VA Health Care: Improved Data, Planning, and Communication Needed for Infrastructure Modernization and Realignment
Fast Facts
VA's health care system offers services to more than 9.5 million people. But VA's facilities are aging, and upgrading them to meet veterans' needs will be a massive undertaking that could cost up to $76 billion.
VA developed more than 1,400 recommendations for modernizing and realigning its health care infrastructure, such as closing some medical facilities and establishing new ones.
However, we found gaps in the data that VA used to inform the recommendations, and the department needs to improve both its planning and its communication with key groups like facility staff. Our recommendations address these issues.
Highlights
What GAO Found
In response to the VA Mission Act of 2018 (MISSION Act), the Department of Veterans Affairs (VA) conducted a system-wide assessment of its capacity to provide health care services to veterans and develop recommendations for modernizing and realigning the department's infrastructure. The MISSION Act also specified that a presidentially appointed and Senate-confirmed commission—the Asset and Infrastructure Review Commission—would review VA's recommendations. The Commission was to then provide its own recommendations to the President by January 2023, according to the act.
However, in June 2022 a bipartisan group of senators announced their opposition to holding confirmation hearings for Commission nominees. These Senators voiced concerns that VA's 1,433 recommendations published in March 2022 would not expand and strengthen VA's infrastructure. Accordingly, no confirmation hearings have occurred as of March 2023.
The Secretary of VA stated that, independent of the Commission's existence, the department has an obligation to veterans to modernize and realign its infrastructure. VA therefore has taken steps to refine its recommendations and plans to conduct recurring system-wide assessments every 4 years as also required by the MISSION Act.
GAO's review determined that 540 of VA's recommendations pertained to facility changes. These changes included closing, replacing, updating, and establishing medical centers, outpatient clinics (e.g., community-based outpatient clinics and other outpatient services sites), and other facilities.
Department of Veterans Affairs' (VA) Recommended Facility Changes, by Facility Type
| Type of recommended infrastructure change | |||||
|---|---|---|---|---|---|
|
Facility type |
Closure |
Replacement |
Update |
Establish new |
Total |
|
VA medical center |
16 |
23 |
80 |
13 |
132 |
|
Outpatient clinica |
139 |
112 |
2 |
112 |
365 |
|
Stand-alone community living center |
1 |
0 |
1 |
28 |
30 |
|
Stand-alone residential rehabilitation treatment program |
1 |
1 |
0 |
11 |
13 |
|
Total |
157 |
136 |
83 |
164 |
540 |
Source: GAO analysis of VA documentation. | GAO-23-106001
aOutpatient clinic includes health care centers, community-based outpatient clinics and other types.
GAO noted differences in how commonly VA recommended changes for facilities by rurality. Specifically, VA recommended closures for facilities in rural areas more commonly than for those in urban areas (60 compared to 35 percent). For facilities in urban areas, VA recommended replacements (38 compared to 31 percent) and updates (27 compared to 9 percent) more commonly compared to facilities in rural areas. According to VA officials, the department recommended changes to its facilities based on a variety of factors including the quality of care, the ability to recruit and retain health care providers, the condition of VA facilities, and the number of veterans served.
GAO's review also determined that VA made 893 recommendations to change inpatient, outpatient, and other services available in VA facilities. These recommended service changes included establishing new or expanding existing services, among others.
Department of Veterans Affairs' (VA) Recommended Changes to Health Care Services
| VA health care services | ||||||
|---|---|---|---|---|---|---|
|
Type of service change |
Inpatienta |
Emergency department or urgent care |
Outpatient |
Community living center |
Residential rehabilitation treatment program |
Total |
|
Establish new or expand existing services |
15 |
7 |
135 |
46 |
35 |
238 |
|
Modernize existing services |
41 |
20 |
16 |
36 |
25 |
138 |
|
Relocate existing services |
79 |
37 |
303 |
40 |
39 |
498 |
|
Total |
135 |
64 |
454 |
122 |
99 |
874 |
Source: GAO analysis of VA documentation. | GAO-23-106001
Note: In addition to the types of services included above, VA also made seven recommendations to modernize or relocate inpatient blind rehabilitation services and 12 recommendations to modernize or relocate inpatient spinal cord injury/disorders services.
aInpatient includes inpatient medical and surgical and inpatient mental health care services.
According to VA officials, the department reviewed specific data to help ensure that the recommendations reflected four key considerations—1) meeting veterans' evolving needs; 2) adapting to health care delivery innovations; 3) addressing VA's education, research, and support missions; and 4) accounting for COVID-19 trends. In reviewing the department's data supporting these considerations, GAO identified gaps in the comprehensiveness of the data used. For example, in determining veteran access to community care, VA reviewed data estimating whether non-VA providers had the capacity to serve veterans. However, VA lacked data on appointment wait times, the total number of appointments, and their associated costs. According to VA officials, VA intends to address data gaps as part of its ongoing planning for the next set of quadrennial market assessments expected in 3 years. However, VA's plans currently do not include specific actions and time frames to determine the data it will use for its upcoming market assessments. By addressing these data gaps and identifying time frames for completing these actions, VA can provide greater assurance that these market assessment account for its key considerations.
VA established a leadership team to, among other things, conduct implementation planning and strategic prioritization of recommendations, and prepare for the next set of market assessments. However, the department does not have a documented, formal plan describing the team's structure and implementation strategy. Having such a plan would help ensure that VA has effective and efficient processes for using its recommendations and future market assessments to address the department's infrastructure needs.
GAO determined that VA restricted the sharing of information when developing its recommendations. Department officials acknowledged that they will need to be more transparent in sharing information with internal and external stakeholders moving forward. VA has taken steps, such as developing draft documents, consistent with such an approach. Finalizing this approach, to help ensure communication with critical stakeholders such as the Congress and veterans' service organizations, is essential to the success of VA's overall modernization and realignment effort including the use of VA's recommendations.
Why GAO Did This Study
VA administers one of the largest health care systems in the nation. The system, which includes 172 medical centers and more than 1,100 outpatient clinics, serves more than 9.5 million enrolled veterans and eligible family members.
Upgrading VA's aging facilities is a massive endeavor. VA estimates that addressing its health care system infrastructure needs could cost up to $76 billion, as of fiscal year 2021.
GAO was asked to review VA's plans and recommendations to address its infrastructure needs. This report (1) describes the Asset and Infrastructure Review Commission and VA's recommendations, (2) examines the data VA used to inform its recommendations and plans VA has to improve such data, and (3) examines the extent of VA's planning for modernizing and realigning its infrastructure and communicating with stakeholders.
GAO analyzed VA's recommendations for modernizing and realigning its infrastructure, and reviewed supporting data and documentation. These data included actual and projected data on demographics and demand for health care. GAO also reviewed documentation describing VA's process to assess its capacity in 96 designated geographic areas, or markets, to provide quality, accessible, and timely health care.
To obtain market-level perspectives, GAO interviewed officials from a non-generalizable selection of four markets. GAO selected the four based on factors such as variation by geographic region and by types of changes recommended (e.g., closures, replacements). GAO also interviewed VA officials responsible for developing the recommendations and for planning to modernize and realign its infrastructure.
Recommendations
GAO is making three recommendations to VA:
- Develop specific actions to address data gaps identified by GAO and others and time frames for completing such actions,
- Develop a documented, formal plan that identifies the leadership team's structure and implementation strategy, and
- Finalize communication approach to increase transparency with internal and external stakeholders.
VA concurred with the recommendations, and identified steps it would take to implement them.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Veterans Affairs | The Secretary of Veterans Affairs should develop specific actions that address the data gaps identified by GAO and others and identify time frames for completing such actions to help ensure that future market assessments fully account for the department's key considerations. (Recommendation 1) |
VA concurred with the recommendation. According to VA, a contract award protest delayed progress on addressing the recommendation. As of November 2024, VA workgroups are collaborating to develop the approach for the next set of market assessments, including how data will be collected, displayed, and utilized, according to VA. Following approval by the workgroups, the approach to data analysis will be reviewed and approved by VA and VHA Data Governance bodies. VA anticipates approval of the approach by the governance bodies by March 2025.
|
| Department of Veterans Affairs | The Secretary of Veterans Affairs should direct VA's leadership team to develop a formal, documented plan that identifies its structure and an implementation strategy for its efforts to modernize and realign the department's infrastructure to help ensure the efficiency and effectiveness of these efforts. (Recommendation 2) |
VA concurred with the recommendation. According to VA officials, the leadership team finalized its health care infrastructure strategy in December 2023. VA noted that, during 2024, the leadership team also collaborated with the department's Infrastructure Governance Board (the accountable stewardship body responsible for life-cycle management of VA's infrastructure portfolio) in developing a comprehensive enterprise-wide infrastructure plan and strategy that reflected the health care strategy. As of February 2025, the department had submitted its comprehensive enterprise-wide infrastructure plan and strategy to the Office of Management and Budget for review as part of the fiscal year 2026 President's Budget submission process. VA anticipates updating the plan and strategy by June 2025 based on feedback from the Office of Management and Budget. To implement this recommendation, VA needs an implementation plan that helps meet its future infrastructure needs, such as the anticipated growth in veteran demand as a result of the Honoring our PACT Act of 2022. Having such a plan would help ensure that VA has effective and efficient processes for implementing its modernization efforts and using future market assessments to address the department's infrastructure needs.
|
| Department of Veterans Affairs | The Secretary of Veterans Affairs should direct its leadership team to finalize its communication approach, such as by developing, documenting, and disseminating how it will increase communication and transparency with internal and external stakeholders, including specifying how and when communication should occur. (Recommendation 3) |
VA concurred with the recommendation. According to VA, the department posted information about its communications approach on a SharePoint site for all stakeholders to review, as of October 2024. VA officials also stated that communications have occurred in monthly meeting minutes and monthly email executive summaries. However, VA officials stated that its communications plan will continue to mature with the evolution of its new infrastructure governing body, including external communication opportunities. As of February 2025, VA has not provided a copy of the communications plan for us to determine to what extent the department has documented and disseminated how communication and transparency with internal and external stakeholders will be increased, including specifying how and when communication should occur.
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