United States Government Accountability Office GAO Report to Congressional Requesters June 2012 PATIENT PROTECTION AND AFFORDABLE CARE ACT IRS Managing Implementation Risks, but Its Approach Could Be Refined GAO-12-690 June 2012 PATIENT PROTECTION AND AFFORDABLE CARE ACT IRS Managing Implementation Risks, but Its Highlights of GAO-12-690, a report to Approach Could Be Refined congressional requesters Why GAO Did This Study What GAO Found PPACA is a significant effort for IRS, with The Internal Revenue Service (IRS) has implemented one of GAO’s four expected costs of $881 million from fiscal recommendations from June 2011 to strengthen the Patient Protection and years 2010 to 2013 and work planned Affordable Care Act (PPACA) implementation efforts by scheduling the through 2018. To implement PPACA, IRS development of performance measures for the PPACA program. IRS has made must work closely with partner agencies to develop information technology varying degrees of progress on the other three recommendations: systems that can share data with other • develop program goals and an integrated project plan; agencies. Additionally, IRS is responsible • develop a cost estimate consistent with GAO’s published guidance; and for providing guidance to taxpayers, employers, insurers, and others to • assure that IRS’s risk management plan identifies strategic level risks and ensure compliance with new tax aspects evaluates associated mitigation options. of the law. Furthermore, it will be IRS’s revised risk management plan meets three of five criteria for risk important for IRS to have systems to consistently identify, assess, mitigate, management plans, but the plan does not have specific guidance for evaluating and monitor potential risks to the and selecting potential risk mitigation options, such as how to program’s success. • identify who conducts and reviews the analysis, As requested, this report (1) describes • determine the availability of resources for a given strategy, and IRS’s progress in addressing GAO • document for future users the rationale behind decisions made. recommendations from June 2011 on PPACA implementation, (2) assesses IRS applied its risk management plan when identifying, tracking, and reporting on IRS’s revised risk management plan, and implementation risks. Although the risk plan calls for risk mitigation strategies to (3) assesses how IRS applies its plan in be evaluated, these evaluations have not been done. IRS officials said that practice. GAO compared IRS’s revised evaluating these strategies would require varying levels of effort because the risk plan to GAO’s criteria for risk probability and magnitude of risks differ. However, the plan was silent on this management and selected 9 provisions point; it provided no guidance as to when and to what extent an evaluation of the law in which IRS had a role to determine whether IRS used the risk plan should be done. Without evaluating potential strategies, IRS may not consider consistently. Because selection focused critical factors that impact the program’s success. on provisions that had the most risks and IRS’s risk management plan was not used when IRS’s Office of Chief Counsel highest dollar impacts, the results are not was responsible for implementing two provisions GAO reviewed. Although these generalizable but are relevant to how IRS managed risks. provisions primarily required legal counsel and guidance, IRS officials said that one of the provisions also affected IRS operations and could have risks that need What GAO Recommends to be managed. Additionally, GAO did not find evidence that a risk plan was used to track and mitigate risks when coordinating with partner agencies, such as the GAO recommends that IRS (1) enhance its guidance on evaluating Department of Health and Human Services. Without a system for tracking shared risk mitigation alternatives and risks, IRS is more likely to overlook risks or duplicate efforts. documenting decisions, (2) use a risk management plan for work led by its Office of Chief Counsel, and (3) develop agreements with external parties to record and track risks that threaten shared goals and objectives. IRS officials agreed with all of GAO’s recommendations. View GAO-12-690. For more information, contact James R. White at (202) 512-9110 or email@example.com. United States Government Accountability Office Contents Letter 1 Background 3 IRS Has Made Varying Degrees of Progress in Implementing Our Recommendations but Has More to Do on Project Planning, Cost Estimating, and Evaluating Risk Mitigation Strategies 6 IRS’s Risk Management Plan Meets Criteria for Three of Five Risk Framework Stages but Lacks Specific Guidance on the Evaluation and Selection of Mitigation Strategies 11 IRS Implemented Its Risk Management Plan Consistently for the Sample Provisions and in Crosscutting Areas, Except for Provisions Led by Counsel and When Coordinating with Partner Agencies 14 Conclusions 18 Recommendations for Executive Action 19 Agency Comments and Our Evaluation 19 Appendix I Scope and Methodology 21 Appendix II How IRS Fulfills GAO Risk Management Criteria 24 Appendix III Provisions Evaluated for Consistent Use of Risk Management Plan 25 Appendix IV Comments from the Internal Revenue Service 27 Appendix V GAO Contact and Staff Acknowledgments 29 Related GAO Products 30 Tables Table 1: IRS PPACA Budget and HIRIF Funding, Fiscal Years 2010 to 2013 6 Page i GAO-12-690 Patient Protection and Affordable Care Act Table 2: Recommendation Status: Developing a Plan to Create Performance Measures 7 Table 3: Recommendation Status: Integrating Goals and Project Plans 8 Table 4: Recommendation Status: Developing a More Complete Cost Estimate 9 Table 5: Recommendations and IRS Status in 2012 for Enhancing IRS’s Managing of Risk 11 Table 6: Assessment of IRS’s Implementation of Its Risk Plan for Sampled Provisions 15 Table 7: How IRS Fulfills GAO Risk Management Criteria 24 Table 8: Consistency with Which IRS Used Its Risk Plan in Implementing Selected PPACA Provisions 25 Figures Figure 1: IRS PPACA Organization Chart 5 Figure 2: Risk Management Framework Stages 10 Figure 3: How IRS Fulfills GAO Risk Management Criteria 12 Page ii GAO-12-690 Patient Protection and Affordable Care Act Abbreviations AGI Adjusted Gross Income BOD Business Operating Division CFO Office of the Chief Financial Officer EPO Estimating Program Office ESC Executive Steering Committee FTE full-time equivalent HCERA Health Care and Education Reconciliation Act of 2010 HHS Department of Health and Human Services HIRIF Health Insurance Reform Implementation Fund HLAP high level action plan IRS Internal Revenue Service IT information technology LB&I Large Business & International Division MITS Modernization and Information Technology Services PMO Program Management Office PPACA Patient Protection and Affordable Care Act RAS Research Analysis and Statistics S&E Services and Enforcement SB/SE Small Business/Self-Employed Division TE/GE Tax Exempt/Government Entities Division W&I Wages & Investment Division This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Page iii GAO-12-690 Patient Protection and Affordable Care Act United States Government Accountability Office Washington, DC 20548 June 13, 2012 The Honorable Richard J. Durbin Chairman The Honorable Jerry Moran Ranking Member Subcommittee on Financial Services and General Government Committee on Appropriations United States Senate The Honorable Sam Graves Chairman Committee on Small Business House of Representatives The Internal Revenue Service’s (IRS) implementation of the Patient Protection and Affordable Care Act (PPACA) 1 is a massive undertaking that involves 47 statutory provisions and extensive coordination across not only IRS, but multiple agencies and external partners. For example, IRS must coordinate with other federal agencies and states in providing assistance to qualifying individuals for health insurance premiums. In June 2011, we reported that IRS had generally followed leading practices for implementing such a large program, particularly at the level of individual offices and projects, and we made four recommendations to improve IRS’s strategic approach to its implementation efforts. 2 IRS has continued to make progress implementing PPACA. However, a number of risks remain. In particular, IRS must quickly design and implement large information technology (IT) systems used to carry out key provisions of the law. The investment is large, as IRS’s implementation costs from fiscal years 2010 through 2013 are expected to total $881 million. IRS also plays a critical role in helping individuals, employers, insurers, health care providers, tax practitioners, state agencies, and other federal agencies understand their obligations under 1 Pub. L. No. 111-148, 124 Stat. 119 (March 23, 2010) as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. No. 111-152). 2 GAO, Patient Protection and Affordable Care Act: IRS Should Expand Its Strategic Approach to Implementation, GAO-11-719 (Washington, D.C.: June 25, 2011). Page 1 GAO-12-690 Patient Protection and Affordable Care Act the law and in ensuring compliance while minimizing the burden of complying. As we emphasized in our June 2011 report, effective management of these efforts requires significant long-term planning by IRS to ensure a comprehensive system for managing and mitigating risks and monitoring progress. Doing so requires IRS to coordinate efforts internally as well as with outside partners, such as the Department of Health and Human Services (HHS), so that all parties understand what they need to do and when to do it (accounting for changes necessary) in a manner that keeps the overall implementation on track. Efforts to manage risk over the long- term led IRS to create a risk management plan specifically for the PPACA program, which IRS revised most recently in February of 2012. Given your interests in tracking IRS’s progress in implementing its responsibilities while managing various risks, you asked us to review IRS’s progress since our June 2011 report and assess IRS’s risk management. In this report we (1) describe IRS’s progress in acting on our four recommendations, (2) assess IRS’s use of leading practices in its revised risk management plan, 3 and (3) assess how IRS follows its risk management plan for a sample of PPACA provisions as well as for four crosscutting management areas: allocating resources, coordinating with partner agencies, determining the need for deadline extensions, and assuring compliance with the law while minimizing burden. To assess IRS’s progress in implementing our recommendations, we met with responsible IRS executives and staff and reviewed IRS documentation, comparing IRS’s planned and ongoing actions to the leading practices discussed in our 2011 report. To assess how IRS designed its plan, we compared IRS's actions to guidelines set by GAO’s risk management approach. We interviewed IRS management and staff about these guidelines and collected documentation on IRS’s adherence. To assess how IRS manages risks for the four key areas, we compared IRS actions to the guidelines outlined in its risk management plan. As part of this work, we analyzed how IRS adhered to these guidelines in implementing 9 provisions that we selected from the IRS-related 3 For purposes of this report, we used leading practices from GAO’s risk management approach to assess IRS’s risk management plan. See GAO, Risk Management: Further Refinements Needed to Assess Risks and Prioritize Protective Measures at Ports and Other Critical Infrastructure, GAO-06-91 (Washington, D.C.: Dec. 15, 2005). Page 2 GAO-12-690 Patient Protection and Affordable Care Act provisions that involved the highest dollar amounts. 4 For details on our methodology, including the selection of the provisions in our sample, see appendix I. We conducted this performance audit from August 2011 through June 2012 in accordance with generally accepted government auditing standards. These standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Enacted on March 23, 2010, PPACA involves major health care Background stakeholders, including federal and state governments, employers, insurers, and health care providers, in an attempt to reform the private insurance market and expand health coverage to the uninsured. IRS is one of several agencies accountable for implementing the legislation and has responsibilities pertaining to 47 PPACA provisions. 5 Some provisions took effect immediately or retroactively while others are to take effect as late as 2018. According to IRS officials, the most challenging of these provisions relate to the health care exchanges to be established by states by 2014. These exchanges are marketplaces for individuals and certain types of employers to purchase health insurance. To support the exchanges, IRS must modify existing or design new IT systems that are capable of transmitting data to and from HHS, help HHS craft eligibility determinations and related definitions, and engage in new interagency coordination, such as with HHS and the Department of Labor. 4 Applying these criteria separately to the 47 provisions, 23 provisions were scored to have revenue or spending impacts of over $1 billion by the Joint Committee on Taxation and Congressional Budget Office. We identified provisions that were implemented when the risk plan was in place and that had multiple, significant risks to narrow this pool of provisions to a judgmental sample of 9. 5 This number does not include a provision from section 9006 of the law calling for expanded information reporting to payments made to corporations and to payments for property and other gross proceeds. The requirements of this provision were repealed on April 14, 2011 by the Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011, Pub. L. No. 112-9. Page 3 GAO-12-690 Patient Protection and Affordable Care Act To coordinate agency-wide efforts, a PPACA Executive Steering Committee (ESC) oversees two Program Management Offices (PMOs) that coordinate with Health Care Counsel—which is part of IRS’s Office of Chief Counsel (Counsel) 6—on the implementation. 7 The Services and Enforcement (S&E) PMO oversees the work completed within IRS’s existing business operating divisions (BOD) 8 as well as the efforts of four workstream teams. The Modernization, Information Technology and Security Services (MITS) PMO leads IT development for the program. The Health Care Counsel provides legal counsel and guidance (see fig. 1). Management of the implementation teams is expected to shift from the program management office to the business operating divisions, MITS, and Counsel as the program is fully implemented. 6 The IRS Chief Counsel also reports to the United States Department of the Treasury General Counsel on certain matters. 7 See GAO-11-719. 8 BODs include: Wage & Investment Division (W&I), Small Business/Self-Employed Division (SB/SE), Large Business & International Division (LB&I), and Tax Exempt/Government Entities Division (TE/GE). Page 4 GAO-12-690 Patient Protection and Affordable Care Act Figure 1: IRS PPACA Organization Chart The program management offices and business operating divisions, along with overall IRS leadership, coordinate with IRS’s Office of the Chief Financial Officer (CFO) to allocate resources for implementation efforts. Implementation costs are expected to reach $881 million through fiscal year 2013, with $521 million of that amount being provided through HHS’s Health Insurance Reform Implementation Fund (HIRIF), a fund to which Congress appropriated $1 billion for federal spending to implement PPACA, and the remainder from IRS’s 2013 budget request. Table 1 shows IRS’s PPACA budget and HIRIF funding amounts. Page 5 GAO-12-690 Patient Protection and Affordable Care Act Table 1: IRS PPACA Budget and HIRIF Funding, Fiscal Years 2010 to 2013 Dollars in millions Fiscal IRS requested budget IRS enacted budget year for PPACA for PPACA HIRIF funding a 2010 $0 $21 a 2011 $0 $168 b 2012 $473 $0 $332 c c 2013 $360 Source: IRS. a PPACA was enacted after IRS requested funding for fiscal years 2010 and 2011. b IRS requested $332 million from the HIRIF for fiscal year 2012 and had received $135 million as of April 27, 2012. c The figures were undetermined at the time of our report. IRS’s risk management efforts are crucial in implementing a program of this size. By evaluating the probability and impact of a given risk’s occurrence, risk management encourages planning for ways to lessen the probability or minimize the impact. Much of the remaining implementation work is new to IRS, such as that related to health care exchanges. IRS is more likely to succeed with steps in place to identify and address risks before they occur and make contingency plans for events that cannot be controlled. Though not a guarantee, IRS’s planning for these tasks make successful implementation more likely. Over half of the 47 provisions requiring action from IRS were statutorily IRS Has Made Varying effective in or prior to 2010, forcing IRS to conduct short-term Degrees of Progress implementations and long-term strategic planning simultaneously. With many short-term projects now completed, IRS has been focusing on its in Implementing Our long-term planning since our 2011 report, and has made varying degrees Recommendations of progress in implementing our four recommendations. These efforts but Has More to Do have helped IRS gain a better understanding and vision for the implementation work and challenges remaining and how IRS would on Project Planning, manage risks to the program’s success. Cost Estimating, and IRS has implemented one of our four recommendations from June 2011 Evaluating Risk to strengthen PPACA implementation efforts by documenting a schedule Mitigation Strategies for developing performance measures for PPACA that are to link to program goals (see table 2). Page 6 GAO-12-690 Patient Protection and Affordable Care Act Table 2: Recommendation Status: Developing a Plan to Create Performance Measures Criteria for meeting recommendation IRS status in 2012 1. Articulate the actions required in developing performance measures. Met: Planning document lists actions to take in developing Steps to be taken should be documented so that progress can be performance measures. tracked. 2. Establish dates by which actions will be completed. Deadline dates Met: Deadline is July 1, 2012. should be specific. Source: GAO analysis based on GAO reports and IRS documentation. IRS made some progress on the remaining three recommendations from our June 2011 report. Absent more progress, IRS may encounter challenges in overseeing the program if activities in project plans are not linked, cost estimates are not current, and risk mitigation strategies are not properly assessed and decisions documented. Integrating Goals and We recommended that IRS develop one set of goals and an integrated Project Plan project plan across IRS to clarify the vision and mitigate the risk that lower level units may work at cross purposes. The program’s governance document now stipulates program goals that align with IRS’s mission. IRS continues to maintain separate project plans for S&E and MITS activities, though it has an additional plan that offers a high level overview of the major PPACA efforts and the related implementation progress across IRS. IRS officials said that the overview provides a sufficient perspective to assess overall progress, but we found it did not align with criteria for leading practices because it is updated manually, leaving it subject to error if those updating the plan are not acting in a timely manner or overlook a change in delivery schedules (see table 3). Page 7 GAO-12-690 Patient Protection and Affordable Care Act Table 3: Recommendation Status: Integrating Goals and Project Plans Criteria for meeting recommendation IRS status in 2012 1. Goals should link to the agency mission. Program goals should be Met: Goals and objectives in Governance Plan link to documented and show a clear link to the agency's mission. IRS’s mission. 2. Goals should communicate a clear vision of the desired outcome. Met: Governance Plan includes PPACA vision and Documentation should show how expectations for desired program guiding principles in implementation. outcomes are communicated. 3. Goals should be established by key stakeholders managing the program Met: Governance Plan created by PPACA ESC. and approved by the main leadership body for the program. 4. Responsibilities and completion dates should be clearly described and Partially met: High level plan has appropriate detail of documented; the schedule should realistically reflect what resources are responsibilities and completion dates; relatively few needed to do the work and determine whether all required resources will activities have been assigned specific resources. be available when needed. 5. The project plan should articulate a clear system of coordination among Partially met: Major milestones and deliverables are project activities. Project schedules should link to recognize impacts of clear; activities and milestones are not linked delays and major handoffs and deliverables should be easily identified. electronically; project schedules between S&E and MITS are not linked electronically. 6. The project plan should track results. Schedule progress should be Partially met: Progress is reported periodically; history reported periodically and updated regularly. The schedule history should of actual completion dates is not maintained; no be maintained with narrative for any delays, changes, additions, or evidence of written narratives for changes to plan; deletions of activities. The schedule should compare a baseline plan to MITS compares current status to a baseline plan, but current status. S&E does not. Source: GAO analysis based on GAO reports and IRS documentation. Developing a More We recommended that IRS adopt the leading practices outlined in the Complete Cost Estimate GAO Cost Guide 9 and shown in table 4 to enhance the reliability of its cost estimate for PPACA. However, little progress has been made as IRS’s cost estimate is largely unchanged since it was developed in 2010. IRS’s Estimating Program Office (EPO) plans to revise the cost estimate this year after reaching a milestone that clarified some business requirements related to IT development. In April 2012, IRS awarded a contract for an independent cost estimate that is slated to include the steps outlined in GAO’s Cost Guide. Our June 2012 report on IRS’s fiscal year 2013 budget recommended that IRS revise its PPACA cost estimate by September 2012, which IRS agreed to do. 10 If IRS’s EPO completes 9 GAO, Cost Estimating and Assessment Guide: Best Practices for Developing and Managing Capital Program Costs, GAO-09-3SP (Washington, D.C.: March 2009). 10 GAO, IRS 2013 Budget: Continuing to Improve Information on Program Costs and Results Could Aid in Resource Decision Making, GAO-12-603 (Washington, D.C.: June 8, 2012). Page 8 GAO-12-690 Patient Protection and Affordable Care Act an estimate and it is compared to an independent estimate, IRS will make significant progress in implementing our recommendation. Table 4: Recommendation Status: Developing a More Complete Cost Estimate Criteria for meeting recommendation IRS status in 2012 1. Estimates should be comprehensive: including all life cycle costs and a Partially met: Documents ground rules and logical work breakdown structure; completely defining the program; and assumptions, but not the entire life cycle; Detail of the detailing all ground rules and assumptions. work necessary does not capture all costs. 2. Estimates should be well-documented: identifying data sources and Partially met: Methodologies behind calculations are data reliability; describing all estimating methods; showing step-by-step described, though several sources of data are unclear cost calculations; documenting review and approval from management; or rely on IRS employee input. Historical data are not and discussing how the technical description is incorporated in the normalized to ensure consistency of cost data. estimate. 3. Estimates should be accurate: unbiased and based on most likely and Partially met: Estimate is unbiased and based on most historical costs; adjusted for inflation; free from errors; updated likely and historical costs, though it was last updated in regularly; and capable of being analyzed for variance between planned October 2010. Analysis of variance between actual and and actual costs. projected costs is not documented. 4. Estimates should be credible: including sensitivity, risk, and uncertainty Minimally met: IRS statement of work for a cost analysis; using more than one method in calculating major cost estimate includes risk and sensitivity analysis, which elements to see if results are similar; and comparing results to would help identify variables most likely to affect the independent cost estimate. estimate. IRS plans to obtain an independent cost estimate in 2012. Source: GAO analysis based on GAO reports and IRS documentation. Enhancing Risk We recommended that IRS’s plan assure that strategic-level risks are Management Plan identified and that alternative mitigation strategies for risks are evaluated. Our conclusion was based on a comparison between IRS’s risk plan from May 18, 2011, and the criteria outlined in GAO’s risk management framework, shown in figure 2. Page 9 GAO-12-690 Patient Protection and Affordable Care Act Figure 2: Risk Management Framework Stages Of the five stages of the risk management framework, IRS’s risk plan did not meet the criteria associated with three stages: risk assessment, alternative evaluation, and management selection (see table 5). Strategic- level risks are now better addressed because the revised plan calls for involvement of higher level executives, but the plan does not specify policies and procedures involved in evaluating and selecting potential risk mitigation strategies. We discuss this topic further in the next section on IRS’s revised risk management plan. Page 10 GAO-12-690 Patient Protection and Affordable Care Act Table 5: Recommendations and IRS Status in 2012 for Enhancing IRS’s Managing of Risk Criteria for meeting recommendation IRS status in 2012 1. Involve high-level management in identifying program risks. The Met: Risk plan states that all PPACA members, including plan should not rely solely on project teams to identify risks, as executives, can identify risks. cross-cutting risks may be overlooked. 2. Include procedures for identifying and evaluating mitigation Partially met: Risk plan calls for selecting a mitigation strategies in the plan. Cost-benefit analysis of mitigation options approach after identifying alternatives and considering such should be done. factors as cost, effort, and return on investment. However, the plan does not provide guidance for performing the analysis, such as who does it and who reviews it. 3. Include procedures for selecting mitigation strategies in the plan and Not met: Risk plan does not provide guidance for selecting documenting the rationale for decisions made. strategies or call for documenting decisions and the related rationale. Source: GAO analysis based on GAO reports and IRS documentation. Our assessment of IRS’s revised risk management plan from IRS’s Risk February 24, 2012, indicated that IRS adheres to the criteria for three of Management Plan the five stages of our framework for risk management. However, the plan’s guidance on evaluating risk mitigation alternatives is not specific or Meets Criteria for comprehensive, nor does the plan address procedures for management Three of Five Risk in selecting strategies and documenting decisions made. Figure 3 Framework Stages summarizes our assessment of the IRS revised plan by comparing it to the five stages (see app. II for the full text included in fig. 3). but Lacks Specific Guidance on the Evaluation and Selection of Mitigation Strategies Page 11 GAO-12-690 Patient Protection and Affordable Care Act Interactive graphic Figure 3: How IRS Fulfills GAO Risk Management Criteria Directions: Roll over risk management framework stages below to see how IRS fulfills GAO criteria. Risk management framework stages IRS risk management plan stages Strategic goals, objectives, and constraints Governance document and high-level action plans Identification Risk assessment Tracking Alternative evaluation Resolution/Mitigation Management selection Implementation and monitoring Reporting Source: GAO analysis of IRS documentation. Print instructions • A printable text version of this graphic is available in appendix II. Page 12 GAO-12-690 Patient Protection and Affordable Care Act As figure 3 indicates, the risk plan’s discussion of evaluating potential risk mitigations is brief, with some processes and responsibilities left undefined. The plan did not provide specific guidance on the process for doing an evaluation, stating only that alternative strategies should be evaluated according to cost, level of effort, and return on investment. For example, the plan did not identify who is responsible for doing or reviewing the evaluation. Further, the plan did not provide guidance on selecting mitigation strategies, including verifying that resources are available for selected strategies. IRS officials acknowledged that the plan did not include these processes and responsibilities but said that they believe that teams considered such factors when making decisions. Additionally, the plan did not provide guidance on documenting the rationale(s) for selecting one alternative over others. As a result, IRS is less likely to have a trail of analysis that explains the decisions to those who work on PPACA projects in the future. Such a trail is important, as PPACA implementation involves many people managing many tasks over a number of years and across multiple offices. In the years ahead, implementation responsibility will shift from the PMOs to staff in the BODs who may not have been involved in these decisions about the mitigations considered and chosen and may have to develop a new mitigation if the original does not work. IRS officials noted that spending resources to do a thorough evaluation and to document the rationale for decisions may not be practical for risks that have a low probability of occurring or that IRS cannot control, such as a lack of funding. While this may be true, IRS’s risk plan does not offer guidance on factors like the probability of a risk’s occurrence that could affect the level of evaluation and amount of documentation to be done. Without specific guidance on evaluating potential mitigation strategies, the likelihood decreases that teams will conduct a thorough evaluation or have a consistent basis for deciding not to do so. Page 13 GAO-12-690 Patient Protection and Affordable Care Act IRS Implemented Its Risk Management Plan Consistently for the Sample Provisions and in Crosscutting Areas, Except for Provisions Led by Counsel and When Coordinating with Partner Agencies Managing Risks for Sample Our analysis indicated that IRS generally implemented its risk Provisions management plan consistently for seven of the nine provisions in our sample. These seven provisions covered responsibilities such as for premium assistance tax credits for eligible individuals purchasing health insurance coverage through state exchanges, penalties on individuals who do not have minimum essential coverage, penalties on larger employers who do not offer coverage as required, and other taxes, credits, and fees. IRS did not follow its risk management plan for two sample provisions that IRS believed primarily required legal guidance and that IRS assigned primary responsibility for implementing to Counsel. 11 In reviewing the seven sample provisions that were expected to have relatively high dollar impacts and greater risks, we asked for evidence that IRS completed the steps prescribed by its risk plan. 12 Table 6 summarizes the steps and results we found in IRS’s implementation of the plan for the seven provisions (see app. III for detail on the sample provisions and our assessment of whether the sample provisions followed the four stages of IRS’s risk plan). 11 Provisions included section 1102 on establishing a temporary reinsurance program for early retirees and section 1409 on the application of the economic substance doctrine. See app. III for a description of these provisions. 12 Our analyses focused on whether rather than how well IRS completed the required steps. Page 14 GAO-12-690 Patient Protection and Affordable Care Act Table 6: Assessment of IRS’s Implementation of Its Risk Plan for Sampled Provisions Key steps included in the Results found in Stage of risk plan stage implementation Identification Brainstorming sessions with IRS provided evidence of taking relevant stakeholders; guidance these steps. from Counsel; complete and document approval of Provision Assessment Form; record identified risks in tracking software, using information from Provision Assessment Form. Tracking Monitor risks weekly. IRS provided evidence of a weekly review meeting for risks. Resolution/ Determine risk levels for each Risk levels were determined; risk Mitigation recorded risk; evaluate and ownership was assigned; little select risk mitigation strategies; evidence of mitigation strategy assign risk ownership; establish evaluation; provisions with earlier performance thresholds that effective dates were more likely offer early warning that chosen to have established early warning mitigation strategies do not indicators. work. Reporting Regularly scheduled reports IRS provided evidence of taking reviewed at meetings by IRS these steps. management committees. Source: GAO analysis of IRS documentation. IRS consistently completed all steps outlined in the plan’s Identification, Tracking, and Reporting stages. While some steps called for in the Resolution/Mitigation stage were consistently completed, we did not find an analysis of alternative risk mitigation strategies for several provisions in our sample. This inconsistency could stem from the lack of guidance, as previously discussed, on how to do mitigation evaluations, including documenting why a mitigation strategy is selected over the alternatives considered. As for the two sample provisions that Counsel was responsible for implementing, the risk management plan was not used. When asked about efforts to identify risks for one of the provisions, a Counsel official said that this responsibility rested with the BODs who ultimately would implement the provision. However, the S&E PMO overseeing the work in the BODs told us that Counsel was responsible for the provision’s implementation, including managing the related risks. As a result of confusion as to who should take the lead in identifying and mitigating risks for provisions in which Counsel had lead responsibility, risks may Page 15 GAO-12-690 Patient Protection and Affordable Care Act not be identified and mitigated. IRS officials acknowledged that the risk plan was not used for these provisions, noting that the provisions were not expected to have an impact on IRS operations. However, one of the two provisions, an imposition of penalties for underpayments attributable to transactions lacking economic substance, had an operational impact in areas such as tax forms, customer service, and compliance checks, indicating that the risk plan should have been used. Managing Risks for Four Looking more broadly beyond the provisions in our sample, we found that Crosscutting Management IRS generally implemented its risk management plan in four crosscutting Areas areas: (1) resource allocation, (2) collaboration with other agencies, (3) decisions to extend deadlines or provide transitional relief, and (4) challenges related to addressing compliance and burden. However, IRS did not have a formal system for managing risks when coordinating with HHS. Managing Risk in Allocating While we noted in Table 3 that most activities in project plans were not Resources assigned specific resources, IRS’s risk plan does facilitate knowledge sharing among the entities involved in allocating resources to the program, with the exception previously stated that it does not provide guidance on verifying that resources are available for selected mitigation strategies. The CFO, along with IRS management, allocates IRS’s appropriation to IRS teams doing the implementation work. By involving the CFO in reviewing identified risks, the risk plan ensures that the CFO is aware of any risks related to the availability of resources. Regularly scheduled meetings between the CFO and PPACA implementation leadership also serve to facilitate discussion of the risks related to resource allocation. To the extent that IRS provides more specific guidance in the risk plan on verifying resources and updates its cost estimate for PPACA implementation, IRS will enhance its ability to manage risks related to allocating resources in an efficient manner. Managing Risk in Coordinating IRS and HHS developed an informal process for regular communication with Partner Agencies on project management, consisting of meetings several times per week to monitor progress on deliverables and solicit needed input on IRS activities that affect other agencies. 13 IRS officials expressed confidence 13 We focused on coordination between IRS and HHS because IRS collaborates with HHS more than any other agency in implementing PPACA. Work includes development of IT systems that share data needed for exchange-related work that IRS described as a major challenge. Page 16 GAO-12-690 Patient Protection and Affordable Care Act that the informal system of coordination worked effectively. The agencies also jointly established more formal guiding principles for their implementation efforts in 2010 to clarify goals and objectives. Although IRS and HHS regularly coordinated, we did not find a formal system for managing risks threatening the agencies’ success in achieving their goals. Without a joint tracking system for risks related to the agencies’ coordinated efforts, the agencies may duplicate efforts. They could also focus on tracking implementation deadlines while losing sight of risks that pose obstacles to meeting those deadlines. Managing Risk in Determining IRS's PPACA implementation teams 14 work with Counsel to develop the Need for Deadline plans for overcoming obstacles that create the need for deadline Extensions and Transitional extensions and transitional relief. The plans are to be guided by three Relief specific criteria—the timing of legislation with respect to the tax year, burden imposed on taxpayers and intermediaries, and IRS effort required—in determining the need for extensions and relief. As of May 2012, seven provisions were granted extensions and relief in consideration of timing issues and the burden imposed criteria. Counsel participates in the risk management process by briefing implementation teams at the outset of work, participating in regular meetings with IRS leadership for PPACA risk management, soliciting comments on guidance from stakeholders and the general public, and helping to monitor progress. Counsel’s involvement in these activities as well as the use of specific criteria should help IRS make decisions on granting extensions and relief as the implementation dates approach for major provisions, such as those related to the exchanges in 2014. Managing Risk in Addressing We found consistent evidence IRS had taken steps to identify potential Compliance and Burden compliance challenges. IRS used its Research, Analysis, and Statistics Challenges (RAS) organization to help project the volume of tax returns that would be subject to PPACA and help identify the likely population requiring outreach and education. When historical data for similar provisions were available, IRS attempted to use the data to construct a baseline of anticipated results. Counsel solicited formal comments from stakeholders and taxpayers in response to preliminary guidance. IRS made limited use of other means, such as focus groups, to gain insight into compliance and 14 This process involves other offices within the U.S. Department of the Treasury, such as the Office of Tax Policy. Page 17 GAO-12-690 Patient Protection and Affordable Care Act burden challenges facing the public. IRS officials said that they received informal feedback from conversations with other tax stakeholders, such as groups representing taxpayers, tax software developers, and tax preparers. We also saw evidence, such as with tax credits for small employers offering health insurance, that IRS enforcement staff attempted to account for known or suspected compliance risks. 15 The risk plan calls for early warning thresholds that indicate that results are below expectations and we saw evidence that such thresholds are used regularly. Since our 2011 report, IRS has gained a better understanding of the work Conclusions and challenges it faces in implementing PPACA. IRS has made varying degrees of progress in implementing our recommendations from 2011. As IRS continues to implement them, IRS leadership will enhance its line of sight over its progress and the challenges that remain. With expected implementation costs approaching $1 billion as IRS gets closer to major milestones in 2014, careful consideration of risks and alternatives for mitigating those risks is crucial in meeting deadlines and making the best use of taxpayer dollars. While IRS developed a risk management plan for PPACA implementation that meets several leading practices, IRS did not take any actions to implement our 2011 recommendation on assessing mitigation strategies. Further, IRS could take specific steps such as providing additional guidance on how to evaluate potential mitigation strategies and document the rationales for decisions made. Without additional guidance, IRS staff selecting mitigation strategies may not fully evaluate all alternatives or verify that resources are available for the strategy chosen. Not knowing the rationale behind selecting a mitigation strategy over others could hinder future decisions if the original strategy did not work and the original decision makers are no longer involved. While IRS’s PPACA implementation teams generally followed the steps of the risk management plan in identifying and mitigating risks, the plan was not followed when Counsel led pieces of the implementation. If the plan is not followed, risks may not be addressed. Additionally, without a shared 15 GAO, Small Employer Health Tax Credit: Factors Contributing to Low Use and Complexity, GAO-12-549 (Washington, D.C.: May 14, 2012). Page 18 GAO-12-690 Patient Protection and Affordable Care Act system for tracking and monitoring risks with partner agencies, such as HHS, the agencies will be more likely to overlook potential challenges or duplicate efforts to mitigate risks. To strengthen the PPACA risk management plan, we recommend that the Recommendations for Commissioner of Internal Revenue enhance guidance on evaluating risk Executive Action mitigation alternatives to • clarify who is responsible for doing the evaluation and making decisions based on the results as well as how they might do the evaluation, • assure that resources are available for the chosen mitigation strategy, and • document the mitigation alternatives considered and rationale(s) for the decisions made. To ensure more consistent implementation of the risk management plan, we recommend that the Commissioner of Internal Revenue take the following two actions: • ensure that the PPACA risk management plan is applied to provisions in which the Office of Chief Counsel assumes lead responsibility for implementation, and • develop agreements with HHS (and other external parties as needed) on a system to record and track details on decisions made or to be made to ensure that risks are identified and mitigated. In a June 1, 2012, letter responding to a draft of this report (which is Agency Comments reprinted in app. IV), the IRS Deputy Commissioner for Services and and Our Evaluation Enforcement provided comments on our findings and recommendations as well as information on IRS efforts and progress to date on its PPACA implementation. IRS agreed with our first recommendation to enhance guidance in its PPACA risk management plan related to evaluating risk mitigation alternatives. Specifically, IRS agreed to revise its plan to (1) clarify responsibilities for doing the evaluation and making related decisions, (2) assure that resources are available for the mitigation strategy chosen, and (3) document the alternatives considered and the rationale(s) for decisions made. Page 19 GAO-12-690 Patient Protection and Affordable Care Act IRS also agreed with our two recommendations to ensure more consistent application of its risk management plan. First, IRS agreed to revise its plan to address the use of the plan for provisions being led by the Office of Chief Counsel. Second, IRS agreed to consult with HHS on the best approach to document and track decisions, risks, or both that affect both agencies. In that this recommendation referenced HHS specifically and possibly other external parties in identifying and mitigating these “joint” risks, we encourage IRS to take similar coordinated steps, as needed, when risks arise that affect IRS and these other parties. We are sending copies of this report to appropriate congressional committees, the Commissioner of Internal Revenue, the Secretary of the Treasury, the Chairman of the IRS Oversight Board, and the Director of the Office of Management and Budget. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staffs have any questions or wish to discuss the material in this report further, please contact me at (202) 512-9110 or at firstname.lastname@example.org. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix V. James R. White Director, Tax Issues Strategic Issues Page 20 GAO-12-690 Patient Protection and Affordable Care Act Appendix I: Scope and Methodology Appendix I: Scope and Methodology To assess IRS’s progress in addressing our 2011 recommendations for improving PPACA implementation efforts, we compared IRS’s planned and ongoing actions to leading practices described in our report. We analyzed IRS documentation and data, including program goals, project plans, cost estimates, risk management plans, governance plan, and presentations. We interviewed IRS officials and staff at IRS’s National Office, including those in the Office of the Chief Financial Officer (CFO); Office of Chief Counsel; and Services & Enforcement (S&E) and Modernization and Information Technology Services (MITS) Program Management Offices (PMO) to clarify our understanding of IRS’s progress and plans for implementing our recommendations. To assess IRS’s risk management plan for PPACA, we compared the contents of IRS’s Risk Management Plan, governance plan, and high- level action plans to the criteria outlined by GAO’s risk management approach. We met with officials from the S&E PMO to confirm our understanding of the policies and procedures included in IRS’s risk management process. To evaluate how consistently IRS applies its risk management plan for PPACA implementation, we analyzed IRS activities across a sample of PPACA provisions to verify that IRS followed the steps included in its risk plan. To assemble our sample, we identified provisions with the greatest likelihood of adverse effects and potential for the most significant financial consequences if risks were not identified and mitigated. We limited the scope of our sample to the 23 provisions with anticipated revenue and expenditure impacts of over $1 billion over the first 10 years of the legislation, as scored by the Joint Committee of Taxation and Congressional Budget Office. We eliminated 14 provisions to arrive at the final sample of 9 provisions based on the following criteria (see app. III for the 9 provisions in the sample). For example, since we focused on IRS’s use of its PPACA risk plan, which was initially drafted in 2011, we removed six provisions, including: • Four provisions that were implemented prior to the existence of IRS’s risk plan: • Section 10909 related to an adoption tax credit, • Section 1408 (HCERA) related to the exclusion of cellulosic biofuel from a tax credit, • Section 9003 related to repealing a tax exclusion in health flexible spending arrangements, and Page 21 GAO-12-690 Patient Protection and Affordable Care Act Appendix I: Scope and Methodology • Section 9004 related to a tax on distributions from certain health savings accounts. • Two provisions for which implementation had not started: • Section 9005 related to the limits on health flexible spending arrangements, and • Section 9001 related to an excise tax on high-cost employer- provided health insurance plans. To target provisions with the greatest likelihood of adverse effects from a failure to mitigate risks, we removed another seven provisions, including: • Three provisions because IRS had identified only low level risks for them: • Section 9013 related to the medical expense deduction threshold, • Section 1405 (HCERA) related to an excise tax on medical devices, and • Section 9012 related to the elimination of an employer deduction for a retiree prescription drug subsidy. • Four provisions for which only 1 risk had been identified: • Section 1322 related to a tax exemption for start-up nonprofit health insurers, • Section 6301 related to a fee on health insurance plans, • Section 10907 related to an excise tax on tanning salon services, and • Section 9010 related to an annual fee on health insurers. Finally, because of overlap in the remaining provisions that required very similar work for IRS, we removed a provision from Section 9015 related to an increase of the Hospital Insurance tax on wages over a specified threshold. We asked IRS to provide evidence of its risk management activity in four key areas. For three of these areas—resource allocation, coordination with external partners, and compliance and burden challenges—we also sought this documentation as part of our work on the nine provisions. We analyzed IRS’s responses and documentation, including risk logs, to determine what gaps, if any, existed between the steps called for by the risk plan and the actions that IRS took. We interviewed IRS officials and staff responsible for PPACA implementation, including officials from the PMOs for S&E and MITS, Office of the Chief Counsel, and Office of the CFO, and officials from the Department of Health and Human Services in conducting this work. Page 22 GAO-12-690 Patient Protection and Affordable Care Act Appendix I: Scope and Methodology For the risks related to the fourth key area—deadline extensions and other transitional relief—we interviewed officials in the Office of Chief Counsel. We sought information on their approach to understand how Chief Counsel coordinates with implementation teams about risks as decisions are considered and made about the extensions and relief. We conducted this performance audit from August 2011 to June 2012 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Page 23 GAO-12-690 Patient Protection and Affordable Care Act Appendix II: How IRS Fulfills GAO Risk Appendix II: How IRS Fulfills GAO Risk Management Criteria Management Criteria To assess how IRS’s revised risk plan meets the criteria for each of GAO’s risk management framework stages, we compared the criteria for each stage of the framework to the steps included in each of the stages of IRS’s risk management plan. Table 7 shows how IRS’s risk management plan meets the criteria for the risk management framework. Table 7: How IRS Fulfills GAO Risk Management Criteria GAO risk management IRS risk management plan framework stages stages How IRS fulfills GAO criteria Strategic Goals, Objectives, N/A The framework calls for documentation of (a) strategic goals and and Constraints objectives of the initiative and (b) the steps needed to attain those results. IRS’s risk management plan does not explicitly address goals, objectives, and constraints. Instead, those strategic plans and objectives are communicated through IRS’s “ACA Governance Plan,” which communicates the agency’s implementation goals and objectives broadly to implementation teams. Additionally, steps to attaining program goals are contained in the agency’s high level action plans (HLAP) for PPACA projects. Risk Assessment Identification The framework calls for documentation of standard operating procedures designed to identify (a) what can go wrong, (b) the likelihood of a risk occurring, and (c) the consequences of an Tracking occurrence. In its identification and tracking stages, IRS has established a consistent process for meeting these criteria. Alternatives Evaluation Resolution/Mitigation The framework calls for a consistent process by which to evaluate potential mitigation strategies using a variety of criteria, particularly cost-benefit analyses. While IRS provides general criteria for teams to evaluate alternatives, including cost, it does not outline specific guidance for performing this analysis. Management Selection The framework calls for a consistent process by which IRS (a) selects a risk mitigation strategy; (b) allocates resources to pursue that strategy; and (c) documents decisions, including the rationale behind the decisions. IRS’s plan does not address procedures for selecting strategies or allocating resources for selected strategies, nor does it outline protocols for documenting decisions made. Implementation and Monitoring Reporting The framework calls for documentation of processes to (a) monitor progress of mitigation strategies and establish timelines and (b) detect failed strategies in need of revision. IRS meets these criteria through its biweekly meetings with workstream risk managers, BOD executive leads, and PPACA senior leadership. These meetings allow for continued review of risks and escalation of risk ownership as risks develop. IRS plans to develop performance measures by July 1, 2012, to help identify strategies in need of revision. Source: GAO analysis. Page 24 GAO-12-690 Patient Protection and Affordable Care Act Appendix III: Provisions Evaluated for Appendix III: Provisions Evaluated for Consistent Use of Risk Management Plan Consistent Use of Risk Management Plan In evaluating IRS’s responses to a sample of nine PPACA provisions, we found that IRS generally followed the plan to identify, track and report risks. As discussed in our report, exceptions were (1) IRS did not consistently evaluate potential risk mitigation strategies in the Resolution/Mitigation stage of its risk plan, and (2) the risk plan was not used when the Office of Chief Counsel led the implementation of provisions related to a reinsurance program for early retirees and the economic substance doctrine. Table 8 shows the results of our evaluation. Table 8: Consistency with Which IRS Used Its Risk Plan in Implementing Selected PPACA Provisions Resolution/ Provision Description Identification Tracking mitigation Reporting Patient Protection and Affordable Care Act (PPACA), Pub. L. No. 111-148, 124 Stat. 119 (Mar. 23, 2010) a 1102 Establishes a temporary reinsurance program to provide reimbursement for a portion of the cost of providing health ○ ○ ○ ○ insurance coverage to early retirees. 1401 Provides premium assistance refundable tax credits for applicable taxpayers who purchase insurance through a state exchange, paid directly to the insurance plans monthly or to ● ● ◑ ● individuals who pay out-of-pocket at the end of the taxable year. 1402 Provides a cost-sharing subsidy for applicable taxpayers to reduce annual out-of-pocket deductibles. ● ● ◑ ● 1421 Provides nonrefundable tax credits for qualified small employers (no more than 25 full-time equivalents (FTE) with annual wages averaging no more than $50,000) for ● ● ◑ ● contributions made on behalf of its employees for premiums for qualified health plans. 1501 Requires all U.S. citizens and legal residents and their dependents to maintain minimum essential insurance coverage unless exempted starting in 2014 and imposes a ● ● ◑ ● fine on those failing to maintain such coverage. 1513 Imposes a penalty on large employers (50+ FTEs) who (1) do not offer coverage for all of their full-time employees, offer unaffordable minimum essential coverage, or offer plans with high out-of-pocket costs and (2) have at least one full-time ● ● ◑ ● employee certified as having purchased health insurance through a state exchange and was eligible for a tax credit or subsidy. Page 25 GAO-12-690 Patient Protection and Affordable Care Act Appendix III: Provisions Evaluated for Consistent Use of Risk Management Plan Resolution/ Provision Description Identification Tracking mitigation Reporting 9008 Imposes a fee on each covered entity engaged in the business of manufacturing or importing branded prescription ● ● ◑ ● drugs. Health Care and Education Reconciliation Act of 2010 (HCERA), Pub. L. No. 111-152, 124 Stat. 1029 (Mar. 30, 2010) 1402 Imposes an unearned income Medicare contribution tax of 3.8 percent on individuals, estates, and trusts on the lesser of net investment income or the excess of modified adjusted ● ● ◑ ● gross income (AGI + foreign earned income) over a threshold of $200,000 (individual) or $250,000 (joint). b 1409 Clarifies and enhances the applications of the economic substance doctrine and imposes penalties for underpayments ○ ○ ○ ○ attributable to transaction lacking economic substance. Legend: ● Consistently followed risk management plan while addressing risks related to implementation ◑ Partially followed risk management plan while addressing risks related to implementation ○ Did not consistently follow risk management plan while addressing risks related to implementation Source: GAO analysis based on IRS data. a Implementation of this provision was led by the Office of Chief Counsel. The ACA Risk Management Plan was not used to track risks related to the implementation of this provision. b Implementation of this provision was led by the Office of Chief Counsel. The ACA Risk Management Plan was not used to track risks related to the implementation of this provision. Page 26 GAO-12-690 Patient Protection and Affordable Care Act Appendix IV: Comments from the Internal Appendix IV: Comments from the Internal Revenue Service Revenue Service Page 27 GAO-12-690 Patient Protection and Affordable Care Act Appendix IV: Comments from the Internal Revenue Service Page 28 GAO-12-690 Patient Protection and Affordable Care Act Appendix V: GAO Contact and Staff Appendix V: GAO Contact and Staff Acknowledgments Acknowledgments James R. White, (202) 512-9110, email@example.com GAO Contact In addition to the to the individual named above, Thomas Short, Assistant Staff Director; Ben Atwater; Linda Baker; Amy Bowser; Dean Campbell; Acknowledgments Jennifer Echard; Rebecca Gambler; Meredith Graves; Sairah Ijaz; Sherrice Kerns; Donna Miller; Patrick Murray; Sabine Paul; and Cynthia Saunders made key contributions to this report. Page 29 GAO-12-690 Patient Protection and Affordable Care Act Related GAO Products Related GAO Products IRS 2013 Budget: Continuing to Improve Information on Program Costs and Results Could Aid in Resource Decision Making. GAO-12-603. Washington, D.C.: June 8, 2012. Small Employer Health Tax Credit: Factors Contributing to Low Use and Complexity. GAO-12-549. Washington, D.C.: May 14, 2012. Patient Protection and Affordable Care Act: IRS Should Expand Its Strategic Approach to Implementation. GAO-11-719. Washington, D.C.: June 25, 2011. GAO Cost Estimating and Assessment Guide: Best Practices for Developing and Managing Capital Program Costs. GAO-09-3SP. Washington, D.C.: March 2, 2009. Risk Management: Further Refinements Needed to Assess Risks and Prioritize Protective Measures at Ports and Other Critical Infrastructure. GAO-06-91. Washington, D.C.: December 15, 2005. Page 30 GAO-12-690 Patient Protection and Affordable Care Act (450943) GAO’s Mission The Government Accountability Office, the audit, evaluation, and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. GAO’s commitment to good government is reflected in its core values of accountability, integrity, and reliability. The fastest and easiest way to obtain copies of GAO documents at no Obtaining Copies of cost is through GAO’s website (www.gao.gov). Each weekday afternoon, GAO Reports and GAO posts on its website newly released reports, testimony, and correspondence. To have GAO e-mail you a list of newly posted products, Testimony go to www.gao.gov and select “E-mail Updates.” Order by Phone The price of each GAO publication reflects GAO’s actual cost of production and distribution and depends on the number of pages in the publication and whether the publication is printed in color or black and white. Pricing and ordering information is posted on GAO’s website, http://www.gao.gov/ordering.htm. Place orders by calling (202) 512-6000, toll free (866) 801-7077, or TDD (202) 512-2537. Orders may be paid for using American Express, Discover Card, MasterCard, Visa, check, or money order. Call for additional information. Connect with GAO on Facebook, Flickr, Twitter, and YouTube. Connect with GAO Subscribe to our RSS Feeds or E-mail Updates. Listen to our Podcasts. Visit GAO on the web at www.gao.gov. Contact: To Report Fraud, Waste, and Abuse in Website: www.gao.gov/fraudnet/fraudnet.htm E-mail: firstname.lastname@example.org Federal Programs Automated answering system: (800) 424-5454 or (202) 512-7470 Katherine Siggerud, Managing Director, email@example.com, (202) 512- Congressional 4400, U.S. Government Accountability Office, 441 G Street NW, Room Relations 7125, Washington, DC 20548 Chuck Young, Managing Director, firstname.lastname@example.org, (202) 512-4800 Public Affairs U.S. Government Accountability Office, 441 G Street NW, Room 7149 Washington, DC 20548 Please Print on Recycled Paper.
Patient Protection and Affordable Care Act: IRS Managing Implementation Risks, but Its Approach Could Be Refined
Published by the Government Accountability Office on 2012-06-13.
Below is a raw (and likely hideous) rendition of the original report. (PDF)