Section 107 of the Persian Gulf War Veterans’ Benefits Act required VA to conduct a study to evaluate the health status of spouses and children of Persian Gulf War veterans. Under the study, VA was directed to provide diagnostic testing and medical examinations to any individual who (1) is the spouse or child of a veteran listed in VA’s Persian Gulf War Veterans’ Registry who is suffering from an illness or disorder; (2) is apparently suffering from, or may have suffered from, an illness or disorder (including a birth defect, miscarriage, or stillbirth) that cannot be disassociated from the veteran’s service in the Southwest Asia theater of operations; and (3) in the case of a spouse, has granted VA permission to include relevant medical data in the Registry. These tests and examinations were to be used to determine the nature and extent of the association, if any, between the illness or disorder of the spouse or child and the illness of the veteran. The Congress authorized VA to use contractors to provide the medical examinations and specified that the amount spent for the program may not exceed $2 million. The entire $2 million was designated for examinations; the program administrative costs are to be covered by each coordinating medical center’s operating budget. The act does not authorize funding for the treatment of family members of Persian Gulf veterans or reimbursement of participants for travel, lodging, or lost wages. The act stipulated that the program was to be carried out from November 1, 1994, through September 30, 1996. Program implementation was delayed until April 1996 because of a disagreement between VA and members of the Senate over the appropriate approach for establishing the program. VA proposed doing research, via the National Health Survey of Persian Gulf Veterans, which was designed to gather information on the incidence and nature of health problems occurring in Persian Gulf veterans and their families. The survey includes the examination of randomly selected Persian Gulf spouses and children as well as a control group, for comparison, of nondeployed Persian Gulf-era veterans and their families. (See app. II for a description of the National Health Survey of Persian Gulf Veterans.) However, in a November 1995 letter, the Ranking Minority Member of the Senate Committee on Veterans’ Affairs and the Senate Minority Leader notified VA that its approach would not meet the mandate expressed in section 107 of the act. The letter stated that VA was expected to provide spouses and children the opportunity to seek medical examinations for conditions that family members believe are related to Persian Gulf service and to enter the examination information in the Persian Gulf Registry. The letter further stated that, while the survey was viewed as an important epidemiological study for which the Congress expressed approval by enactment of section 109 of the act, it would not meet the mandate of section 107 of the act. In response to these concerns, the Secretary of Veterans Affairs indicated in a February 1996 letter to the Ranking Minority Member of the Senate Committee on Veterans’ Affairs that the Veterans Health Administration (VHA) would proceed immediately to provide voluntary examinations to Persian Gulf family members. VA initiated the Persian Gulf Spouse and Children Examination Program in April 1996 when it began accepting requests for clinical examinations. On October 9, 1996, the Veterans’ Health Care Eligibility Reform Act of 1996 (P.L. 104-262) extended the program through December 31, 1998. The program is administered through VHA’s Office of Public Health and Environmental Hazards and is implemented through coordinating VA medical centers established in each of VA’s 22 Veterans Integrated Service Networks (VISN). The program is offered at 36 of VA’s 172 medical centers. (See fig. 1 for a map showing locations of the VISNs and the 36 coordinating medical centers). Coordinating medical centers are responsible for establishing contracts, usually with their university-affiliated medical schools, for the examination of Persian Gulf spouses and children using standard medical protocols and guidelines developed by VA. The Persian Gulf Spouse and Children Examination Program has faced implementation problems that, to this point, have limited the program’s effectiveness. To inform potential participants about the program, VA headquarters initiated national, broad-based outreach efforts with coordinating medical centers providing for local outreach. As of January 1998, VA coordinating medical centers have received 2,802 requests for examinations, but only 31 percent (872) of requested examinations have been completed. Factors contributing to the low completion rate include the lengthy and cumbersome process for scheduling examinations, which we found takes an average of 15 weeks from the time applicants first apply to the time examinations are completed. Also, examination sites are not easily accessible for some participants because only 36 of VA’s 172 medical centers participate in the program, and the law does not allow for VA to reimburse participants for costs such as travel and lodging. In addition, as of January 1998, no examinations had been conducted in 3 of the 16 coordinating medical centers we contacted because those centers had not negotiated contracts with affiliated medical schools or other providers. Problems also existed with obtaining additional diagnostic testing in some locations. VA headquarters initiated national outreach through notices about the program in the Persian Gulf Review (a quarterly newsletter sent to about 67,000 Persian Gulf veterans in the Registry), public service television announcements, nationally broadcast television interviews with VA officials about Persian Gulf issues, and announcements on the Internet. The Office of Public Affairs, through its regional structure, provided coordinating VA medical centers with press releases about the program. All 172 VA medical centers received basic information about the Persian Gulf Spouse and Children Examination Program. Also, one nationwide teleconference, available to all VA medical centers, was held at the start of the program to encourage centers to inform veterans about the availability of free examinations for the family members of Persian Gulf veterans. According to a VA program official, local outreach was the responsibility of the 36 coordinating VA medical centers. Outreach efforts at the medical centers we contacted ranged from direct mailings to veterans on the Persian Gulf Registry to relying only on national outreach efforts. For example, the Tampa and Seattle medical centers contacted all veterans who had received Persian Gulf Registry examinations at their centers by letter or telephone. Some medical centers sent brochures to Persian Gulf veterans, and Persian Gulf coordinators visited reserve units and service organizations and informed them about the program. However, the Denver and Salt Lake City medical centers relied on national outreach efforts to provide program information. Without information on how participants learned of the program or knowledge of the potential universe of Persian Gulf spouses and children who believe their illnesses or disorders may be related to a family member’s service in the Gulf, it is difficult to assess the effectiveness of national or local outreach efforts. However, VA estimated that, on the basis of the $2 million authorized for the program, it could provide about 4,500 examinations, based on an average cost of $400 per examination, and have a reserve of $200,000 to cover the cost of additional diagnostic tests. Examinations were offered on a first come, first served basis. As of January 1998, coordinating medical centers reported they had received 2,802 requests for examinations. By January 1998, about 7 percent ($148,916) had been expended from the $2 million allocated for the program. Eight hundred seventy-two examinations of spouses and children, 31 percent of examinations requested, had been completed as of January 1998. Forty-one percent of family members who requested examinations did not report for appointments, refused examinations, or had not yet responded to requests to schedule examinations, as shown in table 1. Several factors contribute to the low completion rate for requested examinations. For example, obtaining an examination requires several steps in a lengthy and cumbersome process. Individuals cannot contact a VA medical center to request an examination. Instead, requests for examinations are made by calling (toll free) the Persian Gulf War Veterans’ Helpline. Next, Helpline staff forward requests to VA headquarters, which checks the VA and DOD Persian Gulf registries or the DOD Persian Gulf Deployment Listing to see if the veteran served in the Persian Gulf. VA headquarters then refers requests to one of the 36 coordinating VA medical centers to further establish eligibility. The medical center contacts the individual requesting the examination and asks him or her to provide a marriage certificate (for a spouse) or a birth certificate (for a child). Finally, the medical center sends the validated request to the affiliated medical school or provider, whose representative schedules an examination appointment with the requester. Our analysis showed that the process from requesting an examination to completion of the examination takes an average of over 15 weeks. According to a VA program official, the process for scheduling examinations was established as an efficient way to control, verify, and forward requests to the nearest coordinating medical center. Because the Persian Gulf Helpline already existed and operated 24 hours a day, it offered a means to monitor the number of requests received nationally. Also, Helpline staff were knowledgeable about a range of Persian Gulf issues and services available for veterans. Verification of veterans’ service in the Persian Gulf is centrally administered because VA headquarters staff have access to the VA and DOD Persian Gulf registries and the Persian Gulf Deployment Listing. Verification of the child or spousal relationship is assigned to medical center staff who also provide a local VA contact and forward verified requests to examination providers to schedule appointments. Another major deterrent to obtaining examinations is the distance to examination sites or the accessibility of sites. VA implemented the program through 36 of its 172 medical centers. VA’s Office of Public Health and Environmental Hazards issued a directive through the Chief Network VISN Office for each network to identify at least one medical center to participate in the program. All VISNs identified at least one coordinating medical center, 12 networks established two coordinating centers, and one VISN established three coordinating medical centers. A VA official stated that medical center decisions to participate in the program were based on the demographics of the Persian Gulf veteran population and the medical centers’ ability to obtain contracts with their affiliated medical schools.