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115th Congress }                                          { REPORT
                        HOUSE OF REPRESENTATIVES
 1st Session   }                                          { 115-267

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

 
 GROW OUR OWN DIRECTIVE: PHYSICIAN ASSISTANT EMPLOYMENT AND EDUCATION 
                              ACT OF 2017

                                _______
                                

 July 28, 2017.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

    Mr. Roe of Tennessee, from the Committee on Veterans' Affairs, 
                        submitted the following

                              R E P O R T

                        [To accompany H.R. 3262]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Veterans' Affairs, to whom was referred 
the bill (H.R. 3262) to require the Secretary of Veterans 
Affairs to carry out a pilot program to provide educational 
assistance to certain former members of the Armed Forces for 
education and training as physician assistants of the 
Department of Veterans Affairs, to establish pay grades and 
require competitive pay for physician assistants of the 
Department, and for other purposes, 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..............................................     6
Background and Need for Legislation..............................     6
Hearings.........................................................     7
Subcommittee Consideration.......................................     7
Committee Consideration..........................................     7
Committee Votes..................................................     7
Committee Oversight Findings.....................................     7
Statement of General Performance Goals and Objectives............     7
New Budget Authority, Entitlement Authority, and Tax Expenditures     8
Earmarks and Tax and Tariff Benefits.............................     8
Committee Cost Estimate..........................................     8
Congressional Budget Office Estimate.............................     8
Federal Mandates Statement.......................................    11
Advisory Committee Statement.....................................    11
Constitutional Authority Statement...............................    11
Applicability to Legislative Branch..............................    12
Statement on Duplication of Federal Programs.....................    12
Disclosure of Directed Rulemaking................................    12
Section-by-Section Analysis of the Legislation...................    12
Changes in Existing Law Made by the Bill as Reported.............    16

    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 ``Grow Our Own Directive: Physician 
Assistant Employment and Education Act of 2017''.

SEC. 2. PILOT PROGRAM TO PROVIDE EDUCATIONAL ASSISTANCE TO PHYSICIAN 
                    ASSISTANTS TO BE EMPLOYED AT THE DEPARTMENT OF 
                    VETERANS AFFAIRS.

  (a) Pilot Program.--
          (1) In general.--The Secretary of Veterans Affairs shall 
        carry out a pilot program to be known as the ``Grow Our Own 
        Directive'' or ``G.O.O.D.'' pilot program (in this section 
        referred to as the ``pilot program'') to provide educational 
        assistance to certain former members of the Armed Forces for 
        education and training as physician assistants of the 
        Department of Veterans Affairs.
          (2) Information on pilot program.--The Secretary shall 
        provide information on the pilot program to eligible 
        individuals under subsection (b), including information on 
        application requirements and a list of entities with which the 
        Secretary has partnered under subsection (g).
  (b) Eligible Individuals.--An individual is eligible to participate 
in the pilot program if the individual--
          (1) has medical or military health experience gained while 
        serving as a member of the Armed Forces;
          (2) has received a certificate, associate degree, 
        baccalaureate degree, master's degree, or postbaccalaureate 
        training in a science relating to health care;
          (3) is not eligible to participate in educational assistance 
        under chapter 30, 31, 32, 33, 34, or 35 of title 38, United 
        States Code, or chapter 1606 or 1607 of title 10, United States 
        Code;
          (4) has participated in the delivery of health care services 
        or related medical services, including participation in 
        military training relating to the identification, evaluation, 
        treatment, and prevention of diseases and disorders; and
          (5) does not have a degree of doctor of medicine, doctor of 
        osteopathy, or doctor of dentistry.
  (c) Duration.--The pilot program shall be carried out during the 
five-year period beginning on the date that is 180 days after the date 
of the enactment of this Act.
  (d) Selection.--
          (1) In general.--The Secretary shall select not less than 250 
        eligible individuals under subsection (b) to participate in the 
        pilot program.
          (2) Priority for selection.--In selecting individuals to 
        participate in the pilot program under paragraph (1), the 
        Secretary shall give priority to the following individuals:
                  (A) Individuals who participated in the Intermediate 
                Care Technician Pilot Program of the Department that 
                was carried out by the Secretary between January 2011 
                and February 2015.
                  (B) Individuals who agree to be employed as a 
                physician assistant for the Veterans Health 
                Administration at a medical facility of the Department 
                located in a community that--
                          (i) is designated as a medically underserved 
                        population under section 330(b)(3)(A) of the 
                        Public Health Service Act (42 U.S.C. 
                        254b(b)(3)(A)); and
                          (ii) is in a State with a per capita 
                        population of veterans of more than 9 percent 
                        according to the National Center for Veterans 
                        Analysis and Statistics and the United States 
                        Census Bureau.
  (e) Educational Assistance.--
          (1) In general.--In carrying out the pilot program, the 
        Secretary shall provide educational assistance to individuals 
        participating in the pilot program, including through the use 
        of scholarships, to cover the costs to such individuals of 
        obtaining a master's degree in physician assistant studies or a 
        similar master's degree.
          (2) Use of existing programs.--In providing educational 
        assistance under paragraph (1), the Secretary shall use the 
        Department of Veterans Affairs Health Professionals Educational 
        Assistance Program under chapter 76 of title 38, United States 
        Code, and such other educational assistance programs of the 
        Department as the Secretary considers appropriate.
          (3) Use of scholarships.--The Secretary shall provide not 
        less than 35 scholarships under the pilot program to 
        individuals participating in the pilot program during each year 
        in which the pilot program is carried out.
  (f) Period of Obligated Service.--
          (1) In general.--The Secretary shall enter into an agreement 
        with each individual participating in the pilot program in 
        which such individual agrees to be employed as a physician 
        assistant for the Veterans Health Administration for a period 
        of obligated service specified in paragraph (2).
          (2) Period specified.--With respect to each individual 
        participating in the pilot program, the period of obligated 
        service specified in this paragraph for the individual is--
                  (A) if the individual is participating in the pilot 
                program through a program described in subsection 
                (e)(2) that specifies a period of obligated service, 
                the period specified with respect to such program; or
                  (B) if the individual is participating in the pilot 
                program other than through a program described in such 
                subsection, or if such program does not specify a 
                period of obligated service, a period of three years or 
                such other period as the Secretary considers 
                appropriate for purposes of the pilot program.
  (g) Breach.--
          (1) Liability.--Except as provided in paragraph (2), an 
        individual who participates in the pilot program and fails to 
        satisfy the period of obligated service under subsection (f) 
        shall be liable to the United States, in lieu of such obligated 
        service, for the amount that has been paid or is payable to or 
        on behalf of the individual under the pilot program, reduced by 
        the proportion that the number of days served for completion of 
        the period of obligated service bears to the total number of 
        days in the period of obligated service of such individual.
          (2) Exception.--If an individual is participating in the 
        pilot program through a program described in subsection (e)(2) 
        that specifies a period of obligated service, the liability of 
        the individual for failing to satisfy the period of obligated 
        service under subsection (f) shall be determined as specified 
        with respect to such program.
  (h) Mentors.--The Secretary shall ensure that a physician assistant 
mentor or mentors are available for individuals participating in the 
pilot program at each facility of the Veterans Health Administration at 
which a participant in the pilot program is employed.
  (i) Partnerships.--In carrying out the pilot program, the Secretary 
shall seek to partner with the following:
          (1) Not less than 15 institutions of higher education that--
                  (A) offer a master's degree program in physician 
                assistant studies or a similar area of study that is 
                accredited by the Accreditation Review Commission on 
                Education for the Physician Assistant; and
                  (B) agree--
                          (i) to guarantee seats in such master's 
                        degree program for individuals participating in 
                        the pilot program who meet the entrance 
                        requirements for such master's degree program; 
                        and
                          (ii) to provide individuals participating in 
                        the pilot program with information on 
                        admissions criteria and the admissions process.
          (2) Other institutions of higher education that offer 
        programs in physician assistant studies or other similar areas 
        of studies that are accredited by the Accreditation Review 
        Commission on Education for the Physician Assistant.
          (3) The Transition Assistance Program of the Department of 
        Defense.
          (4) The Veterans' Employment and Training Service of the 
        Department of Labor.
          (5) Programs carried out under chapter 41 of title 38, United 
        States Code, for the purpose of marketing and advertising the 
        pilot program to veterans and members of the Armed Forces who 
        may be interested in the pilot program.
  (j) Administration of Pilot Program.--For purposes of carrying out 
the pilot program, the Secretary shall appoint or select within the 
Office of Physician Assistant Services of the Veterans Health 
Administration the following:
          (1) A Deputy Director for Education and Career Development of 
        Physician Assistants who--
                  (A) is a physician assistant, a veteran, and employed 
                by the Department as of the date of the enactment of 
                this Act;
                  (B) is responsible for--
                          (i) overseeing the pilot program;
                          (ii) recruiting candidates to participate in 
                        the pilot program;
                          (iii) coordinating with individuals 
                        participating in the pilot program and 
                        assisting those individuals in applying and 
                        being admitted to a master's degree program 
                        under the pilot program; and
                          (iv) providing information to eligible 
                        individuals under subsection (b) with respect 
                        to the pilot program; and
                  (C) may be employed in the field at a medical center 
                of the Department.
          (2) A Deputy Director of Recruitment and Retention who--
                  (A) is a physician assistant, a veteran, and employed 
                by the Department as of the date of the enactment of 
                this Act;
                  (B) is responsible for--
                          (i) identifying and coordinating the needs of 
                        the pilot program and assist the Secretary in 
                        providing mentors under subsection (h) to 
                        participants in the pilot program; and
                          (ii) coordinating the staff of facilities of 
                        the Veterans Health Administration with respect 
                        to identifying employment positions and mentors 
                        under subsection (h) for participants in the 
                        pilot program; and
                  (C) may be employed in the field at a medical center 
                of the Department.
          (3) A recruiter who--
                  (A) reports directly to the Deputy Director of 
                Recruitment and Retention; and
                  (B) works with the Workforce Management and 
                Consulting Office and the Healthcare Talent Management 
                Office of the Veterans Health Administration to develop 
                and implement national recruiting strategic plans for 
                the recruitment and retention of physician assistants 
                within the Department.
          (4) An administrative assistant, compensated at a rate not 
        less than level GS-6 of the General Schedule, or equivalent, 
        who assists with administrative duties relating to the pilot 
        program in the Office of Physician Assistant Services and such 
        other duties as determined by the Secretary to ensure that the 
        Office runs effectively and efficiently.
  (k) Report.--
          (1) In general.--Not later than one year after the date of 
        the enactment of this Act, the Secretary of Veterans Affairs, 
        in collaboration with the Secretary of Labor, the Secretary of 
        Defense, and the Secretary of Health and Human Services, shall 
        submit to Congress a report on the pilot program.
          (2) Elements.--The report required by paragraph (1) shall 
        include the following:
                  (A) The extent to which the pilot program is 
                effective in improving the ability of eligible 
                individuals under subsection (b) to become physician 
                assistants;
                  (B) An examination of whether the pilot program is 
                achieving the goals of--
                          (i) enabling individuals to build on medical 
                        skills gained as members of the Armed Forces by 
                        entering into the physician assistant workforce 
                        of the Department; and
                          (ii) helping to meet the shortage of 
                        physician assistants employed by the 
                        Department.
                  (C) An identification of such modifications to the 
                pilot program as the Secretary of Veterans Affairs, the 
                Secretary of Labor, the Secretary of Defense, and the 
                Secretary of Health and Human Services consider 
                necessary to meet the goals described in subparagraph 
                (B).
                  (D) An assessment of whether the pilot program could 
                serve as a model for other programs of the Department 
                to assist individuals in obtaining certification and 
                employment in other health care fields.
  (l) Source of Amounts.--Not less than $8,000,000 of the amount 
necessary to carry out the pilot program shall be derived from amounts 
appropriated to the Department of Veterans Affairs before the date of 
the enactment of this Act.

SEC. 3. ESTABLISHMENT OF STANDARDS FOR THE DEPARTMENT OF VETERANS 
                    AFFAIRS FOR USING EDUCATIONAL ASSISTANCE PROGRAMS 
                    TO EDUCATE AND HIRE PHYSICIAN ASSISTANTS.

  (a) In General.--The Secretary of Veterans Affairs shall establish 
standards described in subsection (b) to improve the use by the 
Department of Veterans Affairs of the Department of Veterans Affairs 
Health Professionals Educational Assistance Program under chapter 76 of 
title 38, United States Code, and other educational assistance programs 
of the Department, including the pilot program under section 2, to 
educate and hire physician assistants of the Department.
  (b) Standards.--The standards described in this subsection are the 
following:
          (1) Holding directors of medical centers of the Department 
        accountable for failure to use the educational assistance 
        programs described in subsection (a) and other incentives--
                  (A) to advance employees of the Department in their 
                education as physician assistants; and
                  (B) to improve recruitment and retention of physician 
                assistants.
          (2) Ensuring that the Department of Veterans Affairs 
        Education Debt Reduction Program under subchapter VII of 
        chapter 76 of such title is available for participants in the 
        pilot program under section 2 to fill vacant physician 
        assistant positions at the Department, including by--
                  (A) including in all vacancy announcements for 
                physician assistant positions the availability of the 
                Education Debt Reduction Program; and
                  (B) informing applicants to physician assistant 
                positions of their eligibility for the Education Debt 
                Reduction Program.
          (3) Monitoring compliance with the application process for 
        educational assistance programs described in subsection (a) to 
        ensure that such programs are being fully utilized to carry out 
        this section.
          (4) Creating programs, including through the use of the 
        Department of Veterans Affairs Employee Incentive Scholarship 
        Program under subchapter VI of chapter 76 of such title, to 
        encourage employees of the Department to apply to accredited 
        physician assistant programs.
  (c) Regulations.--The Secretary shall prescribe such regulations as 
the Secretary considers appropriate to carry out this section.

SEC. 4. ESTABLISHMENT OF PAY GRADES FOR PHYSICIAN ASSISTANTS OF THE 
                    DEPARTMENT OF VETERANS AFFAIRS AND REQUIREMENT TO 
                    PROVIDE COMPETITIVE PAY.

  (a) Establishment of Pay Grades.--Section 7404(b) of title 38, United 
States Code, is amended by adding at the end the following:

``PHYSICIAN ASSISTANT SCHEDULE
``Physician Assistant IV.
``Physician Assistant III.
``Physician Assistant II.
``Physician Assistant I.''.

  (b) Competitive Pay.--Section 7451(a)(2) of such title is amended--
          (1) by redesignating subparagraph (B) as subparagraph (C);
          (2) by inserting after subparagraph (A) the following new 
        subparagraph (B):
                  ``(B) Physician assistant.''; and
          (3) in subparagraph (C), as redesignated by paragraph (1), by 
        striking ``and registered nurse'' and inserting ``registered 
        nurse, and physician assistant''.
  (c) National Strategic Plan.--
          (1) In general.--The Secretary of Veterans Affairs shall 
        implement a national strategic plan for the retention and 
        recruitment of physician assistants of the Department of 
        Veterans Affairs that includes the establishment and adoption 
        of standards for the provision of competitive pay to physician 
        assistants of the Department in comparison to the pay of 
        physician assistants in the private sector.
          (2) Report.--Not later than one year after the date of the 
        enactment of this Act, the Secretary shall submit to the 
        Committee on Veterans' Affairs of the Senate and the Committee 
        on Veterans' Affairs of the House of Representatives a report 
        on the implementation of the national strategic plan under 
        paragraph (1).

SEC. 5. EXTENSION OF REQUIREMENT FOR COLLECTION OF FEES FOR HOUSING 
                    LOANS GUARANTEED BY SECRETARY OF VETERANS AFFAIRS.

  Section 3729(b)(2) of title 38, United States Code, is amended--
          (1) in subparagraph (A)--
                  (A) in clause (iii), by striking ``September 30, 
                2024'' and inserting ``December 31, 2024''; and
                  (B) in clause (iv), by striking ``September 30, 
                2024'' and inserting ``December 31, 2024'';
          (2) in subparagraph (B)--
                  (A) in clause (i), by striking ``September 30, 2024'' 
                and inserting ``December 31, 2024''; and
                  (B) in clause (ii), by striking ``September 30, 
                2024'' and inserting ``December 31, 2024'';
          (3) in subparagraph (C)--
                  (A) in clause (i), by striking ``September 30, 2024'' 
                and inserting ``December 31, 2024''; and
                  (B) in clause (ii), by striking ``September 30, 
                2024'' and inserting ``December 31, 2024''; and
          (4) in subparagraph (D)--
                  (A) in clause (i), by striking ``September 30, 2024'' 
                and inserting ``December 31, 2024''; and
                  (B) in clause (ii), by striking ``September 30, 
                2024'' and inserting ``December 31, 2024''.

                          Purpose and Summary

    H.R. 3262, the ``Grow Our Own Directive: Physician 
Assistant Employment and Education Act of 2017,'' was 
introduced by Representative Ann McLane Kuster of New Hampshire 
on July 17, 2017. The bill, as amended, was ordered to be 
favorably reported to the full House on July 19, 2017, by voice 
vote.
    H.R. 3262, as amended, would direct the Department of 
Veterans Affairs (VA) to carry out the Grow Our Own Directive--
or, G.O.O.D.--pilot program to provide educational assistance 
to certain former members of the Armed Forces for education and 
training as VA physician assistants (PAs).

                  Background and Need for Legislation

    The PA profession started in the mid-1960s in response to a 
nationwide shortage of primary care physicians. The first class 
of PAs were primarily composed of Army medics and Navy corpsman 
who had served in the Vietnam War. The significant number of 
veterans working as PAs has continued since that time and is 
illustrative of the unique relationship veterans and the VA 
health care system have historically had with the PA 
profession. According to testimony from the VA Physician 
Assistants Association (VAPAA), VA is the largest single 
federal employer of PAs, and a quarter of all primary care 
patients in the VA health care system are seen by PAs.\1\ 
However, VA has experienced recent difficulties recruiting and 
retaining PAs within the VA health care system, and as such, 
PAs are a top 5 mission-critical occupation for VA, ranking 
fourth according to a January 2015 VA Office of Inspector 
General (OIG) report.\2\
---------------------------------------------------------------------------
    \1\May 15, 2015, Subcommittee on Health hearing, ``Overcoming 
Barriers to More Efficient and Effective VA Staffing,'' http://
veterans.house.gov/hearing/overcoming-barriers-to-more-efficient-and-
effective-va-staffing.
    \2\January 30, 2015, VA Inspector General report, ``Determination 
of VHA Occupational Staffing Shortages,'' http://www.va.gov/oig/pubs/
VAOIG-15-00430-103.pdf.
---------------------------------------------------------------------------
    The Committee believes that PAs are critical to VA's 
ability to provide access to timely, high-quality care to 
veteran patients and encourages VA to prioritize recruitment 
and retention of PAs within the VA health care system. As such, 
the bill would require VA to carry out the G.O.O.D. pilot for 
five years to assist certain veterans in obtaining education 
and training as PAs. Individuals eligible to participate in the 
G.O.O.D. pilot would include those with medical or military 
health experience who have received a certificate, associate 
degree, baccalaureate degree, master's degree, or post-
baccalaureate training in a science relating to health care and 
that have participated in the delivery of health care services 
or related medical services but do not have a doctor of 
medicine, doctor of osteopathy, or doctor of dentistry degree. 
VA would be required to select not less than 250 eligible 
individuals to participate in the pilot and give priority to 
those who participated in the VA Intermediate Care Technician 
pilot program and who agree to work as a PA at VA medical 
facilities in medically underserved communities or in states 
with a per capita population of veterans of more than nine 
percent. The bill would also require VA to provide educational 
assistance--to include not less than 35 scholarships--to 
individuals participating in the pilot program through the VA 
Health Professionals Educational Assistance program, to enter 
into an agreement for a period of obligated service with each 
individual participating in the pilot program who agrees to 
work as a VA PA, and to ensure PA mentors are available for 
pilot program participants. Finally, the bill would require VA 
to appoint a Deputy Director for PA Education and Career 
Development and a Deputy Director for Recruitment and Retention 
from within the VA Office of PAs and to submit a report to 
Congress on the pilot program one year after enactment.

                                Hearings

    There were no full Committee hearings held on H.R. 3262, as 
amended.
    There were no Subcommittee hearings held on H.R. 3262, as 
amended.

                       Subcommittee Consideration

    There were no Subcommittee markups involving H.R. 3262, as 
amended.

                        Committee Consideration

    On July 19, 2017, the full Committee met in open markup 
session, a quorum being present, and ordered H.R. 3262, as 
amended, reported favorably to the House of Representatives by 
voice vote.
    During consideration of the bill, the following amendment 
in the nature of a substitute was considered and agreed to by 
voice vote:

        An Amendment in the Nature of a Substitute to H.R., 
        3262 as amended, offered by Representative Ann McLane 
        Kuster of New Hampshire.

    A motion by Representative Tim Walz of Minnesota to 
favorably report H.R. 3262, as amended, to the House of 
Representatives was agreed to by voice vote.

                            Committee Votes

    In compliance with clause 3(b) of rule XIII of the Rules of 
the House of Representatives, there were no recorded votes 
taken on amendments or in connection with ordering H.R. 3262, 
as amended, reported to the House.

                      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 to ensure VA provides educational 
assistance to certain former members of the Armed Forces for 
education and training as VA physician assistants and increases 
access to care for veteran patients through the increased 
availability of VA physician assistants.

   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. 3262, as amended, 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. 
3262, as amended, 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. 3262, as amended, provided by the Congressional Budget 
Office pursuant to section 402 of the Congressional Budget Act 
of 1974:

                                     U.S. Congress,
                               Congressional Budget Office,
                                     Washington, DC, July 24, 2017.
Hon. Phil Roe, M.D.,
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. 3262, the Grow Our 
Own Directive: Physician Assistant Employment and Education Act 
of 2027.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Ann E. 
Futrell.
            Sincerely,
                                             Mark P. Hadley
                                        (For Keith Hall, Director).
    Enclosure.

H.R. 3262--Grow Our Own Directive: Physician Assistant Employment and 
        Education Act of 2017

    Summary: H.R. 3262 would require the Department of Veterans 
Affairs (VA) to modify compensation levels for physician 
assistants (PAs) and to carry out a five-year pilot program to 
provide educational assistance to veterans training to be PAs 
at the department. CBO estimates that implementing the bill 
would cost $120 million over the 2017-2022 period, assuming 
appropriation of the necessary amounts.
    The bill also would increase the fees charged to certain 
veterans who obtain loans guaranteed by VA. CBO estimates that 
enacting H.R. 3262 would decrease direct spending by $83 
million over the 2017-2027 period. Because enacting the 
legislation would affect direct spending, pay-as-you-go 
procedures apply. Enacting the bill would not affect revenues.
    CBO estimates that enacting H.R. 3262 would not increase 
net direct spending or on-budget deficits in any of the four 
consecutive 10-year periods beginning in 2028.
    H.R. 3262 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA) 
and would impose no costs on state, local, or tribal 
governments.
    Estimated cost to the Federal Government: The estimated 
budgetary effect of H.R. 3262 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--
                                          ----------------------------------------------------------------------
                                             2017      2018      2019      2020      2021      2022    2017-2022
----------------------------------------------------------------------------------------------------------------
                                 INCREASES IN SPENDING SUBJECT TO APPROPRIATION
 
Competitive Pay for Physician Assistants:
    Estimated Authorization Level........         0        12        18        18        21        23         92
    Estimated Outlays....................         0        10        17        17        20        22         86
Pilot Program:
    Estimated Authorization Level........         0         2         7        10        11         6         36
    Estimated Outlays....................         0         2         6         9        11         6         34
    Total Changes
        Estimated Authorization Level....         0        14        25        28        32        29        128
        Estimated Outlays................         0        12        23        26        31        28        120
----------------------------------------------------------------------------------------------------------------
Note: In addition to the costs shown above, enacting H.R. 3262 would decrease mandatory spending by $83 million
  in 2025.

    Basis of estimate: For this estimate, CBO assumes that H.R. 
3262 will be enacted near the start of 2018, that the estimated 
amounts will be appropriated each year, and that outlays will 
follow historical spending patterns for affected programs.

Spending subject to appropriation

    CBO estimates that implementing H.R. 3262 would increase 
personnel and administrative costs at VA by a total of $120 
million over the 2017-2022 period, subject to appropriation of 
the necessary amounts.
    Competitive Pay for Physician Assistants. Section 4 would 
require VA to compensate PAs at rates that are competitive with 
those paid by other health care providers. Currently, VA 
employs about 2,200 physician assistants. Based on wages paid 
in the private sector, CBO estimates that pay for those 
employees would increase by 5 percent in 2018 (from $114,000 to 
$120,000) if VA paid competitive rates. In addition, CBO 
expects that the higher pay level would help ameliorate VA's 
current difficulties in recruiting and retaining physicians 
assistants and would thus increase the total number of PAs 
employed by VA. Based on data from VA on hiring and retaining 
nurses who are paid at competitive rates, CBO estimates that 
under the bill VA would increase the number of PAs it employs 
by about 4 percent above the current staffing level. On that 
basis, CBO estimates that implementing the section would cost 
$86 million over the 2017-2022 period.
    Pilot Program. One of VA's largest staffing shortages is 
for PAs. Section 2 would require VA to establish a five-year 
pilot program to improve the recruitment and retention of PAs 
by providing educational assistance to certain former members 
of the Armed Forces. Participants in the pilot program must 
agree to work as PAs for VA for at least three years. The pilot 
program would offer scholarships to at least 250 candidates and 
provide no less than 35 scholarships each year.
    A master's degree program in physician assistant studies 
takes two years to complete, with an average annual cost of 
$40,000. CBO expects that VA would cover the full tuition of 35 
people in 2018 and up to 145 people a year by 2021. After 
accounting for anticipated inflation, CBO estimates that costs 
for tuition would total $30 million over the 2017-2022 period.
    Section 2 also would require VA to hire two senior 
administrators to oversee and coordinate the pilot program. On 
the basis of information from VA on salaries of senior 
officials, CBO estimates that the salary and fringe benefits 
would be roughly $150,000 (the equivalent of a GS-15 level) for 
each person. In addition, CBO expects VA would need to hire a 
recruiter, with annual costs of $70,000, and an administrative 
assistant, with annual costs of $47,000. In total, CBO 
estimates that the administrative costs of implementing the 
pilot program would be $4 million over the 2017-2022 period.

Direct spending

    Under its Home Loan program, VA guarantees mortgages made 
to veterans; those guarantees enable veterans to get better 
loan terms, such as lower interest rates or smaller down 
payments. The loan guarantee provides a lender a payment of up 
to 25 percent of the outstanding loan balances (subject to some 
limitations on the original loan amounts) in the event that a 
veteran defaults on a guaranteed loan. Section 3 would increase 
some of the fees that VA charges veterans for providing those 
guarantees. Those fees lower the subsidy cost of the guarantees 
by partially offsetting the costs of subsequent defaults.\1\
---------------------------------------------------------------------------
    \1\Under the Federal Credit Reform Act of 1990, the subsidy cost of 
a loan guarantee is the net present value of estimated payments by the 
government to cover defaults and delinquencies, interest subsidies, or 
other expenses, offset by any payments to the government, including 
origination fees, other fees, penalties, and recoveries on defaulted 
loans. Such subsidy costs are calculated by discounting those expected 
cash flows using the rate on Treasury securities of comparable 
maturity. The resulting estimated subsidy costs are recorded in the 
budget when the loans are disbursed.
---------------------------------------------------------------------------
    Under current law, the up-front fee varies on the basis of 
the size of the down payment and whether the veteran has 
previously used the loan-guarantee benefit. Borrowers who are 
members of the reserve component pay an additional fee of 0.25 
percent of the loan amount. Veterans who receive compensation 
for service-connected disabilities are exempt from paying the 
fee. The current fees that would be affected by section 5 are:

           2.15 percent of the loan amount for loans 
        with no down payment,
           1.50 percent of the loan amount for loans 
        with a 5 percent down payment, and
           0.75 percent of the loan amount for loans 
        with a 10 percent down payment.

    Those fees are scheduled to decline on October 1, 2024, to 
1.40 percent, 0.75 percent, and 0.50 percent, respectively.
    Under section 5, that scheduled fee reduction would be 
delayed by three months, until December 31, 2024. Continuing 
the fees at their current level would increase collections by 
VA, thereby lowering the subsidy cost of the loan guarantees. 
Based on data from VA, CBO estimates that enacting section 5 
would reduce direct spending by $83 million in 2025.
    Pay-As-You-Go considerations: The Statutory Pay-As-You-Go 
Act of 2010 establishes budget-reporting and enforcement 
procedures for legislation affecting direct spending or 
revenues. The net changes in outlays that are subject to those 
pay-as-you-go procedures are shown in the following table.

  CBO ESTIMATE OF PAY-AS-YOU-GO EFFECTS FOR H.R. 3262, THE GROW OUR OWN DIRECTIVE: PHYSICIAN ASSISTANT EMPLOYMENT AND EDUCATION ACT OF 2017, AS ORDERED
                                          REPORTED BY THE HOUSE COMMITTEE ON VETERANS' AFFAIRS ON JULY 19, 2017
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                   By fiscal year, in millions of dollars--
                                                     ---------------------------------------------------------------------------------------------------
                                                       2017   2018   2019   2020   2021   2022   2023   2024   2025    2026   2027  2017-2022  2017-2027
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                 NET INCREASE OR DECREASE (-) IN THE [ON-BUDGET] DEFICIT
 
Statutory Pay-As-You-Go Impact                            0      0      0      0      0      0      0      0     -83      0      0         0        -83
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Increase in long-term direct spending and deficits: CBO 
estimates that enacting H.R. 3262 would not increase net direct 
spending or on-budget deficits in any of the four consecutive 
10-year periods beginning in 2028.
    Intergovernmental and private-sector impact: H.R. 3262 
contains no intergovernmental or private-sector mandates as 
defined in UMRA and would impose no costs on state, local, or 
tribal governments.
    Estimate prepared by: Federal costs: Ann E. Futrell and 
Dwayne M. Wright; Impact on state, local, and tribal 
governments: Jon Sperl; Impact on the private sector: Paige 
Piper/Bach.
    Estimate approved by: H. Samuel Papenfuss, Deputy Assistant 
Director for Budget Analysis.

                       Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates regarding H.R. 3262, as amended, 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. 
3262, as amended.

                 Statement of Constitutional Authority

    Pursuant to Article I, section 8 of the United States 
Constitution, H.R. 3262, as amended, is authorized by Congress' 
power to ``provide for the common Defense and general Welfare 
of the United States.''

                  Applicability to Legislative Branch

    The Committee finds that H.R. 3262, as amended, 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.

              Statement on Duplication of Federal Programs

    Pursuant to section 3(g) of H. Res. 5, 115th Cong. (2017), 
the Committee finds that no provision of H.R. 3262, as amended, 
establishes or reauthorizes a program of the Federal Government 
known to be duplicative of another Federal program, a program 
that was included in any report from the Government 
Accountability Office to Congress pursuant to section 21 of 
Public Law 111-139, or a program related to a program 
identified in the most recent Catalog of Federal Domestic 
Assistance.

                   Disclosure of Directed Rulemaking

    Pursuant to section 3(i) of H. Res. 5, 115th Cong. (2017), 
the Committee estimates that H.R. 3262, as amended, contains no 
directed rule making that would require the Secretary to 
prescribe regulations.

             Section-by-Section Analysis of the Legislation


Section 1. Short title

    Section 1 of the bill would provide a short title of H.R. 
3262, as amended, as the ''Grow Our Own Directive: Physician 
Assistant Employment and Education Act of 2017''.

Section 2. Pilot program to provide educational assistance to be 
        employed at the Department of Veterans Affairs

    Section 2(a) of the bill would require VA to carry out a 
pilot program called the ``Grow Our Own Directive'' (or, 
``G.O.O.D.'') to provide assistance to certain former members 
of the Armed Forces for education and training as VA physician 
assistants. Section 2(a) would also require VA to provide 
relevant information--to include information regarding the 
application process and a list of entities with which VA has 
partnered--to individuals eligible for the G.O.O.D. pilot.
    Section 2(b) of the bill would require that the eligibility 
criteria for the G.O.O.D. pilot be defined as follows: (1) 
possession of medical or military health experience gained 
while serving as a member of the Armed Forces; (2) possession 
of a certificate, associate degree, baccalaureate degree, 
master's degree, or post baccalaureate training in a science 
relating to health care; (3) is not eligible to participate in 
education assistance under chapter 30, 31, 32, 33, 34, or 55 of 
title 38, U.S.C., or chapter 1606 or 1607 of title 10, U.S.C.; 
(4) participation in the delivery of health care services or 
related medical services, including military training relating 
to identification, evaluation, treatment, and prevention of 
diseases and disorders; and, (5) is not a doctor of medicine, 
doctor of osteopathy, or doctor of dentistry degree.
    Section 2(c) of the bill would require that the G.O.O.D. 
pilot be carried out for five years, beginning 180 days after 
the date of enactment.
    Section 2(d) of the bill would require VA to select at 
least 250 eligible individuals to participate in the G.O.O.D. 
pilot. This section would stipulate that in selecting eligible 
individuals, VA must give priority to those who participated in 
the Intermediate Care Technician pilot program and those who 
agree to be employed as a physician assistant at a VA facility 
in a community that is designated as serving a medically 
underserved population in a state with a per capita veteran 
population of more than nine percent.
    Section 2(e) of the bill would require VA to provide 
assistance, including through scholarships, to individuals 
participating in the G.O.O.D. pilot to cover the costs of 
obtaining a master's degree in physician assistant studies or a 
similar master's degree. VA would also be required to use the 
VA Health Professionals Education Assistance Program and such 
other educational assistance programs as considered appropriate 
to individuals participating in the G.O.O.D. pilot. VA would be 
required to provide at least 35 scholarships to individuals 
participating in the G.O.O.D. pilot during each year in which 
the pilot is carried out.
    Section 2(f) of the bill would require VA to enter into 
agreements with each G.O.O.D. pilot participant stipulating 
that the participant will be employed as a VA physician 
assistant for a period of three years, unless a participating 
individual is in a program described in subsection (e)(2) of 
the bill and that program specified a period of time during 
which that individual agreed to work for VA.
    Section 2(g) of the bill would require that an individual 
who participated in the G.O.O.D. pilot and who fails to satisfy 
the period of obligated service described in subsection (f)(2) 
of the bill is liable for the amount that has been paid or is 
payable to or on behalf of the individual reduced by the number 
of days served for completion of the period of obligated 
service. If an individual is participating in the G.O.O.D. 
pilot through a program described in subsection (e)(2) that 
specifies a period of obligated service, the liability of the 
individual for failing to satisfy the period of obligated 
service under subsection (f)(1) would be determined as 
specified with respect to such program.
    Section 2(h) of the bill would require VA to ensure 
physician assistant mentors are available for individuals 
participating in the G.O.O.D. pilot at each VA facility at 
which pilot participants are working.
    Section 2(i) of the bill would require that, in carrying 
out the G.O.O.D. pilot, VA seek to partner with: (1) at least 
15 institutions of higher education that offer a master's 
degree program in physician assistant studies or a similar area 
of study that is accredited by the Accreditation Review 
Commission on Education for the Physician Assistant and that 
agree to guarantee seats in such programs for individuals 
participating in the G.O.O.D. pilot who meet the entrance 
requirements and to provide pilot participants with information 
on admissions; (2) other institutions of higher education that 
offer programs in physician assistant studies or other similar 
areas of studies that are accredited by the Accreditation 
Review Commission on Education for the Physician Assistant; (3) 
the Department of Defense Transition Assistance Program; (4) 
the Department of Labor Veterans' Employment and Training 
Service; and (5) programs carried out under chapter 41 of title 
38, U.S.C., for the purpose of marketing and advertising the 
G.O.O.D. pilot to veterans and members of the Armed Forces who 
may be interested.
    Section 2(j) of the bill would require that, for the 
purposes of carrying out the G.O.O.D. pilot, VA appoint from 
within the Office of Physician Assistants, a Deputy Director 
for Education and Career Development of Physician Assistants 
who is a physician assistant, a veteran, and a VAemployee to be 
responsible for the following: (1) overseeing the G.O.O.D. pilot; (2) 
recruiting candidates to participate in the G.O.O.D. pilot; (3) 
coordinating with individuals participating in the G.O.O.D. pilot; and 
(4) assisting individuals participating in the G.O.O.D. pilot in 
applying to master's programs. VA would also be required to select a 
Deputy Director of Recruitment and Retention who is a physician 
assistant employed by VA to be responsible for: (1) identifying and 
coordinating the needs of the pilot program; (2) assisting VA in 
providing mentors to G.O.O.D. pilot participants; and (3) coordinating 
VA facility staff with respect to identifying employment positions and 
mentors. This section would also require VA to select a recruiter to 
report directly to the Deputy Director of Recruitment and Retention and 
work with the Workforce Management and Consulting Office and the 
Healthcare Talent Management Office to develop and implement national 
recruiting strategic plans for the recruitment and retention of VA 
physician assistants. Further, section 2(j) of the bill would require 
VA to select an administrative assistant, compensated at a rate not 
less than level GS-6 or equivalent, to assist with administrative 
duties relating to the G.O.O.D. pilot in the Office of Physician 
Assistant Services and such other duties as determined by the Secretary 
to ensure that the Office runs effectively and efficiently.
    Section 2(k) of the bill would require that, within one 
year of enactment, VA submit to Congress a report on the pilot 
program, in collaboration with the Department of Labor, the 
Department of Defense, and the Department of Health and Human 
Services. The report must include: (1) the extent to which the 
G.O.O.D. pilot is effective in improving the ability of 
participants to become physician assistants; (2) an examination 
of whether the G.O.O.D. pilot is achieving the goal of enabling 
individuals to build on medical skills gained as members of the 
Armed Forces by entering into the VA physician assistant 
workforce and helping to meet the shortage of physician 
assistants employed by VA; (3) an identification of such 
modifications to the pilot program as considered necessary; and 
(4) an assessment of whether the G.O.O.D. pilot could serve as 
a model for other VA programs.
    Section 2(l) of the bill would require that no less than 
$8,000,000 of the amount necessary to carry out the pilot 
program be derived from amounts appropriated to VA before the 
date of the enactment of this act.

Section 3. Establishment of standards for the Department of Veterans 
        Affairs for using educational assistance programs to educate 
        and hire physician assistants

    Section 3(a) of the bill would require VA to establish 
standards described in subsection (b) to improve VA's use of 
the Department's Health Professionals Educational Assistance 
Program under chapter 76 of title 38, U.S.C., and other VA 
educational assistance programs, including the G.O.O.D. pilot, 
to educate and hire physician assistants in VA.
    Section 3(b) of the bill would require that the standards 
described consist of the following: (1) holding directors of 
medical centers of the Department accountable for failure to 
use the educational assistance programs described in subsection 
(a) and other incentives to advance employees of the Department 
in their education as physician assistants and to improve 
recruitment and retention of physician assistants; (2) ensuring 
that the Department of Veterans Affairs Education Debt 
Reduction Program under subchapter VII of chapter 76 of such 
title is available for participants in the pilot program under 
section 2 to fill vacant physician assistant positions at the 
Department, including by including in all vacancy announcements 
for physician assistant positions the availability of the 
Education Debt Reduction Program, and informing applicants to 
physician assistant positions of their eligibility for the 
Education Debt Reduction Program; (3) Monitoring compliance 
with the application process for educational assistance 
programs described in subsection (a) to ensure that such 
programs are being fully utilized to carry out this section; 
and, Creating programs, including through the use of the 
Department of Veterans Affairs Employee Incentive Scholarship 
Program under subchapter VI of chapter 76 of such title, to 
encourage employees of the Department to apply to accredited 
physician assistant programs.
    Section 3(c) of the bill would require that VA prescribe 
such regulations as the Secretary considers appropriate to 
carry out this section.

Section 4. Establishment of pay grades for physician assistants of the 
        Department of Veterans Affairs and requirement to provide 
        competitive pay

    Section 4(a) of the bill would amend section 7404(b) of 
title 38, U.S.C., by adding at the end, ``PHYSICIAN ASSISTANT 
SCHEDULE,'' ``Physician Assistant IV,'' ``Physician Assistant 
III,'' ``Physician Assistant II,'' and ``Physician Assistant 
I.''
    Section 4(b) of the bill would amend section 7451(a)(2) by 
redesignating subparagraph (B) as subparagraph (C); by 
inserting after subparagraph (A) the following new subparagraph 
(B): `(B) Physician assistant.''; and, in subparagraph (C), as 
redesignated by paragraph (1), by striking ``and registered 
nurse'' and inserting ``registered nurse, and physician 
assistant''.
    Section 4(c) of the bill would require that VA implement a 
national strategic plan for the retention and recruitment of VA 
physician assistants that includes the establishment and 
adoption of standards for the provision of competitive pay to 
physician assistants of the Department in comparison to the pay 
of physician assistants in the private sector. This section 
would also require that no later than one year after the date 
of the enactment of this act, the Secretary shall submit to the 
Committee on Veterans' Affairs of the Senate and the Committee 
on Veterans' Affairs of the House of Representatives a report 
on the implementation of the national strategic plan under 
paragraph (1).

Section 5. Extension of requirement for collection of fees for housing 
        loans guaranteed by Secretary of Veterans Affairs

    Section 3 of the bill would amend section 3729(b)(2) of 
title 38, U.S.C. clause (iii) in subparagraph (A) by striking 
``September 30, 2024'' and inserting ``September 30, 2025;'' 
clause (iv) in subparagraph (A) by striking ``September 30, 
2024'' and inserting ``September 30, 2025;'' clause (i) in 
subparagraph (B) by striking ``September 30, 2024'' and 
inserting ``September 30, 2025;'' clause (ii) in subparagraph 
(B) by striking ``September 30, 2024'' and inserting 
``September 30, 2025;'' clause (i) in subparagraph (C) by 
striking ``September 30, 2024'' and inserting ``September 30, 
2025;'' clause (ii) in subparagraph (C) by striking ``September 
30, 2024'' and inserting ``September 30, 2025;'' clause (i) in 
subparagraph (D) by striking ``September 30, 2024'' and 
inserting ``September 30, 2025;'' and, clause (ii) in 
subparagraph (D) by striking ``September 30, 2024'' and 
inserting ``September 30, 2025.''

         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):

         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, and existing law in which no 
change is proposed is shown in roman):

                      TITLE 38, UNITED STATES CODE




           *       *       *       *       *       *       *
PART III--READJUSTMENT AND RELATED BENEFITS

           *       *       *       *       *       *       *


CHAPTER 37--HOUSING AND SMALL BUSINESS LOANS

           *       *       *       *       *       *       *



Subchapter III--ADMINISTRATIVE PROVISIONS

           *       *       *       *       *       *       *


Sec. 3729. Loan fee

  (a) Requirement of Fee.--(1) Except as provided in subsection 
(c), a fee shall be collected from each person obtaining a 
housing loan guaranteed, insured, or made under this chapter, 
and each person assuming a loan to which section 3714 of this 
title applies. No such loan may be guaranteed, insured, made, 
or assumed until the fee payable under this section has been 
remitted to the Secretary.
          (2) The fee may be included in the loan and paid from 
        the proceeds thereof.
  (b) Determination of Fee.--(1) The amount of the fee shall be 
determined from the loan fee table in paragraph (2). The fee is 
expressed as a percentage of the total amount of the loan 
guaranteed, insured, or made, or, in the case of a loan 
assumption, the unpaid principal balance of the loan on the 
date of the transfer of the property.
  (2) The loan fee table referred to in paragraph (1) is as 
follows:


                             LOAN FEE TABLE
------------------------------------------------------------------------
                   Active duty
 Type of loan        veteran            Reservist         Other obligor
------------------------------------------------------------------------
(A)(i) Initial  2.00               2.75                 NA
 loan
 described in
 section
 3710(a) to
 purchase or
 construct a
 dwelling with
 0-down, or
 any other
 initial loan
 described in
 section
 3710(a) other
 than with 5-
 down or 10-
 down (closed
 before
 January 1,
 2004)
(A)(ii)         2.20               2.40                 NA
 Initial loan
 described in
 section
 3710(a) to
 purchase or
 construct a
 dwelling with
 0-down, or
 any other
 initial loan
 described in
 section
 3710(a) other
 than with 5-
 down or 10-
 down (closed
 on or after
 January 1,
 2004, and
 before
 October 1,
 2004)
(A)(iii)        2.15               2.40                 NA
 Initial loan
 described in
 section
 3710(a) to
 purchase or
 construct a
 dwelling with
 0-down, or
 any other
 initial loan
 described in
 section
 3710(a) other
 than with 5-
 down or 10-
 down (closed
 on or after
 October 1,
 2004, and
 before
 [September
 30, 2024]
 December 31,
 2024 )
(A)(iv)         1.40               1.65                 NA
 Initial loan
 described in
 section
 3710(a) to
 purchase or
 construct a
 dwelling with
 0-down, or
 any other
 initial loan
 described in
 section
 3710(a) other
 than with 5-
 down or 10-
 down (closed
 on or after
 [September
 30, 2024]
 December 31,
 2024 )
(B)(i)          3.30               3.30                 NA
 Subsequent
 loan
 described in
 section
 3710(a) to
 purchase or
 construct a
 dwelling with
 0-down, or
 any other
 subsequent
 loan
 described in
 section
 3710(a)
 (closed
 before
 [September
 30, 2024]
 December 31,
 2024 )
(B)(ii)         1.25               1.25                 NA
 Subsequent
 loan
 described in
 section
 3710(a) to
 purchase or
 construct a
 dwelling with
 0-down, or
 any other
 subsequent
 loan
 described in
 section
 3710(a)
 (closed on or
 after
 [September
 30, 2024]
 December 31,
 2024 )
(C)(i) Loan     1.50               1.75                 NA
 described in
 section
 3710(a) to
 purchase or
 construct a
 dwelling with
 5-down
 (closed
 before
 [September
 30, 2024]
 December 31,
 2024 )
(C)(ii) Loan    0.75               1.00                 NA
 described in
 section
 3710(a) to
 purchase or
 construct a
 dwelling with
 5-down
 (closed on or
 after
 [September
 30, 2024]
 December 31,
 2024 )
(D)(i) Initial  1.25               1.50                 NA
 loan
 described in
 section
 3710(a) to
 purchase or
 construct a
 dwelling with
 10-down
 (closed
 before
 [September
 30, 2024]
 December 31,
 2024 )
(D)(ii)         0.50               0.75                 NA
 Initial loan
 described in
 section
 3710(a) to
 purchase or
 construct a
 dwelling with
 10-down
 (closed on or
 after
 [September
 30, 2024]
 December 31,
 2024 )
(E) Interest    0.50               0.50                 NA
 rate
 reduction
 refinancing
 loan
(F) Direct      1.00               1.00                 NA
 loan under
 section 3711
(G)             1.00               1.00                 NA
 Manufactured
 home loan
 under section
 3712 (other
 than an
 interest rate
 reduction
 refinancing
 loan)
(H) Loan to     1.25               1.25                 NA
 Native
 American
 veteran under
 section 3762
 (other than
 an interest
 rate
 reduction
 refinancing
 loan)
(I) Loan        0.50               0.50                 0.50
 assumption
 under section
 3714
(J) Loan under  2.25               2.25                 2.25
 section
 3733(a)
------------------------------------------------------------------------

          (3) Any reference to a section in the ``Type of 
        loan'' column in the loan fee table in paragraph (2) 
        refers to a section of this title.
          (4) For the purposes of paragraph (2):
                  (A) The term ``active duty veteran'' means 
                any veteran eligible for the benefits of this 
                chapter other than a Reservist.
                  (B) The term ``Reservist'' means a veteran 
                described in section 3701(b)(5)(A) of this 
                title who is eligible under section 
                3702(a)(2)(E) of this title.
                  (C) The term ``other obligor'' means a person 
                who is not a veteran, as defined in section 101 
                of this title or other provision of this 
                chapter.
                  (D) The term ``initial loan'' means a loan to 
                a veteran guaranteed under section 3710 or made 
                under section 3711 of this title if the veteran 
                has never obtained a loan guaranteed under 
                section 3710 or made under section 3711 of this 
                title.
                  (E) The term ``subsequent loan'' means a loan 
                to a veteran, other than an interest rate 
                reduction refinancing loan, guaranteed under 
                section 3710 or made under section 3711 of this 
                title if the veteran has previously obtained a 
                loan guaranteed under section 3710 or made 
                under section 3711 of this title.
                  (F) The term ``interest rate reduction 
                refinancing loan'' means a loan described in 
                section 3710(a)(8), 3710(a)(9)(B)(i), 
                3710(a)(11), 3712(a)(1)(F), or 3762(h) of this 
                title.
                  (G) The term ``0-down'' means a downpayment, 
                if any, of less than 5 percent of the total 
                purchase price or construction cost of the 
                dwelling.
                  (H) The term ``5-down'' means a downpayment 
                of at least 5 percent or more, but less than 10 
                percent, of the total purchase price or 
                construction cost of the dwelling.
                  (I) The term ``10-down'' means a downpayment 
                of 10 percent or more of the total purchase 
                price or construction cost of the dwelling.
  (c) Waiver of Fee.--(1) A fee may not be collected under this 
section from a veteran who is receiving compensation (or who, 
but for the receipt of retirement pay or active service pay, 
would be entitled to receive compensation) or from a surviving 
spouse of any veteran (including a person who died in the 
active military, naval, or air service) who died from a 
service-connected disability.
          (2)(A) A veteran described in subparagraph (B) shall 
        be treated as receiving compensation for purposes of 
        this subsection as of the date of the rating described 
        in such subparagraph without regard to whether an 
        effective date of the award of compensation is 
        established as of that date.
                  (B) A veteran described in this subparagraph 
                is a veteran who is rated eligible to receive 
                compensation--
                          (i) as the result of a pre-discharge 
                        disability examination and rating; or
                          (ii) based on a pre-discharge review 
                        of existing medical evidence (including 
                        service medical and treatment records) 
                        that results in the issuance of a 
                        memorandum rating.

           *       *       *       *       *       *       *


PART V--BOARDS, ADMINISTRATIONS, AND SERVICES

           *       *       *       *       *       *       *


CHAPTER 74--VETERANS HEALTH ADMINISTRATION--PERSONNEL

           *       *       *       *       *       *       *



SUBCHAPTER I--APPOINTMENTS

           *       *       *       *       *       *       *



Sec. 7404. Grades and pay scales

  (a)(1)(A) The annual rates or ranges of rates of basic pay 
for positions provided in section? 7306 and 7401(4) of this 
title shall be prescribed from time to time by Executive order 
as authorized by chapter 53 of title 5 or as otherwise 
authorized by law.
                  (B) Section 5377 of title 5 shall apply to a 
                position under section 7401(4) of this title as 
                if such position were included in the 
                definition of ``position'' in section 5377(a) 
                of title 5.
          (2) The pay of physicians and dentists serving in 
        positions to which an Executive order applies under 
        paragraph (1) shall be determined under subchapter III 
        of this chapter instead of such Executive order.
          (3)(A) The rate of basic pay for a position to which 
        an Executive order applies under paragraph (1) and is 
        not described by paragraph (2) shall be set in 
        accordance with section 5382 of title 5 as if such 
        position were a Senior Executive Service position (as 
        such term is defined in section 3132(a) of title 5).
                  (B) A rate of basic pay for a position may 
                not be set under subparagraph (A) in excess 
                of--
                          (i) in the case the position is not 
                        described in clause (ii), the rate of 
                        basic pay payable for level III of the 
                        Executive Schedule; or
                          (ii) in the case that the position is 
                        covered by a performance appraisal 
                        system that meets the certification 
                        criteria established by regulation 
                        under section 5307(d) of title 5, the 
                        rate of basic pay payable for level II 
                        of the Executive Schedule.
                  (C) Notwithstanding the provisions of 
                subsection (d) of section 5307 of title 5, the 
                Secretary may make any certification under that 
                subsection instead of the Office of Personnel 
                Management and without concurrence of the 
                Office of Management and Budget.
  (b) The grades for positions provided for in paragraph (1) of 
section 7401 of this title shall be as follows. The annual 
ranges of rates of basic pay for those grades shall be 
prescribed from time to time by Executive order as authorized 
by chapter 53 of title 5 or as otherwise authorized by law:
  PHYSICIAN AND DENTIST SCHEDULE
Physician grade.
Dentist grade.
  NURSE SCHEDULE
Nurse V.
Nurse IV.
Nurse III.
Nurse II.
Nurse I.
  CLINICAL PODIATRIST, CHIROPRACTOR, AND OPTOMETRIST SCHEDULE
Chief grade.
Senior grade.
Intermediate grade.
Full grade.
Associate grade.
          PHYSICIAN ASSISTANT SCHEDULE
Physician Assistant IV.
Physician Assistant III.
Physician Assistant II.
Physician Assistant I.
  (c) Notwithstanding the provisions of section 7425(a) of this 
title, a person appointed under section 7306 of this title who 
is not eligible for pay under subchapter III shall be deemed to 
be a career appointee for the purposes of sections 4507 and 
5384 of title 5.
  (d) Except as provided under subsection (e), subchapter III, 
and section 7457 of this title, pay for positions for which 
basic pay is paid under this section may not be paid at a rate 
in excess of the rate of basic pay authorized by section 5316 
of title 5 for positions in Level V of the Executive Schedule.
  (e) The position of Chief Nursing Officer, Office of Nursing 
Services, shall be exempt from the provisions of section 7451 
of this title and shall be paid at a rate determined by the 
Secretary, not to exceed the maximum rate established for the 
Senior Executive Service under section 5382 of title 5.

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     SUBCHAPTER IV--PAY FOR NURSES AND OTHER HEALTH-CARE PERSONNEL

Sec. 7451. Nurses and other health-care personnel: competitive pay

  (a)(1) It is the purpose of this section to ensure, by a 
means providing increased responsibility and authority to 
directors of Department health-care facilities, that the rates 
of basic pay for health-care personnel positions described in 
paragraph (2) in each Department health-care facility 
(including the rates of basic pay of personnel employed in such 
positions on a part-time basis) are sufficient for that 
facility to be competitive, on the basis of pay and other 
employee benefits, with non-Department health-care facilities 
in the same labor-market area in the recruitment and retention 
of qualified personnel for those positions.
          (2) The health-care personnel positions referred to 
        in paragraph (1) (hereinafter in this section referred 
        to as ``covered positions'') are the following:
                  (A) Registered nurse.
                  (B) Physician assistant.
                  [(B)] (C) Such positions referred to in 
                paragraphs (1) and (3) of section 7401 of this 
                title (other than the positions of physician, 
                dentist, [and registered nurse] registered 
                nurse, and physician assistant) as the 
                Secretary may determine upon the recommendation 
                of the Under Secretary for Health.
          (3)(A) Except as provided in subparagraph (B), the 
        rates of basic pay for covered positions in the 
        Department shall be established and adjusted in 
        accordance with this section instead of subsection 
        (b)(1) of section 7404 of this title or chapter 53 of 
        title 5.
                  (B) Under such regulations as the Secretary 
                shall prescribe, the Secretary shall establish 
                and adjust the rates of basic pay for covered 
                positions at the following health-care 
                facilities in order to provide rates of basic 
                pay that enable the Secretary to recruit and 
                retain sufficient numbers of health-care 
                personnel in such positions at those 
                facilities:
                          (i) The Veterans Memorial Medical 
                        Center in the Republic of the 
                        Philippines.
                          (ii) Department of Veterans Affairs 
                        health-care facilities located outside 
                        the contiguous States, Alaska, and 
                        Hawaii.
          (4) The Secretary, after receiving the recommendation 
        of the Under Secretary for Health, shall prescribe 
        regulations setting forth criteria and procedures to 
        carry out this section and section 7452 of this title. 
        Requirements in such regulations for directors to 
        provide and maintain documentation of actions taken 
        under this section shall require no more documentation 
        than the minimum essential for responsible 
        administration.
  (b) The Secretary shall maintain the five grade levels for 
nurses employed by the Department under section 7401(1) of this 
title as specified in the Nurse Schedule in section 7404(b) of 
this title. The Secretary shall, pursuant to regulations 
prescribed to carry out this subchapter, establish grades for 
other covered positions as the Secretary considers appropriate.
  (c)(1) For each grade in a covered position, there shall be a 
range of basic pay. The maximum rate of basic pay for a grade 
shall be 133 percent of the minimum rate of basic pay for the 
grade, except that, if the Secretary determines that a higher 
maximum rate is necessary with respect to any such grade in 
order to recruit and retain a sufficient number of high-quality 
health-care personnel, the Secretary may raise the maximum rate 
of basic pay for that grade to a rate not in excess of 175 
percent of the minimum rate of basic pay for the grade. 
Whenever the Secretary exercises the authority under the 
preceding sentence to establish the maximum rate of basic pay 
at a rate in excess of 133 percent of the minimum rate for that 
grade, the Secretary shall, in the next annual report required 
by subsection (g), provide justification for doing so to the 
Committees on Veterans' Affairs of the Senate and House of 
Representatives.
          (2) The maximum rate of basic pay for any grade for a 
        covered position may not exceed the maximum rate of 
        basic pay established for positions in level IV of the 
        Executive Schedule under section 5316 of title 5. The 
        maximum rate of basic pay for a grade for the position 
        of certified registered nurse anesthetist pursuant to 
        an adjustment under subsection (d) may exceed the 
        maximum rate otherwise provided in the preceding 
        sentence.
          (3) The range of basic pay for each such grade shall 
        be divided into equal increments, known as ``steps''. 
        The Secretary shall prescribe the number of steps. Each 
        grade in a covered position shall have the same number 
        of steps. Rates of pay within a grade may not be 
        established at rates other than whole steps. Any 
        increase (other than an adjustment under subsection 
        (d)) within a grade in the rate of basic pay payable to 
        an employee in a covered position shall be by one or 
        more of such step increments.
  (d)(1) Subject to subsection (e), the rates of basic pay for 
each grade in a covered position shall be adjusted periodically 
in accordance with this subsection in order to achieve the 
purposes of this section. Such adjustments shall be made--
                  (A) whenever there is an adjustment under 
                section 5303 of title 5 in the rates of pay 
                under the General Schedule, with the adjustment 
                under this subsection to have the same 
                effective date and to be by the same percentage 
                as the adjustment in the rates of basic pay 
                under the General Schedule; and
                  (B) at such additional times as the director 
                of a Department health-care facility, with 
                respect to employees in that grade at that 
                facility, or the Under Secretary for Health, 
                with respect to covered Regional and Central 
                Office employees in that grade, determines.
          (2) An adjustment in rates of basic pay under this 
        subsection for a grade shall be carried out by 
        adjusting the amount of the minimum rate of basic pay 
        for that grade in accordance with paragraph (3) and 
        then adjusting the other rates for that grade to 
        conform to the requirements of subsection (c). Except 
        as provided in paragraph (1)(A), such an adjustment in 
        the minimum rate of basic pay for a grade shall be made 
        by the director of a Department health-care facility so 
        as to achieve consistency with the beginning rate of 
        compensation for corresponding health-care 
        professionals in the Bureau of Labor Statistics (BLS) 
        labor-market area of that facility.
          (3)(A) In the case of a Department health-care 
        facility located in an area for which there is current 
        information, based upon an industry-wage survey by the 
        Bureau of Labor Statistics for that labor market, on 
        compensation for corresponding health-care 
        professionals for the BLS labor-market area of that 
        facility, the director of the facility concerned shall 
        use that information as the basis for making 
        adjustments in rates of pay under this subsection. 
        Whenever the Bureau of Labor Statistics releases the 
        results of a new industry-wage survey for that labor 
        market that includes information on compensation for 
        corresponding health-care professionals, the director 
        of that facility shall determine, not later than 30 
        days after the results of the survey are released, 
        whether an adjustment in rates of pay for employees at 
        that facility for any covered position is necessary in 
        order to meet the purposes of this section. If the 
        director determines that such an adjustment is 
        necessary, the adjustment, based upon the information 
        determined in the survey, shall take effect on the 
        first day of the first pay period beginning after that 
        determination.
                  (B) In the case of a Department health-care 
                facility located in an area for which the 
                Bureau of Labor Statistics does not have 
                current information on compensation for 
                corresponding health-care professionals for the 
                labor-market area of that facility for any 
                covered position, the director of that facility 
                shall conduct a survey in accordance with this 
                subparagraph and shall adjust the amount of the 
                minimum rate of basic pay for grades in that 
                covered position at that facility based upon 
                that survey. To the extent practicable, the 
                director shall use third-party industry wage 
                surveys to meet the requirements of the 
                preceding sentence. Any such survey shall be 
                conducted in accordance with regulations 
                prescribed by the Secretary. Those regulations 
                shall be developed in consultation with the 
                Secretary of Labor in order to ensure that the 
                director of a facility collects information 
                that is valid and reliable and is consistent 
                with standards of the Bureau. The survey should 
                be conducted using methodology comparable to 
                that used by the Bureau in making industry-wage 
                surveys except to the extent determined 
                infeasible by the Secretary. To the extent 
                practicable, all surveys conducted pursuant to 
                this subparagraph or subparagraph (A) shall 
                include the collection of salary midpoints, 
                actual salaries, lowest and highest salaries, 
                average salaries, bonuses, incentive pays, 
                differential pays, actual beginning rates of 
                pay, and such other information needed to meet 
                the purpose of this section. Upon conducting a 
                survey under this subparagraph, the director 
                concerned shall determine, not later than 30 
                days after the date on which the collection of 
                information through the survey is completed or 
                published, whether an adjustment in rates of 
                pay for employees at that facility for any 
                covered position is necessary in order to meet 
                the purposes of this section. If the director 
                determines that such an adjustment is 
                necessary, the adjustment, based upon the 
                information determined in the survey, shall 
                take effect on the first day of the first pay 
                period beginning after that determination.
                  (C)(i) A director of a Department health-care 
                facility may use data on the compensation paid 
                to certified registered nurse anesthetists who 
                are employed on a salary basis by entities that 
                provide anesthesia services through certified 
                registered nurse anesthetists in the labor-
                market area only if the director--
                                  (I) has conducted a survey of 
                                compensation for certified 
                                registered nurse anesthetists 
                                in the local labor-market area 
                                of the facility under 
                                subparagraph (B);
                                  (II) has used all available 
                                administrative authority with 
                                regard to collection of survey 
                                data; and
                                  (III) makes a determination 
                                (under regulations prescribed 
                                by the Secretary) that such 
                                survey methods are insufficient 
                                to permit the adjustments 
                                referred to in subparagraph (B) 
                                for such nurse anesthetists 
                                employed by the facility.
                          (ii) For the purposes of this 
                        subparagraph, certified registered 
                        nurse anesthetists who are so employed 
                        by such entities shall be deemed to be 
                        corresponding health-care professionals 
                        to the certified registered nurse 
                        anesthetists employed by the facility.
                  (D) The Under Secretary for Health shall 
                prescribe regulations providing for the 
                adjustment of the rates of basic pay for 
                Regional and Central Office employees in 
                covered positions in order to assure that those 
                rates are sufficient and competitive.
                  (E) The director of a facility or Under 
                Secretary for Health may not adjust rates of 
                basic pay under this subsection for any pay 
                grade so that the minimum rate of basic pay for 
                that grade is greater than the beginning rates 
                of compensation for corresponding positions at 
                non-Department health-care facilities.
                  (F) The Under Secretary for Health shall 
                provide appropriate education, training, and 
                support to directors of Department health care 
                facilities in the conduct and use of surveys, 
                including the use of third-party surveys, under 
                this paragraph.
          (4) If the director of a Department health-care 
        facility, or the Under Secretary for Health with 
        respect to Regional and Central Office employees, 
        determines, after any survey under paragraph (3)(B) 
        that it is not necessary to adjust the rates of basic 
        pay for employees in a grade of a covered position at 
        that facility in order to carry out the purpose of this 
        section, such an adjustment for employees at that 
        facility in that grade shall not be made.
          (5) Information collected by the Department in 
        surveys conducted under this subsection is not subject 
        to disclosure under section 552 of title 5.
          (6) In this subsection--
                  (A) The term ``beginning rate of 
                compensation'', with respect to health-care 
                personnel positions in non-Department health-
                care facilities corresponding to a grade of a 
                covered position, means the sum of--
                          (i) the minimum rate of pay 
                        established for personnel in such 
                        positions who have education, training, 
                        and experience equivalent or similar to 
                        the education, training, and experience 
                        required for health-care personnel 
                        employed in the same category of 
                        Department covered positions; and
                          (ii) other employee benefits for 
                        those positions to the extent that 
                        those benefits are reasonably 
                        quantifiable.
                  (B) The term ``corresponding'', with respect 
                to health-care personnel positions in non-
                Department health-care facilities, means those 
                positions for which the education, training, 
                and experience requirements are equivalent or 
                similar to the education, training, and 
                experience requirements for health-care 
                personnel positions in Department health-care 
                facilities.
  (e)(1) An adjustment in a rate of basic pay under subsection 
(d) may not reduce the rate of basic pay applicable to any 
grade of a covered position.
          (2) The director of a Department health-care 
        facility, in determining whether to carry out a wage 
        survey under subsection (d)(3) with respect to rates of 
        basic pay for a grade of a covered position, may not 
        consider as a factor in such determination the absence 
        of a current recruitment or retention problem for 
        personnel in that grade of that position. The director 
        shall make such a determination based upon whether, in 
        accordance with criteria established by the Secretary, 
        there is a significant pay-related staffing problem at 
        that facility in any grade for a position. If the 
        director determines that there is such a problem, or 
        that such a problem is likely to exist in the near 
        future, the Director shall provide for a wage survey in 
        accordance with subsection (d)(3).
          (3) The Under Secretary for Health may, to the extent 
        necessary to carry out the purposes of subsection (d), 
        modify any determination made by the director of a 
        Department health-care facility with respect to 
        adjusting the rates of basic pay applicable to covered 
        positions. If the determination of the director would 
        result in an adjustment in rates of basic pay 
        applicable to covered positions, any action by the 
        Under Secretary under the preceding sentence shall be 
        made before the effective date of such pay adjustment. 
        Upon such action by the Under Secretary, any adjustment 
        shall take effect on the first day of the first pay 
        period beginning after such action. The Secretary shall 
        ensure that the Under Secretary establishes a mechanism 
        for the timely exercise of the authority in this 
        paragraph.
          (4) Each director of a Department health-care 
        facility shall provide to the Secretary, not later than 
        July 31 each year, a report on staffing for covered 
        positions at that facility. The report shall include 
        the following:
                  (A) Information on turnover rates and vacancy 
                rates for each covered position, including a 
                comparison of those rates with the rates for 
                the preceding three years.
                  (B) The director's findings concerning the 
                review and evaluation of the facility's 
                staffing situation, including whether there is, 
                or is likely to be, in accordance with criteria 
                established by the Secretary, a significant 
                pay-related staffing problem at that facility 
                for any covered position and, if so, whether a 
                wage survey was conducted, or will be conducted 
                with respect to that position.
                  (C) In any case in which the director 
                conducts such a wage survey during the period 
                covered by the report, information describing 
                the survey and any actions taken or not taken 
                based on the survey, and the reasons for taking 
                (or not taking) such actions.
                  (D) In any case in which the director 
                conducts such a wage survey during the period 
                covered by the report and makes adjustment in 
                rates of basic pay applicable to one or more 
                covered positions at the facility, information 
                on the methodology used in making such 
                adjustment or adjustments.
                  (E) In any case in which the director, after 
                finding that there is, or is likely to be, in 
                accordance with criteria established by the 
                Secretary, a significant pay-related staffing 
                problem at that facility for any covered 
                position, determines not to conduct a wage 
                survey with respect to that position, a 
                statement of the reasons why the director did 
                not conduct such a survey.
          (5) Not later than September 30 of each year, the 
        Secretary shall submit to the Committees on Veterans' 
        Affairs of the Senate and House of Representatives a 
        report on staffing for covered positions at Department 
        health care facilities. Each such report shall include 
        the following:
                  (A) A summary and analysis of the information 
                contained in the most recent reports submitted 
                by facility directors under paragraph (4).
                  (B) The information for each such facility 
                specified in paragraph (4).
          (6)(A) Upon the request of an individual described in 
        subparagraph (B) for a report provided under paragraph 
        (4) with respect to a Department health-care facility, 
        the Under Secretary for Health or the director of such 
        facility shall provide to the individual the most 
        current report for such facility provided under such 
        paragraph.
                  (B) An individual described in this 
                subparagraph is--
                          (i) an individual in a covered 
                        position at a Department health-care 
                        facility; or
                          (ii) a representative of the labor 
                        organization representing that 
                        individual who is designated by that 
                        individual to make the request.
  (f) For the purposes of this section, the term ``health-care 
facility'' means a medical center, an independent outpatient 
clinic, or an independent domiciliary facility.

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