VA provides health care services to various veteran populations— including an aging veteran population and a growing number of younger veterans returning from the military operations in Afghanistan and Iraq. VA operates approximately 150 hospitals, 130 nursing homes, 850 outpatient clinics, as well as other facilities to provide care to veterans. In general, veterans must enroll in VA health care to receive VA’s medical benefits package—a set of services that includes a full range of hospital and outpatient services, prescription drugs, and long-term care services provided in veterans’ own homes and in other locations in the community. VA’s health care budget estimate includes both the total cost of providing VA health care services as well as estimates of anticipated funding from several sources. These sources include new appropriations, which refer to the appropriations to be provided for the upcoming fiscal year, and with respect to advance appropriations, the next fiscal year. For example, VA estimated it needed $54.6 billion in new appropriations for fiscal year 2014 and $55.6 billion in advance appropriations for fiscal year 2015. In addition to new appropriations, sources of funding include resources expected to be available from unobligated balances and collections and VA’s reimbursements that VA anticipates it will receive in the fiscal year. collections include third-party payments from veterans’ private health care insurance for the treatment of nonservice-connected conditions and veterans’ copayments for outpatient medications. VA’s reimbursements include amounts VA receives for services provided under service agreements with the Department of Defense (DOD). In its budget justification, VA includes estimates related to the following: Ongoing health care services, which include acute care, rehabilitative care, mental health, long-term care, and other health care programs. In addition to new appropriations that VA may receive from Congress as a result of the annual appropriations process, funding may also be available from unobligated balances of multiyear appropriations, which remain available for a fixed period of time in excess of 1 fiscal year. For example, VA’s fiscal year 2013 appropriations provided that about $1.95 billion be available for 2 fiscal years. These funds may be carried over from fiscal year 2013 to fiscal year 2014 if they are not obligated by the end of fiscal year 2013. See Pub. L. No. 113-6, div. E, tit. II, § 226(b), 127 Stat. 198, 407 (2013). Initiatives, which are proposals by the Secretary of VA, the President, or Congress to provide, expand, or create new health care services. Some of the proposed initiatives can be implemented within VA’s existing authority, while other initiatives would require a change in law. Proposed savings, which are changes in the way VA manages its health care system to lower costs, such as changes to its purchasing and contracting strategies. Collections and reimbursements, which are resources VA expects to collect from health insurers of veterans who receive VA care for nonservice-connected conditions and other sources, such as veterans’ copayments, and resources VA expects to receive as reimbursement of services provided to other government agencies or private or nonprofit entities. Each year, Congress provides funding for VA health care through three appropriations accounts: Medical Services, which funds health care services provided to eligible veterans and beneficiaries in VA’s medical centers, outpatient clinic facilities, contract hospitals, state homes, and outpatient programs on a fee basis. Medical Support and Compliance, which funds the management and administration of VA’s health care system—including financial management, human resources, and logistics. Medical Facilities, which funds the operation and maintenance of the VA health care system’s capital infrastructure, such as costs associated with NRM, utilities, facility repair, laundry services, and groundskeeping. Advance appropriations for fiscal year 2014 for the three accounts were made in the following proportions: Medical Services at 80 percent, Medical Support and Compliance at 11 percent, and Medical Facilities at 9 percent. In our prior work reviewing the President’s budget requests for VA health care services, we have reported on a variety of problems related to the reliability, transparency, and consistency of VA’s estimates and information included in its congressional budget justifications. In June 2012 we reported that in its fiscal year 2013 budget justification VA was not transparent about the agency’s fiscal year 2013 estimates for initiatives and ongoing health care services as well as VA’s estimate for initiatives in support of the fiscal year 2014 advance appropriations request. We also raised concerns regarding the reliability of VA’s fiscal year 2013 estimate for NRM, which did not address the long-standing pattern in which VA’s NRM spending has exceeded the agency’s estimates. VA concurred with a recommendation we made to improve the transparency of its estimates for initiatives and ongoing health care services, but did not concur with a recommendation related to the transparency of the agency’s initiative estimate in support of the advance appropriations request. VA also concurred with a third recommendation we made to improve the reliability of the agency’s NRM estimates. In September 2012 we also found that VA did not label health care services consistently in its budget justifications so that it was clear what services were being referred to across appropriations accounts. VA agreed with our recommendation to improve the consistency of the labels used for health care services. Most recently, in February 2013 we raised concerns about the reliability of VA’s estimates for non-NRM facility-related activities.estimates, and VA concurred with our recommendation. VA expanded the use of the EHCPM by using estimates of the amount of care provided—which is known as workload—from the EHCPM to estimate resources needed for 14 long-term care services for fiscal years 2014 and 2015. VA included the 14 long-term care services in the EHCPM, but the agency did not use the estimates of needed resources developed for fiscal years 2014 and 2015 because, according to VA officials, the EHCPM expenditure estimates were determined to be too high to produce reliable estimates of needed resources in light of current expenditure data. As an alternative, the estimates for fiscal years 2014 and 2015 were based on the most current expenditure data available, as VA has done in prior years, and workload estimates from the EHCPM. As a result of this blended approach, VA used the EHCPM, in part or in whole, to develop estimates for 74 health care services that accounted for more than 85 percent of VA’s budget estimate supporting the President’s fiscal year 2014 budget request for VA health care. This represents an increase compared to last year when VA used the EHCPM to estimate needed resources for 59 health care services, or approximately 78 percent of the agency’s fiscal year 2013 budget estimate. (See fig. 1.) While the EHCPM accounted for a larger proportion of VA’s health care budget that supports the President’s budget request, revisions were made to the estimates developed by the EHCPM and other methods. As we have previously reported, these revisions resulted from the iterative and multilevel review process in VA and OMB and reflect the policy decisions and more current information, among other things. Another change in VA’s fiscal year 2014 budget justification was how VA reported its estimate for certain administrative costs. In prior budget justifications, VA has reported its estimates for administrative personnel costs under “Administration” and estimates for administrative contracts under “Administrative Contract Services.” VA reported estimates for these administrative costs in each of the three appropriations accounts as well as for “Medical Care,” which reported the total costs for “Administration” and “Administrative Contract Services” across all three accounts. In its fiscal year 2014 budget justification, VA used a new budget category label—“Administrative Personnel”—when reporting estimated costs related to administrative personnel. VA also identified some of the costs reported under the new label by providing examples of the types of positions the agency considers administrative personnel, such as filing clerks, receptionists, police staff, chaplains, and other staff that are necessary for the effective operations of VA medical facilities. However, VA did not consistently use the new “Administrative Personnel” label in its fiscal year 2014 budget justification. VA used the new label when reporting its Medical Care estimate for administrative personnel costs, but not when reporting the agency’s estimates for each of the three appropriations accounts. Instead, VA used the label “Administration,” even though the estimates reported under this label—$2.0 billion for Medical Services, $3.5 billion for Medical Support and Compliance, and $366 million for Medical Facilities—represented the same personnel costs in the estimate of $5.9 billion reported for “Administrative Personnel.” (See table 1.) VA officials explained that the use of “Administrative Personnel” was incorrect and that the “Administration” label will be used in future budget justifications. The inconsistency for reporting estimates for these costs may imply that VA used different labels to report estimates for different administrative costs. As such, the costs reported under these labels are unclear to Congress and other users of VA’s budget justification. In addition to inconsistent labeling, VA also was not consistent in its reporting of information on the types of personnel positions included in the agency’s estimates for administrative personnel costs reported. VA provided information on the types of personnel positions included in the total estimate for administrative personnel costs under the budget category label “Administrative Personnel,” but did not provide similar information for the estimates for each appropriations account labeled under “Administration.” By not providing information on the types of positions included in these estimates, VA was not transparent about how the information that was provided applied to the estimates of administrative personnel costs in each of the appropriations accounts. For example, it is unclear to what extent police staff and chaplains will be funded across the three appropriations accounts.