oversight

Veterans' Health Care Budget: Transparency and Reliability of Some Estimates Supporting President's Request Could Be Improved

Published by the Government Accountability Office on 2012-06-11.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                             United States Government Accountability Office

GAO                          Report to Congressional Committees




June 2012
                             VETERANS’ HEALTH
                             CARE BUDGET
                             Transparency and
                             Reliability of Some
                             Estimates Supporting
                             President’s Request
                             Could Be Improved



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GAO-12-689
                                              June 2012

                                              VETERANS’ HEALTH CARE BUDGET
                                              Transparency and Reliability of Some Estimates
                                              Supporting President’s Request Could Be Improved
Highlights of GAO-12-689, a report to
congressional committees




Why GAO Did This Study                        What GAO Found
The Veterans Health Care Budget               The President’s fiscal year 2013 budget request for the Department of Veterans
Reform and Transparency Act of 2009           Affairs’ (VA) health care services was $165 million more than the earlier advance
requires GAO to report on the                 appropriations request for the same year. This request reflected a $2 billion
President’s annual budget request to          increase for initiatives and a $2.1 billion decrease for ongoing health care
Congress for VA health care services.         services, for a net decrease of $110 million in expected obligations. This
GAO’s previous work found that VA’s           decrease partially offset a decline in anticipated resources available to VA of
NRM spending exceeded its estimates           $275 million, resulting in the net increase in the President’s request of
in recent years and that some of VA’s         $165 million. Two of the three factors that accounted for most of these changes
estimates of savings from operational
                                              were not transparent. First, VA used a new reporting approach for initiatives that
improvements lacked analytical
                                              combined both funding for initiatives and for certain ongoing health care services
support or were flawed.
                                              in its initiatives estimate. Previously, VA had reported only funding it identified for
Building on GAO’s past work and the           initiatives during that year. This new reporting approach resulted in an increase in
President’s most recent request for VA        VA’s initiatives estimate and a commensurate decrease in VA’s ongoing services
health care, this report examines             estimate. VA officials told GAO that this change was made to be more
(1) key changes to the fiscal year 2013       transparent about the total funding needed for initiatives. However, because VA
budget request compared to the 2013           did not disclose this change in its budget justification, VA has not made it
advance appropriations request, and           transparent that its initiatives estimate is greater and its ongoing health care
certain aspects of the fiscal year 2014       services estimate is lower than they would have been using VA’s past approach.
advance appropriation request and             Second, VA included additional funding in its initiatives estimate, in part, to fund
supporting estimates; and (2) whether
                                              initiatives that were not identified in the fiscal year 2013 advance appropriations
the issues GAO identified regarding
                                              request. VA also did not make transparent in its budget justifications that some
NRM and operational improvements
continue in the estimates for the most        initiatives identified in its fiscal years 2013 and 2014 advance appropriations
recent request. GAO reviewed the              requests may require additional funding if the initiatives are continued. The lack
President’s budget request, VA’s              of transparency regarding VA’s estimates for initiatives and ongoing health care
budget justification, and VA data. GAO        services results in unclear information for congressional deliberation.
interviewed VA officials and staff from       The issues GAO previously identified related to NRM (non-recurring
the Office of Management and Budget.          maintenance), such as renovations and other improvements of VA medical
What GAO Recommends                           facilities, and operational improvements remain. VA’s fiscal year 2013 estimate
                                              for NRM—$710 million—does not appear to correct for the long-standing pattern
GAO recommends that VA state in its           where VA’s NRM spending exceeds VA’s NRM estimates. For example, in fiscal
budget justification whether the              year 2011 VA spent about $2 billion for NRM, which was $867 million more than
estimates for initiatives include funding     estimated. According to VA officials, this pattern has occurred because VA
for ongoing services and whether its          medical facilities have spent more funds on NRM projects that were originally
advance appropriations request                expected to be spent on other activities—such as utilities, grounds maintenance,
reflects funding that may be required if
                                              and janitorial services—which is consistent with VA’s authority to allocate its
initiatives are continued. GAO also
                                              appropriations. When GAO asked if the fiscal year 2013 estimate addressed the
recommends that VA’s NRM estimates
fully account for the long-standing           historical discrepancies between estimated and actual NRM spending, VA
pattern of medical facilities spending        officials said that all information was considered in developing the estimate.
more on NRM than originally expected.         However, they noted that the final estimate was a policy decision and did not say
VA concurred except for the                   specifically whether these discrepancies were addressed. Regarding operational
recommendation on advance                     improvements, VA estimated savings for fiscal year 2013 using the same
appropriations, which GAO believes is         methodologies it used in the past, some of which GAO previously found lacked
needed to improve transparency.               analytical support or were flawed. GAO previously recommended that VA
                                              develop a sound methodology for estimating savings from its operational
View GAO-12-689. For more information,        improvements, which according to officials, VA is addressing for future estimates.
contact Randall B. Williamson at (202) 512-   Until these issues are addressed, VA’s estimates of NRM and operational
7114 or williamsonr@gao.gov or Melissa
Emrey-Arras at (617) 788-0534 or
                                              improvements may not be reliable and are of limited use for decision makers.
emreyarrasm@gao.gov.
                                                                                        United States Government Accountability Office
Contents


Letter                                                                                             1
                       Background                                                                  5
                       VA Changed Estimates Supporting the Request, but Factors That
                         Account for Most of the Changes Were Not Transparent                      8
                       Past Issues in VA’s Estimates for NRM and Operational
                         Improvements Remain                                                     13
                       Conclusions                                                               16
                       Recommendations for Executive Action                                      17
                       Agency Comments and Our Evaluation                                        17

Appendix I             Comments from the Department of Veterans Affairs                          22



Appendix II            GAO Contacts and Staff Acknowledgments                                    25



Related GAO Products                                                                             26



Tables
                       Table 1: Comparison of the Estimates That Supported the
                                President’s Advance Appropriations Request and
                                President’s Budget Request and the Effect of Any
                                Differences on the President’s Budget Request, Fiscal Year
                                2013                                                               9
                       Table 2: Key Factors That Accounted for Changes Made to VA’s
                                Estimates for Ongoing Health Care Services and Initiatives
                                Supporting the President’s Fiscal Year 2013 Budget
                                Request                                                          10
                       Table 3: Comparison of Differences in Estimates for Initiatives
                                That Supported the President’s Advance Appropriations
                                Request and the President’s Budget Request, Fiscal Year
                                2013                                                             12


Figure
                       Figure 1: Non-Recurring Maintenance (NRM) Estimates That
                                Support the President’s Budget Request and VA’s NRM
                                Spending, Fiscal Years 2006 to 2014                              14


                       Page i                                        GAO-12-689 VA Health Care Budget
Abbreviations

DOD               Department of Defense
EHCPM             Enrollee Health Care Projection Model
NRM               non-recurring maintenance
OMB               Office of Management and Budget
VA                Department of Veterans Affairs
VHA               Veterans Health Administration



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Page ii                                                 GAO-12-689 VA Health Care Budget
United States Government Accountability Office
Washington, DC 20548




                                   June 11, 2012

                                   Congressional Committees

                                   The Department of Veterans Affairs (VA) operates one of the largest
                                   health care delivery systems in the nation. VA provides a range of health
                                   care services for eligible veterans, including primary care, inpatient and
                                   outpatient surgery, prosthetics, mental health services, prescription drugs,
                                   and nursing home care. 1 In fiscal year 2011, VA served about 6.2 million
                                   patients and spent $51.4 billion on health care services. Unlike most other
                                   agencies, VA receives advance appropriations for health care in addition
                                   to annual appropriations. 2 In preparation for the appropriations process,
                                   therefore, VA develops an annual estimate of the resources needed to
                                   provide its health care services for 2 fiscal years. This budget estimate is
                                   reviewed through successively higher levels within the agency and
                                   revised until consolidated into a departmentwide annual budget estimate
                                   that is submitted to the Office of Management and Budget (OMB) for
                                   review and consideration. OMB subsequently includes both an


                                   1
                                    Eligibility is determined on the basis of service-connected disability, income, and other
                                   special statuses, such as former prisoners of war, and is used to determine priority for VA
                                   services. VA is required to provide a specified set of health care services, including
                                   hospital care, to eligible veterans. 38 U.S.C. §§ 1710(a)(1), (2), 1701(5), (6). VA is
                                   authorized to provide these health care services to other veterans not identified in these
                                   groups. 38 U.S.C. § 1710(a)(3). The population of veterans to whom VA is required to
                                   provide nursing home care is more limited than the population to whom VA is required to
                                   provide other health care services, although VA also makes nursing home care available
                                   to other veterans on a discretionary basis as resources permit. See 38 U.S.C. § 1710A.
                                   Requirements for VA health care services are effective in any fiscal year only to the
                                   extent and in the amount provided in advance in appropriations acts for such purposes.
                                   38 U.S.C. § 1710(a)(4).
                                   2
                                    The Veterans Health Care Budget Reform and Transparency Act of 2009 provided that
                                   VA’s annual appropriations for health care also include advance appropriations that
                                   become available 1 fiscal year after the fiscal year for which the appropriations act was
                                   enacted. Pub. L. No. 111-81, § 3, 123 Stat. 2137, 2137–38 (2009), codified at 38 U.S.C.
                                   § 117. The act provided for advance appropriations for VA’s Medical Services, Medical
                                   Support and Compliance, and Medical Facilities appropriations accounts and directed VA
                                   to include with information it provides Congress in connection with the annual
                                   appropriations process detailed estimates of funds needed to provide its health
                                   care services for the fiscal year for which advance appropriations are to be provided.
                                   For example, Congress provided annual appropriations for VA health care of about
                                   $51.2 billion for fiscal year 2012 and advance appropriations of $52.6 billion for fiscal
                                   year 2013. Pub. L. No. 112-10, div. B, title X, § 2015, 125 Stat. 38, 175 (2011); Pub. L.
                                   No. 112-74, div. H, title II, 125 Stat. 786, 1149-50 (2011).




                                   Page 1                                                  GAO-12-689 VA Health Care Budget
appropriations request for VA health care services for 1 fiscal year and an
advance appropriations request for the next fiscal year in the President’s
annual budget request, which is submitted to Congress in February of
each year. 3

In support of the President’s request, VA prepares an annual budget
justification for Congress. The budget justification provides Congress and
stakeholders with estimates and other information that support the
policies and spending decisions represented in the President’s budget
request, including information on what VA plans to achieve with the
resources requested. In particular, VA’s budget justification includes
detailed information on estimates of funding needed for ongoing health
care services and health-care-related initiatives proposed by the
Secretary of VA and the President. As such, VA’s budget justification is
used to provide Congress and stakeholders with important information
about agency priorities, as well as the implications of the requested
amounts for VA’s provision of health care services to veterans.

The development of VA’s health care budget estimate is inherently
complex, as assumptions and imperfect information are used to project
the likely quantity and cost of the health care services VA expects to
provide. 4 Most of these projections are made several years into the future
based on data from the most recent fiscal year. As such, VA’s budget
estimate is prepared in the context of uncertainties about the future—not
only about program needs, but also about future economic conditions,
presidential policies, and congressional actions that may affect the
funding needs in the year for which the request is made. Our prior work
has highlighted some of the challenges VA has faced in obtaining
sufficient data; making accurate calculations and realistic assumptions
when formulating its budget estimate; and developing estimates for non-




3
 For example, the President’s fiscal year 2013 budget request included a request for VA
health care for fiscal year 2013 as well as an advance appropriations request for fiscal
year 2014. Next February, the President may request different appropriations for fiscal
year 2014, which, if enacted, would supersede the enacted fiscal year 2014 advance
appropriations.
4
 See GAO, VA Health Care: Challenges in Budget Formulation and Execution,
GAO-09-459T (Washington, D.C.: Mar. 12, 2009).




Page 2                                                 GAO-12-689 VA Health Care Budget
recurring maintenance (NRM), 5 which have been consistently lower than
actual expenditures in recent years. 6 In a February 2012 report, we found
that VA’s estimated savings from some operational improvements—used
to support the President’s budget request for fiscal year 2012 and
advance appropriations request for fiscal year 2013—lacked analytical
support or were flawed. 7 We made a recommendation to improve VA’s
operational improvement estimates. VA concurred with the
recommendation except for two real property initiatives where VA
maintained that the savings estimates were not flawed.

The Veterans Health Care Budget Reform and Transparency Act of 2009
requires us to report on the President’s annual budget request to
Congress for VA health care services. The law requires that we report on
our analysis within 120 days after the President’s budget requests are
submitted in 2011, 2012, and 2013. Our June 2011 report, in response to
the act, noted that in recent years VA’s spending for NRM exceeded the
amounts identified in VA’s budget justifications and reflected in the
President’s budget request. We also raised concerns that VA may have to
make difficult trade-offs to manage within its fiscal years 2012 and 2013
resources if the estimated savings from operational improvements, such
as proposed changes to purchasing and contracting, do not materialize. 8
Building upon our work from our June 2011 report and in light of the



5
 NRM funds are used for expansion, renovation, and infrastructure improvements of VA
health care facilities that cost more than $25,000. Examples include upgrades to safety,
security, and fire alarms; interior or exterior renovations; improving accessibility for
patients with disabilities; improvements to the heating, ventilation, and air conditioning;
and projects to improve the roads or grounds.
6
 For example, see GAO, VA Health Care: Budget Formulation and Reporting on Budget
Execution Need Improvement, GAO-06-958 (Washington, D.C.: Sept. 20, 2006); and VA
Health Care: Long-Term Care Strategic Planning and Budgeting Need Improvement,
GAO-09-145 (Washington, D.C.: Jan. 23, 2009).
7
 Operational improvements are actions the agency plans to undertake to better manage
VA’s health care system in an effort to improve the delivery of care and lower costs. See
GAO, VA Health Care: Methodology for Estimates and Process for Tracking Savings
Need Improvement, GAO-12-305 (Washington, D.C.: Feb. 27, 2012).
8
  GAO, Veterans’ Health Care Budget Estimate: Changes Were Made in Developing the
President’s Budget Request for Fiscal Years 2012 and 2013, GAO-11-622 (Washington,
D.C.: June 14, 2011). In this report, we examined key changes VA identified that were
made to its health care budget estimate to develop the President’s budget request for
fiscal year 2012, including the advance appropriations request for fiscal year 2013, and
how various sources of funding and other factors informed that request.




Page 3                                                   GAO-12-689 VA Health Care Budget
President’s most recent request for VA health care services, which
includes fiscal year 2013 appropriations and advance appropriations for
fiscal year 2014, this report examines: (1) key changes to the President’s
fiscal year 2013 budget request compared to the advance appropriations
request for the same year, as well as certain aspects of the fiscal year
2014 advance appropriations request and supporting estimates; and
(2) whether the issues we previously identified regarding NRM and
operational improvements continue in the estimates that support the
President’s fiscal year 2013 budget request.

To examine key changes between the President’s fiscal year 2013 budget
request and last year’s advance appropriations request for fiscal year
2013, we reviewed and analyzed each request as well as VA documents
and data related to the estimates that support them. We interviewed VA
officials and OMB staff to discuss the key reasons for any differences
between the estimates used to support the two requests. Finally, we
reviewed the budget justification supporting the President’s fiscal year
2013 request in the context of whether it provided Congress relevant
information that could have a significant impact on VA achieving its
objectives, including what VA plans to achieve with the resources
requested. 9 Specifically, we evaluated whether VA informed Congress in
its budget justification about key changes that occurred between the
President’s fiscal year 2013 budget request and the earlier, advance
appropriations request for that same year.

To examine whether the issues we previously identified regarding NRM
and operational improvements continue in the estimates that support the
President’s fiscal year 2013 budget request for VA, we reviewed VA’s
budget justification that supports this request. We also reviewed VA
documents and data that described and supported the amounts VA
estimated for NRM and the savings from the operational improvements.
We interviewed VA officials and OMB staff to discuss the methods VA
used to develop these estimates as well as the consistent pattern in
recent years in which VA’s spending for NRM has exceeded its estimates.
In addition, we assessed the amounts estimated for NRM and operational
improvements in VA’s budget justification in the context of federal


9
 The federal standards for internal control for information and communication, in part,
refer to an agency’s ability to provide relevant information to stakeholders. See GAO,
Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1
(Washington, D.C.: November 1999).




Page 4                                                  GAO-12-689 VA Health Care Budget
             standards of internal control for information and communication.
             Specifically, we evaluated whether VA provided Congress reliable
             information for making decisions based on VA’s NRM and operational
             improvements estimates for fiscal year 2013.

             To assess the reliability of VA’s estimates, we obtained documents
             supporting these data and verified the consistency of the information in
             these documents. We confirmed that the estimates were reflected in the
             President’s fiscal year 2013 budget request for VA health care services
             and VA’s related budget justification. We also relied on our prior work to
             compare data and check for internal consistency and discussed these
             data with VA officials. We found the data reliable for the purposes of
             comparing the fiscal year 2013 President’s budget request with the
             earlier, advance appropriations request for that year and for examining
             whether the issues we previously identified for NRM and operational
             improvements continued in the estimates that support the President’s
             fiscal year 2013 year budget request.

             We conducted this performance audit from December 2011 through 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.


             VA provides health care services to various veteran populations—
Background   including an aging veteran population and a growing number of younger
             veterans returning from the military operations in Afghanistan and Iraq.
             VA operates approximately 150 hospitals, 130 nursing homes, 800
             outpatient clinics, as well as other facilities to provide care to veterans. In
             general, veterans must enroll in VA health care to receive VA’s medical
             benefits package—a set of services that includes a full range of hospital
             and outpatient services, prescription drugs, and long-term care services
             provided in veterans’ own homes and in other locations in the
             community. 10 VA also provides some services that are not part of its


             10
               VA provides adult day care, respite care, and other noninstitutional long-term care
             services as part of the medical benefits package it provides to all enrolled veterans. See
             38 U.S.C. §§ 1701(6)(E), 1710B; 38 C.F.R. § 17.38.




             Page 5                                                   GAO-12-689 VA Health Care Budget
medical benefits package, such as long-term care provided in nursing
homes.

VA develops a health care budget estimate each year of the resources
needed to provide these services for 2 fiscal years. Typically, VA’s
Veterans Health Administration (VHA), which administers VA’s health
care program, starts to develop a health care budget estimate
approximately 10 months before the President submits the budget
request to Congress the following February. The budget estimate
includes the total cost of providing health care services, including direct
patient costs as well as costs associated with management,
administration, and maintenance of facilities. VA develops most of its
budget estimate for health care services using the Enrollee Health Care
Projection Model (EHCPM). 11 VA uses other methods to develop the
remaining parts of its budget estimate, that is, the costs of long-term care
and other health care programs. 12

VA’s annual budget estimate for a fiscal year includes estimates of
anticipated funding from several sources. These sources include new
appropriations, which refer to the appropriations to be provided during the
current annual appropriations process for the upcoming fiscal year, and
with respect to advance appropriations, the next fiscal year. For example,
VA estimated it needed $52.7 billion in new appropriations for fiscal year
2013 and $54.5 billion for fiscal year 2014. In addition to new
appropriations, sources of funding include resources expected to be
available from unobligated balances and collections and reimbursements



11
  See GAO, VA Health Care: VA Uses a Projection Model to Develop Most of Its Health
Care Budget Estimate to Inform the President’s Budget Request, GAO-11-205
(Washington, D.C.: Jan. 31, 2011). For fiscal years 2013 and 2014, VA used the EHCPM
to estimate resources needed for 59 health care services. The estimates are based on
three basic components: the projected number of veterans who will be enrolled in VA
health care, the projected quantity of health care services enrollees are expected to use,
and the projected unit cost of providing these services—unit costs are the costs to VA of
providing a unit of services, such as a 30-day supply of a prescription or a day of care at a
medical facility. The EHCPM makes these projections 3 or 4 years into the future for
budget purposes based on data available from the most recent fiscal year. For example, in
2011, VA used data from fiscal year 2010 to develop its health care budget estimate for
the fiscal year 2013 request and advance appropriations request for 2014.
12
  The estimates for these services are based on factors, such as recent data on the costs
and the amount of care VA provided to veterans, VA’s policy goals for providing such
services, and projections of the number of users.




Page 6                                                   GAO-12-689 VA Health Care Budget
that VA anticipates it will receive in the fiscal year. 13 VA’s collections
include third-party payments from veterans’ private health care insurance
for the treatment of nonservice-connected conditions and veterans’
copayments for outpatient medications. VA’s reimbursements include
amounts VA receives for services provided under service agreements
with the Department of Defense (DOD).

VA’s health care budget estimate informs the President’s annual request
for appropriations for VA health care services, which includes an advance
appropriations request for these services. The budget estimate can
change during each budget formulation cycle, due to the availability of
updated data and the successively higher levels of review in VA and OMB
before the President’s budget request is submitted to Congress. The
Secretary of VA considers the health care budget estimate developed by
VHA when assessing resource requirements among competing interests
within VA, and OMB considers overall resource needs and competing
priorities of other agencies when deciding the level of funding requested
for VA’s health care services. VA prepares a budget justification that
provides information supporting the policy and funding decisions in the
President’s budget request. In its budget justification, VA includes
estimates related to the following:

•    Ongoing health care services, which include acute care,
     rehabilitative care, mental health, long-term care, and other health
     care programs. 14

•    Initiatives, which are proposals by the Secretary of VA or by the
     President to provide, expand, or create new health care services.




13
  In addition to new appropriations that VA may receive from Congress as a result of the
annual appropriations process, funding may also be available from unobligated balances
of multiyear appropriations, which remain available for a fixed period of time in excess of
1 fiscal year. For example, VA’s fiscal year 2012 appropriations provided that about
$1.75 billion be available for 2 fiscal years. These funds may be carried over from fiscal
year 2012 to fiscal year 2013 if they are not obligated by the end of fiscal year 2012. See
Pub. L. No. 112-74, div. H, title II, § 227(b), 125 Stat. 786, 1159 (2011).
14
  Based on fiscal year 2011 data, the largest of VA’s other services was the Civilian
Health and Medical Program of the Department of Veterans Affairs, which provides health
care coverage for the dependents and survivors of veterans who are, or were at the time
of death, permanently and totally disabled from a service-connected disability, or who died
in the line of duty or from a service-connected condition. See 38 U.S.C. § 1781.




Page 7                                                   GAO-12-689 VA Health Care Budget
                                 Some of the proposed initiatives can be implemented within VA’s
                                 existing authority, while other initiatives would require a change in law.

                             •   Operational improvements, which are changes in the way VA
                                 manages its health care system to lower costs, such as changes to its
                                 purchasing and contracting strategies.

                             •   Collections and reimbursements, which are resources VA expects
                                 to collect from health insurers of veterans who receive VA care for
                                 nonservice-connected conditions and other sources, such as
                                 veterans’ copayments, and to receive as reimbursement of services
                                 provided to other government agencies or private or nonprofit entities.



VA Changed
Estimates Supporting
the Request, but
Factors That Account
for Most of the
Changes Were Not
Transparent
Request Increased            The President’s fiscal year 2013 budget request for VA health care
$165 Million, Reflecting     services was $165 million more than the advance appropriations request
an Increase in Initiatives   for the same year. This increase came about as a result of changes in the
                             estimates supporting the two requests. Specifically, the President’s fiscal
and a Decrease in Both       year 2013 request reflected an estimate of funding needed for initiatives
Ongoing Services and         that increased by $2 billion and an estimate for ongoing health care
Available Resources          services that decreased by $2.1 billion, for a net decrease of $110 million.
                             In addition, VA’s estimate of anticipated resources from collections and
                             reimbursements decreased by $275 million. This decline in anticipated
                             resources was partially offset by the $110 million decrease in expected




                             Page 8                                          GAO-12-689 VA Health Care Budget
                                       obligations, which resulted in the net increase in the President’s request
                                       of $165 million. 15 (See table 1.)

Table 1: Comparison of the Estimates That Supported the President’s Advance Appropriations Request and President’s
Budget Request and the Effect of Any Differences on the President’s Budget Request, Fiscal Year 2013

(Dollars in millions)
                                                                                                                                       Effect of the difference
                                          President’s fiscal                                                                                   in estimates on
                                         year 2013 advance                                President’s fiscal                                 President’s fiscal
Description                          appropriations request                       year 2013 budget request                           year 2013 budget request
                           a
Ongoing health care services                               $56,628                                            $54,523                                            ($2,105)
          b
Initiatives                                                  $1,346                                             $3,341                                              $1,995
Operational improvements                                   ($1,284)                                           ($1,284)                                                    $0
Total obligations                                          $56,690                                            $56,580                                               ($110)
Collections and reimbursements                             ($3,649)                                           ($3,374)                                                 $275
Unobligated balances                                          ($500)                                             ($500)                                                   $0
Total appropriations                                       $52,541                                            $52,706                                                  $165
                                       Source: GAO analysis of VA’s congressional budget justification for fiscal year 2013 and VA’s congressional budget justification for
                                       fiscal year 2012—which supported the President’s advance appropriations request for fiscal year 2013.
                                       a
                                        Ongoing health care services include acute care, rehabilitative care, mental health, long-term care,
                                       and other health care programs.
                                       b
                                        Initiatives include those that can be implemented within VA’s existing authority and other initiatives
                                       that would require a change in law.


Three Factors Accounted                Three factors accounted for most of the changes in the estimates that
for Most Changes to                    supported the President’s fiscal year 2013 budget request when
Supporting Estimates, but              compared to the earlier, advance appropriations request; however, VA, in
                                       its budget justification, was not transparent about two of the factors. The
Two Were Not Transparent               three factors that accounted for the $2 billion increase in the initiatives
                                       estimate and the $2.1 billion decrease in the ongoing health care services
                                       estimate were: (1) a new approach in reporting the estimate for initiatives,
                                       (2) updated assumptions and data to estimate ongoing health care


                                       15
                                         Anticipated collections for fiscal year 2013 decreased $325 million from the estimate
                                       provided with the advance appropriations request for that year; however, $50 million of
                                       this decrease was offset by an estimated increase in reimbursements in fiscal year 2013,
                                       compared to the estimate reflected in the advance appropriations request. The decrease
                                       in collections was due to many factors including VA using a new projection model for
                                       collections—rather than historical data—to inform the President’s fiscal year 2013 request,
                                       fewer enrollees having comprehensive health insurance that VA can bill for services that
                                       VA provides, lower payment amounts from insurance companies, and aging enrollees
                                       which results in VA billing more Medigap policies rather than full health insurance policies.




                                       Page 9                                                                              GAO-12-689 VA Health Care Budget
                                          services, and (3) additional funding needed for initiatives. The first
                                          factor—VA’s new reporting approach—accounted for $1.2 billion of the
                                          increase in VA’s initiatives estimate and a corresponding decrease in
                                          VA’s ongoing health care services estimate. The second factor accounted
                                          for a $900 million decrease in VA’s ongoing health care services
                                          estimate. This decrease was largely offset by the third key factor—an
                                          almost $800 million increase in additional funding for initiatives. (See
                                          table 2.)

Table 2: Key Factors That Accounted for Changes Made to VA’s Estimates for Ongoing Health Care Services and Initiatives
Supporting the President’s Fiscal Year 2013 Budget Request

(Dollars in millions)
                                                                                                Ongoing services estimate                          Initiatives estimate
New reporting approach                                                                                                         ($1,213)                                $1,213
Updated data and assumptions for ongoing health care services                                                                     ($892)                    Not applicable
Additional funding for initiatives                                                                                    Not applicable                                      $782
Total difference in estimates due to three key factors                                                                         ($2,105)                                $1,995
                                          Source: GAO analysis of VA’s congressional budget justification for fiscal year 2013 and VA’s congressional budget justification for
                                          fiscal year 2012—which supported the President’s advance appropriations request for fiscal year 2013.



                                          A new approach in reporting the estimate for initiatives. VA used a new
                                          reporting approach for initiatives that combined both funding for initiatives
                                          and funding for certain ongoing health care services in its initiatives
                                          estimate, which increased VA’s initiatives estimate and decreased VA’s
                                          ongoing services estimate. In prior budget justifications, VA’s estimated
                                          funding for initiatives only included funding identified for initiatives during
                                          that year while funding needs for all ongoing services were included in
                                          VA’s estimate for ongoing health care services. However, VA, in its
                                          budget justification, did not disclose that it had used a new reporting
                                          approach for initiatives. OMB staff and VA officials told us that the reason
                                          for this change in reporting was to be more transparent about the total
                                          amount of funding needed to support VA’s initiatives. Nevertheless, by
                                          not stating in its budget justification that it made this change, VA has not
                                          made it transparent that the estimate for initiatives is greater and the
                                          estimate for ongoing services is less than they would have been using
                                          VA’s past reporting approach.

                                          Updated data and assumptions to estimate ongoing health care services.
                                          As reported in its budget justification, VA used updated assumptions and
                                          data, which reduced VA’s estimate for ongoing health care services.
                                          Specifically, the amount of funding needed to support health care
                                          services estimated by the EHCPM decreased because VA updated some


                                          Page 10                                                                             GAO-12-689 VA Health Care Budget
of the assumptions used in the EHCPM. For example, VA updated the
EHCPM’s assumption accounting for the pay freeze for civilian
employees in fiscal years 2011 and 2012, which reduced the base salary
of VA employees in future years. VA also used updated data to adjust the
estimates produced by the EHCPM and the estimates for long-term care
and other health care programs. Updated data for long-term care and
other health care programs generally indicated that costs for these
services would grow at a slower rate than the data used to support the
President’s fiscal year 2013 advance appropriations request indicated.

Additional funding for initiatives. According to VA’s budget justification, as
a result of the reduced estimate for ongoing health care services, VA
increased the estimate of funding needed for its initiatives. This estimate
of funding included funding for all initiatives for which funding was not
requested in the fiscal year 2013 advance appropriations request and
increased funding for some initiatives for which funding had been
identified in the earlier request. 16 However, in its fiscal year 2013 budget
justification, VA did not make it clear that part of the additional increase in
its initiatives estimate occurred because VA’s earlier estimate in support
of the advance appropriations request did not include funding for all the
initiatives the agency intended to continue. According to OMB staff, the
purpose of the advance appropriations request is to provide assurance for
the continuation of ongoing health care services and select initiatives that
represent direct care to veterans. As a result, rather than including
estimates of funding needed to support all initiatives in advance
appropriations requests—including the fiscal year 2013 advance
appropriations request and the fiscal year 2014 advance appropriations
request—the funding needs for all initiatives are taken into account during
the following budget formulation cycle. At that time, once updated data
are available to produce revised estimates for ongoing health care
services, VA and OMB assess the amount of likely resources available to
fund initiatives in the context of overall budget constraints. However, VA
did not state that some initiatives for which estimates were included in the
fiscal years 2013 and 2014 advance appropriations requests would



16
  According to VA officials, VA’s revised initiatives estimate also reflects the use of more
current data, although this was not the primary reason for the increase in the initiatives
estimate. For example, more recent data on the equipment and supplies and additional
personnel costs associated with the activation of completed construction of new or
replacement medical care facilities informed VA’s fiscal year 2013 estimate for the
activation initiative.




Page 11                                                   GAO-12-689 VA Health Care Budget
                                         require additional funding if the initiatives were to be continued. (Table 3
                                         indicates the difference in the fiscal year 2013 initiative estimates
                                         attributable to VA’s new reporting approach versus additional funding.)

Table 3: Comparison of Differences in Estimates for Initiatives That Supported the President’s Advance Appropriations
Request and the President’s Budget Request, Fiscal Year 2013

(Dollars in millions)
                                          President’s fiscal
                                         year 2013 advance                   President’s fiscal                   Difference due to                Difference due to
                                            appropriations                   year 2013 budget                         new reporting               additional funding
                                                                                                                                                                      a
Initiatives and legislative proposals:              request                           request                             approach                     for initiatives
Activations                                                   $344                                $792                                  $83                              $365
Agent Orange                                                  $191                                $191                                    $0                                $0
Amyotrophic Lateral Sclerosis                                   $47                                 $47                                   $0                                $0
Caregivers and Veteran Omnibus
Health Services                                               $248                                $278                                    $0                               $30
DOD/VA Integrated Disability
Evaluations System Enhancement                                  $19                                 $22                                   $0                                $3
Indian Health Services                                          $57                                 $52                                   $0                              ($5)
Homelessness: Zero Homelessness                               $460                             $1,352                                 $678                               $214
New Models of Patient-Centered Care                               $0                              $433                                $354                                 $79
Expand Health Care Access for
Veterans                                                          $0                              $120                                  $98                                $22
Improve the Quality of Health Care
while Reducing Costs                                              $0                                $51                                   $0                               $51
Establish World-Class Health
Informatics Capability                                            $0                                $10                                   $0                               $10
                                b
Improving Veteran Mental Health                 Not applicable                                      $20                                   $0                               $20
Legislative Proposals                                        ($20)                               ($27)                                    $0                              ($7)
Total initiatives                                          $1,346                              $3,341                              $1,213                                $782
                                         Source: GAO analysis of VA’s congressional budget justification for fiscal year 2013 and VA’s congressional budget justification for
                                         fiscal year 2012—which supported the President’s advance appropriations request for fiscal year 2013.
                                         a
                                          According to VA officials, part of the difference in the initiative estimate is also due to revised
                                         estimates for each initiative based on more current data; however, officials stated that this was not a
                                         primary reason for the difference in the initiative estimate between the President’s fiscal year 2013
                                         budget request and the earlier advance appropriations request.
                                         b
                                          The improving Veteran Mental Health initiative was not included in the fiscal year 2013 advance
                                         appropriations request.




                                         Page 12                                                                             GAO-12-689 VA Health Care Budget
                      VA’s budget justification is used to provide Congress with relevant
                      information for making decisions. The lack of transparency regarding the
                      factors that changed VA’s estimates for ongoing health care services and
                      initiatives results in unclear information for congressional deliberation.


                      Our analysis of the estimates supporting the President’s fiscal year 2013
Past Issues in VA’s   budget request found that VA’s supporting estimates (1) do not address
Estimates for NRM     historical discrepancies between estimated and actual NRM spending
                      and (2) lack analytical support for expected savings from some
and Operational       operational improvements.
Improvements
Remain                Regarding NRM, VA’s fiscal year 2013 estimate does not appear to
                      correct for the long-standing pattern of VA’s NRM spending exceeding its
                      estimates and was based on a policy decision. In June 2011, we reported
                      VA’s spending on NRM exceeded the estimates reported in VA’s budget
                      justifications from fiscal years 2006 to 2010. 17 More recently, we found
                      that in fiscal year 2011 VA spent about $2 billion for NRM, which was
                      $867 million more than estimated (see fig. 1). According to VA officials,
                      NRM spending has exceeded estimates of needed funding in recent
                      years because VA medical facilities have spent more funds on NRM
                      projects that were originally expected to be spent on other activities—
                      such as utilities, grounds maintenance, and janitorial services. This
                      spending is consistent with VA’s authority to increase or decrease the
                      amounts VA allocates from the Medical Facilities account for NRM and
                      with congressional committee report language. 18 When we asked VA
                      officials if the fiscal year 2013 estimate addressed the historical
                      discrepancies between amounts estimated and actual spending, VA
                      officials said that all information was considered in developing the
                      estimate. However, VA officials noted that the amount requested was a
                      policy decision and did not specifically say whether these discrepancies
                      were addressed. This explanation suggests that VA has not changed the
                      way in which it determines the final NRM estimate; as we previously
                      reported VA lowered its fiscal year 2012 estimate due to a policy decision
                      to fund other initiatives. 19 Because the fiscal year 2013 estimate of $710



                      17
                       See GAO-11-622.
                      18
                       See, e.g., S. Rep. No. 111-40 (2009), at 57; H.R. Rep. No. 111-188 (2009), at 43-44.
                      19
                       See GAO-11-622.




                      Page 13                                               GAO-12-689 VA Health Care Budget
million is significantly lower than past spending and lower than the
estimate provided last year, it does not appear that medical facilities’
spending was addressed. Furthermore, VA estimates that the NRM
backlog for health care facilities—which reflects the total amount needed
to address facility deficiencies—will remain over $9 billion in fiscal year
2013. As such, the NRM information provided in VA’s budget justification
may not be a reliable estimate of future spending for NRM.

Figure 1: Non-Recurring Maintenance (NRM) Estimates That Support the
President’s Budget Request and VA’s NRM Spending, Fiscal Years 2006 to 2014




Note: NRM spending reflects obligated amounts.
a
 VA was provided $1 billion for NRM—in addition to the fiscal year 2009 appropriations for the
Medical Facilities account—as part of the American Recovery and Reinvestment Act of 2009
(Recovery Act). The Recovery Act funding was outside the scope of the President’s fiscal year 2009
budget request. VA spent about $260 million of this Recovery Act funding on NRM in fiscal year 2009.
b
 The NRM amount reflected in the President’s fiscal year 2010 budget request included $510 million
from the Recovery Act. However, VA had about $740 million in Recovery Act funding available for
fiscal year 2010, and VA spent all of the remaining Recovery Act funding in fiscal year 2010.
c
Amounts spent not available for fiscal years 2012 through 2014.




Page 14                                                      GAO-12-689 VA Health Care Budget
Regarding operational improvements, VA estimated savings for fiscal
year 2013 using the same methodologies it used in the past, some of
which we recently reported lacked analytical support or were flawed. 20
The President’s budget request for fiscal year 2013 reflected VA’s
estimate that it would save about $1.3 billion from the implementation of
six operational improvements:

•     Changing rates. Estimated savings from purchasing dialysis
      treatments and other care from civilian providers at Medicare rates
      instead of current community rates.

•     Acquisitions. Estimated cost savings from changes to VA’s purchasing
      and contracting strategies.

•     Fee Care. Estimated saving from purchasing care from non-VA
      providers at lower rates.

•     Realigning clinical staff and resources. Estimated savings by using
      less costly health care providers, such as licensed practical nurses
      instead of certain types of registered nurses.

•     Medical and administrative support. Estimated savings from
      employing resources more efficiently.

•     VA real property. Estimated saving from initiatives including
      repurposing vacant or underutilized buildings, decreasing energy
      costs, and changing procurement practices for building maintenance.

In a February 2012 report, we highlighted issues regarding VA’s
methodology for estimating savings from some operational
improvements, including changes to VA real property, medical and
administrative support activities, and the realignment of clinical staff and
resources. We also recommended that VA develop a sound methodology
for estimating savings from its operational improvements. 21 In response,
VA concurred with the recommendation except for two real property
initiatives where VA maintained that the savings estimates were not
flawed. However, since our February report was issued after the release


20
    See GAO-12-305.
21
  We also recommended that VA develop a detailed process for tracking actual savings
resulting from those improvements for which we identified concerns. See GAO-12-305.




Page 15                                              GAO-12-689 VA Health Care Budget
              of the President’s budget request for fiscal year 2013, VA has not yet
              implemented our recommendations. VA officials told us during the course
              of our current review that the agency is taking steps to address
              deficiencies in the methodology used for estimating savings for some of
              its operational improvements. Without a sound methodology, VA runs the
              risk of falling short of its estimated savings, which may ultimately require
              VA to make difficult trade-offs to provide health care services with the
              available resources. We determined that the estimates for some of the
              operational improvements provided in VA’s budget justification may not
              be reliable estimates of future savings and therefore are of limited use for
              decision makers.


              VA’s budget justification is intended to provide Congress with estimates of
Conclusions   resource needs and what the agency plans to achieve with requested
              appropriations. Our work shows that changes in the way that VA
              estimates and reports its required resources are responsible for the
              increase in the President’s fiscal year 2013 budget request for VA health
              care, when compared to last year’s advance appropriations request for
              the same year. However, VA was not transparent in its budget justification
              about two of the factors that accounted for the change in VA’s initiatives
              and ongoing health care services estimates. By neither disclosing that it
              used a new reporting approach for initiatives nor indicating that its
              advance appropriations requests did not include funding for continuing
              initiatives, VA did not provide Congress with information relevant to
              understanding these estimates.

              In addition, VA may not have provided Congress reliable information with
              which to make decisions regarding VA’s appropriations in regards to NRM
              and some operational improvements. VA’s most recent NRM estimates
              do not appear to correct for the long-standing pattern where VA’s NRM
              spending exceeds VA’s NRM estimates. VA’s estimates have not
              consistently accounted for additional spending by VA medical facilities. As
              a result, the NRM estimates may be unreliable, as they may continue to
              underestimate VA’s future spending for NRM. Also, VA continued to use
              flawed methodologies we identified in our prior work to develop savings
              estimates for operational improvements. We continue to believe that VA
              should improve its methodology as we previously recommended. Until
              these issues are addressed, VA’s estimates of NRM and operational
              improvements are of limited use for decision makers.




              Page 16                                        GAO-12-689 VA Health Care Budget
                      To improve the transparency and reliability of information presented in
Recommendations for   VA’s congressional budget justifications that support the President’s
Executive Action      budget request for VA health care, we recommend the Secretary of VA
                      take the following three actions:

                      •   State in future budget justifications whether the estimates for
                          initiatives include funding for ongoing health care services.

                      •   State in future budget justifications whether the estimates for
                          initiatives in support of the advance appropriations request reflect all
                          the funding that may be required if all initiatives are to be continued.

                      •   Reflect in future budget justifications estimates of annual resource
                          needs for NRM that fully account for resources that VA medical
                          facilities have consistently spent for this purpose.


                      We provided a draft of this report to the Secretary of VA and the Acting
Agency Comments       Director of OMB for comment. In its written comments signed by the Chief
and Our Evaluation    of Staff and reprinted in appendix I, VA concurred with two of our three
                      recommendations, but did not concur with our recommendation related to
                      the estimates for initiatives that support VA’s advance appropriations
                      requests. In addition, VA stated in its comments that one aspect of our
                      report is not accurate, that it disagrees with a second, and that it had
                      concerns about a third. OMB staff provided a technical comment, which
                      we incorporated.

                      VA concurred with our first recommendation regarding funding for
                      ongoing health care services. VA noted that to implement this
                      recommendation it will include in future budget justifications a narrative
                      description stating whether the estimates for initiatives include funding for
                      ongoing health care services. VA also concurred with our third
                      recommendation regarding its estimates for NRM. VA noted that in order
                      to implement this recommendation, VA will reflect in future budget
                      justifications annual estimates of resources needed for NRM that are
                      consistent with policy decisions and account for past spending on NRM.

                      VA did not concur with our second recommendation related to the
                      estimates for initiatives that support VA’s advance appropriations
                      requests. VA stated that it did not concur because the recommendation is
                      not consistent with its multiyear approach to budgeting for advance
                      appropriations, in which VA estimates what the agency calls essential
                      initial funding for the advance appropriations year. VA then estimates full



                      Page 17                                         GAO-12-689 VA Health Care Budget
funding for initiatives in the next year based on updated information.
However, we do not address VA’s approach to budgeting in this report
and our recommendation is that VA state in future budget justifications
whether the estimates for initiatives in support of the advance
appropriations request reflect all the funding that may be required if all
initiatives are continued. VA’s comments indicate that all funding for these
initiatives is not included in the advance appropriations estimates. VA
could implement our recommendation by making a statement to this
effect in its budget justification.

In addition to its comments on our recommendations, VA had comments
on three sections of our report. VA questioned the accuracy of our
assertion that VA did not disclose the new reporting approach for its
initiatives, which included estimates for certain ongoing health care
services. VA stated that a table footnote in its budget justification
explained that the estimates for initiatives for fiscal years 2012, 2013, and
2014 represented total funding. We do not believe that a table footnote in
a document, which consists of nearly 400 pages, provides adequate
transparency in explaining a change of more than $1 billion that resulted
from a new reporting approach. Moreover, because the footnote does not
explain that this approach is new or that the estimate for ongoing services
was also affected, we continue to believe that the transparency of VA’s
reporting could be improved. We support VA’s plans to include an
expanded narrative regarding its approach to reporting estimates for
initiatives in future budget justifications and believe this will enhance
transparency.

VA also indicated that it disagreed with what VA characterized as our
assertion that Congress cannot use VA’s estimates of costs for ongoing
health care services or initiatives due to a lack of transparency. As
evidence, VA pointed to the detailed information presented in the budget
justification and described how the estimates are determined, including a
description of the actuarial model it uses. However, we did not state that
Congress cannot use VA’s estimates for the cost of ongoing health care
services and initiatives. Instead, what we identified was that the lack of
transparency regarding the factors that changed VA’s estimate for
ongoing health care services and initiatives resulted in unclear
information for congressional deliberation. VA’s concurrence with two of
our recommendations and its implementation of them would address the
concerns we raised and improve the transparency of the information that
VA provides to Congress in its annual budget justifications.




Page 18                                        GAO-12-689 VA Health Care Budget
VA also expressed concern that our conclusions cast doubt on its strong
commitment to stewardship of resources. VA noted that the agency and
its resources need to be flexible and responsive to changes in veterans’
medical care needs, which may occur after its budget estimates are
formulated. VA has the authority to respond to such changes. We have
pointed out, for example, that VA’s NRM spending is consistent with its
authority to increase and decrease the amounts VA allocates from the
Medical Facilities account for NRM. However, in regard to NRM, the long-
standing pattern in which NRM spending has significantly exceeded VA’s
estimates needs to be better accounted for in VA’s budget estimates.
Doing so will not decrease VA’s flexibility to be responsive to veterans’
needs. Moreover, we believe that VA’s plans to address our
recommendation will provide Congress with more reliable estimates with
which to make decisions about VA appropriations.


We are sending copies of this report to the Secretary of Veterans Affairs
and the Acting Director of the Office of Management and Budget, and
appropriate congressional committees. In addition, the report will be
available at no charge on the GAO website http://www.gao.gov.

If you or your staff have any questions about this report, please contact
Randall B. Williamson at (202) 512-7114 or williamsonr@gao.gov, or
Melissa Emrey-Arras at (617) 788-0534 or emreyarrasm@gao.gov.
Contact points for our Offices of Congressional Relations and Public
Affairs are on the last page of this report. GAO staff who made major
contributions to this report are listed in appendix II.




Randall B. Williamson
Director, Health Care



Melissa Emrey-Arras
Acting Director, Strategic Issues




Page 19                                       GAO-12-689 VA Health Care Budget
List of Committees

The Honorable Kent Conrad
Chairman
The Honorable Jeff Sessions
Ranking Member
Committee on the Budget
United States Senate

The Honorable Patty Murray
Chairman
The Honorable Richard Burr
Ranking Member
Committee on Veterans’ Affairs
United States Senate

The Honorable Tim Johnson
Chairman
The Honorable Mark Kirk
Ranking Member
Subcommittee on Military Construction,
 Veterans’ Affairs, and Related Agencies
Committee on Appropriations
United States Senate

The Honorable Paul Ryan
Chairman
The Honorable Chris Van Hollen
Ranking Member
Committee on the Budget
House of Representatives

The Honorable Jeff Miller
Chairman
The Honorable Bob Filner
Ranking Member
Committee on Veterans’ Affairs
House of Representatives




Page 20                                    GAO-12-689 VA Health Care Budget
The Honorable John Culberson
Chairman
The Honorable Sanford Bishop
Ranking Member
Subcommittee on Military Construction,
 Veterans’ Affairs, and Related Agencies
Committee on Appropriations
House of Representatives




Page 21                                    GAO-12-689 VA Health Care Budget
Appendix I: Comments from the Department
             Appendix I: Comments from the Department of
             Veterans Affairs



of Veterans Affairs




             Page 22                                       GAO-12-689 VA Health Care Budget
Appendix I: Comments from the Department of
Veterans Affairs




Page 23                                       GAO-12-689 VA Health Care Budget
Appendix I: Comments from the Department of
Veterans Affairs




Page 24                                       GAO-12-689 VA Health Care Budget
Appendix II: GAO Contacts and Staff
                  Appendix II: GAO Contacts and Staff
                  Acknowledgments



Acknowledgments

                  Randall B. Williamson, Director, Health Care, (202) 512-7114,
Contacts          williamsonr@gao.gov

                  Melissa Emrey-Arras, Acting Director, Strategic Issues, (617) 788-0534,
                  emreyarrasm@gao.gov


                  In addition to the contacts named above, James C. Musselwhite and
Staff             Melissa Wolf, Assistant Directors; Kye Briesath, Deirdre Brown, Krister
Acknowledgments   Friday, Lauren Grossman, Aaron Holling, Wati Kadzai, and Lisa Motley
                  made key contributions to this report.




                  Page 25                                      GAO-12-689 VA Health Care Budget
Related GAO Products
             Related GAO Products




             VA Health Care: Estimates of Available Budget Resources Compared
             with Actual Amounts. GAO-12-383R. Washington, D.C.: March 30, 2012.

             VA Health Care: Methodology for Estimating and Process for Tracking
             Savings Need Improvement. GAO-12-305. Washington, D.C.:
             February 27, 2012.

             Department of Veterans Affairs: Issues Related to Real Property
             Realignment and Future Health Care Costs. GAO-11-877T. Washington,
             D.C.: July 27, 2011.

             Veterans’ Health Care Budget Estimate: Changes Were Made in
             Developing the President’s Budget Request for Fiscal Years 2012 and
             2013. GAO-11-622. Washington, D.C.: June 14, 2011.

             Veterans’ Health Care: VA Uses a Projection Model to Develop Most of
             Its Health Care Budget Estimate to Inform the President’s Budget
             Request. GAO-11-205. Washington, D.C.: January 31, 2011.

             VA Health Care: Spending for and Provision of Prosthetic Items.
             GAO-10-935. Washington, D.C.: September 30, 2010.

             VA Health Care: Reporting of Spending and Workload for Mental
             Health Services Could Be Improved. GAO-10-570. Washington, D.C.:
             May 28, 2010.

             Continuing Resolutions: Uncertainty Limited Management Options and
             Increased Workload in Selected Agencies. GAO-09-879. Washington,
             D.C.: September 24, 2009.

             VA Health Care: Challenges in Budget Formulation and Issues
             Surrounding the Proposal for Advance Appropriations. GAO-09-664T.
             Washington, D.C.: April 29, 2009.

             VA Health Care: Challenges in Budget Formulation and Execution.
             GAO-09-459T. Washington, D.C.: March 12, 2009.

             VA Health Care: Long-Term Care Strategic Planning and Budgeting Need
             Improvement. GAO-09-145. Washington, D.C.: January 23, 2009.

             Federal Real Property: Progress Made in Reducing Unneeded
             Property, but VA Needs Better Information to Make Further Reductions.
             GAO-08-939. Washington, D.C.: September 10, 2008.


             Page 26                                     GAO-12-689 VA Health Care Budget
           Related GAO Products




           VA Health Care: Budget Formulation and Reporting on Budget
           Execution Need Improvement. GAO-06-958. Washington, D.C.:
           September 20, 2006.




(290996)
           Page 27                                  GAO-12-689 VA Health Care Budget
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