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Testimony: 

Before the Committee on Veterans' Affairs, House of Representatives: 

United States Government Accountability Office: 
GAO: 

For Release on Delivery: 
Expected at 10:00 a.m. EDT:
Wednesday, April 29, 2009: 

VA Health Care: 

Challenges in Budget Formulation and Issues Surrounding the Proposal 
for Advance Appropriations: 

Statement of Randall B. Williamson:
Director, Health Care: 

Susan J. Irving:
Director, Federal Budget Analysis, Strategic Issues: 

GAO-09-664T: 

GAO Highlights: 

Highlights of GAO-09-664T, a testimony before the Committee on 
Veterans’ Affairs, House of Representatives. 

Why GAO Did This Study: 

The Department of Veterans Affairs (VA) estimates it will provide 
health care to 5.8 million patients with appropriations of about 
$41 billion in fiscal year 2009. It provides a range of services, 
including primary care, outpatient and inpatient services, long-term 
care, and prescription drugs. VA formulates its health care budget by 
developing annual estimates of its likely spending for all its health 
care programs and services, and includes these estimates in its annual 
congressional budget justification. 

GAO was asked to discuss budgeting for VA health care. As agreed, this 
statement addresses (1) challenges VA faces in formulating its health 
care budget and (2) issues surrounding the possibility of providing 
advance appropriations for VA health care. 

This testimony is based on prior GAO work, including VA Health Care: 
Budget Formulation and Reporting on Budget Execution Need Improvement 
(GAO-06-958) (Sept. 2006); VA Health Care: Long-Term Care Strategic 
Planning and Budgeting Need Improvement (GAO-09-145) (Jan. 2009); and 
VA Health Care: Challenges in Budget Formulation and Execution (GAO-09-
459T) (Mar. 2009); and on GAO reviews of budgets, budget resolutions, 
and related legislative documents. We discussed the contents of this 
statement with VA officials. 

What GAO Found: 

GAO’s prior work highlights some of the challenges VA faces in 
formulating its budget: obtaining sufficient data for useful budget 
projections, making accurate calculations, and making realistic 
assumptions. For example, GAO’s 2006 report on VA’s overall health care 
budget found that VA underestimated the cost of serving veterans 
returning from military operations in Iraq and Afghanistan. According 
to VA officials, the agency did not have sufficient data from the 
Department of Defense, but VA subsequently began receiving the needed 
data monthly rather than quarterly. In addition, VA made calculation 
errors when estimating the effect of its proposed fiscal year 2006 
nursing home policy, and this contributed to requests for supplemental 
funding. GAO recommended that VA strengthen its internal controls to 
better ensure the accuracy of calculations used to prepare budget 
requests. VA agreed and, for its fiscal year 2009 budget justification, 
had an independent actuarial firm validate savings estimates from 
proposals to increase fees for certain types of health care coverage. 
In January 2009, GAO found that VA’s assumptions about the cost of 
providing long-term care appeared unreliable given that assumed cost 
increases were lower than VA’s recent spending experience and guidance 
provided by the Office of Management and Budget. GAO recommended that 
VA use assumptions consistent with recent experience or report the 
rationale for alternative cost assumptions. In a March 23, 2009, letter 
to GAO, VA stated that it concurred and would implement this 
recommendation for future budget submissions. 

The provision of advance appropriations would “use up” discretionary 
budget authority for the next year and so limit Congress’s flexibility 
to respond to changing priorities and needs. While providing funds for 
2 years in a single appropriations act provides certainty about some 
funds, the longer projection period increases the uncertainty of the 
data and projections used. If VA is expected to submit its budget 
proposal for health care for 2 years, the lead time for the second year 
would be 30 months. This additional lead time increases the uncertainty 
of the estimates and could worsen the challenges VA already faces when 
formulating its health care budget. 

Given the challenges VA faces in formulating its health care budget and 
the changing nature of health care, proposals to change the 
availability of the appropriations it receives deserve careful 
scrutiny. Providing advance appropriations will not mitigate or solve 
the problems we have reported regarding data, calculations, or 
assumptions in developing VA’s health care budget. Nor will it address 
any link between cost growth and program design. Congressional 
oversight will continue to be critical. 

View [hyperlink, http://www.gao.gov/products/GAO-09-664T] or key 
components. For more information, contact Randall B. Williamson at 
(202) 512-7114 or williamsonr@gao.gov or Susan J. Irving at (202) 512-
8288 or irvings@gao.gov. 

[End of section] 

Mr. Chairman and Members of the Committee: 

We are pleased to be here today as the committee considers issues in 
budgeting and funding for the Department of Veterans Affairs (VA) 
health care programs. These programs form one of the largest health 
care delivery systems in the nation and provide, for eligible veterans, 
a range of services, including preventive and primary health care, 
outpatient and inpatient services, long-term care, and prescription 
drugs. VA estimated that in fiscal year 2009, its health care programs 
would serve 5.8 million patients with appropriations of about $41 
billion. 

VA health care programs are funded through the annual appropriations 
process along with other areas of critical importance and high priority 
to the nation, including national defense, homeland security, 
transportation, energy and natural resources, education, and public 
health. VA formulates its health care budget by developing annual 
estimates of its likely spending for all of its health care programs 
and services. This is by its very nature challenging, as it is based on 
assumptions and imperfect information on the health care services VA 
expects to provide. For example, VA is responsible for anticipating the 
service needs of two very different populations--an aging veteran 
population and a growing number of veterans returning from the military 
operations in Afghanistan and Iraq--calculating the future costs 
associated with providing VA services, and using these factors to 
develop the department's budget request submitted to the Office of 
Management and Budget (OMB).[Footnote 1] VA provides its annual 
congressional budget justification to the appropriations subcommittees, 
providing additional explanation for the President's budget request. 
[Footnote 2] 

VA uses an actuarial model to develop its annual budget estimates for 
most of its health care programs, including inpatient acute surgery, 
outpatient care, and prescription drugs. This model estimates future VA 
health care costs by using projections of veterans' demand for VA's 
health care services as well as cost estimates associated with 
particular health care services.[Footnote 3] In fiscal year 2006, VA 
used the actuarial model to estimate about 86 percent of its projected 
health care spending for that year. VA uses a separate approach to 
project long-term care demands and costs, which accounted for about 10 
percent of VA's estimated health care spending for fiscal year 2006. VA 
used other approaches to project demand and costs for the remaining 4 
percent of the medical programs budget request for fiscal year 2006. 

In 2006 and 2009, we issued reports that examined some of the 
challenges VA faces in budget formulation; these reports pertained to 
VA's overall health care budget as well as portions of its budget that 
pertain to long-term care.[Footnote 4] We also testified in March 2009 
before the House Subcommittee on Military Construction, Veterans 
Affairs, and Related Agencies, Committee on Appropriations, about 
challenges VA faces in formulating and executing its budget.[Footnote 
5] You asked us to discuss budgeting for VA health care. As agreed, 
today we will discuss (1) challenges VA faces in formulating its health 
care budget and (2) some issues surrounding the possibility of 
providing advance appropriations for VA health care.[Footnote 6] 

For our 2006 report on VA's overall health care budget for fiscal years 
2005 and 2006, we analyzed and reviewed budget documents, including 
VA's budget justifications for health care programs for fiscal years 
2005 and 2006, and interviewed VA officials responsible for VA health 
care budget issues and for developing budget projections. In addition, 
from August to September 2008, we reviewed VA documents to determine 
whether VA had implemented the recommendations we made in our 2006 
report. For our 2009 report on VA's long-term care budget, we reviewed 
VA's fiscal year 2009 congressional budget justification and related 
documents. We also interviewed VA officials. VA did not initially 
comment on the recommendations in our 2009 report, but said it would 
provide an action plan. VA provided this action plan in a March 23, 
2009, letter to GAO. For this statement we reviewed VA's letter and 
action plan. For the discussion of appropriations and budgeting we 
reviewed previous GAO work, budgets, budget resolutions, and related 
legislative documents.[Footnote 7] 

We conducted our work for these performance audits in accordance with 
generally accepted government auditing standards.[Footnote 8] Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives. We discussed the contents of 
this statement with VA officials. 

VA Faces Challenges in Formulating Its Health Care Budget: 

Our prior work highlights some of the challenges VA faces in 
formulating its budget: obtaining sufficient data for useful budget 
projections, making accurate calculations, and making realistic 
assumptions. Our 2006 report on VA's overall health care budget found 
that VA underestimated the cost of serving veterans returning from 
military operations in Afghanistan and Iraq, in part because estimates 
for fiscal year 2005 were based on data that largely predated the Iraq 
conflict.[Footnote 9] In fiscal year 2006, according to VA, the agency 
again underestimated the cost of serving these veterans because it did 
not have sufficient data due to challenges obtaining data needed to 
identify these veterans from the Department of Defense (DOD). According 
to VA officials, the agency subsequently began receiving the DOD data 
needed to identify these veterans on a monthly basis rather than 
quarterly. 

We also reported challenges VA faces in making accurate calculations 
during budget formulation. VA made computation errors when estimating 
the effect of its proposed fiscal year 2006 nursing home policy, and 
this also contributed to requests for supplemental funding. We found 
that VA underestimated workload--that is, the amount of care VA 
provides--and the costs of providing care in all three of its nursing 
home settings.[Footnote 10] VA officials said that the errors resulted 
from calculations being made in haste during the OMB appeal process, 
[Footnote 11] and that a more standardized approach to long-term care 
calculations could provide stronger quality assurance to help prevent 
future mistakes. In 2006, we recommended that VA strengthen its 
internal controls to better ensure the accuracy of calculations it uses 
in preparing budget requests. VA agreed with and implemented this 
recommendation for its fiscal year 2009 budget justification by having 
an independent actuarial firm validate the savings estimates from 
proposals to increase fees for certain types of health care coverage. 

Our 2006 report on VA's overall health care budget also illustrated 
that VA faces challenges making realistic assumptions about the 
budgetary impact of its proposed policies. VA made unrealistic 
assumptions about how quickly the department would realize savings from 
proposed changes in its nursing home policy. We reported the 
President's requests for additional funding for VA's medical programs 
for fiscal years 2005 and 2006 were in part due to these unrealistic 
assumptions.[Footnote 12] We recommended that VA improve its budget 
formulation processes by explaining in its budget justifications the 
relationship between the implementation of proposed policy changes and 
the expected timing of cost savings to be achieved. VA agreed and acted 
on this recommendation in its fiscal year 2009 budget justification. 

In January 2009, we found that VA's spending estimate in its fiscal 
year 2009 budget justification for noninstitutional long-term care 
services appeared unreliable, in part because this spending estimate 
was based on a workload projection that appeared to be unrealistically 
high in relation to recent VA experience.[Footnote 13] VA projected 
that its workload for noninstitutional long-term care would increase 38 
percent from fiscal year 2008 to fiscal year 2009. VA made this 
projection even though from fiscal year 2006 to fiscal year 2007--the 
most recent year for which workload data are available--actual workload 
for these services decreased about 5 percent. In its fiscal year 2009 
budget justification, VA did not provide information regarding its 
plans for how it would increase noninstitutional workload 38 percent 
from fiscal year 2008 to fiscal year 2009. We recommended that VA use 
workload projections in future budget justifications that are 
consistent with VA's recent experience with noninstitutional long-term 
care spending or report the rationale for using alternative 
projections. In its March 23, 2009, letter to GAO, VA stated it concurs 
with this recommendation and will implement our recommendation in 
future budget submissions. 

In January 2009, we also reported that VA may have underestimated its 
nursing home spending and noninstitutional long-term care spending for 
fiscal year 2009 because it used a cost assumption that appeared 
unrealistically low, given recent VA experience and economic forecasts 
of health care cost increases. For example, VA based its nursing home 
spending estimate on an assumption that the cost of providing a day of 
nursing home care would increase 2.5 percent from fiscal year 2008 to 
fiscal year 2009. However, from fiscal year 2006 to fiscal year 2007-- 
the most recent year for which actual cost data are available--these 
costs increased approximately 5.5 percent. VA's 2.5 percent cost- 
increase estimate is also less than the 3.8 percent inflation rate for 
medical services that OMB provided in guidance to VA to help with its 
budget estimates. We recommended that in future budget justifications, 
VA use cost assumptions for estimating both nursing home and 
noninstitutional long-term care spending that are consistent with VA's 
recent experience or report the rationale for alternative cost 
assumptions. In its March 23, 2009, letter to GAO, VA stated it concurs 
with our recommendations and will implement these recommendations in 
future budget submissions. 

Issues in Changing the Appropriations for VA Health Care: 

Consideration of any proposal to change the availability of the 
appropriations VA receives for health care should take into account the 
current structure of the federal budget, the congressional budget 
process--including budget enforcement--and the nature of the nation's 
fiscal challenge. The impact of any change on congressional flexibility 
and oversight also should be considered. 

In the federal budget, spending is divided into two main categories: 
(1) direct spending, or spending that flows directly from authorizing 
legislation--this spending is often referred to as "mandatory 
spending"--and (2) discretionary spending, defined as spending that is 
provided in appropriations acts. 

It is in the annual appropriations process that the Congress considers, 
debates, and makes decisions about the competing claims for federal 
resources. Citizens look to the federal government for action in a wide 
range of areas. Congress is confronted every year with claims that have 
merit but which in total exceed the amount the Congress believes 
appropriate to spend. It is not an easy process--but it is an important 
exercise of its Constitutional power of the purse. 

Special treatment for spending in one area--either through separate 
spending caps or guaranteed minimums or exemption from budget 
enforcement rules--may serve to protect that area from competition with 
other areas for finite resources. The allocation of funds across 
federal activities is not the only thing Congress determines as part of 
the annual appropriations process. It also specifies the purposes for 
which funds may be used and the length of time for which funds are 
available. Further, annually enacted appropriations have long been a 
basic means of exerting and enforcing congressional policy. 

The review of agency funding requests often provides the context for 
the conduct of oversight. For example, in the annual review of the VA 
health care budget, increasing costs may prompt discussion about causes 
and possible responses--and lead to changes in the programs or in 
funding levels. VA health care offers illustrations of and insights 
into growing health care costs. This takes on special significance 
since--as we and others have reported--the nation's long-term fiscal 
challenge is driven largely by the rapid growth in health care costs. 

Both the Congress and the agencies have expressed frustration with the 
budget and appropriations process. Some members of Congress have said 
the process is too lengthy. The public often finds the debate 
confusing. Agencies find it burdensome and time consuming. And the 
frequent need for continuing resolutions[Footnote 14] (CR) has been a 
source of frustration both in the Congress and in agencies. Although 
there is frustration with the current process, changes should be 
considered carefully. The current process is, in part, the cumulative 
result of many changes made to address previous problems. This argues 
for spending time both defining what the problem(s) to be solved are 
and analyzing the impact of any proposed change(s). 

In considering issues surrounding the possibility of providing advance 
appropriations for VA health care--or any other program--it is 
important to recognize that not all funds provided through the existing 
appropriations process expire at the end of a single fiscal year. 
Congress routinely provides multi-year appropriations for accounts or 
projects within accounts when it deems it makes sense to do so. Multi- 
year funds are funds provided in one year that are available for 
obligation beyond the end of that fiscal year. So, for example, multi- 
year funds provided in the fiscal year 2010 appropriations act would be 
available in fiscal year 2010 and remain available for some specified 
number of future years.[Footnote 15] Unobligated balances from such 
multi-year funds may be carried over by the agency into the next fiscal 
year--regardless of whether the agency is operating under a continuing 
resolution or a new appropriations act. For example, in fiscal year 
2009 about $3 billion of approximately $41 billion for VA health care 
programs was made available for two years. Congress also provides 
agencies--including VA--some authority to move funds between 
appropriations accounts. This transfer authority provides flexibility 
to respond to changing circumstances. 

Advance appropriations are different from multi-year appropriations. 
Whereas multi-year appropriations are available in the year in which 
they are provided, advance appropriations represent budget authority 
that becomes available one or more fiscal years after the fiscal year 
covered by the appropriations act in which they are provided. So, for 
example, advance appropriations provided in the fiscal year 2010 
appropriations act would consist of funds that would first be available 
for obligation in fiscal year 2011 or later. 

In considering the proposal to provide advance appropriations, one 
issue is the impact on congressional flexibility and its ability to 
consider competing demands for limited federal funds. Although 
appropriations are made on an annual cycle, both the President and the 
Congress look beyond a single year in setting spending targets. The 
current administration's budget presents spending totals for ten fiscal 
years.[Footnote 16] The concurrent Budget Resolution--which represents 
Congress's overall fiscal plan--includes discretionary spending totals 
for the budget year and each of the four future years.[Footnote 17] The 
provision of advance appropriations would "use up" discretionary budget 
authority for the next year. In doing so it limits Congress's 
flexibility to respond to changing priorities and needs and reduces the 
amount available for other purposes in the next year. 

Another issue would be how and when the limits on such advance 
appropriations would be set. Currently the concurrent Budget Resolution 
both caps the total amount that can be provided through advance 
appropriations and identifies the agencies or programs which may be 
provided such funding.[Footnote 18] It does not specify how the total 
should be allocated among those agencies. 

A related question is what share of VA health care funding would be 
provided in advance appropriations. Is the intent to provide a full 
appropriation for both years in the single appropriations act? This 
would in effect enact the entire appropriation for both the budget year 
and the following fiscal year at the same time. If appropriations for 
VA health care were enacted in two-year increments, under what 
conditions would there be changes in funding in the second year? Would 
the presumption be that there would be no action in that second year 
except under unusual circumstances? Or is the presumption that there 
would be additional funds provided? These questions become critical if 
Congress decides to provide all or most of VA health care's funding in 
advance. Even if only a portion of VA health care funding is to be 
provided in advance appropriations, Congress will need to determine 
what that share should be and how it should be allocated across VA's 
medical accounts. 

While providing funds for 2 years in a single appropriations act 
provides certainty about some funds, the longer projection period 
increases the uncertainty of the data and projections used. Under the 
current annual appropriations cycle, agencies begin budget formulation 
at least 18 months before the relevant fiscal year begins. If VA is 
expected to submit its budget proposal for health care for both years 
at once, the lead time for the second year would be 30 months. This 
additional lead time increases the uncertainty of the estimates and 
could worsen the challenges VA faces when formulating its health care 
budget. 

Concluding Observations: 

Given the challenges VA faces in formulating its health care budget and 
the changing nature of health care, proposals to change the 
availability of the appropriations it receives deserve careful 
scrutiny. Providing advance appropriations will not mitigate or solve 
the problems noted above regarding data, calculations, or assumptions 
in developing VA's health care budget. Nor will it address any link 
between cost growth and program design. Congressional oversight will 
continue to be critical. 

No one would suggest that the current budget and appropriations process 
is perfect. However, it is important to recognize that no process will 
make the difficult choices and tradeoffs Congress faces easy. If VA is 
to receive advance appropriations for health care, the amount of 
discretionary spending available for Congress to allocate to other 
federal activities in that year will be reduced. In addition, providing 
advance appropriations for VA health care will not resolve the problems 
we have identified in VA's budget formulation. 

Mr. Chairman, this concludes our prepared remarks. We would be happy to 
answer any questions you or other members of the Committee may have. 

GAO Contacts and Staff Acknowledgments: 

[End of section] 

For more information regarding this testimony, please contact Randall 
B.Williamson at (202) 512-7114 or williamsonr@gao.gov or Susan J. 
Irving at (202) 512-8288 or irvings@gao.gov. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this statement. In addition to the contributors named 
above, Carol Henn and James C. Musselwhite, Assistant Directors; 
Katherine L. Amoroso, Helen Desaulniers, Felicia M. Lopez, Julie Matta, 
Lisa Motley, Sheila Rajabiun, Steve Robblee, and Timothy Walker made 
key contributions to this testimony. 

[End of section] 

Footnotes: 

[1] VA begins to formulate its own budget request at least 18 months 
before the start of the fiscal year to which the request relates and 
about 10 months before transmission of the President's budget request, 
which usually occurs in early February. 

[2] The President's budget request for VA is developed by the Office of 
Management and Budget. 

[3] The actuarial model reflects factors such as the age, sex, and 
morbidity of the veteran population as well as the extent to which 
veterans are expected to seek care from VA rather than health care 
providers reimbursed by other payers such as Medicare and Medicaid. 

[4] See GAO, VA Health Care: Budget Formulation and Reporting on Budget 
Execution Need Improvement, [hyperlink, 
http://www.gao.gov/products/GAO-06-958] (Washington, D.C.: Sept. 20, 
2006); GAO, VA Health Care: Long-Term Care Strategic Planning and 
Budgeting Need Improvement, [hyperlink, 
http://www.gao.gov/products/GAO-09-145] (Washington, D.C.: Jan. 23, 
2009). 

[5] See GAO, VA Health Care: Challenges in Budget Formulation and 
Execution, [hyperlink, http://www.gao.gov/products/GAO-09-459T] 
(Washington, D.C.: Mar. 12, 2009). 

[6] The Veterans Health Care Budget Reform and Transparency Act of 2009 
would provide for the VA Medical Services, Medical Support and 
Compliance, and Medical Facilities appropriations accounts to receive 
advance appropriations beginning with fiscal year 2011. H.R. 1016 and 
S. 423, 111th Cong. (2009). Advance appropriations represent budget 
authority that becomes available 1 or more fiscal years after the 
fiscal year covered by the appropriations act in which they are made. 

[7] See GAO, Budget Process: Issues in Biennial Budget Proposals, 
[hyperlink, http://www.gao.gov/products/GAO/T-AIMD-96-136] (Washington, 
D.C.: July 24, 1996); GAO, Budget Process: Comments on S.261-Biennial 
Budgeting and Appropriations Act, [hyperlink, 
http://www.gao.gov/products/GAO/T-AIMD-97-84] (Washington, D.C.: Apr. 
23, 1997); GAO, Budget Issues: Cap Structure and Guaranteed Funding, 
[hyperlink, http://www.gao.gov/products/GAO/T-AIMD-99-210] (Washington, 
D.C.: July 21, 1999); GAO, Congressional Directives: Selected Agencies' 
Processes for Responding to Funding Instructions, [hyperlink, 
http://www.gao.gov/products/GAO-08-209] (Washington, D.C.: Jan. 31, 
2008). 

[8] We conducted our work on VA's overall health care budget from 
October 2005 through September 2006, our work on VA's long-term care 
budget from November 2007 through January 2009, and our work for this 
statement in April 2009. The discussion of advance appropriations draws 
on work and analysis conducted on an ongoing basis for over a decade. 

[9] See [hyperlink, http://www.gao.gov/products/GAO-06-958]. 

[10] VA provides nursing home care in VA-operated nursing homes, in 
state veterans' nursing homes, and in community nursing homes under 
local or national contract to VA. 

[11] In late November, OMB "passes back" budget decisions to the 
agencies on the President's budget requests for their programs, a 
process known as "passback." These decisions may involve, among other 
things, funding levels, program policy changes, and personnel ceilings. 
The agencies may appeal decisions with which they disagree. 

[12] In June 2005, the President requested a $975 million supplemental 
appropriation for fiscal year 2005, and in July 2005, the President 
submitted a $1.977 billion budget amendment for the fiscal year 2006 
appropriation. 

[13] VA provides two types of long-term care: institutional long-term 
care, which is provided almost exclusively in nursing homes, and 
noninstitutional long-term care, which is provided in veterans' own 
homes and in other locations in the community. 

[14] When Congress and the President do not reach final decisions about 
one or more regular appropriations acts by the beginning of the federal 
fiscal year, October 1, they often enact a continuing resolution (CR). 
A CR provides agencies with funding for a period of time until final 
appropriations decisions are made or until enactment of another CR. 

[15] Some of these funds are available for two years; some are 
available for a longer specified time; some are available "until 
expended." 

[16] These are usually provided by budget category, by budget function, 
and by agency as well as for the total budget. The President's budget 
for fiscal year 2010 includes summary budget totals for the ten years 
spanning fiscal year 2010 through fiscal year 2019. 

[17] The FY 2010 budget resolution specifies discretionary spending 
amounts--both budget authority and outlays--in total and for each 
budget function for each of fiscal years 2010-2014. (It also specifies 
the amount of new appropriations and outlays for FY 2009). 

[18] A point of order can be raised against advance appropriations 
provided for those entities not identified by the Resolution. 

[End of section] 

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