2021 International Women of Courage Award Recipients Announced

Office of the Spokesperson

Secretary of State Antony J. Blinken to Host Virtual Award Ceremony Featuring Special Remarks by the First Lady, Dr. Jill Biden

On Monday, March 8, at 10:00 a.m., Secretary of State Antony J. Blinken will host the annual International Women of Courage (IWOC) Awards virtual ceremony to honor a group of extraordinary women from around the world, including an honorary award for seven women leaders and activists from Afghanistan who were assassinated for their dedication to improving the lives of Afghans. The First Lady of the United States, Dr. Jill Biden will deliver remarks to recognize the courageous accomplishments of these women.

Out of an abundance of caution and in order to practice safe social distancing, the ceremony will be pooled press coverage only and will be live streamed on www.state.gov.

Now in its 15th year, the Secretary of State’s IWOC Award recognizes women from around the globe who have demonstrated exceptional courage and leadership in advocating for peace, justice, human rights, gender equality, and women’s empowerment – often at great personal risk and sacrifice. From the inception of this award in March 2007 to today, the Department of State has recognized more than 155 awardees from over 75 countries. U.S. diplomatic missions overseas nominate one woman of courage from their respective host countries, and finalists are selected and approved by senior Department officials. Following the virtual IWOC ceremony, the awardees will participate in an International Visitor Leadership Program (IVLP) virtual exchange and connect with their American counterparts. The 2021 awardees are:

Belarus – Maria Kalesnikava

Ahead of the August 9, 2020, presidential election, Belarusian women emerged as a dominant political force and driver of societal change in Belarus due in no small part to Maria Kalesnikava. After authorities jailed or exiled the three most popular male opposition candidates, Maria and her partners mounted a historic and sustained challenge to the 26-year rule of Alyaksandr Lukashenka. Maria continues to be the face of the opposition inside Belarus, courageously facing imprisonment in the aftermath of the disputed election. Despite her detention, Maria continues to keep the democratic movement alive inside Belarus and serves as a source of inspiration for all those seeking to win freedom for themselves and their countries.

Burma – Phyoe Phyoe Aung

An emerging leader who is likely to play a role in shaping the country in the coming years, Phyoe Phyoe Aung is the co-founder of the Wings Institute for Reconciliation, an organization that facilitates exchanges between youth of different ethnic and religious groups. Her work promotes peacebuilding and reconciliation and enables a vital dialogue on federalism and transitional justice. She organized a 2015 protest march from Mandalay to Yangon that was violently suppressed by the Myanmar Police Force as it neared Yangon, and she and her husband were arrested and imprisoned. Phyoe Phyoe was released in April 2016 after 13 months as part of a broad pardon of political prisoners facing court trials.

Cameroon – Maximilienne C. Ngo Mbe

Maximilienne C. Ngo Mbe has demonstrated extraordinary leadership, courage, and perseverance through adversity in promoting human rights in Cameroon and Central Africa. She has been an outspoken voice among civil society actors, often sacrificing her personal safety, in the push for a peaceful solution to the Anglophone crisis in Cameroon. She has called for an end to human rights abuses committed by separatists and security forces in the Northwest and Southwest regions and by security forces in the Far North. Maximilienne has also spoken out against the increased constraints placed on civil society, journalists, and political opposition by the Government of Cameroon. Her commitment to promoting human rights has been unwavering despite the intimidation, threats, and assault she has endured.

China – Wang Yu

Wang Yu was one of the country’s most prominent human rights lawyers until her arrest and imprisonment following China’s nationwide persecution of lawyers and rights advocates during the “709 crackdown.” She had taken on multiple politically sensitive cases, representing activists, scholars, Falun Gong practitioners, farmers, and petitioners in cases involving a wide array of issues, including women’s and children’s rights, and the rights to religion, freedom of expression, assembly, and association. She is now under an exit ban and has been harassed, threatened, searched, and physically assaulted by police since she began to take on rights abuse cases in 2011.

Colombia – Mayerlis Angarita

Mayerlis Angarita has courageously advanced peace and human rights in Colombia, often at great personal risk. Her work has improved the security, livelihoods, and resilience of countless women leaders, conflict victims, and her community. Finding healing in storytelling after her own mother was forcibly disappeared during Colombia’s conflict, she founded the civil society organization “Narrate to Live,” which now serves over 800 women victims of conflict. Additionally, after the most recent attempt on her life, she engaged the highest levels of the Colombian government to advance a comprehensive action plan to prevent violence against women leaders in her community. Her constructive engagement across 27 government entities, civil society, and the international community has been key to the plan’s success and propelled it to become a model for human rights defender protection throughout Colombia.

Democratic Republic of the Congo – Julienne Lusenge

Since 1978, Julienne Lusenge has been the leading female activist in Democratic Republic of the Congo (DRC) fighting against gender-based violence (GBV) and the promotion of the rights of women and girls in conflict situations. In 2000, she created Women’s Solidarity for Peace and Integral Development, the DRC’s foremost organization defending the rights of women and girls against impunity for GBV. Julienne’s vocal testimony has contributed to the adoption of international agreements such as UN 1820, which recognizes sexual violence as a weapon of war. Julienne has touched the lives of millions of women across the DRC, harnessing the attention of the international community to acknowledge and act on the extent of sexual violence shattering DRC’s communities.

Guatemala – Judge Erika Aifan

Judge Erika Lorena Aifan is a trial judge working in the High-Risk Criminal Court with responsibility for high-impact crimes. She has presided over high-profile corruption and war atrocity cases, leading to defamation and threats of violence against her. Despite these challenges, Judge Aifan persisted as a Guatemalan judge independent of political influence. She has demonstrated determination and fortitude in upholding the rule of law in Guatemala. Despite the strong opposition she has faced throughout her tenure, Judge Aifan has become an icon in Guatemala in the fight against corruption, efforts to increase transparency, and actions to improve independence in the justice sector.

Iran – Shohreh Bayat

When Shohreh Bayat boarded her flight on her way to the 2020 Women’s Chess World Championship, she had no idea she might be seeing her native Iran for the last time. Shohreh, the first female Category A international chess arbiter in Asia was photographed at the Championship without her hijab, which is compulsory in Iran. Within 24 hours, the Iranian Chess Federation – which Shohreh had previously led – refused to guarantee Shohreh’s safety if she returned to Iran without first apologizing. Fearing for her safety and unwilling to apologize for the incident, Shohreh made the heart-wrenching decision to seek refuge in the UK, leaving her husband – who lacked a UK visa – in Iran. In that moment, Shohreh chose to be a champion for women’s rights rather than be cowed by the Iranian government’s threats.

Nepal – Muskan Khatun

Muskan Khatun has been instrumental in bringing about new legislation criminalizing acid attacks and imposing strong penalties against perpetrators in Nepal. When Muskan was 15, she was critically injured in an acid attack after she rejected a boy’s romantic propositions. With the help of a social worker, Muskan lobbied for stronger legal action against the perpetrators of acid attacks under duress of threats and the strong social stigma associated with acid attack victims. She went before a parliamentary committee, wrote a letter to Nepal’s Prime Minister, and eventually met with him in person, to request a stronger law. Within a year of her attack, Nepal’s President issued an ordinance with harsh penalties for acid attacks and regulations on the sale of acids, a testament to Muskan’s significant advocacy.

Somalia – Zahra Mohamed Ahmad

For more than 20 years, Zahra Mohamed Ahmad has been at the forefront of defending human rights in Somalia, especially for its most vulnerable groups. As an accomplished lawyer, Zahra began providing legal aid, for sexual and gender-based violence (SGBV) survivors, women on remand status, and women in pre-trial detention. Zahra is the founder of and legal advisor for the Somali Women Development Center, an organization that reports on human rights violations and cases of abuse; supports survivors through legal assistance; established Somalia’s first free hotline service to combat SGBV; and operates one-stop centers for SGBV survivors, mobile legal clinics, family care centers, safe spaces for women and girls, and community child protection centers for internally displaced children.

Spain – Sister Alicia Vacas Moro

A registered nurse, Sister Alicia Vacas Moro ran a medical clinic in Egypt for eight years, helping 150 low income patients a day treat their maladies. She then moved to the biblical town of Bethany to help an impoverished Bedouin community, especially women and children. She set up training programs for women that provided them with previously unavailable economic opportunities, and established kindergartens in Bedouin camps, providing an educational foundation for children. In an environment shaped by the Israeli-Palestinian conflict, Sister Alicia also assisted traumatized refugees and asylum seekers, a job she continues to perform on a larger scale in her current role as the regional coordinator for the Comboni Sisters in the Middle East. When the COVID-19 pandemic struck northern Italy, she flew to Italy to assist and treat fellow sister nuns, undeterred by extreme danger to herself.

Sri Lanka – Ranitha Gnanarajah

Ranitha Gnanarajah, a lawyer, continues to fight for and defend the rights of the marginalized and vulnerable communities in the country, despite threats and challenges by the state. Ranitha has dedicated her career to accountability and justice for victims of enforced disappearances and prisoners detained often for years without charge under Sri Lanka’s Prevention of Terrorism Act by providing free legal aid and related services. As an individual personally affected by the conflict and based on her extensive experience working with victims and their families, Ranitha has demonstrated tremendous passion and dedication to justice and accountability, especially for Sri Lanka’s most vulnerable populations.

Turkey – Canan Gullu

Canan Gullu has been an activist and organizer for 31 years and is the president of the Turkish Federation of Women’s Associations, an umbrella organization of women’s NGOs; she leads186 branches and 52,500 members. Canan has been a steadfast champion of gender equality, working to promote women’s participation in governance, labor force, and education. In 2007, the Turkish Federation of Women Associations established the first emergency hotline for victims of violence in Turkey, which continues its operations. Over the past two years, Canan launched an education and advocacy campaign focused on failures in the Turkish government’s implementation since 2012 of the Istanbul Convention, the Council of Europe’s Convention on preventing and combating violence against women and domestic violence. Canan’s activism has been critical to educating the public about the convention and reinforcing the need to combat gender-based violence, which quelled some politicians’ calls for Turkey’s withdrawal.

Venezuela – Ana Rosario Contreras

As president of the Caracas Nurses’ Association, Ana Rosario Contreras has been on the front lines in the fight for the rights of healthcare professionals, patients, and labor unions. Contreras’ fierce activism has generated widespread support from the Venezuelan people and is at the center of the civil-political movement pushing for democratic change. In a climate where the government routinely jails, tortures, harasses, threatens, or restricts the movement of its opponents, Contreras defends citizens’ rights at great personal risk. She has advocated for labor rights and has worked tirelessly to ensure that healthcare workers could receive a subsidy through Interim President Juan Guido’s Health Heroes program.

In addition to the individual IWOC awards that will be presented on March 8, Secretary Blinken will also present an honorary IWOC award to a group of seven Afghan women who were assassinated in 2020 while serving their communities during a pivotal moment in Afghanistan’s history. These tragic murders underscore the alarming trend of increased targeting of women in Afghanistan and the United States condemns these acts of violence.

· Fatema Natasha Khalil, an official with the Afghanistan Independent Human Rights Commission who was killed, along with her driver, in June 2020 by an IED in Kabul, on her way to her office.

· General Sharmila Frough, the head of the Gender Unit in the National Directorate of Security (NDS) was one of the longest-serving female NDS officers, having served as chief of the anti-kidnapping division and working undercover combating criminal networks. General Frough was assassinated in an IED explosion targeting her vehicle in March 2020 in Kabul.

· Maryam Noorzad, a midwife who served remote locations in Wardak and Bamyan provinces before working for Médecins Sans Frontières Kabul PD13 hospital. On May 12, 2020, three gunmen attacked the maternity ward of the hospital, but Maryam refused to leave her patient, who was in labor. Maryam, her patient, and the newborn baby were killed in the delivery suite.

· Fatima Rajabi, a 23-year-old police officer originally from Ghazni province and a member of the anti-narcotics division. She was traveling to her home village in Jaghori district in a civilian minibus in July 2020 when the Taliban stopped the vehicle and took her captive. Two weeks later, the Taliban killed her and sent her remains, which had gunshot wounds and signs of torture, to her family.

· Freshta, daughter of Amir Mohamed, a 35-year-old prison guard with the Office of Prison Administration. She was walking from her residence in Kandahar City to a taxi on her way to work when she was murdered by an unknown gunman on October 25, 2020.

· Malalai Maiwand, a reporter at Enikas Radio and TV, was shot and killed, along with her driver, by a gunman on December 10, 2020, in an attack on her vehicle in Jalalabad. Malalai was not the first in her family to be targeted. Five years earlier, her mother, an activist, was also killed by unknown gunmen.

· Freshta Kohistani, a 29-year-old women’s rights and democracy activist, was assassinated by unknown gunmen near her home in Kapsia province on December 24, 2020. Kohistani regularly organized events advocating for women’s rights in Afghanistan and used social media as a platform for her messaging.

Given the virtual nature of this year’s IWOC ceremony, the awardees will not be available for in-person interviews. However, media outlets may e-mail MediaRequests@state.gov to schedule virtual interviews with the awardees. We also invite you to use the hashtags #IWOC2021 and #WomenOfCourage on social media for news and updates on this year’s awards. For award inquiries, please contact the Office of Global Women’s Issues (SGWI_PA@state.gov). For IVLP inquiries, please contact (ECA-Press@state.gov).

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  • Public Health: Federal Programs Provide Screening and Treatment for Breast and Cervical Cancer
    In U.S GAO News
    The Centers for Disease Control and Prevention (CDC) operates the National Breast and Cervical Cancer Early Detection Program (the Early Detection Program) to provide cancer screening and diagnostic services to people who are low-income and uninsured or underinsured. For those screened under the program who require treatment, the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (the Treatment Act) allows states to extend Medicaid eligibility to individuals not otherwise eligible for Medicaid. GAO analysis of CDC data show that the Early Detection Program screened 296,225 people in 2018, a decrease from 550,390 in 2011 (about 46 percent). The largest decrease occurred from 2013 to 2014 (see figure). According to a CDC-funded study, the number of people eligible for the Early Detection Program decreased from 2011 through 2017, by about 48 percent for breast cancer and about 49 percent for cervical cancer. CDC officials attributed these declines in screening and eligibility, in part, to improved access to screening under the Patient Protection and Affordable Care Act (PPACA). For example, PPACA required health plans to cover certain women's preventive health care with no cost sharing. Number of People Screened by CDC's Early Detection Program, 2011-2018 GAO analysis of Centers for Medicare & Medicaid Services' (CMS) data found that, in 2019, 43,549 people were enrolled in Medicaid under the Treatment Act to receive treatment for breast or cervical cancer, a decrease from 50,219 in 2016 (13.3 percent). Thirty-seven states experienced a decrease in Medicaid enrollment under the Treatment Act during this time period, 13 states experienced an increase, and one state had no change. CMS officials noted that Medicaid expansion to adults with incomes at or below 133 percent of the federal poverty level under PPACA (the new adult group) is a key factor that contributed to these enrollment trends. CMS officials said that, in Medicaid expansion states, there were some people who previously would have enrolled in Medicaid based on eligibility under the Treatment Act who instead became eligible for Medicaid in the new adult group. The CMS data show that total enrollment under the Treatment Act in Medicaid expansion states decreased by 25.6 percent from 2016 to 2019. In contrast, total enrollment under the Treatment Act in non-expansion states increased by about 1 percent during this time period. According to the CDC, tens of thousands of people die each year from breast or cervical cancer. Early screening and detection, followed by prompt treatment, can improve outcomes and, ultimately, save lives. Federal programs, like CDC's Early Detection Program, are intended to improve access to these services. GAO was asked to examine the implementation of the Early Detection Program and the states' use of Medicaid under the Treatment Act. This report provides information on the number of people who were 1) screened through the Early Detection Program and 2) enrolled in Medicaid under the Treatment Act. GAO analyzed CDC data on the number of people screened by the Early Detection Program from calendar years 2011 through 2018—the most recent available. GAO also analyzed CMS Medicaid enrollment data from 2016 through 2019—the most recent available. Additionally, GAO reviewed a 2020 study funded by CDC that examines the number of people eligible for the Early Detection Program from 2011 through 2017. Finally, GAO interviewed CDC and CMS officials and reviewed relevant CDC and CMS documents. For more information, contact John E. Dicken, (202) 512-7114, dickenj@gao.gov.
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  • Farm Programs: USDA Should Take Additional Steps to Ensure Compliance with Wetland Conservation Provisions
    In U.S GAO News
    What GAO Found The U.S. Department of Agriculture's (USDA) Natural Resources Conservation Service (NRCS) has taken steps to increase the consistency of their determinations about where wetlands exist on farmers' lands. For example, NRCS state offices formed teams to make such determinations in the prairie pothole region (see fig.), which covers parts of Iowa, Minnesota, North Dakota, and South Dakota. These offices also standardized their wetland determination procedures and included more details, such as the types of data that can be used to identify wetland boundaries. Under wetland conservation provisions in federal law, to receive the benefits of certain USDA farm programs, farmers must not convert wetlands to cropland. Wetlands and Cropland in the Prairie Pothole Region NRCS's primary method to ensure compliance with wetland conservation provisions is conducting annual compliance checks of selected tracts of land for farmers in USDA programs. To select tracts, NRCS draws a national random sample. The sample is to include about 1 percent of tracts subject to wetland the provisions nationally, so many tracts are not sampled for years. For 2014 through 2018, NRCS identified fewer than five farmers with wetland conservation violations per year on the approximately 417,000 tracts in North Dakota and South Dakota—the states with the most wetland acres. Agency officials said NRCS has limited resources to conduct more checks. However, some USDA agencies emphasize risk-based criteria, rather than a random sample, in selecting tracts to check for compliance with other provisions. Doing so makes the checks more efficient by targeting the tracts most likely to have violations. If NRCS used a risk-based approach for its compliance checks (e.g., using information on acres cultivated annually on tracts), it could more efficiently ensure compliance with wetland conservation provisions. If NRCS finds violations, USDA's Farm Service Agency (FSA) may withhold program benefits from farmers, or it may grant waivers to farmers who acted in good faith, without intent to commit violations. FSA granted 243 of 301 requests for good-faith waivers from 2010 to 2018, according to FSA data. FSA relies on committees of fellow farmers to decide on waivers by considering factors such as prior violations. GAO found that some committees relied on weak justification to grant waivers even if farmers had prior violations and that FSA had not specified what is adequate justification. By specifying what constitutes adequate justification, FSA could better ensure it provides benefits only to eligible farmers. Why GAO Did This Study Wetlands perform vital ecological functions, and draining them can harm water quality and wildlife habitat. Many wetlands were drained for farming before enactment of wetland conservation provisions in 1985. However, millions of acres of wetlands, known as potholes, remain in the prairie pothole region. NRCS determines where wetlands exist on the land of farmers who participate in USDA farm programs, and it identifies violations of wetland provisions. FSA administers farm program benefits. In 2017, USDA's Office of Inspector General reported that NRCS had implemented wetland determination procedures in the prairie pothole region inconsistently. GAO was asked to review USDA's implementation of wetland conservation provisions in the prairie pothole region. This report examines, among other objectives, the steps NRCS has taken to increase the consistency of wetland determinations and the approaches NRCS and FSA use to ensure compliance with the provisions. GAO reviewed agency manuals, data, and files on wetland determinations and waivers, and interviewed agency officials and stakeholder groups.
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  • Indian Education: Schools Need More Assistance to Provide Distance Learning
    In U.S GAO News
    What GAO Found The Bureau of Indian Education (BIE), within the Department of the Interior (Interior), has not provided BIE-funded schools with comprehensive guidance on distance learning during the COVID-19 pandemic. In March 2020, BIE issued a short memo directing schools to “deliver flexible instruction” and “teach content,” but did not offer specific guidance on how to do so. In July 2020, 13 of the 25 schools that responded to GAO's survey said they wanted BIE to provide information on developing and implementing distance learning programs. In addition, 12 schools responded that they wanted information on distance learning methods for areas without broadband internet access. In August 2020, after some schools had already begun the school year, BIE issued a re-opening guide for the 2020-2021 school year. BIE's guidance focused primarily on preparations for in-person instruction at schools, although nearly all schools provided distance learning during the fall of 2020. The guidance contained little information on distance learning. Providing schools with comprehensive distance learning guidance will help them better navigate the current pandemic as well as potential future emergencies that lead to school building closures. BIE helped improve internet access for students at BIE-operated schools during the pandemic, but many students had not received laptops to access online learning by the end of fall 2020. BIE and other Interior offices provided over 7,000 hotspots to students to improve home internet access, but they did not order laptops for most students until September 2020. Interior officials said a nationwide IT supply shortage contributed to the delayed order for about 10,000 laptops. GAO found, however, that delays were also caused in part by BIE not having complete and accurate information on schools' IT needs. Most schools received laptops from late October 2020 to early January 2021, although some laptops still had not been delivered as of late March 2021. Once laptops were delivered, however, schools also faced challenges configuring them, leading to further delays in distributing them to students. BIE officials told GAO that to address schools' challenges with configuring laptops, they are assessing schools' IT workforce needs. Most BIE students did not receive laptops until months after the school year began, according to GAO's analysis of Interior information. Specifically, none of the laptops Interior ordered in early September 2020 arrived in time to distribute to students by the start of the school year in mid-September; by the end of December 2020, schools had not distributed over 80 percent of the student laptops Interior ordered; and as of late March 2021, schools had not distributed about 20 percent of the student laptops Interior ordered. Without accurate, complete, and up-to-date information on schools' IT needs, BIE was unable to ensure that students received laptops when they needed them. Establishing policies and procedures for assessing schools' IT needs would help guide the agency's IT purchases now and in the future, and position schools to integrate technology into their everyday curricula. Why GAO Did This Study BIE's mission is to provide quality education to approximately 41,000 students at 183 schools it funds on or near Indian reservations in 23 states. About two-thirds of these schools are operated by tribes and the remaining third are operated by BIE. In March 2020, all BIE schools closed their buildings in response to the COVID-19 pandemic. GAO reviewed distance learning at BIE schools as part of its oversight responsibilities under the CARES Act. This testimony examines the extent to which (1) BIE has provided schools with guidance to develop and implement distance learning programs during the COVID-19 pandemic, and (2) students have had the technology they need to participate in such programs. GAO analyzed the guidance BIE provided to schools on distance learning, examined BIE's provision of technology to schools and students, surveyed a non-generalizable sample of 30 schools—including 19 operated by tribes and 11 operated by BIE— with 25 schools responding, selected for geographic diversity and level of community broadband access, among other criteria, reviewed relevant federal statutes, regulations, and agency documentation, and interviewed BIE and school officials.
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  • Child Care: Subsidy Eligibility and Receipt, and Wait Lists
    In U.S GAO News
    An estimated 1.9 million children received child care subsidies in fiscal year 2017, representing approximately 14 percent of all children estimated to be eligible under federal rules – and 22 percent of all children estimated to be eligible under state rules -- in an average month. These figures are from the Department of Health and Human Services' (HHS) analysis of fiscal year 2017 data, the most recent year for which such analysis is available. Generally, fewer families qualify for subsidies under state eligibility rules than under federal eligibility rules since most states use flexibility provided by HHS to set their income eligibility limits below the federal maximum. Health and Human Services’ Estimated Number of Children Eligible Under Federal and State Rules, and Estimated Number Receiving Child Care Subsidies, Fiscal Year 2017 GAO found that the extent to which children who meet federal child care eligibility requirements also meet state eligibility requirements varies by state as does the share of eligible children who receive Child Care and Development Fund (CCDF) subsidies. Under state requirements, the CCDF subsidy receipt rate ranged from 5 percent to 32 percent of eligible children. Under federal requirements, the CCDF subsidy receipt rate ranged from 4 percent to 18 percent of federally eligible children. According to HHS estimates, among families who met federal child care eligibility criteria, children from lower-income families were more likely to receive child care subsidies compared to children from higher-income families. These estimates also showed that preschool-age children were more likely to receive subsidies compared to older, school-age children and that Black children were more likely to receive subsidies compared to children of other races / ethnicities. As reported in previous GAO work, states have varied strategies for managing their wait lists. Some states have a single statewide list while others have sub-state lists that allow sub-state areas to have their own policies. Some states conduct full or partial eligibility determinations prior to placing families on wait lists, and many states require periodic reviews of their wait lists. According to state administrators GAO interviewed, the strategies that states use to manage their wait lists pose certain challenges. For example, state administrators told GAO that sub-state lists can contain duplication, making state-wide estimates of families in need difficult. And administrators told GAO that maintaining up-to-date contact information is challenging, in part due to insufficient technology. The Coronavirus Disease 2019 (COVID-19) pandemic has impacted child care in several ways, including cost, eligibility and subsidy receipt, according to some members of the National Association of State Child Care Administrators (NASCCA). These members told GAO that despite initial declines in the number of families receiving subsidies, some states are seeing their child care costs increase due to, for example, more school-age children using full-day care; increased expenses for additional health and safety measures; paying for more absences and for parent co-pays; and families applying for subsidies for relative care. NASCCA members noted that some states have made changes to policies to help families and providers. To help families access child care, some states have increased income eligibility for subsidies to 85 percent of the state median income; temporarily waived work requirements to receive subsidies; and covered family fees for parents when a family must quarantine due to a COVID-19 exposure. Changes to some state policies aimed at helping providers include providing funds to providers to help with increased costs, such as personal protective equipment (PPE) and additional cleaning supplies; paying providers based on their pre-COVID-19 level authorized enrollments; and raising the state's provider reimbursement rate to help providers cover overhead costs. The federal child care subsidy program known as CCDF is one of the primary sources of federal funding dedicated to assisting low-income families with child care who are working or participating in education and training. Funding for CCDF, which is administered by HHS at the federal level, comes from two funding streams: discretionary funding in the form of block grants authorized by the Child Care and Development Block Grant (CCDBG Act) of 1990, as amended, and mandatory and matching funding authorized under section 418 of the Social Security Act. CCDF was appropriated more than $8 billion in federal funds in 2019. For more information, contact Kathryn Larin at (202) 512-7215 or larink@gao.gov.
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  • Retirement Security: Other Countries’ Experiences with Caregiver Policies
    In U.S GAO News
    For over a decade, Australia, Germany, and the United Kingdom (UK) have developed and implemented national approaches—including strategies, laws, and policies—to support family caregivers, according to experts GAO interviewed. Specifically, experts noted that these efforts could help caregivers maintain workforce attachment, supplement lost income, and save for retirement. As a result, their retirement security could improve. For example, experts said: Care leave allows employees to take time away from work for caregiving responsibilities. Australia's and Germany's policies allow for paid leave (10 days per year of work or instance of caregiving need, respectively), and all three countries allow for unpaid leave though the duration varies. Caregivers can receive income for time spent caregiving. Australia and the UK provide direct payments to those who qualify. Germany provides indirect payments, whereby the care recipient receives an allowance, which they can pass on to their caregiver. Other Countries' Policies to Support Caregivers Experts in all three countries cited some challenges with caregiver support policies. For example, paid leave is not available to all workers in Germany, such as those who work for small firms. In Australia and the UK, experts said eligibility requirements for direct payments (e.g., limits on hours worked or earnings) can make it difficult for someone to work outside their caregiving role. Experts in all three countries said caregivers may be unaware of available supports. For example, identifying caregivers is a challenge in Australia and the UK. As required under the RAISE Family Caregivers Act, the Department of Health and Human Services (HHS) convened the Family Caregiving Advisory Council (FCAC)—a stakeholder group that is to jointly develop a national family caregiving strategy. As of July 2020, HHS and the FCAC reported limited information on other countries' approaches, and neither entity had concrete plans to collect more. In September 2020, HHS officials provided sources they recently reviewed on selected policies in other countries, and they further noted that HHS staff, FCAC members, and collaborating partners have subject-matter expertise and bring perspectives about other countries' efforts into their discussions. Family caregivers play a critical role in supporting the elderly population, which is growing at a rapid rate worldwide. However, those who provide eldercare may risk their own long-term financial security. Other countries have implemented policies to support caregivers. In recognition of challenges caregivers face in the United States, Congress directed HHS, in consultation with other federal entities, to develop a national family caregiving strategy. GAO was asked to provide information about other countries' efforts that could improve the retirement security of parental and spousal caregivers. This report examines (1) other countries' approaches to support family members who provide eldercare, (2) challenges of these approaches, and (3) the status of HHS' efforts to develop a national family caregiving strategy. GAO conducted case studies of three countries—Australia, Germany, and the United Kingdom—selected based on factors including rates of informal care (i.e., help provided to older family members or friends) and the types of policies they have that could improve caregivers' retirement security. GAO interviewed government officials and experts and reviewed relevant federal laws, research, and documents. GAO's draft report recommended that HHS collect additional information about other countries' experiences. In response, in September 2020, HHS provided an update on its efforts to do so. As a result, GAO removed the recommendation and modified the report accordingly. For more information, contact Tranchau (Kris) T. Nguyen at or nguyentt@gao.gov.
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  • Financial Audit: Bureau of the Fiscal Service’s FY 2020 Schedules of the General Fund
    In U.S GAO News
    What GAO Found Deficiencies in internal control over financial reporting and other limitations on the scope of GAO's work resulted in conditions that prevented GAO from expressing an opinion on the Schedules of the General Fund as of and for the fiscal year ended September 30, 2020. Such scope limitations also prevented GAO from obtaining sufficient appropriate audit evidence to provide a basis for an opinion on the effectiveness of the Bureau of the Fiscal Service's (Fiscal Service) internal control over financial reporting relevant to the Schedules of the General Fund as of September 30, 2020. In addition, such scope limitations limited tests of compliance with selected provisions of applicable laws, regulations, contracts, and grant agreements for fiscal year 2020. Fiscal Service was unable to readily provide sufficient appropriate evidence to support certain information reported in the accompanying Schedules of the General Fund. Specifically, Fiscal Service was unable to readily (1) identify and trace General Fund transactions to determine whether they were complete and properly recorded in the correct general ledger accounts and line items within the Schedules of the General Fund and (2) provide documentation to support the account attributes assigned to Treasury Account Symbols that determine how transactions are reported in the Schedules of the General Fund. The resulting scope limitations, the first of which GAO reported in its fiscal year 2018 audit, are the basis for GAO's disclaimer of opinion on the Schedules of the General Fund. As a result of these limitations, GAO cautions that amounts Fiscal Service reported in the Schedules of the General Fund and related notes may not be reliable. Three significant deficiencies in Fiscal Service's internal control over financial reporting relevant to the Schedules of the General Fund, which GAO reported in its fiscal year 2018 audit, continue to exist. One of the continuing significant deficiencies contributed to the first scope limitation discussed above. In addition, GAO identified four other control deficiencies, three newly identified and one reported in its fiscal year 2018 audit, which GAO does not consider to be material weaknesses or significant deficiencies. Fiscal Service worked extensively, both internally and with other federal agencies, to address two scope limitations from GAO's fiscal year 2018 audit, such that GAO no longer considers these to be scope limitations for fiscal year 2020. Fiscal Service also (1) took action to close six of the 12 recommendations that GAO issued as a result of its fiscal year 2018 audit, (2) is implementing plans for remediating the remaining six recommendations over the next few years, and (3) plans to develop corrective actions for the three new recommendations issued in this report. Fiscal Service expressed its commitment to remediating the scope limitations and significant deficiencies reported for fiscal year 2020, acknowledging that it expects to take several years to resolve them, given the nature and complexity of certain identified issues. In addition, GAO is issuing a separate LIMITED OFFICIAL USE ONLY report on information systems controls. Why GAO Did This Study Because GAO audits the consolidated financial statements of the U.S. government and the significance of the General Fund of the United States (General Fund) to the government-wide financial statements, GAO audited the fiscal year 2020 Schedules of the General Fund to determine whether, in all material respects, (1) the schedules are fairly presented and (2) Fiscal Service management maintained effective internal control over financial reporting relevant to the Schedules of the General Fund. Further, GAO tested compliance with selected provisions of laws, regulations, contracts, and grant agreements related to the Schedules of the General Fund. As the reporting entity responsible for accounting for the cash activity of the U.S. government, in fiscal year 2020, the General Fund reported over $23 trillion of cash inflows and nearly $22 trillion of cash outflows. It also reported a budget deficit of $3.1 trillion, the largest recorded federal deficit in history. The CARES Act, enacted in March 2020, and other COVID-19 pandemic relief laws, contained a number of funding provisions that resulted in a significant increase in the cash activity and budget deficit reported by the General Fund during fiscal year 2020.
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    In U.S GAO News
    Literature GAO reviewed indicated that private insurance payments for anesthesia services on average were more than 3-1/2 times those of Medicare payments. This payment difference increased from what GAO reported in 2007—average private insurance payments for certain anesthesia services in 2004 were about 3 times those of Medicare. While Medicare rates for anesthesia services are set by the Centers for Medicare & Medicaid Services (CMS), private insurance rates are set through negotiations between providers and private insurers. GAO identified three recent studies with analyses of private insurance and Medicare payments for anesthesia services: Researchers from Yale University calculated that private insurance payments were 3.67 times Medicare payments, on average, for services provided by anesthesiologists for one large private insurer in 2015 operating across all 50 states and the District of Columbia. The Health Care Cost Institute calculated that in 2017 private insurance payments ranged from 2 to 7 times Medicare payments, on average, across six common services provided by anesthesiologists in 33 states. Wide state-to-state variation within specific services was reported. The American Society of Anesthesiologists reported that private insurance payments were 3.46 times Medicare payments, on average, based on a survey of its members in 2019. According to studies GAO reviewed and stakeholders GAO interviewed, market factors likely enhanced anesthesia providers' negotiating position and allowed them to secure higher private payments. For example, several studies and stakeholders cited market concentration as a key factor that increased private payments for anesthesia services. In a market with high provider concentration—or relatively few providers in a given market—there is little competition between providers, enabling the providers within that market to negotiate for higher payments from private insurers. Studies also indicated that specialists, including anesthesia providers, could negotiate higher in-network payment rates because they were able to leave an insurer's network with little risk of losing patients or revenue. In addition, when anesthesia providers are not a part of a private insurer's network, they are typically able to bill for a higher amount than the insurer would pay for an in-network provider, known as out-of-network billing. This dynamic decreases providers' incentives to participate in insurer networks because it creates an attractive alternative to network participation. GAO's interviews with stakeholders, literature review, and review of agency data generally did not indicate that the supply of anesthesia providers was insufficient for Medicare beneficiaries. CMS data indicate that the number of active anesthesia providers per 100,000 Medicare beneficiaries increased from 2010 through 2018 and that a very small number of anesthesia providers opted out of the Medicare program. Furthermore, researchers and stakeholders GAO interviewed were not aware of any issues with access to anesthesia services for Medicare beneficiaries, including those in traditionally underserved rural areas. In 2018, Medicare paid over $2 billion for anesthesia services, such as general anesthesia administered to beneficiaries undergoing surgical or other invasive procedures. The joint explanatory statement for the Further Consolidated Appropriations Act, 2020 included a provision for GAO to update its 2007 report and examine how differences in payment rates for anesthesia services have changed since that time. In 2007, GAO reported that Medicare payments in 2004 for certain anesthesia services provided by anesthesiologists were on average 67 percent lower than private insurance payments in certain geographic areas—indicating that private payments were about 3 times more than Medicare payments at that time. This report describes what is known about (1) recent trends in differences between Medicare and private payments for anesthesia services, and (2) the sufficiency of the supply of anesthesia providers for Medicare beneficiaries. GAO reviewed literature and available published data on payment differences for anesthesia services, published in the United States since 2010. GAO also reviewed data from CMS on the number of anesthesia providers from 2010, 2018, and 2020. GAO also interviewed a nongeneralizable selection of three research groups, two beneficiary advocacy groups, and five stakeholder groups, including those representing anesthesiologists, nurse anesthetists, and hospitals, to obtain their perspectives on these issues. The Department of Health and Human Services provided no comments on this report. For more information, contact Jessica Farb at (202) 512-7114 or farbj@gao.gov.
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  • Federalism: Opportunities Exist to Improve Coordination and Consultation with State and Local Governments
    In U.S GAO News
    Federal agencies' intergovernmental affairs activities advance agency objectives that require coordination with state and local governments. Most of the 24 Chief Financial Officers (CFO) Act agencies GAO surveyed reported undertaking similar information-sharing and coordination activities, such as serving as liaisons, conducting outreach, and hosting and attending events. The agencies GAO surveyed also reported taking varied approaches to structuring their intergovernmental affairs operations to conduct these activities. Of the 20 agencies with agency-wide intergovernmental affairs offices, half focused on intergovernmental affairs as their sole function while the other half included multiple functions, such as congressional or legislative affairs. How Agencies Organized Their Intergovernmental Affairs Operations Most agencies also reported that intergovernmental affairs activities and responsibilities were dispersed across their agencies. Regional and program offices perform intergovernmental affairs functions at some agencies, while others have an agency-wide office for them. Responsibilities for consulting with state and local governments under Executive Order (E.O.) 13132 also varied. The order requires that each federal agency designate an official to implement the order. Fourteen agencies reported having such an official; 10 did not report having one. Representatives from state and local associations GAO interviewed reported interacting with federal agency intergovernmental affairs offices for outreach and information-sharing purposes. They also cited coordination and consultation challenges, such as difficulty identifying intergovernmental affairs contacts, limited federal agency knowledge of state and local government, and inconsistent consultation on proposed regulations. The Office of Management and Budget (OMB) has primary responsibility for implementing E.O. 13132 and related implementation guidance, including a requirement for the designation of a federalism official. However, OMB could not identify any oversight steps it had taken to ensure federal agencies' designation of a federalism official consistent with its guidance for implementation of the executive order. Taking steps to ensure federal agencies' designation of a federalism official could help ensure that agencies have an accountable process in place for appropriately consulting with state and local governments. Federal programs fulfilling national goals in education, health care, transportation infrastructure, and homeland security, among other issues, are implemented through a complex partnership between federal, state, and local governments. E.O. 13132, Federalism, outlines principles and criteria to guide the formulation and implementation of policies and the appropriate division of responsibilities between levels of government. GAO was asked to review intergovernmental affairs activities at executive branch agencies. This report (1) identifies intergovernmental affairs offices' key responsibilities and activities at selected federal agencies and how these offices are organized, and (2) assesses state and local government officials' interaction with intergovernmental affairs offices, including their reported strengths and challenges. GAO examined relevant policies and executive orders and surveyed officials from the 24 CFO Act agencies. GAO also interviewed a nongeneralizable sample of individuals from 10 associations representing state and local government officials. GAO is recommending that OMB ensure that federal agencies implement its guidance on agency adherence to E.O. 13132 requirements, particularly related to designating a federalism official. OMB neither agreed nor disagreed with the recommendation. For more information, contact Michelle Sager at (202) 512-6806 or sagerm@gao.gov.
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  • Secretary Michael R. Pompeo With Tony Perkins of Washington Watch with Tony Perkins
    In Crime Control and Security News
    Michael R. Pompeo, [Read More…]