The VA estimates it will provide health care to 5.8 million patients with appropriations of about $41 billion in FY 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 for VA health care. This testimony 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. Illustrations.