Veterans Medical Care: FY2010 Appropriations
Congressional research reportJan 21, 2010
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Veterans Medical Care: FY2010
Appropriations
(name redacted)
Specialist in Veterans Policy
January 21, 2010
Congressional Research Service
7-....
www.crs.gov
R40737
CRS Report for Congress
Prepared for Members and Committees of Congress
Veterans Medical Care: FY2010 Appropriations
Summary
The Department of Veterans Affairs (VA) provides benefits to veterans who meet certain
eligibility criteria. Benefits to veterans range from disability compensation and pensions to
hospital and medical care. The VA provides these benefits through three major operating units:
the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the
National Cemetery Administration (NCA).
This report focuses on the VHA. The VHA is primarily a direct service provider of primary care,
specialized care, and related medical and social support services to veterans through the nation’s
largest integrated health care system. Veterans generally must enroll in the VA health care system
to receive medical care. Eligibility for enrollment is based primarily on previous military service,
disability, and income. VA provides free inpatient and outpatient medical care to veterans for
service-connected conditions and to low-income veterans for nonservice-connected conditions.
On February 26, 2009, the President submitted a preliminary budget outline for FY2010, and
submitted his full FY2010 budget proposal to Congress on May 7. The Administration requested
a total of $45.1 billion for VHA (excluding collections). This is a 7.5% increase over the FY2009
enacted level. Including total available resources (including medical care collections), the
President’s budget would provide approximately $48 billion for VHA.
Based on the President’s preliminary budget outline, on April 29, 2009, the House and Senate
agreed to the conference report to accompany the FY2010 budget resolution (S.Con.Res. 13,
H.Rept. 111-89). The conference agreement provides $53.4 billion in discretionary budget
authority and $53.1 billion in mandatory budget authority for VA programs. Sections 402 and 424
of the conference agreement included language exempting the medical services, medical support
and compliance, and medical facilities accounts from a point of order against advance
appropriations. Furthermore, the conference agreement states that VHA is not and should not be
authorized to bill private insurance companies for treatment of health conditions that are related
to veterans’ service-connected disabilities.
On July 10, the House passed its version of the Military Construction and Veterans Affairs
Appropriations Act, 2010 (H.R. 3082, H.Rept. 111-188). The House-passed bill provided a total
of $45.1 billion for VHA. H.R. 3082 also provided $48.2 billion in advance appropriations for
VHA to be available in FY2011. On November 17, the Senate passed H.R. 3082 as amended.
H.R. 3082 as amended by the Senate provided a total of $45.2 billion for VHA, a $160.0 million
increase over the House-passed amount, and $157.6 million over the President’s request.
The Consolidated Appropriations Act was signed into law on December 16, 2009 (P.L. 111-117,
H.Rept. 111-366). Division E of the Consolidated Appropriations Act 2010 included a
compromised version of the House and Senate passed versions of Military Construction and
Veterans Affairs and Related Agencies Appropriations Act, 2010. The Consolidated
Appropriations Act provides a total of $45.1 billion for VHA, same as the Administration’s
request for FY2010, and 7.4% over the FY2009 enacted amount. P.L. 111-117 includes an
advance appropriation of $48.2 billion for the medical services, medical support and compliance,
and medical facilities accounts to be available in FY2011.
With the enactment of the Consolidated Appropriations Act, 2010 (P.L. 111-117), the FY2010
appropriations process for VHA was completed by Congress. This report will not be updated.
Congressional Research Service
Veterans Medical Care: FY2010 Appropriations
Contents
Most Recent Developments.........................................................................................................1
Introduction ................................................................................................................................4
The Veterans Health Care System................................................................................................5
Training of Health Care Professionals .............................................................................9
The Veteran Patient Population.................................................................................................. 11
Eligibility for Veterans Health Care........................................................................................... 13
“The Promise of Free Health Care” ..................................................................................... 13
VHA Health Care Enrollment.............................................................................................. 14
Veteran’s Status............................................................................................................. 15
Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans ........ 16
Medical Benefits Package ............................................................................................. 17
Priority Groups and Scheduling Appointments .............................................................. 17
Formulation of VHA’s Budget ................................................................................................... 18
Funding for the VHA ................................................................................................................ 19
Medical Services................................................................................................................. 19
Medical Support and Compliance (Previously Medical Administration) .............................. 19
Medical Facilities................................................................................................................ 20
Medical and Prosthetic Research ......................................................................................... 20
Medical Care Collections Fund (MCCF) ............................................................................. 20
Consolidated Patient Accounting Centers (CPACs)........................................................ 21
FY2009 Budget Summary......................................................................................................... 23
House Action ...................................................................................................................... 23
Senate Committee Action.................................................................................................... 23
Final MILCON-VA Appropriations Act of 2009 .................................................................. 23
American Recovery and Reinvestment Act (P.L. 111-5) Funds ............................................ 24
FY2010 VHA Budget................................................................................................................ 24
President’s Request ............................................................................................................. 24
FY2010 Congress Congressional Budget Resolution ........................................................... 25
House Action ...................................................................................................................... 25
Senate Action...................................................................................................................... 26
Final MILCON-VA Appropriations Act, 2010...................................................................... 26
Major Issues.............................................................................................................................. 27
Advance Appropriations...................................................................................................... 27
Priority Group 8 Veterans.................................................................................................... 28
Beneficiary Travel Mileage Reimbursement ........................................................................ 30
Figures
Figure 1. Enacted Appropriations for VHA, FY1995-FY2009 .....................................................2
Figure 2. FY2009 VA Budget Allocations....................................................................................5
Figure 3. Veterans Integrated Services Networks (VISNs) ...........................................................7
Congressional Research Service
Veterans Medical Care: FY2010 Appropriations
Figure 4. VA Health Professionals Training Program: Percent Distribution of Program
Participants, FY2008.............................................................................................................. 11
Tables
Table 1. VA Appropriations, FY2009-FY2010, and Advance Appropriations, FY2011 .................3
Table 2. FY2009 VERA Allocations ............................................................................................8
Table 3. Number of Veterans Enrolled in the VA Health Care System, FY2006-FY2010 ........... 12
Table 4. Number of Patients Receiving Care from the VA, FY2006-FY2010 ............................. 13
Table 5. Medical Care Collections, FY2003-FY2008................................................................. 22
Table 6. Enrollment and Expenditures for FY2009- Under Current Policy and Under
Expanded Enrollment Policy .................................................................................................. 29
Table 7. VHA Appropriations by Account, FY2009-FY2010 and Advance Appropriations,
FY2011.................................................................................................................................. 33
Table A-1. VA Priority Groups and Their Eligibility Criteria...................................................... 35
Table B-1. Copayments for Health Care Services: 2010............................................................. 37
Appendixes
Appendix A. VA Priority Groups and Their Eligibility Criteria .................................................. 35
Appendix B. Copayments for Health Care Services: 2010 ......................................................... 37
Appendix C. Financial Income Thresholds for VA Health Care Benefits, Calendar Year
2010 ...................................................................................................................................... 39
Appendix D. 10% Increase to Financial Income Thresholds for VA Health Care
Enrollment, in Priority Group 8, Calendar Year 2010.............................................................. 40
Contacts
Author Contact Information ...................................................................................................... 40
Congressional Research Service
Veterans Medical Care: FY2010 Appropriations
Most Recent Developments
On December 10, 2009, the House adopted the conference report (H.Rept. 111-366) to
accompany the Department of Transportation, Housing and Urban Development appropriations
Act, 2010, and retitled as the Consolidated Appropriations Act 2010 (H.R. 3288). The Senate
adopted the conference report on December 13, 2009. Division E of the Consolidated
Appropriations Act 2010 included a compromise version of the House- and Senate-passed
versions of Military Construction and Veterans Affairs and Related Agencies Appropriations Act
2010 (MILCON-VA Appropriations Act of 2010). The Consolidated Appropriations Act was
singed into law on December 16, 2009 (P.L. 111-117).1
The MILCON-VA Appropriations Act, 2010, provides a total of approximately $45.1 billion for
the Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA). This is a
7.4% increase over the FY2009 enacted amount and the same as the Administration’s budget
request for VHA (see Table 1).2 This amount includes funding for the medical services ($34.7
billion), medical support and compliance ($4.9 billion), medical facilities ($4.9 billion), and
medical and prosthetic research ($581.0 million) accounts. The Consolidated Appropriations Act
(P.L. 111-117) also provides approximately $48.2 billion in advance appropriations for the
medical services, medical support and compliance, and medical facilities accounts to be available
in FY2011.
As seen in Figure 1, funding for VHA has seen significant growth between FY1995 and FY2009.
During this time period funding for VHA increased by 154%, while the average annual increase
was 6.9%. From FY1995 to FY2005 the average annual increase was 6.7% whereas average
annual increase between FY2006 and FY2009 was 12.7% (Figure 1). The growth in funding
could be attributed to aging of many World War II and Korean War veterans with a greater need
for health care services, veterans’ increasing reliance on VHA’s pharmaceutical benefits,3 and
more recent veterans from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom
(OIF) accessing the VA health care system. Veterans from OEF and OIF account for a rising
proportion of VA’s total patient work load. In FY2010 OEF and OIF patients will represent about
7% of the overall VA patient population, compared to about 3% in FY2006.4
1
Among other appropriation bills, the conference agreement included the Commerce, Justice, Science, and Related
Agencies Appropriations Act, 2010; the Financial Services and General Government Appropriations Act, 2010; the
Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2010;
and the Department of State, Foreign Operations, and Related Programs Appropriations Act, 2010.
2
The FY2009 enacted amount includes supplemental funding provided by the American Recovery and Reinvestment
Act (P.L. 111-5).
3
Department of Veterans Affairs, FY2010 Budget Submission, Medical Programs and Information Technology
Programs, Vol. 2 of 4, May 2009, p. 1C-3.
4
Ibid. p. 1I-21, and U.S. Congress, House Committee on Veterans’ Affairs, The Status of the Department of Veterans
Affairs, 111th Cong., 1st sess., February 4, 2009 (Washington: GPO, 2009), p. 49.
Congressional Research Service
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Veterans Medical Care: FY2010 Appropriations
Figure 1. Enacted Appropriations for VHA, FY1995-FY2009
45.0
VHA
budget
shortfalls
reporteda
40.0
OEF
Begins
35.0
34.0
37.2
29.7
30.0
$ in Billions
42.0
29.3
24.4
25.0
26.8
20.7
20.0
16.5
15.0
17.3
16.9
21.9
17.7
17.4
19.3
OIF Begins
10.0
5.0
FY
19
FY 95
19
FY 96
19
FY 97
19
FY 98
19
FY 99
20
FY 00
20
FY 01
20
FY 02
20
FY 03
20
FY 04
20
FY 05
20
FY 06
20
FY 07
20
FY 08
20
09
0.0
Fiscal Year
Source: Congressional Research Service, based on House and Senate Appropriations Committee reports
accompanying the Departments of Veterans Affairs and Housing and Urban Development, and Independent
Agencies Appropriation Acts and Military Construction and Veterans Affairs Appropriations Acts.
Notes: OEF= Operation Enduring Freedom. OEF commenced in October 2001, and includes operations in and
around Afghanistan as well as Guantanamo Bay (Cuba), Djibouti, Eritrea, Ethiopia, Jordan, Kenya, Kyrgyzstan,
Philippines, Seychelles, Sudan, Tajikistan, Turkey, and Yemen.
OIF= Operation Iraqi Freedom. OIF commenced in March 2003, and includes operations in Iraq and in the
Arabian Sea, Bahrain, Gulf of Aden, Gulf of Oman, Iraq, Kuwait, Oman, Persian Gulf, Qatar, Red Sea, Saudi
Arabia, and United Arab Emirates.
Enacted figures include medical services, medical support and compliance (previously medical administration),
medical facilities, and medical and prosthetic research accounts. The figures exclude collections deposited into
the medical care collections fund (MCCF).
a. In June 2005, the Administration requested additional funds from Congress for FY2005 (a $975 million
supplemental appropriation) and in July 2005, the Administration requested additional funds for FY2006 (a
budget amendment of $1.977 billion). For details see CRS Report RL33409, Veterans’ Medical Care:
FY2007 Appropriations, by (name redacted).
The remainder of this report is organized as follows. The first section of the report provides an
overview of the Department of Veterans Affairs (VA) health care system. The second section
provides a description of the veteran patient population and eligibility for VA health care. The
third section provides a brief overview of the FY2009 Veterans Health Administration (VHA)
budget. The fourth section discusses the FY2010 VHA budget including House and Senate action.
Lastly, the report discusses major VA health care issues as they pertain to the FY2010 budget.
Congressional Research Service
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Table 1.VA Appropriations, FY2009-FY2010, and Advance Appropriations, FY2011
($ in thousands)
House
Senate
Enacted
(H.R. 3082)
(H.R. 3082)
(P.L. 111-117)
FY2009
Enacted
FY2010
Request
FY2010
FY2011
FY2010
FY2011
FY2010
FY2011
Total Department of
Veterans Affairs (VA)
$95,948,057
$108,860,775
$108,859,775
—
$109,060,409
—
$109,607,626
—
Total Mandatory
46,742,925
55,821,672
55,821,672
—
55,821,672
—
56,568,316
—
Total Discretionary
49,205,132
53,039,103
53,038,103
—
53,238,737
—
53,039,310
—
Total Veterans
Health
Administration
(VHA)a
$41,958,903
$45,077,500
$45,075,000
—
$45,235,133
—
$45,077,500
—
Memorandum: Advance
appropriations VHAb
—
—
—
$48,183,000
—
$48,183,000
—
$48,183,000
Sources: Congressional Record, vol.154, (September 24, 2008), pp. H9868-H9869, H.Rept. 111-188, S.Rept. 111-40,Congressional Record, vol.155, (July 10, 2009), pp. H7983H7987, Congressional Record, vol.171, (November 18, 2009), pp. S11503-S11508, and Division E of H.Rept. 111-366.
Notes: FY2009 enacted includes funding provided in the American Recovery and Reinvestment Act of 2009 (P.L. 111-5).
a.
Includes funding for medical services, medical support and compliance, medical facilities, and medical and prosthetic research accounts, and excludes collections
deposited into the Medical Care Collections Fund (MCCF).
b.
The House and Senate Military Construction and Veterans Affairs Appropriations bills for FY 2010, and Division E of the Consolidated Appropriations Act 2010
(Military Construction and Veterans Affairs Appropriations Act, 2010) provided budget authority for FY2011 for the following accounts: medical services, medical
support and compliance, and medical facilities. Under current budget scoring guidelines new budget authority for an advance appropriation is scored in the fiscal year in
which the funds become available for obligation. Therefore, in this table the budget authority is recorded in the FY2011 column.
CRS-3
Veterans Medical Care: FY2010 Appropriations
Introduction
The history of the present day Department of Veterans Affairs (VA) can be traced back to July 21,
1930, when President Hoover issued Executive Order 5398 consolidating separate veterans’
programs and creating an independent federal agency known as the Veterans Administration.5 On
October 25, 1988, President Reagan signed legislation (P.L. 100-527) creating a new federal
cabinet-level Department of Veterans Affairs to replace the Veterans Administration effective
March 15, 1989.
The VA provides a range of benefits and services to veterans who meet certain eligibility rules
including hospital and medical care, disability compensation and pensions, 6 education, 7
vocational rehabilitation and employment services, assistance to homeless veterans,8 home loan
guarantees,9 administration of life insurance as well as traumatic injury protection insurance for
servicemembers, and death benefits that cover burial expenses.
The Department carries out its programs nationwide through three administrations and the Board
of Veterans Appeals (BVA). The Veterans Health Administration (VHA) is responsible for health
care services and medical and prosthetic research programs. The Veterans Benefits
Administration (VBA) is responsible for, among other things, providing compensations, pensions,
and education assistance. The National Cemetery Administration (NCA)10 is responsible for
maintaining national veterans cemeteries; providing grants to states for establishing, expanding,
or improving state veterans cemeteries; and providing headstones and markers for the graves of
eligible persons, among other things.
The VA’s budget includes both mandatory and discretionary spending accounts. Mandatory
funding supports disability compensation, pension benefits, education, vocational rehabilitation,
and life insurance, among other benefits and services. Discretionary funding supports a broad
array of benefits and services including medical care. Figure 2 provides a breakdown of FY2009
budget allocations for both mandatory and discretionary programs. In FY2009 the total VA
budget authority was approximately $96 billion; discretionary budget authority accounted for
about 51.2% ($49.2 billion) of the total, with about 85% of this discretionary funding going
toward supporting VA health care programs.
5
In the 1920s three federal agencies, the Veterans Bureau, Bureau of Pensions in the Department of the Interior, and
the National Home for Disabled Volunteer Soldiers administered various benefits for the nation’s veterans.
6
For detailed information on disability compensation and pension programs see CRS Report RL33323, Veterans
Affairs: Benefits for Service-Connected Disabilities, by (name redacted), and CRS Report RS22804,
Veterans’
Benefits: Pension Benefit Programs, by (name redacted) and (name redacted).
7
For details on education benefits see CRS Report R40723, Educational Assistance Programs Administered by the
U.S. Department of Veterans Affairs, by (name redacted).
8
For detailed information on homeless veterans programs see CRS Report RL34024, Veterans and Homelessness, by
(name redacted).
9
For details on the home loan guarantee program see CRS Report RS20533, VA-Home Loan Guaranty Program: An
Overview, by (name redacted).
10
Established by the National Cemeteries Act of 1973 (P.L. 93-43).
Congressional Research Service
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Veterans Medical Care: FY2010 Appropriations
Figure 2. FY2009 VA Budget Allocations
Other, 1%
Mandatory Benefits
Programs, 48%
Medical Programs,
44%
Discretionary
Benefits Programs,
2%
Construction, 2%
Information
Technology, 3%
Source: Chart prepared by Congressional Research Service based on figures contained in Congressional Record,
vol.154, (September 24, 2008), pp. H9868-H9869 and P.L. 111-5.
The Veterans Health Care System
The VHA operates the nation’s largest integrated direct health care delivery system. 11 While
Medicare, Medicaid, and the State Children’s Health Insurance Program (CHIP) are also publicly
funded programs, most health care services under these programs are delivered by private
providers in private facilities. In contrast, the VA health care system is a truly public health care
system in the sense that the federal government owns the medical facilities and employs the
health care providers.12
The VA’s health care system is organized into 21 geographically defined Veterans Integrated
Service Networks (VISNs) (see Figure 3). Although policies and guidelines are developed at VA
headquarters to be applied throughout the VA health care system, management authority for basic
decision making and budgetary responsibilities are delegated to the VISNs.13 Congressionally
appropriated medical care funds are allocated to the VISNs based on the Veterans Equitable
11
Established on January 3, 1946 as the Department of Medicine and Surgery by P.L. 79-293, succeeded in 1989 by the
Veterans Health Services and Research Administration, renamed the Veterans Health Administration in 1991.
12
U.S. Congress, House, Economic Report of the President, 110th Cong., 2nd sess., February 2008, H. Doc. 110-83
(Washington: GPO, 2008), p. 106.
13
Kizer Kenneth, John Demakis, and John Feussner, “Reinventing VA health care: Systematizing Quality
Improvement and Quality Innovation.” Medical Care. vol. 38, no. 6 (June 2000), Suppl 1:I7-16.
Congressional Research Service
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Veterans Medical Care: FY2010 Appropriations
Resource Allocation (VERA) system, which generally bases funding on patient workload. VISNs,
in turn, allocate funds to the medical centers within their networks. Prior to the implementation of
the VERA system, resources were allocated to facilities based primarily on their historical
expenditures. While a thorough description of VERA is beyond the scope of this report, generally
VERA has two types of funds known as General Purpose funds and Specific Purpose funds.
General Purpose funds encompass about 83.5% of VHA total budget allocations to the VISNs.
General Purpose funds are distributed to the 21 VISNs at the beginning of each fiscal year and are
comprised of 8 elements. These elements include basic care, complex care, adjustments for high
cost patients, geographic price adjustment, research support, education support, equipment, and
non-recurring maintenance.
The Specific Purpose funds are given to the 21 VISNs during the year for specific activities
including prosthetics, mental health, homeless grants and per diem program, state home per
diems, transplants, clinical trainees, readjustment counseling, and medical facility activations.
Under VERA each network is provided an allocation that takes into account its unique
characteristics, and that is also adjusted to account for those veterans who receive care in more
than one network.
As seen in Table 2 the largest allocations of funds in FY2009 were to VISNs: 8 (Florida and
Puerto Rico), 16 (Mississippi, Arkansas, Louisiana, Oklahoma, some parts of Texas), 22 (some
parts of California and Nevada), 7 (Alabama, Georgia, and South Carolina), and 21 (some parts
of California, and Nevada, Hawaii and Philippines). While VISNs 8, 16, 7, and 4 have the
greatest number of unique veteran patients, VERA funding is not driven by veteran patient
population alone, but is adjusted for differences in patient mix, high cost patients, and geographic
costs, among other factors.
Congressional Research Service
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Veterans Medical Care: FY2010 Appropriations
Figure 3.Veterans Integrated Services Networks (VISNs)
Source: Department of Veterans Affairs, adapted by Congressional Research Service.
Congressional Research Service
7
Table 2. FY2009 VERA Allocations
($ in thousands)
Network
(VISN)
1
2
3
4
5
6
7
8
9
10
11
12b
15
16
17
18
19
20
21
22
23
VHA
Totala
Basic Carea
$859,369
480,484
698,879
1,033,231
469,096
1,085,729
1,170,695
1,989,487
1,020,301
754,083
874,204
849,628
860,022
1,748,527
959,469
885,212
575,571
871,766
854,866
1,050,766
997,382
$20,088,768
Complex
Carea
High Cost
Patient
Allocationsa
$269,467
165,529
247,079
308,041
194,628
316,845
367,968
465,785
250,836
351,823
230,499
285,821
216,214
332,386
286,368
236,942
158,699
231,393
288,315
336,359
310,752
$171,151
57,603
246,858
143,951
89,646
138,101
122,428
193,712
93,251
77,069
101,074
136,380
67,028
149,759
91,070
66,162
38,850
91,698
188,127
184,100
95,126
Geographic
Price
Adjustmenta
$59,786
(19,845)
86,247
(22,640)
18,284
(31,222)
(47,506)
(109,744)
(51,743)
(17,389)
(20,464)
34,013
(31,783)
(33,185)
(18,321)
(24,645)
(12,934)
11,335
162,012
100,685
(30,939)
$5,851,747
$2,543,145
$0
Research
Supporta
Education
Supporta
Equipmenta
$42,627
3,743
15,077
18,989
17,584
14,501
22,493
14,964
15,756
13,730
17,753
21,315
7,557
17,045
16,475
13,410
11,358
26,320
62,831
42,931
25,540
$36,258
16,618
41,343
20,880
17,641
27,042
32,816
45,612
38,654
19,823
23,163
45,354
23,499
51,244
26,566
22,978
17,961
21,946
32,120
53,164
28,035
$62,795
35,046
50,610
81,067
34,043
74,449
84,484
136,947
69,364
52,640
63,089
61,768
62,289
121,879
67,792
62,343
41,941
60,195
60,662
72,875
75,344
Nonrecurring
Maintenancea
$40,002
21,148
44,205
48,689
18,231
32,886
37,598
67,680
34,225
31,482
38,810
41,908
34,263
54,642
29,732
29,230
21,722
39,089
43,123
49,162
42,174
$442,000
$642,719
$1,431,621
$800,000
Source: Department of Veterans Affairs, Veterans Health Administration, Office of Finance.
a.
Totals may not add-up due to rounding
b.
In January 2002, VISNs 13 and 14 were integrated as VISN 23.
CRS-8
4% Floor
Adjustmenta
Total
General
Purpose
Allocationa
$(1,777)
10,022
8,266
870
7,030
(2,840)
(2,466)
(2,917)
(1,894)
(1,558)
(1,838)
(1,612)
3,481
(2,382)
(2,052)
(1,383)
(1,258)
(1,706)
(2,452)
(2,149)
616
$1,539,678
770,348
1,438,564
1,633,078
866,183
1,655,491
1,788,510
2,801,526
1,468,750
1,281,703
1,326,290
1,474,575
1,242,570
2,439,915
1,457,099
1,290,249
851,910
1,352,036
1,689,604
1,887,893
1,544,030
$0
$31,800,000
Veterans Medical Care: FY2010 Appropriations
As of FY2009, VHA operates 153 hospitals (medical centers), 135 nursing homes, 803
community-based outpatient clinics (CBOCs),14 6 independent outpatient clinics, 271
Readjustment Counseling Centers (Vet Centers).15 VHA also operates 10 mobile outpatient
clinics.
The VHA pays for care provided to veterans by private-sector providers on a fee basis under
certain circumstances. Inpatient and outpatient care are also provided in the private sector to
eligible dependents of veterans under the Civilian Health and Medical Program of the Department
of Veterans Affairs (CHAMPVA).16 The VHA also provides grants for construction of stateowned nursing homes and domiciliary facilities and collaborates with the Department of Defense
(DOD) in sharing health care resources and services.
Apart from providing direct patient care to veterans,17 VHA’s other statutory missions are to
conduct medical research,18 to serve as a contingency back up to the Department of Defense
(DOD) medical system during a national security emergency, 19 to provide support to the National
Disaster Medical System and the Department of Health and Human Services as necessary,20 and
to train health care professionals in order to provide an adequate supply of health personnel for
VA and the Nation. 21
Training of Health Care Professionals
VA’s clinical training program is the largest provider of health care training in the United States.22
It is also the second largest federal payer (after Medicare) for health care training. In FY2008, a
total of 109,882 health professionals had part or all of their clinical training at VA medical
facilities (see Figure 4). This included 34,075 physician residents rotating through 9,545 funded
14
Data on the number of CBOCs differ from source to source. Some sources count clinics located at VA hospitals
while others count only free standing facilities. The number provided in this report excludes outpatient clinics located
at VA hospitals.
15
In FY2009 VA plans to establish 39 new Vet Centers. The new Vet Centers are to be located in the following
counties: Madison, AL; Maricopa, AZ; Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, and San
Diego, CA; Fairfield, CT; Broward, Palm Beach, Pasco, Pinellas, Polk, and Volusia, FL; Cobb, GA; Cook, and
DuPage, IL; Anne Arundel, Baltimore, and Prince George’s, MD; Macomb and, Oakland, MI; Hennepin, MN; Greene,
MO; Onslow, NC; Ocean, NJ; Clark, NV; Comanche, OK; Bucks, and Montgomery, PA; Bexar, Dallas, Harris, and
Tarrant, TX; Virginia Beach, VA; King, WA; and Brown, WI. VA plans to have the 39 sites fully operational by the
end of December 2009. In FY2010 VA plans to establish 28 new Vet Centers. These new Vet Centers would be located
in: Mohave and Yuma Counties, AZ; San Luis Obisbo, CA; Sussex County, DE; Bay, Collier, Lake, Marion, and
Okaloosa Counties, FL; Muscogee and Richmond Counties, GA; Oahu (Western), HI; St. Joseph County, IN; Rapides
County, LA; Grand Traverse County, MI; Boone County, MO; Cascade and Flathead Counties, MT; Stark County,
OH; Deschutes County, OR; Lancaster County, PA; Horry County, SC; Jefferson and Taylor Counties TX; Washington
County UT; Walla Walla County, WA; LaCrosse County, WI; and American Samoa.
16
For further information on CHAMPVA, see CRS Report RS22483, Health Care for Dependents and Survivors of
Veterans, by (name redacted).
17
38 U.S.C. § 7301(b).
18
38 U.S.C. § 7303.
19
38 U.S.C. § 8111A.
20
38 U.S.C. § 8117(e).
21
38 U.S.C. § 7302.
22
U.S. Congress, House Committee on Veterans’ Affairs, Subcommittee on Health, Healthcare Professionals—
Recruitment and Retention, 110th Cong., 1st sess., October 18, 2007 (Washington: GPO, 2008), p. 40.
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graduate medical education (GME) slots (about 8.5% of total U.S. resident positions).23 It should
be noted here that about 3.5 individual physician residents rotate through each of the 9,545
funded positions. 24 Of the total U.S. physician residents about 31% (34,075) receive some or all
of their training from the VA annually. Although a majority of VA’s residency positions are in
primary care, the Department also supports GME in recognized medical specialties and
subspecialties.
In late 2004, VA’s Advisory Committee on GME initiated a review of VA’s resident education
program. The Advisory Committee was charged with examining the philosophy and deployment
of VA’s residency training positions (including the total number of positions, the specialty mix of
resident physician training positions, and the geographic distribution of positions). The Advisory
Committee undertook a broad assessment of graduate medical education in relationship to
veterans’ future health care needs. The Advisory Committee’s recommendations called for
increasing the number of residents in geographic areas and at sites of care where there are
increased capacities to train; expanding training in areas of high relevance to VA; expanding
training in areas of new and emerging specialties; and expanding affiliations with new VA sites of
care. 25
As a result of this Advisory Committee’s recommendation, in 2006 (academic year 2007-2008)
VA began a GME enhancement program. The purpose of this multi-year program is to increase
VA’s share of U.S. resident positions from its low of 8.5% to the range of 10-11%. The five-year
plan is designed to add approximately 2,000 positions to VA’s pre-existing physician resident
positions. In the first three years, the VA has added 967 residency positions to the base allocations
of 72 VA facilities in 66 different specialty training programs.
23
Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations, Briefing to the
Congressional Research Service, April 15, 2009.
24
A single resident position may be filled by multiple residents. Allocations of fractions of slots are possible because
residents may obtain only a part of their training at a VA medical center.
25
The full report can be accessed at http://www.va.gov/oaa/archive/FACA_Report_2005.pdf, accessed on May 20,
2009.
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Figure 4.VA Health Professionals Training Program: Percent Distribution of Program
Participants, FY2008
Associated Health
Professionals, 21%
(23,237)
Advanced
Fellowships, 0.1%
(161)
Nursing Students,
29% (31,654)
Physician Residents
(GME), 31%
(34,075)
Medical Students,
19% (20,755)
Source: Chart prepared by Congressional Research Service, based on data provided by the Department of
Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations.
The Veteran Patient Population
During FY2009, the VHA had an estimated total enrolled veteran population of 8.3 million and
provided medical care to about 5.4 million unique veteran patients (see Table 3 and Table 4 ).26
According to VHA estimates, the number of unique veteran patients is estimated to increase by
approximately 116,000, from 5.42 million in FY2009 to 5.53 million in FY2010. As shown in
Table 4 there will be an estimated 2.1% increase in the total number of unique patients (both
veterans and non-veterans), from 5.92 million in FY2009 to 6.05 million in FY2010. The number
of patients includes veterans from Operation Iraqi Freedom (OIF) and Operation Enduring
Freedom (OEF). In FY2010, VHA estimates that it will treat about 419,000 OIF and OEF
veterans, an increase of about 56,000 patients, or 15.4%, over the FY2009 level. In FY2010, it is
26
“Enrolles” are veterans who are currently enrolled in the VA health care system. “Unique patients” are those
receiving medical care who are counted only once. In any given year, some enrollees do not seek any medical care,
either because they do not become sick or because they rely on other health care resources, such as private health
insurance, for care.
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estimated that VA will be treating over 515,000 non-veterans, an increase of over 5,900 or 1.2%,
over the FY2009 level. 27
The total number of outpatient visits, including visits to Vet Centers, reached 67.6 million during
FY2008 and is projected to increase to approximately 70.9 million in FY2009 and 74.5 million in
FY2010.28 The VHA estimates that in FY2009 it will spend approximately 56.2% of its medical
services obligations on outpatient care.29
Table 3. Number of Veterans Enrolled in the VA Health Care System,
FY2006-FY2010
Priority Groupsa
FY2006
Actual
FY2007
Actual
FY2008
Actual
FY2009
Estimate
FY2010
Estimate
1
912,787
977,389
1,041,754
1,079,852
1,134,117
2
522,829
545,196
550,634
595,548
618,701
3
996,063
1,023,256
1,011,568
1,090,376
1,118,059
4
241,716
244,159
237,208
233,153
230,759
5
2,538,228
2,413,796
2,274,668
2,361,165
2,350,211
6
265,253
312,256
425,588
354,785
370,649
Subtotal Priority Groups
1-6
5,476,876
5,516,052
5,541,420
5,714,879
5,822,496
7
218,248
202,049
164,986
1,056,733
1,058,811
8
2,177,314
2,115,344
2,128,357
1,545,331
1,557,535
Subtotal Priority Groups
7-8
2,395,562
2,317,393
2,293,343
2,602,064
2,616,346
Total Enrollees
7,872,438
7,833,445
7,834,763
8,316,943
8,438,842
Source: Table prepared by Congressional Research Service based on data from Department of Veterans
Affairs, FY2010 Budget Submission, Medical Programs and Information Technology Programs, Vol. 2 of 4, May 2009, pp.
1C-11.
a.
For a description of the Priority Groups see Appendix A.
27
Non-veterans include CHAMPVA patients, reimbursable patients with VA affiliated hospitals and clinics, care
provided on a humanitarian basis, veterans of World War II allied nations, and employees receiving preventative
occupational immunizations such as Hepatitis A&B and flu vaccinations.
28
This number includes outpatient care provided on a contract basis and outpatient visits to readjustment counseling
centers. Department of Veterans Affairs, FY2010 Budget Submission, Medical Programs and Information Technology
Programs, Vol. 2 of 4, May 2009, pp. 1C-12.
29
Ibid., p.1C-14.
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Table 4. Number of Patients Receiving Care from the VA, FY2006-FY2010
Priority Groupa
FY2006
Actual
FY2007
Actual
FY2008
Actual
FY2009
Estimate
FY2010
Estimate
1
768,537
820,410
888,470
919,918
968,516
2
342,023
358,270
365,212
394,768
412,264
3
568,740
590,860
585,032
634,232
654,712
4
177,563
181,572
185,997
186,477
186,369
5
1,645,781
1,544,328
1,484,467
1,580,609
1,590,953
6
134,425
155,939
199,882
174,184
181,944
Subtotal Priority Groups 1-6
3,637,069
3,651,379
3,709,060
3,890,188
3,994,758
7
197,901
173,149
147,785
619,888
622,101
8
1,195,612
1,191,161
1,221,424
909,816
918,896
Subtotal Priority Groups 7-8
1,393,513
1,364,310
1,369,209
1,529,704
1,540,997
Subtotal Unique Veteran Patientsb
5,030,582
5,015,689
5,078,269
5,419,892
5,535,755
Non-veteransc
435,488
463,240
498,420
509,167
515,098
Total Unique Patients
5,466,070
5,478,929
5,576,689
5,929,059
6,050,853
Source: Table prepared by Congressional Research Service based on data from Department of Veterans
Affairs, FY2010 Budget Submission, Medical Programs and Information Technology Programs, Vol. 2 of 4, May 2009, pp.
1C-11.
a.
For a description of the Priority Groups see Appendix A.
b.
Unique veteran patients include Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)
veterans. These patients numbered: 155,272 in FY2006, 205,628 in FY2007, 261,019 in FY2008, and are
estimated to be 363,275 in FY2009 and 419,256 in FY2010.
c.
Non-veterans include CHAMPVA patients, reimbursable patients with VA affiliated hospitals and clinics,
care provided on a humanitarian basis, veterans of World War II allied nations, and employees receiving
preventative occupational immunizations such as Hepatitis A&B and flu vaccinations.
Eligibility for Veterans Health Care
“The Promise of Free Health Care”
To understand some of the issues discussed in this report, it is important to understand eligibility
for VA health care, the VA’s enrollment process, and its enrollment priority groups. VA health care
is not an entitlement program. Contrary to numerous claims made concerning “promises” to
military personnel and veterans with regard to “free health care for life,” not every veteran is
automatically entitled to medical care from the VA. 30 Prior to eligibility reform in 1996,
provisions of law governing eligibility for VA care were complex and not uniform across all
levels of care. All veterans were technically “eligible” for hospital care and nursing home care,
but eligibility did not by itself ensure access to care.
30
For a detailed discussion of “promised benefits,” see CRS Report 98-1006, Military Health Care: The Issue of
“Promised” Benefits, by (name redacted).
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The Veterans’ Health Care Eligibility Reform Act of 1996, P.L. 104-262, established two
eligibility categories and required the VHA to manage the provision of hospital care and medical
services through an enrollment system based on a system of priorities. 31 P.L. 104-262 authorized
the VA to provide all needed hospital care and medical services to veterans with serviceconnected disabilities, former prisoners of war, veterans exposed to toxic substances and
environmental hazards such as Agent Orange, veterans whose attributable income and net worth
are not greater than an established “means test,” and veterans of World War I. These veterans are
generally known as “higher priority” or “core” veterans (see Appendix A, and discussed in more
detail below). 32 The other category of veterans are those with no service-connected disabilities
and with attributable incomes above an established means test (see Appendix C).
P.L. 104-262 also authorized the VA to establish a patient enrollment system to manage access to
VA health care. As stated in the report language accompanying P.L. 104-262, “the Act would
direct the Secretary, in providing for the care of ‘core’ veterans, to establish and operate a system
of annual patient enrollment and require that veterans be enrolled in a manner giving relative
degrees of preference in accordance with specified priorities. At the same time, it would vest
discretion in the Secretary to determine the manner in which such enrollment system would
operate.”33
Furthermore, P.L. 104-262 was clear in its intent that the provision of health care to veterans was
dependent upon the available resources. The committee report accompanying P.L. 104-262 states
that the provision of hospital care and medical services would be provided to “the extent and in
the amount provided in advance in appropriations acts for these purposes. Such language is
intended to clarify that these services would continue to depend upon discretionary
appropriations.”34
VHA Health Care Enrollment
As stated previously, P.L. 104-262 required the establishment of a national enrollment system to
manage the delivery of inpatient and outpatient medical care. The new eligibility standard was
created by Congress to “ensure that medical judgment rather than legal criteria will determine
when care will be provided and the level at which care will be furnished.”35
For most veterans, entry into the veterans’ health care system begins by completing the
application for enrollment. Some veterans are exempt from the enrollment requirement if they
meet special eligibility requirements. 36 A veteran may apply for enrollment by completing the
31
U.S. Congress, House Committee on Veterans Affairs, Veterans’ Health Care Eligibility Reform Act of 1996, report
to accompany H.R. 3118, 104th Cong. 2nd sess., H.Rept. 104-690 p. 2.
32
Ibid., p.5.
33
Ibid., p.6.
34
Ibid., p.5.
35
Ibid., p.4.
36
Veterans do not need to apply for enrollment in the VA’s health care system if they fall into one of the following
categories: veterans with a service-connected disability rated 50% or more (percentages of disability are based upon the
severity of the disability; and those with a rating of 50% or more are placed in Priority Group 1); veterans for whom
less than one year has passed since the veteran was discharged from military service for a disability that the military
determined was incurred or aggravated in the line of duty, but the VA has not yet rated; or the veteran is seeking care
from the VA only for a service-connected disability (even if the rating is only 10%).
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Application for Health Benefits (VA Form 10-10EZ) at any time during the year and submitting
the form online or in person at any VA medical center or clinic, or mailing or faxing the
completed form to the medical center or clinic of the veteran’s choosing. 37 Once a veteran is
enrolled in the VA health care system, the veteran remains in the system and does not have to
reapply for enrollment annually. However, those veterans who have been enrolled in Priority
Group 5 (see Appendix A, discussed in more detail below) based on income must submit a new
VA Form 10-10EZ annually with updated financial information demonstrating inability to defray
the expenses of necessary care.38
Veteran’s Status
Eligibility for VA health care is based primarily on “veteran’s status” resulting from military
service. Veteran’s status is established by active-duty status in the military, naval, or air service
and an honorable discharge or release from active military service. A veteran with an “other than
honorable” discharge or “bad conduct” discharge may still retain eligibility for VA health care
benefits for disabilities incurred or aggravated during service in the military.39
Generally, persons enlisting in one of the armed forces after September 7, 1980, and officers
commissioned after October 16, 1981, must have completed two years of active duty or the full
period of their initial service obligation to be eligible for VA health care benefits. Servicemembers
discharged at any time because of service-connected disabilities are not held to this requirement.
Also, reservists that were called to active duty and who completed the term for which they were
called, and who were granted an other than dishonorable discharge, are exempt from the 24
continuous months of active duty requirement. National Guard members who were called to
active duty by federal executive order are also exempt from this two-year requirement if they (1)
completed the term for which they were called and (2) were granted an other than dishonorable
discharge.
When not activated to full-time federal service, members of the reserve components and National
Guard have limited eligibility for VA health care services. Members of the reserve components
may be granted service-connection for any injury they incurred or aggravated in the line of duty
while attending inactive duty training assemblies, annual training, active duty for training, or
while going directly to or returning directly from such duty. In addition, reserve component
service members may be granted service-connection for a heart attack or stoke if such an event
occurs during these same periods. The granting of service-connection makes them eligible to
receive care from the VA for those conditions. National Guard members are not granted serviceconnection for any injury, heart attack, or stroke that occurs while performing duty ordered by a
governor for state emergencies or activities.40
After veterans’ status has been established, the VA next places applicants into one of two
categories. The first group is composed of veterans with service-connected disabilities or with
incomes below an established means test. These veterans are regarded by the VA as “high
37
38
VA Form 10-10EZ is available at https://www.1010ez.med.va.gov/sec/vha/1010ez/, accessed July 16, 2009.
38 C.F.R. §17.36 (d)(3)(iv) (2008).
39
For a detailed description of discharge criteria see CRS Report RL33113, Veterans Affairs: Basic Eligibility for
Disability Benefit Programs, by (name redacted).
40
38.U.S.C. §101(24); 38 C.F.R. §3.6(c).
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priority” veterans, and they are enrolled in Priority Groups 1-6 (see Appendix A). Veterans
enrolled in Priority Groups 1-6 include
•
veterans in need of care for a service-connected disability;
•
veterans who have a compensable service-connected condition;
•
veterans whose discharge or release from active military, naval, or air service was
for a compensable disability that was incurred or aggravated in the line of duty;
•
veterans who are former prisoners of war (POWs);
•
veterans awarded the Purple Heart;
•
veterans who have been determined by VA to be catastrophically disabled;
•
veterans of World War I;
•
veterans who were exposed to hazardous agents (such as Agent Orange in
Vietnam) while on active duty; and
•
veterans who have an annual income and net worth below a VA-established
means test threshold.
The VA looks at applicants’ income and net worth to determine their specific priority category
and whether they have to pay copayments for nonservice-connected care. In addition, veterans are
asked to provide the VA with information on any health insurance coverage they have, including
coverage through employment or through a spouse. The VA may bill these payers for treatment of
conditions that are not a result of injuries or illnesses incurred or aggravated during military
service. Appendix B provides information on what categories of veterans pay for which services.
The second group of veterans is composed of those who do not fall into one of the first six
priority groups—primarily veterans with nonservice-connected medical conditions and with
incomes and net worth above the VA-established means test threshold. These veterans are
enrolled in Priority Group 7 or 8.41 Appendix C provides information on income thresholds for
VA health care benefits.
Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)
Veterans
The National Defense Authorization Act (NDAA), FY2008 (P.L. 110-181) extended the period of
enrollment for VA health care from two to five years for veterans who served in a theater of
combat operations after November 11, 1998 (generally, OEF and OIF veterans who served in a
combat theater).
According to the VA, currently enrolled combat veterans will have their enrollment eligibility
period extended to five years from their most recent date of discharge. New servicemembers
41
The VA considers a veteran’s previous year’s total household income (both earned and unearned income, as well as
his/her spouse’s and dependent children’s income). Earned income is usually wages received from working. Unearned
income includes interest earned, dividends received, money from retirement funds, Social Security payments, annuities,
and earnings from other assets. The number of persons in the veterans’ family will be factored into the calculation to
determine the applicable income threshold. 38 C.F.R. § 17.36(b)(7) (2008).
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discharged from active duty on or after January 28, 2003, could enroll for a period of up to five
years after their most recent discharge date from active duty. Veterans who served in a theater of
combat, and who never enrolled, and were discharged from active duty between November 11,
1998 and January 27, 2003 may apply for this enhanced enrollment opportunity through January
27, 2011.
Generally, new OEF and OIF veterans are assigned to Priority Group 6, unless eligible for a
higher Priority Group, and are not charged copays for medication and/or treatment of conditions
that are potentially related to their combat service. Veterans who enroll in the VA health care
system under this extended enrollment authority will continue to be enrolled even after the fiveyear eligibility period ends. At the end of the five-year period, veterans enrolled in Priority Group
6 may be re-enrolled in Priority Group 7 or 8, depending on their service-connected disability
status and income level, and may be required to make copayments for nonservice-connected
conditions. The above criteria apply to National Guard and Reserve personnel who were called to
active duty by federal executive order and served in a theater of combat operations after
November 11, 1998.
Medical Benefits Package
Once enrolled all veterans are offered a standard medical benefits package. This package includes
a full range of inpatient, outpatient, and preventive medical services such as: medical, surgical,
and mental health care, including care for substance abuse; prescription drugs, including over-thecounter drugs and medical and surgical supplies available under the VA national formulary
system; durable medical equipment and prosthetic and orthotic devices, including eyeglasses and
hearing aids; home health services, hospice care, palliative care, and institutional respite care; and
noninstitutional adult day health care and noninstitutional respite care; and periodic medical
exams, among other services. 42
Priority Groups and Scheduling Appointments
The VHA is mandated to provide priority care for non-emergency outpatient medical care for any
condition of a service-connected veteran rated 50% or more, or for a veteran’s service-connected
condition. 43 According to VHA policies, patients with emergency or urgent medical needs must be
provided care, or must be scheduled to receive care as soon as practicable, independent of
service-connected status, and whether care is purchased or provided directly by the VA. Veterans
whose conditions are 50% or more service-connected disabled must be scheduled to be seen
within 30 days of the desired date for any condition.
Veterans who are rated less than 50% service-connected disabled, and who require care for a
service-connected condition, must be scheduled to be seen within 30 days of the desired date.
When VHA staff is in doubt as to whether the request for care is for a service-connected
condition, they are required to assume, on behalf of the veteran, that the veteran is entitled to
priority access and schedule within 30 days of the desired date.44
42
A detail listing of VHA’s standardized medical benefits package is available at 38 C.F.R. § 17.38 (2008).
VHA Directive 2006-055, October 11, 2006.
44
Ibid.
43
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Veterans who are rated less than 50% service-connected, and who require care for a nonserviceconnected condition, are to be scheduled to be seen within 120 days of the desired date.
According to VHA policies, all outpatient appointment requests must be acted on as soon as
possible, but no later than seven calendar days from the date of the request. The VHA also
requires that priority scheduling of any veteran must not affect the medical care of any other
previously scheduled veteran. Furthermore, VHA guidelines state that veterans with serviceconnected conditions cannot be prioritized over other veterans with more acute health care
needs. 45
Formulation of VHA’s Budget
Historically, the major determinant of VHA’s budget size and character was the number of
operating beds—which was controlled by Congress.46 The preliminary budget estimate, to a large
extent, was based on the funding and activity of the previous year. VHA developed system-wide
workload estimates, by type of care, by forecasts submitted by field stations. Unit costs were
derived from the field stations’ reports of the estimated distribution of expenses by type of care.
Costs associated with new programs were estimated by VA central office and added to the budget
estimate.47 The costs associated with staffing improvements, pay increases and inflation were also
added to this estimate. Therefore, it could be stated that the principal assumption at each phase of
the budget formulation process was that the preceding year’s budget was the starting point.48
In 1996, Congress enacted the Departments of Veterans Affairs and Housing and Urban
Development and Independent Agencies Appropriations Act of 1997 (P.L. 104-204). This Act
required VHA to develop a plan for the allocation of health care resources to ensure that veterans
eligible for medical care who have similar economic status and eligibility priority have similar
access to such care, regardless of where they reside. 49 The plan was to “account for forecasts in
expected workload and to ensure fairness to facilities that provide cost-efficient health care.”50
In response to the above-mentioned Congressional mandate, as well as the mandate in the Health
Care Eligibility Reform Act of 1996 (P.L. 104-262) that required the VHA to establish a prioritybased enrollment system, VHA established the Enrollee Health Care Projection Model in 1998.
The VHA’s the Enrollee Health Care Projection Model (EHCPM), which has evolved over time,
develops estimates of future veteran enrollment, enrollees’ expected utilization of health care
services, and the costs associated with that utilization. These 20-year projections are by fiscal
year, enrollment priority, age, Veterans Integrated Service Networks (VISN), market, and facility.
The VHA budget is formulated using the model projections.51
45
Ibid.
U.S. Congress, House Committee on Veterans’ Affairs, Health Care for American Veterans, prepared by the
National Academy of Sciences, National Research Council, 95th Cong., 1st sess., June 7, 1977, House Committee Print
No. 36 (Washington: GPO, 1977), p. 37.
47
Ibid, p .42.
48
Ibid.
49
Department of Veterans Affairs, Office of Inspector General, Report of Audit Congressional Concerns Over
Veterans Health Administration’s Budget Execution, Report No. 06-01414-160, Washington, DC, June 30, 2006, p. 2.
50
Ibid.
51
For a discussion of the EHCPM see CRS Report R40489, Advance Appropriations for Veterans’ Health Care: Issues
and Options for Congress , by (name redacted), and also see Katherine M. Harris, James P. Galasso, and
(continued...)
46
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VHA’s budget request to Congress begins with the formulations of the budget based on the
EHCPM to estimate the demand for medical services among veterans in future years. These
estimates are then used to develop a budget request that is then included with the total VA budget
request to Congress.
Funding for the VHA
The VHA is funded through multiple appropriations accounts that are supplemented by other
sources of revenue. Although the appropriations account structure has been subject to change
from year to year, the appropriation accounts used to support the VHA traditionally include
medical care, medical and prosthetic research, and medical administration. In addition, Congress
also appropriates funds for construction of medical facilities through a larger appropriations
account for construction for all VA facilities. In FY2004, “to provide better oversight and [to]
receive a more accurate accounting of funds,” Congress changed the VHA’s appropriations
structure.52 The Department of Veterans Affairs and Housing and Urban Development and
Independent Agencies Appropriations Act, 2004 (P.L. 108-199, H.Rept. 108-401), funded VHA
through four accounts: (1) medical services, (2) medical administration (currently known as
medical support and compliance), (3) medical facilities, and (4) medical and prosthetic research.
Provided below are brief descriptions of these accounts.
Medical Services
The medical services account covers expenses for furnishing inpatient and outpatient care and
treatment of veterans and certain dependents, including care and treatment in non-VA facilities;
outpatient care on a fee basis; medical supplies and equipment; salaries and expenses of
employees hired under Title 38, United States Code; and aid to state veterans homes. In its
FY2008 budget request to Congress, the VA requested the transfer of food service operations
costs from the medical facilities appropriations to the medical services appropriations. The House
and Senate Appropriations Committees concurred with this request.53
Medical Support and Compliance (Previously Medical
Administration)
The medical support and compliance account provides funds for the expenses related to the
administration of hospitals, nursing homes, and domiciliaries, billing and coding activities, public
health and environmental hazard programs, quality and performance management, medical
inspection, human research oversight, training programs and continuing education, security,
volunteer operations, and human resources management.
(...continued)
Christine Eibner, Review and Evaluation of the VA Enrollee Health Care Projection Model, The RAND Corporation,
Center for Military Health Policy Research, 2008.
52
U.S. Congress, Conference Committees, Consolidated Appropriations Act, 2004, conference report to accompany
H.R. 2673, 108th Cong., 1st sess., H.Rept. 108-401, p. 1036.
53
The cost of food service operations support hospital food service workers, provisions, and supplies related to the
direct care of patients.
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Medical Facilities
The medical facilities account covers, among other things, expenses for the maintenance and
operation of VHA facilities; administrative expenses related to planning, design, project
management, real property acquisition and deposition, construction, and renovation of any VHA
facility; leases of facilities; and laundry services.
Medical and Prosthetic Research
This account provides funding for VA researchers to investigate a broad array of veteran-centric
health topics, such as treatment of mental health conditions; rehabilitation of veterans with limb
loss, traumatic brain injury, and spinal cord injury; organ transplantation; and the organization of
the health care delivery system. VA researchers receive funding not only through this account but
also from the Department of Defense (DOD), the National Institutes of Health (NIH), and private
sources.
Unlike other federal agencies such as NIH and DOD, VA does not have the statutory authority to
make research grants to colleges and universities, cities and states, or any other non-VA entities.
In general, VA’s research program is intramural, that is, research is performed by VA investigators
at VA facilities and approved off-site locations.
Medical Care Collections Fund (MCCF)
In addition to direct appropriations accounts mentioned above, the Committees on Appropriations
include medical care cost recovery collections when considering the amount of resources needed
to provide funding for the VHA. The Consolidated Omnibus Budget Reconciliation Act of 1985
(P.L. 99-272), enacted into law in 1986, gave the VHA the authority to bill some veterans and
most health care insurers for nonservice-connected care provided to veterans enrolled in the VA
health care system, to help defray the cost of delivering medical services to veterans.54 This law
also established means testing for veterans seeking care for nonservice-connected conditions.
However, P.L. 99-272 did not provide the VA with specific authority to retain the third-party
payments it collected and VA was required to deposit these third-party collections in the General
Fund of the U.S. Treasury.
The Balanced Budget Act of 1997 (P.L. 105-33) gave the VHA the authority to retain these funds
in the Medical Care Collections Fund (MCCF). Instead of returning the funds to the Treasury, the
VA can use them for medical services for veterans without fiscal year limitations. 55 To increase
the VA’s third-party collections, P.L. 105-33 also gave the VA the authority to change its basis of
billing insurers from “reasonable costs” to “reasonable charges.”56 This change in billing was
intended to enhance VA collections to the extent that reasonable charges result in higher payments
than reasonable costs.57 In FY2004, the Administration’s budget requested consolidating several
54
Veterans’ Health-Care and Compensation Rate Amendments of 1985; 100 Stat. 372, 373, 383.
For a detailed history of funding for VHA from FY1995 to FY2004, see CRS Report RL32732, Veterans’ Medical
Care Funding: FY1995-FY2004, by (name redacted).
56
Under “reasonable costs,” the VA billed insurers based on its average cost to provide a particular episode of care.
Under “reasonable charges,” the VA bills insurers based on market pricing for health care services.
57
U.S. Government Accountability Office (GAO), VA Health Care: Third-Party Charges Based on Sound
(continued...)
55
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existing medical collections accounts into one MCCF. The conferees of the Consolidated
Appropriations Act of 2004 (H.Rept. 108-401) recommended that collections that would
otherwise be deposited in the Health Services Improvement Fund (former name), Veterans
Extended Care Revolving Fund (former name), Special Therapeutic and Rehabilitation Activities
Fund (former name), Medical Facilities Revolving Fund (former name), and the Parking
Revolving Fund (former name) should be deposited in MCCF.58 The Consolidated Appropriations
Act of 2005 (P.L. 108-447, H.Rept. 108-792) provided the VA with permanent authority to
deposit funds from these five accounts into the MCCF. The funds deposited into the MCCF
would be available for medical services for veterans. These collected funds do not have to be
spent in any particular fiscal year and are available until expended.
Consolidated Patient Accounting Centers (CPACs)
In 2005, VA established a Mid-Atlantic CPAC in North Carolina to help maximize its collections
by using a private-sector model tailored to VA’s billing and collection needs. 59 The conferees of
the FY2006 Military Construction, Military Quality of Life and Veterans Affairs Appropriations
Act (P.L. 109-114, H.Rept. 109-305) required the VA to establish a revenue improvement
demonstration project. The purpose of this pilot project was to provide a “comprehensive
restructuring of the complete revenue cycle including cash-flow management and accounts
receivable.”60 The conferees included this provision because the Appropriations Committees were
concerned that the VHA was collecting only 41% percent of the billed amounts from third-party
insurance companies. Due to their similar missions, VA established the Revenue Improvement
Demonstration Project at the Mid-Atlantic CPAC.61 There are eight VA medical centers under the
CPAC demonstration project. In a report issued in June 2008, the Government Accountability
Office (GAO) stated that VA had ineffective controls over medical center billings.62 The GAO
estimated that $1.2 to $1.4 billion dollars are going uncollected by VA. Furthermore, in the same
2008 report, GAO noted that the Mid-Atlantic CPAC achieved better billing performance and has
been able to reduce billing times.63 The Veterans Mental Health and Other Improvements Act of
2008 (P.L. 110-387) required the VA to establish, within five years, no more than seven CPACs
modeled after the existing CPAC and Revenue Improvement Demonstration Project in Asheville,
North Carolina.
(...continued)
Methodology; Implementation Challenges Remain, GAO/HEHS-99-124, June 1999.
58
For a detailed description of these former accounts, see CRS Report RL32548, Veterans’ Medical Care
Appropriations and Funding Process, by (name redacted).
59
U.S. Congress, House Committee on Veterans’ Affairs, Veterans’ Health Care Policy Enhancement Act of 2008,
report to accompany H.R. 6445, 110th Cong., 2nd sess., July 29, 2008, H.Rept. 110-789, p. 7.
60
U.S. Congress, Conference Committees, Military Construction, Military Quality of Life and Veterans Affairs
Appropriations Act, 2006, conference report to accompany H.R. 2528, 109th Congress, 1st session, H.Rept. 109-305, p.
43.
61
U.S. Congress, House Committee on Veterans’ Affairs, Veterans’ Health Care Policy Enhancement Act of 2008,
report to accompany H.R. 6445, 110th Cong., 2nd sess., July 29, 2008, H.Rept. 110-789, p. 7.
62
For details on whether medical centers under the CPAC initiative had more effective controls over third-party
billings and collections, see U.S. Government Accountability Office, VA Health Care: Ineffective Controls over
Medical Center Billings and Collections Limit Revenue from Third- Party Insurance Companies, GAO-08-675, June
2008.
63
Ibid.
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As shown in Table 5 MCCF collections increased from $1.5 billion in FY2003 to $2.4 billion in
FY2008. During this same period, first-party collections increased by 35%, from $685 million to
$922 million. In FY2008, first-party collections represented approximately 37.2% of total MCCF
collections.
Table 5. Medical Care Collections, FY2003-FY2008
($ in thousands)
FY2003
Actual
FY2004
Actual
FY2005
Actual
FY2006
Actual
FY2007
Actual
FY2008
Actual
First-party pharmacy
copaymentsa
$576,554
$623,215
$648,204
$723,027
$760,616
$749,685
First-party copayments
for inpatient and
outpatient care
104,994
113,878
118,626
135,575
150,964
168,274
First-party long-term
care copaymentsb
3,461
5,077
5,411
4,347
3,699
3,751
Third-party insurance
collections
804,141
960,176
1,055,597
1,095,810
1,261,346
1,497,449
Enhanced use leasing
revenuec
234
459
26,861
3,379
1,692
1,422
Compensated work
therapy collectionsd
38,834
40,488
36,516
40,081
43,296
52,372
Parking feese
3,296
3,349
3,443
3,083
3,136
3,355
376
634
2,431
2,075
1,904
1,572
1,531,890
1,747,276
1,897,089
2,007,377
2,226,653
2,477,880
Compensation and
pension living expensesf
MCCF Total
Sources: Table prepared by Congressional Research Service, based on data provided by the VA, and
Department of Veterans Affairs, FY2010 Budget Submission, Medical Programs and Information Technology Programs,
Vol. 2 of 4, May 2009, pp. 1C-8.
Notes: The following accounts were not consolidated into the MCCF until FY2004: enhanced use leasing
revenue, compensated work therapy collections, parking fees, and compensation and pension living expenses.
Collection figures for these accounts for FY2003 are provided for comparison purposes.
a.
In FY2002, Congress created the Health Services Improvement Fund (HSIF) to collect increases in
pharmacy copayments (from $2 to $7 for a 30-day supply of outpatient medication) that went into effect on
February 4, 2002. The Consolidated Appropriations Resolution, 2003 (P.L. 108-7) granted the VA the
authority to consolidate the HSIF with the MCCF and granted permanent authority to recover copayments
for outpatient medications.
b.
Authority to collect long-term care copayments was established by the Millennium Health Care and Benefits
Act (P.L. 106-117). Certain veteran patients receiving extended care services from VA providers or outside
contractors are charged copayments.
c.
Under the enhanced-use lease authority, the VA may lease land or buildings to the private sector for up to
75 years. In return the VA receives fair consideration in cash and/or in-kind. Funds received as monetary
considerations may be used to provide care for veterans.
d.
The compensated work therapy program is a comprehensive rehabilitation program that prepares veterans
for competitive employment and independent living. As part of their work therapy, veterans produce items
for sale or undertake subcontracts to provide certain products and/or services, such as providing
temporary staffing to a private firm. Funds collected from the sale of these products and/or services are
deposited into the MCCF.
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e.
The Parking program provides funds for construction and acquisition of parking garages at VA medical
facilities. The VA collects fees for use of these parking facilities.
f.
Under the compensation and pension living expenses program, veterans who do not have either a spouse
or child would have their monthly pension reduced to $90 after the third month a veteran is admitted for
nursing home care. The difference between the veteran’s pension and the $90 is used for the operation of
the VA medical facility.
FY2009 Budget Summary64
On February 4, 2008, President George W. Bush submitted his FY2009 budget proposal to
Congress. The Administration requested a total of $39.2 billion (excluding collections) for VHA.
This was a 5.3%, or $2 billion increase compared to the FY2008 enacted level. Including total
available resources (including medical collections) the Administration’s budget would have
provided $41.1 billion for VHA. The President’s budget proposal also requested $4.7 billion for
the medical facilities account, an increase of $561 million over the FY2008 enacted level. The
Administration’s budget proposal for FY2009 requested $442 million for the medical and
prosthetic research account, a 7.9% decrease ($38 million) below the FY2008 enacted level. As in
previous budget requests (FY2003 through FY2008), the Administration’s FY2009 budget
request included several cost-sharing proposals.
House Action
On August 1, 2008, the House passed the Military Construction and Veterans Affairs
Appropriations bill (H.R. 6599; H.Rept. 110-775), for FY2009 (MILCON-VA Appropriations
bill). The House-passed bill provided $40.8 billion for VHA, a $1.6 billion increase over the
Administration’s FY2009 request, and $3.6 billion over the FY2008 enacted amount. This
amount included $31 billion for the medical services account, $4.4 billion for the medical support
and compliance account, $5 billion for the medical facilities account, and $500 million for the
medical and prosthetic research account.
Senate Committee Action
On July 17, 2008, the Senate Appropriations Committee marked up its version of the FY2009
Military Construction and Veterans Affairs and Related Agencies Appropriations bill (S. 3301,
S.Rept. 110-428). The Senate Appropriations Committee recommended $41.1 billion (excluding
collections) for VHA for FY2009. This was a 4.8% increase over the FY2009 request, and $294
million above the House Appropriations Committee-recommended amount. S. 3301, as marked
up by the Committee, also provided $5.0 billion for medical facilities, and $527 million for the
medical and prosthetic research account. The full Senate did not consider S. 3301.
Final MILCON-VA Appropriations Act of 2009
Prior to the start of FY2009, a compromise version of H.R. 6599 and S. 3301 was included as
Division E in the Consolidated Security, Disaster Assistance, and Continuing Appropriations Act,
64
For a detailed description of appropriations for the Veterans Health Administration for FY2009, see CRS Report
RL34598, Veterans Medical Care: FY2009 Appropriations, by (name redacted).
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2009 (H.R. 2638). The bill was signed into law on September 30, 2008, as P.L. 110-329. The
MILCON-VA Appropriations Act of 2009 provided a total of $40.9 billion (excluding collections)
for VHA
American Recovery and Reinvestment Act (P.L. 111-5) Funds
VHA received $1.0 billion for the medical facilities account under the American Recovery and
Reinvestment Act of 2009, for non-recurring maintenance projects and renewable energy and
energy efficiency projects across VHA facilities. Non- recurring maintenance projects include
patient privacy corrections, life safety corrections (such as installation of fire walls and fire
barrier walls and automatic sprinkler systems), utility system upgrades, and mental health
improvements.
FY2010 VHA Budget
President’s Request
On February 26, 2009, President Barack Obama released an initial budget outline for FY2010.65
The initial budget outline did not provide details on funding levels for VHA. On May 7, the
Administration released the full VHA budget proposal for FY2010. The President requested a
total of $45.1 billion for VHA (excluding collections). This is a 7.4 % increase over the FY2009
enacted amount of approximately $42 billion (see Table 7). This amount includes $34.7 billion in
appropriated budget authority for the medical services account. According to the Administration’s
budget proposal this level of funding would allow for the gradual expansion of enrollment of
Priority Group 8 veterans. VHA plans to enroll nearly 550,000 eligible Priority Group 8 veterans
into the VA health care system between 2010 and 2013 (see discussion of Priority Group 8
veterans later in this report).
For FY2010, the Administration requested $5.1 billion for the medical support and compliance
account. This is a 14.6% over the FY2009 enacted amount. The President’s request also includes
$4.7 billion for the medical facilities account, a decrease of 22.2% compared to the enacted
amount. The reason for this decrease in funding is because the Administration is planning to use
about $490 million of the $1.0 billion appropriated in the American Recovery and Reinvestment
Act of 2009 (P.L. 111-5) for non-recurring maintenance and energy projects during FY2009 and
the remaining $510 million in FY2010 for these same type of projects.66 Furthermore, the
President’s request included $580 million for the medical and prosthetic research account.
The Administration’s budget proposal did not include specific amounts for advance
appropriations for veterans medical care in FY2011. However, in its budget submissions to
Congress it indicated that it would work with Congress to provide advance appropriations for the
VA medical care program.67
65
Office of Management and Budget, A New Era of Responsibility: Renewing America’s Promise, February 26, 2009.
66
Office of Management and Budget, Budget of the United States Government: Fiscal Year 2010, Appendix, May
2009, p. 1027.
67
Ibid. p. 1335.
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FY2010 Congress Congressional Budget Resolution68
On March 25, 2009, the House Budget Committee marked up and voted to report the House
version of the FY2010 budget resolution (H.Con.Res. 85, H.Rept. 111-60). The House agreed to
H.Con.Res. 85 on April 2. H.Con.Res. 85 as agreed to by the House provided $53.3 billion in
discretionary budget authority, and $53.1 billion in mandatory budget authority for VA programs.
A majority of this discretionary funding is for VA medical care. The House agreed upon version
of the budget resolution affirmed that “VA should not be authorized to bill private insurance
companies for treatment of health conditions that are related to veterans’ military service.”69
H.Con.Res. 85 did not contain any language exempting certain VHA accounts against a point of
order if funded under an advance appropriation for FY2011.
On March 26, the Senate Budget Committee voted to report the Senate version of the FY2010
budget resolution (S.Con.Res. 13). The Senate agreed to S.Con.Res. 13 on April 2. S.Con.Res. 13
as agreed to by the Senate provides $53.2 in discretionary budget authority and $53.1 billion in
mandatory budget authority for VA programs.
During the Senate debate of S.Con.Res. 13, Senator James Inhofe offered an amendment
(S.Amdt. 742) that was adopted by the Senate. This amendment allowed for an advance
appropriation for the medical services, medical administration, medical facilities, and medical and
prosthetic research accounts of VHA and did not subject those accounts to a point of order under
section 302 of S.Con.Res. 13
After negotiations between the two chambers, the House and Senate agreed to the conference
report to accompany the FY2010 budget resolution (S.Con.Res. 13, H.Rept. 111-89) on April 29.
The conference agreement provides $53.4 billion in discretionary budget authority and $53.1
billion in mandatory budget authority for VA programs. Sections 402 and 424 of the conference
agreement included language exempting the following VA accounts from a point of order against
advance appropriations: medical services, medical support and compliance, and medical facilities.
House Action
The House Subcommittee on Military Construction and Veterans Affairs and Related Agencies
marked-up a draft version of the Military Construction and Veterans Affairs Appropriations Act,
2010 (MILCON-VA Appropriations Act of 2010) on June 16, 2009. On June 24, the House
Committee on Appropriations marked-up a draft version of the MILCON-VA Appropriations Act
of 2010, and the bill was reported on June 26 (H.R. 3082, H.Rept. 111-188). H.R. 3082 as passed
by the committee provided a total of approximately $45.1 billion for the Veterans Health
Administration (VHA) for FY2010. The House Appropriations Committee provided $34.7 billion
for medical services, $4.9 billion for medical support and compliance, $4.8 billion for the medical
facilities, and $580 million for the medical and prosthetic research accounts. Apart from minor
adjustments to the funding levels for each of the above accounts, the House Committee approved
measure provided about the same funding levels as the President’s request. The House
68
For a detailed analysis of the FY2010 budget resolution, see CRS Report R40559, S.Con.Res. 13: The Budget
Resolution for FY2010, by Megan Suzanne Lynch and (name redacted).
69
U.S. Congress, House Committee on the Budget, Concurrent Resolution on the Budget-FY2010, report to
accompany H.Con.Res. 85, 111th Cong., 1st sess., March 27, 2009, H.Rept. 111-60 (Washington: GPO, 2009), p. 38.
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Appropriations Committee also provided advance appropriations totaling $48.2 billion for the
medical services, medical support and compliance, and medical facilities accounts, an 8.3 %
increase over the FY2010 House-passed funding level.
On July 10, the House passed H.R. 3082. During floor consideration of H.R. 3082 several
amendments were offered. The following amendments changed the level of funding for some
VHA accounts. H.Amdt. 313 offered by Representative Edwards on behalf of Representative
Cohen transferred $1 million from the general operating expenses account to the medical services
account. This additional amount of funding would be used towards increasing the level of funding
for VHA’s Education Debt Reduction Program (EDRP).70 Moreover, Representative Filner and
Representative Langevin offered H.Amdt. 314. This amendment increased the level of funding
for the Department of Veterans Affairs, Office of National Veterans’ Sports Programs and Special
Events by $3.5 million and decreased funding for the VA’s medical support and compliance
account by $3.5 million. 71 The final House-passed amounts for VHA’s accounts are provided in
Table 7.
Senate Action
On July 6 2009, the Senate Subcommittee on Military Construction, Veterans Affairs, and Related
Agencies approved a draft version of its MILCON-VA Appropriations Act of FY2010. On July 7,
the full Senate Appropriations Committee reported S. 1407 (S.Rept. 111-40). The committee
approved measure provides a total of $45.2 billion for VHA, a $159.3 million increase over the
House-passed amount. S. 1407 as reported by the committee provides $5.1 billion for the medical
support and compliance account, $203.5 million increase over the House-passed amount and
same as the President’s request (see Table 7). Similar to H.R. 3082, S. 1407 provided advance
appropriations totaling $48.2 billion for medical services, medical support and compliance, and
medical facilities accounts (see Table 7).
On November 17, the Senate passed H.R. 3082 as amended. H.R. 3082 as amended by the Senate
provided a total of $45.2 billion for VHA, a $160.0 million increase over the House-passed
amount, and $157.6 million over the President’s request. This amount included $34.7 billion for
the medical services account, $5.1 billion for medical support and compliance account, $4.8
billion for medical facilities, and $580.0 million for the medical and prosthetic research account
(see Table 7). The Senate-passed version of H.R. 3082 provided advance appropriations totaling
$48.2 billion for medical services, medical support and compliance, and medical facilities
accounts.
Final MILCON-VA Appropriations Act, 2010
On December 10, 2009, the House adopted the conference report (H.Rept. 111-366) to
accompany the Department of Transportation, Housing and Urban Development appropriations
bill and retitled as the Consolidated Appropriations Act 2010 (H.R. 3288). The Senate adopted the
conference report on December 13. Division E of the Consolidated Appropriations Act 2010
included a compromised version of the House and Senate passed versions of the MILCON-VA
70
“Military Construction and Veterans Affairs Appropriations Act, 2010,” House, Congressional Record, vol. 155
(July 10, 2009), p. H7983.
71
Ibid. p. H7984.
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Appropriations Act of 2010. The Consolidated Appropriations Act, 2010, was singed into law on
December 16, 2009 (P.L. 111-117). The Consolidated Appropriations Act, 2010 provides a total of
$45.1 billion for VHA without medical care collections, same as the Administration’s request for
FY2010. Among other things, P.L. 111-117 (H.Rept. 111-366) provides an additional $1.0 million
to the medical services account to fund the Education Debt Reduction Program to be used as an
incentive when hiring mental health professionals,72 as well as an additional $2.0 million for the
Guide and Service Dog Program. 73 The conference agreement includes an advance appropriation
for the medical services, medical support and compliance, and medical facilities accounts.
According the conference report “the goal of this advance appropriation is to provide the Veterans
Health Administration with reliable and timely funding for their current services so the delivery
of medical care is not disrupted.”74 See Table 7 for detailed account level funding for VHA for
FY2010.
Major Issues
Advance Appropriations75
A coalition of veterans’ service organizations (VSOs) has been calling on Congress to provide
VHA with a budget which is “sufficient, timely, and predictable.” These organizations have
asserted that VHA has underestimated its budget in the past. Moreover, VSOs contend that
Congress has not enacted the VA budget by the beginning of the fiscal year. According to these
organizations the delays in the enactment of the budget have exacerbated operational
challenges—such as, differing capital expenditures, delaying recruitment, restricting acquisitions,
limiting maintenance—faced by VHA network directors. To mitigate these issues VSO’s have
proposed that Congress change the funding process for VHA to an advance appropriation.
In the 111th Congress H.R. 1016 and S. 423 were introduced, and these measures would authorize
advance appropriations for certain medical care accounts of the Department of Veterans Affairs
by providing two-fiscal year budget authority. The House passed H.R. 1016 (H.Rept. 111-171) as
amended on June 23, and the Senate Veterans Affairs Committee reported S. 423 on July 8
72
The Education Debt Reduction Program (EDRP) was authorized with the enactment of the Veterans Programs
Enhancement Act of 1998 (P.L. 105-368). It was amended by the Department of Veterans Affairs Health Care
Programs Enhancement Act of 2001 (P.L. 107-135). The EDRP was implemented in May 2002. The program serves as
both a recruitment and a retention tool. EDRP authorizes VA to provide education debt reduction payments to
employees with qualifying loans who are recently appointed to Title 38 U.S.C. positions providing direct-patient care
services or services incident to direct-patient care for which recruitment and retention of qualified personnel is difficult.
An employee is considered to be recently appointed to a position if the individual has held that position for less than 6
months.
73
Department of Veterans Affairs Health Care Programs Enhancement Act of 2001(P.L. 107-135) authorized the
VA—at the discretion of the VA Secretary—to provide service dogs to veterans that are hearing or mobility impaired.
Conference report language (H.Rept. 111-366) accompanying the Consolidated Appropriations Act, 2010 (P.L. 111117) indicated the lack of progress the VA has made to fully implement P.L. 107-135 regarding the provision of guide
dogs and service dogs to qualified veterans seeking such services.
74
U.S. Congress, House Committee on Appropriations, Departments of Transportation and Housing and Urban
Development, and Related Agencies Appropriations Act, 2010, conference report to accompany H.R. 3288, 111th
Cong., December 8, 2009, H.Rept. 111-366 (Washington: GPO, 2009), p. 1349.
75
For a detailed discussion of advance appropriations for VA health care accounts see CRS Report R40489, Advance
Appropriations for Veterans’ Health Care: Issues and Options for Congress, by (name redacted).
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(S.Rept. 111-41). S. 423 passed the Senate on August 6, 2009, as a substitute amendment to H.R.
1016. On October 8, the House agreed to the Senate amendment pursuant to H.Res. 804, and the
Senate agreed to the House amendment to the Senate amendment on October 13. The Veterans
Health Care Budget Reform and Transparency Act of 2009 (H.R. 1016) was signed into law (P.L.
111-81) on October 22. Under P.L. 111-81 beginning with FY2011, advance appropriations is
authorized for the medical services, medical support and compliance, and medical facilities,
accounts of the VHA. It also requires the VA to provide additional detailed budget estimates in
support of advance appropriations for these accounts in the President’s annual budget request to
Congress. It also requires the VA to submit a report to Congress, no later than July 31 of each
year, on the sufficiency of the Department’s resources for the provision of medical care for the
upcoming fiscal year. Furthermore, the Act would require the Comptroller General (U.S.
Government Accountability Office) to conduct a study of the adequacy and accuracy of
projections for health care expenditures and submit reports to the appropriate committees of
Congress and to the Secretary of Veterans Affairs, in 2011, 2012, and 2013. These reports must
state whether the amounts requested in the President’s budget are consistent with anticipated
expenditures for health care in such fiscal year as determined utilizing the Enrollee Health Care
Projection Model. 76 The Comptroller General is required to submit these reports not later than
120 days after the President has submitted his annual budget request to Congress.
Priority Group 8 Veterans
Since January 17, 2003, the VA has not enrolled veterans in Priority Group 8 unless they had been
previously enrolled in another priority group and no longer qualified for enrollment in that
previous priority group (see Appendix A). Since the suspension was promulgated, veterans
advocates have urged Congress to lift the suspension on Priority Group 8 veterans since they
believe that all veterans must be able to receive care from the VA because they have served their
country. 77
The Veterans Health Care Eligibility Reform Act of 1996 (P.L. 104-262) included language that
stipulated that medical care to veterans will be furnished to the extent appropriations were made
available by Congress on an annual basis. Based on this statutory authority, the Secretary of
Veterans Affairs announced on January 17, 2003 that VA would temporarily suspend enrolling
Priority Group 8 veterans.78 Those who enrolled prior to January 17, 2003 in VA’s health care
system were not to be affected by this suspension. VA claimed that, despite its funding increases,
it could not provide all enrolled veterans with timely access to medical services because of the
increase in the number of veterans seeking care from VA. 79
The Consolidated Security, Disaster Assistance, and Continuing Appropriations Act, 2009 (P.L.
110-329) was enacted on September 30, 2008. The accompanying report language stated that
funding “has been provided within the Medical Services; Medical Support and Compliance;
76
For a discussion of the Enrollee Health Care Projection Model see CRS Report R40489, Advance Appropriations for
Veterans’ Health Care: Issues and Options for Congress, by (name redacted).
77
U.S. Congress, House Committee on Veterans’ Affairs, Priority Group 8 Veterans, 110th Cong., 1st sess., June 20,
2007 (Washington: GPO, 2008), pp. 61-63.
78
Department of Veterans Affairs, “Enrollment-Provision of Hospital and Outpatient Care to Veterans in Subpriorities
of Priority Categories 7 and 8 and Annual Enrollment Level Decision,” 68 Federal Register 2669-2673, January 17,
2003.
79
Ibid.
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Medical Facilities; Construction, Minor Projects; and Information Technology Systems accounts
to support increased enrollment for Priority 8 veterans whose income exceeds the current veterans
means test and geographic means test income thresholds by 10 % or less.”80 P.L. 110-329
provided $375 million for FY2009 to fund this increased enrollment. On January 21, 2009, VA
issued regulations indicating that it plans to enroll an estimated 258,705 new Priority Group 8
veterans.81 VA began enrolling new veterans starting June 15, 2009. Table 6 provides details of
the projected enrollment and expenditures under the current suspension scenario for FY2009, and
estimated enrollment and expenditure figures under the proposed expanded enrollment scenario—
reopening enrollment for Priority Group 8 veterans whose incomes exceed the current VA means
test and geographic means test income thresholds by 10% or less—for FY2009. Furthermore, as
stated before, the President’s FY2010 Budget Request to Congress also states that by 2013 VA
plans to enroll about 550,000 new nonservice-connected veterans.82
Table 6. Enrollment and Expenditures for FY2009- Under Current Policy and Under
Expanded Enrollment Policy
$ in Thousands
Priority Group
Estimated Enrollment
Estimated Expenditures
1
1,079,852
$10,552,246
2
595,548
2,352,417
3
1,090,376
3,517,387
4
233,153
3,461,043
5
2,361,166
11,513,021
6
354,785
606,349
7
1,056,733
2,041,244
8
1,286,626
2,692,952
Total without Expansion
8,058,238
36,706,661
8(Expanded Enrollment)a
258,705
485,247
Total with Expansion
8,316,943
$37,191,908
Source: Department of Veterans Affairs, “Expansion of Enrollment in the VA Health Care System,” 74 Federal
Register 3535-3540, January 21, 2009.
Notes: Numbers may not add-up due to rounding.
a.
The total number of Priority Group 8 veterans after enrollment would be 1,545,331 and the estimated
expenditures for this category of veterans would be $3,2 billion.
A veteran applying for enrollment on or after June 15, 2009, who does not qualify for a higher
priority group and whose income exceeds VA’s national and geographically-adjusted means test
threshold by 10% of less will be placed in Priority Group 8b (if the Veteran has a
80
P.L. 110-329, U.S. Congress, House Committee on Appropriations, Consolidated Security, Disaster Assistance, and
Continuing Appropriations Act, 2009, committee print, 110th Cong., 2nd sess., (Washington: GPO, 2008), p. 750.
81
Department of Veterans Affairs, “Expansion of Enrollment in the VA Health Care System,” 74 Federal Register
3535-3540, January 21, 2009.
82
Office of Management and Budget, Budget of the U.S. Government: Fiscal Year 2010, Appendix, Washington, DC,
May 2009, p. 1024.
Congressional Research Service
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Veterans Medical Care: FY2010 Appropriations
noncompensable 0% service-connected condition) or 8d (if the Veteran has no service-connected
condition) and enrolled in the VA health care system. This new financial threshold is referred to
as the enrollment threshold (see Appendix D). Veterans who applied on or after January 1, 2009
and were denied enrollment have been notified that VA will re-determine their enrollment after
June 15, 2009.
Because VA uses previous year’s income in its enrollment determination, veterans who applied
but were rejected for enrollment prior to January 1, 2009 may complete a VA Form 10-10EZR,
Health Benefits Renewal form to have their eligibility for enrollment reassessed against the new
enrollment threshold. Veterans may also self-determine their eligibility for enrollment under this
new provision by entering their information into VA’s on-line calculator 83
In general, veterans who are unable to defray the expenses of necessary care are eligible to
receive care from the VA free of charge. 84 To determine if the veteran is eligible for free health
care, the VA conducts a financial assessment. Under current law and regulations VA uses the
veteran’s previous year’s (that is, the calendar year preceding the year in which the veteran
applies for care or services) total household income (including income of the veteran, spouse, and
dependent children) to make this determination.85 However, in accordance with current VA
regulations, if a veteran’s current year income is projected to be less than his/her prior year’s
income, the veteran can submit a request for a hardship determination.86 Thus, a veteran meeting
this eligibility criterion may be placed in Priority Group 5 even though the veteran’s prior year
total gross household income is above the applicable national VA means test threshold.
Furthermore, under certain financial hardship circumstances, VA may use the projected income
for the current year of the veteran, spouse, and dependent children if the projected income is
below the VA’s means test threshold and above a geographic means test threshold.87 Therefore, a
veteran meeting this eligibility criterion may be placed in Priority Group 7 even though the
veteran’s prior year total gross household income is above the applicable geographic means test
for the area in which the veteran resides. Circumstances that would warrant financial hardship
consideration would be loss of employment, business bankruptcy, or unreimbursed medical
expenses paid by the veteran or spouse for a family member or others for whom the veteran has a
“moral responsibility to assist.” The hardship determination will be valid through the end of the
calendar year in which it was approved. Veterans must contact their nearest VA medical facility to
determine if they would be eligible to enroll in VA health care under the financial hardship
criteria.
Beneficiary Travel Mileage Reimbursement
In general, the beneficiary travel program reimburses certain veterans for the cost of travel to VA
medical facilities when seeking health care. P.L. 76-432, passed by Congress on March 14, 1940,
mandated VA to pay either the actual travel expenses, or an allowance based upon the mileage
traveled by any veteran traveling to and from a VA facility or other place for the purpose of
83
http://www.va.gov/healtheligibility/apps/enrollmentcalculator/.
38 U.S.C. § 1710(a)(2)(G).
85
38 U.S.C. § 1722; 38 C.F.R. § 17.36 (b)(7).
86
38 U.S.C. § 1722(e); .38 C.F.R. § 1747(d)(6).
87
38 C.F.R. § 1736(b)(7).
84
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Veterans Medical Care: FY2010 Appropriations
examination, treatment, or care. P.L. 85-857, signed into law on September 2, 1958, authorized
VA to pay necessary travel expenses to any veteran traveling to or from a VA facility or other
place in connection with vocational rehabilitation counseling or for the purpose of examination,
treatment, or care. However, this law changed VA’s travel reimbursement into a discretionary
authority by stating that VA “may pay” expenses of travel.
Due to rapidly increasing costs of the beneficiary travel program, on March 12, 1987, VA
published final regulations that sharply curtailed eligibility for the beneficiary travel program. 88
Under these regulations beneficiary travel payments to eligible veterans were paid when
specialized modes of transportation, such as ambulance or wheelchair van, were medically
required. In addition, payment was authorized for travel in conjunction with compensation and
pension examinations, as well as travel beyond a 100-mile radius from the nearest VA medical
care facility. It also authorized the VA to provide transportation costs, when necessary, to transfer
any veteran from one health care facility (either a VA or contract care facility) to another in order
to continue care paid for by the VA. The following transportation costs were not authorized under
these regulations:
•
Cost of travel by privately owned vehicle in any amount in excess of the cost of
such travel by public transportation unless public transportation was not
reasonably accessible or was medically inadvisable.
•
Cost of travel in excess of the actual expense incurred by any person as certified
by that person in writing.
•
Cost of routine travel in conjunction with admission for domiciliary care, or
travel for family members of veterans receiving mental health services from the
VA except for such travel performed beyond a 100-mile radius from the nearest
VA medical care facility.
Travel expenses of all other veterans were not authorized unless the veterans were able to present
clear and convincing evidence to show the inability to pay the cost of transportation, or except
when medically-indicated ambulance transportation was claimed and an administrative
determination was made regarding the veteran’s ability to bear the cost of such transportation.89
The Veterans’ Benefits and Services Act of 1988 (P.L. 100-322, section 108) restored in large
part, the travel reimbursement benefits. It required that if VA provides any beneficiary travel
reimbursement under Section 111 of Title 38 U.S.C. in any given fiscal year, then payments must
be provided in that year in the case of travel for health care services for all the categories of
beneficiaries specified in the statute. In order to limit the overall cost of this program, the law
imposed a $3 one-way deductible applicable to all travel, except for veterans otherwise eligible
for beneficiary travel reimbursement who are traveling by special modes of transportation such as
ambulance, air ambulance, wheelchair van, or to receive a compensation and pension
examination. In order to limit the overall impact on veterans whose clinical needs dictate frequent
travel for VA medical care, an $18-per-calendar-month cap on the deductible was imposed for
those veterans who are pre-approved as needing to travel on a frequent basis.
88
Veterans Administration, “Transportation of Claimants and Beneficiaries,” final regulations, 52 FR 7575-01, March
12, 1987. These regulations became effective on April 13, 1987.
89
Ibid.
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Veterans Medical Care: FY2010 Appropriations
Veterans may qualify for travel reimbursement if (1) they have a service-connected disability
rated 30% or more; (2) they are traveling for treatment of a service-connected disability; (3) they
receive a VA pension; (4) their income does not exceed the maximum annual VA pension rate; or
(5) they are traveling for a scheduled compensation or pension examination.
The FY2008 Appropriations Act (P.L. 110-161) provided funding for VA to increase the
beneficiary travel mileage reimbursement rate from 11 cents per mile to 28.5 cents per mile. The
increase went into effect on February 1, 2008. While increasing the payment, VA, as mandated by
law, also increased proportionately the deductible amounts applied to certain mileage
reimbursements. The new deductibles were $7.77 for a one way trip, $15.54 for a round trip, with
a maximum of $46.62 per calendar month. However, these deductibles could have been waived if
they cause a financial hardship to the veteran.
The final MILCON-VA Appropriations Act of 2009 (P.L. 110-329) provided an additional $133
million to increase the mileage reimbursement rate to 41.5 cents a mile and included an
administrative provision to freeze the deductible at the FY2008 levels (i.e. $7.77 for a one way
trip, $15.54 for a round trip, with a maximum of $46.62 per calendar month).
The Veterans’ Mental Health and Other Care Improvements Act of 2008 (S. 2162, P.L. 110-387),
which was signed into law on October 10, 2008, contained a provision that required the VA to
raise its current reimbursement rate to conform with the General Services Administration’s (GSA)
rate at which federal employees are reimbursed when using private automobiles for official
business. The provision also amended the law that allowed the VA to raise or lower the deductible
for reimbursements in proportion to a change in the mileage rate. The VA is no longer able to
increase the deductible rate unless new deductible rates are mandated by Congress. It also
restored the deductible amounts for the beneficiary travel reimbursement program to those in
effect prior to February 1, 2008, when VA increased the deductible rate (i.e. $3 for a one way trip,
$6 for a round trip, with a maximum of $18 per calendar month).
The reports accompanying the MILCON-VA Appropriations Act of 2010 (H.Rept. 111-188 and
S.Rept. 111-40) state that VA should continue to provide beneficiary travel reimbursements at
41.5 cents a mile. 90
90
Current GSA rates are as follows: if government-owned vehicle is not available, the rate is $0.55; if a governmentowned vehicle is available, the rate is $0.285; see http://www.gsa.gov/mileage.
Congressional Research Service
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Table 7.VHA Appropriations by Account, FY2009-FY2010 and Advance Appropriations, FY2011
($ in thousands)
House (H.R. 3082)
Senate (H.R. 3082)
Enacted (P.L. 111-117)
FY2009
Enacted
FY2010
Request
FY2010
FY2011
FY2010
FY2011
FY2010
FY2011
Medical Services
$30,969,903
$34,704,500
$34,705,500
—
$34,705,250
—
$34,707,500
—
Subtotal Medical Services
30,969,903
34,704,500
34,705,500
—
34,705,250
—
34,707,500
—
Medical Support and
Compliance (Previously
Medical Administration)
4,450,000
5,100,000
4,896,500
—
5,100,000
—
4,930,000
—
Subtotal Medical Support
and Compliance
(Previously Medical
Administration)
4,450,000
5,100,000
4,896,500
—
5,100,000
—
4,930,000
—
Medical Facilities
5,029,000
4,693,000
4,893,000
—
4,849,883
—
4,859,000
—
American Recovery and
Reinvestment Act, 2009
(P.L. 111-5)
1,000,000
—
—
—
—
—
—
—
Subtotal Medical Facilities
6,029,000
4,693,000
4,893,000
—
4,849,883
—
4,859,000
—
Medical and Prosthetic
Research
510,000
580,000
580,000
—
580,000
—
581,000
—
Subtotal Medical and
Prosthetic Research
510,000
580,000
580,000
—
580,000
—
581,000
—
41,958,903
45,077,500
45,075,000
—
45,235,133
—
45,077,500
—
2,544,000
2,954,000
2,954,000
—
2,954,000
—
2,954,000
—
$44,502,903
$48,031,500
$48,029,000
—
$48,189,133
—
$48,031,500
—
Account
Total VHA
appropriations
(without collections)
Medical care cost
collections (MCCF)
Total VHA
appropriations (with
collections)
CRS-33
House (H.R. 3082)
FY2009
Enacted
FY2010
Request
FY2010
Medical Services
—
—
—
$37,136,000
Subtotal Medical Support
and Compliance
(Previously Medical
Administration)
—
—
—
Medical Facilities
—
—
Total VHA advance
appropriations
(without collections )a
—
—
Account
FY2011
Senate (H.R. 3082)
FY2010
Enacted (P.L. 111-117)
FY2011
FY2010
FY2011
—
$37,136,000
—
$37,136,000
5,307,000
—
5,307,000
—
5,307,000
—
5,740,000
—
5,740,000
—
5,740,000
—
$48,183,000
—
$48,183,000
—
$48,183,000
Memorandum:
Advance
Appropriations
Sources: Table prepared by Congressional Research Service, based on H.Rept. 110-775; S.Rept. 110-428; Congressional Record, vol.154, (September 24, 2008), pp. H9868H9869, H.Rept. 111-188, S.Rept. 111-40, Congressional Record, vol.155, (July 10, 2009), pp. H7983-H7987, Congressional Record, vol. 155 (November 18, 2009), pp. S1150011508, and Division E of P.L. 111-117.
a.
CRS-34
The House and Senate Military Construction and Veterans Affairs Appropriations bills for FY 2010, and Division E of the Consolidated Appropriations Act 2010
(Military Construction and Veterans Affairs Appropriations Act, 2010) provided budget authority for FY2011 for the following accounts: medical services, medical
support and compliance, and medical facilities. Under current budget scoring guidelines new budget authority for an advance appropriation is scored in the fiscal year in
which the funds become available for obligation. Therefore, in this table the budget authority is recorded in the FY2011 column.
Veterans Medical Care: FY2010 Appropriations
Appendix A. VA Priority Groups and Their
Eligibility Criteria
Table A-1.VA Priority Groups and Their Eligibility Criteria
Priority Group 1
Veterans with service-connected disabilities rated 50% or more disabling
Priority Group 2
Veterans with service-connected disabilities rated 30% or 40% disabling
Priority Group 3
Veterans who are former POWs
Veterans awarded the Purple Hearta
Veterans whose discharge was for a disability that was incurred or aggravated in the line of duty
Veterans with service-connected disabilities rated 10% or 20% disabling
Veterans awarded special eligibility classification under Title 38, U.S.C., Section 1151, “benefits for individuals disabled
by treatment or vocational rehabilitation”
Priority Group 4
Veterans who are receiving aid and attendance or housebound benefits
Veterans who have been determined by VA to be catastrophically disabled
Priority Group 5
Nonservice-connected veterans and noncompensable service-connected veterans rated 0% disabled whose annual
income and net worth are below the established VA means test thresholds
Veterans receiving VA pension benefits
Veterans eligible for Medicaid benefits
Priority Group 6
Compensable 0% service-connected veterans
World War I veterans
Mexican Border War veterans
Veterans solely seeking care for disorders associated with
—exposure to herbicides while serving in Vietnam; or
—ionizing radiation during atmospheric testing or during the occupation of Hiroshima and Nagasaki; or
—for disorders associated with service in the Gulf War; or
—for any illness associated with service in combat in a war after the Gulf War or during a period of hostility after
November 11, 1998 as follows:
- Veterans discharged from active duty on or after January 28, 2003, who were enrolled as of January 28, 2008
and veterans who apply for enrollment after January 28, 2008, for 5 years post discharge
-Veterans discharged from active duty before January 28, 2003, who apply for enrollment after January 28, 2008,
until January 27, 2011
Congressional Research Service
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Veterans Medical Care: FY2010 Appropriations
Priority Group 7
Veterans who agree to pay specified copayments with income and/or net worth above the VA means test threshold
and income below the VA national geographic income thresholds
Priority Group 8
Veterans who agree to pay specified copayments with income and/or net worth above the VA means test threshold
and the VA national geographic threshold
Subpriority a: Noncompensable 0% service-connected and enrolled as of January 16, 2003, and who have remained
enrolled since that date and/or placed in this subpriority due to changed eligibility status
Subpriority b: Noncompensable 0% service-connected and enrolled on or after June 15, 2009 whose income exceeds
the current VA means test threshold or VA national geographic income thresholds by 10% or less
Subpriority c: Nonservice-connected veterans enrolled as of January 16, 2003, and who have remained enrolled since
that date and/or placed in this subpriority due to changed eligibility status
Subpriority d: Nonservice-connected veterans enrolled on or after June 15, 2009 whose income exceeds the current
VA means test threshold or VA national geographic income thresholds by 10% or less
Subpriority e: Noncompensable 0% service-connected veterans not meeting the above criteria
Subpriority g: Nonservice-connected veterans not meeting the above criteria
Source: Department of Veterans Affairs
Notes: Service-connected disability means with respect to disability, that such disability was incurred or
aggravated in the line of duty in the active military, naval or air service.
a.
Veterans in receipt of a Purple Heart are in Priority Group 3. This change occurred with the enactment of
the Veterans Millennium Health Care and Benefits Act (P.L. 106-117) on Nov.30, 1999.
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Veterans Medical Care: FY2010 Appropriations
Appendix B. Copayments for Health Care Services:
2010
Table B-1. Copayments for Health Care Services: 2010
Outpatient
medication
Long-term care
services
($15 Primary Care;
$50 Specialty Care;
$0 for x-rays, lab,
immunizations, etc.)
($8 per 30-day
supply;
Priority
Groups 2-6
calendar year
cap - $960)
(Institutional
nursing home care
units, respite care,
geriatric evaluation
- $0-97 per day.
Non-institutional
respite care,
geriatric evaluation,
adult day
healthcare - $15 per
day;
domiciliary care $5 per day)
NO
NO
NO
NO
Priority Groups 2 and
3
(Veterans with
service-connected
disabilities rated 10% 40% disabling)a
NO
NO
YES
NO
Priority Group 4
Copay rules apply if
placed from lower
priority group based
on VHA catastrophic
disability
determination
NO
NO
NO
NO
Priority Group 5b
NO
NO
YES
YES
Priority Group 6c
NO
NO
NO
NO
Priority Group 7d
YES
YES
YES
YES
Priority Group 8e
YES
YES
YES
YES
Inpatient care
Outpatient care
($10/day +
$1068 for first
90 days and
$534 after 90
days—based on
365-day period)
Priority Group 1
(service-connected
disabilities rated 50%
or more disabling)
Source: Table prepared by CRS based on information from the Department of Veterans Affairs.
a.
No medication copayments if medication is for a service-connected disability. Former POWs are exempt
from all medications copayments.
b.
No medication or long-term care copayments if veteran is in receipt of VA pension or has an income below
applicable pension threshold.
c.
Priority Group 6 are veterans claiming exposure to Agent Orange; veterans claiming exposure to
environmental contaminants; veterans exposed to ionizing radiation; combat veterans within five years of
discharge from the military; veterans who participated in Project 112/SHAD; veterans claiming military
sexual trauma; and veterans with head and neck cancer who received nasopharyngeal radium treatment
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Veterans Medical Care: FY2010 Appropriations
while in the military are subject to copayments when their treatment or medication is not related to their
exposure or experience. The initial registry examination and follow-up visits to receive results of the
examination are not billed to the health insurance carrier and are not subject to copayments. However,
care provided that is not related to exposure, if it is nonservice-connected, will be billed to the insurance
carrier and copayments can apply.
d.
Priority Group 7a and 7c veterans have income above the VA Means Test threshold but below the
Geographic Means Test threshold and are responsible for 20% of the inpatient copayment and 20% of the
inpatient per diem copayment. The Geographic Means Test copayment reduction does not apply to
outpatient and medication copayment, and veterans will be assessed the full applicable copayment charges.
e.
Priority Group 8a and 8c veterans have income above the VA Means Test threshold and above the
Geographic Means Test threshold. Veterans enrolled in this priority group are responsible for the full
inpatient copayment and the inpatient per diem copayment for care of their nonservice-connected
conditions. Veterans in this priority group are also responsible for outpatient and medication copayments
for care of their nonservice-connected conditions.
OEF/OIF Combat Veterans Enhanced Eligibility for Health Care Benefits: Combat veterans
discharged from active duty on or after January 28, 2003 are eligible for enrollment in Priority
Group 6 for five years following discharge unless eligible for a higher enrollment priority.
Combat veterans discharged from active duty before January 28, 2003, who apply for enrollment
on or after January 28, 2008, are eligible for enrollment in Priority Group 6 until January 27,
2011. After the special eligibility period ends, these veterans will be reassigned to the appropriate
priority group and will be subject to copayments if applicable. Copayments are applicable for
Priority Group 6 combat veteran enrollees for care related to a condition that is congenital or
developmental (e.g., scoliosis) that existed before military service (unless aggravated by combat
service) or has a specific etiology that began after military service, such as a common cold, etc.
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Veterans Medical Care: FY2010 Appropriations
Appendix C. Financial Income Thresholds for VA
Health Care Benefits, Calendar Year 2010
Veterans with—
Free VA prescriptions and travel benefits for
veterans with incomes of—
Free VA Heath Care for
veterans with incomes of—
No dependents
$11,830 or less
$29,402 or less
1 dependent
$15,493 or less
$35,284 or less
2 dependents
$17,513 or less
$37,304 or less
3 dependents
$19,533 or less
$39,324 or less
4 dependents
$21,553 or less
$41,344 or less
$2,020
$2,020
For each additional
dependent, add:
Source: Department of Veterans Affairs.
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Veterans Medical Care: FY2010 Appropriations
Appendix D. 10% Increase to Financial Income
Thresholds for VA Health Care Enrollment, in
Priority Group 8, Calendar Year 2010
Veterans
with—
Enrollment in the VA Health Care System with
required copayments for veterans with 0% serviceconnected ratings and nonservice-connected veterans
with incomes of—
No dependents
$32,342
1 dependent
$38,812
2 dependents
$41,034
3 dependents
$43,256
4 dependents
$45,478
For each
additional
dependent, add:
$2,222
Source: Department of Veterans Affairs.
Author Contact Information
(name redacted)
Specialist in Veterans Policy
[redacted]@crs.loc.gov, 7-....
Congressional Research Service
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