[House Report 110-817]
[From the U.S. Government Publishing Office]
110th Congress Report
HOUSE OF REPRESENTATIVES
2d Session 110-817
======================================================================
RURAL VETERANS ACCESS TO CARE ACT
_______
August 1, 2008.--Committed to the Committee of the Whole House on the
State of the Union and ordered to be printed
_______
Mr. Filner, from the Committee on Veterans' Affairs, submitted the
following
R E P O R T
[To accompany H.R. 1527]
[Including cost estimate of the Congressional Budget Office]
The Committee on Veterans' Affairs, to whom was referred the
bill (H.R. 1527) to amend title 38, United States Code, to
allow highly rural veterans enrolled in the health system of
the Department of Veterans Affairs to receive covered health
services through providers other than those of the Department,
and for other purposes, having considered the same, report
favorably thereon with amendments and recommend that the bill
as amended do pass.
CONTENTS
Page
Amendment........................................................ 2
Purpose and Summary.............................................. 3
Background and Need for Legislation.............................. 3
Hearings......................................................... 4
Subcommittee Consideration....................................... 5
Committee Consideration.......................................... 5
Committee Votes.................................................. 5
Committee Oversight Findings..................................... 5
Statement of General Performance Goals and Objectives............ 5
New Budget Authority, Entitlement Authority, and Tax Expenditures 5
Earmarks and Tax and Tariff Benefits............................. 5
Committee Cost Estimate.......................................... 6
Congressional Budget Office Estimate............................. 6
Federal Mandates Statement....................................... 8
Advisory Committee Statement..................................... 8
Constitutional Authority Statement............................... 8
Applicability to Legislative Branch.............................. 8
Section-by-Section Analysis of the Legislation................... 9
Changes in Existing Law Made by the Bill as Reported............. 9
Amendment
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Rural Veterans Access to Care Act''.
SEC. 2. PILOT PROGRAM OF ENHANCED CONTRACT CARE AUTHORITY FOR HEALTH
CARE NEEDS OF VETERANS IN HIGHLY RURAL AREAS.
(a) In General.--Section 1703 of title 38, United States Code, is
amended by adding at the end the following new subsection:
``(e)(1) The Secretary shall conduct a pilot program which permits
highly rural veterans--
``(A) who are enrolled in the system of patient enrollment
established under section 1705(a) of this title, and
``(B) who reside within Veterans Integrated Service Network
1, 15, 18, and 19,
to elect to receive covered health services for which such veterans are
eligible through a non-Department health-care provider.
``(2) The election under paragraph (1) shall be made by submitting an
application to the Secretary in accordance with such regulations as the
Secretary prescribes. The Secretary shall authorize such services to be
furnished to the veteran pursuant to contracting with such a provider
to furnish such services to such veteran.
``(3) For purposes of this subsection, a highly rural veteran is one
who--
``(A) resides in a location that is--
``(i) more than 60 miles driving distance from the
nearest Department health-care facility providing
primary care services, if the veteran is seeking such
services;
``(ii) more than 120 miles driving distance from the
nearest Department health-care facility providing acute
hospital care, if the veteran is seeking such care; or
``(iii) more than 240 miles driving distance from the
nearest Department health-care facility providing
tertiary care, if the veteran is seeking such care; or
``(B) in the case of a veteran who resides in a location less
than the distance indicated in clause (i), (ii), or (iii) of
subparagraph (A), as applicable, experiences such hardship or
other difficulties in travel to the nearest appropriate
Department health-care facility that such travel is not in the
best interest of the veteran, as determined by the Secretary
pursuant to regulations prescribed for purposes of this
subsection.
``(4) For purposes of this subsection, a covered health service is
any hospital care, medical service, rehabilitative service, or
preventative health service authorized to be provided by the Secretary
under this chapter or any other provision of law.
``(5) For purposes of this subsection, a health-care provider is any
qualified entity or individual furnishing a covered health service.
``(6) In meeting the requirements of this subsection, the Secretary
shall develop the functional capability to provide for the exchange of
medical information between the Department and non-Department health-
care providers.
``(7) This subsection shall apply to covered health services provided
during the 3-year period beginning on the 120th day after the date of
the enactment of this subsection.
``(8) Not later than the 30th day after the close of each year of the
period described in paragraph (7), the Secretary shall submit a report
to the Committees of Veterans' Affairs of the House of Representatives
and the Senate a report which includes--
``(A) the Secretary's assessment of the program under this
subsection, including its cost, volume, quality, patient
satisfaction, benefit to veterans, and any other findings and
conclusions of the Secretary with respect to such program, and
``(B) any recommendations that the Secretary may have for--
``(i) continuing the program,
``(ii) extending the program to other or all service
regions of the Department, and
``(iii) making the program permanent.''.
(b) Effective Date.--The Secretary of Veterans Affairs shall
implement the amendment made by subsection (a) not later than the 120th
day after the date of the enactment of this Act.
Amend the title so as to read:
A bill to amend title 38, United States Code, to direct the
Secretary of Veterans Affairs to conduct a pilot program to
permit certain highly rural veterans enrolled in the health
system of the Department of Veterans Affairs to receive covered
health services through providers other than those of the
Department.
Purpose and Summary
H.R. 1527 was introduced by Representative Jerry Moran of
Kansas on March 14, 2007. H.R. 1527, as amended, would require
the Department of Veterans Affairs (VA) to conduct a three-year
demonstration project in Veterans Integrated Service Networks
(VISNs) 1, 15, 18, and 19 to allow highly rural veterans
enrolled in VA health care to receive covered services through
non-VA providers.
The bill would define a highly rural veteran as one who
resides 60 miles from VA primary care services, 120 miles from
the nearest VA facility providing acute hospital care, or more
than 240 miles from the nearest VA facility providing tertiary
care.
The bill would require VA to develop the functional
capability to exchange medical information between VA and non-
VA providers in the pilot.
The bill would direct the VA to submit a report to Congress
upon the conclusion of the first year of the pilot, and each
year thereafter, that includes an assessment of the program
cost, volume, quality, patient satisfaction, and benefit to
veterans; and, any recommendations for continuation, extension,
or for making the program permanent.
Background and Need for Legislation
Approximately 39 percent of enrolled veterans utilizing the
VA health care system live in rural areas. It is a challenge
for these veterans to access VA health care services because of
their geographic distance from VA facilities and limited
transportation services.
VA is undertaking a number of initiatives to help veterans
in rural areas gain better access to health care services.
Central to this effort is the expansion of community-based
outpatient care. VA is scheduled to activate 44 new clinics
over the next 15 months. This would increase VA's network of
independent and community-based clinics to 782, an addition of
more than 100 clinics over the past five years. VA is also
expanding readjustment counseling services through community-
based Vet Centers. Today, VA operates 232 Vet Centers and will
open an additional 39 centers across the country by the end of
2009. Additionally, VA is expanding its telehealth and
telemedicine programs, which are using new technology to bring
doctors to their patients, rather than patients to their
doctors.
In 2007, pursuant to the Veterans Benefits, Health Care,
and Information Technology Act of 2006 (Public Law 109-461) VA
established an Office of Rural Health (ORH). The purpose of the
ORH is to develop policies to provide the best solutions to the
challenges of providing rural health care and innovative
practices to support the unique needs of veterans residing in
rural areas. In June 2008, a Rural Health Advisory Committee
was created to advise the Secretary on health care issues
facing enrolled veterans in rural areas.
The Committee recognizes and commends the steps VA is
taking to improve care and services for veterans in rural and
highly rural areas. However, we remain concerned that there are
still barriers to accessing VA care for veterans in highly
rural areas and there is a need to expand opportunities for
veterans living the farthest away from VA facilities to receive
needed primary care locally in non-VA facilities.
Current law authorizes VA to provide fee-for-service care
in a veteran's local community when the treating facility
cannot provide the required care or because of geographical
inaccessibility. However, the decision to utilize such care is
left to the facility providing the care.
H.R. 1527, as amended, would require VA to conduct a three-
year demonstration project to allow enrolled highly rural
veterans in four VISNs with large rural populations to receive
covered services through non-VA providers. To ensure continuity
of care, the legislation would require VA to develop the
functional capability to exchange veterans' medical information
between VA and non-VA providers in the pilot. To effectively
implement the pilot program, the Committee also expects the
Secretary to establish regulations for payment that would be
consistent with the authorized allowable reimbursement rate VA
currently has established of 70 percent of the applicable
Medicare rate.
The Committee believes that this pilot program would
support VA's efforts to improve care and services for veterans
who reside in rural areas.
Hearings
On April 26, 2007, the Subcommittee on Health held a
legislative hearing on a number of bills introduced during the
110th Congress, including H.R. 1527. The following witnesses
testified: The Honorable Stevan Pearce of New Mexico; The
Honorable Ginny Brown-Waite of Florida; The Honorable Solomon
P. Ortiz of Texas; The Honorable Steven R. Rothman of New
Jersey; The Honorable Hilda L. Solis of California; The
Honorable Tom Latham of Iowa; The Honorable Jason Altmire of
Pennsylvania; The Honorable Jerry Moran of Kansas; The
Honorable Bob Filner of California; Ms. Shannon Middleton,
Deputy Director for Health, Veterans Affairs and Rehabilitation
Commission, The American Legion; Mr. Kimo S. Hollingsworth,
National Legislative Director, American Veterans (AMVETS); Mr.
Adrian M. Atizado, Assistant National Legislative Director,
Disabled American Veterans; Mr. Carl Blake, National
Legislative Director, Paralyzed Veterans of America; Mr. Dennis
M. Cullinan, Director, National Legislative Service, Veterans
of Foreign Wars of the United States; Mr. Richard F. Weidman,
Executive Director for Policy and Government Affairs, Vietnam
Veterans of America; Gerald M. Cross, M.D., FAAFP, Acting
Principal Deputy Under Secretary for Health, Veterans Health
Administration, U.S. Department of Veterans Affairs,
accompanied by Mr. Walter A. Hall, Assistant General Counsel,
U.S. Department of Veterans Affairs. Those submitting
statements for the record included: the American Academy of
Neurology, and The Honorable Ruben Hinojosa of Texas.
Subcommittee Consideration
On July 10, 2008, the Subcommittee on Health met in open
markup session and ordered favorably forwarded to the full
Committee H.R. 1527, as amended, by voice vote. During
consideration of the bill the following amendment was
considered: An amendment in the nature of a substitute by Mr.
Moran of Kansas to create a pilot program and establish the
four VISNs where the pilot program will be conducted as VISNs
1, 15, 18 and 19, was agreed to by voice vote.
Committee Consideration
On July 16, 2008, the full Committee met in an open markup
session, a quorum being present, and ordered H.R. 1527, as
amended, reported favorably to the House of Representatives, by
voice vote.
Committee Votes
Clause 3(b) of rule XIII of the Rules of the House of
Representatives requires the Committee to list the record votes
on the motion to report the legislation and amendments thereto.
There were no record votes taken on amendments or in connection
with ordering H.R. 1527 reported to the House. A motion by Mr.
Buyer of Indiana to order H.R. 1527, as amended, reported
favorably to the House of Representatives was agreed to by
voice vote.
Committee Oversight Findings
In compliance with clause 3(c)(1) of rule XIII and clause
2(b)(1) of rule X of the Rules of the House of Representatives,
the Committee's oversight findings and recommendations are
reflected in the descriptive portions of this report.
Statement of General Performance Goals and Objectives
In accordance with clause 3(c)(4) of rule XIII of the Rules
of the House of Representatives, the Committee's performance
goals and objectives are reflected in the descriptive portions
of this report.
New Budget Authority, Entitlement Authority, and Tax Expenditures
In compliance with clause 3(c)(2) of rule XIII of the Rules
of the House of Representatives, the Committee adopts as its
own the estimate of new budget authority, entitlement
authority, or tax expenditures or revenues contained in the
cost estimate prepared by the Director of the Congressional
Budget Office pursuant to section 402 of the Congressional
Budget Act of 1974.
Earmarks and Tax and Tariff Benefits
H.R. 1527 does not contain any congressional earmarks,
limited tax benefits, or limited tariff benefits as defined in
clause 9(d), 9(e), or 9(f) of rule XXI of the Rules of the
House of Representatives.
Committee Cost Estimate
The Committee adopts as its own the cost estimate on H.R.
1527 prepared by the Director of the Congressional Budget
Office pursuant to section 402 of the Congressional Budget Act
of 1974.
Congressional Budget Office Cost Estimate
Pursuant to clause 3(c)(3) of rule XIII of the Rules of the
House of Representatives, the following is the cost estimate
for H.R. 1527 provided by the Congressional Budget Office
pursuant to section 402 of the Congressional Budget Act of
1974:
U.S. Congress,
Congressional Budget Office,
Washington, DC, July 31, 2008.
Hon. Bob Filner,
Chairman, Committee on Veterans' Affairs,
House of Representatives, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for H.R. 1527, the Rural
Veterans Access to Care Act.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Sunita
D'Monte.
Sincerely,
Peter H. Fontaine
(For Peter R. Orszag, Director).
Enclosure.
H.R. 1527--Rural Veterans Access to Care Act
Summary: H.R. 1527 would require the Department of Veterans
Affairs (VA) to implement a pilot program that would pay for
certain veterans who are enrolled in the VA health care program
to receive medical care outside the VA system. The program
would be carried out over a three-year period in four specific
Veterans Integrated Services Networks (VISNs), which are
regional networks of medical facilities. CBO estimates that
implementing H.R. 1527 would cost about $1.6 billion over the
2009-2013 period, assuming appropriation of the necessary
amounts.
Enacting the bill also could affect direct spending for
Medicare, but CBO estimates any such effects would not be
significant. Enacting the bill would not affect revenues.
H.R. 1527 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA)
and would impose no costs on state, local, or tribal
governments.
Estimated cost to the Federal Government: The estimated
budgetary impact of H.R. 1527 is shown in the following table.
The costs of this legislation fall within budget function 700
(veterans benefits and services).
----------------------------------------------------------------------------------------------------------------
By fiscal year in millions of dollars--
----------------------------------------------------
2009 2010 2011 2012 2013 2009-2013
----------------------------------------------------------------------------------------------------------------
CHANGES IN SPENDING SUBJECT TO APPROPRIATION\1\
Estimated Authorization Level.............................. 210 440 685 235 0 1,570
Estimated Outlays.......................................... 190 415 660 280 25 1,570
----------------------------------------------------------------------------------------------------------------
\1\In addition to the effects on spending subject to appropriation shown in this table, CBO estimates that
enacting H.R. 1529 could increase direct spending, but that any such changes would be less than $500,000 a
year.
Basis of estimate: For this estimate, CBO assumes that the
legislation will be enacted near the end of fiscal year 2008,
that the estimated amounts will be appropriated for each year,
and that outlays will follow historical spending patterns for
the VA medical services program.
Spending subject to appropriation
H.R. 1527 would require VA to implement a pilot program to
pay for certain enrollees to receive medical care outside the
VA system. The program would be carried out over a three-year
period--from February 2009 through January 2012--in VISNs 1,
15, 18, and 19. Those VISNs include states in various parts of
the country, including the northeast, central, southwest, and
northwest. Under the bill, enrollees could elect to receive
health care through non-VA providers and VA would pay for such
care if:
The enrollee requires primary care and lives
more than 60 miles driving distance from the nearest VA
facility providing such care,
The enrollee requires acute hospital care
and lives more than 120 miles driving distance from the
nearest VA facility providing such care,
The enrollee requires tertiary care and
lives more than 240 miles driving distance from the
nearest VA facility providing such care, or
The enrollee does not meet the criteria
above but has difficulty traveling to VA facilities, as
determined by the Secretary of the VA.
VA has indicated that the department would implement the
pilot program required under the bill in the same fashion as
its current fee-basis program. Under that program, VA has the
authority to contract with health care providers outside the VA
system to provide pre-approved services for certain veterans.
VA negotiates the price of such services and pays the
providers. Thus, under the pilot program, CBO assumes that VA
will provide the required services through contracts with
private health care providers, and that VA will pay the full
cost of such care.
Data from VA indicate that about 800,000 veterans in VISNs
1, 15, 18, and 19 would be eligible for the pilot program.
(That figure combines both current enrollees in the VA health
system and veterans that are currently not enrolled.) Of that
total, about 300,000 are currently using some VA-provided
health care. Of the remainder, CBO estimates that about 200,000
might choose to receive care in 2009 through the pilot program.
CBO expects that, under the bill, eligible veterans would
receive about 95 percent of their health care through VA. After
adjusting for inflation and an estimated 10 percent increase in
health care costs (care provided at non-VA facilities is
generally more expensive than care provided at VA facilities),
CBO estimates that in 2009 the department would spend an
average of roughly $5,000 per new patient under the pilot
program and less than $3,500, on average, for existing patients
that participate in this pilot program. Those averages account
for the different usage patterns of veterans, with some
enrollees in the new program receiving only primary care, acute
care, or tertiary care, and others receiving a combination of
those three types of care.
Using the above estimates of per-patient costs, and
assuming appropriation of sufficient amounts to cover all those
who choose to use the program, implementing it could cost as
much as $2 billion a year, CBO estimates. However, because the
proposed pilot program is temporary, CBO expects that not all
eligible veterans would be able to enroll in the program during
the three-year period, and that local health care providers
would hesitate to invest in expanded facilities to accommodate
veterans. Accounting for a slow, incremental take-up of the
temporary benefit, CBO estimates that costs would rise from
almost $200 million in 2009 to $660 million in 2011 (costs fall
sharply in 2012 because the program would expire that year).
Direct spending
Enacting H.R. 1527 could affect spending for Medicare, if
community-based providers of health care would seek to recover
costs from those programs before billing VA. However, under the
current fee-basis program, VA pays for the entire cost of care,
and CBO assumes the same would be true for the pilot program.
Thus, for this estimate, CBO expects that any direct spending
effects would be insignificant. (If VA chooses to implement
this pilot program differently, Medicare could become the
primary payer for veterans in this program, thus increasing
direct spending significantly for that program.)
Intergovernmental and private-sector impact: H.R. 1527
contains no intergovernmental or private-sector mandates as
defined in UMRA and would impose no costs on state, local, or
tribal governments.
Estimate prepared by: Federal Costs: Sunita D'Monte; Impact
on State, Local, and Tribal Governments: Lisa Ramirez-Branum;
Impact on the Private Sector: Daniel Frisk.
Estimate approved by: Peter H. Fontaine, Assistant Director
for Budget Analysis.
Federal Mandates Statement
The Committee adopts as its own the estimate of Federal
mandates regarding H.R. 1527 prepared by the Director of the
Congressional Budget Office pursuant to section 423 of the
Unfunded Mandates Reform Act.
Advisory Committee Statement
No advisory committees within the meaning of section 5(b)
of the Federal Advisory Committee Act would be created by H.R.
1527.
Constitutional Authority Statement
Pursuant to clause 3(d)(1) of rule XIII of the Rules of the
House of Representatives, the Committee finds that the
Constitutional authority for H.R. 1527 is provided by article
I, section 8 of the Constitution of the United States.
Applicability to Legislative Branch
The Committee finds that the legislation does not relate to
the terms and conditions of employment or access to public
services or accommodations within the meaning of section
102(b)(3) of the Congressional Accountability Act.
Section-by-Section Analysis of the Legislation
Section 1. Short title
This section would provide the short title of H.R. 1527 as
the ``Rural Veterans Access to Care Act.''
Section 2. Pilot program of enhanced contract care authority for health
care needs of veterans in highly rural areas
This section would amend section 1703 of title 38, United
States Code, by inserting a requirement that the VA establish a
3-year pilot program allowing highly rural veterans residing in
VISNs 1, 15, 18, and 19 to receive covered health services
through a provider outside of the VA. A ``highly rural''
veteran would be defined as a veteran who lives more than 60
miles driving distance from the nearest VA facility providing
primary care services; more than 120 miles from the nearest VA
facility providing acute hospital care; or more than 240 miles
from the nearest VA facility providing tertiary care.
Additionally, veterans who fail to meet these distance
requirements but are subject to hardship or difficulty in
travel to the nearest appropriate VA facilities may be eligible
for the program at the determination of the Secretary. The
Secretary would also be directed to develop the functional
capability to share medical information with non-departmental
providers. The 3-year pilot would be effective 120 days
following enactment and the Secretary would be required to
submit an annual assessment of the program to the Committee.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (new matter is
printed in italic and existing law in which no change is
proposed is shown in roman):
SECTION 1703 OF TITLE 38, UNITED STATES CODE
Sec. 1703. Contracts for hospital care and medical services in non-
Department facilities
(a) * * *
* * * * * * *
(e)(1) The Secretary shall conduct a pilot program which
permits highly rural veterans--
(A) who are enrolled in the system of patient
enrollment established under section 1705(a) of this
title, and
(B) who reside within Veterans Integrated Service
Network 1, 15, 18, and 19,
to elect to receive covered health services for which such
veterans are eligible through a non-Department health-care
provider.
(2) The election under paragraph (1) shall be made by
submitting an application to the Secretary in accordance with
such regulations as the Secretary prescribes. The Secretary
shall authorize such services to be furnished to the veteran
pursuant to contracting with such a provider to furnish such
services to such veteran.
(3) For purposes of this subsection, a highly rural veteran
is one who--
(A) resides in a location that is--
(i) more than 60 miles driving distance from
the nearest Department health-care facility
providing primary care services, if the veteran
is seeking such services;
(ii) more than 120 miles driving distance
from the nearest Department health-care
facility providing acute hospital care, if the
veteran is seeking such care; or
(iii) more than 240 miles driving distance
from the nearest Department health-care
facility providing tertiary care, if the
veteran is seeking such care; or
(B) in the case of a veteran who resides in a
location less than the distance indicated in clause
(i), (ii), or (iii) of subparagraph (A), as applicable,
experiences such hardship or other difficulties in
travel to the nearest appropriate Department health-
care facility that such travel is not in the best
interest of the veteran, as determined by the Secretary
pursuant to regulations prescribed for purposes of this
subsection.
(4) For purposes of this subsection, a covered health service
is any hospital care, medical service, rehabilitative service,
or preventative health service authorized to be provided by the
Secretary under this chapter or any other provision of law.
(5) For purposes of this subsection, a health-care provider
is any qualified entity or individual furnishing a covered
health service.
(6) In meeting the requirements of this subsection, the
Secretary shall develop the functional capability to provide
for the exchange of medical information between the Department
and non-Department health-care providers.
(7) This subsection shall apply to covered health services
provided during the 3-year period beginning on the 120th day
after the date of the enactment of this subsection.
(8) Not later than the 30th day after the close of each year
of the period described in paragraph (7), the Secretary shall
submit a report to the Committees of Veterans' Affairs of the
House of Representatives and the Senate a report which
includes--
(A) the Secretary's assessment of the program under
this subsection, including its cost, volume, quality,
patient satisfaction, benefit to veterans, and any
other findings and conclusions of the Secretary with
respect to such program, and
(B) any recommendations that the Secretary may have
for--
(i) continuing the program,
(ii) extending the program to other or all
service regions of the Department, and
(iii) making the program permanent.