VETERANS’ HEALTH 

CARE BUDGET

Better Labeling of 

Services and More 

Detailed Information 

Could Improve the 

Congressional Budget 

Justification

Report to Congressional Committees

September 2012

GAO-12-908

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-12-908, a report to 

congressional committees 

September 2012

VETERANS’ HEALTH CARE BUDGET

Better Labeling of Services and More Detailed

Information Could Improve the Congressional 

Budget Justification 

Why GAO Did This Study

The VA operates one of the largest 

health care delivery systems in the 

nation. Within VA, VHA provides a 

range of health care services for 

eligible veterans, such as primary care, 

inpatient and outpatient surgery, and

nursing home care. In the past, VHA 

received medical care funds primarily 

through a single appropriations 

account. However, to “provide better 

oversight and receive a more accurate 

accounting of funds,” in 2004, 

Congress established a new three

appropriations account structure. 

GAO was asked to (1) describe the 

relationship between VHA’s 

appropriations account structure and 

VA’s development of the budget 

request; and (2) examine how VA 

presents information about the three 

VHA appropriations accounts in its 

CBJ. To conduct this work GAO 

reviewed VA budget policy documents, 

VA’s fiscal year 2009-2013 CBJs, prior 

GAO work on budget formulation at 

VA, and interviewed VHA budget 

officials. 

What GAO Recommends

GAO recommends that VA label health 

care services consistently so it is clear 

what services are being referred to 

across appropriations accounts. GAO 

also recommends that VA further 

consult with congressional decision 

makers when determining what

detailed information related to 

appropriations accounts should be 

presented—and how— in its CBJ. VA 

generally agrees with GAO’s 

conclusions and concurs with GAO’s 

recommendations. VA stated what 

actions it will take to implement the 

recommendations.

What GAO Found

The Department of Veterans Affairs (VA) creates its budget request through its

Enrollee Health Care Projection Model (EHCPM) using data from systems 

designed for the former single-account structure. These systems do not explicitly 

consider the three appropriations accounts: Medical Services, Medical Support 

and Compliance, and Medical Facilities. According to Veterans Health 

Administration (VHA) officials, VHA formulates its budget based on the single 

appropriations account, in part, because the systems to formulate the request 

were in place prior to 2004, which was when the three-account structure was 

established. VA then presents the information in the Congressional Budget 

Justification (CBJ) by taking the data developed by the EHCPM and then, based 

on historical percentages and future projections, assigning the requested 

amounts to the three appropriations accounts. 

The information about VA’s health care accounts in its CBJ can be difficult to 

follow because information is not displayed consistently across the three medical 

care appropriations accounts. This is due to inconsistent labeling and varying 

levels of detail among the three appropriations accounts throughout the 

justification. VHA officials stated that inconsistent labeling in the CBJ’s tables

was inadvertent. With respect to varying levels of detail among the three 

appropriations accounts, VHA officials said that the administrative and facilities 

costs for some programs are relatively small compared to the Medical Services 

costs. Thus they are not displayed for all three accounts. However, in at least 

one instance, the amount of administrative and facilities costs not shown was 

about 31 percent—a total of $1.05 billion—of the program’s cost. Finally, VA 

presents several summary tables that highlight program costs; however, 

information on how most of these costs break down across the three accounts 

cannot be found in the CBJ. The lack of such account-level information can make 

it more difficult for congressional decision makers to make appropriations

decisions and to conduct oversight.

VA Medical Care Appropriations Accounts

View GAO-12-908. For more information, 

contact Melissa Emrey-Arras at (617) 788-

0534 or emreyarrasm@gao.gov. 
Page i GAO-12-908 Veterans’ Health Care Budget 

Letter 1 

Background 2

VA’s Budget Request Is Based on Data from Systems Designed for 

the Former Single-Account Structure 7

VA Provides Inconsistent Information across VHA’s Three Medical 

Care Appropriations Accounts 7

Conclusions 12

Recommendations for Executive Action 12

Agency Comments 12

Appendix I Comments from the Department of Veterans Affairs 14

Appendix II GAO Contact and Staff Acknowledgments 16

Tables

Table 1: Excerpts from VA’s CBJ Showing Different Labels for the 

Same Service 9

Table 2: Excerpts from VA’s CBJ Showing Similar Labels for 

Different Services 9

Table 3: Information from VA’s CBJ Comparing Obligations 

Provided for Nursing Home Care and Long-Term Care 10

Figure

Figure 1: VA Medical Care Appropriations Accounts 4

Contents
Page ii GAO-12-908 Veterans’ Health Care Budget 

Abbreviations

CBJ Congressional Budget Justification

CHAMPVA Civilian Health and Medical Program of the Department of 

Veterans Affairs

CWVV Children of Women Vietnam Veterans

EHCPM Enrollee Health Care Projection Model

FMP Foreign Medical Program

OMB Office of Management and Budget

VA Department of Veterans Affairs

VA CLC Veterans Affairs Community Living Centers

VHA Veterans Health Administration

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Page 1 GAO-12-908 Veterans’ Health Care Budget 

United States Government Accountability Office 

Washington, DC 20548

September 18, 2012

The Honorable Patty Murray

Chairman

The Honorable Richard Burr

Ranking Member

Committee on Veterans’ Affairs

United States Senate

The Honorable Jeff Miller

Chairman

The Honorable Bob Filner

Ranking Member

Committee on Veterans’ Affairs

House of Representatives

The Department of Veterans Affairs (VA) operates one of the largest 

health care delivery systems in the nation. Within VA, the Veterans Health 

Administration (VHA) 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. In the past, VHA received medical care funds primarily through a 

single appropriations account. However, in 2004, Congress established a 

new account structure to “provide better oversight and receive a more 

accurate accounting of funds.”1

An appropriations account structure broadly reflects how the House and 

Senate appropriations committees make resource allocation choices, the 

preferences of these appropriations committees, and the types of control 

and incentives these committees consider most important. Previously, we 

reported that changes to the budget structure and Congressional Budget 

Justifications (CBJ)—documents that support agency budget requests—

This changed VHA’s medical care 

appropriations account structure from one account to three: Medical 

Services, Medical Support and Compliance, and Medical Facilities. These 

three accounts are considered to comprise VHA’s “medical care” 

accounts.

 

1

H.R. Rep. No. 108-401, at 1036 (2003).

 
 

Page 2 GAO-12-908 Veterans’ Health Care Budget 

have the potential to help reframe budget choices.2 Moreover, in the past, 

we have emphasized the importance of transparency in federal agencies’ 

CBJs—that is, they should be clear and easy to understand—in part 

because Congress relies on the information in them to make resource 

allocation decisions and conduct oversight.3

To complete our work, we reviewed VA budget policy documents, its 

fiscal years 2009 through 2013 CBJs, and our prior work on budget 

formulation at VA, and we interviewed VHA budget officials. We 

conducted this performance audit from June 2011 to September 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.

This report responds to your 

request that we (1) describe the relationship between VHA’s 

appropriations account structure and VA’s development of the budget 

request and (2) examine how VA presents information about the three 

VHA appropriations accounts in its CBJ.

In fiscal year 2011, approximately 6.2 million patients received health 

care from VA.4

 

2

GAO, Performance Budgeting: Efforts to Restructure Budgets to Better Align Resources 

with Performance, 

In providing that care, VA operates 152 hospitals, 133 

nursing homes, 824 community-based outpatient clinics, and other 

facilities through 21 regional health care networks.

GAO-05-117SP (Washington, D.C.: February 2005).

3

GAO, Internal Revenue Service: Assessment of Budget Justification for Fiscal Year 2011 

Identified Opportunities to Enhance Transparency, GAO-10-687R (Washington, D.C.: May 

26, 2010).

4

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. 

Background
 

Page 3 GAO-12-908 Veterans’ Health Care Budget 

A variety of activities are funded through VHA’s three appropriations 

accounts for medical care:

• The Medical Services account includes funds for health care services 

provided to eligible veterans and beneficiaries in VA’s medical 

centers, outpatient clinic facilities, contract hospitals, state homes, 

and outpatient programs on a fee basis.5 For fiscal year 2012, VA 

received more than $39.6 billion in the Medical Services account.6

• The Medical Support and Compliance account includes funds for the 

management and administration of the VA health care system, 

including financial management, human resources, and logistics. For 

fiscal year 2012, VA received more than $5.5 billion in the Medical 

Support and Compliance account.7

• The Medical Facilities account includes funds for the operation and 

maintenance of the VA health care system’s capital infrastructure, 

such as costs associated with nonrecurring maintenance, utilities, 

facility repair, laundry services, and grounds keeping.8 For fiscal year 

2012, VA received more than $5.4 billion in the Medical Facilities 

account.9

 

5

Beneficiaries may include nonveterans, such as family members receiving Civilian Health 

and Medical Program of the Department of Veterans Affairs benefits. 

6

Pub. L. No. 112-10, div. B, title X, § 2015, 125 Stat. 38, 175 (Apr. 15, 2011). In addition to 

new appropriations that VA receives during 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 2011 appropriations provided that $1.2 billion be available for 2 fiscal years. 

Pub. L. No. 112-10, § 2014. VA’s other sources of funding include collections and 

reimbursements. VA’s collections include third-party payments from veterans’ private 

health care insurance for the treatment of non-service-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. 

See GAO, Veterans’ Health Care Budget: Transparency and Reliability of Some Estimates 

Supporting President’s Request Could Be Improved, GAO-12-689 (Washington, D.C.: 

June 11, 2012). 

7

Pub. L. No. 112-10, § 2015.

8

This account does not include funding for major or minor construction or for information 

technology because separate appropriations provide funds for these purposes.

9

Pub. L. No. 112-10, § 2015.
 

Page 4 GAO-12-908 Veterans’ Health Care Budget 

Figure 1 depicts the current appropriations account structure for VA 

medical care.

Figure 1: VA Medical Care Appropriations Accounts

The amount of funding Congress gives VA to provide its health care 

services is determined by the annual appropriations process. The 

development of VA’s annual budget estimate is inherently complex, as 

assumptions and imperfect information are used to project the likely 

quantity and cost of the health care services VHA expects it will be 

required to provide.10 Unlike most other agencies, VA receives advance 

appropriations for health care in addition to annual appropriations.11

 

10GAO, VA Health Care: Challenges in Budget Formulation and Execution, 

Accordingly, in preparation for the appropriations process, VA begins 

developing an annual estimate of the resources needed to provide its 

GAO-09-459T 

(Washington, D.C.: Mar. 12, 2009). 

11The 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. The act also 

required VA to include additional information in its annual CBJ. Specifically, the VA 

Secretary must include detailed estimates of the funds necessary to provide VA health 

care services for the fiscal year for which advance appropriations will be provided. 
 

Page 5 GAO-12-908 Veterans’ Health Care Budget 

health care services for 2 fiscal years well in advance.12 This budget 

estimate is reviewed through successively higher levels within the agency 

and revised until consolidated into a department-wide annual budget 

estimate that is submitted to the Office of Management and Budget 

(OMB) for review and consideration. OMB subsequently includes both an 

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.13

VA develops more than 80 percent of its budget estimates for health care 

services using the Enrollee Health Care Projection Model (EHCPM).

This estimate must include assumptions about 

future economic conditions, presidential policies, and congressional 

actions that may affect the funding needs in the year for which the 

request is made. Because VA is required to provide services to eligible 

veterans, VA’s budget estimates must also accommodate the future 

demand for the total cost of providing health care services, including 

direct patient costs as well as costs associated with management, 

administration, and maintenance of facilities.

14

 

12VA begins formulating a budget request approximately 10 months before the President 

submits the budget to Congress in early February. This is approximately 18 months before 

the start of the fiscal year to which the request relates and about 30 months prior to the 

start of the fiscal year to which the advance appropriations request relates.

The EHCPM’s estimates, which are largely based on the historical costs 

of health care services, include three basic components: the projected 

number of veterans who will be enrolled in VA health care, the projected 

demand for health care services by these enrollees, and the projected 

unit cost of providing these services. VHA uses the EHCPM to estimate 

the resources needed to meet expected demand for over 70 health care 

services such as surgery, pharmacy, and prosthetics. Other methods are 

used to develop the remaining parts of its budget request; that is, the 

13For example, in the spring of 2011, VA began formulating the President’s VA health care 

request for fiscal year 2013 and an advance appropriations request for fiscal year 2014. In 

the spring of 2012, VA began updating the request for fiscal year 2014. Before or during 

fiscal year 2013, Congress and the President may enact advance appropriations for the 

needs of fiscal year 2014. If Congress and the President later enact different 

appropriations for fiscal year 2014, those appropriations would then supersede any 

previously enacted advance appropriations. 

14GAO-11-205. 
 

Page 6 GAO-12-908 Veterans’ Health Care Budget 

costs of long-term care and other health care programs.15

In support of the President’s budget request, VA prepares a CBJ. This 

CBJ provides Congress 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, the CBJ reflects 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 and provides information about agency priorities, as well as the 

implications of the requested amounts for VHA’s provision of health care 

services to veterans. While VA must present the budget using the threeaccount structure, as mentioned previously, it also presents the three 

accounts in aggregate under the name “medical care.” Instead of 

breaking down obligations by account, the medical care table breaks 

down obligations using other broad health care categories such as 

rehabilitative care, mental health, and institutional long-term care.

According to 

VA, starting in the President’s fiscal year 2014 budget request, long-term 

care estimates will be developed using a new model similar to and 

grounded in the EHCPM, but specific to the nature of long-term care 

costs.

The CBJ is a key document that helps Congress make appropriations 

decisions, conduct oversight, and provide control over VA’s funds. The 

structure of the CBJ reflects OMB guidance and the interests of the 

House and Senate appropriations committees. This allows agencies the 

flexibility to tailor the contents of the CBJ to the various needs of the 

primary users of this information; that is, the appropriations committees of 

jurisdiction. Over time, the content and structure of CBJs have evolved to 

accommodate changing circumstances and priorities. According to VA 

officials, the CBJ was developed by VHA along with OMB in response to 

the appropriations committee’s questions about specific areas of medical 

care.

 

15The estimates for these services are based on factors, such as recent data on the costs 

and the amount of care VHA provided to veterans, VHA’s policy goals for providing such 

services, and projections of the number of users.
 

Page 7 GAO-12-908 Veterans’ Health Care Budget 

VA creates its budget request through the EHCPM using data from 

systems designed for the former single-account structure.16 These 

systems do not explicitly consider the three appropriations accounts.17

VA presents the budget request in the CBJ using the three-account 

structure created by Congress. According to VHA officials, this is done by 

taking the data about the costs of the over 70 health care services 

developed by the EHCPM and then based on historical percentages and 

future projections, assigning the requested amounts to the three 

appropriations accounts.

According to VHA officials, VHA formulates its budget based on the single 

appropriations account, in part, because the systems to formulate the 

request were in place prior to 2004, which was when the three-account 

structure was established.

VA’s CBJ can be difficult to follow because information is not displayed 

consistently across the three medical care appropriations accounts. There 

are three key reasons for this:

1) health care service labels are inconsistent across the three 

appropriations accounts,

2) health care services are described in varying levels of detail across 

the three appropriations accounts, and

3) summary tables lack detailed account-level information. 

Consistent information across the three accounts is important to 

achieving the stated purposes of changing to the three-account structure; 

that is, to provide better oversight and a more accurate accounting of 

funds. Moreover, our past work states that in order to facilitate decision 

making, information needs to be clear and organized in a way that is 

 

16The Decision Support System is VHA’s cost accounting system, which aggregates cost 

information from VA’s workload and financial systems. This system provides EHCPM with 

data to develop future year budget estimates.

17Although the systems used to formulate VA’s budget request in the CBJ do not explicitly 

consider the three appropriations accounts, VHA officials told us that they manage their 

resources within the appropriation limits.

VA’s Budget Request 

Is Based on Data from 

Systems Designed for 

the Former SingleAccount Structure

VA Provides 

Inconsistent 

Information across 

VHA’s Three Medical 

Care Appropriations 

Accounts
 

Page 8 GAO-12-908 Veterans’ Health Care Budget 

meaningful to its users.18 While the House and Senate appropriations 

committees are the primary users of the CBJ, other committees also use 

the information presented in the CBJ. For instance, the House and 

Senate Committees on Veterans’ Affairs—the authorizing committees—

use the CBJ as one tool in conducting oversight.

Inconsistent service labels in the CBJ contribute to a confusing 

presentation. Service labels are inconsistent in that different labels may 

refer to the same services. For example, as shown in table 1, what is 

referred to as “psychiatric care” in the detailed presentation of the Medical 

Support and Compliance and Medical Facilities accounts is referred to as 

“mental health” in the detailed presentation for the Medical Services 

account.19 We determined that mental health and psychiatric care refer to 

the same services by comparing the totals and confirming this with VHA 

officials. The situation is the same as with the Civilian Health and Medical 

Program of the Department of Veterans Affairs (CHAMPVA) in the 

Medical Support and Compliance and Medical Facilities accounts. As 

seen in table 1, this service is labeled as CHAMPVA, Spina Bifida, 

Foreign Medical Program (FMP), and Children of Women Vietnam 

Veterans (CWVV) in the displays of the Medical Services account. The 

smaller programs of Spina Bifida, FMP, and CWVV are included in the 

Medical Support and Compliance and Medical Facilities accounts, but not 

listed by name. According to VHA officials, the inconsistent labeling was 

inadvertent.

 

18GAO-10-687R and GAO-05-117SP. 

19The CBJ presents two levels of detail for the Medical Services account. Although the 

detailed presentation uses different labels than what is shown for the other two accounts, 

the less detailed presentation provides the same labels across all three accounts. 

Health Care Service Labels 

Are Inconsistent across the 

Three Appropriations 

Accounts
 

Page 9 GAO-12-908 Veterans’ Health Care Budget 

Table 1: Excerpts from VA’s CBJ Showing Different Labels for the Same Service

Dollars in millions

VHA medical care accounts 

Medical Support and 

Compliance Medical Facilities Medical Services

Total 

medical care

Description 2011 

obligations

Description 2011 

obligations

Description 2011 

obligations

2011 

obligations

Psychiatric care $708 Psychiatric care $827 Mental health $3,984 $5,519 

CHAMPVA 78 CHAMPVA 5 CHAMPVA, Spina Bifida, 

FMP, and CWVV

1,138 1,221

Source: GAO presentation of VA’s 2013 CBJ data.

Note: We created this table using data provided in the Department of Veterans Affairs Congressional 

Submission, FY 2013 Funding and FY 2014 Advance Appropriations Request, Vol. 2, Medical 

Programs and Information Technology Programs, 1A-5,1C-3, 1D-8, and 1E-12. 

In addition to the inconsistencies in labeling among the same services, 

similar labeling may refer to entirely different services. For example, as 

shown in table 2, a user might think that the “acute hospital care” and 

“subacute care” services listed under the Medical Support and 

Compliance and Medical Facilities accounts are subcomponents of the 

“acute care” services shown under the Medical Services account. 

However, they are not subcomponents of acute care. The terminology 

and presentation are not consistent with terminology and presentation 

used elsewhere. According to VHA officials, the tables represent several 

ways of breaking down the subcomponents of the total appropriation and 

are a response to requests for different ways to display the information 

that have been requested over time.

Table 2: Excerpts from VA’s CBJ Showing Similar Labels for Different Services

Dollars in millions

VHA medical care accounts

Medical Support and 

Compliance Medical Facilities Medical Services

Total medical 

care

Description

2011 

obligations Description

2011 

obligations Description

2011 

obligations

2011 

obligations

 Acute care $27,049 $34,933 

Acute hospital care $1,130 Acute hospital care $1,296 

Subacute care 10 Subacute care 12 

Source: GAO presentation of VA’s 2013 CBJ data.

Note: We created this table using data provided in the Department of Veterans Affairs Congressional 

Submission, FY 2013 Funding and FY 2014 Advance Appropriations Request, Vol.2, Medical 

Programs and Information Technology Programs, 1A-5, 1C-3, 1D-8, and 1E-12. 
 

Page 10 GAO-12-908 Veterans’ Health Care Budget 

Another area of inconsistency in the CBJ is that levels of detail vary 

across the three appropriations accounts. Specifically, the level of detail 

provided for the Medical Services account is significantly greater than 

what is provided for the Medical Support and Compliance and Medical 

Facilities accounts. For example, as shown in table 3, resources 

requested for VA community living centers (VA CLC), community nursing 

homes, and state nursing homes are provided for the Medical Services 

account but not for the Medical Support and Compliance or Medical 

Facilities accounts. While the state nursing home, community nursing 

homes, and VA CLC programs do consume resources from the Medical 

Support and Compliance and Medical Facilities accounts, the amounts 

from those accounts are not shown.

Table 3: Information from VA’s CBJ Comparing Obligations Provided for Nursing Home Care and Long-Term Care

Dollars in millions

VHA medical care accounts

Medical Support and 

Compliance Medical Facilities Medical Services Total medical care

Description

2011 

obligations Description

2011 

obligations Description

2011 

obligations

2011 

obligations

Difference–(not 

Shown in CBJ)b

Nursing 

home care

$481 Nursing 

home care

$578 Nursing 

home carea

 

$3,756 $4,815 $1,059

 VA CLC 2,374 3,425 1,051

Community 

nursing 

homes

607 614 7 

State nursing 

homes

775 775 0 

Source: GAO presentation of VA’s 2013 CBJ data.

Note: We created this table using data provided in the Department of Veterans Affairs Congressional 

Submission, FY 2013 Funding and FY 2014 Advance Appropriations Request, Vol. 2, Medical 

Programs and Information Technology Programs, 1A-5,1C-3, 1C-24, 1D-8, and 1E-12. 

a

While nursing home care does not appear in aggregate alongside its subcomponents in the CBJ, for 

the sake of clarity, we present this information together in this table. 

b

This represents the difference between the dollar amounts provided in the medical care detailed 

table and the medical services detailed table. 

VHA officials explained that they do not produce separate estimates or 

display obligations for the Medical Support and Compliance and Medical 

Facilities costs because the costs for those accounts are relatively small 

compared to the Medical Services account. However, in at least one 

instance, the amount not shown was considerable. For example, about 31 

percent—a total of $1.05 billion—was obligated for administrative and 

Levels of Detail Vary 

Across the Three 

Appropriations Accounts
 

Page 11 GAO-12-908 Veterans’ Health Care Budget 

facilities costs combined for VA CLC, but the CBJ does not show this 

number or the specific breakdown between the Medical Support and 

Compliance and Medical Facilities accounts. Congress may consider the 

administrative and facilities costs for VA CLC to be significant and 

important to decision making.

VA presents several summary tables that highlight program costs; 

however, information on how most of these costs break down across the 

three accounts cannot be found in the CBJ. For example, in the table of 

“selected program highlights,” which VA officials informed us is one of the 

key tables of interest to Congress, most program costs are not also 

broken out across the three accounts.20

Congressional committees have recently requested more information 

about VA’s spending and voiced concerns about VA’s CBJ. Specifically, 

the House Committee on Appropriations recently requested that VA 

provide additional detail on, for example, administrative costs by 

headquarters, regional network, and medical center, in order to help 

inform congressional decisions.

The lack of such account-level 

information can make it more difficult for Congressional decision makers 

to conduct oversight.

21 The Senate Committee on 

Appropriations also recently expressed concern that the “justifications 

continue to lack specificity and the degree of detail needed to ensure 

informed and timely evaluation of requested funds and proper oversight of 

a Department the size of the VA.”22

 

20One exception to this is information on CHAMPVA/FMP/Spina Bifida/CWVV. Accountlevel information on this program is found in CBJ Vol. 2, Medical Programs and 

Information Technology Programs, 1A-5,1C-3, 1D-8, and 1E-12.

In addition, according to some 

authorizing committee staff, the CBJ is confusing and after the switch to 

the three-account structure, information in the CBJ has not become more 

detailed or transparent. According to VHA officials, the CBJ reflects the 

information Congress has asked VA to provide. They added that both the 

House and Senate appropriations committees have expressed an interest 

in more detailed information in the CBJ to increase oversight, but have 

not asked VA to change the structure or content of the CBJ as a whole.

21H.R. Rep. No. 112-491, at 47 (2012).

22S. Rep. No. 112-168, at 32 (2012).

Summary Tables Detail 

Costs by Program but Not 

by Appropriations 

Accounts
 

Page 12 GAO-12-908 Veterans’ Health Care Budget 

VA’s CBJ is intended to provide congressional committees with 

information they need to make decisions. To facilitate decision making, 

information needs to be clear and organized in a way that is meaningful to 

its users. Our work has demonstrated that there are concerns with the 

clarity and usefulness of the information presented in the CBJ. Users of 

the CBJ should be able to rely on consistency in labeling to help them 

understand the information being presented. 

Increasing congressional oversight was one of the motivations to 

establish the current account structure. Our work has identified areas 

where the information as presented across the three accounts does not 

provide the level of detail desired to improve oversight. Various 

congressional committees have also stated that the information is not 

meeting their needs. 

To improve the clarity and usefulness 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 Veterans 

Affairs take the following two actions: 

 Label health care services consistently so it is clear what services, such 

as mental health, are being referred to across appropriations accounts. 

 Further consult with congressional decision makers to determine what 

detailed information related to the three appropriations accounts 

should be presented, and how, in its congressional budget 

justification. 

We provided a draft of this report to the Secretary of Veterans Affairs for 

comment. In its written comments, reproduced in appendix I, his Chief of 

Staff generally agrees with our conclusions and concurs with our 

recommendations. In response to our first recommendation, VA stated 

they will undertake a review of the programmatic reference in the CBJ 

volume for the medical programs and standardize throughout. In addition, 

VA will initiate discussions with the Office of Management and Budget to 

determine whether the references in the President’s Budget Appendix can 

also be made consistent. In response to our second recommendation, VA 

also stated it would consult with Congress to identify any additional 

information to include in the budget justification document. Finally, VA 

provided technical comments that were incorporated, as appropriate. 

Conclusions 

Recommendations for 

Executive Action 

Agency Comments 
 

Page 13 GAO-12-908 Veterans’ Health Care Budget 

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

and appropriate congressional committees. In addition, the report is 

available at no charge on the GAO website at http://www.gao.gov. 

If you or your staff have any questions about this report, please contact 

Melissa Emrey-Arras at (617) 788-0534 or emreyarrasm@gao.gov. 

Contact points for our Offices of Congressional Relations and Public 

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Melissa Emrey-Arras 

Acting Director

Strategic Issues 
Appendix I: Comments from the Department of 

Veterans Affairs

Page 14 GAO-12-908 Veterans’ Health Care Budget 

Appendix I: Comments from the Department 

of Veterans Affairs
Appendix I: Comments from the Department of 

Veterans Affairs

Page 15 GAO-12-908 Veterans’ Health Care Budget 
Appendix II: GAO Contact and Staff 

Acknowledgments 

Page 16 GAO-12-908 Veterans’ Health Care Budget 

Melissa Emrey-Arras, (617) 788-0534, emreyarrasm@gao.gov

In addition to the contact named above, Denise Fantone (Director), Carol 

Henn (Assistant Director), Melissa Wolf (Assistant Director), Amber 

Edwards, Katherine Wulff, Tara Jayant, Lauren Grossman, James 

Musselwhite, Melanie Papasian, Leah Probst, and Cindy Saunders made 

key contributions to this report. 

Appendix II: GAO Contact and Staff 

Acknowledgments 

GAO Contact 

Staff 

Acknowledgments 

(450932)
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