Compacts of Free Association: VA Is Pursuing Partial Implementation of Health Care Authorities in the Freely Associated States

What GAO Found GAO found that veterans face multiple challenges in accessing health care in the Freely Associated States (FAS), according to VA assessments and interviews with VA and FAS officials. These challenges include limited availability of specialty services, such as mental health and cardiology, and the inability to utilize telehealth services with VA health providers. FAS veterans must travel to VA health facilities in U.S. states or territories to utilize their health benefits, but do not receive beneficiary travel reimbursement for travel to the U.S. Map of Health Care Facilities Providing Veteran Care in Pacific Region VA completed a variety of assessments from March 2024 to March 2025 on the implementation of veteran health benefits authorized under the Compact of Free Association Amendments Act of 2024. These assessments included an environmental scan of the health care landscape in the FAS, and an analysis of policy implications of changes to FAS veteran benefits. VA described potential costs and regulatory requirements for implementation options, ranging from maintaining the current status quo to full implementation of authorized health care for FAS veterans. For example, changes to reimbursement and beneficiary travel benefits would necessitate additional staffing to process claims. In an April 2025 memo provided to Congress, VA stated that it would not exercise its new authorities, asserting this decision was “to ensure equity with all U.S. veterans.” VA confirmed in June 2026 it had concluded its engagement with the FAS. However, in July 2026, VA officials told GAO that they intended to resume engagement with the FAS and, in August 2026, confirmed they were pursuing partial implementation of its authorities, including telehealth services, delivery of pharmaceutical products and medical surgical products, reimbursements for care in the FAS, and beneficiary travel benefits to service-connected veterans in the FAS. They did not provide a timeline for doing so. Why GAO Did This Study The U.S. maintains compacts of free association with three foreign countries in the Pacific—the Federated States of Micronesia (FSM), the Republic of the Marshall Islands (RMI), and the Republic of Palau—collectively known as the Freely Associated States (FAS). Under these compacts, citizens of the FAS can enlist in the U.S. military. Some are eligible for certain VA benefits. The Compact of Free Association Amendments Act of 2024 gave VA discretionary authority to expand health care services for eligible veterans in the FAS by providing hospital care, medical services, and beneficiary travel payments. GAO was asked to examine implementation of veteran health benefits as part of our mandate under the Compact of Free Association Amendments Act of 2024. This report (1) identifies challenges veterans face in obtaining health benefits in the FAS and (2) describes analysis completed by VA to assess implementation of veteran health service benefits authorized under the Compact of Free Association Amendments Act of 2024. For more information, contact Nagla'a El-Hodiri at elhodirin@gao.gov.

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