What GAO Found The Departments of State and Defense (DOD) are the primary U.S. agencies responsible for managing the sale or transfer of U.S. defense articles, such as weapons and equipment. The transfer of these articles to other countries is governed by laws and policies, including human rights requirements. U.S. law generally prohibits assistance to any country where the government consistently violates internationally recognized human rights. In 2023, the Biden administration updated its arms transfer policy to place a greater emphasis on human rights and require U.S. agencies to conduct “appropriate monitoring” to ensure arms are used responsibly. In 2024, the Biden administration required State to obtain additional assurances from recipients that they will respect human rights obligations. State did not pause any arms transfers as a result of these updated policies. Agency processes do not fully address the risk that recipients may use transferred U.S. defense articles to commit human rights abuses. Existing agency processes, such as vetting recipients and verifying custody of transferred defense articles, address aspects of this risk. Since 2023, State and DOD have also developed processes to respond to reports of civilian harm—including human rights abuses—involving U.S. defense articles. In response to a GAO recommendation, State developed a process called the Civilian Harm Incident Response Guidance, but it does not allow reports from non-U.S. government parties. For example, State received 617 civilian harm reports from August 2023 to December 2024. However, non-U.S. government parties such as the United Nations have identified thousands of civilian harm incidents resulting from the Israel-Hamas conflict alone. Incorporating external reports into its response process would give State a fuller picture of the scope of civilian harm incidents. Further, as of December 2024, State had not completed any investigations into reports it deemed credible. State officials said they needed additional resources to manage this workload. By developing and implementing a strategy to identify appropriate staffing and resources for the process, State could investigate the full scope of reported incidents in a more timely manner. U.S. Defense Articles Delivered to Israel in October 2023 Why GAO Did This Study The United States is the world's largest provider of defense articles to other nations. State and DOD have jointly approved over $100 billion in transfers annually. Public reports have raised concerns that recipients may be using U.S. defense articles in activities that violate human rights. House Report 118-125 includes a provision for GAO to review laws and policies related to transfers of defense articles and human rights as well as efforts to conduct monitoring of potential human rights violations involving U.S. defense articles. This report examines (1) laws and policies related to human rights and the transfer or use of U.S. defense articles and (2) the extent to which agencies mitigate and respond to the risk that U.S. defense articles may be involved in human rights violations. GAO analyzed relevant laws, policies, guidance, and State and DOD information on monitoring and civilian harm response processes. GAO also interviewed agency officials.

What GAO Found The Department of Defense's (DOD) Defense Health Agency (DHA) has 13 contracts with private sector companies to provide TRICARE health, dental, and pharmacy benefits generally through networks of civilian providers. Current TRICARE Contracts for Health, Dental, and Pharmacy Benefits GAO identified changes in the key characteristics of these current contracts compared with the prior version of these contracts that had recently ended. For example, 11 of the 13 current contracts had an increase in their total contract value at the time of award (i.e., the sum value of the contract's base period including all option years). GAO found various reasons that contributed to the higher award values, including changes in geographic service areas and longer periods of performance. DHA officials also told GAO that health care costs have increased significantly over the last 10 years due to inflation and the COVID-19 pandemic. GAO also found that seven of the 13 TRICARE contracts were competitively awarded and of those, four received fewer bids for the current contracts compared with the prior contracts. The remaining three competitively awarded contracts received the same number of bids for the current and prior contracts, with one contract receiving a single bid each time. In addition, DHA awarded six of the seven contracts to the incumbent contractors. Why GAO Did This Study DOD offers health care services to over 9 million eligible beneficiaries through its TRICARE program. TRICARE beneficiaries may obtain care through either military medical treatment facilities, including medical centers, hospitals, and clinics or through the private sector care system of civilian providers. Within DOD, DHA is responsible for TRICARE, including the award, administration, and oversight of 13 health, dental, and pharmacy contracts used to provide care and services through civilian providers. As of September 30, 2024, these current contracts were collectively valued at about $168 billion. The James M. Inhofe National Defense Authorization Act for Fiscal Year 2023 includes a provision for GAO to report on key characteristics of certain contracts related to the TRICARE program. Some of these key characteristics include total contract values, the products or services procured, and health care or service delivery time frames. Among other things, this report describes changes in the key characteristics between the current and prior TRICARE health, dental, and pharmacy contracts. GAO analyzed DHA documentation for the current and prior TRICARE contracts for health, dental, and pharmacy benefits. In addition, GAO reviewed data from the Federal Procurement Data System. GAO also interviewed DHA officials responsible for each of the TRICARE contracts. For more information, contact Sharon M. Silas at SilasS@gao.gov.

What GAO Found Levees are man-made structures, such as earthen embankments or concrete floodwalls, that play a vital role in reducing the risk of flooding. The National Levee Database contains critical information for all known levees nationwide. Such information includes a levee’s location and condition as well as the population and number of vulnerable structures behind a levee should a levee fail or be overtopped with floodwaters. The U.S. Army Corps of Engineers(Corps) and the Federal Emergency Management Agency (FEMA) update data in the National Levee Database on an ongoing basis, typically in conjunction with scheduled levee inspections and efforts to map flood risks, respectively. The Corps and FEMA routinely share information from the database. Corps Inspector Using a Mobile Device to Record Levee Information According to FEMA officials, data updates regarding levee conditions may not substantially affect the cost of insurance premiums for those participating in the National Flood Insurance Program (NFIP), which FEMA administers. This is because the premiums are based on multiple factors, including geographical, structural, and policy variables, such as distance from the flooding source, type of structure impacted, and amount of insurance coverage requested by policyholders. Moreover, the premiums remain in effect until policies are due for renewal, and annual increases are generally limited by statute. GAO found that the Corps does not typically rely on data in the National Levee Database for analyzing the benefits and costs associated with flood risk management activities, including levees. The Corps obtains the information it needs from other entities, such as state and local governments, that operate and maintain federally authorized levees. Why GAO Did This Study The Corps established the National Levee Database—the first centralized repository of information on the nation’s levees––in the aftermath of destructive levee failures during Hurricanes Katrina and Rita in 2005. The database was established under the National Levee Safety Act of 2007 and became publicly available in 2011. The database is intended to help decision-makers better understand the scope of the nation’s levees, including their location and condition. The database also provides other benefits, such as supporting community preparedness and quantifying the nation's flood exposure. Corps and FEMA each have roles and responsibilities regarding the levee database. For example, the Corps hosts the database, which contains information on levees managed by the Corps as well as other entities. The Corps works in partnership with FEMA, which populates and maintains certain information in the database including data related to NFIP. This program makes flood insurance available to property and business owners located in communities that participate in the program by adopting minimum floodplain standards. This report provides information on how the Corps and FEMA enter, share, and use levee information in the database. For more information, contact Cardell D. Johnson at JohnsonCD1@gao.gov.

What GAO Found Sepsis is a life-threatening condition caused by an extreme response to an infection in the body and typically requires hospital care. GAO's analysis of Defense Health Agency data indicates that the number of inpatient admissions at military medical treatment facilities that involved sepsis was relatively consistent from fiscal year 2017 through fiscal year 2023. These admissions accounted for more than 15,000 (about 1 percent) of the almost 1.3 million total inpatient admissions for this 7-year period. Further, for 86 percent of the admissions involving sepsis, the condition was present when the patient was admitted. The Defense Health Agency formed a Sepsis Working Group in 2021 to standardize efforts related to sepsis detection, diagnosis, and treatment across military medical treatment facilities. In February 2025, the Defense Health Agency released a policy memorandum developed by the Sepsis Working Group. This memorandum establishes a sepsis strategy in the military medical treatment facilities, referencing national standards and guidelines, such as the Centers for Disease Control and Prevention's Hospital Sepsis Program Core Elements and the Surviving Sepsis Campaign guidelines. The Defense Health Agency tracks information on four sepsis-related quality measures. For these measures, military medical treatment facilities generally performed comparable to, or better than, the benchmark rates for all hospitals applicable to calendar year 2023. For example, military medical treatment facilities performed comparable to, or better than, the benchmark rates for all hospitals for measures pertaining to patients receiving appropriate care for sepsis in hospital settings, the death rate among surgical inpatients with sepsis as a serious treatable complication, and the rate of postoperative sepsis. Staff GAO interviewed at selected military medical treatment facilities did not report experiencing any major challenges specific to sepsis diagnosis and treatment. Why GAO Did This Study  The Department of Defense is responsible for providing health care to approximately 9.4 million beneficiaries, including care that could involve the diagnosis and treatment of sepsis. The department's Defense Health Agency coordinates the delivery of these health services, in part through care provided at agency-operated military medical treatment facilities. The House Report accompanying the National Defense Authorization Act for Fiscal Year 2024 includes a provision for GAO to report on various issues related to sepsis within the Department of Defense. This report describes admissions involving sepsis at military medical treatment facilities and sepsis management efforts within the Defense Health Agency, including what entities focus on sepsis, what information is tracked, and selected military medical treatment facility experiences with sepsis diagnosis and treatment. To conduct this work, GAO analyzed Defense Health Agency data on inpatient admissions involving sepsis at military medical treatment facilities from fiscal year 2017 through fiscal year 2023—the most recent data available. GAO also reviewed information on sepsis-related quality measures tracked by the Defense Health Agency and facilities' performance on these measures. GAO interviewed and obtained information from Defense Health Agency officials and staff from selected military medical treatment facilities, which were selected for variation in the number of sepsis cases treated, inpatient bed capacity, affiliated service branch, and geography. For more information, contact Alyssa M. Hundrup at HundrupA@gao.gov.

What GAO Found Generative artificial intelligence (AI) could revolutionize entire industries. In the nearer term, it may dramatically increase productivity and transform daily tasks in many sectors. However, both its benefits and risks, including its environmental and human effects, are unknown or unclear. Generative AI uses significant energy and water resources, but companies are generally not reporting details of these uses. Most estimates of environmental effects of generative AI technologies have focused on quantifying the energy consumed, and carbon emissions associated with generating that energy, required to train the generative AI model. Estimates of water consumption by generative AI are limited. Generative AI is expected to be a driving force for data center demand, but what portion of data center electricity consumption is related to generative AI is unclear. According to the International Energy Agency, U.S. data center electricity consumption was approximately 4 percent of U.S. electricity demand in 2022 and could be 6 percent of demand in 2026. While generative AI may bring beneficial effects for people, GAO highlights five risks and challenges that could result in negative human effects on society, culture, and people from generative AI (see figure). For example, unsafe systems may produce outputs that compromise safety, such as inaccurate information, undesirable content, or the enabling of malicious behavior. However, definitive statements about these risks and challenges are difficult to make because generative AI is rapidly evolving, and private developers do not disclose some key technical information. Selected generative artificial antelligence risks and challenges that could result in human effects GAO identified policy options to consider that could enhance the benefits or address the challenges of environmental and human effects of generative AI. These policy options identify possible actions by policymakers, which include Congress, federal agencies, state and local governments, academic and research institutions, and industry. In addition, policymakers could choose to maintain the status quo, whereby they would not take additional action beyond current efforts. See below for details on the policy options. Policy options that could enhance the benefits or address the challenges of environmental and human effects of generative artificial intelligence (AI). Policy Option Example implementation approaches Opportunities and considerations 4.1 Environmental Effects Maintain status quo (report page 29) Continue technical innovations in hardware. Continue technical innovations in algorithms and models. Continue current federal agency efforts. Technical innovations may address some challenges described in this report without additional resources. Current efforts may not fully address the challenges described in this report, given the existing knowledge gaps and uncertain future demand of generative AI. Improve data collection and reporting (report page 29) Encourage industry to share the environmental effects of building and disposing of their equipment. Developers could provide information such as model details, infrastructure used for training and using generative AI, energy consumption, carbon emissions, and water consumption. Efforts to address gaps in understanding of environmental effects can assist policymakers in identifying specific environmental effects to address. Industry and developers may not wish to release information they view as proprietary. As generative AI becomes integrated into industry products and services, differentiating between energy and water use by generative AI, other AI, and non-AI capabilities could be difficult. Encourage innovation (report page 30) Government could encourage developers and researchers to create more resource-efficient models and training techniques. Industry and researchers could increase efforts to develop more efficient hardware and infrastructure to reduce energy and water use. Development of technical methods to reduce environmental effects may need improved data collection and reporting by industry. Industry may resist developing new innovations until development, engineering, and economic costs are better understood. 4.2 Human Effects Maintain status quo (report page 30) Government policymakers are taking various policy actions to begin efforts aimed at understanding and addressing human effects of artificial intelligence. Existing policy actions relevant to AI in general, some of which are not fully implemented, may not fully address the specific human effects of generative AI challenges identified in this report Encourage use of AI frameworks (report page 31) Developers could create acceptable use policies that inform a product’s user community of policies they must adhere to while using the developer’s product. Government could encourage the use of available frameworks, such as GAO’s AI Accountability Framework and National Institute of Standards and Technology’s AI Risk Management Framework. Developers can use these frameworks to manage risks and challenges of generative AI development and use and to increase public transparency and other trustworthiness characteristics. Internal testing and external, independent review methods applying frameworks may be insufficient, costly, and time-consuming. Available frameworks may not sufficiently address human effects brought by new technology developments in generative AI. Share best practices and establish standards (report page 32) Industry or other standards-developing organizations could identify the areas in which best practices and standards would be most beneficial across different sectors or applications that use generative AI technologies. This could require adoption of knowledge sharing mechanisms to share best practices for the management of human effects challenges. Consensus from many public- and private-sector stakeholders can be time- and resource-intensive. Source: GAO. | GAO-25-107172 Why GAO Did This Study Generative AI uses large amounts of energy and water. Additionally, generative AI may displace workers, help spread false information, and create or elevate risks to national security. The benefits and risks of generative AI are unclear, and estimates of its effects are highly variable because of a lack of available data. The continued growth of generative AI products and services raises questions about the scale of benefits and risks. GAO was asked to conduct a technology assessment of generative AI effects, particularly its risks. GAO examined: (1) potential environmental effects of generative AI technologies, (2) potential human effects of generative AI technologies, and (3) what policy options exist to enhance the benefits or mitigate the environmental and human effects of generative AI technologies For more information, contact Brian Bothwell at BothwellB@gao.gov or Kevin Walsh at WalshK@gao.gov.

What GAO Found The Department of Defense's (DOD) Defense Health Agency (DHA) oversees the TRICARE program that provides health care to beneficiaries—active-duty service members and their dependents. Beneficiaries receive care in military medical treatment facilities (direct care) and through civilian providers, generally administered by two managed care support contractors (private sector care). This care includes addressing mental health conditions that occur during and up to 1 year after pregnancy, known as the perinatal period. GAO estimates that 52 percent of the 6,151 service members who delivered through direct care in fiscal year 2022 received DHA's three recommended perinatal mental health screenings. These screenings used one of two DHA-recommended tools and were performed at DHA's specified time intervals. All service members were screened at least once during their perinatal period. Estimated Percentage of Service Members Screened for Perinatal Mental Health Conditions in Direct Care, Fiscal Year 2022 Note: The percentages in the figure represent those screenings that were conducted in accordance with DHA recommendations. GAO reviewed medical records for a random sample of 291 service members with live births in direct care—in a military medical treatment facility—in fiscal year 2022 out of a total population of 6,151. Estimates in this figure have a margin of error within plus or minus 6 percent at the 95 percent confidence interval. For TRICARE beneficiaries in private sector care, two 2022 DHA contractor reviews showed significantly lower screening rates than direct care. For example, one contractor found that 30 percent of beneficiaries were screened at least once, and about 6 percent were screened more than once. GAO found that DHA does not monitor or direct its contractors to monitor the frequency of perinatal mental health screenings in direct or private sector care. DOD has indicated that screening is its main prevention strategy for this high-risk group. Missing screenings could result in undiagnosed and untreated perinatal mental health conditions in TRICARE beneficiaries. By routinely monitoring the frequency of screenings in direct and private sector care, and taking corrective actions as needed to ensure adherence to DHA's recommendations and evidence-based practices, DHA can help ensure that beneficiaries consistently receive high-quality care. Why GAO Did This Study TRICARE provides health care to about 9.5 million eligible beneficiaries. In fiscal year 2023, there were about 89,000 births among TRICARE beneficiaries. Research shows mental health conditions such as depression and anxiety are the most common complications that develop during the perinatal period. Mental health is a critical part of military readiness. Factors such as isolation from social support networks may place military beneficiaries at risk of developing perinatal mental health conditions. A report accompanying the National Defense Authorization Act for Fiscal Year 2024 includes a provision for GAO to review issues related to perinatal mental health in the military. This report examines the screening of TRICARE beneficiaries for perinatal mental health conditions in direct and private sector care. GAO reviewed a generalizable sample of 291 service members' medical records that had a live birth in a military medical treatment facility in fiscal year 2022—the most recent year for which complete data were available. GAO reviewed DHA documents, two contractor reviews, and relevant laws. GAO also interviewed DHA officials and contractor representatives.

What GAO Found Federal information collections include applications and other forms that individuals must complete to obtain federal benefits, such as food assistance, medical care, and cash aid. In April 2022, the Office of Management and Budget (OMB) issued guidance to agencies for documenting administrative burdens that individuals experience in submitting the required information. OMB has directed agencies to document these burdens in the supporting statements for each information collection request provided to OMB for review and approval. These burdens include learning, compliance, and psychological costs. Administrative Burdens Imposed by Information Collection Requirements for Federal Benefit Programs GAO reviewed supporting statements for 51 of the 8,613 approved information collection requests submitted to OMB between April 2022 and April 2024. These 51 requests met the following criteria: The preparing agency was a Chief Financial Officers Act agency. The request set requirements that individuals and households must meet to obtain or retain federal benefits. The agency estimated the request would impose at least 75,000 burden hours on the public. OMB's instructions for preparing these statements do not fully incorporate OMB's burden reduction guidance. For example, OMB's instructions do not direct agencies to discuss potential learning or psychological costs as part of their statements. As a result, agencies may not be fully documenting the administrative burdens imposed by benefit program requirements, limiting transparency and potentially missing opportunities to identify and reduce burdens on the public. As of December 2024, the Departments of Agriculture (USDA) and Veterans Affairs (VA) and the Social Security Administration (SSA) had established offices for improving customer experience. These offices helped to collect data to monitor customer feedback. They also helped to identify solutions for reducing administrative burdens in support of broader efforts to improve customer satisfaction. USDA, VA, and SSA have also taken steps to integrate burden reduction priorities into strategic goals, strategic objectives, and performance goals associated with some of their largest programs and services. Why GAO Did This Study According to an estimate cited by OMB, eligible Americans forgo claiming more than $140 billion in federal benefits each year. They do so, in part, due to administrative burdens—the time and other resources expended to obtain or retain these benefits. Reducing such burdens can help reduce economic insecurity and improve the public's experiences with federal programs, a longstanding priority of Congress and the executive branch. GAO was asked to review federal agencies' efforts to reduce administrative burdens for federal benefit programs. This report examines selected federal agencies' efforts to (1) implement OMB guidance for reducing administrative burdens, (2) support burden reduction efforts, and (3) integrate burden reduction priorities into their performance management activities. GAO compared nine federal agencies' information collection requests to OMB's burden reduction guidance and documentation instructions for agencies. GAO also compared performance management documentation developed by three selected federal agencies that administer three of the largest federal benefit programs—USDA, SSA, and VA—to relevant OMB guidance. GAO interviewed officials at OMB and the three selected agencies about their burden reduction efforts.