VA Health Care
Challenges in Budget Formulation and Issues Surrounding the Proposal for Advance Appropriations
Gao ID: GAO-09-664T April 29, 2009
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.
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.
GAO-09-664T, VA Health Care: Challenges in Budget Formulation and Issues Surrounding the Proposal for Advance Appropriations
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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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