H. Rept. 111-171 - VETERANS HEALTH CARE BUDGET REFORM AND TRANSPARENCY ACT OF 2009111th Congress (2009-2010)
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111th Congress Report
HOUSE OF REPRESENTATIVES
1st Session 111-171
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VETERANS HEALTH CARE BUDGET REFORM AND TRANSPARENCY ACT OF 2009
_______
June 19, 2009.--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
together with
ADDITIONAL VIEWS
[To accompany H.R. 1016]
[Including cost estimate of the Congressional Budget Office]
The Committee on Veterans' Affairs, to whom was referred the
bill (H.R. 1016) to amend title 38, United States Code, to
provide advance appropriations authority for certain medical
care accounts of the Department of Veterans Affairs, 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.............................. 4
Hearings......................................................... 9
Committee Consideration.......................................... 9
Committee Votes.................................................. 10
Committee Oversight Findings..................................... 14
Statement of General Performance Goals and Objectives............ 14
New Budget Authority, Entitlement Authority, and Tax Expenditures 14
Earmarks and Tax and Tariff Benefits............................. 14
Committee Cost Estimate.......................................... 14
Congressional Budget Office Cost Estimate........................ 14
Federal Mandates Statement....................................... 16
Advisory Committee Statement..................................... 16
Constitutional Authority Statement............................... 16
Applicability to Legislative Branch.............................. 16
Section-by-Section Analysis of the Legislation................... 16
Changes in Existing Law Made by the Bill as Reported............. 17
Additional Views................................................. 20
Amendment
The amendments are as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Veterans Health Care Budget Reform and
Transparency Act of 2009''.
SEC. 2. SENSE OF CONGRESS.
It is the sense of Congress that the provision of health care
services to veterans could be more effectively and efficiently planned
and managed if funding was provided for the management and provision of
such services in the form of advance appropriations.
SEC. 3. PRESIDENTS' BUDGET SUBMISSIONS.
Section 1105(a) of title 31, United States Code, is amended by adding
at the end the following new paragraph:
``(36) information on estimates of appropriations for the
fiscal year following the fiscal year for which the budget is
submitted for the following accounts of the Department of
Veterans Affairs:
``(A) Medical Services.
``(B) Medical Support and Compliance.
``(C) Medical Facilities.
``(D) Information Technology Systems.
``(E) Medical and Prosthetic Research.''.
SEC. 4. ADVANCE APPROPRIATIONS FOR CERTAIN ACCOUNTS OF THE DEPARTMENT
OF VETERANS AFFAIRS.
(a) Advance Appropriations for Certain Accounts.--
(1) In general.--Chapter 1 of title 38, United States Code,
is amended by inserting after section 116 the following new
section:
``Sec. 117. Advance appropriations for certain accounts
``(a) In General.--For each fiscal year, beginning with fiscal year
2011, discretionary new budget authority provided in an appropriations
Act for the appropriations accounts of the Department specified in
subsection (c) shall--
``(1) be made available for that fiscal year; and
``(2) include, for each such appropriations account, advance
discretionary new budget authority that first becomes available
for the first fiscal year after the budget year.
``(b) Estimates Required.--The Secretary shall include in documents
submitted to Congress in support of the President's budget submitted
pursuant to section 1105 of title 31, United States Code, detailed
estimates of the funds necessary for the accounts of the Department
specified in subsection (c) or the fiscal year following the fiscal
year for which the budget is submitted.
``(c) Accounts Specified.--The accounts specified in this subsection
are the following accounts of the Department of Veterans Affairs:
``(1) Medical Services.
``(2) Medical Support and Compliance.
``(3) Medical Facilities.
``(4) Information Technology Systems.
``(5) Medical and Prosthetic Research.
``(d) Annual Report.--Not later than July 31 of each year, the
Secretary shall submit to Congress an annual report on the sufficiency
of the Department's resources for the next fiscal year beginning after
the date of the submittal of the report for the provision of medical
care. Such report shall also include estimates of the workload and
demand data for that fiscal year.''.
(2) Clerical amendment.--The table of sections at the
beginning of such chapter is amended by inserting after the
item relating to section 113 the following new line:
``117. Advance appropriations for certain accounts.''.
SEC. 5. COMPTROLLER GENERAL STUDY ON ADEQUACY AND ACCURACY OF BASELINE
MODEL PROJECTIONS OF THE DEPARTMENT OF VETERANS
AFFAIRS FOR HEALTH CARE EXPENDITURES.
(a) Study of Adequacy and Accuracy of Base Line Model Projections.--
The Comptroller General shall conduct a study of the adequacy and
accuracy of the budget projections made by the Enrollee Health Care
Projection Model (in this section referred to as the ``Model''), its
equivalent, or other methodologies utilized for the purpose of
estimating and projecting health care expenditures of the Department of
Veterans Affairs with respect to the fiscal year involved and the
subsequent four fiscal years.
(b) Reports.--
(1) In general.--Not later than the date of each year in
2011, 2012, and 2013, on which the President submits the budget
request for the next fiscal year under section 1105 of title
31, United States Code, the Comptroller General shall submit to
the appropriate committees of Congress and to the Secretary of
Veterans Affairs a report.
(2) Elements.--Each report under this paragraph shall
include, for the fiscal year concerning the year for which the
budget is submitted, the following:
(A) A statement whether the amount requested in the
budget of the President for expenditures of the
Department for health care in such fiscal year is
consistent with anticipated expenditures of the
Department for health care in such fiscal year as
determined utilizing the Model.
(B) The basis for such statement.
(C) Such additional information as the Comptroller
General determines appropriate.
(3) Availability to the public.--Each report submitted under
this subsection shall be made available to the public by the
Comptroller General.
(4) Appropriate committees of congress defined.--In this
subsection, the term ``appropriate committees of Congress''
means--
(A) the Committees on Veterans' Affairs,
Appropriations, and the Budget of the Senate; and
(B) the Committees on Veterans' Affairs,
Appropriations, and the Budget of the House of
Representatives.
SEC. 6. REPORT TO CONGRESS.
Not later than 90 days after the date of the enactment of this Act,
the Secretary of Veterans Affairs, shall submit to the Committees on
Veterans' Affairs, Appropriations, and the Budget of the Senate and
House of Representatives a report on the requirements of this Act and
the amendments made by this Act. Such report shall include--
(1) the Secretary's plans for improving the capability of the
Department of Veterans Affairs to better and more accurately
estimate future health care costs and demands; and
(2) a description of impediments, statutory or otherwise, to
providing future year estimates and advance appropriations for
the Medical Services, Medical Support and Compliance, Medical
Facilities, Information Technology Systems, and Medical and
Prosthetic Research accounts of the Department.
Amend the title so as to read:
A bill to amend title 38, United States Code, to provide
advance appropriations authority for certain accounts of the
Department of Veterans Affairs, and for other purposes.
Purpose and Summary
H.R. 1016 was introduced on February 12, 2009, by
Representative Bob Filner of California, Chairman of the
Committee on Veterans' Affairs. This legislation would provide
advance appropriations authority for certain Department of
Veterans Affairs (VA) accounts. H.R. 1016, as amended, would
require the Administration and the VA to provide budget
estimates in support of advance appropriations. H.R. 1016 would
require the Government Accountability Office to study the
adequacy and accuracy of the VA's health care projection model
and would require the VA to provide an initial report to
Congress regarding any impediments to providing future year
estimates and the VA's plans to improve its capability to
better and more accurately estimate future health care costs
and demands as well as an annual report to Congress regarding
the sufficiency of resources in the upcoming fiscal year for
the provision of health care services for veterans.
Background and Need for Legislation
The VA, through the Veterans Health Administration (VHA),
operates the largest integrated direct health care system in
the nation.\1\ The VA health care system is also the largest
Federal health care program funded through discretionary
spending.\2\ The President requested, for FY 2010, $44.5
billion in appropriations for VA medical care. For comparison
purposes, the Administration requested $3.6 billion for the
Indian Health Service which is also a discretionary program.
The largest Federal health care program, Medicare, which is
funded with mandatory spending, was provided $450 billion in
budget authority in the FY 2010 budget resolution. For FY 2010,
the Administration requested a total VA budget of $109 billion
comprised of $53 billion in discretionary funding and $56
billion in mandatory funding.
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\1\CRS Report ``Veterans' Medical Care: FY 2009 Appropriations''
October 24, 2008, RL34598.
\2\Federal spending is generally characterized as discretionary or
mandatory. According to the CRS ``[d]iscretionary spending is
controlled through the appropriations process. Appropriations
legislation is considered each fiscal year and provides funding for
numerous programs such as national defense, education, and homeland
security. Direct spending, alternately, is provided for in legislation
outside of appropriations acts. Direct spending programs are typically
established in permanent law and continue in effect until such time as
revised or terminated by another law.'' CRS Report ``The Budget
Resolution and Spending Legislation'' June 9, 2009, R40472.
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The Congressional Research Service (CRS) describes the
appropriations process generally:
An appropriations act is a law passed by Congress
that provides federal agencies legal authority to incur
obligations and the Treasury Department authority to
make payments for designated purposes. The power of
appropriation derives from the Constitution, which in
Article I, Section 9, provides that ``[n]o money shall
be drawn from the Treasury but in consequence of
appropriations made by law.'' The power to appropriate
is exclusively a legislative power; it functions as a
limitation on the executive branch. An agency may not
spend more than the amount appropriated to it, and it
may use available funds only for the purposes and
according to the conditions provided by Congress.
The Constitution does not require annual
appropriations, but since the First Congress the
practice has been to make appropriations for a single
fiscal year. Appropriations must be used (obligated) in
the fiscal year for which they are provided, unless the
law provides that they shall be available for a longer
period of time. All provisions in an appropriations
act, such as limitations on the use of funds, expire at
the end of the fiscal year, unless the language of the
act extends their period of effectiveness.\3\
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\3\CRS Report ``Introduction to the Federal Budget Process''
November 20, 2008, 98-721.
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Currently, VA medical care funding is provided through
three appropriations accounts in annual appropriations
measures: Medical Services, Medical Support and Compliance
(formerly the Medical Administration account), and Medical
Facilities. Prior to Public Law 108-199 (118 Stat. 3), the
Consolidated Appropriations Act of 2004, medical care was
funded through a Medical Care account.\4\ The VHA is funded
through these three accounts and the Medical and Prosthetic
Research account. In addition, the Information Technology
Systems account provides funding for VHA information technology
systems.
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\4\The Conference Report accompanying H.R. 2673 (H.Rept. 108-401)
stated that ``the conferees have agreed to fund VHA through a new
account structure comprised of four accounts: medical services, medical
administration, medical facilities, and medical and prosthetic
research.''
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The VA budget has been in place at the start of the fiscal
year only four times in the last 20 years (fiscal years 1989,
1995, 1997, and 2009).\5\ Veterans' groups have grown
increasingly alarmed over the years at the impact this delay
may be having upon the provision of health care for veterans
and the ability of the VA to properly plan and manage its
resources. The FY 2010 Independent Budget stated that:
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\5\CRS Report ``Advance Appropriations for Veterans'' Health Care:
Issues and Options for Congress'' April 28, 2008, R40489
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Although significant strides have been made to
increase the level of VA health-care funding during the
past several years, the inability of Congress and the
Administration to agree upon and enact veterans'
health-care appropriations legislation on time
continues to hamper and threaten VA health care. When
VA does not receive its funding in a timely manner, it
is forced to ration health care. Much-needed medical
staff cannot be hired, medical equipment cannot be
procured, waiting times for veterans increase, and the
quality of care suffers.
Only through a comprehensive reform of the budget and
appropriations process, such as advance appropriations,
will Congress be able to ensure the long-term viability
and quality of VA's health-care system.\6\
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\6\The Independent Budget for the Department of Veterans Affairs
for Fiscal Year 2010 (annual budget request co-authored by AMVETS,
Disabled American Veterans, Paralyzed Veterans of America, and Veterans
of Foreign Wars), at 43.
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In a statement submitted for the record at the April 29,
2009 hearing, a coalition of former VA officials wrote:
We know well the challenge of managing the Nation's
largest integrated health care delivery system when,
year after year, we did not know what level of funding
we would receive or when it would arrive. Having been
granted the privilege of serving on the front lines of
health care for America's veterans has given us close-
up perspective of the agonizing results of uncertain
budgets and continuing resolutions and the anxieties
they inflict upon the delivery of health care. Among
the recurring problems: drug and medical equipment
purchases are stalled; hiring of health care
professionals and other staff are delayed or deferred;
repairs and replacement work to fix and modernize
facilities are put on hold; and veterans medical
appointments are pushed back.
[.]
We urge the Committee and Congress to use your
authority to adopt this simple budgeting tool to help
ensure that VA has the resources to continue meeting
the health care needs of veterans. We urge you to pass,
and the President to sign, legislation to provide
advance appropriations for veterans' health care.\7\
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\7\Statement of Coalition of Former VA Officials (comprised of the
following former VA officials: Anthony J. Principi, Secretary (2001-
2004); Hershel W. Gober, Deputy Secretary (1993-2001); Gordon H.
Mansfield, Deputy Secretary (2005-2008); Kenneth Kizer, MD, MPH, Under
Secretary for Health (1994-1999); Thomas L. Garthwaite, MD, Under
Secretary for Health (1999-2002); Robert H. Roswell, MD, Under
Secretary for Health (2002-2004); Jonathan B. Perlin, MD, PHD, Under
Secretary for Health (2004-2006); Frances M. Murphy, MD, MPH, Deputy
Under Secretary for Health; Laura J. Miller, MPA, MPH, Deputy Under
Secretary for Health; C. Wayne Hawkins, Deputy Under Secretary for
Health; J. Arthur Klein, Director of Budget and Forecasting Service,
VHA; Kenneth J. Clark, VISN 22 Director (CA, NV); Larry Deal, VISN 7
Director (AL, GA, SC); James J. Farsetta, FACHE, VISN 3 Director (NJ,
NYC); Dennis M. Lewis, FACHE, VISN 20 Director (WA, OR, ID, AK); Robert
E. Lynch, MD, VISN 16 Director (AR, LA, MS, OK); Fred Malphurs, VISN 2
Director (NY); James J. Nocks, MD, MSHA, VISN 5 Director (DC, MD, WV);
Clyde Parkis, FACHE, VISN 10 Director (OH); James W. Dudley, VA Medical
Center Director, Richmond, VA; John R. Fears, VA Medical Center
Director, Phoenix, AZ; Joseph M. Manley, VA Medical Center Director,
Spokane, WA; Robert A. Perreault, VA Medical Center Director,
Charleston, SC; Wayne C. Tippets, MHA, VA Medical Center Director,
Boise, ID; and Timothy B. Williams, VA Medical Center Director,
Seattle, WA).
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In order to advocate for changing the manner in which the
VA health care budget is provided, nine veterans' groups formed
The Partnership for Veterans Health Care Budget Reform. These
nine groups include The American Legion, AMVETS, Blinded
Veterans Association, Disabled American Veterans, Jewish War
Veterans, Military Order of the Purple Heart, Paralyzed
Veterans of America, Veterans of Foreign Wars, and Vietnam
Veterans of America. According to the Partnership's website,\8\
these groups ``have all urged Congress for more than a decade
to reform the system of funding VA health care so that it is
sufficient, timely and predictable. This reform is necessary to
ensuring that today's and tomorrow's veterans always have
access to the quality medical care they need, have earned, and
deserve.'' The Partnership's stated goal is to ensure that VA
medical care is provided with ``sufficient, timely, and
predictable funding.''\9\
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\8\http://fundingforvets.org/about.html
\9\Testimony of Carl Blake, National Legislative Director,
Paralyzed Veterans of America, April 29, 2009. Blake stated: ``The
Veterans Health Care Budget Reform and Transparency Act would ensure
that the goals of the Partnership--sufficient, timely, and predictable
funding--are met. Historically, advance appropriations have been used
to make a program function more effectively, better align with funding
cycles of program recipients, or provide insulation from annual
partisan political maneuvering. By moving to advance appropriations,
veterans' health care programs would accrue all three of these
benefits.''
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Veterans' groups have argued that providing VA medical care
funding through advance appropriations would better enable the
VA to plan in that it would know what levels of funding are in
place at the beginning of the fiscal year. The Congressional
Research Service describes advance appropriations in the
following manner:
An advance appropriation means appropriation of new
budget authority that becomes available one or more
fiscal years beyond the fiscal year for which the
appropriations act was passed (that is beyond the
budget year). For example, if the following language
appeared in an appropriations act for FY2010, it would
provide an advance appropriation for FY2011: ``For
medical services, $30,854,000,000 to become available
on October 1, 2010 (the start of the FY2011).'' Under
the current scoring guidelines, new budget authority
for an advance appropriation is scored in the fiscal
year in which the funds become available for
obligation. In this example, you would record the
budget authority in FY2011. [Footnote omitted].\10\
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\10\CRS Report ``Advance Appropriations for Veterans' Health Care:
Issues and Options for Congress'' April 28, 2008, R40489
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The VA forecasts health care demand and costs through its
Enrollee Health Care Projection Model.
The Enrollee Health Care Projection Model, or VA
Model, is a comprehensive enrollment, utilization, and
expenditure projection model. It was originally
developed in 1998 in partnership with Milliman, Inc.,
the largest actuarial firm in the country. Through the
past 11 years of periodic updates and continuous
refinement, VA and Milliman have developed a strong
partnership that has resulted in a powerful modeling
tool. VA guides the overall development of the VA Model
and ensures that it meets the needs of stakeholders. VA
program staff provide expertise on the unique needs of
Veterans, patterns of practice in the VA health-care
system, and how the system is expected to evolve over
the next 20 years. Milliman brings specialized
expertise, access to extensive amounts of health-care
utilization data VA, and excellent research to the
overall modeling effort.\11\
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\11\Statement of the Honorable Eric K. Shinseki, Secretary,
Department of Veterans Affairs, hearing on Funding the U.S. Department
of Veterans Affairs of the Future, Committee on Veterans' Affairs,
April 29, 2009.
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The RAND Corporation conducted a study on the VA's EHCPM
and published a report entitled ``Review and Evaluation of the
VA Enrollee Health Care Projection Model.''\12\ Katherine M.
Harris, the study's director, testified at the April 29, 2009,
hearing that:
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\12\RAND Center for Military Health Policy Research, 2008.
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The RAND evaluation found that the EHCPM supports
VA's short-term budget planning and monitoring in a
stable policy and practice environment. The model
identifies factors that drive specific types of
spending or spending for specific types of enrollees
and can adjust those factors as needed. Model results
can also help the VA to develop more informed
strategies for managing expenditures. In addition, the
current model allows the VA to monitor budget execution
and performance relative to pre-established benchmarks.
Assuming there are no short-term ``shocks'' to the
system, only the accuracy and timeliness of VA data
systems--not the model's structure--limit the EHCPM's
utility for short-term budget planning and monitoring.
However, for longer-term strategic planning and
policy analysis, the model could yield misleading
results because the model structure does not account
for two things: key drivers of future demand for VA
care and the costs of delivering it. Using the model to
inform scenarios beyond the current policy and
budgetary environment requires information about a wide
range of factors, including the VA's future cost
structure, how rapidly the VA can expand its capacity
to meet demand, factors driving enrollment, and the
relationships among enrollee health status, VA
treatment capacity, and enrollees' preferences for
treatment in VA facilities versus other facilities. In
many cases, required information does not exist or was
not available to model developers. In the absence of
such information, model forecasts rely on a number of
unrealistic assumptions. Thus, substantial
modifications to model subcomponents and enhancements
of supporting data inputs would likely be required
before the EHCPM could effectively support longer-range
planning.
Veterans' groups have also commented favorably on the VA
model. Carl Blake, National Legislative Director of the
Paralyzed Veterans of America, testifying on behalf of the
Partnership stated that ``[t]he final results produced by the
Model provide the most comprehensive, robust and accurate
estimate of what it will cost VA in future years to provide
current services authorized in law to the veterans expected to
seek those services.''
As introduced, H.R. 1016 included the three VA medical care
accounts for advance appropriations. At the April 29, 2009,
Committee hearing, CRS testified regarding a possible concern
with limiting advance appropriations to these three accounts:
Another issue that may arise would be how funding for
VHA information technology programs including its
electronic medical records system relate to funding the
rest of the VHA under an advance appropriation.
Beginning in 2005, VA consolidated all information
technology (IT) functions throughout the VA and brought
them under control of the VA Chief Information Officer
(CIO). As a result of this reorganization, VHA's health
IT budget was brought under central control. Currently,
all IT programs within the VA are funded under the
Information Technology account. Therefore, providing an
advance appropriation for some VHA accounts and funding
IT accounts under a regular appropriation act could
create a situation whereby, for example, VHA could not
purchase computer software although it has procured
medical equipment that needs software. Another example
would be the difficulty of procuring the IT
infrastructure to support the opening of a new
community-based outpatient clinic (CBOC).\13\
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\13\Statement of Sidath Viranga Panangala, Analyst in Veterans
Policy, CRS, Library of Congress, hearing on Funding the U.S.
Department of Veterans Affairs of the Future, Committee on Veterans'
Affairs, April 29, 2009.
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To address this concern, an amendment was offered by
Representative Steve Buyer of Indiana, the Ranking Member, and
agreed to by the Committee to include the Information
Technology Systems and the Medical and Prosthetic Research
accounts.
As amended, H.R. 1016 creates a framework to support the
provision of advance appropriations by requiring the President
to submit budget estimates; VA to provide Congress with details
behind the estimates, and an annual report due no later than
July 31 of each year that would enable the VA to inform
Congress as to whether or not it has sufficient resources to
provide the expected level of health care services for the
fiscal year beginning 61 days later on October 1.
The Committee believes the July report is an important
component of the advance appropriations framework in that it
can guard against the VA facing a budget shortfall, as it
experienced in 2005. The date was chosen to fall after the
Administration's Mid-Session Review while still providing
Congress with a window within which to act to provide
additional resources if needed.
The Committee looks forward to receiving the initial report
from the VA, due within 90 days of enactment, concerning the
Secretary's plans to improve the capability of the VA to better
and more accurately estimate future health care costs and
demands and describing any impediments, statutory or otherwise,
to providing future year estimates and advance appropriations.
The Committee intends the VA to highlight any difficulties it
faces, especially of a statutory nature, in meeting its
requirements under H.R. 1016. The Committee has long taken an
interest in the VA's health care forecasting activities and
plans to work closely with the VA to better improve the
Department's ability to forecast future health care demand and
costs.
Hearings
On April 29, 2009, the Committee on Veterans' Affairs held
a hearing entitled ``Funding the U.S. Department of Veterans
Affairs of the Future.'' The following witnesses testified:
Joseph A. Violante, National Legislative Director, Disabled
American Veterans, on behalf of the Partnership for Veterans
Health Care Budget Reform; Steve Robertson, Director, National
Legislative Commission, The American Legion, on behalf of the
Partnership for Veterans Health Care Budget Reform; Carl Blake,
National Legislative Director, Paralyzed Veterans of America,
on behalf of the Partnership for Veterans Health Care Budget
Reform; Katherine M. Harris, Ph.D., Study Director, Review and
Evaluation of the VA Enrollee Projection Model, RAND
Corporation; Sidath Viranga Panangala, Analyst in Veterans
Policy, Congressional Research Service, Library of Congress;
Jessica Banthin, Ph.D., Director of Modeling and Simulation,
Center for Financing, Access and Cost Trends, Agency for
Healthcare Research and Quality, U.S. Department of Health and
Human Services; Randall B. Williamson, Director, Health Care,
U.S. Government Accountability Office, accompanied by Susan J.
Irving, Director, Federal Budget Analysis, Strategic Issues,
U.S. Government Accountability Office; and, The Honorable Eric
K. Shinseki, Secretary, U.S. Department of Veterans Affairs,
accompanied by Patricia Vandenberg MHA, BSN, Assistant Deputy
Under Secretary for Health for Policy and Planning, Veterans
Health Administration, U.S. Department of Veterans Affairs.
Submitted for the record was a statement made in support of
advance appropriations by a Coalition of Former VA Officials.
Committee Consideration
On June 10, 2009, the full Committee met in an open markup
session, a quorum being present, and ordered H.R. 1016, as
amended, reported favorably to the House of Representatives by
voice vote. During consideration of the bill, the following
amendments were considered:
An amendment offered by Mr. Buyer of Indiana adding the
Information Technology Systems and Medical and Prosthetic
Research accounts was agreed to by a record vote.
A substitute amendment to the amendment in the nature of a
substitute offered by Mr. Buyer of Indiana that would create an
Advanced Quarter Appropriations Fund of $15 billion was not
agreed to by voice vote.
An amendment offered by Mr. Buyer of Indiana requiring an
additional report on implementation was withdrawn.
An amendment in the nature of a substitute offered by Mr.
Filner of California was agreed to 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.
A substitute amendment to the amendment in the nature of a
substitute offered by Mr. Buyer of Indiana that would create an
Advanced Quarter Appropriations Fund of $15 billion was not
agreed to by voice vote. An amendment in the nature of a
substitute offered by Mr. Filner of California was agreed to by
voice vote.
An amendment by Mr. Buyer of Indiana adding the Information
Technology Systems and Medical and Prosthetic Research accounts
was agreed to by a record vote of 17 yeas and 8 nays. The names
of Members voting for and against follow:
Final passage of H.R. 1016, as amended, was agreed to by a
record vote of 21 yeas and 0 nays:
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. 1016 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.
1016 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. 1016 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, June 16, 2009.
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. 1016, the Veterans
Health Care Budget Reform and Transparency Act of 2009.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Sunita
D'Monte.
Sincerely,
Douglas W. Elmendorf, Director.
Enclosure.
H.R. 1016--Veterans Health Care Budget Reform and Transparency Act of
2009
Summary: H.R. 1016 would authorize appropriations for
certain programs within the Department of Veterans Affairs
(VA). CBO estimates that implementing the bill would cost
almost $187 billion over the 2010-2014 period, assuming
appropriation of the necessary amounts. Enacting the bill would
not affect direct spending or revenues.
H.R. 1016 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA)
and would not affect the budgets of state, local, or tribal
governments.
Estimated cost to the Federal Government: The estimated
budgetary impact of H.R. 1016 is shown in the following table.
The costs of this legislation fall within budget function 700
(veterans benefits and services).
Basis of estimate: For this estimate, CBO assumes that the
specified and estimated authorizations will be appropriated
near the start of each fiscal year beginning with 2011, and
that outlays will follow historical patterns for similar and
existing programs.
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars.--
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2010 2011 2012 2013 2014 2010 2014
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CHANGES IN SPENDING SUBJECT TO APPROPRIATION
Medical Services:
Estimated Authorization Level............. 0 34,715 35,333 35,925 36,727 142,700
Estimated Outlays......................... 0 30,548 34,529 35,595 36,429 137,101
Medical Facilities:
Estimated Authorization Level............. 0 5,198 5,258 5,316 5,398 21,170
Estimated Outlays......................... 0 4,025 4,773 5,095 5,322 19,215
Medical Support and Compliance:
Estimated Authorization Level............. 0 4,760 4,864 4,972 5,107 19,703
Estimated Outlays......................... 0 4,231 4,781 4,925 5,066 19,003
Information Technology Systems:
Estimated Authorization Level............. 0 2,572 2,601 2,630 2,670 10,473
Estimated Outlays 0 1,929 2,465 2,621 2,659 9,674
Medical and Prosthetic Research:
Estimated Authorization Level............. 0 532 539 547 557 2,175
Estimated Outlays......................... 0 335 478 538 552 1,903
Total Changes:
Estimated Authorization Level............. 0 47,777 48,595 49,390 50,459 196,221
Estimated Outlays......................... 0 41,068 47,026 48,774 50,028 186,896
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H.R. 1016 would authorize appropriations for five specific
budget accounts:
Medical Services,
Medical Facilities,
Medical Support and Compliance,
Information technology Systems, and
Medical and Prosthetic Research.
Under current law, appropriations for those budget accounts
are provided each year. Starting in 2011 for each account
listed above, the bill would authorize appropriations for that
fiscal year as well as advance appropriations for the following
fiscal year. CBO estimates that implementing the bill would
cost almost $187 billion over the 2010-2014 period, assuming
appropriation of the necessary amounts.
CBO's estimate of the authorization of appropriations
required under the bill are the same as projections for the
2011-2014 period in the most recent CBO baseline, completed in
March 2009. Those amounts are derived from the 2009
appropriated level for each account and adjusted for
anticipated inflation. CBO expects that those amounts would be
sufficient to provide services at the current level. However,
if VA were to significantly expand its health care programs--
for example, to include certain veterans with higher incomes
who are currently ineligible--additional funding would be
required.
Intergovernmental and private-sector impact: H.R. 1016
contains no intergovernmental or private-sector mandates as
defined in UMRA and would not affect the budgets of 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: Elizabeth Bass.
Estimate approved by: Theresa Gullo, Deputy Assistant
Director for Budget Analysis.
Federal Mandates Statement
The Committee adopts as its own the estimate of Federal
mandates regarding H.R. 1016 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.
1016.
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. 1016 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 provides the short title of H.R. 1016 as the
``Veterans Health Care Budget Reform and Transparency Act of
2009.''
Section 2. Sense of Congress
This section would state that it is the sense of Congress
that the provision of health care services to veterans could be
more effectively and efficiently planned and managed if funding
was provided in the form of advance appropriations.
Section 3. Presidents' budget submissions
This section amends section 1105 of title 31, United States
Code, to require the President to submit information on
estimates of appropriations for the fiscal year following the
fiscal year for which the budget is submitted for the Medical
Services, Medical Support and Compliance, Medical Facilities,
Information Technology Systems, and Medical and Prosthetic
Research accounts of the VA.
Section 4. Advance appropriations for certain accounts of the
Department of Veterans Affairs
This section amends title 38, United States Code, to add a
new section providing authority for the provision of advance
appropriations for the Medical Services, Medical Support and
Compliance, Medical Facilities, Information Technology Systems,
and Medical and Prosthetic Research accounts of the VA.
This new section would require the VA to provide additional
detailed budget estimates in support of advance appropriations
for certain VA accounts in the annual information it provides
to Congress in support of the VA's budget request.
This new section would require a report, not later than
July 31 of each year, to be submitted annually to Congress on
the sufficiency of the VA's resources for the fiscal year
beginning after the date of the submission of the report for
the provision of medical care and include estimates of workload
and demand data for that fiscal year.
Section 5. Comptroller General Study on adequacy and accuracy of
baseline model projections of the Department of Veterans
Affairs for health care expenditures
This section would require a report from the Government
Accountability Office in 2011, 2012, and 2013 as to whether the
amount requested in the President's budget submission is
consistent with the anticipated expenditures of the VA for
health care referenced to the amount projected to be necessary
by the VA's Enrollee Health Care Projection model.
Section 6. Report to Congress
This section would require the VA to submit a report within
90 days of enactment to the Senate and House of Representatives
Committees on Veterans' Affairs, Appropriations, and the Budget
detailing the VA's plans for improving its capability to more
accurately estimate future health care costs and demands and
describe any impediments, statutory or otherwise, to providing
future year estimates for the Medical Services, Medical Support
and Compliance, Medical Facilities, Information Technology
Systems, and Medical and Prosthetic Research accounts of the
VA.
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):
TITLE 31, UNITED STATES CODE
* * * * * * *
SUBTITLE II--THE BUDGET PROCESS
* * * * * * *
CHAPTER 11--THE BUDGET AND FISCAL, BUDGET, AND PROGRAM INFORMATION
* * * * * * *
Sec. 1105. Budget contents and submission to Congress
(a) On or after the first Monday in January but not later
than the first Monday in February of each year, the President
shall submit a budget of the United States Government for the
following fiscal year. Each budget shall include a budget
message and summary and supporting information. The President
shall include in each budget the following:
(1) * * *
* * * * * * *
(36) information on estimates of appropriations for
the fiscal year following the fiscal year for which the
budget is submitted for the following accounts of the
Department of Veterans Affairs:
(A) Medical Services.
(B) Medical Support and Compliance.
(C) Medical Facilities.
(D) Information Technology Systems.
(E) Medical and Prosthetic Research.
* * * * * * *
----------
TITLE 38, UNITED STATES CODE
* * * * * * *
PART I--GENERAL PROVISIONS
* * * * * * *
CHAPTER 1--GENERAL
Sec.
101. Definitions.
* * * * * * *
117. Advance appropriations for certain accounts.
* * * * * * *
Sec. 117. Advance appropriations for certain accounts
(a) In General.--For each fiscal year, beginning with fiscal
year 2011, discretionary new budget authority provided in an
appropriations Act for the appropriations accounts of the
Department specified in subsection (c) shall--
(1) be made available for that fiscal year; and
(2) include, for each such appropriations account,
advance discretionary new budget authority that first
becomes available for the first fiscal year after the
budget year.
(b) Estimates Required.--The Secretary shall include in
documents submitted to Congress in support of the President's
budget submitted pursuant to section 1105 of title 31, United
States Code, detailed estimates of the funds necessary for the
accounts of the Department specified in subsection (c) for the
fiscal year following the fiscal year for which the budget is
submitted.
(c) Accounts Specified.--The accounts specified in this
subsection are the following accounts of the Department of
Veterans Affairs:
(1) Medical Services.
(2) Medical Support and Compliance.
(3) Medical Facilities.
(4) Information Technology Systems.
(5) Medical and Prosthetic Research.
(d) Annual Report.--Not later than July 31 of each year, the
Secretary shall submit to Congress an annual report on the
sufficiency of the Department's resources for the next fiscal
year beginning after the date of the submittal of the report
for the provision of medical care. Such report shall also
include estimates of the workload and demand data for that
fiscal year.
ADDITIONAL VIEWS
In my view, it is premature for the House of
Representatives to consider H.R. 1016, as amended.
The Committee on Veterans' Affairs did not hold a
legislative hearing on the bill and the Administration has not
provided its official views on the bill, although it has stated
its support for the concept of advance appropriations. The
failure to follow regular order and the unnecessary haste with
which this bill is being advanced means that it will need
additional changes later, if the House passes the bill in its
present form.
H.R. 1016 was not considered by the Subcommittee on Health,
to which it was referred. At the Committee markup, I offered an
amendment that was adopted to include the information
technology, and medical and prosthetic research accounts of the
Department of Veterans Affairs (VA) among those covered by
advance appropriations. I offered the amendment because both
the Congressional Research Service (CRS) and the Secretary of
Veterans Affairs, the Honorable Eric Shinseki, raised concerns
at the April 29, 2009, Committee hearing on ``Funding the U.S.
Department of Veterans Affairs of the Future,'' that
information technology should be included in advance
appropriations legislation because of its close relationship to
the provision of medical care. In a report dated April 28,
2009, CRS also discussed potential problems if medical and
prosthetic research were not included in such legislation.\1\
While I am pleased that these accounts are now included in the
bill, a legislative hearing by the subcommittee with
jurisdiction over the bill would have allowed the issue to be
more fully considered at the appropriate stage of the
legislative process.
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\1\Congressional Research Service Report (2009). ``Advance
Appropriations for Veterans' Health Care: Issues and Options for
Congress.'' April 28, 2009, RL40489, p. 13.
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Also, at the oversight hearing on the future funding of the
VA, the Government Accountability Office (GAO) expressed
reservations about its possible role in advance appropriations.
Subsequently, in its written response of June 17, 2009, to one
of my hearing questions, GAO made a strong statement which
leads me to believe that section 5 of the amended bill (section
4 of the bill as introduced) is not workable to the extent that
it requires GAO to obtain budgetary information from the VA
before the department makes its fiscal year budget request. GAO
stated:
``. . . we do question whether GAO could conduct the
required studies due at or before the date the
President's budget request is submitted to Congress
because of challenges in obtaining, evaluating, and
reporting on the relevant budgetary and technical
information. Section 4 contemplates that information
regarding the President's requests for VA health care
funding would be available to GAO as they are
developed. While GAO has a broad statutory right of
access to agency records under section 716(a) of title
31, United States Code, executive agencies have
consistently resisted making detailed information about
the development of the President's budget available to
GAO (footnote omitted). In light of the extensive
negotiations typically required to resolve requests for
this type of information, as well as the need for
timely information for congressional deliberations on
VA funding, GAO believes that a requirement like that
contained in section 4 is inadvisable.''
VA's official views on this issue are currently unknown,
but it is my belief that any administration would likely find
this process objectionable. I believe that it has not been
adequately considered and that it should have been addressed
before H.R. 1016, as amended, is reported to the House.