs implement their statutory responsibilities. For example, CISA officials stated they are updating key guidance documents, including the 2013 National Infrastructure Protection Plan and templates for revising sector-specific guidance documents. CISA officials also described efforts underway to improve coordination with sector partners, such as reconvening a leadership council. SRMA officials for a majority of critical infrastructure sectors reported that additional guidance and improved coordination from CISA would help them implement their statutory responsibilities. However, CISA has not developed milestones and timelines to complete its efforts. Establishing milestones and timelines would help ensure CISA does so in a timely manner. Why GAO Did This Study Critical infrastructure provides essential functions––such as supplying water, generating energy, and producing food––that underpin American society. Disruption or destruction of the nation's critical infrastructure could have debilitating effects. CISA is the national coordinator for infrastructure protection. The William M. (Mac) Thornberry National Defense Authorization Act for Fiscal Year 2021 includes a provision for GAO to report on the effectiveness of SRMAs in carrying out responsibilities set forth in the act. This statement addresses (1) how the act changed agencies' responsibilities, and the actions agencies have reported taking to address them; and (2) the extent to which CISA identified and undertook efforts to help agencies implement their responsibilities set forth in the act. This statement is based on GAO's February 2023 report on SRMA efforts to carry out critical infrastructure protection responsibilities and CISA's efforts to help SRMAs implement those responsibilities. For that report, GAO analyzed the act and relevant policy directives, collected written responses from all 16 sectors using a standardized information collection tool, reviewed other DHS documents, and interviewed CISA officials.

GAO continued to demonstrate its value in fiscal year (FY) 2022. GAO’s work yielded $55.6 billion in financial benefits, a return of about $74 for every dollar invested in GAO. Over the past five years, on average, GAO has returned $145 for every dollar appropriated to us. In FY 2022, GAO also delivered 1,260 program and operational benefits that led to improved services to the American people, strengthened public safety, and spurred program and operational improvements across the government. Congress also continues to use GAO’s work to inform its legislative decisions. For example, the National Defense Authorization Act for 2023 contained more than 20 actions based on GAO work and the Consolidated Appropriations Act for FY 2023 included 40 directives that would spur agency action on GAO’s recommendations. GAO’s FY 2024 budget request reflects the continued demand for GAO services. In addition to the hundreds of requests from committee leadership for GAO studies we receive each year, Congress directs us to conduct hundreds of studies in legislation and related committee reports. For example, Congress directed us to provide oversight of the federal assistance provided to Ukraine and Inflation Reduction Act spending, which will require dozens and dozens of audits. Congressionally mandated studies reflect the broadest representation of congressional demand for and interest in GAO work. Completing these mandated studies are our highest priority. They can also account for significant staff resources. GAO Mandated Studies from Selected Recent Public Laws Public Law Number of Mandates Estimated FTE P.L 117-263   James M. Inhofe National Defense Authorization Act for Fiscal Year 2023 158 312 P.L 117-328   Consolidated Appropriations Act, 2023 97 191 P.L. 117-103  Consolidated Appropriations Act, 2022 58 114 P.L. 117-167  CHIPS Act of 2022 10 20 P.L. 117-58    Infrastructure Investment and Jobs Act 35 69 Total 358 706 Source: GAO | GAO-23-900493 Note: These numbers reflect mandates in statute and in related committee reports. Estimated FTE is for staff to complete work and does not include overhead or other costs. GAO’s FY 2024 budget requests $859.7 million in appropriated funds and uses $93.8 million in offsets and supplemental appropriations.  This request would enable GAO to modestly increase its staffing levels to 3,675 full-time equivalents to meet the demand for GAO services and ensure GAO employees have access to modern information technology tools and to a safe and secure work place.  As outlined in the budget request, GAO plans to maximize its science and technology reporting capabilities to report on transformative technologies like artificial intelligence and blockchain, given the policy implications of these advances on government decision-making. GAO will also prioritize our reporting on government-wide cybersecurity capabilities; and continued evaluations of healthcare spending, military readiness, and defense weapons systems development. Background GAO’s mission is to support Congress in meeting its constitutional responsibilities and to help improve government performance.  Since 2002, GAO’s work has resulted in about $1.31 trillion in financial benefits and over 27,000 program and operational benefits. Congress relies on GAO’s nonpartisan, objective, and high-quality work to help inform congressional deliberations as well as oversight of the executive branch. GAO’s work spans the full breadth and scope of the federal government’s responsibilities. In fiscal year 2022, GAO issued over 500 reports with 1,255 new recommendations and over 450 legal opinions, and handled about 1,600 bid protests. GAO was asked to conduct work for the Chairs or Ranking Members for over 90 percent of all standing committees. GAO testified 72 times before 43 separate committees or subcommittees on topics such as DOD and VA suicide prevention efforts, NASA’s moon landing plans, and the Biodefense National Strategy. For more information, contact A. Nicole Clowers at (202) 512-4400 or clowersa@gao.gov.

What GAO Found The goal of regenerative medicine and advanced therapies is to repair or replace damaged human cells, tissues, or organs to supplement or restore function. The field is developing therapies that go beyond existing treatments to address underlying causes of disease or provide cures for previously untreatable diseases and conditions. The regenerative medicine and advanced therapies workforce is generally reflective of the larger life sciences workforce, with individuals occupying a wide range of jobs across research and development, biomanufacturing, clinical care, and regulatory affairs, as shown below. Examples of Regenerative Medicine and Advanced Therapy Occupations aTranslational scientists take discoveries made in the laboratory, clinic, or field, and transform them into new treatments and approaches that help improve the health of the population. bBiomanufacturing activities include the production of therapies using living cells. Individuals working with regenerative medicine and advanced therapies would need postsecondary degrees appropriate to their area of work. For example, researchers would generally need science- and engineering-based degrees, and clinical occupations would generally need clinical and professional degrees. Further, stakeholders noted that many occupations would likely need additional specialized training, such as training in laboratory techniques, or medical fellowships in topics and practices specific to the field. Many of the eight stakeholders GAO interviewed discussed shortages in the number of current and projected laboratory and biomanufacturing technicians to support the development of regenerative medicine and advanced therapies, as well as gaps in other positions, such as data scientists. Some stakeholders said that education for these technicians at the community and technical college level is insufficient to meet current and future workforce needs. In addition, many stakeholders noted that there is no nationally recognized education curriculum for the field. One of these stakeholders agreed that a core curriculum that reflects the diverse, interdisciplinary nature of regenerative medicine and advanced therapies would help support a competent, robust workforce. Why GAO Did This Study The field of regenerative medicine and advanced therapies—including cell, gene, and tissue-based therapies—is evolving and interdisciplinary. Practitioners believe these therapies have the potential to revolutionize patient care and improve lives. The promise of such therapies to ameliorate, or cure, previously untreatable diseases and conditions depends, in part, on the existence of a robust, well-trained workforce. The Timely ReAuthorization of Necessary Stem-cell Programs Lends Access to Needed Therapies (TRANSPLANT) Act of 2021 included a provision for GAO to study the regenerative medicine and advanced therapies workforce in the commercial and academic sectors. This report provides information on (1) the makeup of this workforce, (2) education and training for this workforce, and (3) current and future workforce and education and training needs. GAO interviewed officials from the Department of Health and Human Services (HHS), and eight stakeholder organizations selected for representation across the occupational areas GAO identified for this work, as well as other criteria. GAO also reviewed related reports and job postings. Existing workforce and education data do not contain information specific to the regenerative medicine workforce. To quantify the number of stakeholders who made certain statements, “some” means two to four stakeholders and “many” means five to seven stakeholders. For more information, contact Leslie V. Gordon at (202) 512-7114 or GordonLV@gao.gov.

What GAO Found In response to the VA Mission Act of 2018 (MISSION Act), the Department of Veterans Affairs (VA) conducted a system-wide assessment of its capacity to provide health care services to veterans and develop recommendations for modernizing and realigning the department's infrastructure. The MISSION Act also specified that a presidentially appointed and Senate-confirmed commission—the Asset and Infrastructure Review Commission—would review VA's recommendations. The Commission was to then provide its own recommendations to the President by January 2023, according to the act. However, in June 2022 a bipartisan group of senators announced their opposition to holding confirmation hearings for Commission nominees. These Senators voiced concerns that VA's 1,433 recommendations published in March 2022 would not expand and strengthen VA's infrastructure. Accordingly, no confirmation hearings have occurred as of March 2023. The Secretary of VA stated that, independent of the Commission's existence, the department has an obligation to veterans to modernize and realign its infrastructure. VA therefore has taken steps to refine its recommendations and plans to conduct recurring system-wide assessments every 4 years as also required by the MISSION Act. GAO's review determined that 540 of VA's recommendations pertained to facility changes. These changes included closing, replacing, updating, and establishing medical centers, outpatient clinics (e.g., community-based outpatient clinics and other outpatient services sites), and other facilities. Department of Veterans Affairs' (VA) Recommended Facility Changes, by Facility Type   Type of recommended infrastructure change Facility type Closure Replacement Update Establish new Total VA medical center 16 23 80 13 132 Outpatient clinica 139 112 2 112 365 Stand-alone community living center 1 0 1 28 30 Stand-alone residential rehabilitation treatment program 1 1 0 11 13 Total 157 136 83 164 540 Source: GAO analysis of VA documentation. | GAO-23-106001aOutpatient clinic includes health care centers, community-based outpatient clinics and other types. GAO noted differences in how commonly VA recommended changes for facilities by rurality. Specifically, VA recommended closures for facilities in rural areas more commonly than for those in urban areas (60 compared to 35 percent). For facilities in urban areas, VA recommended replacements (38 compared to 31 percent) and updates (27 compared to 9 percent) more commonly compared to facilities in rural areas. According to VA officials, the department recommended changes to its facilities based on a variety of factors including the quality of care, the ability to recruit and retain health care providers, the condition of VA facilities, and the number of veterans served. GAO's review also determined that VA made 893 recommendations to change inpatient, outpatient, and other services available in VA facilities. These recommended service changes included establishing new or expanding existing services, among others. Department of Veterans Affairs' (VA) Recommended Changes to Health Care Services                                                                                                            VA health care services Type of service change Inpatienta Emergency department or urgent care Outpatient Community living center Residential rehabilitation treatment program Total Establish new or expand existing services 15 7 135 46 35 238 Modernize existing services 41 20 16 36 25 138 Relocate existing services 79 37 303 40 39 498 Total 135 64 454 122 99 874 Source: GAO analysis of VA documentation. | GAO-23-106001 Note: In addition to the types of services included above, VA also made seven recommendations to modernize or relocate inpatient blind rehabilitation services and 12 recommendations to modernize or relocate inpatient spinal cord injury/disorders services.aInpatient includes inpatient medical and surgical and inpatient mental health care services. According to VA officials, the department reviewed specific data to help ensure that the recommendations reflected four key considerations—1) meeting veterans' evolving needs; 2) adapting to health care delivery innovations; 3) addressing VA's education, research, and support missions; and 4) accounting for COVID-19 trends. In reviewing the department's data supporting these considerations, GAO identified gaps in the comprehensiveness of the data used. For example, in determining veteran access to community care, VA reviewed data estimating whether non-VA providers had the capacity to serve veterans. However, VA lacked data on appointment wait times, the total number of appointments, and their associated costs. According to VA officials, VA intends to address data gaps as part of its ongoing planning for the next set of quadrennial market assessments expected in 3 years. However, VA's plans currently do not include specific actions and time frames to determine the data it will use for its upcoming market assessments. By addressing these data gaps and identifying time frames for completing these actions, VA can provide greater assurance that these market assessment account for its key considerations. VA established a leadership team to, among other things, conduct implementation planning and strategic prioritization of recommendations, and prepare for the next set of market assessments. However, the department does not have a documented, formal plan describing the team's structure and implementation strategy. Having such a plan would help ensure that VA has effective and efficient processes for using its recommendations and future market assessments to address the department's infrastructure needs. GAO determined that VA restricted the sharing of information when developing its recommendations. Department officials acknowledged that they will need to be more transparent in sharing information with internal and external stakeholders moving forward. VA has taken steps, such as developing draft documents, consistent with such an approach. Finalizing this approach, to help ensure communication with critical stakeholders such as the Congress and veterans' service organizations, is essential to the success of VA's overall modernization and realignment effort including the use of VA's recommendations. Why GAO Did This Study VA administers one of the largest health care systems in the nation. The system, which includes 172 medical centers and more than 1,100 outpatient clinics, serves more than 9.5 million enrolled veterans and eligible family members. Upgrading VA's aging facilities is a massive endeavor. VA estimates that addressing its health care system infrastructure needs could cost up to $76 billion, as of fiscal year 2021. GAO was asked to review VA's plans and recommendations to address its infrastructure needs. This report (1) describes the Asset and Infrastructure Review Commission and VA's recommendations, (2) examines the data VA used to inform its recommendations and plans VA has to improve such data, and (3) examines the extent of VA's planning for modernizing and realigning its infrastructure and communicating with stakeholders. GAO analyzed VA's recommendations for modernizing and realigning its infrastructure, and reviewed supporting data and documentation. These data included actual and projected data on demographics and demand for health care. GAO also reviewed documentation describing VA's process to assess its capacity in 96 designated geographic areas, or markets, to provide quality, accessible, and timely health care. To obtain market-level perspectives, GAO interviewed officials from a non-generalizable selection of four markets. GAO selected the four based on factors such as variation by geographic region and by types of changes recommended (e.g., closures, replacements). GAO also interviewed VA officials responsible for developing the recommendations and for planning to modernize and realign its infrastructure.

What GAO Found Since the enactment of the First Step Act of 2018, the Department of Justice (DOJ) developed a risk assessment tool to measure an incarcerated person's risk of recidivism. In addition, the Bureau of Prisons (BOP) modified its existing needs assessment system to identify incarcerated people's needs, that if addressed may reduce their recidivism risk. However, BOP does not have readily-available, complete, and accurate data to determine if assessments were conducted within required First Step Act and internal timeframes. As of October 2022, BOP plans to implement monitoring efforts to assess First Step Act requirements, but has not determined if these efforts will measure whether assessments are completed on time. Without such data and monitoring, BOP is not in a position to determine if staff complete assessments on time, which are necessary for earning First Step Act time credits. These time credits may allow incarcerated people to reduce the amount of time they spend in a BOP facility. BOP created a plan to evaluate its evidence-based programs, as required by the First Step Act. However, the plan did not include quantifiable goals that align with certain First Step Act requirements, or have clear milestone dates. By including such elements in its plan, BOP will be better positioned to ensure its evaluations are conducted in a timely manner, and align with the First Step Act. BOP has some data on who participates in its programs and activities, but does not have a mechanism to monitor if it offers a sufficient amount. Without such a mechanism, BOP cannot ensure it is meeting the incarcerated population's needs. Further, while BOP offers unstructured productive activities for which incarcerated people may earn time credits, BOP has not documented a complete list or monitored them. Without doing so, BOP cannot ensure it provides transparent information. BOP's procedure for applying time credits has evolved over time (see figure). Initially, BOP did not have data necessary to track time credits and developed an interim approach in January 2022. Subsequently, BOP implemented an automated-calculation application for time credits that took into account factors the interim procedure did not. As a result, some incarcerated people may have had their time credits reduced. In November 2022, BOP issued its First Step Act Time Credits program statement, with new procedures. Timeline of the Department of Justice (DOJ) and Federal Bureau of Prisons (BOP) Implementation of the First Step Act Time Credit Procedure Why GAO Did This Study Approximately 45 percent of people released from a federal prison are re-arrested or return within 3 years of their release. The First Step Act included certain requirements for DOJ and BOP aimed to reduce recidivism, including requiring the development of a system to assess the recidivism risk and needs of incarcerated people. It also required BOP to provide incarcerated people with programs and activities to address their needs and if eligible, earn time credits. The First Step Act required GAO to assess the DOJ and BOP's implementation of certain requirements. This report addresses the extent to which DOJ and BOP implemented certain First Step Act requirements related to the (1) risk and needs assessment system, (2) identification and evaluation of programs and activities, and (3) application of time credits. GAO reviewed legislation and DOJ and BOP documents; analyzed 2022 BOP data; and interviewed DOJ and BOP headquarters officials and BOP's employee union. GAO also conducted non-generalizable interviews with officials from four BOP regional offices facilities, selected to ensure a mix of different facility characteristics.

What GAO Found The Department of Health and Human Services (HHS), primarily through the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention, has led the federal response to the COVID-19 pandemic in nursing homes. The expert roundtable GAO convened identified actions aimed at improving infection prevention and control in nursing homes, including six actions HHS should continue, seven it should enhance, and one it should discontinue. Note: The actions in this report are not listed in any specific rank or order, and their inclusion should not be interpreted as GAO endorsing any of them. Implementing any one action or a combination of actions listed in this report might require additional efforts to address program design or legal issues. Except in those areas directly related to GAO's prior recommendations, GAO did not assess how effective the actions listed in this report may be or the extent to which legislative changes and federal financial support would be needed to implement them. Many of the actions identified by GAO's expert roundtable are consistent with prior recommendations made to HHS to improve infection prevention and control. Specifically, reports from CMS's Coronavirus Commission on Safety and Quality in Nursing Homes, and the National Academies' Committee on the Quality of Care in Nursing Homes, as well as prior GAO reports, have examined infection prevention and control challenges in nursing homes and made similar recommendations. HHS's continued leadership in prioritizing infection prevention and control—in coordination with other federal, state, and private entities—is critical to better protect nursing home residents from the enduring risks of declining health and premature death posed by infections. The actions identified by GAO's expert roundtable may, for example, assist HHS in addressing prior recommendations from GAO and others, presenting new solutions, or expanding on current efforts. Why GAO Did This Study Before the COVID-19 pandemic led to devastating consequences in nursing homes, infections were a leading cause of hospitalization and death among nursing home residents. As the nation moves forward, COVID-19 and other infectious diseases will continue to present a threat to these individuals. Proper infection prevention and control procedures, such as hand hygiene, will remain critical to ensuring resident safety. The CARES Act includes a provision for GAO to monitor and report on the federal pandemic response. GAO was also asked to review federal oversight of nursing homes in light of the pandemic. This report: (1) describes actions experts identified that HHS should continue, enhance, or discontinue to improve infection prevention and control practices in nursing homes and (2) compares actions identified by experts with prior recommendations from GAO and others. GAO convened a roundtable of 13 experts to discuss actions to improve infection prevention and control in nursing homes. GAO contracted with the National Academies of Sciences, Engineering, and Medicine to help identify experts representing a range of perspectives on nursing homes and infection prevention and control, including researchers and infectious disease specialists, nursing home staff, individuals with nursing home oversight and regulatory experience, as well as representatives for residents and their families. GAO also interviewed officials from CMS and the Centers for Disease Control and Prevention. For more information, contact John E. Dicken at (202) 512-7114 or dickenj@gao.gov.