The CAA amended sections of the Children’s Health Act of 2000—which  required HHS to conduct activities related to autism research,  surveillance, and coordination—by revising some sections and repealing  other sections of that law as well as establishing new requirements.CAA authorized, but did not appropriate, federal funding to carry out  these activities in fiscal year 2007 through fiscal year 2011. HHS Agencies Responded to the CAA by Establishing New Autism Activities and Continuing Others

HHS agencies responded to the CAA with new or continuing autism  activities. In fiscal year 2008, HRSA created the Combating Autism Act  Initiative in response to specific directives included in the CAA. Through  this initiative, HRSA expanded its existing training programs to include an  autism-specific component and established new autism research and  state grants. NIH and CDC continued the autism activities each implemented prior to  the enactment of the CAA, but did not create new programs as a direct  result of the CAA. Since the enactment of the CAA,  NIH continued to fund, expand, and coordinate autism research through  its Autism Centers of Excellence and autism-specific grants and  contracts. According to agency officials, NIH awards these grants and  contracts under its general Public Health Service Act authorities and not  under the specific authorities provided in the CAA.fund its regional centers of excellence for autism epidemiology and other  activities, such as an awareness campaign on autism and other  developmental disabilities. As required by the CAA, the Interagency Autism Coordinating Committee  (IACC)—initially established under the Children’s Health Act— restructured its membership and assumed additional responsibilities to  coordinate autism efforts within HHS. IACC membership expanded to include 11 nonfederal  members that represented individuals with autism and parents of children  with autism. Since fiscal year 2007,  the IACC issued several reports as a means to coordinate HHS autism  efforts and monitor federal autism activities, some of which were  specifically required by the CAA, such as the development of an autism  strategic plan and a summary of advances in autism research.appendix II for a description of the documents produced by the IACC. In addition to the changes to the IACC, in 2008, NIH created the Office of  Autism Research Coordination (OARC) within the National Institute of  Mental Health (NIMH) to coordinate and manage the IACC and related  cross-agency activities, programs, and policies. While the CAA authorized appropriations for HRSA, NIH, and CDC autism activities, the  CAA did not appropriate funds for this purpose. Reinvestment Act of 2009. The IACC’s funding increased  significantly from fiscal year 2006 to 2011. From fiscal year 2006 through  fiscal year 2011, the IACC also received funds from the annual NIH  appropriation. HRSA Routinely Collects and Reviews Information to Oversee CAA Grantees

HRSA, the only HHS agency that awarded grants specifically as a result  of the CAA, regularly collects and reviews information from grantees to  oversee individual CAA grantees as well as to provide oversight to its  CAA programs. HRSA awarded approximately $164 million in grants to  110 CAA grantees from fiscal years 2008 to 2011. As part of the agency’s oversight of its CAA grantees, HRSA requires  periodic reports from these grantees, which are reviewed by HRSA staff. Semiannual progress reports. In addition to reports, HRSA also requires grantees to submit written  requests before making certain changes to the grant project, known as  prior-approval requests. For example, a change in the director of the  grant project requires prior approval, as does a request to carry over  unobligated funds to the next budget period or a request for a no-cost  extension—an extension for a limited period beyond the end of the project  period so that the grantee can complete project activities. Generally, grantees submitted required  reports and HRSA staff documented their review of these reports. Specifically, the 22 grantees in our unbiased random sample submitted  all of the 106 reports they were required to submit and most of these  reports were submitted on time. Our review confirmed that HRSA has conducted a number of site visits to  monitor CAA grantees. For example, nine of the grantees in our review  had documentation indicating that a site visit had been conducted, with  only two of these being required site visits. Besides overseeing specific grantees, HRSA monitors its CAA activities  at the program level by regularly collecting performance reports from  grantees. Finally, to further help oversee CAA programs and consolidate  information on its monitoring approach for these programs, in December  2012 HRSA released a grant-management operations manual to outline  its overall approach for monitoring these programs. Agency Comments

We provided a draft of this report to HHS for comment. HHS provided  technical comments that we incorporated, as appropriate. Appendix III: Department of Health and Human Services (HHS) Funding for Autism Activities for Fiscal Years 2006 through 2011

HHS component  Health Resources and Services Administration (HRSA)
Centers for Disease Control and Prevention (CDC)
HRSA’s totals include autism grant awards, as well as, for example, funding used for HRSA’s  personnel expenses, travel, supplies, and overhead related to reviewing these grants.
Why GAO Did This Study

CDC considers autism to be an important public health concern. In 2012, CDC reported that an estimated 1 in 88 children in the United States has been identified as having autisma 23 percent increase from its estimate of 1 in 110 reported in 2009. Autism is a developmental disorder involving communication and social impairment. Symptoms usually become evident in early childhood. There are many suspected causes and no known cure.
HHS agencies fund educational and support services for individuals diagnosed with autism and fund research in a variety of areas, such as identifying the causes of autism and intervention options. The CAA amended sections of the Childrens Health Act of 2000 related to autism and established new requirements. The CAA, enacted in December 2006, authorized the expansion of HHSs activities related to autism research, surveillance, prevention, intervention, and education through fiscal year 2011. The CAA authorized, but did not appropriate, federal funding to carry out these activities.
In this report, GAO (1) describes the actions that HHS agencies have taken as a result of the CAA, and (2) examines the oversight of CAA grantees. To address these objectives, GAO reviewed CAA and HHS documents and interviewed agency officials to identify the autism activities resulting from the CAA. GAO also determined the amount certain HHS agencies spent on autism activities from fiscal year 2006prior to the CAAthrough fiscal year 2011. In addition, GAO reviewed files for a random sample of CAA grantees to examine oversight from 2008 to 2011.

What GAO Found

Department of Health and Human Services (HHS) agencies responded to the Combating Autism Act of 2006 (CAA) by establishing some new autism activities and continuing others. The Health Resources and Services Administration (HRSA) created a new initiative to address specific directives in the CAA. Through this initiative, HRSA expanded its existing training programs by requiring grantees to include training specific to autism. It also established new autism research grants and funded new state grants to improve services for children with autism. HRSA awards its autism grants under the authority of the CAA. The National Institutes of Health (NIH) and Centers for Disease Control and Prevention (CDC) continued their autism activities--some of which were undertaken in response to the Children's Health Act of 2000--but did not create new programs as a direct result of the CAA. NIH continued to fund, expand, and coordinate autism research through its Autism Centers of Excellence and autism-specific grants and contracts. CDC continued to fund its regional centers of excellence for autism epidemiology and other activities, such as an awareness campaign. HHS's Interagency Autism Coordinating Committee (IACC)--reauthorized by the CAA--assumed additional responsibilities to coordinate autism efforts within HHS and restructured its membership to include more nonfederal members. NIH created the Office of Autism Research Coordination to coordinate and manage the IACC. The CAA did not appropriate funds to any HHS agency. Nevertheless, overall spending on HRSA, NIH, CDC, and IACC autism activities increased from approximately $143.6 million in fiscal year 2006 to approximately $240.4 million in fiscal year 2011.
HRSA, the only HHS agency that has awarded grants specifically as a result of the CAA, regularly collects and reviews information from grantees to oversee individual CAA grantees and programs. HRSA awarded approximately $164 million in grants to 110 CAA grantees from fiscal years 2008 to 2011; though, some of these grantees were already receiving funds prior to the CAA. To oversee these grantees, HRSA requires they regularly submit progress reports and financial reports. The agency also requires grantees to obtain prior approval before making certain changes to their projects. GAO reviewed documentation for an unbiased random sample of 22 grantees, which were representative of the 110 CAA grantees. GAO found that CAA grantees submitted all required reports. Many grantees submitted prior-approval requests for changes to their projects. Most frequently, grantees requested to carry over unobligated funds from the current year to the next budget period. GAO found that HRSA staff routinely collected and reviewed information submitted by the grantees and appropriately documented their review and approval of these submissions. HRSA also conducted site visits and provided technical assistance as a means of overseeing grantees. HRSA conducted site visits with 9 of the grantees in our sample during the period of our review, while only 2 of these were required sites visits. Besides overseeing grantees, HRSA monitors its overall CAA programs by regularly collecting performance reports from grantees. In addition, in December 2012, HRSA released a grant-management operations manual to outline its overall approach for monitoring its CAA programs.
GAO provided a draft of this report to HHS for comment. In response, HHS provided technical comments that were incorporated, as appropriate.