VETERANS’ HEALTH 

CARE BUDGET

Transparency and 

Reliability of Some

Estimates Supporting 

President’s Request 

Could Be Improved

Report to Congressional Committees

June 2012

GAO-12-689

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United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-12-689, a report to 

congressional committees

June 2012

VETERANS’ HEALTH CARE BUDGET

Transparency and Reliability of Some Estimates 

Supporting President’s Request Could Be Improved

Why GAO Did This Study

The Veterans Health Care Budget 

Reform and Transparency Act of 2009 

requires GAO to report on the 

President’s annual budget request to 

Congress for VA health care services. 

GAO’s previous work found that VA’s 

NRM spending exceeded its estimates 

in recent years and that some of VA’s 

estimates of savings from operational 

improvements lacked analytical 

support or were flawed.

Building on GAO’s past work and the 

President’s most recent request for VA 

health care, this report examines 

(1) key changes to the fiscal year 2013 

budget request compared to the 2013 

advance appropriations request, and 

certain aspects of the fiscal year 2014 

advance appropriation request and 

supporting estimates; and (2) whether 

the issues GAO identified regarding 

NRM and operational improvements 

continue in the estimates for the most 

recent request. GAO reviewed the 

President’s budget request, VA’s 

budget justification, and VA data. GAO 

interviewed VA officials and staff from 

the Office of Management and Budget.

What GAO Recommends

GAO recommends that VA state in its 

budget justification whether the 

estimates for initiatives include funding 

for ongoing services and whether its 

advance appropriations request 

reflects funding that may be required if 

initiatives are continued. GAO also 

recommends that VA’s NRM estimates 

fully account for the long-standing 

pattern of medical facilities spending 

more on NRM than originally expected. 

VA concurred except for the 

recommendation on advance 

appropriations, which GAO believes is 

needed to improve transparency. 

What GAO Found

The President’s fiscal year 2013 budget request for the Department of Veterans 

Affairs’ (VA) health care services was $165 million more than the earlier advance 

appropriations request for the same year. This request reflected a $2 billion 

increase for initiatives and a $2.1 billion decrease for ongoing health care 

services, for a net decrease of $110 million in expected obligations. This 

decrease partially offset a decline in anticipated resources available to VA of 

$275 million, resulting in the net increase in the President’s request of 

$165 million. Two of the three factors that accounted for most of these changes 

were not transparent. First, VA used a new reporting approach for initiatives that 

combined both funding for initiatives and for certain ongoing health care services 

in its initiatives estimate. Previously, VA had reported only funding it identified for 

initiatives during that year. This new reporting approach resulted in an increase in 

VA’s initiatives estimate and a commensurate decrease in VA’s ongoing services 

estimate. VA officials told GAO that this change was made to be more 

transparent about the total funding needed for initiatives. However, because VA 

did not disclose this change in its budget justification, VA has not made it 

transparent that its initiatives estimate is greater and its ongoing health care 

services estimate is lower than they would have been using VA’s past approach. 

Second, VA included additional funding in its initiatives estimate, in part, to fund 

initiatives that were not identified in the fiscal year 2013 advance appropriations 

request. VA also did not make transparent in its budget justifications that some 

initiatives identified in its fiscal years 2013 and 2014 advance appropriations 

requests may require additional funding if the initiatives are continued. The lack 

of transparency regarding VA’s estimates for initiatives and ongoing health care 

services results in unclear information for congressional deliberation.

The issues GAO previously identified related to NRM (non-recurring 

maintenance), such as renovations and other improvements of VA medical 

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 

where VA’s NRM spending exceeds VA’s NRM estimates. For example, in fiscal 

year 2011 VA spent about $2 billion for NRM, which was $867 million more than 

estimated. According to VA officials, this pattern has occurred 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—which is consistent with VA’s authority to allocate its 

appropriations. When GAO asked if the fiscal year 2013 estimate addressed the 

historical discrepancies between estimated and actual NRM spending, VA 

officials said that all information was considered in developing the estimate. 

However, they noted that the final estimate was a policy decision and did not say 

specifically whether these discrepancies were addressed. Regarding operational 

improvements, VA estimated savings for fiscal year 2013 using the same 

methodologies it used in the past, some of which GAO previously found lacked 

analytical support or were flawed. GAO previously recommended that VA 

develop a sound methodology for estimating savings from its operational 

improvements, which according to officials, VA is addressing for future estimates. 

Until these issues are addressed, VA’s estimates of NRM and operational 

improvements may not be reliable and are of limited use for decision makers. 

View GAO-12-689. For more information, 

contact Randall B. Williamson at (202) 512-

7114 or williamsonr@gao.gov or Melissa 

Emrey-Arras at (617) 788-0534 or 

emreyarrasm@gao.gov.
Page i GAO-12-689 VA Health Care Budget

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

Contents
Page ii 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 1 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

 

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).

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 

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 2 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

 

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.

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 non4

See GAO, VA Health Care: Challenges in Budget Formulation and Execution, 

GAO-09-459T (Washington, D.C.: Mar. 12, 2009).
 

Page 3 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

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.

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.

8

 

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.

Building upon our work from our June 2011 report and in light of the 

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 4 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

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 

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.

 

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 5 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—

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

 

10VA 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.

VA also provides some services that are not part of its 

Background 
 

Page 6 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 

 

11See 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.

12The 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 7 GAO-12-689 VA Health Care Budget

that VA anticipates it will receive in the fiscal year.13

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:

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).

• 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. 

 

13In 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).

14Based 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 8 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.

The President’s fiscal year 2013 budget request for VA health care 

services was $165 million more than the advance appropriations request 

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 

year 2013 request reflected an estimate of funding needed for initiatives 

that increased by $2 billion and an estimate for ongoing health care 

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 

VA Changed 

Estimates Supporting 

the Request, but 

Factors That Account 

for Most of the 

Changes Were Not 

Transparent 

Request Increased 

$165 Million, Reflecting 

an Increase in Initiatives 

and a Decrease in Both 

Ongoing Services and 

Available Resources
 

Page 9 GAO-12-689 VA Health Care Budget

obligations, which resulted in the net increase in the President’s request 

of $165 million.15

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 

(See table 1.)

(Dollars in millions)

Description

President’s fiscal 

year 2013 advance 

appropriations request 

President’s fiscal 

year 2013 budget request 

Effect of the difference 

in estimates on 

President’s fiscal 

year 2013 budget request

Ongoing health care services $56,628 a $54,523 ($2,105)

Initiatives $1,346 b $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 for most of the changes in the estimates that 

supported the President’s fiscal year 2013 budget request when 

compared to the earlier, advance appropriations request; however, VA, in 

its budget justification, was not transparent about two of the factors. The 

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 

 

15Anticipated 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.

Three Factors Accounted 

for Most Changes to 

Supporting Estimates, but 

Two Were Not Transparent
 

Page 10 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 11 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

 

16According 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.

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 
 

Page 12 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)

Initiatives and legislative proposals:

President’s fiscal 

year 2013 advance 

appropriations 

request

President’s fiscal 

year 2013 budget 

request

Difference due to 

new reporting 

approach

Difference due to 

additional funding 

for initiatives

Activations

a

$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

Improving Veteran Mental Health Not applicable b $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 13 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 

budget request found that VA’s supporting estimates (1) do not address 

historical discrepancies between estimated and actual NRM spending 

and (2) lack analytical support for expected savings from some 

operational improvements.

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

 

17See 

Because the fiscal year 2013 estimate of $710 

GAO-11-622. 

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

19See GAO-11-622. 

Past Issues in VA’s 

Estimates for NRM 

and Operational 

Improvements 

Remain 
 

Page 14 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 15 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

• Changing rates. Estimated savings from purchasing dialysis 

treatments and other care from civilian providers at Medicare rates 

instead of current community rates.

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:

• 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

 

20See 

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 

GAO-12-305. 

21We 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 16 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 

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.

Conclusions 
 

Page 17 GAO-12-689 VA Health Care Budget

To improve the transparency and reliability of information presented in 

VA’s congressional budget justifications that support the President’s 

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 

Director of OMB for comment. In its written comments signed by the Chief 

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 

Recommendations for 

Executive Action

Agency Comments 

and Our Evaluation
 

Page 18 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 19 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 longstanding 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 20 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 21 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
Appendix I: Comments from the Department of 

Veterans Affairs

Page 22 GAO-12-689 VA Health Care Budget

Appendix I: Comments from the Department 

of Veterans Affairs
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 

Acknowledgments

Page 25 GAO-12-689 VA Health Care Budget

Randall B. Williamson, Director, Health Care, (202) 512-7114, 

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 

Melissa Wolf, Assistant Directors; Kye Briesath, Deirdre Brown, Krister 

Friday, Lauren Grossman, Aaron Holling, Wati Kadzai, and Lisa Motley 

made key contributions to this report.

Appendix II: GAO Contacts and Staff 

Acknowledgments 

Contacts 

Staff 

Acknowledgments 
Related GAO Products

Page 26 GAO-12-689 VA Health Care Budget

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.

Related GAO Products
Related GAO Products

Page 27 GAO-12-689 VA Health Care Budget

VA Health Care: Budget Formulation and Reporting on Budget 

Execution Need Improvement. GAO-06-958. Washington, D.C.: 

September 20, 2006.

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