NOTEWORTHY

Background: The House of Representatives overwhelmingly passed its amendment to S.2372, the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (VA MISSION Act) of 2018, by a vote of 347 to 70. This bill was negotiated between the House and Senate Veterans’ Affairs Committees.

Floor Situation: On May 17, Majority Leader McConnell filed cloture on the motion to concur in the House Amendment to S. 2372. The amendment tree is filled. All first-degree amendments must be filed at the desk by 5:00 p.m., May 21.

Executive Summary: The VA MISSION Act will permanently create a new Veteran Community Care Program to streamline the delivery of free market health care to veterans. It removes some previous restrictions on veterans accessing free market health care, including the 30-day rule and the 40-mile rule. The VA MISSION Act also expands benefits from only post-9/11 veteran caregivers to veteran caregivers of all eras. 

OVERVIEW OF THE ISSUE

Veteran Health Care

The Department of Veterans Affairs operates more than 100 government hospitals and more than 1,000 government outpatient clinics to provide health care to potentially 9 million veterans. Not all enrolled and eligible veterans receive care from the VA in a given year. Some veterans use private insurance, Medicare, Tricare (DOD’s health care system), or another option to obtain health care. Eligibility for health care at a VA hospital or clinic is not open to all veterans who served. In general, veterans receive care at VA facilities only if they have a military service-connected disability.

VA health care differs from other health care delivery in the federal government or the free market because eligible veterans do not pay any premiums. They may pay a copay or have their health insurance billed, if they have insurance.

In response to a series of scandals over the manipulation of VA scheduling systems and lengthy wait times for veterans, Congress created the Veterans Choice Program in 2014. It allowed certain veterans to obtain care from doctors and nurses in the free market if care was not easily accessible through the VA system. Congress provided $10 billion for VCP, which was deemed to be temporary, emergency, and mandatory spending exempt from budget caps. Congress provided an additional $5 billion for VA to hire more doctors and nurses. Funding for VCP is anticipated to be exhausted by the end of this month.

Media investigations revealed that veterans died while awaiting appointments for VA care that might have saved their lives. VA schedulers manipulated the scheduling system and misled veterans requesting appointments to make it appear that veterans were being seen sooner than actually occurred. Critics of the VA have concluded the department’s closed system and extensive delays effectively rationed health care to veterans.

Veteran Community Care Program to Replace the Veteran Choice Program

Congress created the Veterans Choice Program to allow certain veterans to obtain care from outside of the VA system in order to receive it sooner. However, VCP is not an insurance program. Veterans choosing to receive health care through the VA must still work with the VA and with one of the third-party administrators to choose the medical providers and assist with the scheduling. The two third-party administrators are Health Net and TriWest. To qualify for VCP, veterans must generally be unable to obtain a medical appointment within 30 days or live more than 40 miles from an eligible VA facility.

As of March 7, more than 4 million authorizations for care were completed under VCP. The number of appointments completed is higher, as each authorization is used for the initial appointment and any follow-up appointments.

The VA MISSION Act permanently creates a new Veteran Community Care Program to streamline the delivery of free market health care to veterans and replace the Veteran Choice Program.

Veteran Caregiver Programs

In 2010 Congress passed the Caregivers and Veterans Omnibus Health Services Act to provide benefits to caregivers of seriously disabled veterans injured after September 11, 2001. The VA’s Comprehensive Assistance for Family Caregivers program is for the caregiver of the veteran, usually a spouse or a child but sometimes a parent, who must devote a large amount of time to help a severely injured veteran with activities of daily living. Benefits include a cash stipend, training, medical benefits, respite care, and peer support.

Caregivers of veterans injured before 2001 did not receive the same benefits and were not eligible for the cash stipend and medical benefits. The VA MISSION Act expands the benefits for caregivers of veterans of all eras. 

NOTABLE BILL PROVISIONS

Title I – CARING FOR OUR VETERANS

Section 101

Establishes the Veterans Community Care Program as a permanent program in the VA. Consolidates all of the community care programs into one program and removes previous requirements on veterans accessing community care such as the veteran living more than 40 miles from a VA facility or waiting more than 30 days for a medical appointment in the VA.

Section 102

Authorizes the VA to enter into “veteran care agreements” with a medical provider if the VA determines that a veteran requires medical care not available through the VA, the VCCP, or other provisions of law. Veteran care agreements would be exempt from the Federal Acquisition Regulation and exempt from other laws from which Medicare providers are exempt.

Section 103

Authorizes the VA to enter into Veteran Care Agreements with state veterans homes and conforms previous laws governing State Veterans Homes.

Section 104

Requires the VA to establish clear, useful, and timely standards for providing medical services to veterans.

Section 105

Allows veterans access to “walk-in care” and requires the VA to contract with commercial providers of no-appointment medical care to furnish such care. Includes directions on medical record sharing and stipulates that a veteran utilizing “walk-in care” would not have a copay for the first two visits in a calendar year if the veteran does not have a copay for VA care.

Section 106

Establishes the Quadrennial Veterans Health Administration Review to conduct a study every four years regarding demand for VA health care, inventory of VA’s capacity to provide health care, and an assessment of community care capacity and other federal health care capacity for veterans.

Section 107

Exempts veteran care agreement providers from regulations in a similar manner as TRICARE providers.

Section 108

Prevents medical providers who have lost their license or otherwise been removed as VA medical providers from providing care to veterans under the VCCP, a veteran care agreement, or another provision of law.

Section 109

Requires a remediation plan for any VA medical service line not meeting the standards for quality. A medical service line is defined as a clinic within a VA medical center.

Section 111

Requires the VA to pay or deny payment for medical services within 30 days (electronic submission) or 45 days (paper submission).

Section 112

Authorizes VA to pay for medical care even if a medical provider was not covered by a VA contract or agreement at the time.

Section 113

Improves the ability of the VA to recover from third-parties such as health insurance companies the cost of medical care paid for by the VA for care that is not service-connected.

Section 114

Allows VA to use a third-party entity to electronically process health care claims from medical providers.

Section 121

Requires VA to develop and administer a VA health care education program to inform veterans about their health care options and responsibilities.

Section 122

Requires VA to develop and implement a training program for employees and contractors of the VA to assist the management of community care programs, particularly in relation to prescription opioids.

Section 123

Establishes a continuing medical education program for free market medical providers under VA community care, veteran care agreements, or other provisions of law.

Section 131

Requires all non-VA health care providers to certify review of evidence-based guidelines for prescribing opioids as written by the department’s Opioid Safety Initiative. Directs the VA to take appropriate action if a medical provider is not complying with the guidelines.

Section 132

Clarifies current law regarding information sharing with non-VA providers and removes certain restrictions to enable VA to recover funds from third parties for the cost of non-service-connected care.

Section 133

Requires VA to establish competency standards for care provided by non-VA providers for post-traumatic stress disorder, military sexual trauma-related conditions, and traumatic brain injuries.

Section 134

Includes VA participation in the national network of state-based prescription drug monitoring programs.

Section 141

Requires VA to submit supplemental funding requests at least 45 days prior to any impact on VA programs or services.

Section 142

Authorizes the VA to use any remaining Veteran Choice funding for any health care outside the VA beginning March 2019.

Section 143

Establishes a sunset date for the Veteran Choice Program one year after enactment of the bill.

Section 144

Conforms various authorities within Title 38 to the new Veterans Community Care Program.

Section 151

Allows covered medical providers to practice telemedicine across state lines.

Section 152

Authorizes VA to implement pilot programs for new and innovative payment and delivery models for VA health care. Limits VA to no more than 10 pilot programs and no more than $50 million per fiscal year spent on all programs.

Section 153

Authorizes VA to pay for a non-veteran organ donor’s operation and care if intended for the benefit of a veteran.

Section 161

Expands veteran caregiver benefits to caregivers of veterans of all eras in a phased manner, following implementation of an IT system required by the bill. Initially, all veterans seriously injured in the line of duty on or before May 7, 1975, will be eligible. Two years after this expansion, eligibility will be opened to veterans who served after May 7, 1975. Caregivers of post-9/11 veterans are already eligible for caregiver benefits from the VA.

Section 162

Requires the VA to implement an IT system to support the Family Caregiver Program.

Section 163

Adds a reporting requirement regarding the Family Caregiver Program.

Title II – ASSET AND INFRASTRUCTURE REVIEW

Section 202

Establishes the VA Asset and Infrastructure Review Commission. Requires the president to appoint nine commissioners with the advice and consent of the Senate. The commission will operate during calendar years 2021 to 2023 only and will examine the utilization of existing VA facilities and make recommendations to Congress for modernization or realignment.

Section 203

Requires the VA to create and publish its criteria regarding modernization or realignment of the VA’s medical centers and clinics prior to the commission’s work. The commission will submit a report to the president and Congress in January 2023.

Section 204

Requires VA to implement the commission’s recommendations absent a resolution of congressional disapproval.

Section 205

Authorizes VA to modernize or realign VA facilities under this title with certain provisions and waivers.

Section 206

Creates a new budget account in the VA budget for the VA asset and infrastructure review.

Section 207

Outlines the procedure under which Congress will consider a joint resolution of disapproval of the VA asset and infrastructure review.

Section 208

Requires the online publication of all communications between the VA, the commission, and the president regarding this title.

Section 211

Implements a construction and facilities management training and certification program for VA personnel.

Section 212

Requires OMB review of any VA enhanced use lease before it goes into effect.

Section 213

Assesses VA health care delivery to veterans in Guam, American Samoa, and the Northern Mariana Islands.

Title III – IMPROVEMENTS TO RECRUITMENT OF HEALTH CARE PROFESSIONALS

Section 301

Awards at least 50 scholarships per year for people enrolled in a medical or dental school program. Conditions of the scholarship include an agreement for the person to work for the VA for 18 months for every school year of scholarship funding.

Section 302

Increases the amount of debt reduction under the VA’s Education Debt Reduction program to $200,000 total over five years.

Section 303

Creates a new loan repayment program designated for people pursuing education in difficult-to-recruit-for medical specialties at the VA.

Section 304

Creates a pilot program for VA to pay the full medical education of 18 eligible veterans.

Section 305

Increases overall sums authorized for VA bonus awards and funding for recruitment, relocation, and retention bonuses.

Section 306

Includes vet center employees as eligible for education debt relief programs at the VA.

Title IV – HEALTH CARE IN UNDERSERVED AREAS

Section 401

Requires VA to issue criteria and designate certain medical facilities of the VA as underserved.

Section 402

Authorizes a pilot program for the VA to use “mobile deployment teams” to underserved facilities.

Section 403

Authorizes a pilot program for funding medical resident programs at a medical facilities operated by an Indian tribe or by the Indian Health Service in an area that is underserved.

Title V – OTHER MATTERS

Section 501

Requires a report to Congress on all performance awards and bonuses.

Section 502

Mandates equivalent treatment in the VA of doctors of podiatric medicine with respect to promotions and pay.

Section 503

Raises the definition of a major medical facility from $10 million to $20 million.

Section 504

Authorizes VA construction of medical facilities in Livermore, California.

Section 505

Requires VA to publish online the following personnel actions for each medical facility quarterly: number of jobs; number of employees hired and fired; number of vacancies; and how long it took to hire employees as compared to OPM metrics.

Section 506

Establishes a peer specialist program at VA to place at least two peer specialists in patient care teams at 30 VA medical centers. Requires female peer specialists to be available for female veterans.

Section 507

Authorizes a pilot program for medical scribes to assist physicians in entering information into electronic health records at VA medical centers.

Section 508

Extends the collection of fees for home loans guaranteed by the VA by one year.

Section 509

Extends the reduction in pensions to certain veterans in nursing homes.

Section 510

Authorizes and appropriates $5.2 billion for the Veterans Choice Fund.

ADMINISTRATION POSITION

The White House has issued a statement of administration policy in support of the bill. President Trump has urged its passage before the Memorial Day recess.

COST

The Congressional Budget Office estimates S 2372 will cost $46.5 billion over five years in spending subject to appropriation. The bill will increase direct spending by $4.5 billion.

AMENDMENTS

The filing deadline for first degree amendments to the VA MISSION Act is 5:00 p.m. on May 21.