# Recent Reports

Reports News from the GAO

- Veterans Community Care Program: Additional Information on VA Statutory Appointment Timeliness Measurements is Needed What GAO FoundThe Department of Veterans Affairs (VA) met some but not all of the statutory requirements related to the administration of the Veterans Community Care Program. This critical program allows eligible veterans to obtain health care from community providers under certain conditions. Specifically, VA met the statutory requirement to review and report on community care staffing and training at VA facilities, as required by the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020 (Isakson-Roe Act).However, VA did not meet the statutorily required measurements on the timeliness of scheduling community care appointments because its approach prevents it from making certain measurements. Specifically, VA's approach cannot yield data on a certain time point—the date a provider accepts a referral for care—which is needed to calculate two required measurements. According to VA, staff are not required to collect referral acceptance dates. VA told GAO it monitors the scheduling process through other standard reports. While VA disclosed the limitation in its January 2022 report to Congress on the required measurements, it did not indicate how it planned to resolve it to comply with the statute, or if it sought legislative relief in light of changes in its scheduling process since the act was enacted. VA is continuing to internally update these timeliness measurements biweekly, as required by the statute. By engaging with Congress on the limitations it faces, VA could determine any refinements needed to address Congress's oversight needs, or seek legislative relief, as appropriate.VA developed 15 metrics that measure periods of time within its community care scheduling process. It uses these to inform the broader timeliness measurements discussed above. However, GAO found four of the 15 metrics to be unreliable, as these metrics also require data on provider referral acceptance dates (described above) in order to be calculated. For example, GAO found that of the 20,463 referrals for community care completed at nine selected VA facilities from Aug. 16-31, 2023 (the most recent data available at the time of GAO's analysis), only 3 percent (673 referrals) were included in VA's calculations of the four metrics due to the incomplete data on referral acceptance dates. Since VA is continuing to internally update its timeliness data, ensuring that VA discloses to any users of the data the quantity of referrals used to generate the timeliness data would help ensure users understand what the data represent.Why GAO Did This StudyGAO and others have previously identified challenges VA has had in scheduling community care appointments in a timely manner. The Isakson-Roe Act included requirements for VA related to administering community care and to measuring appointment scheduling timeliness, from the date the veteran requires care to the date the community care appointment occurs. It also includes a provision for GAO to review VA's compliance with section 3103 of the act.This report examines (1) VA's compliance with statutory requirements to review and report on community care staffing and training, (2) VA's compliance with statutory requirements to measure community care appointment scheduling timeliness, and (3) the reliability of the metrics VA used to inform the statutorily required timeliness measurements.GAO reviewed community care program reports VA submitted to Congress on staffing, training, and appointment scheduling timeliness. GAO also analyzed the reliability of timeliness data (metrics) for nine VA medical facilities selected for geographic diversity.
- Veterans Health Care: Improvements Needed in Patient Tracking for Non-Biological Implantable Medical Devices What GAO FoundMultiple Veterans Health Administration (VHA) offices are involved in overseeing implantable medical devices received by veterans. VHA's National Center for Patient Safety, the lead office for patient safety issues, is responsible for monitoring device safety issues. This office evaluates patient risk when safety issues are identified and collaborates with VHA's clinical program offices to develop VHA's response. National program offices for clinical specialties such as the National Cardiac Device Surveillance Program and the National Surgery Office are also responsible for overseeing cardiac electronic and orthopedic devices, respectively.GAO found that VHA is unable to ensure that all non-biological implantable medical devices are tracked to individual patients. Such tracking is important so that when a safety issue occurs VHA can ensure patients are notified and receive appropriate care. For the two clinical specialties reviewed, the National Cardiac Surveillance Program was able to effectively track cardiac electronic devices to individual patients, but the National Surgery Office was not able to effectively do so for orthopedic devices. VHA policy requires tracking outside the medical record for cardiac devices but does not require it for orthopedic devices. Accordingly, this gap adversely affects VHA's ability to ensure such tracking is occurring.Example of Knee and Hip Replacement Implantable Medical DevicesGAO also found VHA has not fully assessed, across all specialties, its ability to ensure that non-biological implantable medical devices can be effectively tracked to individual patients. Officials with the National Center for Patient Safety and others have recognized the need to develop better tracking capabilities across VHA. An assessment of VHA's ability to track all non-biological implantable medical devices across all clinical specialties could help the agency target and prioritize the most critical devices. This would help ensure these patients receive appropriate care in the event of safety issues.Why GAO Did This StudyVHA provided health care to over 6 million veterans in fiscal year 2022. Such care can include receiving an implantable medical device. The approximately 226,000 implants provided each year by VHA include biological implants made from body tissues, such as skin grafts, or non-biological implants made from materials such as plastic or metal. Examples of the latter include pacemakers and hip replacements.The James M. Inhofe National Defense Authorization Act for Fiscal Year 2023 includes a provision for GAO to study VHA's oversight of implantable medical devices. This report (1) describes VHA offices that oversee implantable medical devices; (2) describes VHA's monitoring of implant safety issues; and (3) examines how VHA ensures tracking of non-biological implants to individual patients.GAO reviewed policies, data, safety reports, and other information on non-biological implants with a focus on certain cardiology and orthopedic implants. GAO interviewed officials from VHA and four VA medical centers (and their regional management), selected based on factors such as the volume of cardiology and orthopedic implants, facility size, and location.
- Service Members Transitioning to Civilian Life: Agencies Can Improve Warm Handovers for Additional Assistance What GAO FoundTo assist certain service members who may be at risk for a difficult transition from military to civilian life, the Department of Defense (DOD) provides them with a person-to-person connection, known as a “warm handover,” to other agencies. These other agencies include the Department of Veterans Affairs (VA) and the Department of Labor (DOL), which can help the service members obtain additional transition services. Through its Transition Assistance Program, DOD ensures these service members receive agency contact information, but does not ensure that a connection with a person actually occurs (see figure). DOD provided at least one warm handover to about 41,000 service members, according to available data from April 1, 2021, to March 31, 2023. However, during this same time period the agency did not provide a warm handover to over 4,300 other service members who were also considered at-risk of having a challenging transition. DOD officials said the agency has not analyzed the reasons why these service members did not receive a warm handover. Without developing a written plan to analyze its data, DOD cannot ensure that the thousands of service members transitioning annually have access to the additional assistance they need and the benefits they have earned.DOD's Warm Handover Process Does Not Ensure Service Members Connect with Agencies for Additional Assistance with Their Transition to Civilian LifeTransition Assistance Program counselors and others told GAO that warm handovers could be helpful to some service members, but DOD has not assessed their helpfulness. DOD has recently worked with VA and DOL on pilot projects that will provide some additional information, but these efforts are expected to provide limited information on warm handovers, and other agency efforts to assess the Transition Assistance Program do not focus on warm handovers. Without a plan to assess the helpfulness of warm handovers, program officials may be missing opportunities to ensure they are meeting the needs of service members.Agencies generally collaborated effectively to implement pilot projects aimed at refining warm handovers, but they have not identified criteria to make decisions about scaling all of the piloted approaches. Without identifying specific criteria, these agencies risk not collecting data needed to decide whether and how to scale the piloted approaches to the broader Transition Assistance Program and warm handover processes.Why GAO Did This StudyHundreds of thousands of service members transition from military service to civilian life each year, and some can be at risk for unemployment, homelessness, or gaps in medical care. To help them succeed, DOD provides certain service members with a warm handover to other agencies and organizations for additional assistance.Senate report 117-130 includes a provision for GAO to review DOD's warm handover process. GAO's report addresses the extent to which DOD: (1) ensures that service members receive a warm handover as appropriate, (2) assesses information on the helpfulness of warm handovers, and (3) collaborates with VA and DOL in their efforts to refine the warm handover process.GAO analyzed DOD program data for April 1, 2021, to March 31, 2023, the most recent available. GAO also reviewed relevant federal laws, policies, and agency documents, and interviewed officials from relevant federal agencies and five military installations selected for diversity in numbers of transitioning service members, geographic location, and service branch.
- VA Health Care: Organization of the Office of Mental Health and Suicide Prevention What GAO FoundThe Department of Veterans Affairs (VA) bases its approach for suicide prevention on its 2018 National Strategy for Preventing Veteran Suicide. This strategy outlines a comprehensive public health approach to suicide prevention that includes a combination of (1) clinically-based interventions, such as suicide risk screening for individual patients, and (2) community-based programs and services, such as programs to promote firearm safety to the public to reduce the risk of suicide by firearms.In 2017, the Veterans Health Administration (VHA) organizationally combined the Office of Suicide Prevention and the Veterans Crisis Line——which GAO refers to collectively as suicide prevention programs—with mental health policy and operations in its newly created Office of Mental Health and Suicide Prevention (OMHSP). VHA stated that it created OMHSP to ensure oversight and management of evidence-based strategies within VHA and the community related to identifying veterans with mental health care needs, identifying veterans in crisis, and decreasing the rate of veteran suicide.OMHSP leadership officials identified benefits and challenges related to the placement of suicide prevention programs within OMHSP. For example, OMHSP's leadership officials reported that including suicide prevention and mental health within the same office facilitated internal coordination, which was beneficial when implementing new legislation that targeted suicide prevention and mental health issues. However, Suicide Prevention Branch officials reported challenges related to the office's public health suicide prevention efforts. For example, officials said their placement within OMHSP has given them less autonomy with decision-making, such as decisions about suicide prevention initiatives, which require multiple levels of approval.In July 2023, VHA approved a number of changes to its organizational structure that include moving both the Suicide Prevention Program and Veterans Crisis Line out of OMHSP into a separate program office within VHA's Office for Clinical Services. VHA conducted an assessment to determine the best placement for these programs. VHA's assessment and officials GAO spoke with identified several benefits and challenges related to this organizational change. The benefits included the importance of having the Suicide Prevention Office in a more elevated position within Clinical Services given its priority within the department and its need to coordinate across multiple VHA offices. The challenges included that keeping suicide prevention within the Office for Clinical Services could give the impression that suicide prevention is solely a clinical issue. VHA documents indicate that it plans to implement this change in 2024. As VHA implements these organizational changes, it will be important for it to determine whether this structure achieves the benefits it has anticipated and addresses anticipated, as well as any unanticipated, challenges or risks.Why GAO Did This StudySuicide is a persistent public health problem facing all populations, but particularly veterans. Veterans suffer a disproportionately higher rate of suicide compared to non-veterans. An average of almost 18 veterans died by suicide each day in 2021—a rate about 72 percent higher than the general adult population. VA reported that about 62 percent of the veterans who died by suicide in 2021 had not obtained recent health care through VHA. VHA works to build networks of support, communication, and health care across communities in which veterans live and work to help prevent deaths by suicide of veterans who do not obtain care through VA' health system.Suicide prevention is VA's stated top clinical priority. VHA's suicide prevention programs have the lead responsibility for overseeing and implementing the department's suicide prevention initiatives. Among its responsibilities, the Suicide Prevention Program helps implement VA's National Strategy. VHA's Crisis Hotline is a national toll-free number that supports veterans in emotional crisis. Since establishing these programs in 2007, VHA has moved their organizational placement within various program offices at its national headquarters, also referred to as the central office, multiple times.In May 2017, both suicide prevention programs were placed alongside VHA's mental health programs within the newly established OMHSP. However, in July 2023, VHA approved a number of changes to its organizational structure, including changes to the placement of these suicide prevention programs.GAO conducted its review of VA's management of its mental health and suicide prevention services, including OMHSP's organizational structure, pursuant to law. This report answers key questions related to the organization of OMHSP and its suicide prevention programs.For more information, contact Alyssa M. Hundrup at (202) 512-7114 or hundrupa@gao.gov.
- VA Health Care: Opportunities Exist to Further Meet Student Veterans' Mental Health Needs What GAO FoundThe Department of Veterans Affairs (VA) provides health care to veterans for mental health conditions, such as depression and substance use disorders. VA data showed that the percentage of student veterans who received mental health care at VA facilities increased from fiscal years 2017 through 2022, and at a higher rate than that of the total veteran population. (See figure.) VA data show student veterans were primarily treated for depression-related disorders, post-traumatic stress disorder, and anxiety-related disorders. VA officials said younger veterans typically seek mental health care more than older veterans, and most student veterans are younger than age 34. Further, the COVID-19 pandemic exacerbated mental health conditions for the general population, including for veterans.Comparison of Student Veterans and All Veterans Receiving Mental Health Care at VA Facilities, Fiscal Years 2017 through 2022Note: The percentages reflect student veterans and all veterans receiving mental health care (i.e., at least one visit for any mental health diagnosis), among student veterans and all veterans who received any health care at VA facilities, respectively. In fiscal year 2022, 261,000 student veterans and 5,966,000 veterans in total received health care at VA facilities.VA administers the Veterans Integration to Academic Leadership program to support the mental health needs of student veterans. Under this voluntary program, VA health care systems—including medical centers and other facilities—can partner with local colleges and universities to provide campus-based mental health support to student veterans. As of October 2023, 32 of 139 health care systems have such programs. However, GAO found VA does not communicate comprehensive information to its health care systems to help them consider when and how to implement programs, such as the types of staffing needed. Instead, VA communicates information about the program upon request. By more regularly communicating comprehensive information across its health care systems, such as through guidance, VA could help ensure its systems all have the information they need to consider participating in the program. This, in turn, would help ensure VA's ability to support the mental health needs of its student veteran population.Why GAO Did This StudyMental health conditions have been a persistent and growing issue for the nation's veterans. Research suggests that student veterans—those pursuing a course of education using VA's educational assistance benefits—are more likely to experience anxiety, stress, depression, and suicidal ideation than their nonveteran peers.The Support the Resiliency of Our Nation's Great Veterans Act of 2022 includes a provision for GAO to study the mental health needs of student veterans. Among other objectives, this report (1) describes what available VA data show on the use of mental health care by student veterans and (2) examines VA efforts to address the mental health needs of student veterans through its Veterans Integration to Academic Leadership program.GAO reviewed VA documentation and data for fiscal years 2017-2022 (the most recent available) on mental health care use and diagnoses and conducted a literature search. GAO also interviewed officials from VA and a non-generalizable selection of three veterans service organizations, as well as 12 student veterans identified by one of the veterans service organizations.
- Veterans Affairs: Improvements Needed in Estimating Funding for Potential Future Health Emergencies What GAO FoundAs of September 30, 2023, the Department of Veterans Affairs (VA) obligated roughly $36.2 billion (98.6 percent) of its CARES Act, Families First Coronavirus Response Act, and American Rescue Plan Act of 2021 funds, with the majority obligated by its Veterans Health Administration (VHA).VA Obligations of COVID-19 Supplemental Funding Totaled $36.2 Billion as of September 30, 2023VA used COVID-19 supplemental funds to support new efforts in response to the pandemic, such as expanding VA's information technology infrastructure to provide telehealth services. It also used the funding to support already established VA programs, such as providing health care at VA medical facilities.When the COVID-19 pandemic emerged, VHA requested supplemental funding to continue operations to meet its mission. However, VA found it was not prepared to estimate the amount of supplemental funding needed during such a catastrophic event, because it did not have the modeling capacity to do so. VHA officials told GAO they have not developed the modeling capacity needed to estimate the costs of future catastrophes, such as a pandemic, because such modeling is outside of the scope of its contract with its actuarial consultant responsible for developing VA's budget projections. By developing modeling capacity for estimating the resources needed to respond to potential future health emergencies, VHA would be better prepared to quickly estimate resource needs to allow better management and planning.Why GAO Did This StudyIn response to the COVID-19 pandemic, VA received approximately $36.70 billion in supplemental funding between 2020 and 2021. CARES Act and Families First Coronavirus Response Act funds were available until September 30, 2021, and September 30, 2022, respectively. American Rescue Plan Act of 2021 funds were generally available until September 30, 2023.The VA Transparency &amp; Trust Act of 2021 includes a provision for GAO to review VA's requests for and use of COVID-19 supplemental funding, including American Rescue Plan Act of 2021 funds. Among other issues, this report describes how VA used these funds and examines how VA estimated its funding needs to inform the fiscal year 2024 budget request for key areas previously supported with COVID-19 supplemental funds.GAO reviewed VA data and spending plans for COVID-19 supplemental funding and VA processes used to develop budget request estimates for fiscal years 2022 through 2024. GAO also interviewed VA officials and VA's actuarial consultant responsible for developing estimates.
- Veterans Health Care: VHA Has Taken Steps towards Improving Vet Centers What GAO FoundThe Veterans Health Administration's (VHA) Readjustment Counseling Service (RCS) provides counseling to individuals, groups, couples, and families through 303 Vet Centers nationwide. In fiscal year 2023, RCS data show that Vet Centers provided about 1.3 million counseling visits to more than 104,000 clients.Example of a Department of Veterans Affairs Vet Center ExteriorIn its May 2022 report, GAO found that VHA lacked processes that would help it better assess Vet Center activities. Specifically,VHA did not collectively assess whether Vet Centers were meeting clients' needs.  GAO found that RCS and Vet Centers used assessments and feedback surveys to assess each individual client's needs. However, RCS had not assessed the extent to which Vet Centers were meeting the needs of client subpopulations, like those with traumatic brain injury, that may experience different readjustment challenges.	VHA lacked data to tailor outreach and assess its effectiveness.  GAO found that Vet Centers used data from outreach activities, such as the number of contacts made, to try to assess their effectiveness. However, there were limitations to using these data because not all outreach activities resulted in contacts, according to officials from RCS and Vet Centers.	VHA did not identify whether its actions were minimizing barriers to Vet Center care.  GAO found that RCS and Vet Center officials identified barriers to Vet Center care, such as lack of awareness of Vet Center services. Officials also identified steps they have taken to address barriers. However, RCS officials did not know the extent to which barriers to Vet Center care remained because RCS did not have an assessment process.Based on these findings, GAO made five recommendations in its May 2022 report. As of January 2024, VHA had implemented one of GAO's recommendations by assessing the extent to which Vet Centers were meeting the needs of their clients collectively. VHA has taken some steps towards implementing the other four recommendations. Continued attention to these recommendations will help ensure veterans and servicemembers are receiving the help they need readjusting to civilian life or to continued military service.Why GAO Did This StudySome veterans and servicemembers experience challenges, such as mental illness, when readjusting to civilian life or continued military service. This can be due to trauma experienced during military service. VHA's Vet Centers provide services to eligible veterans, servicemembers, and their families.This statement describes the findings from GAO's May 2022 report, GAO-22-105039, which examined VHA's efforts to assess Vet Center clients' needs, tailor outreach activities and assess their effectiveness, and identify and address barriers to care. This statement also describes the status of VHA's efforts to implement GAO's recommendations. For this statement, GAO reviewed VHA's reports of steps RCS has taken to address GAO's recommendations.
- VA Acquisition Management: Oversight of Service Contracts Needing Heightened Management Attention Could Be Improved What GAO FoundThe Department of Veterans Affairs (VA) has increasingly relied on contractors to perform tasks and services—such as medical, professional and management support, and hospital construction and maintenance services—to achieve its mission.Department of Veterans Affairs (VA) Obligations on Service Contracts, Fiscal Years 2018 through 2022GAO cannot report on VA's use of service contracts involving functions needing heightened management attention because VA's data are unreliable and incomplete. VA is required by law to analyze data about its service contracts annually to ensure, among other things, oversight of service contracts involving functions that need heightened management attention. However, VA's data analysis excluded contracts for medical and social services, which accounted for most of VA's obligations on contracts coded as needing heightened management attention. This is in part due to VA misinterpreting guidance from the Office of Management and Budget's Office of Federal Procurement Policy (OFPP) when selecting functions for the analysis.OFPP issued guidance in 2011 to assist agencies in managing potential risks associated with contracts including functions that need heightened management attention, but VA has not fully implemented it. Specifically:VA guidance does not provide directions for how to plan and conduct oversight of these contracts.	VA has yet to strategically plan its workforce to ensure sufficient personnel are available to provide heightened management attention.	VA does not routinely offer related training to its employees.VA officials for the 12 service contracts that GAO reviewed also reported uneven awareness and limited oversight of contracts including functions needing heightened management attention.By taking steps to more fully implement OFPP guidance and improve the completeness of its service contract data, VA can position itself to better ensure it mitigates the potential risks associated with contractors performing functions that need heightened management attention.Why GAO Did This StudyFor certain service functions, OFPP guidance identifies agency responsibilities for addressing possible risks. These risks include the potential for contractors to inappropriately influence the government's authority, control, and accountability for decisions. Contracts with these risks need heightened management attention. GAO has previously reported how other federal agencies could better mitigate challenges to overseeing service contracts involving functions that need heightened management attention, such as by developing related guidance.GAO was asked to review VA's use of service contracts involving functions needing this heightened attention. This report assesses, among other things, the extent to which VA uses and oversees these contracts.GAO analyzed data that VA personnel entered in the Federal Procurement Data System from fiscal years 2018–2022; selected a sample of 12 contracts reflecting a range of contracting activities for in-depth review; interviewed VA officials and contracting personnel; and reviewed policies, guidance, and documentation.
- Higher Education: VA Should Provide Additional Information to Its Staff and Schools on the Rogers STEM Scholarship What GAO FoundMore than 7,000 veterans have used the Edith Nourse Rogers STEM Scholarship since the program began in August 2019. The scholarship provides financial assistance to eligible veterans pursuing degrees in science, technology, engineering, and mathematics (STEM). The vast majority of veterans (99 percent) used the scholarship towards an undergraduate STEM degree, and about 2,000 veterans graduated while using the scholarship.GAO found that the Department of Veterans Affairs has tools—such as staff training and guidance—to help ensure consistent Rogers STEM scholarship application processing, and more information for its staff and schools would bolster these efforts. Some STEM majors are easy to identify (e.g., engineering or mathematics). VA staff judgement becomes part of the application award process in the small number of applications where a veteran's major is not easily identifiable as STEM.Using VA data, GAO identified more than 100 instances where VA potentially made erroneous scholarship award decisions because the major approved for the scholarship did not appear to be STEM. VA confirmed that in 56 instances it appeared the agency approved scholarships for veterans pursuing ineligible majors, such as applied management and construction management. These 56 instances reflect VA's approval of up to $1.7 million in scholarship funds for veterans to use toward majors not in STEM fields.Through data analysis, review of VA documents, and interviews with VA staff, GAO identified two areas where VA could provide additional information to help ensure consistent scholarship award decisions. Specifically:Information for VA staff.  VA does not have a complete list of eligible majors for its staff to use when processing applications and deciding whether to award the scholarship. VA also does not have formal procedures to ensure its staff raise questions or further examine applications with majors that appear to be non-STEM.	Information for schools. School officials provide key information during the application process, however, the resources that VA provides to schools do not fully describe the school's role. As a result, schools do not always provide the information needed and VA may deny the scholarship to an otherwise eligible veteran, according to VA staff.Providing this additional information to VA staff and schools can help ensure consistent scholarship award decisions.Why GAO Did This StudyVeterans who received technical training in the military may be well suited to pursue degrees in STEM. The Edith Nourse Rogers STEM Scholarship provides up to $30,000 to assist veterans with continuing qualifying STEM programs after they exhaust their Post-9/11 GI Bill benefits.The Harry W. Colmery Veterans Educational Assistance Act of 2017 includes a provision for GAO to provide an interim and final assessment of the Rogers STEM scholarship program. This final assessment (1) reports the number of veterans that pursued and obtained STEM degrees using the Rogers STEM scholarship, and (2) evaluates how consistently VA processes Rogers STEM scholarship applications. GAO analyzed VA administrative data from August 2019 to June 2023, the most recently available data at the time of GAO's analysis. GAO also held four discussion groups with VA staff who process scholarship applications and reviewed relevant VA documents.
- Veterans Health: VA Should Improve Its Monitoring of Severe Maternal Complications and Mental Health Screenings What GAO FoundThe Department of Veterans Affairs (VA) set a goal to understand and reduce veterans' maternal deaths and severe maternal morbidity, which is an unexpected outcome or complication of labor and delivery resulting in significant health consequences. VA data showed that 13 veterans died from pregnancy-related causes out of about 40,000 VA-paid delivery hospitalizations from fiscal years 2011 through 2020, 11 of whom were White. Further, GAO's analysis indicates the severe maternal morbidity rate increased from 93.5 per 10,000 VA-paid delivery hospitalizations in fiscal year 2011 to 184.6 per 10,000 in fiscal year 2020. This rate was highest among Black or African American veterans. VA monitors information on maternal deaths by race and ethnicity, and intends to start monitoring severe maternal morbidity rates. However, VA has not specified whether it will monitor these rates by race and ethnicity, among other veteran characteristics. Doing so would enhance VA's ability to improve this adverse maternal health outcome by identifying needed medical interventions or care coordination improvements for particular populations.Severe Maternal Morbidity Rates by Veterans' Race, Fiscal Years 2011—2020Note: VA data capture the number of veterans who had at least one severe maternal morbidity that was not a blood products transfusion as of labor and delivery, using the Centers for Disease Control and Prevention's definition of such morbidity and the Office of Management and Budget's categories of race. American Indian or Alaska Native, Asian, and Native Hawaiian or other Pacific Islander veterans had fewer than 1,000 VA-paid delivery hospitalizations each from fiscal years 2011 through 2020; thus, rates for these groups may be subject to fluctuations if calculated for different periods.According to research, mental health conditions may increase the risk for severe maternal health complications, as well as the risk of maternal death by suicide. VA requires that each VA medical center designate a maternity care coordinator to serve as a liaison among pregnant and postpartum veterans and their health care providers. These staff are required to screen veterans for depression, suicide risk, and, as of October 2023, anxiety and post-traumatic stress disorder. VA officials have taken initial steps to monitor the occurrence and results of these screenings by hiring knowledgeable staff to help identify relevant data. However, VA officials have yet to determine when they will begin such monitoring or how frequently it will occur. As a result, VA may not have necessary information to ensure screenings are completed, which may be particularly important as the new screenings are implemented. Further, VA may lack information on ways to improve maternity care coordination based on screening results.Why GAO Did This StudyPregnant veterans are more likely than other pregnant women to have physical and mental health conditions that may contribute to adverse maternal health outcomes, according to research. Veterans' hospital deliveries, a service VA pays for by referral to community providers, grew by about 85 percent (from 2,567 to 4,766 deliveries) from fiscal years 2011 through 2020.Congress included a provision in statute for GAO to review veterans' maternal health. This report, among other objectives, examines available VA data on, and VA's monitoring of, maternal health outcomes, as well as mental health screenings for pregnant and postpartum veterans.GAO analyzed VA data on deaths and severe maternal morbidity among pregnant and postpartum veterans from fiscal years 2011 through 2020 (the most recent data available); reviewed VA policy and guidance on maternity care coordination; and interviewed VA officials and VA medical center staff. Staff were from four medical centers GAO selected for variation in the average number of deliveries among veterans, among other factors.
- VA Health Care: Office of Rural Health Efforts and Recommendations for Improvement What GAO FoundVeterans living in rural areas can face challenges that lead to disparities in access and quality of health care compared with their urban counterparts. For example, previous GAO work and research have highlighted staffing shortages and limited access to broadband internet that may affect rural veterans' access to health care. The Department of Veterans Affairs (VA) identified the Office of Rural Health, within the Veterans Health Administration (VHA), as one of the main offices responsible for increasing rural veterans' access to care. The office's mission is to improve the health and well-being of rural veterans through research, innovation, and the dissemination of best practices. To support its mission, the office provides two types of funding:Initiatives.  Funds are used by VHA program offices to expand existing VHA services to rural veterans, such as providing transportation to medical care.	Research.  Projects are used by VA researchers to develop, test, and disseminate research in areas outlined in the office's goals and mission. The office's five resource centers, which are field-based hubs, manage a portfolio of research projects in support of the office's mission.In a May 2023 report GAO recommended that the office require its five resource centers to communicate available research funding opportunities across VA. Each of the resource centers is responsible for identifying research projects to fund; however, GAO found the centers only communicate funding opportunities to VA researchers by word-of-mouth, rather than through a formal process. Relying on informal processes to communicate the availability of funding potentially creates a disadvantage for researchers with whom the resource center staff do not have existing relationships. VA concurred with the recommendation. As of October 2023, it reported that the office has begun taking steps to develop standard operating procedures for communicating research funding opportunities. VA anticipates developing standardized procedures by May 2024.GAO also recommended that the Office of Rural Health develop performance goals that reflect leading practices, such as being objective and measurable. For years 2020 through 2024, the office's strategic goals are topromote federal and community care solutions for rural veterans,	reduce rural health care workforce disparities, and	enrich rural veteran health research and innovation.However, in its May 2023 report, GAO found the office had not developed performance goals that define the level of performance the office aims to achieve during a particular year. For example, while the office collects data on the number of clinicians trained through its funded initiatives and research projects, it had not defined how many clinicians should be trained each year to achieve its strategic goal of reducing health care workforce disparities. By developing performance goals that reflect leading practices, the office can determine which strategic goals may need additional focus or resources to ultimately improve rural veterans' health and well-being. VA concurred with the recommendation. As of October 2023, the office began taking steps to develop performance goals to include in its 2025 – 2029 strategic plan.Why GAO Did This StudyIn fiscal year 2022, about one-third of the 8.3 million veterans enrolled in VHA lived in a rural area. Comparatively, about one-fifth of Americans lived in a rural area. VA projects rural veterans will continue to represent a significant proportion of the nation's veterans. VA identified rural veterans as an underserved population in its strategic plan and included an objective to increase health care access for rural veterans.VHA's Office of Rural Health was established in 2006. In fiscal year 2022, the office's budget was about $311 million, which it used to fund initiatives and research projects. That same year, the office served about 547,000 veterans, according to officials.This statement describes GAO's recent work examining VHA's Office of Rural Health, including recommendations GAO made on (1) communicating research funding opportunities across VA and (2) developing performance goals.This statement is based on GAO's work issued in May 2023 (GAO-23-105855). GAO also reviewed information on VHA's efforts to implement GAO's recommendations.For more information, contact Alyssa M. Hundrup at (202) 512-7114 or hundrupa@gao.gov.
- Small Business Administration: Procedures for Reporting on Veteran-Owned Businesses Need Improvement What GAO FoundThe characteristics of small businesses owned by veterans generally were similar to those owned by nonveterans, according to GAO analysis of 2020 Annual Business Survey data. For both types, most businesses had fewer than 10 employees and were in urban areas. Among the most common challenges to accessing capital that veteran-owned businesses cited were long wait times for credit decisions, difficulty with application processes, and high interest rates, according to GAO analysis of Small Business Credit Survey data.The Small Business Administration (SBA) provides training and education on small business ownership through veterans business outreach centers, which state and local agencies and other eligible organizations operate. SBA requires the centers to submit quarterly performance reports. GAO found that some of the reports did not include all the required information, such as the number of counseling sessions. By developing procedures for ensuring compliance with reporting requirements, SBA would have better information with which to oversee centers.SBA facilitates access to capital for small business owners, including veterans, through three loan programs. The 7(a) program provides financing through commercial lenders, the 504 program provides financing for fixed assets (such as buildings or machinery), and the Microloan program provides financing up to $50,000 and technical assistance. Veteran-owned small businesses received about 2–5 percent of all loans in the three programs in fiscal years 2016–2021.Percentage of Loans to Veterans, for SBA's 7(a), 504, and Microloan Programs, Fiscal Years 2016–2021SBA does not have policies and procedures for complying with selected statutory requirements concerning veterans. For instance, SBA's standard operating procedures did not explain how the agency will provide special consideration to veterans in accordance with the Small Business Act and SBA's implementing regulation. SBA also lacked procedures for reporting to congressional committees and could not demonstrate compliance in recent years. Establishing policies and procedures for these requirements would provide greater assurance that SBA is keeping Congress informed and providing special consideration to veterans, as required by law.Why GAO Did This StudyApproximately 6 percent of businesses with paid employees were veteran-owned in 2020, but veteran entrepreneurs may face challenges in accessing small business capital. The Small Business Act authorizes certain SBA small business lending programs, requires SBA to give special consideration to veterans, and authorizes SBA to establish veterans outreach programs.GAO was asked to examine capital access for veteran-owned small businesses and SBA's role in serving these businesses. This report (1) describes characteristics of veteran-owned businesses and their challenges in accessing capital, (2) examines SBA performance data on its veterans outreach program, (3) examines SBA lending to veteran-owned small businesses in 2016–2021, and (4) assesses SBA policies and procedures for complying with selected statutory requirements concerning veterans. GAO reviewed national small business data and SBA policies, procedures, and data on lending programs and also interviewed agency officials, 22 veterans outreach center directors, and 11 veterans who participated in SBA programs.
- VA Health Care: The Medically Underserved Facilities Initiative What GAO FoundThe Department of Veterans Affairs' (VA) medically underserved facilities initiative began in fiscal year 2019 to address the needs of veterans whose requests for care exceed the facility's ability to meet those needs in a timely manner. VA developed and implemented models to identify medical facilities that were underserved for primary care and mental health services. In fiscal year 2022, VA (1) ranked all VA medical facilities from most to least underserved, (2) designated five facilities as the most underserved for primary care and five medical facilities as the most underserved for mental health, and (3) required these facilities to develop action plans to address access needs.Officials GAO interviewed from all 10 designated underserved facilities described their experiences providing access to care for veterans. Officials from seven of those facilities reported varying experiences with the overall effect of the initiative's ability to improve access—that it was a benefit to the facility, a hindrance, or in some cases both. These ranged from bringing attention to the needs of the facilities to too much effort for a limited effect on access to care.VA Medical Facility Officials' Reported Experiences with the Medically Underserved Facilities Initiative&nbsp;						Facility 					&nbsp;						A 									B 									C 									D 									E 									F 									G 								Benefit						&nbsp;						x 						&nbsp;			&nbsp;						x 									x 						&nbsp;					Hindrance									x 						&nbsp;			&nbsp;			&nbsp;						x 									x 						&nbsp;					No or limited effect on access to care						&nbsp;			&nbsp;						x 									x 						&nbsp;			&nbsp;						x 					Source: GAO analysis of interviews with Department of Veterans Affairs' (VA) medical facility officials. | GAO-24-106306Note: Due to staff turnover, officials from three of the 10 facilities were not familiar enough with the initiative to characterize its overall effect because they were not generally involved in the initiative in fiscal year 2022.According to VA, its medically underserved facilities initiative has yet to produce clear indicators of success. Although there has been some movement in facilities' ranking from year to year, VA noted that any such changes to underserved rankings were due to a combination of changes in model criteria and action plans implemented, not necessarily a change in how underserved a facility was. Further, VA's 2022 evaluation of the initiative and interviews with officials revealed different perspectives on actions that could be taken to improve the effectiveness of the underserved facilities initiative. These actions were to either (1) bolster the resources allocated to underserved facilities or (2) reduce the total number of agency-wide initiatives related to access to allow VA to better identify and address underlying challenges to providing access. Given the mixed response to the underserved facilities initiative, VA reported in its 2022 evaluation report in a section on expanding the initiative to other specialties that “perhaps the transparency the [initiative] is bringing to these issues is the best possible outcome, rather than anticipating that the underserved [initiative] can actually move the needle on access” to care for veterans.Why GAO Did This StudyAccording to VA, most veterans enrolled in VA health care live in areas with limited access to some health care services. Each year, VA designates certain facilities to participate in the medically underserved facilities initiative for primary care or mental health based on criteria it developed.GAO was asked to review VA's medically underserved facilities initiative, which the agency implemented in response to section 401 of the VA MISSION Act of 2018. This report describes (1) the criteria VA has used to identify medically underserved facilities and which facilities are designated as underserved; (2) what officials from the designated underserved facilities reported about their experiences with the initiative; and (3) what VA information shows about the effectiveness of the initiative.GAO reviewed documentation related to the medically underserved facilities initiative. This included evaluation reports. GAO also interviewed officials from the VA Office of Integrated Veteran Care, which is responsible for implementing the initiative. GAO analyzed data on medically underserved facilities from fiscal years 2019 through 2022. GAO interviewed officials from the 10 medical facilities VA designated as the most underserved in fiscal year 2022 as well as officials from the Veterans Integrated Services Networks that oversee these 10 facilities.For more information, contact Sharon M. Silas at (202) 512-7114 or SilasS@gao.gov.
- VA Health Care: Actions Needed to Improve Information Reported on Mobile Medical Units What GAO FoundThe Department of Veterans Affairs (VA) operates mobile medical units to provide medical services to veterans. These units can deliver primary and specialty care to veterans in communities with veteran populations too small to support local facilities, such as VA clinics, or in areas with limited access to specialty care.Example of a Department of Veterans Affairs Mobile Medical UnitGAO found that VA's annual reports to Congress about the operations and performance of mobile medical units did not have quality information. Specifically, VA reported some information that was inaccurate or lacked context on why some operational requirements were not being met. For example, in its 2023 report, VA reported there were 52 active units. However, 25 of them reported appointment data. GAO also found:VA inaccurately included nine of the 20 mobile medical units in GAO's review in its total number of active units. Per VA's definition, these nine units were not active, meaning they were not open and treating patients away from parent facilities. VA officials said they do not assess the reliability of information they report on the units because such information is taken from existing databases.	VA did not provide context for why 20 of 25 mobile medical units reporting appointment data did not meet VA's operational requirement to conduct 845 appointments. For example, one unit in GAO's review conducted 17 appointments; however, the unit was not yet fully operational. VA is not required to include such context, but without it, VA's report suggests that unit was underperforming.Without quality information, VA and Congress cannot rely on VA's reports for a complete picture of overall operations and performance of mobile medical units. As a result, they may miss opportunities to use these units effectively to help ensure access to care for rural veterans, especially those living in areas with limited access.Why GAO Did This StudyMobile medical units are vehicles equipped to deliver clinical services in self-contained environments away from parent facilities. Congress included a provision in the Veterans Access, Choice, and Accountability Act of 2014 for VA to develop operational requirements for these units and annually report on performance against those requirements.GAO was asked to review VA's mobile medical units. This report's objectives include examining the information VA reports to Congress on the units' operations and performance.GAO reviewed VA's annual reports to Congress for 2018 through 2023, VA policies, and data for fiscal year 2022. GAO also interviewed officials from the Veterans Health Administration's Office of Emergency Management and from five regional networks and the 12 VA medical centers in those regional networks about their 20 units. Regional networks were selected for variation in geographic location and number of units, and to include a mixture of rural and urban VA medical centers. GAO also interviewed representatives from two veterans service organizations.
- Armed Forces Retirement Home: Congress and Agency Management Should Take Actions to Improve Financial Sustainability What GAO FoundThe Armed Forces Retirement Home (AFRH) prepares at least four financial projections yearly for varying purposes. However, GAO found that AFRH's processes for preparing these projections do not conform to actuarial standards and practices. Specifically, AFRH used inaccurate and inconsistent data, did not have sufficient supporting information for its assumptions of future events and values, and did not make trust fund projections based on reasonable assumptions of expected occupancy levels. Without policies and procedures for preparing financial projections to help ensure staff consistently apply relevant standards and consult with appropriate experts, such as actuaries, AFRH increases the risk that its projections will not be useful for decision-making.AFRH has identified several proposals to generate revenue and address potential financial shortfalls. However, challenges affect its plans to implement them, including factors outside of AFRH's control. AFRH's planned proposals include a statutory increase in military withholdings, requiring all military service members who are currently eligible for AFRH residency to contribute, and obtaining health and medical care reimbursements from programs such as TRICARE and Medicare for services it provides. However, these proposals require actions from Congress for AFRH to effectively implement them.GAO developed projections of AFRH's trust fund balance through fiscal year 2042 under two scenarios: AFRH continuing to operate as-is and AFRH operating with all quantifiable proposals implemented. GAO's analysis shows that whether AFRH continues to operate under its current scenario or implements all proposals, the trust fund will likely continue to decline without other significant efforts to bolster it (see figure). Additionally, AFRH is not projected to meet its goal for the trust fund balance.GAO Projection of Armed Forces Retirement Home's Trust Fund BalanceAFRH has not achieved its goals to raise its declining occupancy or to implement its other proposals. Also, AFRH faces further financial risks from costly repairs to deteriorating facilities. AFRH has not developed plans to address these issues. Without further actions, AFRH may continue to face financial shortfalls that in the future could affect its ability to fulfill its mission.Why GAO Did This StudyAFRH is an independent entity within the executive branch designed to provide housing, health care, and well-being assistance to eligible veterans. AFRH is financed through a dedicated trust fund. However, certain revenue sources for its funding have decreased or remained static over time while costs have increased. To address its financial challenges without cutting services to residents, AFRH has worked to identify new revenue sources to help rebuild its trust fund balance.House Report 117-397 includes a provision for GAO to review the financial sustainability of AFRH. GAO examined the extent to which AFRH projected estimated revenues and expenses for its trust fund through 2042, and developed plans to address any potential financing shortfalls, among other objectives.GAO reviewed relevant laws, federal guidance, audit reports, and agency guidance and policies; interviewed agency officials and actuarial experts; conducted site visits; and developed a projection to analyze AFRH's financial position.
- Veterans Health Administration: Actions Needed to Address Persistent Control Weaknesses and Related Risks in Employee Screening Processes What GAO FoundThe Veterans Health Administration (VHA) received information regarding some employees but did not have control procedures to ensure it responded as required. For example, VHA received information about some employees' controlled substance-related felony convictions and actions taken against certain employees by the Drug Enforcement Administration (DEA). VHA was required to obtain waivers from DEA for any of these employees whose job gave them access to controlled substances.Drug Enforcement Administration (DEA) Employment Waiver RequirementsaDEA registrations are required for certain health care practitioners licensed to dispense, administer, or prescribe controlled substances.GAO identified 12,569 VHA employees with indications of controlled substance-related criminal history. Of these, GAO obtained further information about a generalizable sample of 305 employees and found 50 of them had one or more controlled substance-related felony convictions. However, VHA has no policy regarding DEA employment waivers, including guidance for determining whether an employee has access to controlled substances. VHA confirmed that it did not request waivers for 48 of the 50 employees GAO identified. VHA did not confirm whether it requested waivers for the remaining two. GAO previously recommended the development of a waiver policy and, while VA agreed, it had not yet developed the policy. Therefore, in February 2023, GAO recommended that VHA establish a timeline for finalizing and implementing a waiver policy. In November 2023, VA informed GAO that it is developing a DEA waiver policy and expects to implement it in March 2024. Until VHA implements such a policy with guidance for determining whether an employee has access to controlled substances, it cannot assess whether its employees need waivers. VHA also lacks assurance that its facilities are complying with DEA regulations and controlling against theft and diversion of controlled substances.GAO also identified vulnerabilities in VHA's process for completing employee background investigations. For example, GAO found that 13 of the 305 employees in the generalizable sample did not have background investigations as required by regulation and policy. From the universe of the approximately 12,569 VHA employees, GAO estimated that about 400 (3 percent) did not have completed background investigations. As a result, in February 2023, GAO recommended that VHA establish control procedures to ensure background investigations are completed as required. In November 2023, VA informed GAO this recommendation would be implemented by March 2024.Why GAO Did This StudyThe Department of Veterans Affairs (VA) operates one of the largest health care systems in the nation, with over 9 million veterans enrolled in the VHA health care program. VHA is responsible for ensuring that its more than 400,000 health care providers and support staff are qualified, competent, and suitable to provide safe care.This testimony discusses (1) VHA's policies and procedures for dealing with employees with controlled substance-related felony convictions and the need to obtain waivers from DEA before employing these people in certain positions; and (2) VHA's suitability process, including control weaknesses associated with the conduct of background investigations.This testimony is based primarily on GAO's February 2023 report on VHA's employee screening processes. For that report, GAO analyzed a generalizable sample of 305 VHA employees employed as of January and June 2020 with indications of controlled substance-related criminal history. GAO examined court records and other documentation, reviewed regulations and policies, and interviewed officials from VHA, DEA, and other agencies. For this statement, GAO also obtained updates on actions VA has taken to address related GAO recommendations.
- VA Disability Benefits: Board of Veterans' Appeals Should Address Gaps in Its Quality Assurance Process What GAO FoundThe Board of Veterans' Appeals (Board) has a quality assurance (QA) process and a related accuracy measure for its decisions. Specifically, its QA process involves: 1) checking a random sample of draft decisions for certain types of Board-defined errors each month through its case review process; and 2) monitoring outcomes of Board decisions that were further appealed to the U.S. Court of Appeals for Veterans Claims (CAVC). The Board uses results from these activities to provide various interventions, such as individual feedback to veteran law judges (VLJs) or training. The Board also calculates and publishes an accuracy rate that represents error-free adjudications. However, GAO found shortfalls in the Board's process for calculating this measure. Contrary to federal internal control standards, GAO found that the Board did not have:(1) written policies or procedures for calculating its accuracy rate or managing case review error data, or(2) checks on its accuracy rate calculation.As a result, the Board lost data and GAO could not verify accuracy rates provided by the Board in 2 of 4 fiscal years. Until the Board develops written policies and procedures, the Board will likely continue to have difficulty supporting the accuracy of its publicly reported measure.GAO found gaps in the Board's efforts to build and use evidence—such as a lack of data and analysis—to assess its QA process and related activities. GAO analyses of CAVC and Board data show that over the past 3 fiscal years, CAVC remanded (sent back) about 80 percent of appealed Board decisions, often because CAVC found the Board's explanation of its findings to be inadequate. However, GAO found that the Board lacked evidence to better understand and address these and other issues and set priorities to help improve its QA process. Specifically:Board officials told GAO it has no comprehensive, written plan outlining how it will accomplish the mission and goals of its QA process.	Board officials told GAO they had not fully analyzed trends or underlying causes of the most common Board-identified errors or CAVC remands.	The Board has not systematically or comprehensively built or used evidence to better understand and improve its interventions, such as collecting feedback about training.	The Board does not assess VLJ decisions for consistency, such as whether common misunderstandings of policy or law exist in decisions.GAO's prior work has identified key practices for evidence-based decision-making. These practices involve building and assessing evidence and using it to foster a culture of continuous improvement. Absent such a process and a plan to guide it, the Board is not positioned to fully understand and address underlying causes of the most common errors and remands or understand consistency—evidence which is needed to target and implement effective interventions and foster continuous improvement of its QA efforts.Why GAO Did This StudyEach year, the Board adjudicates thousands of cases in which a veteran was dissatisfied with the Department of Veterans Affairs' (VA) initial decision on their claim for benefits. However, researchers and Congress have raised questions about how the Board ensures the quality of its adjudications.GAO was asked to review the Board's QA process. This testimony examines (1) how the Board assures and measures the quality of its adjudicative decisions, and (2) the extent to which the Board builds and uses evidence to assess its QA process.GAO reviewed relevant federal laws and Board documents. GAO analyzed QA data provided by the Board for fiscal years 2019 through 2022 and assessed its reliability. GAO also reviewed relevant quality assurance literature and interviewed VA officials, attorneys, VLJs, and subject matter experts, including researchers and veterans service organizations. GAO also conducted group discussions with randomly selected Board decision-writing attorneys and VLJs.
- Veterans Health Care: VA Has Taken Steps to Improve Its Appointment Scheduling Process, but Additional Actions Are Needed What GAO FoundIn January 2023, GAO reported that the Department of Veterans' Affairs' (VA) Veterans Health Administration (VHA) had set timeliness standards for how long it should take, following a referral, to get a specialty care appointment scheduled at either a VHA facility or with a community care provider. However, GAO found that VHA did not have timeliness standards for how many days until the appointment occurs—that is, how long the veteran has to wait to receive care. GAO recommended then that VHA develop a standard for the number of days within which appointments with VHA facility providers should occur. VHA recently implemented this recommendation. In the January 2023 report, GAO also reiterated a similar recommendation from a 2018 report—that VHA develop a standard for the number of days within which an appointment with a community care provider should occur. VHA agreed with the 2018 recommendation and has taken steps to address it but has not yet fully implemented it.Scheduling of appointments at VHA facilities must take place within 3 business days of referral and community care appointments within 7 days, according to VHA's standards. However, in January 2023 GAO found that VHA facilities were more timely in scheduling appointments at VHA facilities than in scheduling community care appointments, according to VHA data (see figure).Percentage of Referrals Meeting Scheduling Timeliness Standards by Veterans Affairs Medical Center, Third Quarter Fiscal Year 2022 Further, GAO found in January 2023 that VA's analysis that informed the establishment of the community care scheduling timeliness standard of 7 days was limited. GAO recommended then that VHA conduct a comprehensive analysis of scheduling data from all VHA facilities to determine whether the community care standards are achievable and revise them as necessary. VHA agreed with this recommendation but has not yet fully implemented it.Why GAO Did This StudyVHA operates the largest health care delivery system in the U.S., providing health care to approximately 6 million veterans in fiscal year 2022. In the last decade, Congress has taken steps to expand the ability of eligible veterans to receive care from community health care providers. GAO and others have identified challenges VHA has had in scheduling appointments both with VHA facility providers and community care providers in a timely manner.This statement focuses on (1) VHA's timeliness standards for specialty care appointments and any gaps in those standards; and (2) VHA facilities' performance in meeting those standards. This statement is based on GAO reports that were issued in January 2023, September 2020, and June 2018. See GAO-23-105617, GAO-20-643, and GAO-18-281. GAO's methodologies are detailed in those reports. This statement also includes updated information on the status of the recommendations made in those reports.
- VA Disability Benefits: Actions Needed to Address Challenges Reserve Component Members Face Accessing Compensation What GAO FoundThe Department of Veterans Affairs (VA) approved 11 to 20 percent fewer initial disability compensation claims from members of the reserve components—the Reserves and National Guard—than the active components (i.e., full-time active-duty military) each year from 2012 through 2021, the most recent data available. VA and Department of Defense (DOD) officials were unaware of this difference. Reserve component approval rates remained lower across characteristics such as military rank and age, but the size of the difference sometimes varied.Active and Reserve Component VA Disability Compensation Claim Approval RatesDOD and VA partially addressed challenges reserve component members face accessing disability compensation. Disability compensation claims generally must include evidence of a health condition that developed during military duty and led to a disability. Stakeholders—who study or work with reserve component members—identified challenges related to reserve component members' timely documentation of their health conditions and VA claims processors' ability to obtain evidence to support their claims. For example:All 15 stakeholders told GAO that reserve component members do not always understand the importance of immediately documenting health conditions to support any future disability compensation claims. DOD and VA guidance does not address this knowledge gap.	Thirteen stakeholders and several claims processors told GAO that finding evidence needed to support reserve component claims, such as service dates, is difficult. One form lists active-duty service but not reserve component members' two-week annual training. DOD designed a new form that will list dates of annual training, but the military services have not fully applied sound planning practices to implement it. VA claims processors also lack a reliable data source for the dates of monthly weekend drills.Guidance on documenting health conditions, efficient rollout of DOD's new form, and better VA data on service dates could help reserve component members prove that their disabilities are connected to their military service. Without this proof, VA claims processors will likely deny disability compensation claims.Why GAO Did This StudyOver one-third of the U.S. military serve in the reserve components. In return for their service, the nation has committed to compensate veterans for service-connected disabilities. The Identifying Barriers and Best Practices Study Act includes a provision for GAO to study reserve component members' access to VA disability benefits.This report examines VA's approval rates for reserve and active component disability compensation claims and how DOD and VA addressed stakeholder-identified challenges facing reserve component members in accessing disability compensation, among other topics.GAO analyzed VA data; reviewed relevant federal laws, DOD and VA policies, and other documents; and interviewed VA and DOD officials and 15 selected stakeholders, including researchers and veterans service organizations.
- VA Whistleblowers: Retaliation Claim Investigations and Settlement Agreements  [Reissued with revisions on Oct. 27, 2023] What GAO FoundThe number of whistleblower retaliation cases that the Department of Veterans Affairs (VA) Office of Accountability and Whistleblower Protection (OAWP) has received increased since fiscal year 2020. The number of other cases also increased. Specifically, OAWP received 577 whistleblower retaliation cases in fiscal year 2020 and 736 in fiscal year 2023. The non-whistleblower retaliation cases that OAWP received increased from 1,594 in fiscal year 2020 to 1,972 in fiscal year 2023.Office of Special Counsel (OSC) investigations of allegations of whistleblower retaliation from VA employees have decreased in number and have increasingly closed with a favorable action that benefits the complainant (i.e., whistleblower). Most OSC investigations of complaints from VA employees included allegations of whistleblower retaliation. From fiscal years 2018 through 2022, 69 percent of OSC cases involving VA employees included allegations of whistleblower retaliation. Specifically, OSC received 901 whistleblower retaliation cases involving VA in fiscal year 2018 and 515 in fiscal year 2022 (see figure). The percentage of these cases with a favorable action increased from 3 percent to 10 percent.Volume of Office of Special Counsel (OSC) Cases Involving Department of Veterans Affairs Employees, Fiscal Years 2018–2022 According to VA OGC officials, the settlement agreement process involves three distinct phases: initiation, negotiation, and monitoring. VA and a complainant can settle claims of whistleblower retaliation in the office where a dispute arises at any point in the complaint process. The agency has settled 71 whistleblower retaliation cases since it began tracking them in 2022. OAWP tracking information showed that most of the settlements included monetary awards for the whistleblower, ranging from about $1,800 to 525,000. In addition, the settlement may also have included salary adjustments or back-pay. OAWP information also showed that complaints come from program offices across the agency, but most of the settlements originate from complaints out of VA's Veteran's Health Administration, the largest of VA's three administrations.Why GAO Did This StudyWhistleblowers can help protect the public interest by reporting allegations of wrongdoing, such as a violation of law or gross mismanagement. While whistleblowers potentially safeguard the government from fraud, waste, and abuse, they may risk reprisal from their agencies for disclosures, such as demotion, reassignment or termination.VA is one of the largest federal agencies and employs around 400,000 people across hundreds of medical facilities, clinics, and benefits offices. Whistleblowers at the VA can file complaints of retaliation internally, through the agency's OAWP, or externally with other agencies, such as OSC. In some cases, whistleblowers will enter into a settlement agreement with VA to resolve the dispute.This testimony summarizes GAO's May 2023 report on VA whistleblower retaliation claims and settlements, as well as preliminary observations from related ongoing work. Specifically, this testimony examines: 1) the characteristics of OAWP whistleblower retaliation investigations, 2) the characteristics of OSC whistleblower retaliation investigations, and 3) how VA resolves such allegations through settlement agreements.GAO reviewed OSC and VA documents, interviewed agency officials, analyzed OSC case management system data from fiscal years 2018-22, which were the most recent data at the time of the report. In addition, as part of our ongoing work, we collected additional information on whistleblower retaliation claims and settlements from OAWP's Matter Tracking System.For more information, contact Thomas Costa at (202) 512-4769 or costat@gao.gov.
- Military and Veteran Support: Programs to Help Servicemembers and New Veterans Transition to Civilian Life Could Be Enhanced What GAO FoundGAO reviewed selected programs to help servicemembers transition to civilian life and has made numerous recommendations to the Departments of Defense (DOD) and Veterans Affairs (VA) to enhance their performance.Servicemembers have the opportunity to obtain civilian credentials related to their military training and skills before they leave the military, which they can use to obtain civilian jobs after they leave. DOD facilitates credential attainment through two programs:Credentialing Opportunities Online helps servicemembers match their military occupations to civilian occupational credentials and may pay expenses related to pursuing professional certification, including books, tuition, and exam fees.	United Services Military Apprenticeship Program allows servicemembers to complete civilian apprenticeship requirements while on active duty.In February 2022, GAO found that DOD had not fully assessed the effectiveness of these programs, resulting in an evidence gap. Such an assessment would enhance DOD's decision-making and ability to help servicemembers succeed in the civilian workforce after leaving the military.Servicemembers preparing to leave the military generally must participate in the Transition Assistance Program (TAP). DOD service branches have implemented elements of TAP, such as ensuring that servicemembers meet with a TAP counselor, attend tailored 2-day classes, and participate in a counseling pathway tailored to the level of transition support a servicemember needs. However, in July 2021, GAO found that selected small or remote installations experienced implementation challenges, according to TAP officials. Challenges included limited nearby employment opportunities, which officials mitigated by building relationships with local employers. In addition, GAO's December 2022 analysis of TAP data from April 1, 2021, to March 31, 2022, showed that nearly a quarter of servicemembers who were required to attend a 2-day TAP class did not do so. GAO also found that most servicemembers (70 percent) did not start TAP more than 1 year in advance, as generally required. Additionally, DOD and the service branches were not using available performance data to understand root causes of poor participation and take appropriate corrective action.Solid Start provides tailored information about resources and benefits to support veterans during their first year after leaving the military. GAO found in January 2023 that VA representatives successfully contacted about 71 percent of eligible veterans in 2021, and these veterans used VA benefits to a greater extent than those who did not speak with a representative. However, GAO found that VA had not collaborated with veterans organizations to help connect with hard-to-reach veterans. As a result, GAO recommended greater collaboration with these organizations. VA has since implemented the recommendation by augmenting its collaboration and outreach efforts. As a result, VA should be able to connect directly with even more veterans and make them aware of their benefits.Why GAO Did This StudyEach year, around 200,000 servicemembers transition out of the military. Various federal programs are designed to facilitate this transition. This includes helping servicemembers achieve their education, employment, and other goals and overcome potential challenges in adjusting to civilian life.This testimony is based on GAO's past work on transition assistance and addresses: (1) DOD credentialing programs; (2) DOD's Transition Assistance Program; and (3) VA's Solid Start program.For that work, GAO analyzed DOD and VA data and documents; interviewed relevant agency officials and representatives of selected veterans organizations; conducted site visits to military installations selected based on numbers of transitioning servicemembers and variation in service branch and location; and reviewed relevant federal laws and policies.
- Veterans Employment: Identifying Lessons Learned from Rapid Retraining Program Could Benefit Future Efforts What GAO FoundThe Department of Veterans Affairs (VA) implemented the Veterans Rapid Retraining Assistance Program (VRRAP). VRRAP included up to 12 months of housing and tuition assistance for veterans who lost their jobs because of the COVID-19 pandemic. VA certified the majority of applicants for VRRAP and obligated the majority of VRRAP funding, with some challenges reported by stakeholders. VA certified 22,851 of the 31,625 VRRAP applicants as eligible to participate in the program. Of those certified VRRAP applicants, over 50 percent enrolled in an education program, 19 percent went on to complete their education program, and 5 percent of those originally certified obtained employment. As of April 2023, VA reported that it had obligated 95 percent of the $386 million in VRRAP funds. VA spent an average of $17,270 per veteran. Selected stakeholders reported program benefits, such as the assistance the program provided to veterans without other educational resources. Stakeholders also reported challenges, such as VA's delayed program outreach efforts to veterans.In implementing VRRAP, VA collected data on VRRAP participants as well as feedback from veterans and schools. These data highlight a number of program benefits and challenges, such as when participants found employment or issues with the amount or quality of support veterans received from VA, but VA had no plans to analyze the lessons that can be learned from its experience operating the program or validate and document them for future use. By implementing the key practices of a lessons-learned process, VA can leverage data it has already collected and improve future programs with insights from VRRAP (see fig.).Key Practices of a Lessons-Learned ProcessWhy GAO Did This StudyVA carried out VRRAP as directed by the American Rescue Plan Act of 2021. Later in 2021, the Training in High-demand Roles to Improve Veteran Employment Act made changes to VRRAP and includes a provision for GAO to report on the outcomes and effectiveness of VRRAP. This report reviews (1) VA's outreach efforts, VRRAP applications processed, and demographics for participating veterans; (2) program funds used and outcomes for participating veterans; (3) VRRAP benefits and challenges reported by surveyed veterans, selected veteran service organizations (VSO), and selected schools; and (4) steps VA has taken to identify lessons learned in the design and implementation of VRRAP.To address the first two objectives, GAO analyzed VA data from March 2021 to December 2022 on its outreach efforts, analyzed VA data from April 2021 through March 2023 on participating veterans, analyzed VA data on participating schools as of February 2023, and analyzed Census American Community Survey data from 2021. To address the third and fourth objectives, GAO reviewed VA data from a survey of VRRAP participants and interviewed VA officials as well as nonrepresentative samples of four VSOs and nine participating schools. For the fourth objective, GAO also assessed VA's efforts to implement six key practices for collecting and using lessons learned.
- VA Equal Employment Opportunity: Increased Attention Needed to Improve Program Effectiveness What GAO FoundThe Department of Veterans Affairs (VA) has a diverse workforce, but disparities exist in career outcomes. GAO found that VA had higher representation of certain historically underrepresented racial and ethnic groups from fiscal years 2017 to 2021 than the national civilian labor force from 2014 to 2018 (the most recent data available). However, within VA's workforce, GAO estimated that from 2000 to 2021, certain of these groups hired into similar occupations had lower pay and attained fewer promotions than White men, on average (see figure).Estimated Differences in Promotions of Department of Veterans Affairs (VA) workers Hired into Similar Jobs 10 years after Starting Employment, by Race, Ethnicity, and Gender, Fiscal Years 2000-2021 (Percent Difference Relative to White Men)VA tracks complaints of alleged racial discrimination and harassment, but has not fully analyzed other data to understand potential prevalence. While VA has a goal to develop a dashboard to assess data on workplace climate, it has not planned for or conducted this analysis. Until doing so, VA is not best positioned to identify and address trends in potential discrimination and harassment.The continued misalignment of its equal employment opportunity (EEO) program with a federal directive hinders VA's ability to prevent and address employment discrimination. In 2020, GAO recommended that VA address these misalignment issues by ensuring VA's EEO director is not responsible for personnel functions and completing VA's planned realignment of its EEO Program Managers. As of April 2023, VA has not taken action to fully implement these recommendations.While VA has several programs that can receive complaints from veterans who feel they have been discriminated against in VA programs, it does not have a comprehensive policy to ensure complaints are addressed. This created several issues, such as (1) inconsistent processing of complaints; (2) lack of communication with veterans; (3) lack of coordination across the offices receiving complaints; and (4) lack of data on complaints. As a result, VA may not have visibility into whether veterans' complaints have been fully addressed, or the potential extent of discrimination against veterans in VA programs.Why GAO Did This StudyFederal law prohibits employment discrimination against federal employees and discrimination in federal programs on the basis of race, among other things. GAO was asked to review VA's efforts to ensure equitable treatment of its employees and veterans receiving its services or participating in its programs.This report examines (1) what disparities, if any, exist between VA employees from different racial and ethnic groups; (2) how VA tracks potential racial discrimination against its employees; (3) the extent to which VA has practices to prevent and address employment discrimination; and (4) how VA assesses and addresses issues related to the treatment of veterans based on race in VA programs. GAO reviewed relevant federal laws, and VA policies and documents; analyzed employee personnel data, survey data, and data on EEO complaints; held discussion groups with VA employees; and interviewed VA officials, representatives from VA's unions, employee affinity groups, and veterans service organizations.
- Unwanted Sexual Behavior: Improved Guidance, Access to Care, and Training Needed to Better Address Victims' Behavioral Health Needs What GAO FoundThe Department of Defense (DOD) and Department of Veterans Affairs (VA) offer behavioral health care to active-duty service members and veterans who experience unwanted sexual behavior. Unwanted sexual behavior includes sexual harassment, sexual assault, and domestic sexual abuse. However, several issues limit screening for and access to related care. For example:VA requires clients in VA medical facilities to be screened for military sexual trauma; DOD screens for behavioral health conditions but not specifically for experiences with unwanted sexual behavior. Without developing guidance specifying how and when DOD medical providers should screen for such experiences, DOD cannot ensure consistent patient support or care.	Service members who have experienced unwanted sexual behavior may confidentially access non-medical counseling through VA. However, longer-term medical behavioral health care requires a referral from DOD, which may deter service members from seeking care. Until DOD considers how best to enable service members to access longer-term services through VA, without a referral, some service members may not seek needed care.Analysis of separation data shows that service members who made unrestricted, formal, or some informal reports of experiences with unwanted sexual behavior left the military—voluntarily and involuntarily—at substantially higher rates than the overall active-duty population from fiscal years 2015 through 2021 (see fig.).Separation Rates for All Active-Duty Service Members Compared to Those who Reported an Experience with Unwanted Sexual Behavior, Fiscal Years 2015–2021However, multiple factors impede DOD's ability to determine if an experience with unwanted sexual behavior played a role in separation decisions. For example, certain processes related to medical examinations and higher-level reviews of involuntary separations are available only for victims of sexual assault, for specific time periods, and for certain behavioral health diagnoses. Until DOD considers potential modifications to these processes service members may be unable to benefit from actions that may affect eligibility for VA benefits.Why GAO Did This StudyService members who experience unwanted sexual behavior—sexual harassment, sexual assault, and domestic sexual abuse—during military service may suffer from chronic mental health conditions. Service members who have such experiences are also more likely to separate from the military, exacerbating DOD's critical recruitment and retention challenges.GAO was asked to review service member mental health related to experiences with unwanted sexual behavior. This report examines, among other issues, the extent to which (1) DOD and VA screen for and provide access to behavioral health care services for such experiences, and (2) such experiences play a role in voluntary and involuntary separations of service members from the military. GAO reviewed guidance, analyzed DOD and VA behavioral health care data and DOD separation data, and interviewed DOD and VA officials at the headquarters level and at a nongeneralizable sample of military installations and VA medical facilities.
- VA Health Care: Office of the Medical Inspector Should Strengthen Oversight of Recommendations and Assess Performance What GAO FoundThe Office of the Medical Inspector's mission is to investigate concerns about the quality of health care provided by the Veterans Health Administration (VHA). The office conducts investigations in response to referrals from other Department of Veterans Affairs (VA) and VHA components, and the U.S. Office of Special Counsel, which stem from concerns raised by whistleblowers and others. Such concerns are typically clinical in nature, such as concerns about improper equipment sterilization. The office reported opening between 25 and 74 cases each fiscal year from 2017 through 2022. Its authorized staffing levels were 20 full-time employees in 2022, but three of those positions were unfilled. Nearly all completed cases during the 6-year period resulted in recommendations for corrective action, which were typically made to VHA health care facilities.For any given case, a clinical program manager within the Office of the Medical Inspector is responsible for determining (1) whether proposed corrective actions adequately address recommendations, and (2) when the actions have been completed, according to officials. However, the office does not conduct supervisory review of these determinations. Doing so would provide greater assurance that the recommendations are implemented to fully address the underlying concerns.GAO found the Office of the Medical Inspector has not assessed its overall progress toward meeting its mission. Specifically, the office has not taken the three key performance management steps (see figure).Steps to Assess Progress toward Meeting MissionOffice of the Medical Inspector officials indicated that timeliness and quality are important factors in conducting their work. However, the office has not established goals and performance measures that define the specific results it expects to accomplish—for example, related to timeliness or quality of various aspects of the office's work. As a result, the office does not know to what extent it is meeting its mission. Furthermore, establishing performance information would allow VHA leadership to more fully understand and assess how the office's work complements that of other oversight offices and help better ensure collective oversight and accountability across VHA's vast health care system.Why GAO Did This StudyVHA operates one of the largest health care systems in the nation, serving about 9 million veterans annually. The Office of the Medical Inspector is one of several oversight offices within VHA and is responsible for investigating quality-of-care concerns at VHA health care facilities.GAO was asked to review the Office of the Medical Inspector. Among other objectives, this report examines the office's (1) caseload and staffing levels, (2) process for determining whether recommendations have been implemented, and (3) efforts to assess its performance.GAO examined the Office of the Medical Inspector's documentation, such as policies, and information about its cases, staffing levels, and recommendations from fiscal years 2017 through 2022 (the most recent information available at the time). GAO also interviewed officials from the Office of the Medical Inspector and other relevant VA offices.
- VA Disability Exams: Opportunities Remain to Improve Program Planning and Oversight What GAO FoundIn recent years, the Department of Veterans Affairs (VA) increasingly has transferred its disability exam workload from Veterans Health Administration (VHA)-employed examiners to Veterans Benefits Administration (VBA) contracted examiners. In light of growing exam workloads and backlogs, GAO recommended in March 2021 that VBA use sound planning practices to develop and document plans for future workload allocations between VHA and contracted examiners. VBA developed a workload allocation plan that incorporated some of the sound planning practices GAO identified, but other information was missing. For example, it did not include information on potential volumes or timeframes for future transfers of disability exam workloads from VHA medical facilities to contracted examiners, or detailed assessments of potential risks associated with VA's increased reliance on contracted examiners.In a June 2023 report, GAO found that VHA did not provide medical facilities with clear information to inform examiner staffing decisions. For example, although legislation was enacted that required VA to temporarily suspend efforts to eliminate disability examiner positions, the guidance VHA provided to its facilities did not include clear instructions on how to comply with this requirement. As a result, officials at the five facilities GAO selected for review had different interpretations of whether and how the guidance applied to them. Without VHA clarifying the guidance, facilities may not implement it as intended, and they risk not being positioned to help address veterans' exam needs.GAO also found that VA used available flexibilities to help meet exam demand during the COVID-19 pandemic. For example, VBA's contracted exam vendors and VHA increased their use of telehealth during the pandemic. Additionally, VBA and its vendors said that they used a temporary expansion of license portability—which allows contracted examiners in certain specialties to conduct exams in states other than where they are licensed—and that this flexibility helped expand access to exams in underserved areas. However, the guidelines VBA provided to its vendors included inaccuracies, and VBA conducted inadequate monitoring of the vendors. This contributed to vendors allowing ineligible examiners to conduct exams using license portability. During the course of GAO's review, VBA took steps to address these deficiencies, including clarifying its guidance on eligible examiners. However, VBA has not yet completed, as GAO recommended, a formal assessment of exams that were erroneously completed under license portability and any potential risks to veteran claim decisions. Completing such an assessment will help VBA identify and take any necessary corrective actions to ensure veterans' claims have been properly decided.Why GAO Did This StudyIn June 2023, GAO issued a report entitled VA Disability Exams: Actions Needed to Clarify Program Requirements Regarding Examiners (GAO-23-105787). This testimony summarizes the findings and recommendations from that report, which included relevant updates from prior reporting on disability medical exam workload management (GAO-21-444T).
- VA Disability Benefits: Actions Needed to Further Examine Racial and Ethnic Disparities in Compensation What GAO FoundThe Department of Veterans Affairs (VA) has taken steps to improve how it collects race and ethnicity data to understand the experiences of veterans who may apply for disability compensation through the Veterans Benefits Administration (VBA). For example, VA created a working group that specifically focused on improving demographic data collection. VA's collection efforts could enhance the data available to VBA to assess racial and ethnic disparities in disability compensation. However, VA has not developed a documented plan for how it will improve the availability of data for certain racial and ethnic groups who may not be accessing VA services and benefits. Without a plan to identify and document concrete actions, VA will not have the data it needs to ensure veterans are treated equitably.GAO's analysis of fiscal year 2010 through 2020 compared initial claims approval rates for all racial and ethnic groups to Non-Hispanic White (White) veterans—the largest group with decisions. GAO found that Non-Hispanic Black or African American (Black) veterans had the lowest approval rate among all groups (see figure). Similarly, GAO's analysis of selected medical conditions most frequently decided by VA found that differences in approval rates were particularly prominent between Black male and White male veterans, with Black male veterans' rates being 3 to 22 percentage points lower. These differences were prevalent for nine of the 10 conditions GAO analyzed such as tinnitus and posttraumatic stress disorder. VBA has conducted studies on racial and ethnic disparities in disability compensation for some conditions and found disparities. However, it has not comprehensively studied the root causes of the disparities it has found or potential disparities in the provisions of compensation more broadly. As a result, VA lacks the information it needs to ensure equitable decisions.VA Disability Compensation Approval Rates for Initial Claims, by Race and Ethnicity (Fiscal Years 2010–2020)Note: GAO grouped individuals of Hispanic ethnicity under that designation regardless of race.Why GAO Did This StudyVeterans from historically disadvantaged racial and ethnic groups comprised almost 24 percent of the total veteran population in 2017, according to a VA report. By 2045, this group of veterans will make up over 36 percent of all living veterans, according to VA projections.Public Law 117-66 includes a provision for GAO to assess whether there are racial and ethnic disparities with respect to disability compensation, among other areas. This report examines the extent to which (1) VA has taken steps to collect and assess data about the racial and ethnic composition of veterans who may apply for disability compensation; and (2) racial and ethnic disparities exist in the provision of compensation, and what factors could contribute to disparate outcomes.GAO reviewed relevant federal laws, regulations, and VA policies; analyzed VA's claims data by race, ethnicity, and sex from fiscal year 2010 through 2020 (the most recent full year of data available); and interviewed VA officials and representatives from a VA advisory group and selected veterans service organizations.
- VA Disability Exams: Actions Needed to Clarify Program Requirements Regarding Examiners What GAO FoundThe Veterans Benefits Administration (VBA) and Veterans Health Administration (VHA) within the Department of Veterans Affairs (VA) reported expanding their use of telehealth for disability medical exams since the start of the COVID-19 pandemic. Both VA officials and the vendors that VBA contracts with to provide examiners reported a range of benefits associated with telehealth use, including more easily reaching veterans in underserved areas. VBA's vendors and VHA primarily used telehealth to conduct mental health exams, according to GAO analysis and interviews. However, the full extent of telehealth use is unknown because VHA medical facilities did not accurately record this information. In September 2021, VHA provided guidance to facilities to improve data collection.VBA officials and vendors said that the temporary expansion of license portability–which allows contracted examiners in certain specialties to conduct exams in states other than where they are licensed–also expanded access in underserved areas. However, the guidelines VBA provided to its contracted exam vendors included inaccuracies, and VBA conducted inadequate monitoring of the vendors. This contributed to vendors allowing ineligible examiners to conduct exams using license portability. Examples of issues GAO found include:Inaccurate guidelines:  VBA incorrectly listed dentists as eligible for license portability in the guidelines it provided to vendors. This contributed to two of VBA's three vendors using dentists to conduct exams in states other than where they were licensed.	&nbsp;	Inadequate monitoring:  VBA did not review vendor-reported data to identify the types of examiners using license portability. GAO's review of these data found that one vendor used optometrists to conduct exams in states other than where they were licensed, which VBA officials said was not permitted.During the course of GAO's review, VBA took steps to address these deficiencies. VBA issued new guidance memos to its vendors specifying that dentists and optometrists are not eligible for license portability. VBA also updated its monitoring process to review data on the types of examiners used for such exams. However, VBA has not yet developed formal procedures or documentation to guide this monitoring process. Without doing so, VBA cannot be confident that vendors are using license portability as intended.VHA did not provide medical facilities with clear information to inform the recruitment and retention of VHA examiners. For example, VHA provided facilities with guidance to halt programmatic changes and comply with a requirement to pause efforts to eliminate examiner positions. However, the guidance did not clearly define what constituted a programmatic change or an examiner position. As a result, officials at the five facilities GAO selected for review had different interpretations of how and whether the guidance applied to them. Without clarifying the guidance, facilities may not implement it as intended, and they risk not being positioned to help address veterans' exam needs.Why GAO Did This StudyIn fiscal year 2021, VA paid nearly $99 billion in disability compensation to over 5 million veterans with service-connected disabilities. VA may ask a veteran to undergo a disability medical exam to help determine eligibility for disability compensation. VHA employees and examiners contracted by VBA conduct these exams.The Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020 includes a provision for GAO to review certain aspects of VA's disability exam program. This report examines (1) VA's use of telehealth for disability medical exams, (2) how VA and its vendors used a temporary expansion of license portability, and (3) VHA's efforts to recruit and retain examiners and provide information to its medical facilities to inform such efforts.GAO analyzed data on VA's use of telehealth from April 2020 through September 2022 and reviewed relevant VA guidance. GAO compared VA's guidance and practices to relevant federal standards for internal control. In addition, GAO interviewed officials from VA, exam vendors, and a non-generalizable sample of five VHA medical facilities, selected in part for variation in the number of exams completed and geographic location.
- Veterans Employment: GI Bill Benefits Can Help Lead to Outdoor Recreation Careers What GAO FoundEligible veterans can use the GI Bill and other education benefits from the Department of Veterans Affairs (VA) to pursue certificate or college degree programs related to outdoor recreation. This is a $159 billion industry involving outdoor physical activities, such as skiing or fishing, according to a 2021 federal estimate. GAO identified 34 GI Bill-approved certificate programs and about 1,400 college degree programs related to outdoor recreation. However, veterans may face challenges pursuing outdoor recreation education, such as the seasonality or specific locations of some programs. For example, some courses in avalanche rescue are available only in mountainous regions during the winter.  Examples of Veterans' Potential Education Pathways to Outdoor Recreation Careers Using Department of Veterans Affairs (VA) BenefitsIn 2021 federal agencies employed about 4,900 veterans in a number of outdoor recreation positions. These veterans comprised 11 percent of the more than 44,000 federal outdoor recreation employees, according to GAO's analysis of Office of Personnel Management (OPM) data. GAO identified 11 federal outdoor recreation positions at the Departments of Agriculture and the Interior, National Oceanic and Atmospheric Administration (NOAA), and the U.S. Army Corps of Engineers. Officials at these agencies told GAO that they attract veterans to outdoor recreation positions through career fairs, internships, and other programs or initiatives. More than one-third of these employees hold seasonal or part-time jobs. This can deter veterans seeking full-time, year-round employment from pursuing these careers. Further, federal officials told GAO that some outdoor recreation jobs are entry level and low paying, and thus may not be a good fit for veterans who are transitioning to civilian employment mid-career.Most Common Federal Outdoor Recreation Positions for Veterans, as of 2021			Outdoor recreation position category 									Number of veterans employed 								Forestry technician									1,710								General natural resources management and biological sciences									967								Maintenance mechanic (e.g., trail worker)									959								Park ranger									732					Source: GAO analysis of September 2021 Office of Personnel Management data for selected agencies.Note: For more details, see Table 1 in GAO-23-106149.Why GAO Did This StudySome veterans leave military service with wilderness survival and other skills related to outdoor recreation. VA also provides eligible veterans with benefits to pursue additional education and training. However, little is known about the educational or employment pathways for veterans into the outdoor recreation sector.The Consolidated Appropriations Act, 2022, includes provisions for GAO to review veterans' use of educational benefits and pursuit of careers in outdoor recreation. This report describes the opportunities and challenges for veterans to (1) use the GI Bill and other VA benefits toward outdoor recreation education and (2) pursue federal employment in outdoor recreation.GAO identified GI Bill-approved outdoor recreation education programs as of 2022 using VA and Department of Education data. GAO also analyzed 2021 OPM data—the most recent available—on federal employment at four agencies with missions connected to the outdoors: the Departments of Agriculture and the Interior, NOAA, and the U.S. Army Corps of Engineers. GAO also interviewed officials at these four agencies and reviewed relevant federal laws and regulations.In addition, GAO interviewed officials at VA and outdoor recreation certificate programs selected based on veteran enrollment and approval for VA educational benefits. GAO also interviewed representatives of an outdoor recreation industry association and veteran advocacy groups.For more information, contact Melissa Emrey-Arras at (617) 788-0534 or emreyarrasm@gao.gov.
- Priority Open Recommendations: Department of Veterans Affairs What GAO FoundIn June 2022, GAO identified 22 priority recommendations for the Department of Veterans Affairs (VA). Since then, VA has implemented 6 of those recommendations by, among other things, publishing procedures for reporting deaths by suicide on VA property. In May 2023, GAO identified 13 additional priority recommendations for VA, bringing the total number to 29. These recommendations involve the following areas:veterans' access to timely health care,	veterans community care program,	human capital management,&nbsp;	appeals reform for disability benefits,	quality of care and patient safety,	VA health care system efficiency,	acquisition management,	protecting the privacy of sensitive information, and	electronic health record modernization.VA's continued attention to these issues could lead to significant improvements in government operations.Why GAO Did This StudyPriority open recommendations are the GAO recommendations that warrant priority attention from heads of key departments or agencies because their implementation could save large amounts of money; improve congressional or executive branch decision-making on major issues; eliminate mismanagement, fraud, and abuse; or ensure that programs comply with laws and funds are legally spent, among other benefits. Since 2015, GAO has sent letters to selected agencies to highlight the importance of implementing such recommendations.For more information, contact Jessica Farb (202) 512-7114 or farbj@gao.gov.