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111th Congress                                                   Report
                        HOUSE OF REPRESENTATIVES
 2d Session                                                     111-488

======================================================================



 
            CHIROPRACTIC CARE AVAILABLE TO ALL VETERANS ACT

                                _______
                                

  May 20, 2010.--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. 1017]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Veterans' Affairs, to whom was referred 
the bill (H.R. 1017) to amend the Department of Veterans 
Affairs Health Care Programs Enhancement Act of 2001 and title 
38, United States Code, to require the provision of 
chiropractic care and services to veterans at all Department of 
Veterans Affairs medical centers and to expand access to such 
care and services, having considered the same, report favorably 
thereon with an amendment and recommend that the bill as 
amended do pass.

                                CONTENTS

                                                                   Page
Amendment........................................................     2
Purpose and Summary..............................................     2
Background and Need for Legislation..............................     2
Hearings.........................................................     4
Subcommittee Consideration.......................................     4
Committee Consideration..........................................     4
Committee Votes..................................................     4
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..........................................     5
Congressional Budget Office Cost Estimate........................     5
Federal Mandates Statement.......................................     6
Advisory Committee Statement.....................................     6
Constitutional Authority Statement...............................     7
Applicability to Legislative Branch..............................     7
Section-by-Section Analysis of the Legislation...................     7
Changes in Existing Law Made by the Bill, as Reported............     7

                               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 ``Chiropractic Care Available to All 
Veterans Act''.

SEC. 2. PROGRAM FOR PROVISION OF CHIROPRACTIC CARE AND SERVICES TO 
                    VETERANS.

    Section 204(c) of the Department of Veterans Affairs Health Care 
Programs Enhancement Act of 2001 (38 U.S.C. 1710 note) is amended--
          (1) by inserting ``(1)'' before ``The program''; and
          (2) by adding at the end the following new paragraph:
    ``(2) The program shall be carried out at not fewer than 75 medical 
centers by not later than December 31, 2011, and at all medical centers 
by not later than December 31, 2013.''.

SEC. 3. EXPANDED CHIROPRACTOR SERVICES AVAILABLE TO VETERANS.

    (a) Medical Services.--Paragraph (6) of section 1701 of title 38, 
United States Code, is amended by adding at the end the following new 
subparagraph:
          ``(H) Chiropractic services.''.
    (b) Rehabilitative Services.--Paragraph (8) of such section is 
amended by inserting ``chiropractic,'' after ``counseling,''.
    (c) Preventive Health Services.--Paragraph (9) of such section is 
amended--
          (1) by redesignating subparagraphs (F) through (K) as 
        subparagraphs (G) through (L), respectively; and
          (2) by inserting after subparagraph (E) the following new 
        subparagraph (F):
          ``(F) periodic and preventative chiropractic examinations and 
        services;''.

                          Purpose and Summary

    H.R. 1017 was introduced by Representative Bob Filner of 
California, Chairman of the Committee on Veterans' Affairs, on 
February 12, 2009. H.R. 1017, as amended, would expand access 
to chiropractic care at U.S. Department of Veterans Affairs 
(VA) facilities and clinics.

                  Background and Need for Legislation

    According to the VA, musculoskeletal injuries, such as 
painful and disabling joint and back disorders, are a leading 
health problem of veterans returning from Iraq and Afghanistan. 
This is the result of multiple tours of duty and missions that 
require servicemembers to use heavy combat gear and protective 
body armor. For example, a servicemember on foot patrol may 
wear and carry a helmet, bullet-resistant body armor, a rifle, 
medical kit, radio, grenades, water pouch, a pistol, and 
ammunition which can weigh as much as 55 pounds.
    There is a long history of this Committee's actions on 
issues of chiropractic care. First, section 303 of Public Law 
106-117 (113 Stat. 1545), the Veterans Millennium Health Care 
and Benefits Act, required the VA's Under Secretary for Health 
to establish a defined policy on the role of chiropractic care 
for veterans enrolled in the Veterans Health Administration 
(VHA). Nearly a year after the enactment of this measure, the 
Under Secretary for Health published a directive on 
chiropractic care, but the Committee found the policy to be 
unacceptable as it did not improve veterans' access to 
chiropractic care at the VA. As a result, section 204 of Public 
Law 107-135 (115 Stat. 2446), the Department of Veterans 
Affairs Health Care Programs Enhancement Act of 2001, required 
the Secretary to create a program to provide chiropractic care 
and services for veterans who are enrolled in the VA's health 
care system. This law further specified that each of the 21 
Veterans Integrated Service Networks (VISNs) establish at least 
one chiropractic care program, and required the establishment 
of a chiropractic advisory committee within the VA. The VA 
contended that it lacked a specified statutory authority 
authorizing the appointment of VA-specific chiropractors. In 
response, section 302 of Public Law 108-170 (117 Stat. 2042), 
the Veterans Health Care, Capital Asset, and Business 
Improvement Act of 2003, authorized VA to appoint chiropractors 
within VHA. This measure also included provisions concerning 
periods of appointment, promotions, pay grades, and other pay 
matters for VHA appointed chiropractors. It further designated 
chiropractors as scarce medical specialists for contracting 
purposes.
    As a result of these efforts, chiropractic care is 
available to eligible veterans at 32 VA medical facilities 
using hired or contracted staff and through VA's outpatient fee 
basis program for veterans who live in areas distant from these 
locations.
    The Committee is concerned that with the high number of 
veterans reporting symptoms of musculoskeletal ailments, there 
is a clear need for expanded access to chiropractic care at VA 
medical facilities. Chiropractic care remains largely 
unavailable at 121, or the majority, of VA's 153 medical 
centers. This means that veterans living in or near major 
metropolitan areas such as Detroit, Denver, and Chicago do not 
have access to chiropractic care at their local VA medical 
center. H.R. 1017 would correct this by requiring the VA to 
phase in the availability of chiropractic care at the remaining 
121 VA medical centers that do not offer such care so that 
veterans can more easily receive medical attention for their 
musculoskeletal ailments.
    In addition to the services provided at current and future 
VA medical center locations, the Committee also expects VA to 
continue to ensure that chiropractic care remains available 
through VA's fee basis program when such care is needed and 
would benefit the health status of an eligible veteran. The 
Committee recognizes that for a veteran to receive the full 
potential benefits of chiropractic care, multiple treatments 
occurring with some frequency may be required. Particularly if 
an eligible veteran lives some distance from a VA medical 
center, requiring multiple trips for chiropractic treatment is 
not always in their best interest.Therefore, the cumulative 
impact of the travel burden on a veteran should be taken into 
consideration as a major factor when consideration is given to 
providing access through VA's fee basis program. Additionally, 
prior to implementation of this legislation, a veteran patient 
may have been receiving care through VA's fee basis program and 
developed a beneficial relationship with a local doctor of 
chiropractic. In such circumstances, the Committee expects VA 
to place great weight and emphasis on the potential benefits of 
allowing such veteran continued access to fee basis local 
chiropractic care regardless of whether or not chiropractic 
care is otherwise available at the nearest VA medical center. 
Accordingly, this legislation should not lessen the use of VA's 
fee basis program as an option and mechanism to ensure system-
wide access to chiropractic care, regardless of whether a VA 
medical center does or does not have doctors of chiropractic on 
staff.
    The Committee expects VA to recruit, hire and place doctors 
of chiropractic on staff in such numbers and at such locations 
as to minimize the need for fee basis referrals and to take 
steps to eliminate excessive waiting times for referrals for 
chiropractic care whether such care is to be provided by 
doctors of chiropractic employed by VA or local doctors of 
chiropractic through VA's fee basis program.

                                Hearings

    On October 1, 2009, the Subcommittee on Health held a 
legislative hearing on several bills introduced in the 111th 
Congress, including H.R. 1017. The following witnesses 
testified: The Honorable Bob Filner of California; The 
Honorable Stephanie Herseth Sandlin of South Dakota; The 
Honorable Phil Hare of Illinois; The Honorable Ciro D. 
Rodriguez of Texas; The Honorable Glenn Nye of Virginia; The 
Honorable Harry Teague of New Mexico; The Honorable Michael A. 
Arcuri of New York; Mr. Joseph Wilson, Deputy Director, 
Veterans Affairs and Rehabilitation Commission, The American 
Legion; Mr. Justin Brown, Legislative Associate, National 
Legislative Service, Veterans of Foreign Wars; Mr. Rick 
Weidman, Executive Director, Policy and Government Affairs, 
Vietnam Veterans of America; Mr. Blake C. Ortner, Senior 
Associate Legislative Director, Paralyzed Veterans of America; 
Mr. Peter H. Dougherty, Director, Homeless Veterans Programs, 
U.S. Department of Veterans Affairs who was accompanied by Mr. 
Paul E. Smits, Associate Chief Consultant, Homeless and 
Residential Rehabilitation and Treatment Programs, U.S. 
Department of Veterans Affairs; and, Ms. Jane Clare Joyner, 
Deputy Assistant General Counsel, U.S. Department of Veterans 
Affairs. Those submitting for the record included: Rick A. 
McMichael, DC, President, American Chiropractic Association; 
the American Physical Therapy Association; and, the American 
Tinnitus Association.

                       Subcommittee Consideration

    On April 29, 2010, the Subcommittee on Health met in open 
markup session and ordered favorably forwarded to the full 
Committee H.R. 1017, as amended, by voice vote. During 
consideration of the bill the following amendment was 
considered:

          An amendment by Mr. Michaud of Maine to update the 
        implementation date for the provision of chiropractic 
        care at additional VA facilities was agreed to by voice 
        vote.

                        Committee Consideration

    On May 12, 2010, the full Committee met in an open markup 
session, a quorum being present, and ordered H.R. 1017, 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. 1017 reported to the House. A motion by Mr. 
Stearns of Florida to order H.R. 1017, 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. 1017 does not contain any congressional earmarks, 
limited tax benefits, or limited tariff benefits as defined in 
clause 9 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. 
1017 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. 1017 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, May 18, 2010.
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. 1017, the 
Chiropractic Care Available to All Veterans 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,
                                      Douglas W. Elmendorf,
                                                          Director.
    Enclosure.

H.R. 1017--Chiropractic Care Available to All Veterans Act

    H.R. 1017 would require the Department of Veterans Affairs 
(VA) to provide chiropractic care to veterans at all VA medical 
centers (VAMCs). CBO estimates that implementing the bill would 
cost $46 million over the 2011-2015 period, assuming 
appropriation of the necessary amounts. Enacting this 
legislation would not affect direct spending or revenues; 
therefore, pay-as-you-go procedures would not apply.
    H.R. 1017 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act and 
would not affect the budgets of state, local, or tribal 
governments.
    The estimated budgetary impact of H.R. 1017 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--
                                                       ---------------------------------------------------------
                                                          2011     2012     2013     2014     2015    2011-2015
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATION

Estimated Authorization Level.........................        3        6       12       13       13           47
Estimated Outlays.....................................        3        6       11       13       13           46
----------------------------------------------------------------------------------------------------------------

    VA currently has 28 chiropractors providing care at 36 
VAMCs. The bill would require VA to provide care at 75 VAMCs by 
the end of calendar year 2011 and at all 153 VAMCs by the end 
of calendar year 2013. Assuming that chiropractic care would be 
provided at the current level of service to individual centers, 
CBO estimates that VA would require 24 additional chiropractors 
in 2011, growing to 93 chiropractors by 2014. Based on an 
average cost per chiropractor of $115,000 in 2010 and after 
adjusting for inflation, CBO estimates that implementing the 
bill would cost $3 million in 2011, growing to $13 million a 
year by 2014.
    The CBO staff contact for this estimate is Sunita D'Monte. 
The estimate was 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. 1017 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. 
1017.

                   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. 1017 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. 1017, as 
amended, as the ``Chiropractic Care Available to All Veterans 
Act.''

Section 2. Program for provision of chiropractic care and services to 
        veterans

    This section requires the Department of Veterans Affairs to 
provide chiropractic care and services to veterans through VA 
medical centers and clinics at no fewer than 75 medical centers 
by December 31, 2011, and at all medical centers by December 
31, 2013.

Section 3. Expanded chiropractor services available to veterans

    This section adds chiropractic examinations and services to 
the list of medical, rehabilitative, and preventive health care 
services that the VA is authorized to provide.

         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 (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, existing law in which no change is 
proposed is shown in roman):

DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE PROGRAMS ENHANCEMENT ACT OF 
2001

           *       *       *       *       *       *       *



TITLE II--OTHER MATTERS

           *       *       *       *       *       *       *



SEC. 204. PROGRAM FOR PROVISION OF CHIROPRACTIC CARE AND SERVICES TO 
                    VETERANS.

  (a) * * *

           *       *       *       *       *       *       *

  (c) Location of Program.--(1) The program shall be carried 
out at sites designated by the Secretary for purposes of the 
program. The Secretary shall designate at least one site for 
such program in each geographic service area of the Veterans 
Health Administration. The sites so designated shall be medical 
centers and clinics located in urban areas and in rural areas.
  (2) The program shall be carried out at not fewer than 75 
medical centers by not later than December 31, 2011, and at all 
medical centers by not later than December 31, 2013.

           *       *       *       *       *       *       *

                              ----------                              


TITLE 38, UNITED STATES CODE

           *       *       *       *       *       *       *


PART II--GENERAL BENEFITS

           *       *       *       *       *       *       *


CHAPTER 17--HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE

           *       *       *       *       *       *       *


                         SUBCHAPTER I--GENERAL

Sec. 1701. Definitions

  For the purposes of this chapter--
  (1) * * *

           *       *       *       *       *       *       *

  (6) The term ``medical services'' includes, in addition to 
medical examination, treatment, and rehabilitative services, 
the following:
          (A) * * *

           *       *       *       *       *       *       *

          (H) Chiropractic services.

           *       *       *       *       *       *       *

  (8) The term ``rehabilitative services'' means such 
professional, counseling, chiropractic, and guidance services 
and treatment programs as are necessary to restore, to the 
maximum extent possible, the physical, mental, and 
psychological functioning of an ill or disabled person.
  (9) The term ``preventive health services'' means--
          (A) * * *

           *       *       *       *       *       *       *

          (F) periodic and preventative chiropractic 
        examinations and services;
          [(F)] (G) immunizations against infectious disease;
          [(G)] (H) prevention of musculoskeletal deformity or 
        other gradually developing disabilities of a metabolic 
        or degenerative nature;
          [(H)] (I) genetic counseling concerning inheritance 
        of genetically determined diseases;
          [(I)] (J) routine vision testing and eye care 
        services;
          [(J)] (K) periodic reexamination of members of likely 
        target populations (high-risk groups) for selected 
        diseases and for functional decline of sensory organs, 
        together with attendant appropriate remedial 
        intervention; and
          [(K)] (L) such other health-care services as the 
        Secretary may determine to be necessary to provide 
        effective and economical preventive health care.

           *       *       *       *       *       *       *