Disaster Housing: Improved Cost Data and Guidance Would Aid FEMA Activation Decisions

What GAO Found

The Federal Emergency Management Agency (FEMA) relied primarily on rental assistance payments to assist 2017 and 2018 hurricane survivors but also used direct housing programs to address housing needs, as shown in the table below. GAO found that FEMA provided rental assistance to about 746,000 households and direct housing assistance to about 5,400 households. FEMA did not use the Disaster Housing Assistance Program (DHAP)—a pilot grant program managed jointly with the Department of Housing and Urban Development (HUD)—because FEMA viewed its direct housing programs to be more efficient and cost-effective and did not consider DHAP to be a standard post-disaster housing assistance program.

Number of Households Affected by the 2017 and 2018 Hurricanes That Received Rental and Direct Temporary Housing Assistance, by State or Territory

State or territory

Rental assistance

Direct housing assistance

Florida

422,230

1,241

North Carolina

20,198

656

Puerto Rico

147,620

414

Texas

143,465

2,988

U.S. Virgin Islands

12,147

69

Total number of households

745,660

5,368

Source: Federal Emergency Management Agency (FEMA). | GAO-21-116

Notes: FEMA provided the vast majority of its direct housing assistance through transportable temporary housing units such as manufactured housing. Rental assistance data are as of February 13, 2020, and direct housing assistance data are as of July 15, 2020.

FEMA’s analyses of the cost-effectiveness of housing assistance programs were limited because program cost data were incomplete or not readily useable. The Robert T. Stafford Disaster Relief and Emergency Assistance Act requires FEMA to consider factors including cost-effectiveness when determining which types of housing assistance to provide. Although FEMA has stated its direct housing programs were relatively more cost-effective than DHAP, FEMA generally could not support these statements with cost data. Specifically, FEMA does not collect key program data in its system, such as monthly subsidy and administrative costs, in a manner that would allow it to analyze the full costs of providing the assistance. Without such information, the agency’s program activation decisions will not be well informed, particularly with regard to cost-effectiveness. FEMA policy guidance also says that FEMA is to compare the projected costs of the direct housing programs it is considering activating, but does not consistently specify what cost information to consider, such as whether to use both programmatic and administrative costs. Without such guidance, FEMA cannot reasonably assure that its assessments and their results incorporate consistent and comparable data.

Why GAO Did This Study

The 2017 and 2018 hurricanes (Harvey, Irma, Maria, Florence, and Michael) caused $325 billion in damage. FEMA provided post-disaster assistance, including rental and direct housing assistance. DHAP was a pilot grant program that provided temporary rental assistance and was used to respond to several hurricanes before 2017.

GAO was asked to review issues related to major disasters in 2018 and housing assistance provided after the 2017 and 2018 hurricanes. This report (1) describes the assistance FEMA provided in response to those hurricanes, and (2) evaluates the extent to which FEMA considered cost-effectiveness in activating programs.

GAO reviewed FEMA and HUD policies, communications, and other documentation; analyzed FEMA data; and interviewed officials at FEMA headquarters and regional offices, HUD, and Texas state and local government offices.

What GAO Recommends

GAO makes two recommendations to FEMA for its temporary housing programs: (1) identify and make changes to its data systems to allow for capture and analysis of programs’ full costs, and (2) specify the information needed to compare projected program costs in its guidance on activating programs. DHS agreed with both recommendations, and said it planned to implement them in 2021–2022.

For more information, contact John Pendleton at (202) 512-8678 or pendletonj@gao.gov.

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    The Department of Defense (DOD) has a general expectation that its health care beneficiaries, upon receiving an urgent referral to see a specialist, will access that specialty care in 3 days or less. GAO's analysis of 16,754 urgent referrals at military treatment facilities (MTF) shows that DOD beneficiaries accessed specialty care services in 3 days or less for more than half of the urgent referrals. About 9 percent of the urgent referrals involved beneficiaries waiting 3 weeks or longer to be seen. According to DOD officials, some beneficiaries may have waited longer than 3 days due to factors such as patient preference, appointment availability, or waiting for lab results. Time to access care varied by specialty, with beneficiaries urgently referred to ophthalmology generally seeing a specialist the fastest, and those urgently referred to mental health and oncology generally waiting the longest. According to DOD officials, MTFs are responsible for monitoring beneficiaries' access to specialty care through urgent referrals. GAO found that the monitoring processes used varied by MTF and specialty care clinic at the five selected MTFs that GAO reviewed. For example, officials from one MTF told GAO they centrally manage all urgent referrals using a daily report to address any delays, while officials from another MTF told GAO that individual specialty care clinics are responsible for managing their own urgent referrals. DOD officials acknowledged such variation and MTFs have been directed to centralize their referral management and monitoring processes—an effort that is currently underway. GAO found that DOD monitors the rates at which beneficiaries receive timely and effective care, in part, through 10 outpatient health care quality measures. These measures allow DOD to make comparisons to civilian health care systems, and they are reviewed by various DOD groups at least quarterly. However, DOD officials told GAO that since October 2017, they have been unable to monitor nine of the 10 measures for MTFs using Military Health System (MHS) Genesis, DOD's new electronic health record system. According to the officials, DOD's current data warehouse—a system that stores some MHS Genesis data and can be used by MTFs to create reports on quality measures—is not capable of producing accurate reports for those measures. DOD officials told GAO they expect to implement a new data warehouse by the end of 2020. DOD officials also said they are importing data related to quality measures into another system used for quality monitoring; however, DOD does not have a targeted date for completing these data imports. Until these actions are fully implemented, groups responsible for monitoring quality care will continue to lack the data needed to offer assurance that the growing number of MTFs using MHS Genesis are providing beneficiaries with timely and effective care that will lead to better health outcomes. A draft of this report recommended that DOD establish a timeline to complete importing the quality measure-related data from MHS Genesis into DOD's system used for quality monitoring. In its review of the draft, DOD concurred with the recommendation and established a timeline for importing the data, to be available in DOD's system no later than May 2021. After reviewing the information DOD provided, GAO removed the recommendation from the final report. DOD is responsible for ensuring that beneficiaries have access to specialty care for conditions that, while not life-threatening, require immediate attention, as well as for ensuring that beneficiaries receive timely and effective care for certain routine or other services. A report accompanying the National Defense Authorization Act for Fiscal Year 2020 included a provision for GAO to review the quality of health care in the MHS. This report examines (1) the timeliness with which beneficiaries access specialty care at MTFs through urgent referrals and DOD's efforts to monitor access, and (2) DOD's use of quality measures to monitor and improve the rates of timely and effective care received by beneficiaries at MTFs. GAO examined relevant policies, national DOD referral data (a total of 16,754 urgent referrals) for a 1-year period ending August 2019, and the most recent available quality measure data (April 2020). GAO interviewed officials from five MTFs, selected for variation in military services, geography, provision of select specialty services, and use of the electronic health record system. For more information, contact Debra A. Draper at (202) 512-7114 or draperd@gao.gov.
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    In U.S GAO News
    The U.S. Patent and Trademark Office (USPTO) offers multiple programs that help small businesses and inventors with acquiring intellectual property protections, which can help protect creative works or ideas. These programs, such as the Inventors Assistance Center, are aimed at assisting the public, especially small businesses and inventors, with intellectual property protections. Several stakeholders GAO interviewed said that USPTO programs have been helpful, but they were also not aware of some USPTO programs. Although these programs individually evaluate how they help small businesses and inventors, the agency does not collect and evaluate overall information on whether these programs are effectively reaching out to and meeting the needs of these groups. Under federal internal control standards, an agency should use quality information to achieve its objectives. Without an agency-wide approach to collect information to help evaluate the extent to which its programs serve small businesses and inventors, USPTO may not have the quality information needed to fully evaluate the effectiveness of its outreach and assistance for these groups and thus make improvements where necessary. Although the Small Business Administration (SBA) coordinates with USPTO through targeted efforts to provide intellectual property training to small businesses, it has not fully implemented some statutory requirements that can further enhance this coordination. While SBA and the Small Business Development Centers (SBDCs) coordinate with USPTO programs at the local level to train small businesses on intellectual property protection (see figure), this coordination is inconsistent. For example, two of the 12 SBDCs that GAO interviewed reported working primarily with USPTO to help small businesses protect their intellectual property, but the other 10 did not. The Small Business Innovation Protection Act of 2017 requires SBA and USPTO to coordinate and build on existing intellectual property training programs, and requires that SBA's local partners, specifically the SBDCs, provide intellectual property training, in coordination with USPTO. SBA officials reported that they are in the process of implementing requirements of this act. Incorporating selected leading practices for collaboration, such as documenting the partnership agreement and clarifying roles and responsibilities, could help SBA and USPTO fully and consistently communicate their existing resources to their partners and programs, enabling them to refer these resources to small businesses and inventors. Figure: The Small Business Administration (SBA) and the U.S. Patent and Trademark Office (USPTO) Coordinate at the Local Level, but Are Inconsistent Small businesses employ about half of the U.S. private workforce and create approximately two-thirds of the nation's jobs. For many small businesses, intellectual property aids in building market share and creating jobs. Among the federal agencies assisting small businesses with intellectual property are USPTO, which grants patents and registers trademarks, and SBA, which assists small businesses on a variety of business development issues, including intellectual property. GAO was asked to review resources available to help small businesses and inventors protect intellectual property, and their effectiveness. This report examines, among other things, (1) the extent to which USPTO evaluates the effectiveness of its efforts to assist small businesses and (2) SBA's coordination with USPTO to assist small businesses. GAO analyzed agency documents and interviewed officials who train and assist small businesses. GAO also interviewed stakeholders, including small businesses, and, among other things, reviewed federal internal control standards and selected leading practices for enhancing interagency collaboration. GAO is making four recommendations, including that USPTO develop an agency-wide approach to evaluate the effectiveness of its efforts to help small businesses and inventors, and that SBA document its partnership agreement with USPTO and clarify roles and responsibilities for coordinating with USPTO to provide training. Both agencies agreed with GAO's recommendations. For more information, contact John Neumann, (202) 512-6888, NeumannJ@gao.gov. 
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    GAO found that the Patient-Centered Outcomes Research Institute (PCORI)—a federally funded, nonprofit corporation—and the Department of Health and Human Services (HHS) have continued to perform comparative clinical effectiveness research (CER) activities required by law since our prior report issued in 2015. CER evaluates and compares health outcomes, risks, and benefits of medical treatments, services, or items. The requirements direct PCORI and HHS to, among other things, fund CER and disseminate and facilitate the implementation of CER findings. GAO's analysis of PCORI and HHS documents show that they allocated a total of about $3.6 billion for CER activities and program support during fiscal years 2010 through 2019 from the Patient Centered Outcomes Research Trust Fund (Trust Fund). Specifically, PCORI allocated about $2 billion for research awards and another $542 million for other awards, to be paid over multiple years. HHS allocated about $598 million for activities such as the dissemination and implementation of CER findings. PCORI and HHS also allocated about $470 million for program support. PCORI and HHS Allocations for Comparative Clinical Effectiveness Research (CER) Activities, Fiscal Years 2010 through 2019 aTotals may not add up due to rounding. bPCORI and HHS allocated $457 million and $13 million for program support, respectively. PCORI assessed the effectiveness of its activities using performance measures and targets. Since fiscal year 2017, when early CER projects were completed, PCORI officials reported that the institute met its performance targets, such as an increased number of research citations of its CER findings in news and online sources. HHS described accomplishments or assessed the effectiveness of its dissemination and implementation activities. PCORI and HHS officials told GAO they are planning comprehensive evaluations of their CER dissemination and implementation activities as part of their strategic plans for the next 10 years. The 2010 Patient Protection and Affordable Care Act (PPACA) authorized establishment of PCORI to conduct CER and improve its quality and relevance. PPACA also established new requirements for HHS to, among other things, disseminate findings from federally funded CER and coordinate federal programs to build data capacity for this research. To fund CER activities, PPACA established the Trust Fund, which provided a total of about $3.6 billion to PCORI and HHS for CER activities during fiscal years 2010 through 2019. The Further Consolidated Appropriations Act, 2020, added new CER requirements and extended funding at similar levels through fiscal year 2029. PPACA and the Appropriations Act 2020 included provisions that GAO review PCORI and HHS's CER activities. This report describes (1) the CER activities PCORI and HHS carried out to meet legislative requirements, (2) how PCORI and HHS allocated funding to those CER activities, and (3) PCORI and HHS efforts to evaluate the effectiveness of their CER dissemination and implementation activities, such as changes in medical practice. GAO reviewed legislative requirements and PCORI and HHS documentation and data for fiscal years 2010-2019. GAO also interviewed PCORI and HHS officials and obtained information from nine selected stakeholder groups that were familiar with PCORI's or HHS's CER activities. These groups included payer, provider, and patient organizations. GAO incorporated technical comments from PCORI and HHS as appropriate. For more information, contact John Dicken at (202) 512-7114 or dickenj@gao.gov.
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  • Federal Employees’ Compensation Act: Comparisons of Benefits in Retirement and Actions Needed to Help Injured Workers Choose Best Option
    In U.S GAO News
    Factors such as the timing of an injury in a career affect how Federal Employees' Compensation Act (FECA) total disability benefits compare to income security from typical federal retirement. The FECA program compensates federal employees for lost wages from work-related injuries, among other benefits. FECA recipients can receive this compensation for as long as their disability continues. At retirement age, they can remain on FECA or, instead, choose to receive their benefits from the Federal Employees Retirement System (FERS). Thus, FECA benefits represent a significant portion of retirement income for some injured federal employees. Through simulations, GAO found that factors such as the length of retirees' careers absent injury affected how similar their hypothetical FECA benefits packages were to their FERS packages in 2018. FERS benefits increase substantially the longer a federal employee works. As a result, median current and reduced FECA packages were greater than the FERS median for retirees with shorter careers absent injury. However, median FECA packages were similar to or less than FERS for retirees with longer careers (see figure). Median FECA Benefits as a Percentage of FERS Benefits by Career Length Absent an Injury For FECA recipients who choose to compare their FECA and FERS benefit options at retirement, estimates for most components of those benefits packages are available. However, the Department of Labor (DOL) does not routinely remind recipients to compare benefits, so they may be unaware of their options or how to consider them. In addition, DOL and the Social Security Administration (SSA) use a manual and highly complex process to calculate one key component of a FECA recipient's compensation in retirement related to Social Security benefits. As a result, estimates of FECA benefits in retirement that include this component are not readily available prior to retirement. These challenges hinder recipients' ability to accurately compare their options and may result in some recipients not choosing their best option at retirement. The President's budgets for fiscal years 2019-2021 have proposed several FECA reforms, including reducing disability compensation at retirement age. In a series of reports published in 2012, GAO analyzed the effects of similar proposed revisions to FECA compensation. GAO was asked to update its FECA and FERS benefit comparisons. This report examines (1) how FERS and total disability FECA benefits at retirement age compare under current and previously proposed reduced FECA compensation rates, and (2) the extent to which FECA recipients have access to information to compare their FECA and FERS benefits options. GAO compared the FERS benefits selected retirees received in 2018 with the hypothetical total disability FECA benefits they would have received from simulated injuries. GAO reviewed agency documents and interviewed officials from DOL, SSA, and other federal agencies. GAO is recommending that DOL remind FECA recipients as they approach retirement to obtain FERS benefit estimates for comparisons with FECA, and that DOL and SSA take steps to modernize and improve their process for calculating and providing information on certain FECA benefits in retirement that would enable recipients to make complete comparisons of retirement options. DOL and SSA concurred with all three recommendations. For more information, contact Cindy Brown Barnes at (202) 512-7215 or brownbarnesc@gao.gov.
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    In U.S GAO News
    According to Substance Abuse and Mental Health Services Administration (SAMHSA) data, the number of substance use disorder (SUD) treatment facilities and services increased since 2009. However, potential gaps in treatment capacity remain. For example, SAMHSA data show that, as of May 2020, most counties did not have all levels of SUD treatment available, including outpatient, residential, and hospital inpatient services; nearly one-third of counties had no levels of treatment available. Stakeholders GAO interviewed said it is important to have access to each level for treating individuals with varying SUD severity. Availability of Substance Use Disorder Treatment Levels, by County, as of May 2020 SAMHSA primarily relies on the number of individuals served to assess the effect of three of its largest grant programs on access to SUD treatment and recovery support services. However, GAO found the agency lacks two elements of reliable data—that they be consistent and relevant—for the number of individuals served under the Substance Abuse Prevention and Treatment Block Grant (SABG) program. For example, grantee reporting includes individuals served outside of the program, which limits this measure's relevance for program assessment of access. SAMHSA plans to implement data quality improvements for the SABG program starting in fiscal year 2021. However, the agency has not identified specific changes needed to improve the information it collects on individuals served. As SAMHSA moves forward with its plans, it will be important for it to identify and implement such changes. Doing so will allow SAMHSA to better assess whether the SABG program is achieving a key goal of improving access to SUD treatment and recovery services or whether changes may be needed. Treatment for SUD—the recurrent use of substances, such as illicit drugs, causing significant impairment—can help individuals reduce or stop substance use and improve their quality of life. SUDs, and in particular drug misuse, have been a persistent and long-standing public health issue in the United States. Senate Report 115-289 contains a provision for GAO to review SUD treatment capacity. This report, among other things, describes what is known about SUD treatment facilities, services, and overall capacity; and examines the information SAMHSA uses to assess the effect of three grant programs on access to SUD treatment. GAO analyzed national SAMHSA data on SUD treatment facilities and providers, and reviewed studies that assessed treatment capacity. GAO also reviewed documentation for three of SAMHSA's largest grant programs available to states, and compared the agency's grant data quality to federal internal control standards. Finally, GAO interviewed SAMHSA officials and stakeholders, including provider groups. GAO is recommending that SAMHSA identify and implement changes to the SABG program's data collection efforts to improve two elements of reliability—the consistency and relevance—of data collected on individuals served. SAMHSA concurred with this recommendation. For more information, contact Alyssa M. Hundrup at (202) 512-7114 or HundrupA@gao.gov.
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