VETERANS’ HEALTH 

CARE

Improvements Needed 

to Ensure That Budget 

Estimates Are Reliable 

and That Spending for 

Facility Maintenance 

Is Consistent with 

Priorities

Report to Congressional Requesters

February 2013

GAO-13-220

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-13-220, a report to 

congressional requesters

February 2013

VETERANS’ HEALTH CARE 

Improvements Needed to Ensure That Budget 

Estimates Are Reliable and That Spending for 

Facility Maintenance Is Consistent with Priorities

Why GAO Did This Study

VA operates about 1,000 medical 

facilities—such as hospitals and 

outpatient clinics—that provide 

services to more than 6 million patients 

annually. The operation and 

maintenance of its facilities, including 

NRM, is funded from VA’s Medical 

Facilities appropriations account, one 

of three accounts through which 

Congress provides resources for VA 

health care services.

In prior work, GAO found that VA’s 

spending on NRM has consistently 

exceeded its estimates. GAO 

recommended that VA ensure that its 

NRM estimates fully account for this 

long-standing pattern, and VA agreed 

to implement this recommendation.

GAO was asked to conduct additional 

work on NRM spending. In this report,

GAO examines, for fiscal years 2006 

through 2012, (1) what accounted for 

the pattern of NRM spending 

exceeding VA’s budget estimates; 

(2) VA’s allocation of resources for 

NRM to its health care networks; and 

(3) VA’s process for prioritizing NRM 

spending and the extent to which NRM 

spending was consistent with these 

priorities. GAO reviewed VA’s budget 

justifications and VA data and 

interviewed officials from headquarters 

and selected networks.

What GAO Recommends

GAO recommends that VA determine 

why it has overestimated spending for 

non-NRM and use the results to 

improve future, non-NRM budget 

estimates. GAO also recommends that 

VA provide networks with written 

guidance for prioritizing belowthreshold NRM projects. VA concurred 

with GAO’s recommendations.

What GAO Found

During fiscal years 2006 through 2012, the Department of Veterans Affairs (VA) 

had higher than estimated resources available for facility maintenance and 

improvement—referred to as non-recurring maintenance (NRM); these resources 

accounted for the $4.9 billion in VA’s NRM spending that exceeded budget 

estimates. The additional resources came from two sources. First, VA spent less 

than it estimated on non-NRM, facility-related activities such as administrative 

functions, utilities, and rent, which allowed VA to spend over $2.5 billion more 

than originally estimated. Lower spending for administrative functions, utilities, 

and rent accounted for most of the resources estimated but not spent on 

non-NRM activities. Given that VA has consistently overestimated the costs of 

such activities in recent years, VA’s budget estimates for its non-NRM activities 

may not be reliable. Second, more than $2.3 billion of the higher than estimated 

spending on NRM can be attributed to VA having higher than estimated budget 

resources available. In some years VA received higher appropriations from 

Congress than requested and supplemental appropriations for NRM—such as 

those included in the American Recovery and Reinvestment Act of 2009. The 

additional budget resources VA used for NRM also included transfers of funds 

from the agency’s appropriations account that funds health care services.

VA allocated about $7.5 billion in resources for NRM to its 21 health care 

networks from fiscal year 2006 through fiscal year 2012. VA allocated about

$4.6 billion of these resources at the beginning of each fiscal year through the 

Veterans Equitable Resource Allocation—its national, formula-driven system. In 

addition, VA allocated $2.9 billion during this period from higher than requested 

annual appropriations and its national reserve account, which is maintained to 

address contingencies that may develop each fiscal year. In anticipation of such 

resources, networks typically identify projects that can be implemented if 

additional funds become available. VA officials told us that they do this to better 

address the backlog of identified building deficiencies most recently estimated to 

cost over $9 billion.

To prioritize NRM spending more centrally, VA established a new process for 

projects above a minimum threshold, and from fiscal years 2006 through 2012 

spending on NRM was generally consistent with VA priorities. Prior to fiscal year 

2012, VA provided oral guidance to networks for prioritizing NRM spending and 

relied on its 21 health care networks to prioritize NRM projects to maintain 

medical facilities in good working condition and address deficiencies. Beginning 

in fiscal year 2012, as part of VA’s Strategic Capital Investment Planning (SCIP) 

process, VA headquarters assumed responsibility for prioritizing more costly 

NRM projects using a set of weighted criteria. For fiscal year 2012, the threshold 

for NRM projects to be included in this centralized process was $1 million, while 

networks remain responsible for prioritizing “below-threshold” NRM projects. 

NRM spending during fiscal years 2006 through 2012 was generally consistent 

with VA priorities: at least 85 percent of the projects funded in each year were 

identified by networks as priorities. However, VA has not provided written policies 

for networks on how to apply SCIP criteria to below-threshold projects, which 

represented over 40 percent of VA’s fiscal year 2012 NRM spending. Without 

such written policies, VA does not have reasonable assurance that network 

spending for below-threshold NRM projects will be consistent with SCIP criteria.

View GAO-13-220. For more information, 

contact Randall B. Williamson at 

(202) 512-7114 or williamsonr@gao.gov.
Page i GAO-13-220 Veterans’ Health Care

Letter 1 

Background 5

Availability of Higher Than Estimated Resources Accounted for 

NRM Spending That Exceeded Budget Estimates 9

VA Used VERA to Allocate Most NRM Resources at the Start of a 

Fiscal Year and Network Requests to Allocate Additional NRM 

Resources Later 12

VA Relied on Networks to Prioritize NRM Spending before 

Centralizing Prioritization Recently for More Costly Projects, 

and Spending Was Generally Consistent with Priorities 15

Conclusions 20

Recommendations for Executive Action 20

Agency Comments 21

Appendix I Comments from the Department of Veterans Affairs 23

Appendix II GAO Contact and Staff Acknowledgments 25

Related GAO Products 26

Figures

Figure 1: Non-Recurring Maintenance (NRM) Budget Estimates and 

Actual Spending, Fiscal Years 2006 through 2012 8

Figure 2: Non-Recurring Maintenance (NRM) Spending That 

Exceeded Budget Estimates, by Funding Source, Fiscal 

Years 2006 through 2012 10

Figure 3: Resources Allocated for Non-Recurring Maintenance 

(NRM), by Allocation Method, Fiscal Years 2006 through 

2012 13

Figure 4: Percentage of Funded Non-Recurring Maintenance 

(NRM) Projects Listed in VA Health Care Networks’ 

Operating Plans, Fiscal Years 2006 through 2012 19

Contents 
Page ii GAO-13-220 Veterans’ Health Care

Abbreviations

FCA Facility Condition Assessment

NRM non-recurring maintenance

Recovery Act American Recovery and Reinvestment Act of 2009

SCIP Strategic Capital Investment Planning

VA Department of Veterans Affairs

VERA Veterans Equitable Resource Allocation

VHA Veterans Health Administration

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Page 1 GAO-13-220 Veterans’ Health Care

United States Government Accountability Office

Washington, DC 20548

February 22, 2013

Congressional Requesters

The Department of Veterans Affairs (VA) is one of the nation’s largest 

health care systems. VA operates more than 150 hospitals, 130 nursing 

homes, and 800 outpatient clinics providing health care services to more 

than 6 million patients in fiscal year 2012. Many of the buildings in 

which VA’s medical facilities are housed, however, were built more than 

50 years ago and may not be suitable for providing accessible, highquality, and cost-effective health care in the 21st century. One way in 

which VA addresses these building deficiencies and modernizes its 

medical facilities is by performing various maintenance and improvement 

projects—referred to as non-recurring maintenance (NRM).1 NRM 

projects include remodeling space used to deliver mental health or other 

clinical services; replacing roofing, windows, and doors; upgrading 

heating, ventilation, and air conditioning systems; and repaving roads and 

parking lots. VA spent about $1.5 billion on NRM in fiscal year 2012 and 

estimates the cost of addressing all existing building deficiencies—known 

as the NRM backlog—to be over $9 billion.2

While the amount of funding VA receives for its health care services—

which includes resources for NRM—is determined by Congress in the 

annual appropriations process, VA has flexibility as to how the agency 

allocates its resources. In preparation for the appropriations process, VA 

develops estimates of the resources needed to provide health care 

services to veterans. These estimates are subsequently used to help 

inform the President’s budget request to Congress for VA health care 

appropriations.3

 

1

In general, NRM projects are repairs and renovations within the existing square footage 

of a facility that total more than $25,000. NRM projects that are strictly meant to ensure 

facilities are in good working condition are limited to $10 million. NRM projects may 

include expansion of new space, but associated costs may not exceed $500,000.

In particular, VA’s estimates for NRM help inform the 

2

Specifically, the NRM backlog represents a cumulative total of the estimated costs to 

address all deficiencies identified during facility condition assessments conducted at VA 

medical facilities.

3

VA prepares an annual budget justification for congressional deliberation during the

appropriations process. 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.

 
 

Page 2 GAO-13-220 Veterans’ Health Care

President’s request for VA’s Medical Facilities appropriations account—

one of three appropriations accounts used for VA health care services. At 

the beginning of each fiscal year, VA performs an initial allocation of most 

of its health care appropriations to its 21 health care networks. During the 

course of a fiscal year, however, VA and its networks have the flexibility 

to increase or decrease the amounts available for a specific program or 

activity, such as NRM, within applicable authority.

In recent years, we have highlighted VA’s higher than estimated spending 

on NRM, and the agency’s budget estimates. In June 2011 we reported 

that VA’s spending for NRM exceeded its budget estimates for fiscal 

years 2006 through 2010.4 Similarly, in June 2012, we reported that this 

pattern for NRM spending continued in fiscal year 2011 and, according to 

VA officials, was the result of VA medical facilities spending more on 

NRM using resources that were originally intended for other, non-NRM 

activities funded from the Medical Facilities account, such as utilities and 

janitorial services.5

In light of our previous findings, you asked us to further review VA’s 

spending for NRM. In this report we examine, for fiscal years 2006 

through 2012, (1) what accounted for the pattern of NRM spending 

exceeding VA’s budget estimates; (2) VA’s allocation of resources for 

NRM to its health care networks; and (3) VA’s process for prioritizing 

NRM spending and the extent to which NRM spending was consistent 

with these priorities.

Furthermore, in fiscal year 2012, VA’s spending on 

NRM again exceeded its estimates. In our June 2012 report, we 

recommended that VA ensure that its NRM estimates fully account for the 

long-standing pattern of medical facilities spending more on NRM than 

VA estimated. VA agreed with our recommendation, noting that future 

annual estimates of resources needed for NRM will be consistent with 

policy decisions and will account for past spending levels on NRM.

 

4

See GAO, Veterans’ Health Care Budget: 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). We have also issued other reports on VA’s budget process. See the 

Related GAO Products page at the end of this report.

5

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). 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. See, for example, S. Rep. No. 111-40 (2009), 

at 57; H.R. Rep. No. 111-188 (2009), at 43-44.
 

Page 3 GAO-13-220 Veterans’ Health Care

To examine the factors that accounted for the pattern of NRM spending 

exceeding VA’s budget estimates in fiscal years 2006 through 2012, we 

reviewed and analyzed data related to VA’s Medical Facilities 

appropriations account.6

To determine how, for fiscal years 2006 through 2012, VA allocated NRM 

resources to its 21 networks, we analyzed detailed NRM allocation data. 

We also reviewed relevant documentation, including manuals for VA’s 

Veterans Equitable Resource Allocation (VERA), congressional budget 

justifications, and applicable laws and regulations.

In particular, we compared estimated and actual 

amounts for VA’s spending for NRM and non-NRM activities, and 

estimated and actual amounts for annual appropriations and other budget 

resources. We also reviewed VA’s congressional budget justifications for 

fiscal years 2006 through 2012. We interviewed knowledgeable officials 

from VA’s Veterans Health Administration’s (VHA) Office of Finance and 

Office of Capital Asset Management Engineering and Support. We also 

interviewed officials from 2 of VA’s 21 health care networks—Network 4 

(Pittsburgh, Pennsylvania) and Network 16 (Jackson, Mississippi) to 

inquire about networks’ effect on VA’s NRM spending. We selected these 

networks because they were among the networks whose spending on

NRM exceeded their initial allocation the most in fiscal years 2006 

through 2012. While our selection allowed us to obtain additional insight 

into how networks manage spending related to estimates, the information 

is not representative of VA’s 21 networks. As part of these interviews, we 

explored with VA officials why VA’s NRM spending exceeded the 

agency’s estimates based on experience in their networks regarding initial 

allocations for NRM and the amounts spent for NRM during the fiscal 

year.

7 We interviewed 

knowledgeable officials from VHA’s Office of Finance and Office of 

Capital Asset Management Service to inquire about VA’s allocation of 

resources to networks for NRM.

 

6

For purposes of our work, we used data on VA’s obligations to report the agency’s 

annual spending for NRM and other activities. Obligations refer to a definite commitment 

creating a legal liability to make payments immediately or in the future. An obligation is 

incurred, for example, when an agency awards a contract to a private entity.

7

VERA is a national, formula-driven system used by VA to allocate most of its health care 

appropriations to its 21 health care networks.
 

Page 4 GAO-13-220 Veterans’ Health Care

To examine VA’s process for prioritizing NRM spending for fiscal years 

2006 through 2012, we reviewed VA’s policies for its NRM program, 

including VHA Directive 1002.1, Non-Recurring Maintenance Program 

and VA Handbook 0011, Strategic Capital Investment Planning Process, 

and other related documentation.8 We also interviewed knowledgeable 

officials from VHA’s Office of Finance and Office of Capital Asset 

Management Engineering and Support and from our two selected health 

care networks to inquire about VA’s process for prioritizing NRM projects 

and request relevant documentation. We assessed to what extent VA 

established formal written policies documenting its guidance for 

prioritizing NRM spending.9

To assess the reliability of VA’s estimated and actual spending for its 

Medical Facilities appropriations account, we verified the consistency of 

the data we received from VA with amounts contained in VA’s 

congressional budget justifications for fiscal years 2006 through 2012. To 

assess the reliability of VA’s allocation of NRM resources, we verified the 

consistency of the data with information and amounts reported in the 

VERA manuals for fiscal years 2006 through 2012 and applicable laws. 

We discussed these data as well as the data on planned and funded 

NRM projects with VA officials. We also relied on our prior work to 

compare data and check for internal consistency. We found the data 

reliable for the purposes of this report.

To determine the extent to which funded 

NRM projects were consistent with VA’s NRM priorities, we analyzed data 

on planned and funded NRM projects for fiscal years 2006 through 2012. 

We interviewed officials from our two selected networks to corroborate 

information we received from VA headquarters officials and to inquire 

about VA’s NRM priorities and spending at the network level. We also 

reviewed documentation related to VA’s current process for monitoring 

NRM spending and interviewed knowledgeable officials from VHA’s Office 

of Capital Asset Management Engineering and Support. 

 

8

VA implemented its Strategic Capital Investment planning (SCIP) process in fiscal year 

2012 to prioritize more costly NRM projects and other capital investment projects.

9

The federal standards of internal control specify that agency policies should be 

documented and that all documentation should be properly managed and maintained. See 

GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1

(Washington, D.C.: November 1999).
 

Page 5 GAO-13-220 Veterans’ Health Care

We conducted this performance audit from July 2012 through February 

2013 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.

In support of the President’s annual budget request for VA health care 

services, which includes a request for advance appropriations,10 VA 

develops a budget estimate of the resources needed to provide such 

services for 2 fiscal years.11

 

10The 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).

Typically, VHA starts to develop a health care 

budget estimate approximately 10 months before the President submits 

the budget request to Congress in 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. VA’s health care budget estimate 

includes estimates of the total cost of providing health care services as 

well as costs associated with management, administration, and 

maintenance of facilities. VA develops most of its budget estimate for 

11VA 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. 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.

Background 
 

Page 6 GAO-13-220 Veterans’ Health Care

health care services using the Enrollee Health Care Projection Model.12

VA uses other methods to estimate needed resources for long-term care, 

other services, and health-care-related initiatives proposed by the 

Secretary of Veterans Affairs or the President.

13

After determining the amount of VA’s appropriations, Congress provides 

VA resources for health care through three accounts:

• Medical Services, which funds 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;

• Medical Facilities, which funds the operation and maintenance of the 

VA health care system’s capital infrastructure, including costs 

associated with NRM14 and non-NRM activities, such as utilities, 

facility repair, laundry services, and grounds keeping; and

• Medical Support and Compliance, which funds the management 

and administration of the VA health care system, including financial 

management, human resources, and logistics.

VA allocates most of its health care resources for these three accounts 

through VERA—a national, formula-driven system—at the beginning of 

each fiscal year and allocates additional resources throughout the year. 

VA allocates about 80 percent of the health care appropriations to its 

21 health care networks through VERA. VA uses methods other than 

VERA to allocate the remaining resources to networks and medical 

centers for such programs as prosthetics, homeless grants, and state 

nursing homes. VA may also use methods other than VERA to allocate 

 

12See 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).

13The estimates for long-term care and other 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.

14NRM is one of four types of capital investment programs used by VA. The remaining 

three types of capital investment programs are major construction, minor construction, and 

leasing. The major construction program funds construction projects estimated to cost 

more than $10 million, and the minor construction program funds construction projects 

estimated to cost $10 million or less. See 38 U.S.C. § 8104(a)(3)(A).
 

Page 7 GAO-13-220 Veterans’ Health Care

any additional resources it may receive from Congress during the year. 

The networks in turn allocate resources received through VERA and other 

methods to their respective medical facilities, as part of their role in 

overseeing all medical facilities within their networks. In addition to 

amounts allocated to networks and medical facilities at the beginning of 

the fiscal year, VA also sets aside resources from each of VA’s three 

health care appropriations accounts—in what is known as a national 

reserve—so that resources are available for contingencies that may arise 

during the year. In general, VA allocates resources from the national 

reserve to match network spending needs for each appropriations 

account.

Within each appropriations account, VA also has flexibility as to how the 

resources are used. For example, within the Medical Services account, 

VA has the authority to use resources for outpatient services instead of 

hospital services, should the demand for hospital services be lower than 

expected and demand for outpatient services be higher. In a similar 

manner, VA has the authority to use resources in the Medical Facilities 

account for NRM instead of non-NRM activities—such as utilities—should 

spending for those activities be less than estimated.

In June 2012, we reported that VA’s NRM spending has consistently 

exceeded the estimates reported in VA’s budget justifications from fiscal 

years 2006 to 2011.15

 

15

This pattern continued in fiscal year 2012 when VA 

spent about $1.5 billion for NRM, which was $622 million more than 

estimated. (See fig. 1.)

GAO-12-689. 
 

Page 8 GAO-13-220 Veterans’ Health Care

Figure 1: Non-Recurring Maintenance (NRM) Budget Estimates and Actual 

Spending, Fiscal Years 2006 through 2012

Notes: 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 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.

To help inform its budget estimates for NRM, VA collects information on 

facility repair and maintenance needs as part of an ongoing process to 

evaluate the condition of its medical facilities. VA conducts facility 

condition assessments (FCA) at each of its medical facilities at least 

once every 3 years. VA uses contractors to conduct FCAs, and these 

contractors are responsible for inspecting all major systems 

(e.g., structural, mechanical, plumbing, and others) and assigning each a 

grade of A (for a system in like-new condition) through F (for a system in 

critical condition that requires immediate attention). As part of this 

assessment, the contractors use an industry cost database to estimate 
 

Page 9 GAO-13-220 Veterans’ Health Care

the correction costs for each system graded D or F. According to VA 

officials, the agency’s reported NRM backlog represents the total cost of 

correcting these FCA-identified deficiencies.

Our analysis of data for fiscal years 2006 through 2012 found that in each 

of these years VA had higher than estimated resources available in its 

Medical Facilities account, which VA used to increase NRM spending by 

about $4.9 billion. These resources derived from two sources: (1) lower 

than estimated non-NRM spending, which made more resources 

available for NRM, and (2) higher than estimated budget resources, which 

included annual appropriations, supplemental appropriations, 

reimbursements,16 transfers,17 and unobligated balances.18

 

16VA’s reimbursements include amounts VA receives for services provided under service 

agreements with the Department of Defense.

As figure 

2 shows, after fiscal year 2008, lower than estimated spending on nonNRM activities accounted for most of VA’s spending on NRM that 

exceeded VA’s budget estimates.

17In each of the fiscal years we reviewed, Congress provided VA authority to move funds 

among its three health care appropriations accounts subject to congressional notification 

or approval. Any transfers to or from the Medical Facilities account require approval from 

the House and Senate Committees on Appropriations. See, for example, Pub. L. 

No. 112-74, div. H, tit. II, § 202, 125 Stat. 786, 1154 (2011). This transfer authority 

provides flexibility to respond to changing circumstances.

18VA’s unobligated balances include resources VA has not spent that it is authorized to 

carry over into the following fiscal year from the previous one.

Availability of Higher 

Than Estimated 

Resources Accounted 

for NRM Spending 

That Exceeded 

Budget Estimates
 

Page 10 GAO-13-220 Veterans’ Health Care

Figure 2: Non-Recurring Maintenance (NRM) Spending That Exceeded Budget 

Estimates, by Funding Source, Fiscal Years 2006 through 2012

Notes: NRM spending reflects obligated amounts. Lower than estimated non-NRM spending refers to 

the difference between estimated and actual obligations for other, non-NRM activities funded through 

VA’s Medical Facilities account. Higher than estimated budget resources included annual 

appropriations and supplemental appropriations as well as transfers, reimbursements, and 

unobligated balances.

a

For fiscal year 2006, VA had $89 million in higher than estimated budget resources available, which 

it used to increase spending for both NRM and non-NRM activities beyond the amounts estimated.

b

For fiscal year 2007, VA had $549 million in higher than estimated budget resources available, which 

it used to increase spending for both NRM and non-NRM activities beyond the amounts estimated.

c

For fiscal year 2008, VA had $1.1 billion in higher than estimated resources available, which it used 

to increase spending for both NRM and non-NRM activities beyond the amounts estimated.

d

For fiscal year 2009, VA had $461 million in resources from lower than estimated non-NRM spending 

available, which it used to increase spending for NRM beyond the amounts estimated. VA also used 

$383 million of higher than estimated budget resources to increase spending for NRM beyond the 

amounts estimated.

e

For fiscal year 2010, VA had $616 million in resources from lower than estimated non-NRM spending 

available, which it used to increase spending for NRM beyond the amounts estimated. VA also used 

$569 million of higher than estimated budget resources to increase spending for NRM beyond the 

amounts estimated.
 

Page 11 GAO-13-220 Veterans’ Health Care

f

For fiscal year 2011, VA had $840 million in resources from lower than estimated non-NRM 

spending, which it used to increase spending for NRM beyond the amounts estimated. VA also used 

$27 million of higher than estimated budget resources to increase spending for NRM beyond the 

amounts estimated.

g

For fiscal year 2012, VA had $724 million in resources from lower than estimated non-NRM spending 

available. VA used $102 million to fund estimated NRM spending and $622 million to increase 

spending for NRM beyond the amounts estimated.

Lower than estimated non-NRM spending. VA spent fewer resources 

from the Medical Facilities account on non-NRM activities than it 

estimated, which allowed the agency to spend over $2.5 billion more on 

NRM than it originally estimated in fiscal years 2009 through 2012. When 

we asked why VA spent more on NRM projects than estimated, VA 

officials said one reason was that the agency spent less than it estimated 

on non-NRM activities and that the most practical use of these unspent 

resources was to increase spending on NRM because of the large 

backlog of FCA-identified deficiencies. VA officials further explained that 

VA spent less for non-NRM activities than anticipated because of a 

decrease in the demand for utilities and other weather-dependent nonNRM activities because of mild weather patterns during the last four 

winters. However, lower spending on these weather-dependent activities 

only accounted for $460 million—18 percent—of the resources eventually 

used for NRM. The remaining 82 percent eventually used for NRM came 

from resources originally intended to be used for various other activities, 

including administrative functions and rent.19

Higher than estimated budget resources. VA had more budget resources 

available in its Medical Facilities account than the agency estimated it 

would have, and this allowed VA to spend over $2.3 billion more on NRM 

than it originally estimated. When we asked why VA spent more on NRM 

projects than estimated, VA officials said that in addition to spending less 

on non-NRM activities the agency also received higher annual 

appropriations than requested and unanticipated supplemental 

appropriations from Congress. For example, in fiscal year 2009 VA 

received $300 million more than it requested in annual appropriations as 

well as $1 billion in supplemental appropriations included in the American 

VA has consistently 

overestimated spending for these non-NRM activities, and if the agency 

continues to determine estimates for such activities in the same way, its 

future budget estimates of spending for non-NRM may not be reliable.

 

19Less than estimated spending for administrative functions and rent accounted for about 

$1.3 billion of the total $2.5 billion in resources eventually used for NRM.
 

Page 12 GAO-13-220 Veterans’ Health Care

Recovery and Reinvestment Act of 2009 (Recovery Act).

20 VA also 

received $550 million in supplemental appropriations as part of the U.S. 

Troop Readiness, Veterans’ Care, Katrina Recovery, and Iraq

Accountability Appropriations Act, 2007.21

In addition to higher annual appropriations and supplemental 

appropriations, we also found that VA used other budget resources to 

increase NRM spending. The budget resources included transfers from 

VA’s other appropriations accounts, reimbursements for services 

provided under service agreements with the Department of Defense, and 

unobligated balances carried over from prior fiscal years. While, 

according to VA officials, the agency did not track the use of specific 

resources used to increase NRM spending, data provided by VA 

suggests that more than $1.8 billion from higher than requested 

appropriations and about $762 million from other budget resources were 

available for this spending in fiscal years 2006 through 2012.

All of these supplemental 

appropriations were specifically for NRM.

VA used VERA to perform an initial allocation of resources for NRM at the 

beginning of each fiscal year for fiscal years 2006 through 2012, 

allocating a total of about $4.6 billion over this time frame. In addition, for 

fiscal years 2009 through 2012, VA allocated $2.9 billion in total for NRM 

from higher than requested appropriations and its reserve account. Figure 

3 shows the nearly $7.5 billion allocated for NRM using VERA and other 

methods, which included network estimated costs to maintain medical 

facilities in good working condition—that is for sustainment—and costs to 

address the NRM backlog of FCA-identified deficiencies for fiscal years 

2006 through 2012.

 

20In February of 2009, Congress appropriated $1 billion for NRM as part of the Recovery 

Act, which remained available for obligation through fiscal year 2010. See Pub. L. 

No. 111-5, 123 Stat. 115, 199 (2009). VA spent $259 million in fiscal year 2009 and 

carried over the remaining $731 million into fiscal year 2010. Because of the timing of the 

act, VA was able to include an estimate of the carry over in its budget justification for fiscal 

year 2010 and a corresponding budget estimate for NRM. However, the $259 million VA 

spent in fiscal year 2009 was $231 million less than anticipated. As a result, VA carried 

over $231 million more than estimated. This contributed to NRM spending that exceeded 

budget estimates in fiscal year 2010.

21See Pub. L. No. 110-28, 121 Stat. 112, 168 (2007).

VA Used VERA to 

Allocate Most NRM 

Resources at the Start 

of a Fiscal Year and 

Network Requests to 

Allocate Additional 

NRM Resources Later
 

Page 13 GAO-13-220 Veterans’ Health Care

Figure 3: Resources Allocated for Non-Recurring Maintenance (NRM), by Allocation 

Method, Fiscal Years 2006 through 2012

Notes: VERA is a national, formula-driven system used by VA to allocate most of the health care 

appropriations to its 21 health care networks. Other methods include network estimated costs to 

maintain medical facilities in good working condition—that is for sustainment—and costs to address 

the NRM backlog of identified deficiencies and requests for reserve amounts

a

According to VA officials, prior to fiscal year 2010, VA did not track amounts allocated for NRM from 

its reserve amounts and therefore was unable to provide data on these allocations for fiscal years 

2006 through 2009

Over the course of allocating about $4.6 billion for NRM using VERA 

between fiscal years 2006 and 2012, VA changed VERA’s NRM 

allocation formula from one being based primarily on patient workload in 

the networks to one that primarily considers both sustainment of buildings 

and the NRM backlog in each network. Prior to fiscal year 2009, VA used 

VERA to allocate nearly $1.5 billion of NRM resources on the basis of 

patient workload and adjusting the cost of construction.22

 

22VA adjusted the cost of construction by using an annually adjusted trade index of 

construction costs for various types of buildings, to adjust network workload.

Under this 
 

Page 14 GAO-13-220 Veterans’ Health Care

formula, networks that treated the largest number of patients received the 

most resources for NRM, according to VA officials. Beginning in fiscal 

year 2009, VA used VERA to allocate resources for NRM primarily based 

on each network’s estimated cost for sustainment and the cost for 

addressing the NRM backlog. VA used VERA to allocate about 

$2.6 billion from fiscal year 2009 through 2012—which according to VA 

officials resulted in more resources being allocated to networks with a 

higher proportion of more expensive building space. In addition, since 

fiscal year 2009, VA has also used VERA to allocate about $512 million to 

NRM projects that improve access or provide accommodations for 

specific health care services, such as research, women’s health, and 

mental health, and certain other NRM projects.23

In fiscal years 2009 and 2010, VA allocated more than $1.4 billion of 

higher than requested Medical Facilities appropriations using methods 

other than VERA. Over the course of both fiscal years, VA allocated 

$1 billion of supplemental appropriations included in the Recovery Act

mostly on the basis of each network’s estimated cost of addressing FCAidentified deficiencies, according to VA officials. In both fiscal years, 

Congress also provided higher appropriations in the Medical Facilities 

account than the President requested, in part, to fund additional NRM 

projects. In providing these higher appropriations for NRM, Congress 

required VA to allocate a specific amount using methods other than 

VERA. In fiscal year 2009, VA allocated $300 million based on each 

network’s estimated cost of addressing the NRM backlog of FCAidentified deficiencies.24 In fiscal year 2010, VA allocated $130 million on 

the basis of networks’ estimated sustainment costs and their cost to 

address the NRM backlog.25

In addition, VA allocated, in fiscal years 2010 through 2012, about 

$1.4 billion for NRM from VA’s national reserve for the Medical Facilities 

account primarily based on sustainment costs and the cost of addressing 

 

23For fiscal year 2012, VA used VERA to allocate a total of $68.6 million to its 21 networks 

for the design phase of NRM projects prioritized through its Strategic Capital Investment 

Planning process.

24See Pub. L. No. 110-329, div. E, tit. II, 122 Stat. 3574, 3705 (2008).

25See Pub. L. No. 111-117, div. E, tit. II, 123 Stat. 3034, 3299-300 (2009).
 

Page 15 GAO-13-220 Veterans’ Health Care

the backlog of FCA-identified deficiencies.26 According to VA officials, 

Medical Facilities appropriations in the reserve that are not used for nonNRM purposes are available for NRM. The Under Secretary for Health 

determines whether funds in the reserve are available and recommends 

allocations of those funds to the Secretary of Veterans Affairs, who 

approves the allocations. VA officials explained that the allocation of 

funds from the reserve for NRM were typically based on sustainment 

costs as well as the cost of addressing FCA-identified deficiencies and 

other VA NRM priorities, such as VA’s energy investment “Green” 

initiatives. These allocations are also subject to the networks’ ability to 

award the projects and obligate the additional funds prior to their 

expiration. In anticipation of the availability of such resources, networks 

typically identify in advance projects that can be implemented if additional 

funds become available, according to VA officials. Officials explained 

further that the networks do this to better address the NRM backlog.

VA relied on its networks to prioritize all NRM spending until centralizing 

this process for more costly projects in fiscal year 2012. NRM projects VA 

funded were generally consistent with VA priorities.

 

26According to VA officials, prior to fiscal year 2010, VA did not track amounts allocated 

for NRM from its reserve amounts and therefore was unable to provide data on these 

allocations for fiscal years 2006 through 2009.

VA Relied on 

Networks to Prioritize 

NRM Spending before 

Centralizing 

Prioritization 

Recently for More 

Costly Projects, and 

Spending Was 

Generally Consistent 

with Priorities
 

Page 16 GAO-13-220 Veterans’ Health Care

For fiscal years 2006 through 2011, VA relied on its networks to prioritize 

projects for NRM spending. Each fiscal year, networks provided VA 

headquarters with a list of prioritized NRM projects, known as NRM 

operating plans.27

Beginning in fiscal year 2012, VA changed its process for prioritizing more 

costly NRM projects. Specifically, VA headquarters assumed 

responsibility for prioritizing these NRM projects as part of VA’s newly 

established Strategic Capital Investment Planning process, known as 

SCIP. Through SCIP, VA headquarters evaluates these more costly NRM 

projects and other types of capital investment projects using a set of 

weighted criteria in order to develop a list of prioritized projects to guide 

the agency’s capital planning decisions.

According to officials from headquarters and the two 

selected networks, NRM operating plans represented all of the NRM 

projects that a network plans to fund and carry out in a given year. VA 

officials told us that to prioritize NRM projects during this period, the 

networks used oral guidance communicated to the networks during 

management meetings with VA headquarters that encouraged the 

networks to prioritize projects addressing critical FCA-identified 

deficiencies and sustainment.

28

1. improve the safety and security of VA facilities by mitigating potential 

damage to buildings facing the risk of damage from natural disaster, 

For fiscal year 2012, the 

threshold for including NRM projects in this centralized prioritization 

process was $1 million. VA used this process to identify 190 projects as 

the agency’s highest NRM priorities for fiscal year 2012. Under SCIP, VA 

prioritizes NRM projects based on the extent to which they meet the 

following six criteria:

 

27Operating plans include information about the networks’ prioritized NRM projects, 

including whether a project addresses FCA-identified deficiencies and the total estimated 

cost of the project.

28The SCIP process begins approximately 23 months before the start of the fiscal year 

with VA headquarters’ providing a set of SCIP guidelines to the networks and facilities for 

the fiscal year. As part of this SCIP process, analyses are conducted with facility-level 

data to determine “gaps” between current and future needs and VA’s agency-wide targets. 

Facilities then develop a 10-year action plan, which identifies NRM and other capital 

improvement projects to address identified gaps within a 10-year period. A panel 

evaluates NRM projects with estimated costs of $1 million or more and scores them based 

on the extent to which they address the six SCIP criteria using the assigned weights. 

Ultimately, VA headquarters selects and ranks a national list of NRM projects to receive 

funding during the year.

VA Relied on Networks to 

Prioritize NRM Spending 

before Centralizing This 

Process for More Costly 

Projects in Fiscal Year 

2012
 

Page 17 GAO-13-220 Veterans’ Health Care

improving compliance with safety and security laws and regulations, 

and ensuring that VA can provide service in the wake of a 

catastrophic event;

2. address selected key major initiatives and supporting initiatives 

identified in VA’s strategic plan;29

3. address existing deficiencies in its facilities that negatively affect the 

delivery of services and benefits to veterans;

4. reduce the time and distance a veteran has to travel to receive 

services and benefits, increase the number of veterans utilizing VA’s 

services, and improve the services provided;

5. right-size VA’s inventory by building new space, converting 

underutilized space, or reducing excess space; and

6. ensure cost-effectiveness and the reduction of operating costs for new 

capital investments.

While VA uses SCIP to prioritize more costly NRM projects, the networks 

remain responsible for prioritizing all other or “below-threshold” NRM 

projects. However, VA has not provided its networks with written policies 

on how to prioritize these projects. According to a VA official, in fiscal 

year 2012, below-threshold projects accounted for over $625 million or 

42 percent of VA’s NRM spending. According to officials, instead of 

providing written guidance, VA officials have orally encouraged the 

networks to apply the same criteria included in SCIP when prioritizing 

below-threshold NRM projects.

VA’s lack of written policies for prioritizing below-threshold NRM projects 

is inconsistent with federal internal control standards,30

 

29VA’s major initiatives include eliminating veteran homelessness, improving veterans’ 

mental health, enhancing veterans’ access to health care, and improving VA’s humancapital management, among others. The supporting initiatives provide more detailed 

goals, delegated to specific programs within VA, that are meant to help the agency meet 

its major initiatives and other strategic goals.

which specify that 

agency policies should be documented and that all documentation should 

be properly managed and maintained. Without written policies that clearly 

document VA’s guidance to networks for prioritizing these less costly 

NRM projects, there is an increased risk that networks may not apply, or 

may inconsistently apply, the criteria included in SCIP.

30GAO/AIMD-00-21.3.1.
 

Page 18 GAO-13-220 Veterans’ Health Care

Our review of VA data shows that for fiscal years 2006 through 2011 the 

majority of the NRM projects that were funded by the networks were 

projects that the networks had prioritized in their operating plans. 

Specifically, in each year during this period, at least 85 percent of the 

NRM projects the networks funded were listed in the networks’ operating 

plans. For example, of the 2,905 NRM projects that networks funded in 

fiscal year 2011, over 2,400 projects (85 percent) were listed on the 

operating plans. When asked about funded projects that were not listed 

on networks’ operating plans, VA officials told us that networks may fund 

NRM projects in response to emerging needs during the course of the 

year.

For fiscal year 2012, our analysis of VA data also shows that NRM 

projects funded that year were generally consistent with projects 

prioritized using SCIP and those prioritized by the networks in their 

operating plans. Specifically, in fiscal year 2012, 189 NRM projects that 

were prioritized through the SCIP process received funding. Moreover, as 

figure 4 shows, of the 1,909 NRM projects that were funded by the 

networks outside of the SCIP process in fiscal year 2012, 1,668 

(87 percent) were listed on the networks’ 2012 operating plans. This 

consistency notwithstanding, because VA has not provided its networks 

with written policies for prioritizing below-threshold projects, the agency 

faces an ongoing risk that NRM projects could be funded in a manner 

inconsistent with the SCIP criteria.

Funded NRM Projects 

Were Generally Consistent 

with VA Priorities
 

Page 19 GAO-13-220 Veterans’ Health Care

Figure 4: Percentage of Funded Non-Recurring Maintenance (NRM) Projects Listed 

in VA Health Care Networks’ Operating Plans, Fiscal Years 2006 through 2012

Note: According to VA officials, the network’s NRM operating plans represented all of the NRM 

projects that a network plans to fund and carry out in a given year, and the remaining projects not 

listed in NRM operating plans were funded in response to emerging needs that arose during the 

course of each year.

Officials at VA headquarters have taken several steps in recent years to 

better monitor NRM spending to ensure that funded projects were 

consistent with the agency’s priorities. In fiscal years 2009 and 2010, in 

compliance with congressional requirements, VA tracked and reported 

spending on NRM projects that used funding provided through the 

Recovery Act. Recognizing the value of such monitoring, VA 

headquarters officials decided to expand efforts tracking NRM spending 

by project on a monthly basis. Since fiscal year 2011, VA has used what it 

calls its capital assets database to manage and monitor NRM spending 

on a monthly basis. As part of these efforts, VA has instructed its project 

managers to update the information on each project on a monthly basis 

and review tracking reports to ensure that spending for each project is 

within its estimated cost. VA officials told us that there are new efforts 

under way to improve the data reliability of the capital assets database 

and to incorporate its tracking reports into the SCIP process.
 

Page 20 GAO-13-220 Veterans’ Health Care

Our work shows that VA has consistently spent more on NRM than 

estimated because of the availability of higher than estimated resources 

in its Medical Facilities account. These additional resources derived from 

lower than estimated spending for non-NRM activities and higher than 

requested appropriations. Further, our work shows that spending for 

administrative functions, utilities, and rent accounted for most of the lower 

than estimated non-NRM spending in recent years. Thus, given the 

underestimates for these activities, VA’s future budget estimates for nonNRM activities in its budget justification may not be reliable if the agency 

continues to determine its estimates in the same way.

VA has taken important steps in establishing a centralized process for 

prioritizing more costly NRM projects through SCIP, and during the period 

we reviewed, VA’s funded NRM projects were generally consistent with 

agency priorities. However, VA does not have reasonable assurance that 

spending on NRM will be consistent with criteria included in SCIP. Our 

work shows that while networks remain responsible for prioritizing belowthreshold NRM projects, VA has not provided its networks with written 

policies for prioritizing these less costly NRM projects. Spending on these 

projects is not insignificant: in fiscal year 2012, spending on projects 

below the threshold was over $625 million or 42 percent of VA’s spending 

on NRM. Without written policies that clearly document VA’s guidance to 

networks for prioritizing below-threshold NRM projects, VA faces a 

continued risk that its networks may not apply, or may inconsistently 

apply, the criteria included in SCIP when funding these projects.

We recommend the Secretary of Veterans Affairs take the following 

actions:

• to improve the reliability of information presented in VA’s 

congressional budget justifications that support the President’s budget 

request for VA health care, determine why recent justifications have 

overestimated spending for non-NRM activities and incorporate the 

results to improve future budget estimates for such activities; and

• to provide reasonable assurance that VA’s networks prioritize NRM 

spending consistent with VA’s overall NRM priorities, establish written 

policies for its networks for applying SCIP criteria when prioritizing the 

funding of NRM projects that are below the threshold for inclusion in 

VA’s centralized prioritization process.

Conclusions 

Recommendations for 

Executive Action
 

Page 21 GAO-13-220 Veterans’ Health Care

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

comment. In the agency’s comments—reprinted in appendix I—VA 

concurred with both of our recommendations. In concurring with our first 

recommendation regarding improvements needed in its estimates for 

non-NRM activities, VA noted that the budget formulation process has 

been modified to include a better synchronization of events that play a 

significant role in the overestimated spending for non-NRM activities. VA 

stated that this modification has been incorporated in the fiscal year 2014 

President’s budget. In concurring with our second recommendation 

regarding written guidance on the application of SCIP criteria to 

prioritization of below-threshold NRM projects, VA noted that the NRM 

handbook and related guidance will be updated to direct facilities and 

networks to apply SCIP criteria when prioritizing below-threshold NRM 

projects. In addition, networks’ Capital Asset Managers, who are 

responsible for monitoring and evaluating each network’s NRM program,

will be required to review below-threshold NRM projects included in a 

network’s operating plan. VHA’s Office of Capital Asset Management 

Engineering and Support will also review networks’ operating plans to 

ensure compliance.

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

and appropriate congressional committees. In addition, the report will be 

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 

me at (202) 512-7114 or williamsonr@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

Agency Comments
Page 22 GAO-13-220 Veterans’ Health Care

List of Requesters

The Honorable Patty Murray

Chairman

Committee on the Budget

United States Senate

The Honorable Bernie Sanders

Chairman

The Honorable Richard Burr

Ranking Member

Committee on Veterans’ Affairs

United States Senate

The Honorable Jeff Miller

Chairman

The Honorable Michael Michaud

Ranking Member

Committee on Veterans’ Affairs

House of Representatives
Appendix I: Comments from the Department of 

Veterans Affairs

Page 23 GAO-13-220 Veterans’ Health Care

Appendix I: Comments from the Department 

of Veterans Affairs
Appendix I: Comments from the Department of 

Veterans Affairs

Page 24 GAO-13-220 Veterans’ Health Care
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 25 GAO-13-220 Veterans’ Health Care

Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov

In addition to the contact named above, James C. Musselwhite, 

Assistant Director; Krister Friday; Aaron Holling; Lisa Motley; and 

Said Sariolghalam made key contributions to this report.

Appendix II: GAO Contact and Staff 

Acknowledgments 

GAO Contact 

Staff 

Acknowledgments 
Related GAO Products

Page 26 GAO-13-220 Veterans’ Health Care

Veterans’ Health Care Budget: Better Labeling of Services and More 

Detailed Information Could Improve the Congressional Budget 

Justification. GAO-12-908. Washington, D.C.: September 18, 2012.

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.

VA Health Care: Estimates of Available Resources Compared with Actual 

Amounts. GAO-12-383R. Washington, D.C.: March 20, 2012.

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: 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.

VA Health Care: Need for More Transparency in New Resource 

Allocation Process and for Written Policies on Monitoring Resources. 

GAO-11-426. Washington, D.C.: April 29, 2011.

VA Real Property: Realignment Progressing, but Greater Transparency 

about Future Priorities Is Needed. GAO-11-521T. Washington, D.C.: 

April 5, 2011.

VA Real Property: Realignment Progressing, but Greater Transparency 

about Future Priorities Is Needed. GAO-11-197. Washington, D.C.: 

January 31, 2011.

Veterans’ Health Care: VA Uses a Projection Model to Develop Most of 

Its Budget Estimate to Inform President’s Budget Request. GAO-11-205. 

Washington, D.C.: January 28, 2011.

VA Health Care: Overview of VA’s Capital Asset Management. 

GAO-09-686T. Washington, D.C.: June 9, 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.

Related GAO Products
Related GAO Products

Page 27 GAO-13-220 Veterans’ Health Care

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.

VA Health Care: VA Should Better Monitor Implementation and Impact of 

Capital Asset Alignment Decisions. GAO-07-408. Washington, D.C.: 

March 21, 2007.

VA Health Care: Budget Formulation and Reporting on Budget Execution 

Need Improvement. GAO-06-958. Washington, D.C.: September 20, 

2006.

VA Health Care: Preliminary Findings on the Department of Veterans 

Affairs Health Care Budget Formulation for Fiscal Years 2005 and 2006. 

GAO-06-430R. Washington, D.C.: February 6, 2006.

(291065)
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