COVID-19 Pandemic: VA Provides Health Care Assistance to Civilians as Part of the Federal Response
Summary
GAO report GAO-21-395 to congressional addressees, COVID-19 Pandemic: VA Provides Health Care Assistance to Civilians as Part of the Federal Response, dated May 2021. It describes how the Department of Veterans Affairs (VA) takes part in a multiagency council that includes the Federal Emergency Management Agency (FEMA), whose approved requests for emergency resources become mission assignments issued by FEMA. The report explains how VA consults its regional networks and medical facilities to decide its capacity to accept mission assignments, and describes the number and types of assignments VA conducted from March 2020 through February 2021. GAO interviewed VA, FEMA and Department of Health and Human Services officials and analyzed VA documents.
Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used
Full text
United States Government Accountability Office
Report to Congressional Addressees
COVID-19
May 2021
PANDEMIC
VA Provides Health
Care Assistance to
Civilians as Part of the
Federal Response
GAO-21-395
May 2021
COVID-19 PANDEMIC
VA Provides Health Care Assistance to Civilians as
Part of the Federal Response
Highlights of GAO-21-395, a report to
congressional addressees
Why GAO Did This Study What GAO Found
As the nation’s largest integrated As part of its federal response to COVID-19, the Department of Veterans Affairs
health care system, VA has significant (VA) participates in a multiagency council, which includes the Federal
resources to respond to large-scale Emergency Management Agency (FEMA). The council reviews requests for
disasters and emergencies requiring a emergency resources; upon approval by the council, these requests become
public health response. As a part of the mission assignments issued by FEMA. To determine its capacity to accept
nation’s federal response to COVID- mission assignments from FEMA, VA consults with its regional networks and
19, FEMA tasked VA to provide medical facilities (see figure).
emergency resources to support
states, territories, tribes, and other How VA Accepts and Conducts Mission Assignments in Response to COVID-19 Pandemic
federal agencies through mission
assignments. The CARES Act included
a provision for GAO to report on the
ongoing monitoring and oversight
efforts related to the COVID-19
pandemic.
This report describes (1) how VA
determines its capacity to accept
mission assignments and (2) the
number and types of mission
assignments VA conducted from
March 2020 through February 2021,
among other objectives.
GAO interviewed VA officials and
analyzed documents related to VA’s
civilian health care response to
COVID-19, including VA’s mission
assignments from March 2020 through
February 2021. GAO also interviewed
FEMA and Department of Health and
Human Services officials to obtain
information on the interagency
coordination efforts to assign and
conduct mission assignments.
GAO provided a draft of this report to
VA, FEMA, and the Department of
Health and Human Services for
comment. VA and FEMA provided
technical comments only, which GAO
incorporated as appropriate, and the
Department of Health and Human
Services did not provide any
comments.
From March 2020 through February 2021, VA conducted 117 mission
assignments across 38 states, one territory, and four tribes in response to
COVID-19. The most common types of assistance provided were deploying VA
View GAO-21-395. For more information, staff to help treat patients at community medical facilities and providing inpatient
contact Debra Draper at (202) 512-7114 or care to civilians at VA medical facilities.
draperd@gao.gov.
United States Government Accountability Office
Contents
Letter 1
Background 5
VA Consults with Its Regional Networks and Medical Facilities to
Determine Its Capacity to Accept Mission Assignments 8
VA Conducted 117 Mission Assignments of Various Types of
Civilian Health Care Assistance in Response to the COVID-19
Pandemic 11
VA Reviewed Certain Aspects of Mission Assignments Conducted
in the Initial Months of Its Pandemic Response 19
Agency Comments 22
Appendix I VA’s Fourth Mission—Preparing for and Responding to Disasters
and Emergencies 25
Appendix II Mission Assignments the Department of Veterans Affairs (VA)
Conducted, March 2020 to February 2021 29
Appendix III Comments from the Department of Veterans Affairs 33
Appendix IV GAO Contact and Staff Acknowledgments 34
Tables
Table 1: Estimated Costs of Mission Assignments Conducted by
the Department of Veterans Affairs (VA) from March 2020
to February 2021, by Type of Assignment 14
Table 2: Department of Veterans Affairs’ (VA) Reports Reviewing
Aspects of Mission Assignments Conducted in the Initial
Months of the Response to COVID-19, March to June
2020 19
Table 3: Direct Federal Assistance Mission Assignments
Conducted by the Department of Veteran Affairs (VA) by
State or Territory, Estimated Cost, and Type of
Assistance, March 2020 to February 2021 29
Page i GAO-21-395 VA Civilian COVID-19 Response
Table 4: Direct Federal Assistance Mission Assignments
Conducted by the Department of Veteran Affairs (VA) by
State or Territory and Type of Recipient, March 2020 to
February 2021 31
Figures
Figure 1: Number of Mission Assignments, by Month of Initiation,
Conducted by the Department of Veterans Affairs (VA) in
Response to COVID-19 from March 2020 to February
2021 13
Figure 2: The Geographical Distribution of Direct Federal
Assistance Mission Assignments Conducted by the
Department of Veterans Affairs (VA) from March 2020 to
February 2021 15
Figure 3: Assistance Provided to Civilians through Direct Federal
Assistance Mission Assignments Conducted by the
Department of Veterans Affairs (VA) in Response to
COVID-19 from March 2020 to February 2021 16
Figure 4: Number and Estimated Costs of Direct Federal
Assistance Mission Assignments Conducted at
Community Medical Facilities by the Department of
Veteran Affairs (VA) from March 2020 to January 2021,
by Type of Assistance 17
Page ii GAO-21-395 VA Civilian COVID-19 Response
Abbreviations
Council Public Health and Medical Services Emergency
Support Function Council
COVID-19 Coronavirus Disease 2019
DOD Department of Defense
FEMA Federal Emergency Management Agency
HHS Department of Health and Human Services
OEM Office of Emergency Management
VA Department of Veterans Affairs
VHA Veterans Health Administration
This is a work of the U.S. government and is not subject to copyright protection in the
United States. The published product may be reproduced and distributed in its entirety
without further permission from GAO. However, because this work may contain
copyrighted images or other material, permission from the copyright holder may be
necessary if you wish to reproduce this material separately.
Page iii GAO-21-395 VA Civilian COVID-19 Response
Letter
441 G St. N.W.
Washington, DC 20548
May 20, 2021
Congressional Addressees
In December 2019, a new strain of coronavirus emerged and quickly
spread around the globe. On January 31, 2020, the Secretary of Health
and Human Services declared a public health emergency in response to
the Coronavirus Disease 2019 (COVID-19), and on March 13, 2020, the
President of the United States declared a national emergency pursuant to
the National Emergencies Act and a nationwide emergency under the
Robert T. Stafford Disaster Relief and Emergency Assistance Act
(Stafford Act). In response to the pandemic, major disaster declarations
were simultaneously issued for all U.S. states, the District of Columbia,
U.S. territories, and a number of tribes—the first time in history this has
occurred. 1
The Department of Veterans Affairs (VA)—the nation’s largest integrated
hospital system—has resources vital to a large-scale public health
disaster response, including medical facilities and staff. While the
agency’s first priority is to care for veterans and their eligible dependents,
in times of emergency, VA also may provide assistance to individuals
ineligible for VA health care, and be called upon to support the needs of
1Major disaster declarations were issued to all 50 states, the District of Columbia, five
territories, the Seminole Tribe of Florida, and the Navajo Nation. In addition, 45 tribes are
working directly with the Federal Emergency Management Agency under the March 13,
2020, national emergency declaration.
For purposes of this report, the term tribes refers to those that are federally recognized by
the government of the United States. According to the Bureau of Indian Affairs’ website,
there are 574 federally recognized tribes in the United States. See
https://www.bia.gov/frequently-asked-questions, accessed March 15, 2021.
Page 1 GAO-21-395 VA Civilian COVID-19 Response
active-duty military personnel, due to its significant health care
capabilities. 2 This is also known as VA’s “fourth mission.” 3
VA coordinates the deployment of its resources with the Federal
Emergency Management Agency (FEMA). 4 One way VA can respond to
a public health disaster is through a FEMA work order, known as a
mission assignment. FEMA issues mission assignments to task federal
agencies with providing necessary resources, such as critical goods and
services, to support states, territories, tribes, and other federal agencies.
FEMA may reimburse federal agencies for the associated costs of
providing assistance under a mission assignment. As of March 2020, of
all federal agencies to which FEMA obligated funds for mission
assignments in response to COVID-19, FEMA obligated the third highest
2For purposes of this report, we will refer to individuals ineligible for VA health care whom
VA may serve during times of emergency collectively as civilians, unless otherwise
specified.
VA is authorized to furnish hospital care and medical services to civilians responding to,
involved in, or otherwise affected by an ongoing or recently occurred disaster or
emergency for which the President has declared a major disaster or emergency under the
Stafford Act, or in which the National Disaster Medical System is activated by the
Secretary of HHS. 38 U.S.C. § 1785. Under these circumstances, VA also may provide
such care to members of the Armed Forces on active duty responding to or involved in
that disaster or emergency, either during or immediately following the disaster or
emergency. 38 U.S.C. § 8111A. In addition, VA may furnish hospital care or medical
services to civilians as a humanitarian service in emergency cases, but VA is required to
charge for such care and services at rates prescribed by VA. 38 U.S.C. § 1784.
For example, in addition to mission assignments, VA provided health care services in
response to the COVID-19 pandemic to non-veteran beneficiaries of the Indian Health
Service, an agency within HHS that provides health care for over 2 million American
Indians and Alaska Natives who are members or descendants of federally recognized
tribes. On October 28, 2020, VA and Indian Health Service entered into an interagency
agreement outlining the terms under which VA will bill the Indian Health Service for
services provided to non-veteran beneficiaries during the COVID-19 public health
emergency declared by the Secretary of HHS and in response to other emergencies as
specified in the agreement.
3According to VA’s website, its other three missions are veterans’ health care, veterans’
benefits, and national cemeteries. See https://www.va.gov/about_va/, accessed on
February 11, 2021.
4FEMA is an agency within the Department of Homeland Security. The Department of
Health and Human Services (HHS) and FEMA lead the federal response to COVID-19
through the Unified Coordination Group. HHS is designated as the lead agency to address
the public health and medical portion of the response, and FEMA is designated as the
lead agency for coordinating the overall federal response.
Page 2 GAO-21-395 VA Civilian COVID-19 Response
amount to VA, behind the Department of Defense (DOD) and the Army
Corps of Engineers.
The CARES Act included a provision for GAO to conduct monitoring and
oversight of the authorities and funding provided to address the COVID-
19 pandemic and the effect of the pandemic on the health, economy, and
public and private institutions of the United States. 5 This report is part of
our body of work related to the CARES Act and focuses on VA’s civilian
health care assistance in response to COVID-19. This report describes, in
response to COVID-19,
1. how VA determines its capacity to accept mission assignments;
2. the number and types of mission assignments VA conducted from
March 2020 through February 2021; and
3. VA’s efforts to review the mission assignments it conducted.
To describe how VA determines its capacity to accept mission
assignments in response to the COVID-19 pandemic, we interviewed
officials from the Veterans Health Administration’s (VHA) Office of
Emergency Management (OEM) and Administrative Operations, and VA’s
Office of Finance. We reviewed relevant documents and laws related to
VA’s authorities to provide civilian health care assistance. To obtain
perspectives on VA’s role in interagency coordination efforts to assign
and conduct mission assignments, we also interviewed officials from the
Department of Health and Human Services (HHS), the agency leading
the national public health response to COVID-19, and FEMA, the lead
agency for coordinating the overall federal response, including officials
from three of the ten FEMA regions (1, 4, and 5). 6 We selected the FEMA
regions with the highest proportion of VA mission assignments from
5Pub. L. No. 116-136, § 19010(b), 134 Stat. 281, 580 (2020). We regularly issue
government-wide reports on the federal response to COVID-19. For the latest report, see
GAO, COVID-19: Sustained Federal Action Is Crucial as Pandemic Enters Its Second
Year, GAO-21-387 (Washington, D.C.: Mar. 31, 2021). Our next government-wide report
will be issued in July 2021 and will be available on GAO’s website at
https://www.gao.gov/coronavirus.
6These FEMA regions represent different areas of the United States. Region 1 includes
Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont. Region
4 includes Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South
Carolina, and Tennessee. Region 5 includes Illinois, Indiana, Michigan, Minnesota, Ohio,
and Wisconsin.
Page 3 GAO-21-395 VA Civilian COVID-19 Response
March through June 2020. We also reviewed relevant documents and
laws related to the nation’s emergency response.
To describe the number and types of mission assignments VA conducted,
we obtained and reviewed documentation for 130 mission assignments
VA accepted from March 23, 2020 through February 28, 2021. 7 Of these
130 mission assignments, FEMA closed and de-obligated the total
amount of funds associated with 13 mission assignments because, for
example, the assignments were reissued to change the statement of work
or VA conducted no actions under the assignments. 8 Since FEMA de-
obligated the total amount of funds for these 13 mission assignments, we
excluded them, and included a total of 117 mission assignments in our
analysis. As of March 2, 2021, VA reported 23 of these mission
assignments were ongoing and 94 were completed. For purposes of this
report, we use the term “conducted” to refer to both ongoing and
completed mission assignments. We reviewed the mission assignment
documentation to analyze the length of mission assignments, types of
assistance provided, recipients of assistance, and estimated costs agreed
upon by VA and FEMA. 9 According to FEMA, mission assignment
amendments do not significantly change the mission assignments’
original scope of work, but can modify the terms, such as increasing or
decreasing the amount of funding or changing the period of performance.
For purposes of our analysis, we did not count amendments as discrete
mission assignments. We analyzed each mission assignment and its
related amendments to summarize the type of the assistance VA
provided, including estimated cost and length of the assignments. We
interviewed OEM officials to obtain further clarification on VA’s mission
assignments.
To describe VA’s efforts to review the mission assignments it carried out,
we examined three VA reports conducted in 2020 that reviewed VA’s
7FEMA Form 010-0-8.
8Of these 13 de-obligated mission assignments, VA reissued nine as new mission
assignments. These reissued mission assignments are among those included in our
analysis.
9Mission assignment cost estimates are developed jointly by FEMA staff and the
performing agencies. These cost estimates include reimbursable costs, such as personnel
wages, overtime, travel, and per diem and the costs of materials, equipment, and
supplies, to provide disaster assistance. A signed mission assignment document provides
the basis for obligating FEMA's funds. A mission assignment’s estimated costs may not
reflect the actual costs of performing the mission assignment.
Page 4 GAO-21-395 VA Civilian COVID-19 Response
pandemic response. Of these three reports, two were internal reviews in
draft form provided to GAO by VA and the third was prepared by a
contractor and is publically available. 10 We interviewed and received
written responses from VHA’s OEM and Administrative Operations
officials to obtain additional context on their efforts, including actions VA
may have taken to address identified areas for improvement.
We conducted this performance audit from May 2020 to May 2021 in
accordance with generally accepted government auditing standards.
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.
VA serves the health care needs of veterans and other eligible individuals
Background through VHA’s 170 medical centers and 1,074 outpatient clinics. These
medical facilities are organized into 18 regional networks across the
country. 11 VA is designated as a key support agency under the National
Response Framework—the federal government’s plan for mobilizing
resources and assisting state and local governments in responding to
emergencies. For more information about VA’s emergency support
responsibilities, see appendix I.
National Response The National Response Framework is a guide to how the nation responds
Framework and Its to all types of disasters and emergencies. The National Response
Framework has 15 emergency support functions, each of which covers an
Emergency Support
area of specific federal resources and capabilities most frequently needed
Functions in a national response, such as transportation, communications, public
works and engineering, and logistics.
Public Health and Medical VA supports the National Response Framework’s Public Health and
Services Emergency Medical Services Emergency Support Function, which FEMA activated on
March 18, 2020 in response to the COVID-19 pandemic. Led by HHS, the
Support Function
Public Health and Medical Services Emergency Support Function has a
coordinating council (Council) to carry out the responsibilities of the
10Deloitte Consulting, LLP, Veterans Health Administration (VHA) Coronavirus Disease
2019 (COVID-19) Response Report, a report prepared at the request of the Department of
Veterans Affairs, Veterans Health Administration, Oct. 27, 2020.
11These regional networks are responsible for managing and overseeing the medical
centers within their networks.
Page 5 GAO-21-395 VA Civilian COVID-19 Response
emergency support function under the COVID-19 pandemic. The Council
consists of senior leaders from multiple agencies including VA, FEMA, the
Centers for Disease Control and Prevention, the United States Public
Health Service Commissioned Corps, and DOD. 12 This Council reviews
and approves requests for mission assignments from states, territories,
tribes, and federal agencies. For example, when considering requests for
mission assignments, representatives on the Council discuss the nature
of assistance requested; what national resources are available to
respond; and how best to allocate them.
Mission Assignments FEMA can make two types of mission assignments to VA and other
federal agencies after they are approved by the Council:
• Federal operations support. These mission assignments provide
federal agency-to-federal agency support. According to FEMA mission
assignment guidance, the primary purpose is to augment the capacity
and capability of a National Response Framework emergency support
function by pre-positioning or delivering critical goods or services. For
example, through a federal operations support mission assignment,
VA provided liaisons to its National Response Coordination Center
and Regional Response Coordination Centers to improve coordination
of resources in March 2020.
• Direct federal assistance. These mission assignments direct federal
agencies to provide emergency goods and services after states,
territories, and tribes have exhausted their own capabilities to provide
those goods and services. Initially, during the COVID-19 pandemic,
states, territories, and tribes were subject to a 25 percent cost share
of the mission assignment. For example, if a mission assignment is
estimated to cost $10 million dollars to complete, the state, territory, or
12According to HHS, officials from the HHS Secretary’s Operation Center—the agency’s
primary emergency operations structure tasked with protecting the health, safety, and
security of the nation—lead the Council. In 2019, VA deployed a permanent liaison to the
HHS Secretary’s Operation Center.
The Secretary of HHS declared the COVID-19 pandemic to be a public health emergency
on January 31, 2020, prior to the President’s declaration of a national emergency in March
2020. Under the public health emergency declaration, VA supported HHS in responding to
COVID-19 through 10 task orders for services provided for a certain period of time. VA
deployed 22 staff in support of HHS through these task orders. For six of these task
orders, VA deployed liaisons to support HHS in various locations. For example, VA
embedded a liaison with the incident management team based at Travis Air Force Base in
Fairfield, California to assist with the quarantine and return of cruise ship travelers,
particularly veterans, to their home states. According to HHS, VA’s services rendered
under task orders may not be fully reimbursable as is the case with mission assignments.
Page 6 GAO-21-395 VA Civilian COVID-19 Response
tribe is responsible for paying FEMA $2.5 million upon completion.
However, through presidential memoranda issued on January 21,
2021 and February 2, 2021, the President authorized the federal
government to assume 100 percent of the costs for mission
assignments conducted in response to COVID-19 through September
30, 2021 and retroactive to January 20, 2020. 13
States, territories, tribes, and federal agencies submit requests for
assistance to FEMA’s electronic crisis management system, known as
Web-based Emergency Operations Center. If a request for assistance is
approved by the Council, FEMA is responsible for processing the
requests as mission assignments, directing mission assignments to
agencies that will provide the assistance (such as VA), and coordinating
the response.
FEMA’s Role in Response FEMA’s National Response Coordination Center is the hub for
Coordination coordinating response actions and resources across federal agencies.
The National Response Coordination Center is a multiagency
coordination center located within FEMA Headquarters. The center’s staff
coordinates the overall federal support for major incidents and
emergencies. In addition, FEMA operates Regional Response
Coordination Centers within each of its 10 regional offices to facilitate
communication between the National Response Coordination Center and
states, territories, and tribes. According to FEMA, these regional offices
help to ensure that states, territories, and tribes receive important
information and are able to ask questions regarding COVID-19 response
efforts. Typically, FEMA personnel in FEMA’s Regional Response
Coordination Centers receive and initiate the review of requests for
assistance submitted by states, territories, and tribes.
13The 100 percent reimbursement of expenses to provide for the safe opening and
operation of eligible schools, child-care facilities, healthcare facilities, non-congregate
shelters, domestic violence shelters, transit systems, and other eligible applicants is only
retroactive to January 21, 2021. 86 Fed. Reg. 8281 (Feb. 2, 2021).
Page 7 GAO-21-395 VA Civilian COVID-19 Response
According to VA officials and a VA-commissioned report on its response
VA Consults with Its to COVID-19, VA consults internally with its regional networks and
Regional Networks medical facilities to determine the agency’s capacity to fulfill requests for
mission assignments, which are reviewed and approved by the Council.
and Medical Facilities In cases where VA determines that it has the capacity to fulfil a request
to Determine Its and the Council concludes that VA is best positioned to respond, VA
accepts those requests as mission assignments and coordinates with
Capacity to Accept FEMA to fulfill them.
Mission Assignments
VA’s internal process to determine its capacity to accept mission
assignments involves coordination with several stakeholders throughout
the agency. According to the VA-commissioned report, after the Acting
Deputy Under Secretary for Health joined the Council in April 2020 to
represent VA, he developed a process by which he consults with the
regional network directors to identify the agency’s capacity to respond to
requests for assistance. 14 According to VA officials, this is done with
support from OEM, VHA’s office primarily responsible for managing all
internal and external VHA actions necessary to prepare for, respond to,
and recover from emergencies. Specifically, OEM staff assist with
gathering relevant information and facilitating its flow between the
regional networks and medical facilities, and the agency’s leadership.
According to VA, the flow of information may be bidirectional; for
example, there are times when the agency’s leadership requires the input
of facilities, and other times when the facilities may need clarification from
leadership. According to VA officials, this process allows VA to determine
its capacity to assist civilians in key areas such as the following:
• Inpatient hospital beds. According to the VA-commissioned report
on VA’s response to COVID-19, regional networks planned to commit
up to 80 percent of medical center capacity to meet a surge in
demand among the veteran population (the agency’s first priority) and
apply the remaining capacity towards mission assignments for civilian
health care assistance. 15 In effect, VA committed to making available
to FEMA up to 1,500 inpatient medical center beds across the country
for civilians for the duration of the national emergency.
• Emergency medical staff. OEM manages an emergency medical
staff program, where staff who are typically based at medical facilities
can volunteer and register, in advance, for deployment to community
facilities or other locations during an emergency. These staff can
14Deloitte Consulting, VHA COVID-19 Response Report.
15Deloitte Consulting, VHA COVID-19 Response Report.
Page 8 GAO-21-395 VA Civilian COVID-19 Response
include physicians, nurses, and technicians. According to VA, the total
number of staff registered nationally more than doubled from 6,949 in
January 2020 to 16,676 as of mid-February 2021, in large part due to
efforts by VA to increase the availability of staff to deploy to areas of
need. For example, according to a March 29, 2020, memo issued to
VA regional networks, VA required facilities to take appropriate action
to leverage the capacity of their staff with acute care capabilities,
including registering health care professionals with specialties in
areas such as cardiology, emergency medicine, and geriatrics, in the
emergency medical staff database for potential deployment.
• Supplies and testing. According to the VA-commissioned report on
VA’s response to COVID-19, like many states and U.S. health care
systems, VA had limited quantities of key supplies such as personal
protective equipment and ventilators, and limited capabilities for
COVID-19 testing early in the pandemic. 16 According to VA, the
agency took various actions to acquire needed items directly, and also
requested items from FEMA in order to build capacity to support
anticipated mission assignments. 17 According to an OEM official, a VA
liaison actively engaged with FEMA and HHS officials regarding the
availability of personal protective equipment and other items in the
Strategic National Stockpile. 18 In addition, according to the report on
VA’s response to COVID-19, VA worked with HHS to develop its
capacity for COVID-19 testing as the national availability of devices,
supplies, and reagents gradually increased.
VA considers a number of factors when determining whether it will accept
a mission assignment. According to VA officials, the agency aims to
accept as many mission assignments as is feasible. VA stated that each
request is individually considered based upon the specifics of the request.
In some cases, before accepting an assignment, VA officials said they
16Deloitte Consulting, VHA COVID-19 Response Report.
17See GAO, VA Acquisition Management: COVID-19 Response Strains Supply Chain
While Modernization Delays Continue, GAO-20-716T (Washington, D.C.: Sept. 16, 2020)
for more information on items VA received from FEMA. In addition, we plan to issue a
report in spring 2021 on our review of VA’s procurement response for COVID-19,
including the amount of funding obligated for COVID-19 related contracts.
18According to the HHS website, the Strategic National Stockpile's role is to supplement
state and local medical supplies and equipment during public health emergencies. The
supplies, medicines, and devices for lifesaving care contained in the stockpile can be used
as a short-term, stopgap buffer when the immediate supply of these materials may not be
available or sufficient. See https://www.phe.gov/about/sns/Pages/default.aspx, accessed
on March 10, 2021.
Page 9 GAO-21-395 VA Civilian COVID-19 Response
have negotiated the type or amount of resources initially requested based
on the availability of VA resources at the time. When determining its
capacity to accept an assignment, VA officials said a key factor in its
decision-making is to ensure that veterans are not negatively impacted.
These officials said, for example, VA would only make inpatient beds
available to civilians if there is excess capacity beyond what is necessary
to care for veterans. VA officials said that they prioritize requests from
state veterans homes and community nursing homes, given VHA’s
expertise with these patient populations. 19 VA also works to accept
requests from tribes; officials cited the higher proportion of veterans from
these communities and noted that these populations are frequently
underserved and experience health care disparities.
In an effort to further expedite the identification and coordination of
available resources at the regional and local levels, in March 2020, OEM
embedded its existing area emergency managers at each of FEMA’s ten
Regional Response Coordination Centers on a temporary basis in
response to a mission assignment issued by FEMA. These emergency
managers are OEM staff with emergency management technical
expertise that serve as consultants to assist VA regional networks and
medical facilities. OEM officials said this was the first time VA had
embedded VA staff in the Regional Response Coordination Centers in
response to a national emergency. According to FEMA officials we
interviewed at three of the ten Regional Response Coordination Centers,
these VA liaisons were critical to providing timely and important
information about potential resources at the local level, as well as helping
to explore the feasibility of potential mission assignments (see sidebar).
19State veterans homes and community nursing homes are a type of long-term care
facility, which provides a variety of services, both medical and personal care, to people
who are unable to live independently. State veterans homes typically serve veterans only
while community nursing homes are open to all who are eligible, including veterans. VA
may pay for the long-term care of eligible veterans in public or privately owned community
nursing homes or state veterans homes, the latter of which are owned, operated, and
managed by state governments.
Page 10 GAO-21-395 VA Civilian COVID-19 Response
Example of how VA accepted a mission After VA accepts a mission assignment, OEM works closely with VA’s
assignment for a state veterans home regional networks and medical facilities to officially initiate the
According to Department of Veterans Affairs assignment. As a part of this process, OEM prepares a statement of work
(VA) officials, a state veterans home in
Wisconsin was experiencing a COVID-19
and a cost estimate. OEM also consults with VA’s Office of General
outbreak in the summer of 2020 and needed Counsel to ensure the mission assignment is within VA’s legal authority to
additional medical staff. The state veterans conduct. Throughout the duration of a mission assignment, OEM, the
home contacted the neighboring VA regional
network about its situation and requested involved regional networks and medical facilities coordinate closely to
nursing staff. The VA area emergency facilitate its completion. After the mission assignment is completed, VA
manager assigned to that Federal Emergency
Management Agency (FEMA) region was requests reimbursement from FEMA for costs incurred. FEMA verifies
alerted to the situation from officials at the VA VA’s completion of the work, reimburses VA for expenditures, and closes
regional network. The VA area emergency the mission assignment.
manager worked with the state veterans home
and the state government to determine the
exact needs, while VA assessed its internal
capacity to address the request. When VA
determined that it had the resources to fulfill
the request, the VA area emergency manager
helped the state government develop and
submit a request for assistance to FEMA in
accordance with the mission assignment
process. FEMA routed the request through
the Public Health and Medical Services
Emergency Support Function Council
(Council) and VA accepted this request as a
mission assignment. The VA area emergency
manager noted this entire process took about
36 hours.
Source: GAO. | GAO-21-395
VA Conducted 117
Mission Assignments
of Various Types of
Civilian Health Care
Assistance in
Response to the
COVID-19 Pandemic
VA Conducted 117 Mission Our analysis of VA’s mission assignments shows that from March 2020
Assignments for COVID- through February 2021 VA conducted 117 mission assignments in
response to COVID-19, and continues to accept assignments to provide
19 between March 2020
and February 2021
Page 11 GAO-21-395 VA Civilian COVID-19 Response
civilian health care assistance. 20 According to VA officials, the agency’s
response to the COVID-19 pandemic has been unprecedented in terms of
the magnitude, duration, and scope when compared to previous
emergencies. Under the COVID-19 national emergency, VA received
mission assignments directly from FEMA for the first time. Under prior
emergencies, VA generally functioned in a support role to HHS. 21
VA’s mission assignments, by month of initiation, peaked in April 2020,
and VA started over 10 mission assignments in each of the months of
May, June, and July (see fig. 1). The duration of the 94 mission
assignments completed as of February 28, 2021 ranged from a single day
to 270 days, with an average of 60 days. 22
20These mission assignments were amended over 200 times. For example, these
amendments modified the amount of funding or period of performance requested in the
original mission assignment.
21VA’s assistance through HHS included flights evacuating civilian patients from disaster
areas to VA medical facilities, and providing medical care to civilian patients.
22According to FEMA Mission Assignment Policy, FP 104-010-2, mission assignments
should not exceed 60 days, but assignments can be extended through amendments.
Page 12 GAO-21-395 VA Civilian COVID-19 Response
Figure 1: Number of Mission Assignments, by Month of Initiation, Conducted by the Department of Veterans Affairs (VA) in
Response to COVID-19 from March 2020 to February 2021
Note: The month indicates the mission assignment’s projected start date. A mission assignment is a
Federal Emergency Management Agency work order under the Robert T. Stafford Disaster Relief and
Emergency Assistance Act for another agency.
Of the 117 mission assignments, VA conducted 13 assignments to assist
other federal agencies (federal operations support assignments) and 104
assignments to assist states, territories, and tribes (direct federal
assistance assignments) (see table 1). For example, through a federal
operations support mission assignment, VA deployed liaisons to FEMA’s
National and Regional Response Coordination Centers to improve
coordination of VA resources.
Page 13 GAO-21-395 VA Civilian COVID-19 Response
Table 1: Estimated Costs of Mission Assignments Conducted by the Department of
Veterans Affairs (VA) from March 2020 to February 2021, by Type of Assignment
Estimated cost
Type of mission assignment Number (millions)
Direct federal assistance to states, territories, and tribes 104a $265.5
Federal operations support to federal agencies 13 $4.8
Total 117 $270.3
Source: GAO analysis of VA information. l GAO-21-395
Note: A mission assignment is a Federal Emergency Management Agency (FEMA) work order under
the Robert T. Stafford Disaster Relief and Emergency Assistance Act for another agency. Mission
assignment cost estimates are developed jointly by FEMA staff and the performing agencies. A
mission assignment’s estimated costs may not reflect the actual costs of performing the mission
assignment.
a
VA conducted 98 mission assignments for states, one mission assignment for a territory, and five
mission assignments to support tribes.
From March, 2020 through February, 2021, VA conducted direct federal
assistance mission assignments that were distributed geographically
across 38 states and one territory, including mission assignments to
support four tribes. 23 The numbers and estimated costs of mission
assignments varied by state, territory, and tribe (see fig. 2). The state
where VA conducted the most mission assignments (8) was New Jersey.
The estimated costs of VA’s assistance through mission assignments by
geographic location ranged from $1,135 in Kansas to $45 million in
Oregon. VA’s most expensive individual mission assignment (estimated
$25 million) was in New York (New York City), where VA provided
inpatient care for civilians at VA facilities. For more detail on estimated
costs of mission assignments by state, see appendix II.
23VA conducted mission assignments to support four tribes: the Navajo Nation, the White
Mountain Apache Tribe of the Fort Apache Reservation, the Hopi Tribe, and the
Mississippi Band of Choctaw Indians. Three mission assignments were for the Navajo
Nation, which spans across three states–Arizona, New Mexico, and Utah. Another
assignment supported the White Mountain Apache Tribe of the Fort Apache Reservation
and the Hopi Tribe, which are both located within Arizona, and the Navajo Nation. In
addition, VA conducted one mission assignment to support the Mississippi Band of
Choctaw Indians. VA conducted one mission assignment in the U.S. territory of American
Samoa.
Page 14 GAO-21-395 VA Civilian COVID-19 Response
Figure 2: The Geographical Distribution of Direct Federal Assistance Mission Assignments Conducted by the Department of
Veterans Affairs (VA) from March 2020 to February 2021
Notes: VA conducted 104 direct federal assistance mission assignments. A direct federal assistance
mission assignment is a work order, issued by the Federal Emergency Management Agency (FEMA)
under the Robert T. Stafford Disaster Relief and Emergency Assistance Act, directing another federal
agency to provide needed assistance to a state, territory or federally-recognized tribe. Mission
assignment cost estimates are developed jointly by FEMA staff and the performing agencies. A
mission assignment’s estimated costs may not reflect the actual costs of performing the mission
assignment. The estimated costs associated with mission assignments conducted to support tribes
are included in the state in which VA conducted them. In Arizona, VA conducted three mission
assignments, two for the Navajo Nation, and one for the Navajo Nation, the White Mountain Apache
Tribe of the Fort Apache Reservation, and the Hopi Tribe. In New Mexico, VA conducted one mission
assignment for the Navajo Nation. In Mississippi, VA conducted one mission assignment for the
Mississippi Band of Choctaw Indians. VA conducted one mission assignment in the U.S. territory of
American Samoa.
a
VA reported these mission assignments either were emergent and had no available cost estimates,
or VA requested no funds to conduct the mission assignment.
Page 15 GAO-21-395 VA Civilian COVID-19 Response
VA’s Assistance to States VA provided inpatient hospital care for civilian patients in VA facilities and
and Tribes Included deployed staff and resources to community medical facilities through VA’s
104 direct federal assistance mission assignments conducted from March
Providing Care to Civilians
2020 through February 2021 (see fig. 3). The agency’s 25 mission
in VA Medical Facilities assignments for providing VA inpatient care to civilian patients had the
and Deploying Staff and highest estimated cost, while the majority of the mission assignments (58)
Resources to Community comprised the deployment of VA staff to assist community medical
Medical Facilities facilities.
Figure 3: Assistance Provided to Civilians through Direct Federal Assistance
Mission Assignments Conducted by the Department of Veterans Affairs (VA) in
Response to COVID-19 from March 2020 to February 2021
Note: A direct federal assistance mission assignment is a Federal Emergency Management Agency
(FEMA) work order, under the Robert T. Stafford Disaster Relief and Emergency Assistance Act,
directing another federal agency to provide needed assistance to a state, territory, or federally-
recognized tribe. VA conducted mission assignments at long-term care facilities, such as community
nursing homes, state veterans homes, group homes, and psychiatric facilities
VA inpatient care for civilians. To supplement medical surge capacity in
local communities experiencing outbreaks, VA provided hospital beds for
Page 16 GAO-21-395 VA Civilian COVID-19 Response
civilian patients in its facilities for treatment of both COVID-19 and non-
COVID-19 illnesses through mission assignments. These inpatient
services included intensive care, acute care, and nursing home care.
Through 25 mission assignments, states and tribes requested a total of
as many as 692 VA beds for civilian patients at an estimated cost of
$220.6 million. 24 For example, VA provided 15 intensive care beds and 45
acute care beds between three Illinois VA facilities in Chicago, Hines, and
Marion. The care VA provided in its Illinois facilities included various
resources, such as 24-hour medical, administrative, and support staff,
medical equipment and supplies, and pharmaceuticals for COVID-19 and
non-COVID-19 patients.
Resources deployed to community facilities for civilians. VA
deployed staff, testing, supplies, and vaccination support to community
medical facilities, including civilian hospitals, state veterans homes,
community nursing homes, and medical facilities in tribal communities, for
79 mission assignments (see fig. 4). Mission assignments can include
goods and services for more than one facility. For example, VA reported it
conducted a mission assignment in Florida that covered more than 800
long-term care facilities. For more information on the recipients of mission
assignments in each state, see appendix II.
Figure 4: Number and Estimated Costs of Direct Federal Assistance Mission
Assignments Conducted at Community Medical Facilities by the Department of
Veteran Affairs (VA) from March 2020 to January 2021, by Type of Assistance
Note: A direct federal assistance mission assignment is a work order, issued by the Federal
Emergency Management Agency (FEMA) under the Robert T. Stafford Disaster Relief and
24As of February 2021, VA reported caring for 488 civilian patients in VA facilities under
mission assignments for COVID-19.
Page 17 GAO-21-395 VA Civilian COVID-19 Response
Emergency Assistance Act, directing another federal agency to provide needed assistance to a state,
territory, or federally-recognized tribe. Mission assignment cost estimates are developed jointly by
FEMA staff and the performing agencies. A mission assignment’s estimated costs may not reflect the
actual costs of performing the mission assignment.
• Staff. VA reported deploying up to 2,934 staff to provide medical care
through 58 mission assignments in community medical facilities. A
majority (40) of these mission assignments supported long-term care
facilities, including 27 for state veterans homes. 25 VA also deployed
staff for medical facilities in tribal communities through four mission
assignments. States and tribes primarily requested registered and
licensed practical nurses; other staff VA deployed included
physicians, nurse assistants, therapists, and social workers. For
example, VA supported five medical facilities in Arizona where staffing
levels were critically impacted from COVID-19 by providing staff,
including up to 45 intensive care nurses, four lab technicians, and four
respiratory therapists.
• Testing. VA conducted eight mission assignments for testing support
in community medical facilities, which included the collection and
processing of COVID-19 tests. A majority (six) of these mission
assignments supported state veterans homes. For example, VA
assisted in the collection and processing of biological samples for
COVID-19 testing and analysis at two state veterans homes in Texas.
VA staff collected samples from state veterans home patients and
transported them to VA facilities, which sent the samples to testing
labs for confirmation of COVID-19 suspected patients.
• Supplies and equipment. VA supported community medical facilities
by providing supplies and equipment through six mission
assignments, including ventilators and mobile pharmacy units. 26 For
example, for two mission assignments, VA provided eight ventilators
to support hospitalized patients in Kansas. In another mission
assignment, at the state of Michigan’s request, VA provided a mobile
pharmacy unit to support an HHS-deployed federal medical station in
Detroit. 27 VA did not provide medication or pharmacy personnel with
25VA conducted mission assignments at long-term care facilities, such as community
nursing homes, state veterans homes, group homes, and psychiatric facilities.
26VA maintains a fleet of mobile pharmacy units to assist veterans, staff, and civilians
during emergencies. These units function as an outpatient pharmacy capable of delivering
pharmaceuticals.
27A federal medical station is a temporary HHS healthcare facility created in response to
disasters or emergencies that can provide surge beds to support healthcare systems in
the United States.
Page 18 GAO-21-395 VA Civilian COVID-19 Response
the mobile pharmacy unit, but the assistance provided did include a
driver for transportation, staging, and return of the unit and a subject
matter expert to familiarize HHS and state of Michigan staff with the
unit.
• Vaccinations. VA conducted seven mission assignments to support
COVID-19 vaccination efforts in states and territories. For example, in
New Jersey, VA provided pharmacy support at six vaccination sites
across the state. For another mission assignment, VA provided a
support team to augment services at a vaccination site in New York.
FEMA, HHS, and the State of New York provided the vaccine and
vaccine supplies.
In efforts to assess and improve upon its COVID-19 response, VA
VA Reviewed Certain reviewed certain aspects of the mission assignments it conducted from
Aspects of Mission March to June 2020 in response to the COVID-19 pandemic. According to
VA, as of February 2021, VA conducted three reviews, two of which were
Assignments internal reports in draft form and the third was prepared by a contractor
Conducted in the and is publically available (see table 2).
Initial Months of Its
Pandemic Response
Table 2: Department of Veterans Affairs’ (VA) Reports Reviewing Aspects of Mission Assignments Conducted in the Initial
Months of the Response to COVID-19, March to June 2020
Title Description of scope Source of information
The Veterans Health Administration’s This report focused on the performance of OEM’s Electronic surveys sent to VA program
(VHA) Office of Emergency response coordination center, including its facilitation offices, such as the Public Health and
Management (OEM) of VA mission assignments and deployment of VA Population Health Services Program
COVID-19 Response: After-Action emergency medical staff.a Offices.
Report and Improvement Plan (Draft)
The COVID-19 VHA’s Rapid and This report identified lessons learned from mission Listening sessions with deployed VA
Agile Response to State Veterans assignments conducted to assist community medical staff, and state veterans and
Homes and Community Nursing facilities, such as state veterans homes and community nursing homes’ facility
Homes: Listening Sessions and community nursing homes.b leadership, VA senior leaders, and VA
Lessons-Learned Report (Draft) regional network leadership
VHA Coronavirus Disease 2019 This VA-commissioned report reviewed the agency’s Interviews with VA senior leaders, VA
Response Report overall initial efforts to respond to the COVID-19 subject matter experts, VA regional
pandemic, including its capacity to fulfill requests for network leadership, and non-VA
assistance and conduct mission assignments. stakeholders
Source: GAO summary of VA information. l GAO-21-395
a
OEM is responsible for managing all internal and external VHA actions necessary to prepare for,
respond to, and recover from emergencies.
b
State veterans homes are long-term care facilities for veterans that are owned and operated by
states. State veterans homes typically serve veterans only, while community nursing homes are open
Page 19 GAO-21-395 VA Civilian COVID-19 Response
to all who are eligible, including veterans. These long-term care facilities provide a variety of services,
both medical and personal care, to people who are unable to live independently.
The reports identified recommendations as to how VA conducts its
mission assignments, including the following examples:
• Improve VA staff understanding of the FEMA mission
assignment process. In spring of 2020, instead of requesting
assistance through FEMA, some community medical facilities
requested VA resources directly from neighboring VA regional
networks and medical facilities. These VA entities provided assistance
without a mission assignment in place. 28 VA officials told us these
occurrences were rare. As a result, as described in the OEM draft
report, VA leadership did not always have full visibility on the needs of
communities and what resources were utilized to respond to them. To
address this, OEM provided VA regional network and medical facility
staff with training on the mission assignment process to ensure that
requests for assistance are submitted to FEMA before VA assistance
can be offered. According to VA, this training was intended to help
staff adhere to the mission assignment process to enable leadership
to have full visibility on the needs of the communities and determine
VA’s capacity to fulfill requests for assistance.
• Upgrade the emergency medical staff deployment database. By
April 2020, the number of mission assignments requiring VA
emergency medical staff deployment surged. 29 According to OEM
officials and the OEM draft report, the emergency medical staff
program database was not equipped to handle the volume of staff
volunteering and registering for deployment to community facilities or
other locations to fulfill mission assignments. According to this draft
report, the database needed upgrading to allow increased numbers of
volunteers to register. The database also lacked the functionality to
enable emergency medical staff coordinators to build rosters of
deployable staff directly from the database, according to OEM
28Deloitte Consulting, VHA COVID-19 Response Report. According to this report, in some
cases, these requests were redirected to the mission assignment process before the
assistance was provided. In other cases, the requests were not intercepted in time and
were reassigned as mission assignments after the assistance was provided.
29OEM manages an emergency medical staff program, where staff who are typically
based at medical facilities can volunteer and register, in advance, for deployment to
community facilities or other locations during an emergency.
Page 20 GAO-21-395 VA Civilian COVID-19 Response
officials. 30 To fulfill the mission assignments in a timely manner, VA
deployed emergency medical staff to community facilities and other
locations without using the database. As a result, OEM, as the
operator of the database, did not have visibility on a majority of these
deployments, which created challenges for managing mission
assignments. These challenges included limited access to real-time
data on deployments and posed a risk of not being able to ensure that
deployed emergency medical staff had the appropriate credentials. To
address these problems, VA recommended that OEM make
improvements to the database to upgrade the staff registration and
roster building functionalities. According to VA officials, as of
November 2020, OEM made improvements to the database, including
improving its ease and ability to register larger numbers of staff and
build rosters of available staff.
• Increase federal coordination efforts. Prior to March 2020, there
was limited VA representation at FEMA’s National and Regional
Response Coordination Centers, which did not allow VA to
communicate its capacity to accept mission assignments and keep
pace with the rapid changes to the response, according to one of the
reports. 31 In response to a mission assignment, VA added liaisons at
FEMA’s National and Regional Response Coordination Centers.
Specifically, OEM temporarily embedded its existing VA area
emergency managers at FEMA’s ten Regional Response
Coordination Centers. According to the report, VA’s increased
representation at these national and regional emergency coordination
centers improved its federal coordination efforts during the pandemic
response, including its process to determine capacity to accept
mission assignments. 32
According to officials, as of February 2021, VA is currently developing an
update to the VHA Coronavirus Disease 2019 Response Report; this
update is planned to cover the period of time from July 2020 through the
end of 2020 and to be published in April 2021. According to officials, the
update will provide more current data and will identify new or adjusted
conclusions and recommendations regarding the effectiveness of the
30According to VHA Disaster Emergency Medical Personnel System Program and
Database Handbook, these coordinators are located at the medical centers and update
the rosters of available volunteer medical staff within the database.
31Deloitte Consulting, VHA COVID-19 Response Report.
32Deloitte Consulting, VHA COVID-19 Response Report.
Page 21 GAO-21-395 VA Civilian COVID-19 Response
ongoing response and the agency’s preparedness for future responses to
public health emergencies.
We provided a draft of this report to VA, FEMA, and HHS for comment. In
Agency Comments a written response, reprinted in appendix III, VA stated that it had
technical comments on the draft report, which we incorporated as
appropriate. FEMA provided technical comments only, which we
incorporated as appropriate, and HHS did not provide any comments.
We are sending copies of this report to the appropriate congressional
committees and the Secretaries of Veterans Affairs, Homeland Security,
and Health and Human Services, and other interested parties. In addition,
the report is available at no charge on the GAO website at
http://www.gao.gov. Contact points for our Offices of Congressional
Relations and Public Affairs are on the last page of this report. GAO staff
who made major contributions to this report are listed in appendix IV.
If you or your staff has any questions about this report, please contact me
at (202) 512-7114 or at draperd@gao.gov.
Debra A. Draper
Director, Health Care
Page 22 GAO-21-395 VA Civilian COVID-19 Response
List of Addressees
The Honorable Patrick Leahy
Chairman
The Honorable Richard Shelby
Vice Chairman
Committee on Appropriations
United States Senate
The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate
The Honorable Patty Murray
Chair
The Honorable Richard Burr
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Gary C. Peters
Chairman
The Honorable Rob Portman
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate
The Honorable Rosa L. DeLauro
Chairwoman
The Honorable Kay Granger
Ranking Member
Committee on Appropriations
House of Representatives
The Honorable Frank Pallone, Jr.
Chair
The Honorable Cathy McMorris Rodgers
Republican Leader
Committee on Energy and Commerce
House of Representatives
Page 23 GAO-21-395 VA Civilian COVID-19 Response
The Honorable Bennie G. Thompson
Chair
The Honorable John Katko
Ranking Member
Committee on Homeland Security
House of Representatives
The Honorable Carolyn B. Maloney
Chairwoman
The Honorable James Comer
Ranking Member
Committee on Oversight and Reform
House of Representatives
The Honorable Mark Takano
Chairman
Committee on Veterans’ Affairs
House of Representatives
The Honorable Richard E. Neal
Chairman
The Honorable Kevin Brady
Republican Leader
Committee on Ways and Means
House of Representatives
The Honorable Julia Brownley
Chairwoman
Subcommittee on Health
Committee on Veterans’ Affairs
House of Representatives
Page 24 GAO-21-395 VA Civilian COVID-19 Response
Appendix I: VA’s Fourth Mission—Preparing
Appendix I: VA’s Fourth Mission—Preparing
for and Responding to Disasters and
for and Responding to Disasters and
Emergencies
Emergencies
In addition to providing health care services to eligible veterans and
certain dependents, the Department of Veterans Affairs (VA) plays an
important role in both preparing for and responding to a disaster or
emergency. The department is required to take appropriate actions to
ensure VA medical facilities are prepared to protect patients and staff
during a public health emergency. 1 In responding to a public health
emergency, in particular, VA may play three different roles:
• Contingency backup for Department of Defense (DOD) care. VA
may serve as a contingency backup to the DOD medical system
during a national emergency. 2
• Civilian care. VA can provide support, such as hospital care and
medical services, to the Department of Health and Human Services
(HHS), among others, as necessary in response to a national
emergency or disaster. 3
• Humanitarian care. VA may furnish hospital care or medical services
as a humanitarian service in emergency cases. 4
These statutory responsibilities make up what is commonly referred to as
VA’s fourth mission.
In 2002, in response to emergency preparedness issues confronting VA
in the wake of the terrorist attacks of September 11, 2001, the
Department of Veterans Affairs Emergency Preparedness Act of 2002
codified the duties of the Secretary of VA related to emergency
preparedness. 5 The Act required VA to take appropriate actions to
provide for the readiness of VA medical facilities to protect patients and
staff from a public health emergency or otherwise to respond to such an
1 38 U.S.C. § 8117. This authority also includes VA supporting incidents covered by the
National Response Plan or any successor plan. The National Response Framework,
which replaced the National Response Plan in 2008, is issued by the Department of
Homeland Security and is a guide to how the nation responds to all types of disasters and
emergencies.
2 38 U.S.C. § 8111A.
3 38 U.S.C. § 1785.
4 38 U.S.C. § 1784. According to VA, this authority allows VA to furnish care to an
individual experiencing a medical emergency and does not authorize the agency to
provide care more generally during a public health emergency.
5The Department of Veterans Affairs Emergency Preparedness Act of 2002, Pub. L. No.
107-287, § 6(a)(1), 116 Stat. 2024, 2030 (2002), codified at 38 U.S.C. § 8117.
Page 25 GAO-21-395 VA Civilian COVID-19 Response
Appendix I: VA’s Fourth Mission—Preparing
for and Responding to Disasters and
Emergencies
emergency to enable these facilities to fulfill their obligations as part of the
federal response to such emergencies. These actions include providing
and offering training on decontamination equipment and personal
protection equipment at VA medical facilities; organizing, training, and
equipping facility staff to support HHS activities in the event of a public
health emergency and incidents covered by the National Response
Framework; and providing medical logistical support to the National
Disaster Medical System and HHS as necessary, on a reimbursable
basis, and in coordination with other designated Federal agencies. Other
preparatory responsibilities include providing security at VA medical and
research facilities, including staff and patients at such centers and
facilities; tracking of pharmaceuticals and medical supplies and
equipment; training resident physicians and health care personnel in
medical matters relating to public health emergencies; establishing and
maintaining a training program to facilitate the participation of VA medical
facility staff and community providers in the National Disaster Medical
System; and providing mental health counseling following a public health
emergency to veterans, local and community emergency response
providers, active duty military personnel, and individuals seeking care at
VA medical facilities. 6
In responding to public health emergencies, VA has served as a
contingency backup to DOD’s medical system during a national security
emergency since 1982. The Veterans’ Administration and Department of
Defense Health Resources Sharing and Emergency Operations Act
established VA to serve as the contingency backup to the military health
care system during and immediately following an outbreak of war or
national emergency. 7 At the time, Congress found that during and
immediately after a period of war or national emergency involving the use
of the Armed Forces of the United States in armed conflict, DOD might
not have adequate health-care resources to care for military personnel
wounded in combat and other active-duty military personnel. Congress
6The National Disaster Medical System is led by the Office of the Assistant Secretary for
Preparedness and Response, a division within the Department of Health and Human
Services, and is a coordinated effort of HHS, Department of Homeland Security, DOD,
and VA. 42 U.S.C. § 300hh-11. The National Disaster Medical System provides medical-
related assistance to respond to the needs of victims of public health emergencies.
Participants in the National Disaster Medical System are volunteers who serve as
intermittent federal employees when activated.
7Pub. L. No. 97-174, § 2(b), 96 Stat. 70 (1982), codified, as amended at 38 U.S.C. §
8111A. See also, 38 C.F.R. § 17.230.
Page 26 GAO-21-395 VA Civilian COVID-19 Response
Appendix I: VA’s Fourth Mission—Preparing
for and Responding to Disasters and
Emergencies
also found that VA has an extensive, comprehensive health-care system
that could be used to assist DOD in caring for such personnel in such a
situation, and designated VA to be DOD’s health care backup, if the need
arose. VA may give higher priority in the furnishing of this care and
services in VA medical facilities to members of the Armed Forces on
active duty than to any other group of persons eligible for such care and
services with the exception of veterans with service-connected
disabilities. 8
In addition, the Department of Veterans Affairs Emergency Preparedness
Act of 2002 authorized VA to provide hospital care and medical services
for civilians, i.e. nonveterans, as well as veterans not enrolled in the VA
health care system, responding to, involved in, or otherwise affected by a
disaster or emergency. 9 These individuals may include active duty service
members, as well as National Guard and Reserve component members
activated by state or federal authority, and veterans not enrolled in the VA
health care system. This authority is available when the President has
declared a major disaster or emergency under the Robert T. Stafford
Disaster Relief and Emergency Assistance Act (the Stafford Act), or
where the HHS Secretary has declared a disaster or emergency
activating the National Disaster Medical System. 10 The President’s March
13, 2020, declaration of a national emergency under Section 501(b) of the
Stafford Act allows VA to use this authority to respond to the COVID-19
pandemic. 11 The law requires that the cost of any care or services
provided to an officer or employee of a department outside of VA are to
be reimbursed by that department. 12 When providing disaster or
emergency assistance under a mission assignment from the Federal
Emergency Management Agency (FEMA), VA may seek reimbursement
838 U.S.C. § 8111A(a)(3) .
9Pub. L. No. 107-287, § 4(a)(1), 116 Stat. at2028, codified at 38 U.S.C. § 1785. See
implementing regulations at 38 C.F.R. § 17.86.
1038 U.S.C. § 1785(b). The Stafford Act, as amended, defines the federal government’s
role during disaster response and recovery. The act also establishes programs and
processes through which the federal government provides disaster assistance to state,
tribal, territorial, and local governments, as well as certain nonprofit organizations and
individuals. 42 U.S.C. § 5121 et seq.
1185 Fed. Reg. 53 (March 18, 2020).
1238 U.S.C. § 1785(d).
Page 27 GAO-21-395 VA Civilian COVID-19 Response
Appendix I: VA’s Fourth Mission—Preparing
for and Responding to Disasters and
Emergencies
for such care from FEMA. 13 Unless another federal agency reimburses
VA, individuals could be charged for this care. Individuals who receive
hospital care or medical services under this authority are responsible for
the cost of the hospital care or medical services when charges are
mandated by federal law or when the cost of care or services is not
reimbursed by other-than-VA federal departments or agencies. 14
Lastly, VA may furnish hospital care or medical services as a
humanitarian service in emergency cases, but VA is required to charge
patients for such care and services at rates prescribed by VA. 15
1342 U.S.C. § 5192(a)(1). The Stafford Act authorizes the President to direct any federal
agency, with or without reimbursement, to utilize its authorities and the resources granted
to it under federal law in support of state and local response efforts for emergencies. This
tasking authority, delegated to the FEMA Administrator, is carried out through a mission
assignment.
14See 38 C.F.R. § 17.86(e).
1538 U.S.C. § 1784.
Page 28 GAO-21-395 VA Civilian COVID-19 Response
Appendix II: Mission Assignments the Appendix II: Mission Assignments the
Department of Veterans Affairs (VA)
Department of Veterans Affairs (VA)
Conducted, March 2020 to February 2021
Conducted, March 2020 to February 2021
Table 3: Direct Federal Assistance Mission Assignments Conducted by the Department of Veteran Affairs (VA) by State or
Territory, Estimated Cost, and Type of Assistance, March 2020 to February 2021
Number of mission assignments by type of assistance
Inpatient Supplies/
State/territory Estimated cost Total care Staff equipment Testing Vaccinations
State or territory for which VA did not provide assistance
Alaska $- 0 0 0 0 0 0
District of Columbia $- 0 0 0 0 0 0
Georgia $- 0 0 0 0 0 0
Indiana $- 0 0 0 0 0 0
Montana $- 0 0 0 0 0 0
Nebraska $- 0 0 0 0 0 0
North Dakota $- 0 0 0 0 0 0
Ohio $- 0 0 0 0 0 0
South Dakota $- 0 0 0 0 0 0
Tennessee $- 0 0 0 0 0 0
Vermont $- 0 0 0 0 0 0
West Virginia $- 0 0 0 0 0 0
Wyoming $- 0 0 0 0 0 0
State or territory for which VA provided assistance without a cost estimatea
New Mexicob $- 1 1 0 0 0 0
State or territory for which VA provided assistance for zero estimated cost
Nevada $- 1 0 1 0 0 0
State or territory for which VA provided up to $1 million in assistance
Kansas $ 1,135 2 0 0 2 0 0
Maine $ 34,859 1 0 1 0 0 0
Connecticut $ 66,897 2 0 2 0 0 0
American Samoa $ 122,600 1 0 0 0 0 1
Alabama $ 150,691 1 0 1 0 0 0
Kentucky $ 272,389 2 0 1 0 1 0
South Carolina $ 312,593 1 0 1 0 0 0
Oklahoma $ 345,000 1 0 1 0 0 0
New Hampshire $ 370,355 3 0 3 0 0 0
Maryland $ 675,000 1 0 1 0 0 0
Delaware $ 700,000 2 0 2 0 0 0
Rhode Island $ 708,050 3 0 2 0 0 1
Wisconsin $ 879,000 4 0 4 0 0 0
Page 29 GAO-21-395 VA Civilian COVID-19 Response
Appendix II: Mission Assignments the
Department of Veterans Affairs (VA)
Conducted, March 2020 to February 2021
Number of mission assignments by type of assistance
Inpatient Supplies/
State/territory Estimated cost Total care Staff equipment Testing Vaccinations
State or territory for which VA provided greater than $1 million, up to $10 million in assistance
Hawaii $ 1,018,173 3 0 3 0 0 0
North Carolina $ 1,228,259 2 0 1 0 1 0
Pennsylvania $ 1,230,000 2 0 2 0 0 0
Missouri $ 1,600,896 5 0 5 0 0 0
Utah $ 1,654,650 1 1 0 0 0 0
Mississippic $ 2,225,510 3 1 2 0 0 0
Idaho $ 2,238,000 3 0 1 1 1 0
Virginia $ 3,321,250 3 0 2 0 1 0
Arkansas $ 4,001,544 2 1 1 0 0 0
Iowa $ 4,848,037 3 1 2 0 0 0
Massachusetts $ 5,191,650 3 1 1 0 1 0
Minnesota $ 5,391,000 2 1 1 0 0 0
Colorado $ 5,836,500 1 1 0 0 0 0
Louisiana $ 8,625,790 6 2 4 0 0 0
Arizonad $ 9,148,933 6 2 4 0 0 0
State or territory for which VA provided greater than $10 million in assistance
Florida $ 14,242,576 2 1 1 0 0 0
Texas $ 15,079,702 3 1 0 0 1 1
Washington $ 18,100,000 2 1 0 0 1 0
California $ 18,141,539 4 2 1 0 1 0
Michigan $ 18,838,000 2 1 0 1 0 0
New Jersey $ 19,127,864 8 1 5 0 0 2
Illinois $ 26,409,400 4 2 0 1 0 1
New York $ 28,340,736 2 1 0 0 0 1
Oregon $ 45,008,500 6 3 2 1 0 0
Total $265,487,078 104 25 58 6 8 7
Source: GAO analysis of VA information. l GAO-21-395
Note: A direct federal assistance mission assignment is a work order, issued by the Federal
Emergency Management Agency under the Robert T. Stafford Disaster Relief and Emergency
Assistance Act, directing another federal agency to provide needed assistance to a state, territory, or
federally-recognized tribe. Mission assignment cost estimates are developed jointly by FEMA staff
and the performing agencies. A mission assignment’s estimated costs may not reflect the actual costs
of performing the mission assignment. The estimated costs associated with mission assignments
conducted to support tribes are included in the state in which VA conducted them.
a
VA reported this mission assignment was an emergent request and no cost estimate was available.
b
VA conducted one mission assignment for the Navajo Nation in New Mexico.
c
VA conducted one mission assignment to support the Mississippi Band of Choctaw Indians.
Page 30 GAO-21-395 VA Civilian COVID-19 Response
Appendix II: Mission Assignments the
Department of Veterans Affairs (VA)
Conducted, March 2020 to February 2021
d
VA conducted two mission assignments for the Navajo Nation in Arizona. VA also conducted one
mission assignment in Arizona that included assistance to the Navajo Nation, White Mountain Apache
Tribe of the Fort Apache Reservation, and the Hopi Tribe.
Table 4: Direct Federal Assistance Mission Assignments Conducted by the Department of Veteran Affairs (VA) by State or
Territory and Type of Recipient, March 2020 to February 2021
Long-term care facilities
Total number of
mission State Tribal Other community
State or territory assignments Total veterans homes communities medical facilities
Alaska 0 0 0 0 0
District of Columbia 0 0 0 0 0
Georgia 0 0 0 0 0
Indiana 0 0 0 0 0
Montana 0 0 0 0 0
Nebraska 0 0 0 0 0
North Dakota 0 0 0 0 0
Ohio 0 0 0 0 0
South Dakota 0 0 0 0 0
Tennessee 0 0 0 0 0
Vermont 0 0 0 0 0
West Virginia 0 0 0 0 0
Wyoming 0 0 0 0 0
American Samoa 1 0 0 0 1
Utah 1 0 0 0 1
Nevada 1 1 1 0 0
New Mexicoa 1 0 0 1 0
Maine 1 1 0 0 0
Alabama 1 1 1 0 0
South Carolina 1 1 1 0 0
Oklahoma 1 1 1 0 0
Maryland 1 1 1 0 0
Colorado 1 0 0 0 1
New York 2 0 0 0 2
Kentucky 2 2 2 0 0
Kansas 2 0 0 0 2
Connecticut 2 1 1 0 1
Delaware 2 1 0 0 1
North Carolina 2 0 0 0 2
Page 31 GAO-21-395 VA Civilian COVID-19 Response
Appendix II: Mission Assignments the
Department of Veterans Affairs (VA)
Conducted, March 2020 to February 2021
Long-term care facilities
Total number of
mission State Tribal Other community
State or territory assignments Total veterans homes communities medical facilities
Pennsylvania 2 2 2 0 0
Arkansas 2 0 0 0 2
Florida 2 1 0 0 1
Washington 2 1 1 0 1
Michigan 2 0 0 0 2
Minnesota 2 1 0 0 1
Rhode Island 3 2 1 0 1
New Hampshire 3 2 0 0 1
Idaho 3 0 0 0 3
Texas 3 1 1 0 2
Hawaii 3 2 1 0 1
Virginia 3 2 1 0 1
Iowa 3 2 2 0 1
Massachusetts 3 3 3 0 0
Mississippib 3 1 1 1 1
Illinois 4 1 0 0 3
Wisconsin 4 1 1 0 3
California 4 2 1 0 2
Missouri 5 5 5 0 0
Oregon 6 2 0 0 4
Arizonac 6 0 0 3 3
Louisiana 6 3 3 0 3
New Jersey 8 4 3 0 4
Total 104 48 34 5 51
Source: GAO analysis of VA information. l GAO-21-395
Notes: A direct federal assistance mission assignment is a work order, issued by the Federal
Emergency Management Agency under the Robert T. Stafford Disaster Relief and Emergency
Assistance Act, directing another federal agency to provide needed assistance to a state, territory, or
federally-recognized tribe. VA may provide assistance to more than one facility in each mission
assignment. For example, VA reported it conducted a mission assignment in Florida that covered
more than 800 long-term care facilities.
a
VA conducted one mission assignment for the Navajo Nation in New Mexico.
b
VA conducted one mission assignment to support the Mississippi Band of Choctaw Indians.
c
VA conducted two mission assignments for the Navajo Nation in Arizona. VA also conducted one
mission assignment in Arizona that included assistance to the Navajo Nation, White Mountain Apache
Tribe of the Fort Apache Reservation, and the Hopi Tribe.
Page 32 GAO-21-395 VA Civilian COVID-19 Response
Appendix III: Comments from the
Appendix III: Comments from the Department
of Veterans Affairs
Department of Veterans Affairs
Page 33 GAO-21-395 VA Civilian COVID-19 Response
Appendix IV: GAO Contact and Staff
Appendix IV: GAO Contact and Staff
Acknowledgments
Acknowledgments
Debra A. Draper, (202) 512-7114 or DraperD@gao.gov.
GAO Contact
In addition to the contact named above, Ann Tynan (Assistant Director),
Staff Stella Chiang (Analyst-in-Charge), Colin Ashwood, Kenisha Cantrell
Acknowledgments made key contributions to this report. Also contributing were Cathleen J.
Hamann, Jacquelyn Hamilton, and Vikki Porter.
(104335)
Page 34 GAO-21-395 VA Civilian COVID-19 Response
The Government Accountability Office, the audit, evaluation, and investigative
GAO’s Mission arm of Congress, exists to support Congress in meeting its constitutional
responsibilities and to help improve the performance and accountability of the
federal government for the American people. GAO examines the use of public
funds; evaluates federal programs and policies; and provides analyses,
recommendations, and other assistance to help Congress make informed
oversight, policy, and funding decisions. GAO’s commitment to good government
is reflected in its core values of accountability, integrity, and reliability.
The fastest and easiest way to obtain copies of GAO documents at no cost is
Obtaining Copies of through our website. Each weekday afternoon, GAO posts on its website newly
GAO Reports and released reports, testimony, and correspondence. You can also subscribe to
GAO’s email updates to receive notification of newly posted products.
Testimony
Order by Phone The price of each GAO publication reflects GAO’s actual cost of production and
distribution and depends on the number of pages in the publication and whether
the publication is printed in color or black and white. Pricing and ordering
information is posted on GAO’s website, https://www.gao.gov/ordering.htm.
Place orders by calling (202) 512-6000, toll free (866) 801-7077, or
TDD (202) 512-2537.
Orders may be paid for using American Express, Discover Card, MasterCard,
Visa, check, or money order. Call for additional information.
Connect with GAO on Facebook, Flickr, Twitter, and YouTube.
Connect with GAO Subscribe to our RSS Feeds or Email Updates. Listen to our Podcasts.
Visit GAO on the web at https://www.gao.gov.
Contact FraudNet:
To Report Fraud,
Website: https://www.gao.gov/about/what-gao-does/fraudnet
Waste, and Abuse in
Automated answering system: (800) 424-5454 or (202) 512-7700
Federal Programs
Orice Williams Brown, Managing Director, WilliamsO@gao.gov, (202) 512-4400,
Congressional U.S. Government Accountability Office, 441 G Street NW, Room 7125,
Relations Washington, DC 20548
Chuck Young, Managing Director, youngc1@gao.gov, (202) 512-4800
Public Affairs U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, DC 20548
Stephen J. Sanford, Acting Managing Director, spel@gao.gov, (202) 512-4707
Strategic Planning and U.S. Government Accountability Office, 441 G Street NW, Room 7814,
External Liaison Washington, DC 20548
Please Print on Recycled Paper.
File and source
- File
- gao-21-395.pdf
- Size
- 1,304,609 bytes
- SHA-256
- ef5bb90fa6497537c4d8c0914a72f44358bf62177bf2d6c32890d68175822655
- Our copy
- gao-21-395.pdf
- Original
- www.gao.gov