July 31, 2014

H.R. 3230 – Veterans Access, Choice, and Accountability Act

Background: The Veterans Access, Choice, and Accountability Act of 2014, is a result of a conference committee reconciling the differences between the House and Senate bills on this matter. It came out of conference committee without objection. The House passed it by a vote of 420-5.

Floor Situation: It appears likely the Senate will consider this bill before departing for recess.

Executive Summary: The bill’s main feature is to authorize a “Veterans choice card” for certain veterans so they can get health services outside the VA system if they cannot get an appointment in that system within the department’s wait time goals. It also provides the card to veterans residing more than 40 miles from a VA facility. The government is then to reimburse the non-VA health care provider for the services provided to the veteran. The bill authorizes and appropriates $10 billion for this purpose. This program is authorized for three years or until these funds are exhausted, whichever is earlier.

It creates a Commission on Care to examine the access of veterans to VA health care and how best to deliver health care to veterans over the next 20 years.

It authorizes the secretary to hold accountable senior executives if the secretary determines performance warrants it.

CBO estimates the bill will increase the deficit by $12.8 billion over the next five years and by $10 billion in the 10-year budget window.

Overview of the Issue

Despite more than a 60 percent increase in veterans spending under the Obama administration, the performance of the veterans health care system has been criticized recently. A recent VA audit found there are more than 57,000 veterans nationwide currently waiting to be scheduled for care. It further found another 64,000 “who over the past ten years have enrolled in [the VA] healthcare system and have not been seen for an appointment.”

A review of the Phoenix Health Care System found the facility manipulated its wait time performance by not placing close to 1,700 veterans who were waiting for a primary care appointment on the official electronic waiting list. It found the effect of this is that “the Phoenix HCS leadership significantly understated the time new patients waited for their primary care appointment in their FY2013 performance appraisal accomplishments, which is one of the factors considered for awards and salary increases.” More generally, it found “inappropriate scheduling practices are systemic” throughout the Veterans Health Administration.

This is a management and competence issue of the VA, not a resource issue. The VA itself claimed in its fiscal year 2015 budget submission that “total VA funding has grown in 2015 by nearly 68% from 2009.”

Notable Bill Provisions

Section 101 – Expanded availability of medical services

Authorizes the issuance of a “Veterans choice card” to certain veterans for them to seek care from certain providers outside the VA system, namely from providers participating in the Medicare program or funded by the Department of Defense or Indian Health Service. To be eligible, a veteran must be enrolled in the VA system and either have attempted to schedule an appointment within that system that cannot be provided within the department’s wait time goals or reside more than 40 miles from a VA facility or community-based outpatient clinic. Wait time goals are defined as not more than 30 days after a veteran’s request for a medical appointment, unless the secretary alters that definition. This authorization shall terminate either three years after the date of enactment or when the $10 billion appropriated for this purpose by section 802 is exhausted, whichever is earlier.

It further directs the secretary to enter into contracts to carry out this program, particularly as it pertains to the reimbursement rate, to be no more than rates paid out under the Medicare program. The secretary may negotiate a higher reimbursement rate for furnishing care to veterans residing in a “highly rural area,” defined as a county with fewer than seven people per square mile.

If a veteran is covered under a health care plan not administered by the VA, the VA is to be secondarily responsible for the coverage of medical services provided in relation to a non-service-connected disability.

The section also requires a variety of reports on this program, to include an inspector general audit of the program, and an assessment by the secretary on the feasibility and advisability of continuing this program after its termination.

Section 105 – Prompt payment

Requires VA to implement a system to pay claims for health care provided by a non-VA provider and would require VA to comply with the “prompt payment rule.”

Section 201 – Independent Assessment

Directs VA to enter into contract with independent third-parties to assess hospital care, medical services, and other VA health care processes and provide an assessment report.

Section 202 – Commission on Care

Creates a Commission on Care to examine the access of veterans to VA health care and how best to deliver health care to veterans over the next 20 years.

Section 205 – Improved performance metrics

Requires the secretary to ensure that scheduling and wait time metrics are not used as factors in the determination of performance bonuses.

Section 206 – Improved transparency

Requires the publication of the department’s wait time goals and current wait times at its medical centers.

Section 208 – Budget information

Directs the president to submit, as part of his budget request, information on the number of veterans who received health services pursuant to section 101 (the Veterans choice card).

Sections 301 and 303 – Treatment of staffing shortage

These sections are directed at identifying the health provider occupations with the largest staffing shortages, remedying that, and improving health care management through training.

Section 601 – Medical facility leases

This section authorizes the department to carry out major medical facility leases specified in the bill. Current law requires congressional authorization for the VA to lease its space for use as a new medical facility if it expects an average annual rent of more than $1 million.

Section 705 – Limitation on bonuses

Directs the secretary to limit the aggregate amount of bonuses paid to $360 million in each of the next 10 fiscal years.

Section 707 – Removal of senior executives

Authorizes the secretary to remove or demote a senior executive if the secretary determines that person’s performance warrants such action. The secretary must then notify Congress within 30 days of removing or demoting an individual. The senior executive would be allowed an expedited review by the Merit Systems Protection Board. 

Section 801 – Appropriation of emergency amounts for increasing access to care

This section authorizes and appropriates $5 billion for the secretary to hire additional care providers and medical staff, as well as to carry out the provisions of section 301 and 302 directed at remedying staff shortages.

Section 802 – Appropriation of emergency amounts for Veterans choice card

This section authorizes the establishment of the Veterans Choice Fund and appropriates $10 billion for it to carry out the new entitlement created in section 101.

Section 803 – Emergency designations

Designates this act as an emergency requirement under the Statutory Pay-As-You-Go Act of 2010 and under the fiscal year 2010 budget resolution. This has the effect of waiving the mandatory spending restrictions that would ordinarily be imposed by these measures.

Administration Position

The administration has not published a Statement of Administration Policy regarding the bill at this time.


The Congressional Budget Office estimates the bill will increase the deficit by $12.8 billion over the next five years and by $10 billion in the 10-year budget window.

In a press conference, Senator Sanders said the money provided in this bill is not sufficient and more money will need to be provided for its programs.


No amendments will be in order during the consideration of this conference report.