[House Report 111-488]
[From the U.S. Government Publishing Office]
111th Congress Report
HOUSE OF REPRESENTATIVES
2d Session 111-488
======================================================================
CHIROPRACTIC CARE AVAILABLE TO ALL VETERANS ACT
_______
May 20, 2010.--Committed to the Committee of the Whole House on the
State of the Union and ordered to be printed
_______
Mr. Filner, from the Committee on Veterans' Affairs, submitted the
following
R E P O R T
[To accompany H.R. 1017]
[Including cost estimate of the Congressional Budget Office]
The Committee on Veterans' Affairs, to whom was referred
the bill (H.R. 1017) to amend the Department of Veterans
Affairs Health Care Programs Enhancement Act of 2001 and title
38, United States Code, to require the provision of
chiropractic care and services to veterans at all Department of
Veterans Affairs medical centers and to expand access to such
care and services, having considered the same, report favorably
thereon with an amendment and recommend that the bill as
amended do pass.
CONTENTS
Page
Amendment........................................................ 2
Purpose and Summary.............................................. 2
Background and Need for Legislation.............................. 2
Hearings......................................................... 4
Subcommittee Consideration....................................... 4
Committee Consideration.......................................... 4
Committee Votes.................................................. 4
Committee Oversight Findings..................................... 5
Statement of General Performance Goals and Objectives............ 5
New Budget Authority, Entitlement Authority, and Tax Expenditures 5
Earmarks and Tax and Tariff Benefits............................. 5
Committee Cost Estimate.......................................... 5
Congressional Budget Office Cost Estimate........................ 5
Federal Mandates Statement....................................... 6
Advisory Committee Statement..................................... 6
Constitutional Authority Statement............................... 7
Applicability to Legislative Branch.............................. 7
Section-by-Section Analysis of the Legislation................... 7
Changes in Existing Law Made by the Bill, as Reported............ 7
Amendment
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Chiropractic Care Available to All
Veterans Act''.
SEC. 2. PROGRAM FOR PROVISION OF CHIROPRACTIC CARE AND SERVICES TO
VETERANS.
Section 204(c) of the Department of Veterans Affairs Health Care
Programs Enhancement Act of 2001 (38 U.S.C. 1710 note) is amended--
(1) by inserting ``(1)'' before ``The program''; and
(2) by adding at the end the following new paragraph:
``(2) The program shall be carried out at not fewer than 75 medical
centers by not later than December 31, 2011, and at all medical centers
by not later than December 31, 2013.''.
SEC. 3. EXPANDED CHIROPRACTOR SERVICES AVAILABLE TO VETERANS.
(a) Medical Services.--Paragraph (6) of section 1701 of title 38,
United States Code, is amended by adding at the end the following new
subparagraph:
``(H) Chiropractic services.''.
(b) Rehabilitative Services.--Paragraph (8) of such section is
amended by inserting ``chiropractic,'' after ``counseling,''.
(c) Preventive Health Services.--Paragraph (9) of such section is
amended--
(1) by redesignating subparagraphs (F) through (K) as
subparagraphs (G) through (L), respectively; and
(2) by inserting after subparagraph (E) the following new
subparagraph (F):
``(F) periodic and preventative chiropractic examinations and
services;''.
Purpose and Summary
H.R. 1017 was introduced by Representative Bob Filner of
California, Chairman of the Committee on Veterans' Affairs, on
February 12, 2009. H.R. 1017, as amended, would expand access
to chiropractic care at U.S. Department of Veterans Affairs
(VA) facilities and clinics.
Background and Need for Legislation
According to the VA, musculoskeletal injuries, such as
painful and disabling joint and back disorders, are a leading
health problem of veterans returning from Iraq and Afghanistan.
This is the result of multiple tours of duty and missions that
require servicemembers to use heavy combat gear and protective
body armor. For example, a servicemember on foot patrol may
wear and carry a helmet, bullet-resistant body armor, a rifle,
medical kit, radio, grenades, water pouch, a pistol, and
ammunition which can weigh as much as 55 pounds.
There is a long history of this Committee's actions on
issues of chiropractic care. First, section 303 of Public Law
106-117 (113 Stat. 1545), the Veterans Millennium Health Care
and Benefits Act, required the VA's Under Secretary for Health
to establish a defined policy on the role of chiropractic care
for veterans enrolled in the Veterans Health Administration
(VHA). Nearly a year after the enactment of this measure, the
Under Secretary for Health published a directive on
chiropractic care, but the Committee found the policy to be
unacceptable as it did not improve veterans' access to
chiropractic care at the VA. As a result, section 204 of Public
Law 107-135 (115 Stat. 2446), the Department of Veterans
Affairs Health Care Programs Enhancement Act of 2001, required
the Secretary to create a program to provide chiropractic care
and services for veterans who are enrolled in the VA's health
care system. This law further specified that each of the 21
Veterans Integrated Service Networks (VISNs) establish at least
one chiropractic care program, and required the establishment
of a chiropractic advisory committee within the VA. The VA
contended that it lacked a specified statutory authority
authorizing the appointment of VA-specific chiropractors. In
response, section 302 of Public Law 108-170 (117 Stat. 2042),
the Veterans Health Care, Capital Asset, and Business
Improvement Act of 2003, authorized VA to appoint chiropractors
within VHA. This measure also included provisions concerning
periods of appointment, promotions, pay grades, and other pay
matters for VHA appointed chiropractors. It further designated
chiropractors as scarce medical specialists for contracting
purposes.
As a result of these efforts, chiropractic care is
available to eligible veterans at 32 VA medical facilities
using hired or contracted staff and through VA's outpatient fee
basis program for veterans who live in areas distant from these
locations.
The Committee is concerned that with the high number of
veterans reporting symptoms of musculoskeletal ailments, there
is a clear need for expanded access to chiropractic care at VA
medical facilities. Chiropractic care remains largely
unavailable at 121, or the majority, of VA's 153 medical
centers. This means that veterans living in or near major
metropolitan areas such as Detroit, Denver, and Chicago do not
have access to chiropractic care at their local VA medical
center. H.R. 1017 would correct this by requiring the VA to
phase in the availability of chiropractic care at the remaining
121 VA medical centers that do not offer such care so that
veterans can more easily receive medical attention for their
musculoskeletal ailments.
In addition to the services provided at current and future
VA medical center locations, the Committee also expects VA to
continue to ensure that chiropractic care remains available
through VA's fee basis program when such care is needed and
would benefit the health status of an eligible veteran. The
Committee recognizes that for a veteran to receive the full
potential benefits of chiropractic care, multiple treatments
occurring with some frequency may be required. Particularly if
an eligible veteran lives some distance from a VA medical
center, requiring multiple trips for chiropractic treatment is
not always in their best interest.Therefore, the cumulative
impact of the travel burden on a veteran should be taken into
consideration as a major factor when consideration is given to
providing access through VA's fee basis program. Additionally,
prior to implementation of this legislation, a veteran patient
may have been receiving care through VA's fee basis program and
developed a beneficial relationship with a local doctor of
chiropractic. In such circumstances, the Committee expects VA
to place great weight and emphasis on the potential benefits of
allowing such veteran continued access to fee basis local
chiropractic care regardless of whether or not chiropractic
care is otherwise available at the nearest VA medical center.
Accordingly, this legislation should not lessen the use of VA's
fee basis program as an option and mechanism to ensure system-
wide access to chiropractic care, regardless of whether a VA
medical center does or does not have doctors of chiropractic on
staff.
The Committee expects VA to recruit, hire and place doctors
of chiropractic on staff in such numbers and at such locations
as to minimize the need for fee basis referrals and to take
steps to eliminate excessive waiting times for referrals for
chiropractic care whether such care is to be provided by
doctors of chiropractic employed by VA or local doctors of
chiropractic through VA's fee basis program.
Hearings
On October 1, 2009, the Subcommittee on Health held a
legislative hearing on several bills introduced in the 111th
Congress, including H.R. 1017. The following witnesses
testified: The Honorable Bob Filner of California; The
Honorable Stephanie Herseth Sandlin of South Dakota; The
Honorable Phil Hare of Illinois; The Honorable Ciro D.
Rodriguez of Texas; The Honorable Glenn Nye of Virginia; The
Honorable Harry Teague of New Mexico; The Honorable Michael A.
Arcuri of New York; Mr. Joseph Wilson, Deputy Director,
Veterans Affairs and Rehabilitation Commission, The American
Legion; Mr. Justin Brown, Legislative Associate, National
Legislative Service, Veterans of Foreign Wars; Mr. Rick
Weidman, Executive Director, Policy and Government Affairs,
Vietnam Veterans of America; Mr. Blake C. Ortner, Senior
Associate Legislative Director, Paralyzed Veterans of America;
Mr. Peter H. Dougherty, Director, Homeless Veterans Programs,
U.S. Department of Veterans Affairs who was accompanied by Mr.
Paul E. Smits, Associate Chief Consultant, Homeless and
Residential Rehabilitation and Treatment Programs, U.S.
Department of Veterans Affairs; and, Ms. Jane Clare Joyner,
Deputy Assistant General Counsel, U.S. Department of Veterans
Affairs. Those submitting for the record included: Rick A.
McMichael, DC, President, American Chiropractic Association;
the American Physical Therapy Association; and, the American
Tinnitus Association.
Subcommittee Consideration
On April 29, 2010, the Subcommittee on Health met in open
markup session and ordered favorably forwarded to the full
Committee H.R. 1017, as amended, by voice vote. During
consideration of the bill the following amendment was
considered:
An amendment by Mr. Michaud of Maine to update the
implementation date for the provision of chiropractic
care at additional VA facilities was agreed to by voice
vote.
Committee Consideration
On May 12, 2010, the full Committee met in an open markup
session, a quorum being present, and ordered H.R. 1017, as
amended, reported favorably to the House of Representatives, by
voice vote.
Committee Votes
Clause 3(b) of rule XIII of the Rules of the House of
Representatives requires the Committee to list the record votes
on the motion to report the legislation and amendments thereto.
There were no record votes taken on amendments or in connection
with ordering H.R. 1017 reported to the House. A motion by Mr.
Stearns of Florida to order H.R. 1017, as amended, reported
favorably to the House of Representatives was agreed to by
voice vote.
Committee Oversight Findings
In compliance with clause 3(c)(1) of rule XIII and clause
2(b)(1) of rule X of the Rules of the House of Representatives,
the Committee's oversight findings and recommendations are
reflected in the descriptive portions of this report.
Statement of General Performance Goals and Objectives
In accordance with clause 3(c)(4) of rule XIII of the Rules
of the House of Representatives, the Committee's performance
goals and objectives are reflected in the descriptive portions
of this report.
New Budget Authority, Entitlement Authority, and Tax Expenditures
In compliance with clause 3(c)(2) of rule XIII of the Rules
of the House of Representatives, the Committee adopts as its
own the estimate of new budget authority, entitlement
authority, or tax expenditures or revenues contained in the
cost estimate prepared by the Director of the Congressional
Budget Office pursuant to section 402 of the Congressional
Budget Act of 1974.
Earmarks and Tax and Tariff Benefits
H.R. 1017 does not contain any congressional earmarks,
limited tax benefits, or limited tariff benefits as defined in
clause 9 of rule XXI of the Rules of the House of
Representatives.
Committee Cost Estimate
The Committee adopts as its own the cost estimate on H.R.
1017 prepared by the Director of the Congressional Budget
Office pursuant to section 402 of the Congressional Budget Act
of 1974.
Congressional Budget Office Cost Estimate
Pursuant to clause 3(c)(3) of rule XIII of the Rules of the
House of Representatives, the following is the cost estimate
for H.R. 1017 provided by the Congressional Budget Office
pursuant to section 402 of the Congressional Budget Act of
1974:
U.S. Congress,
Congressional Budget Office,
Washington, DC, May 18, 2010.
Hon. Bob Filner,
Chairman, Committee on Veterans' Affairs, House of Representatives,
Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for H.R. 1017, the
Chiropractic Care Available to All Veterans Act.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Sunita
D'Monte.
Sincerely,
Douglas W. Elmendorf,
Director.
Enclosure.
H.R. 1017--Chiropractic Care Available to All Veterans Act
H.R. 1017 would require the Department of Veterans Affairs
(VA) to provide chiropractic care to veterans at all VA medical
centers (VAMCs). CBO estimates that implementing the bill would
cost $46 million over the 2011-2015 period, assuming
appropriation of the necessary amounts. Enacting this
legislation would not affect direct spending or revenues;
therefore, pay-as-you-go procedures would not apply.
H.R. 1017 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act and
would not affect the budgets of state, local, or tribal
governments.
The estimated budgetary impact of H.R. 1017 is shown in the
following table. The costs of this legislation fall within
budget function 700 (veterans benefits and services).
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
---------------------------------------------------------
2011 2012 2013 2014 2015 2011-2015
----------------------------------------------------------------------------------------------------------------
CHANGES IN SPENDING SUBJECT TO APPROPRIATION
Estimated Authorization Level......................... 3 6 12 13 13 47
Estimated Outlays..................................... 3 6 11 13 13 46
----------------------------------------------------------------------------------------------------------------
VA currently has 28 chiropractors providing care at 36
VAMCs. The bill would require VA to provide care at 75 VAMCs by
the end of calendar year 2011 and at all 153 VAMCs by the end
of calendar year 2013. Assuming that chiropractic care would be
provided at the current level of service to individual centers,
CBO estimates that VA would require 24 additional chiropractors
in 2011, growing to 93 chiropractors by 2014. Based on an
average cost per chiropractor of $115,000 in 2010 and after
adjusting for inflation, CBO estimates that implementing the
bill would cost $3 million in 2011, growing to $13 million a
year by 2014.
The CBO staff contact for this estimate is Sunita D'Monte.
The estimate was approved by Theresa Gullo, Deputy Assistant
Director for Budget Analysis.
Federal Mandates Statement
The Committee adopts as its own the estimate of Federal
mandates regarding H.R. 1017 prepared by the Director of the
Congressional Budget Office pursuant to section 423 of the
Unfunded Mandates Reform Act.
Advisory Committee Statement
No advisory committees within the meaning of section 5(b)
of the Federal Advisory Committee Act would be created by H.R.
1017.
Constitutional Authority Statement
Pursuant to clause 3(d)(1) of rule XIII of the Rules of the
House of Representatives, the Committee finds that the
Constitutional authority for H.R. 1017 is provided by Article
I, section 8 of the Constitution of the United States.
Applicability to Legislative Branch
The Committee finds that the legislation does not relate to
the terms and conditions of employment or access to public
services or accommodations within the meaning of section
102(b)(3) of the Congressional Accountability Act.
Section-by-Section Analysis of the Legislation
Section 1. Short title
This section provides the short title of H.R. 1017, as
amended, as the ``Chiropractic Care Available to All Veterans
Act.''
Section 2. Program for provision of chiropractic care and services to
veterans
This section requires the Department of Veterans Affairs to
provide chiropractic care and services to veterans through VA
medical centers and clinics at no fewer than 75 medical centers
by December 31, 2011, and at all medical centers by December
31, 2013.
Section 3. Expanded chiropractor services available to veterans
This section adds chiropractic examinations and services to
the list of medical, rehabilitative, and preventive health care
services that the VA is authorized to provide.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, existing law in which no change is
proposed is shown in roman):
DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE PROGRAMS ENHANCEMENT ACT OF
2001
* * * * * * *
TITLE II--OTHER MATTERS
* * * * * * *
SEC. 204. PROGRAM FOR PROVISION OF CHIROPRACTIC CARE AND SERVICES TO
VETERANS.
(a) * * *
* * * * * * *
(c) Location of Program.--(1) The program shall be carried
out at sites designated by the Secretary for purposes of the
program. The Secretary shall designate at least one site for
such program in each geographic service area of the Veterans
Health Administration. The sites so designated shall be medical
centers and clinics located in urban areas and in rural areas.
(2) The program shall be carried out at not fewer than 75
medical centers by not later than December 31, 2011, and at all
medical centers by not later than December 31, 2013.
* * * * * * *
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TITLE 38, UNITED STATES CODE
* * * * * * *
PART II--GENERAL BENEFITS
* * * * * * *
CHAPTER 17--HOSPITAL, NURSING HOME, DOMICILIARY, AND MEDICAL CARE
* * * * * * *
SUBCHAPTER I--GENERAL
Sec. 1701. Definitions
For the purposes of this chapter--
(1) * * *
* * * * * * *
(6) The term ``medical services'' includes, in addition to
medical examination, treatment, and rehabilitative services,
the following:
(A) * * *
* * * * * * *
(H) Chiropractic services.
* * * * * * *
(8) The term ``rehabilitative services'' means such
professional, counseling, chiropractic, and guidance services
and treatment programs as are necessary to restore, to the
maximum extent possible, the physical, mental, and
psychological functioning of an ill or disabled person.
(9) The term ``preventive health services'' means--
(A) * * *
* * * * * * *
(F) periodic and preventative chiropractic
examinations and services;
[(F)] (G) immunizations against infectious disease;
[(G)] (H) prevention of musculoskeletal deformity or
other gradually developing disabilities of a metabolic
or degenerative nature;
[(H)] (I) genetic counseling concerning inheritance
of genetically determined diseases;
[(I)] (J) routine vision testing and eye care
services;
[(J)] (K) periodic reexamination of members of likely
target populations (high-risk groups) for selected
diseases and for functional decline of sensory organs,
together with attendant appropriate remedial
intervention; and
[(K)] (L) such other health-care services as the
Secretary may determine to be necessary to provide
effective and economical preventive health care.
* * * * * * *