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115th Congress    }                                    {        Report
                        HOUSE OF REPRESENTATIVES
 1st Session      }                                    {       115-394

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



 
         VETERANS E-HEALTH AND TELEMEDICINE SUPPORT ACT OF 2017

                                _______
                                

November 7, 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. 2123]

    The Committee on Veterans' Affairs, to whom was referred 
the bill (H.R. 2123) to amend title 38, United States Code, to 
improve the ability of health care professionals to treat 
veterans through the use of telemedicine, and for other 
purposes, having considered the same, report favorably thereon 
without amendment and recommend that the bill do pass.

                                CONTENTS

                                                                   Page
Purpose and Summary..............................................     2
Background and Need for Legislation..............................     2
Hearings.........................................................     3
Subcommittee Consideration.......................................     4
Committee Consideration..........................................     4
Committee Votes..................................................     4
Committee Oversight Findings.....................................     5
Statement of General Performance Goals and Objectives............     5
New Budget Authority, Entitlement Authority, and Tax Expenditures     5
Earmarks and Tax and Tariff Benefits.............................     5
Committee Cost Estimate..........................................     5
Congressional Budget Office Estimate.............................     5
Federal Mandates Statement.......................................     6
Advisory Committee Statement.....................................     6
Constitutional Authority Statement...............................     6
Applicability to Legislative Branch..............................     6
Statement on Duplication of Federal Programs.....................     6
Disclosure of Directed Rulemaking................................     6
Section-by-Section Analysis of the Legislation...................     6
Changes in Existing Law Made by the Bill as Reported.............     7

                          Purpose and Summary

    H.R. 2123, the ``Veterans E-Health and Telemedicine Support 
Act of 2017,'' would authorize a licensed health care provider 
of the Department of Veterans Affairs (VA) to practice 
telemedicine at any location in any state, regardless of where 
the provider or patient is located and whether or not the 
patient or provider is located on federal government property. 
Representative Glenn Thompson of Pennsylvania introduced H.R. 
2123 on April 25, 2017.

                  Background and Need for Legislation

    As a national, integrated health care system, the Veterans 
Health Administration (VHA) has a responsibility to ensure that 
veteran patients receive the same level of and access to care 
no matter where the veteran patient is located.\1\ This is a 
particular challenge for veteran patients residing in remote, 
rural, or medically underserved areas far from VA medical 
facilities and for veteran patients with mobility or other 
issues that impact their ability to travel to VA medical 
facilities to receive care.\2\
---------------------------------------------------------------------------
    \1\Authority of Health Care Providers to Practice Telehealth. 
https://www.federalregister.gov/documents/2017/10/02/2017-20951/
authority-of-health-care-providers-to-practice-telehealth. Accessed 
October 31, 2017.
    \2\Ibid.
---------------------------------------------------------------------------
    Telemedicine refers to ``the use of telehealth technologies 
to provide clinical care in circumstances where distance 
separates those receiving services and those providing 
services.''\3\ By allowing VA clinicians to provide ``the right 
care in the right place at the right time,'' telemedicine is 
critical to VA's ability to deliver health care to veteran 
patients who could not otherwise access such care.\4\\5\ 
According to VA, ``[telemedicine] increases the accessibility 
of VA health care, bringing VA medical services to locations 
convenient for beneficiaries, including clinics in remote 
communities and beneficiaries' homes.''\6\ In fiscal year 2016, 
VA health care providers provided more than 2 million episodes 
of care via telemedicine to more than 700,000 veteran patients, 
approximately 12 percent of VA's total patient population.\7\ 
Veteran patients who have had experience with VA telemedicine 
programs have demonstrated improved health outcomes, including 
decreases in hospital admissions.\8\
---------------------------------------------------------------------------
    \3\VA Telehealth Services. https://www.telehealth.va.gov/ Accessed 
October 30, 2017.
    \4\Ibid.
    \5\Authority of Health Care Providers to Practice Telehealth. 
https://www.federalregister.gov/documents/2017/10/02/2017-20951/
authority-of-health-care-providers-to-practice-telehealth. Accessed 
October 31, 2017.
    \6\Ibid.
    \7\Ibid.
    \8\Ibid.
---------------------------------------------------------------------------
    However, the continued expansion of telemedicine across the 
VA health care system is constrained by restrictions on the 
ability of VA providers to practice telemedicine across state 
lines without jeopardizing their state licensure and facing 
potential penalties for the unauthorized practice of 
medicine.\9\ VA claims that this disparity--between VA health 
care practice and state medical licensure laws--has severely 
inhibited the provision of telemedicine in VA and, therefore, 
reduced the availability and accessibility of care for veteran 
patients.\10\
---------------------------------------------------------------------------
    \9\Ibid.
    \10\Ibid.
---------------------------------------------------------------------------
    In response to this, Secretary Shulkin announced on August 
3, 2017, that VA would be amending regulations to allow VA 
health care providers who are licensed, registered, or 
certified in ``a state'' to practice in any state when they are 
acting within the scope of their VA employment--regardless of 
individual state licensure, registration, or certification 
restrictions except for applicable state restrictions on the 
authority to prescribe and administer controlled 
substances.\11\ VA claims that this action would serve to 
``authorize VA health care providers to furnish care, 
consistent with their employment obligations, through 
[telemedicine], without fear of adverse action by any 
state.''\12\ Despite this rulemaking, Secretary Shulkin 
testified during an October 24th Committee hearing that 
legislation was needed to ``[provide] statutory protection and 
[codify] VA's longstanding practice of allowing VA providers to 
practice in any state as long as they are licensed in a 
state.''\13\
---------------------------------------------------------------------------
    \11\Ibid.
    \12\Ibid.
    \13\United States Cong. House Committee on Veterans' Affairs. 
Legislative Hearing. October 24, 2017. 115th Cong. 1st sess. 
Washington: GPO, 2017 (statement from the Honorable David Shulkin M.D., 
Secretary of Veterans Affairs).
---------------------------------------------------------------------------
    Therefore, section 2 of the bill would exercise preemption 
of state licensure, registration, and certification laws, 
rules, and regulations or requirements to the extent such state 
laws conflict with the ability of VA providers to engage in the 
practice of telehealth while acting within the state of their 
VA employment and authorize a VA licensed health care provider 
to practice telemedicine at any location in any state, 
regardless of where the provider or patient is located and 
whether or not the patient or provider is on federal government 
property. The Committee believes that the continued expansion 
of telemedicine across the VA healthcare system will aid 
veterans in receiving timely, quality care from VA and in 
achieving improved health outcomes. Further, the Committee 
concurs with the American Medical Association that providing VA 
healthcare providers the authority to practice telemedicine 
across state lines would, ``address the significant and unique 
need to expand access to health care services for veterans 
being treated within the VA system while also ensuring that 
important patient protections remain in place, including the 
direct oversight, accountability, training, and quality control 
specific to VA-employed physicians and other health care 
professionals.''\14\ Section 2 of the bill would also require 
VA to submit a report to Congress on the Department's 
telemedicine programs, which would allow the effectiveness of 
VA telemedicine to be better understood.
---------------------------------------------------------------------------
    \14\United States Cong. House Committee on Veterans' Affairs. 
Legislative Hearing. October 24, 2017. 115th Cong. 1st sess. 
Washington: GPO, 2017 (statement for the record from the American 
Medical Association).
---------------------------------------------------------------------------

                                Hearings

    There were no Subcommittee hearings held on H.R. 2123.
    On October 24, 2017, the full Committee conducted a 
legislative hearing on a number of bills including H.R. 2123.
    The following witnesses testified:
          The Honorable Jim Banks, U.S. House of 
        Representatives, 3rd District, Indiana; The Honorable 
        Mike Gallagher, U.S. House of Representatives, 8th 
        District, Wisconsin; The Honorable John R. Carter, U.S. 
        House of Representatives, 31st District, Texas; The 
        Honorable Glenn Thompson, U.S. House of 
        Representatives, 5th District, Pennsylvania; The 
        Honorable Neal P. Dunn, U.S. House of Representatives, 
        2nd District, Florida; The Honorable Andy Barr, U.S. 
        House of Representatives, 6th District, Kentucky; The 
        Honorable David J. Shulkin, M.D., Secretary, U.S. 
        Department of Veterans Affairs, who was accompanied by 
        Carolyn Clancy M.D., the Executive in Charge of the 
        Veterans Health Administration, and Laurie Zephyrin 
        M.D., MPH, MBA, the Acting Deputy Under Secretary for 
        Health for Community Care for the Veterans Health 
        Administration; Adrian M. Atizado, Deputy National 
        Legislative Director, Disabled American Veterans; 
        Roscoe G. Butler, Deputy Director for Health Care, 
        Veterans Affairs and Rehabilitation Division, The 
        American Legion; and, Kayda Keleher, Associate 
        Director, National Legislative Service, Veterans of 
        Foreign Wars of the United States.
    Statements for the record were submitted by:
          American Federation of Government Employees, AFL-CIO; 
        American Health Care Association; American Medical 
        Association; AMVETS; Concerned Veterans of America; 
        Fleet Reserve Association; Got Your 6; Health IT Now; 
        Iraq and Afghanistan Veterans of America; Military 
        Officers Association of America; Military Order of the 
        Purple Heart; National Alliance on Mental Illness; 
        National Guard Association of the United States; Nurses 
        Organization of Veterans Affairs/Association of VA 
        Psychologist Leaders/Association of VA Social Workers/
        Veterans Healthcare Action Campaign; Paralyzed Veterans 
        of America; Reserve Officers Association; University of 
        Pittsburgh; Vietnam Veterans of America; the Wounded 
        Warrior Project; The American Congress of Obstetrics 
        and Gynecologists; the University of California, 
        Riverside School of Medicine; the American Society of 
        Transplant Surgeons; and, the National Indian Health 
        Board.

                       Subcommittee Consideration

    There was no Subcommittee consideration of H.R. 2123.

                        Committee Consideration

    On November 2, 2017, the full Committee met in open markup 
session, a quorum being present, and ordered H.R. 2123 to be 
reported favorably to the House of Representatives 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. 2123 
reported to the House. A motion by Representative Tim Walz of 
Minnesota, Ranking Member of the Committee on Veterans' 
Affairs, to report H.R. 2123 favorably to the House of 
Representatives was agreed to by voice vote.

                      Committee Oversight Findings

    In compliance with clause 3(c)(1) of rule XIII and clause 
(2)(b)(1) of rule X of the Rules of the House of 
Representatives, the Committee's oversight findings and 
recommendations are reflected in the descriptive portions of 
this report.

         Statement of General Performance Goals and Objectives

    In accordance with clause 3(c)(4) of rule XIII of the Rules 
of the House of Representatives, the Committee's performance 
goals and objectives are to increase the provision of 
telemedicine to veteran patients by authorizing VA providers to 
practice telemedicine across state lines.

   New Budget Authority, Entitlement Authority, and Tax Expenditures

    With respect to the requirement with respect to clause 
3(c)(2) of rule XIII of the Rules of the House of 
Representatives, the Committee has requested but not received 
from the Director of the Congressional Budget Office an 
estimate of new budget authority, entitlement authority, or tax 
expenditures or revenues.

                  Earmarks and Tax and Tariff Benefits

    H.R. 2123 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

    Clause 3(d)(2) of rule XIII of the Rules of the House of 
Representatives requires an estimate and a comparison by the 
Committee of the costs that would be incurred in carrying out 
this bill. However, clause 3(d)(3)(B) of that Rule provides 
that this requirement does not apply when the Committee has 
included in its report a timely submitted cost estimate of the 
bill prepared by the Director of the Congressional Budget 
Office under section 402 of the Congressional Budget Act of 
1974. The Committee has requested but not received a cost 
estimate for this bill from the Director of the Congressional 
Budget Office. The Committee believes, according to a 
preliminary score from the Congressional Budget Office, that 
enactment of H.R. 2123 would have minimal discretionary costs 
over a five year period.

     Budget Authority and Congressional Budget Office Cost Estimate

    With respect to the requirements of clause 3(c)(2) of rule 
XIII of the Rules of the House of Representatives and section 
308(a) of the Congressional Budget Act of 1974 and with respect 
to requirements of clause (3)(c)(3) of rule XIII of the Rules 
of the House of Representatives and section 402 of the 
Congressional Budget Act of 1974, the Committee has requested 
but not received a cost estimate for this bill from the 
Director of Congressional Budget Office. The Committee has 
requested but not received from the Director of the 
Congressional Budget Office a statement as to whether this bill 
contains any new budget authority, spending authority, credit 
authority, or an increase or decrease in revenues or tax 
expenditures.

                       Federal Mandates Statement

    With respect to the requirements of Section 423 of the 
Congressional Budget and Impoundment Control Act (as amended by 
Section 101(a)(2) of the Unfunded Mandate Reform Act, P.L. 104-
4), the Committee has requested but not received from the 
Director of the Congressional Budget Office a statement as to 
whether the provisions of the reported bill include unfunded 
mandates.

                      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. 
2123.

                 Statement of Constitutional Authority

    Pursuant to Article I, section 8 of the United States 
Constitution, H.R. 2123 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. 2123 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. 2123 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. 2123 contains no directed 
rulemaking 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 the short title for 
H.R. 2123, as the ``Veterans E-Health and Telemedicine Support 
Act of 2017'' or ``the VETS Act of 2017''.

Section 2. Licensure of health care professionals of the Department of 
        Veterans Affairs providing treatment via telemedicine

    Section 2(a) of the bill would amend chapter 17 of title 38 
U.S.C. by inserting after section 1730A a new section 1730B. 
Licensure of health care professionals providing treatment via 
telemedicine. The new section 1730B(a) would, notwithstanding 
any provision of law regarding the licensure of health care 
professionals, authorize a covered health professional to 
practice the health care profession of the health care 
professional at any location in any State, regardless of where 
the covered health care professional or patient is located, if 
the covered health care professional is using telemedicine to 
provide treatment to an individual under this chapter. The new 
section 1730B(b) would require the new section 1730(a) to apply 
to a covered health care professional providing treatment to a 
patient regardless of whether the covered health care 
professional or patient is located in a facility owned by the 
Federal government during such treatment. The new section 
1730B(c) would state that nothing in this section may be 
construed to remove, limit, or otherwise affect any obligation 
of a covered health care professional under the Controlled 
Substances Act (21 U.S.C. 801 et seq.). The new section 
1730B(d) would define a ``covered health care professional'' as 
a health care professional who: (1) is a VA employee appointed 
under sections 7306, 7401, 7405, 7406, or 7408 of title 38 
U.S.C. or title 5 U.S.C.; (2) is authorized by VA to provide 
health care under this chapter; (3) is required to adhere to 
all quality standards relating to the provision of telemedicine 
in accordance with applicable VA policies; and (4) has an 
active, current, full, and unrestricted license, registration, 
or certification in a State to practice the health care 
profession of the health care professional.
    Section 2(b) of the bill would amend the table of sections 
at the beginning of chapter 17 of title 38 U.S.C. by inserting 
after the item relating to section 1730A the following new 
item: ``1730B. Licensure of health care professionals providing 
treatment via telemedicine.''.
    Section 2(c) of the bill would require VA, after than one 
year after date of enactment of this Act, to submit to the 
Committees on Veterans' Affairs of the Senate and the House of 
Representatives a report on the effectiveness of the use of 
telemedicine by VA to include an assessment of: veterans 
satisfaction with the telemedicine furnished by VA; the 
satisfaction of health care providers in providing telemedicine 
furnished by VA; the effect of telemedicine on the ability of 
veterans to access health care from VA and from non-VA health 
care providers, the frequency of veterans use of telemedicine, 
the productivity of health care providers, wait times for an 
appointment for receipt of health care from VA, and, the 
reduction--if any--in the use by veterans of in-person services 
at VA facilities and non-VA facilities; the types of 
appointments for the receipt of VA telemedicine that were 
provided during the one-year period preceding the submittal of 
the report; the number of appointments for the receipt of 
telemedicine furnished by VA that were requested during such 
period, disaggregated by Veterans Integrated Service Network 
(VISN); and, VA savings (including travel costs)--if any--of 
furnishing health care through telemedicine during such period.

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (new matter is 
printed in italic and existing law in which no change is 
proposed is shown in roman):

                      TITLE 38, UNITED STATES CODE




           *       *       *       *       *       *       *
PART II--GENERAL BENEFITS

           *       *       *       *       *       *       *


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


                          SUBCHAPTER I--GENERAL

Sec.
1701. Definitions.
     * * * * * * *

   SUBCHAPTER III--MISCELLANEOUS PROVISIONS RELATING TO HOSPITAL AND 
           NURSING HOME CARE AND MEDICAL TREATMENT OF VETERANS

     * * * * * * *
1730B. Licensure of health care professionals providing treatment via 
          telemedicine.

           *       *       *       *       *       *       *


   SUBCHAPTER III--MISCELLANEOUS PROVISIONS RELATING TO HOSPITAL AND 
NURSING HOME CARE AND MEDICAL TREATMENT OF VETERANS

           *       *       *       *       *       *       *


Sec. 1730B. Licensure of health care professionals providing treatment 
                    via telemedicine

  (a) In General.--Notwithstanding any provision of law 
regarding the licensure of health care professionals, a covered 
health care professional may practice the health care 
profession of the health care professional at any location in 
any State, regardless of where the covered health care 
professional or the patient is located, if the covered health 
care professional is using telemedicine to provide treatment to 
an individual under this chapter.
  (b) Property of Federal Government.--Subsection (a) shall 
apply to a covered health care professional providing treatment 
to a patient regardless of whether the covered health care 
professional or patient is located in a facility owned by the 
Federal Government during such treatment.
  (c) Construction.--Nothing in this section may be construed 
to remove, limit, or otherwise affect any obligation of a 
covered health care professional under the Controlled 
Substances Act (21 U.S.C. 801 et seq.).
  (d) Covered Health Care Professional Defined.--In this 
section, the term ``covered health care professional'' means a 
health care professional who--
          (1) is an employee of the Department appointed under 
        the authority under sections 7306, 7401, 7405, 7406, or 
        7408 of this title, or title 5;
          (2) is authorized by the Secretary to provide health 
        care under this chapter;
          (3) is required to adhere to all quality standards 
        relating to the provision of telemedicine in accordance 
        with applicable policies of the Department; and
          (4) has an active, current, full, and unrestricted 
        license, registration, or certification in a State to 
        practice the health care profession of the health care 
        professional.

           *       *       *       *       *       *       *


                                  [all]