United States Government Accountability Office

Washington, DC 20548 

February 6, 2006 

The Honorable Steve Buyer 

Chairman 

Committee on Veterans’ Affairs 

House of Representatives 

The Honorable Daniel K. Akaka 

Ranking Minority Member 

Committee on Veterans’ Affairs 

United States Senate 

The Honorable Richard J. Durbin 

The Honorable Patty Murray 

The Honorable Ken Salazar 

United States Senate 

Subject: VA Health Care: Preliminary Findings on the Department of Veterans 

Affairs Health Care Budget Formulation for Fiscal Years 2005 and 2006 

This report documents the information we provided to you in a briefing on February 

2, 2006, in response to your request concerning the Department of Veterans Affairs 

(VA) internal budget formulation process. (See enclosure.) This includes information 

that VA develops for its budget submission to the Office of Management and Budget 

(OMB), but it does not include information on subsequent interactions that occur 

between VA and OMB. We will do additional work to incorporate information from 

OMB and complete our analysis in a report to be issued at a later date. You requested 

information on VA’s budget formulation process because of your interest in ensuring 

that VA’s budget forecasts are accurate and based on valid patient estimates. 

As you know, VA provides a uniform set of medical benefits to eligible veterans. If 

sufficient resources are not available to provide care that is timely and acceptable in 

quality, VA is required to restrict medical benefits based on veterans’ eligibility 

priorities.1

 VA also provides other services, such as nursing home care, to certain 

veterans. VA’s provision of medical care is dependent upon the availability of 

appropriations. For fiscal year 2005, Congress appropriated $31.5 billion for all of 

VA’s medical programs, and VA provided medical care to about 5 million veterans. 

 1

Priority categories are generally determined on the basis of service-connected disability and income. 

There are currently eight priority categories. VA used this system to restrict enrollment in January 

2003 to no longer allow Priority 8 veterans, those in the lowest priority category who generally do not 

have service-connected disabilities or low income, to enroll. This policy remains in effect. 

 GAO-06-430R VA Health Care Budget Formulation 
During fiscal year 2005, the President requested a $975 million supplemental request 

for that fiscal year and a $1.977 billion amendment to the President’s budget request 

for fiscal year 2006. In congressional testimonies in the summer of 2005, VA stated 

that its actuarial model understated growth in patient workload and services and the 

resources required to provide these services.2

In response to your request for information on VA’s internal budget formulation 

process, this report provides the following for fiscal years 2005 and 2006: 

• A description of VA’s process for developing its budget submission to OMB for 

its medical programs, and the role of VA’s actuarial model. 

• A description of the medical program activities cited by VA as needing 

additional funding, and how VA identified these activities. 

• Key factors in VA’s budget formulation process that contributed to the 

requests for additional funding. 

To conduct our work, we interviewed VA officials, including those in the Veterans 

Health Administration’s Office of the Chief Financial Officer and Office of the 

Assistant Deputy Under Secretary for Health for Policy and Planning. We also 

interviewed officials in VA’s Office of the Deputy Assistant Secretary for Budget. We 

also analyzed documents concerning VA’s actuarial model, budgetary data, and 

workload and expenditure data and reviewed our past work. We tested the reliability 

of the data and determined they were adequate for our purposes. We have not yet met 

with OMB officials to discuss the budget formulation process for fiscal years 2005 

and 2006 and the President’s subsequent request for additional appropriations. We 

conducted our review from October 2005 through January 2006 in accordance with 

generally accepted government auditing standards. 

Results in Brief 

VA’s internal process for formulating the medical programs funding requests was 

informed by, but not driven by, projected demand. VA projected costs based on 

projected demand for medical care under current policy. Throughout the process, VA 

compared projected costs to its anticipated request level for the OMB submission and 

made adjustments to address the difference. VA officials stated that this was done in 

two ways: through cost-saving policy proposals, such as assessing an annual health 

care enrollment fee, and management efficiencies.3

 After making adjustments to 

 2

Senate Committee on Veterans’ Affairs, Statement of the Secretary, Department of Veterans Affairs, 

Emergency Hearing to Examine the Shortfall in VA’s Medical Care Budget, 109th Congress, June 28, 

2005; House Committee on Veterans’ Affairs, Statement of the Secretary, Department of Veterans 

Affairs, Full Committee Hearing on the Department of Veterans Affairs Health Care Budget, 109th

Congress, June 30, 2005; and House Committee on Veterans’ Affairs, Statement of the Under Secretary 

for Health, Department of Veterans Affairs, Full Committee Hearing on the Department of Veterans 

Affairs Proposed Health Care Budget Amendment for Fiscal Year 2006, 109th Congress, July 21, 2005. 

3

See GAO, Veterans Affairs: Limited Support for Reported Health Care Management Efficiency 

Savings, GAO-06-359R (Washington, D.C.: Feb. 1, 2006). 

2 GAO-06-430R VA Health Care Budget Formulation
address the difference between projected costs and its anticipated request level, VA 

developed its budget submission for OMB. 

VA later cited a number of activities as needing additional funding based on 

programmatic priorities and an analysis of expenditure data. Among the activities 

that were cited for fiscal year 2005 was $273 million for veterans returning from Iraq 

and Afghanistan; $226 million for long-term care; and almost $400 million for 

increases in the number of patients, as well as increases in both utilization and 

intensity of care. For the fiscal year 2006 budget, VA cited $677 million to cover a 2 

percent increase in the number of patients, $600 million to correct VA’s estimate for 

long-term care costs, $400 million for an unexpected 1.2 percent increase in average 

cost per patient, and $300 million to replace funds VA planned to carry over from

fiscal year 2005 to fiscal year 2006. VA officials said that they chose to highlight 

activities that were of high programmatic priority and could be supported by 

workload and expenditure data (e.g. veterans returning from Iraq and Afghanistan). 

They also reviewed spending and workload trends to determine whether spending 

trends were on target or whether adjustments were needed. 

An unrealistic assumption, errors in estimation, and insufficient data were key factors 

in VA’s budget formulation process that contributed to the requests for additional 

funding. According to VA, an unrealistic assumption about the speed with which VA 

could implement a policy to reduce nursing home patient workload in VA-operated 

nursing homes for fiscal year 2005 led to a need for additional funds. VA officials told 

us that errors in estimating the effect of a nursing home policy to reduce workload in 

all three of its nursing home settings—VA-operated nursing homes, community 

nursing homes, and state veterans’ nursing homes—accounted for a request for 

additional funding for fiscal year 2006. VA officials said that the error resulted from 

calculations being made in haste during the OMB appeal process. Finally, VA officials 

told us that insufficient data on certain activities contributed to the requests for 

additional funds for both years. For example, inadequate data on veterans returning 

from Iraq and Afghanistan resulted in an underestimate in the initial funding request. 

Agency Comments 

We requested comments on a draft of the enclosed briefing slides from VA. VA 

provided us with technical comments on the briefing slides, which have been 

incorporated as appropriate. 

- - - - - 

We are sending copies of this report to the Secretary of Veterans Affairs, the Director 

of the Office of Management and Budget, and appropriate congressional committees. 

We will also provide copies to others upon request. In addition, the report is available 

at no charge on GAO’s home page at http://www:gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on the last page 

of this report. 

3 GAO-06-430R VA Health Care Budget Formulation
If you and your staff have any questions or need additional information, please 

contact me at (202) 512-7101, or ekstrandl@gao.gov. Major contributors to this letter 

were James Musselwhite, Assistant Director; Denise Fantone; Michael Kendix; Dean 

Koulouris; Tiffany Tanner; Thomas Walke; and Greg Whitney. 

Laurie E. Ekstrand 

Director, Health Care 

Enclosure 

4 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

1

VA Health Care: Budget Formulation 

for Fiscal Years 2005 and 2006 

Status Briefing

Briefing on VA’s Internal Process to Congressional Staff

February 2, 2006

5 GAO-06-430R VA Health Care Budget Formulation 
Enclosure 

2

Requested by:

Chairman, Honorable Steve Buyer

House Committee on Veterans’ Affairs 

Ranking Minority Member, Honorable Daniel K. Akaka

Senate Committee on Veterans’ Affairs

Honorable Richard J. Durbin

Honorable Patty Murray

Honorable Ken Salazar

United States Senate

VA Health Care: Budget Formulation 

for Fiscal Years 2005 and 2006 

6 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

3

Overview

• Introduction

• Objectives

• Scope and Methodology

• Findings

7 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

4

Introduction

• The Department of Veterans Affairs (VA) provides a uniform set of medical

benefits to eligible veterans. These benefits include preventive and primary 

health care, and a range of outpatient and inpatient services. In addition, 

VA provides other benefits, such as nursing home care, to certain veterans. 

The Veterans Health Administration (VHA) is responsible for operating

VA’s medical care system. 

• VA’s provision of medical care for veterans is dependent upon the 

availability of appropriations. For fiscal year 2005, Congress appropriated 

about $31.5 billion for all of VA’s medical programs and VA provided 

medical care to about 5 million veterans. 

• For each fiscal year since 1997, Congress has appropriated more for VA 

medical care than requested by the President. (See fig. 1.)

8 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

5

Introduction

Figure 1: President's Budget Request Compared to Appropriations for VHA Accounts, Fiscal 

Years 1997-2005

aFiscal year 2005 appropriation is estimated.

Note: Totals include medical care collections, but do not include VA construction accounts.

9 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

6

Introduction

• Increased appropriations during this period coincided with the passage of the 

Veterans’ Health Care Eligibility Reform Act of 1996, which simplified eligibility 

standards for veterans in need of hospital and outpatient care and made available

services not previously available to veterans without service-connected disabilities or 

low incomes.1

• As required by this act, VA established an enrollment system with priority categories

to manage access to hospital and outpatient care in relation to available resources.

• The act requires VA to restrict enrollment for purposes of these benefits consistent

with its priority categories if sufficient resources are not available to provide care that

is timely and acceptable in quality.

2 In January 2003, VA restricted enrollment by no

longer allowing Priority 8 veterans, those in the lowest priority category, to enroll.

This policy remains in effect.

1Pub. L. No. 104-262, §§ 101, 104, 110 Stat. 3177, 3178-81 and 3182-84. 2The act called for seven priority categories; subsequent legislation provided for eight categories. Priority categories are generally determined on the basis of service-connected 

disability and income.

10 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

7

Introduction

• During fiscal year 2005, the President requested a $975 million 

supplemental for that fiscal year and a $1.977 billion amendment to the 

President’s budget request for fiscal year 2006. 

• In its congressional testimonies in June and July of 2005, VA stated that 

its actuarial model understated growth in patient workload and services and 

the resources required to provide these services.

• Congress is interested in ensuring that VA’s budget forecasts are accurate

and based on valid patient estimates. 

11 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

8

Objectives 

1. To describe VA’s process for developing its budget submission to the 

Office of Management and Budget (OMB) for its medical programs for 

fiscal years 2005 and 2006, and to describe the role of VA’s actuarial

model.

2. To describe medical program activities cited by VA as needing additional 

funding for fiscal years 2005 and 2006, and how VA identified these 

activities.

3. To identify key factors in VA’s budget formulation process that contributed 

to the requests for additional funding for fiscal years 2005 and 2006.

12 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

9

Scope and Methodology

• For this briefing, we focused our work on VA’s process for formulating its 

funding request for its medical programs for fiscal years 2005 and 2006.

• Interviewed VA officials in:

• VHA Office of the Chief Financial Officer

• VHA Office of the Assistant Deputy Under Secretary for Health for 

Policy and Planning

• VA’s Office of the Deputy Assistant Secretary for Budget

• Analyzed data from publicly available documents and from VA including:

• Actuarial model information

• Budgetary data

• Workload and expenditure data

13 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

10

Scope and Methodology

• Past GAO work.

• In doing our work, we tested the reliability of the data and determined they

were adequate for our purposes. 

• We conducted our review from October 2005 through January 2006 in

accordance with generally accepted government auditing standards.

14 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

11

Summary of Findings to Date

• VA’s Internal Process for Formulating the Medical Programs Funding 

Requests Was Informed by, but Not Driven by, Projected Demand

• VA Cited a Number of Activities as Needing Additional Funding Based 

on Programmatic Priorities and Analysis of Expenditure Data

• An Unrealistic Assumption, Errors in Estimation, and Insufficient Data 

Were Key Factors in VA’s Budget Formulation Process that

Contributed to the Requests for Additional Funding 

15 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

12

VA’s Internal Process for Formulating the Medical Programs

Funding Requests Was Informed by, but Not Driven by, Projected 

Demand 

• VA projected costs based on projected demand for medical care

under current policy.

• Throughout the process, VA compared projected costs to its 

anticipated request level for the OMB submission and made 

adjustments to address the difference.

• After making adjustments to address the difference between 

projected costs and its anticipated request level, VA developed 

its budget submission for OMB.

16 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

13

For fiscal years 2005 and 2006, VA projected costs based on

projected demand for medical care under current policy.

According to VA officials:

• VA used an actuarial model to project workload and costs for about 86 

percent of its medical programs funding request.3

• VA also used a separate model to project long-term care workload and 

costs, which account for about 10 percent of its medical programs

funding request.

• For the remaining 4 percent, most projections were developed by adding inflation to actual expenditures. In some cases, VA used other

methods, including projecting trends from workload and expenditure

data. 

3For fiscal year 2005, model projections were based on fiscal year 2002 data; for fiscal year 2006, the model projections were based on fiscal year 2003 data.

17 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

14

Throughout the process, VA compared projected costs to its 

anticipated request level for the OMB submission and made 

adjustments to address the difference.

• VA officials stated that they developed a request that reflects OMB 

guidance and direction from VA senior management. This request 

included anticipated resources from reimbursements, collections, and

unobligated balances.

• In both fiscal years 2005 and 2006 projected costs exceeded the 

anticipated request level. VA officials stated that the difference was 

addressed in two ways:

(1) cost-saving policy proposals

(2) management efficiencies 

18 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

15

Throughout the process, VA compared projected costs to its 

anticipated request level for the OMB submission and made 

adjustments to address the difference. (cont.)

• VA used several methods to estimate cost savings from various policy

proposals.

• VA used the actuarial model to estimate the impact of its cost- sharing proposals (e.g., increasing the copayment for prescriptions 

and assessing an annual enrollment fee).

• VA used other methods to estimate the cost savings from proposed

policy changes for nursing home care.

• GAO will issue a report shortly on VA’s methodology for projecting 

management efficiency savings. 

19 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

16

After making adjustments to address the difference between 

projected costs and its anticipated request level, VA developed 

its budget submission for OMB.

• According to VA officials, there is not a direct linkage between the 

way its budget submission is formulated and the way it is 

presented. 

• Instead, VA based the detail in its budget submission primarily on 

the previous year’s appropriations with adjustments for salaries, 

inflation, workload, and new policies.

20 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

17

VA Cited a Number of Activities as Needing Additional Funding 

Based on Programmatic Priorities and Analysis of Expenditure

Data

• VA identified a number of activities that it said needed additional

funding in fiscal years 2005 and 2006.

• VA described the processes for identifying the activities.

21 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

18

In discussing the fiscal year 2005 supplemental request, VA identified

a number of activities that it said needed additional funding that 

totaled $975 million:

• $273 million for veterans returning from Iraq and Afghanistan, 

Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF)

• $226 million for long-term care

• $200 million for Priority 1-6 patient workload

• $179 million for greater than expected increase in the utilization of 

services and intensity of patient workload

• $58 million for reducing patient backlog on waiting lists

• $39 million for health care needs of dependents of 100 percent 

service-connected veterans

22 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

19

In discussing the fiscal year 2006 budget amendment request, VA 

identified a number of activities that it said needed additional funding 

that totaled $1.977 billion:

• $677 million to cover a 2 percent increase in number of patients, $276 

million of which is for veterans returning from Iraq and Afghanistan 

(OIF/OEF)

• $600 million to correct VA’s estimate of long-term care costs

• $400 million to cover an unexpected 1.2 percent increase in average 

cost per patient

• $300 million to replace funds VA planned to carry over5 from fiscal 

year 2005 to fiscal year 2006

5 Certain funds are available to VA for more than one fiscal year. For example, patient copayments and collections from third-party insurance are available to VA without fiscal

year limitation.

23 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

20

VA described the processes for identifying the activities that it said 

needed additional funding for fiscal years 2005 and 2006. 

• VA officials told us that they chose to highlight activities for fiscal years

2005 and 2006 that were of high programmatic priority to the administration

and Congress and could be supported by workload and expenditure data 

(e.g., veterans returning from Iraq and Afghanistan).

• VA reviewed spending and workload trends on a monthly basis with the 

Deputy Secretary to determine whether spending trends were on target or 

whether adjustments were needed. VA tracked:

• Spending at a budget object level (e.g., personnel and travel) and

• Patient workload, as measured by number of unique patients, by

enrollment priority group (Priorities 1-8) with a 60-day lag in data 

availability.

24 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

21

VA described the processes for identifying the activities that it said 

needed additional funding for fiscal years 2005 and 2006 (cont.).

• When VA management initially identified that the fiscal year 2005 actual 

workload was exceeding projections, rather than initiating a supplemental

request, VA planned to address this difference by:

• Reducing the fiscal year 2006 carryover balance by $375 million.

• Deferring $600 million for equipment and nonrecurring maintenance.

25 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

22

An Unrealistic Assumption, Errors in Estimation, and Insufficient 

Data Were Key Factors in VA’s Budget Formulation Process that

Contributed to the Requests for Additional Funding

• An unrealistic assumption about implementation of a proposal

expected to result in cost savings contributed to the request for 

additional funding in fiscal year 2005.

• Errors in estimating the effect of a nursing home policy contributed to 

the request for additional funding in fiscal year 2006.

• Insufficient data on certain activities contributed to the requests for 

additional funding in fiscal years 2005 and 2006.

26 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

23

An unrealistic assumption about implementation of a proposal

expected to result in cost savings contributed to the request for

additional funding in fiscal year 2005.

• According to VA, an unrealistic assumption about the speed with

which VA could implement a policy to reduce nursing home

patient workload in VA-operated nursing homes for fiscal year 

2005 accounted for $226 million in the request for additional 

funding in fiscal year 2005.

• The President’s fiscal year 2005 budget request included a policy

to reduce patient workload, as measured by average daily census, in VA-operated nursing homes to 8,500. 

• VA officials said this policy was “unrealistic,” because the 

assumptions required an immediate reduction from an average 

daily census of about 12,000.

27 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

24

Errors in estimating the effect of a nursing home policy contributed 

to the request for additional funding in fiscal year 2006.

• According to VA, errors in estimating the effect of a nursing home

policy to reduce workload in all three nursing home settings 

accounted for $600 million of the request for additional fiscal year 

2006 funding. 

• VA proposed to reduce patient workload and costs by prioritizing

the veterans who would receive nursing home care in its VAoperated nursing homes, community nursing homes, and state 

veterans’ nursing homes.

28 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

25

Errors in estimating the effect of a nursing home policy contributed 

to the request for additional funding in fiscal year 2006. (cont.)

• The estimated savings from this policy were understated in the 

fiscal year 2006 President’s Budget request because of errors in

estimation of average daily census, average costs, and rates of 

patient turnover in nursing homes.

• VA officials said that the error resulted from calculations being 

made in haste during the OMB appeal process.

29 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

26

Insufficient data on certain activities contributed to the requests for 

additional funding in fiscal years 2005 and 2006

• VA officials stated, for example, that insufficient data on OIF/OEF 

veterans accounted for $273 million and $276 million of the requests

for additional funding in fiscal years 2005 and 2006, respectively. 

• According to VA officials, the projections for providing care were 

understated for fiscal years 2005 and 2006, because

• Modeled projections were based on fiscal years 2002 and 2003 

data, which did not include adequate data on OIF because this 

operation began in March 2003.

6

• VA also initially experienced delays in receiving Department of 

Defense (DOD) data on the identification of veterans returning from

OIF/OEF. 6VA discovered the issue after submission of the fiscal year 2006 budget request.

30 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

27

Insufficient data on certain activities contributed to the requests for 

additional funding in fiscal years 2005 and 2006 (cont.).

• Based on experience through the first 6 months of fiscal year 2005, VA 

revised its original workload and cost estimates for OIF/OEF 

returnees.

• According to revised projections for fiscal year 2005, VA expected to 

provide care to about an additional 76,000 patients for an additional

cost of $273 million from estimates generated from the actuarial

model.

31 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

28

Agency Comments

• VA provided technical comments, which we incorporated as appropriate.

• VA said that it will provide written comments on a report on this topic, 

expected to be issued in the spring of 2006.

32 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

29

Next Steps

• Discuss with OMB

• Conduct additional analysis

33 GAO-06-430R VA Health Care Budget Formulation
Enclosure 

30

Contact Information

• For questions about this briefing, please contact Laurie E. Ekstrand, 

Director, Health Care at (202) 512-7101 or ekstrandl@gao.gov

(290527) 

34 GAO-06-430R VA Health Care Budget Formulation
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