79–010 

Calendar No. 101 

111TH CONGRESS REPORT " ! SENATE 1st Session 111–41 

VETERANS’ HEALTH CARE BUDGET REFORM AND 

TRANSPARENCY ACT OF 2009 

JULY 8, 2009.—Ordered to be printed 

Mr. AKAKA, from the Committee on Veterans’ Affairs, 

submitted the following 

R E P O R T 

[To accompany S. 423] 

The Committee on Veterans’ Affairs (hereinafter, ‘‘Committee’’), 

to which was referred the bill (S. 423), to amend title 38, United 

States Code, to authorize advance appropriations for certain medical care accounts of the Department of Veterans Affairs by providing two-fiscal year budget authority, and for other purposes, 

having considered the same, reports favorably thereon without 

amendment and recommends that the bill do pass. 

INTRODUCTION

On February 12, 2009, Committee Chairman Daniel K. Akaka introduced S. 423, a bill to authorize, beginning in fiscal year 2011, 

advance appropriations for certain medical care accounts of the Department of Veterans Affairs by providing two-fiscal year budget 

authority, and for other purposes. Committee Ranking Minority 

Member Richard Burr is an original cosponsor of S. 423, as are 

Senators Olympia J. Snowe, Tim Johnson, John D. Rockefeller IV, 

Bernard Sanders, Jon Tester, Mark Begich, Jeff Bingaman, Barbara Boxer, Russell D. Feingold, Mary L. Landrieu, Frank R. Lautenberg, Robert Menendez, Lisa Murkowski, Debbie Stabenow, 

John Thune, David Vitter, and Charles E. Schumer. Senators 

James M. Inhofe, Blanche L. Lincoln, Ron Wyden, Arlen Specter, 

Johnny Isakson, John Ensign, Tom Coburn, John F. Kerry, Jeff 

Sessions, Max Baucus, Roland W. Burris, Saxby Chambliss, Kay R. 

Hagan, Barbara A. Mikulski, Bob Corker, Mark Udall, Patrick J. 

Leahy, Susan M. Collins, Patty Murray, Claire McCaskill, Robert 

F. Bennett, Joseph I. Lieberman, Sherrod Brown, Benjamin E. NelVerDate Nov 24 2008 06:28 Jul 09, 2009 Jkt 079010 PO 00000 Frm 00001 Fmt 6659 Sfmt 6602 E:\HR\OC\SR041.XXX SR041

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son, Amy Klobuchar, Chuck Grassley, Sam Brownback, Richard 

Durbin, Michael F. Bennet, Mike Johanns, Jack Reed, Sheldon 

Whitehouse, Robert P. Casey, Jr., Mel Martinez, and Kirsten E. 

Gillibrand are also cosponsors of S. 423. 

COMMITTEE HEARING

On April 22, 2009, the Committee held a hearing on legislation 

pending before the Committee. Among the measures on which the 

Committee received testimony was S. 423. Testimony on S. 423, 

among other bills, was offered by: Gerald M. Cross, M.D., Principal 

Deputy Under Secretary for Health, Department of Veterans Affairs; Adrian Atizado, Assistant National Legislative Director, Disabled American Veterans; Ammie Hilsabeck, RN, Oscar G. Johnson 

VA Medical Center, representing American Federation of Government Employees; and Blake Ortner, Senior Associate Legislative 

Director, Paralyzed Veterans of America. 

COMMITTEE MEETING

On May 21, 2009, the Committee met in open session to consider 

legislation pending before the Committee. Among the measures so 

considered was S. 423. The Committee voted without dissent to report favorably S. 423 to the Senate. 

SUMMARY OF THE COMMITTEE BILL AS REPORTED

S. 423, as reported, (hereinafter, ‘‘the Committee bill’’) would authorize, beginning in fiscal year 2011, advance appropriations for 

certain medical care accounts of the Department of Veterans Affairs by providing two-fiscal year budget authority, and for other 

purposes. 

Sec. 1. Short Title 

Section 1 would designate the short title of the Committee Bill 

as ‘‘Veterans Health Care Budget Reform and Transparency Act of 

2009’’. 

Sec. 2. Findings 

Section 2 would outline the findings of the Congress. These include that, for 19 of the past 22 fiscal years, funds have not been 

appropriated to VA on time, causing serious difficulties for VA in 

planning and providing health care to veterans. Further, that these 

difficulties endanger VA’s ability to provide timely and quality 

care, and that they disrupt VA’s ability to plan which programs 

and services can be funded from year to year. The Congress also 

finds that providing sufficient, timely and predictable funding 

would help VA plan and manage their health care system more effectively, thus improving their ability to meet the health care needs 

of veterans. 

Sec. 3. Two-Fiscal Year Budget Authority for Certain Medical Care 

Accounts of the Department of Veterans Affairs 

Section 3 would authorize, beginning in fiscal year 2011, advance 

appropriations for certain medical care accounts of the Department 

of Veterans Affairs by providing two-fiscal year budget authority. 


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Sec. 4. Comptroller General of the United States Study on Adequacy 

and Accuracy of Baseline Model Projections of the Department 

of Veterans Affairs for Health Care Expenditures 

Section 4 would provide enhanced oversight of the VA health 

care budget process by requiring the Comptroller General to conduct a study of the adequacy and accuracy of baseline model projections for VA health care expenditures with respect to the fiscal 

year involved and the subsequent four fiscal years. 

BACKGROUND AND DISCUSSION

Section 2. Findings 

For more than two decades, the VA health care system has been 

plagued by consistently late and, at times, inadequate budgets. 

Final VA appropriations have not been enacted prior to the start 

of the fiscal year in 19 of the past 22 years, and requests for supplemental appropriations for VA health care have increased in frequency during recent years. Over the past 7 years, final VA appropriations were late approximately 3 months on average. 

Furthermore, over the past decade, as the number of veteran enrollees and users rose dramatically, funding requests for VA health 

care often lagged behind the resource requirements that VA itself 

identified. In 2004, the Secretary of Veterans Affairs stated that 

his appropriation budget request for health care was reduced by 

$1.2 billion during the OMB review process; Congress restored that 

funding during the appropriation process. In 2005, the new Secretary informed Congress that VA’s funding request presented to 

the Committee earlier in the year was no longer adequate, and that 

$2 billion in additional funding was required for fiscal year 2006, 

and $975 million in supplemental funding was required for fiscal 

year 2005; Congress provided those additional appropriations. 

Faced with late and, at times, inadequate budgets so often in the 

past, VA has had to find ways to reduce demand or ration care to 

veterans, such as curtailing enrollment of Priority 8 veterans or 

limiting access to services through increased waiting times. Furthermore, late arriving budgets have often delayed the hiring of 

new medical personnel or procurement of new equipment or supplies. While there has been some impact on the timeliness and 

overall quality of VA care from these financial and management 

difficulties in the past, there is a serious concern that continued 

funding problems could significantly weaken the quality of veterans’ health care. Providing sufficient, timely and predictable 

funding to the VA health care system would mitigate these dangers 

and allow VA administrators and directors to more efficiently and 

effectively provide medical care to veterans. 

The findings section concludes with the finding that the most 

viable means by which to provide sufficient, timely, and predictable 

health care funding for veterans health care is through advanced 

appropriations and the assignment of a new oversight role to the 

Government Accountability Office (GAO) that will ensure the integrity of VA’s budget preparation and presentation process. 


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Section 3. Two-Fiscal Year Budget Authority for Certain Medical 

Care Accounts of the Department of Veterans Affairs 

Section 3(a). Two-Fiscal Year Budget Authority 

Section 3(a) would amend chapter 1 of title 38, United States 

Code by creating a 2-year fiscal budget authority for certain medical care accounts. 

Background. The Committee notes that there have been and continue to be a number of other Federal programs that receive advance appropriations. As stated in the President’s Fiscal Year 2010 

Budget Appendix, in fiscal year 2009, programs receiving advance 

appropriations include the Employment and Training Administration, Job Corps, Education for the Disadvantaged, School Improvement, Children and Family Services (Head Start), Special Education, Adult Education, Postal Service, Tenant-based Rental Assistance, Project-based Rental Assistance, and the Corporation for 

Public Broadcasting. 

At the Committee’s April 22, 2009 hearing, Mr. Blake Ortner of 

Paralyzed Veterans of America testified that: 

Historically, advance appropriations have been used to 

make a program function more effectively, better align 

with funding cycles of program recipients, or provide insulation from annual partisan political maneuvering. By 

moving to advance appropriations, veterans’ health care 

programs will accrue all three of these benefits. 

Mr. Adrian Atizado of the Disabled American Veterans stated 

that: 

* * * not knowing when or at what level VA will receive 

funding from year to year—or whether Congress would approve or oppose the Administration’s proposals—hinders 

the ability of VA officials to efficiently plan and responsibly manage VA health care. Broken financing causes unnecessary delays and backlogs in the system: hiring key 

staff is put off, or just not done, while injuries like PTSD 

or Traumatic Brain Injury are too often not diagnosed or 

treated in a timely manner. 

Dr. Gerald Cross, Principal Deputy Under Secretary for Health, 

testified on behalf of the Department in support of S. 423 at the 

April 22, 2009 hearing, and stated that: 

* * * the President emphasized that care for Veterans 

should never be hindered by budget delays and expressed 

support for advanced funding for Veterans’ medical care. 

We believe that advanced funding will ensure that sufficient resources are available from the first day of the fiscal 

year so that the health care needs of Veterans can be provided on a timely basis. 

The Committee Bill has been endorsed by The Partnership for 

Veterans Health Care Budget Reform, an organization made up of 

nine major veterans service organizations; The Independent Budget; The Military Coalition, an organization of 35 veterans and military service organizations; and the American Federation for Government Employees, which represents 600,000 government employees, including tens of thousands who work for VA. Advance approVerDate Nov 24 2008 06:28 Jul 09, 2009 Jkt 079010 PO 00000 Frm 00004 Fmt 6659 Sfmt 6602 E:\HR\OC\SR041.XXX SR041

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priations for veterans’ health care programs have also been endorsed by a coalition of more than two dozen former VA senior 

leaders, including one former Secretary, two former Deputy Secretaries, four former Under Secretaries for Health, three former Deputy Under Secretaries for Health, eight former VISN Directors, and 

seven former Medical Center Directors. 

Advance appropriations for veterans’ medical care will provide a 

number of advantages over the regular appropriations process. 

Having an approved appropriations bill in place a year or more before the fiscal year begins will eliminate the negative consequences 

that arise from continuing resolutions, particularly when funding 

would have been frozen at the prior year’s level. When continuing 

resolutions have been enacted, VA’s medical centers and outpatient 

clinics have been prevented from increasing the number of health 

care personnel required to provide care even when there were increases in workload. With advance appropriations, VA will have 

sufficient lead time to plan on the appropriate composition of its 

medical personnel, procure needed equipment, and negotiate new 

leases and contracts so that they are in place on the first day of 

the fiscal year. 

The Committee expects that advance appropriations will allow 

VA officials to better plan and manage the Department’s resources, 

resulting in more efficient use of appropriated dollars and more 

timely and accurate reporting to Congress of how such funds have 

been and will be utilized. The Committee also expects that VA will 

be able to ensure that the medical system has qualified doctors, 

nurses, and other health care personnel when and where they are 

needed. 

The Committee notes that veterans’ health care programs, like 

other Federal programs that receive advance appropriations, must 

still submit and justify budget requests every year; that Congress 

will retain all its prerogatives for determining budget and appropriation levels for VA medical care; that Congress will retain all of 

its powers to determine veterans’ health care benefits and services; 

that Congress will retain all of its ability to restrict or rescind 

funding, when appropriate; and that VA health care will remain 

subject to the full range of oversight activities performed by Congress. 

Committee Bill. Section 3 would amend chapter 1 of title 38 to 

add a new section—Section 113A. Two-fiscal year budget authority 

for certain medical care accounts—which would authorize, beginning in fiscal year 2011, advance appropriations for the three medical care accounts of the Department of Veterans Affairs by providing two-fiscal year budget authority. The advance appropriations would be made for fiscal year 2011 and for each year that follows in which VA is provided funding in an appropriations bill. The 

three medical accounts that will receive appropriations are Medical 

Services, Medical Support and Compliance, and Medical Facilities. 

Section 4. Comptroller General of the United States Study on Adequacy and Accuracy of Baseline Model Projections of the Department of Veterans Affairs for Health Care Expenditures 

Background. Over the past decade, disagreements in Congress 

and with the Administration over funding levels for VA health care 

programs have frequently led to inadequate and late-arriving budgVerDate Nov 24 2008 06:28 Jul 09, 2009 Jkt 079010 PO 00000 Frm 00005 Fmt 6659 Sfmt 6602 E:\HR\OC\SR041.XXX SR041

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ets. As noted above, in both 2004 and 2005 VA itself admitted that 

the budget requests presented to Congress were inadequate to meet 

the needs of veterans who were expected to seek care at VA medical facilities. Over the past decade, the Committee has routinely 

recommended significant increases above VA’s budget requests, and 

the final enacted appropriation levels for veterans’ health care programs have, in many cases, reflected those recommendations. 

VA recognized the limitations in its budget forecasting capabilities almost 10 years ago, particularly as enrollment rose rapidly between 2000 and 2004. During that time, VA developed and deployed a new budget forecasting methodology, which today is 

known as the Enrollee Health Care Projection Model (hereinafter 

referred to as the ‘‘Model’’). The Model is an actuarial model developed in cooperation with Milliman, Inc., a leading private sector actuarial firm. The Model is comprised of three sub-models: one for 

projected enrollment of veterans, one for anticipated utilization 

rates, and one for unit costs for health care services. The Model 

combines these three sub-models and then makes a series of adjustments to account for additional demographic factors and trends 

to arrive at a projected total resource requirement for the three VA 

medical care accounts combined. 

Although the model itself is a data-driven assessment of the resource needs of the VA health care system, that resource need has 

not always been communicated to Congress in a transparent manner. In a September 2006 Report to Congress, GAO found that VA’s 

budget request was constricted by ‘‘* * * guidance published by 

OMB that outlined the President’s budget priorities * * *.’’ This 

‘‘guidance’’ set targets for the level of resources that VA could anticipate OMB approving based upon prior year budgets, not based 

upon the Model’s estimates of projected costs. GAO further reported that: 

VA officials stated that differences between projected costs 

and anticipated resources in budget requests for those 

years were addressed in two ways: (1) cost-saving policy 

proposals and (2) management efficiency savings. 

Congress rejected the cost-saving policy proposals in each of the 

years they were proposed, even though the Administration’s budget 

requests assumed Congress would enact them. With Congress’s rejection of these proposals, sufficient appropriations were required 

to make up the difference in what the Model suggested was the VA 

health care system’s resource need and the target set by OMB. 

Furthermore, in a February 2006 report, GAO found that VA 

lacked a methodology for making ‘‘management efficiency’’ assumptions and, therefore, was unable to provide support for those estimates. The combined effect of assuming Congressional enactment 

of cost-saving proposals and relying on cost savings from unspecified management efficiencies rendered the true resource needs of 

the system, as estimated by the Model, more difficult to determine. 

In addition, cost savings from policy proposals thought achievable by the Administration itself also turned out to be problematic. 

In a September 2006 Report to Congress reviewing the budget 

shortfalls of 2005, GAO found that although: 

* * * VA used an actuarial model to project demand and 

costs for about 86 percent of its medical programs budget 


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estimate for fiscal years 2005 and 2006 * * *. Unrealistic 

assumptions, errors in estimation, and insufficient data 

were key factors in VA’s budget formulation process that 

contributed to the requests for additional funding for fiscal 

years 2005 and 2006. 

GAO found that VA unrealistically estimated how quickly VA 

could execute a proposal to reduce its long-term care bed capacity, 

and that it erred in estimating savings derived from this proposal. 

Finally, GAO faulted VA for having insufficient data to accurately 

forecast the number of unique users of the health care system, such 

as recently returning Iraq and Afghanistan veterans. These errors, 

coupled with those noted above, hastened the call by Congress and 

veterans’ advocates for greater transparency in VA’s budget submissions. 

The Committee believes that if the Model’s output and forecasts, 

along with other data VA uses to forecast its resource needs, had 

been available for Congress to review during those years, it would 

have been apparent that prior budget requests were built upon unrealistic assumptions about policy proposals and savings. Furthermore, had there been an independent, expert review of the Model 

and its forecasts, the ‘‘errors in estimation’’ and ‘‘insufficient data’’ 

identified by GAO could have been discovered before the budget 

and appropriations process had been completed. 

The Committee has reviewed the Model and despite some of its 

inherent weaknesses, finds it to be the most accurate methodology 

available today for estimating VA’s medical care budget requirements. A 2008 Rand Corporation report commissioned by VA to 

study the Enrollee Health Care Projection Model (referred to as 

‘‘EHCPM’’ by Rand) concluded that, ‘‘* * * the EHCPM is likely to 

be valid for short-term budget planning * * * [and] 

* * * represents a substantial improvement over the budgeting 

methodologies used by the VA in the past * * *.’’ 

Rand provided a number of suggestions on how to improve the 

Model’s validity and accuracy, particularly in how VA forecasts 

unmet demand caused by constraints resulting from VA’s current 

infrastructure. The Committee expects that VA will review the 

Rand recommendations, implement those which it adjudges to be 

improvements, and report to Congress on how these changes will 

increase accuracy in its budget forecasting. 

The Committee notes that the Model is constructed of current 

and past data about veterans enrollment, utilization rates and 

health care costs, combined with expert assumptions about how 

those factors will change in the future under a current policy environment. In essence, the Model establishes a baseline for VA’s future resource requirements; proposed changes in VA health care 

rules, regulations or laws, whether by the Administration or Congress, will require adjustments to those estimates. 

The Committee believes that the best way to ensure that Congress can accurately measure the effect of proposed policy changes 

by VA, and thereby provide more accurate appropriations levels to 

meet VA’s resource requirements, is by allowing Congress to view 

the Model’s data and estimates. The Committee recognizes that the 

Model relies in part upon proprietary information owned by 

Milliman and does not seek to impinge upon Milliman’s intellectual 

property. The intent of the Committee is to provide transparency 


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to the data, assumptions, and estimates that are the inputs and 

outputs of the Model, not to unnecessarily expose proprietary elements of the Model. Given the complexity of the Model, the Committee believes that a certain level of actuarial expertise is required to assess the integrity of the Model process, and that GAO 

is the most appropriate Federal agency to undertake this role by 

virtue of its existing accounting, budget, and health care policy expertise, as well as its overall mission. 

Committee Bill. Section 4(a) of the Committee bill, in a freestanding provision, would require the Comptroller General of the 

United States, the head of GAO, to conduct a study of the adequacy 

and accuracy of the budget projections made by the Enrollee 

Health Care Projection Model and any other model or methodology 

used to measure health care expenditures of VA. The study would 

cover the five fiscal years included in each budget submission; however, the focus is intended to be upon the fiscal year for which the 

advance appropriation would be made. The study is intended to 

provide the basis for the reports required by section 4(b) of the 

Committee bill. 

In requiring GAO to study VA’s Model, the Committee’s intent 

is to provide an independent and expert review of the Model that 

would be useful in identifying ways to improve the accuracy of VA’s 

budget estimates. Because the Model estimates approximately 90% 

of the resource requirements that make up VA’s three medical care 

accounts, GAO would also review the other models or methodologies used to estimate the remaining 10%, which include the Civilian Health and Medical Program of VA, long-term care, Vet Centers, and the State Veterans Home per diem program. 

Committee Bill. Section 4(b) of the Committee bill, in a freestanding provision, would set out a requirement for GAO to submit 

reports no later than the date of each year in 2011, 2012, and 2013 

on which the President submits the budget request for the following fiscal year. GAO would be required to submit such reports 

to both the appropriate committees of Congress—Budget, Appropriations, and Veterans Affairs—and the Secretary of Veterans Affairs. 

Each report would be required to include a statement of whether 

the amount requested in the President’s budget for VA’s health 

care expenditures in each fiscal year is consistent with what GAO 

estimates would be required based upon what the Model projects. 

The Committee expects that each report will include a detailed explanation for how GAO arrived at its estimates, along with any additional recommendations to improve the process. 

The study and reports required in Section 4 are intended to provide Congress with new tools and information to more accurately 

estimate appropriation levels that are sufficient to meet the health 

care needs of veterans, during the timeframe in which budget and 

appropriations decisions are made by Congress. The reports would 

provide Congress with an assessment of whether the Model’s resource requirement estimates have been transmitted accurately in 

VA’s budget request, and help Congress understand how those estimates have been impacted by policy proposals contained in, or assumed within, the budget submission. These GAO reports are intended to provide an assessment of the integrity of the process, as 


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well as to provide an independent analysis of how the process could 

be improved. 

The Committee expects that GAO have timely access to VA’s 

Model process, including how data is gathered and transmitted, 

how assumptions are made, how the Model is run, and how the 

Model’s outputs are presented to Congress in the budget submission. The Committee anticipates that GAO would require access to 

the Model and VA’s budget preparation process throughout each of 

the study years so their reports could be provide concurrently with 

the budget submission to Congress. 

The Committee bill also requires that the GAO’s reports be made 

available to the public at the same time they are transmitted to 

Congress. Transparency in the development of VA’s health care 

budget will allow veterans, veterans’ organizations, and the general 

public to have greater confidence that sufficient funding is being 

provided to meet the health care needs of veterans. With this additional transparency, the Committee anticipates that veterans’ organizations and other interested parties will be able to undertake 

independent reviews of the VA health care budget formulation 

process to aid Congress’ deliberations. 

COST ESTIMATE

In compliance with paragraph 11(a) of rule XXVI of the Standing 

Rules of the Senate, the Committee based on information supplied 

by the CBO, estimates that enactment of the Committee bill would, 

relative to current law, cost $175 billion over the 2010–2014 period, 

assuming appropriation of the necessary amounts. Enacting the bill 

would not affect direct spending or revenues. Enactment of the 

Committee bill would not affect receipts and would not affect the 

budget of state, local or tribal governments. 

The cost estimate provided by CBO, setting forth a detailed 

breakdown of costs, follows: 

CONGRESSIONAL BUDGET OFFICE, 

Washington, DC, June 17, 2009. 

Hon. DANIEL K. AKAKA, 

Chairman, 

Committee on Veterans’ Affairs, 

U.S. Senate, Washington, DC. 

DEAR MR. CHAIRMAN: The Congressional Budget Office has prepared the enclosed cost estimate for S. 423, the Veterans Health 

Care Budget Reform and Transparency Act of 2009. 

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 

S. 423, Veterans Health Care Budget Reform and Transparency Act 

of 2009 

Summary: S. 423 would authorize appropriations for certain programs within the Department of Veterans Affairs (VA). CBO estiVerDate Nov 24 2008 06:28 Jul 09, 2009 Jkt 079010 PO 00000 Frm 00009 Fmt 6659 Sfmt 6602 E:\HR\OC\SR041.XXX SR041

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mates that implementing the bill would cost $175 billion over the 

2010–2014 period, assuming appropriation of the necessary 

amounts. Enacting the bill would not affect direct spending or revenues. 

S. 423 contains no intergovernmental or private-sector mandates 

as defined in the Unfunded Mandates Reform Act (UMRA) and 

would not affect the budgets of state, local, or tribal governments. 

Estimated cost to the Federal Government: The estimated budgetary impact of S. 423 is shown in the following table. The costs of 

this legislation fall within budget function 700 (veterans benefits 

and services). 

Basis of estimate: For this estimate, CBO assumes that the specified and estimated authorizations will be appropriated near the 

start of each fiscal year beginning with 2011, and that outlays will 

follow historical patterns for similar and existing programs. 

By fiscal year, in millions of dollars— 

2010 2011 2012 2013 2014 2010–2014 

CHANGES IN SPENDING SUBJECT TO APPROPRIATION 

Medical Services 

Estimated Authorization Level ......................... 0 34,715 35,333 35,925 36,727 142,700 

Estimated Outlays ............................................ 0 30,548 34,529 35,595 36,429 137,101 

Medical Facilities 

Estimated Authorization Level ......................... 0 5,198 5,258 5,316 5,398 21,170 

Estimated Outlays ............................................ 0 4,025 4,773 5,095 5,322 19,215 

Medical Support and Compliance 

Estimated Authorization Level ......................... 0 4,760 4,864 4,972 5,107 19,703 

Estimated Outlays ............................................ 0 4,231 4,781 4,925 5,066 19,003 

Total Changes 

Estimated Authorization Level ................ 0 44,673 45,455 46,213 47,232 183,573 

Estimated Outlays ................................... 0 38,804 44,083 45,615 46,817 175,319 

S. 423 would authorize appropriations for three specific budget 

accounts: 

• Medical Services, 

• Medical Facilities, and 

• Medical Support and Compliance. 

Under current law, appropriations for those budget accounts are 

provided each year. Starting in 2011 for each account listed above, 

the bill would authorize appropriations for that fiscal year as well 

as advance appropriations for the following fiscal year. CBO estimates that implementing the bill would cost $175 billion over the 

2010–2014 period, assuming appropriation of the necessary 

amounts. 

CBO’s estimates of the authorization of appropriations required 

under the bill are the same as projections for the 2011–2014 period 

in the most recent CBO baseline, completed in March 2009. Those 

amounts are derived from the 2009 appropriated level for each account and adjusted for anticipated inflation. CBO expects that 

those amounts would be sufficient to provide services at the current level. However, if VA were to significantly expand its health 

care programs—for example, to include certain veterans with higher incomes who are currently ineligible—additional funding would 

be required. 

Intergovernmental and private-sector impact: S. 423 contains 

no intergovernmental or private-sector mandates as defined in 


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UMRA and would not affect the budgets of state, local, or tribal 

governments. 

Previous CBO estimate: On June 16, 2009, CBO transmitted a 

cost estimate for H.R. 1016, the Veterans Health Care Budget Reform and Transparency Act of 2009, as ordered reported by the 

House Committee on Veterans’ Affairs on June 10, 2009. The bills 

are similar, but H.R. 1016 would authorize appropriations for two 

additional budget accounts and CBO estimated it would cost almost 

$187 billion over the 2010–2014 period, assuming appropriation of 

the necessary amounts. 

Estimate prepared by: Federal Costs: Sunita D’Monte; Impact on 

State, Local, and Tribal Governments: Lisa Ramirez-Branum; Impact on the Private Sector: Elizabeth Bass. 

Estimate approved by: Theresa Gullo, Deputy Assistant Director 

for Budget Analysis. 

REGULATORY IMPACT

In compliance with paragraph 11(b) of rule XXVI of the Standing 

Rules of the Senate, the Committee on Veterans’ Affairs has made 

an evaluation of the regulatory impact that would be incurred in 

carrying out the Committee bill. The Committee finds that S. 423 

would not entail any regulation of individuals or businesses or result in any impact on the personal privacy of any individuals and 

that the paperwork resulting from enactment would be minimal. 

TABULATION OF VOTES CAST IN COMMITTEE

In compliance with paragraph 7 of rule XXVI of the Standing 

Rules of the Senate, the following is a tabulation of votes cast in 

person or by proxy by Members of the Committee on Veterans’ Affairs at its May 21, 2009, meeting. On that date, the Committee 

considered and ordered reported S. 423, a bill to amend title 38, 

United States Code, to authorize advance appropriations for certain 

medical care accounts of the Department of Veterans Affairs by 

providing two-fiscal year budget authority, and for other purposes. 

The Committee bill was agreed to by a vote of 14 to 0. 

Yeas Senator Nays 

X (by proxy) Mr. Rockefeller 

X Mrs. Murray 

X (by proxy) Mr. Sanders 

X Mr. Brown 

X Mr. Webb 

X Mr. Tester 

X Mr. Begich 

X Mr. Burris 

X (by proxy) Mr. Specter 

X Mr. Burr 

X Mr. Isakson 

X (by proxy) Mr. Wicker 

X Mr. Johanns 

Mr. Graham 

X Mr. Akaka, Chairman 

14 TALLY 0 


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AGENCY REPORT

On April 22, 2009, Gerald M, Cross, MD, Principal Deputy Under 

Secretary for Health, Department of Veterans Affairs, appeared before the Committee and submitted testimony on various bills, including S. 423. Excerpts of the testimony are reprinted below: 

STATEMENT OF GERALD M. CROSS, MD, FAAFP, 

PRINCIPAL DEPUTY UNDER SECRETARY FOR 

HEALTH, DEPARTMENT OF VETERANS AFFAIRS 

S. 423 would authorize advance appropriations for certain medical accounts of the Department by providing twofiscal year budget authority. Mr. Chairman, we know that 

Congress and the Administration share the same objective—to ensure VA delivers timely, accessible, and highquality care that Veterans expect and deserve. On April 9, 

2009, the President emphasized that care for Veterans 

should never be hindered by budget delays and expressed 

support for advanced funding for Veterans’ medical care. 

We believe that advanced funding will ensure that sufficient resources are available from the first day of the fiscal 

year so that the health care needs of Veterans can be provided on a timely basis. We look forward to working with 

Congress to make advanced funding for VA health care a 

reality. 


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CHANGES IN EXISTING LAW

In compliance with paragraph 12 of Rule XXVI of the Standing 

Rules of the Senate, 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). 

TITLE 38. VETERANS’ BENEFITS 

PART I. GENERAL PROVISIONS 

CHAPTER 1. GENERAL 

Sec. 

101. Definitions. 

* * * * * * * 

113. Treatment of certain programs under sequestration procedures. 

113A. Two-fiscal year budget authority for certain medical care accounts. 

114. Multiyear procurement. 

* * * * * * * 

CHAPTER 1. GENERAL 

SEC. 101. DEFINITIONS 

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SEC. 113A. TWO-FISCAL YEAR BUDGET AUTHORITY FOR CERTAIN MEDICAL CARE ACCOUNTS 

(a) IN GENERAL.—Beginning with fiscal year 2011, new discretionary budget authority provided in an appropriations Act for the 

appropriations accounts of the Department specified in subsection 

(b) shall be made available for the fiscal year involved, and shall 

include new discretionary budget authority for such appropriations 

accounts that first become available for the first fiscal year after 

such fiscal year. 

(b) MEDICAL CARE ACCOUNTS.—The medical care accounts of the 

Department specified in this subsection are the medical care accounts of the Veterans Health Administration as follows: 

(1) Medical Services. 

(2) Medical Support and Compliance. 

(3) Medical Facilities. 

SEC. 114. MULTIYEAR PROCUREMENT 

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