II 115th CONGRESS 1st Session S. 1526 IN THE SENATE OF THE UNITED STATES July 11, 2017 Mr. Tester (for himself, Mr. King , Mr. Sanders , Mrs. Murray , Mr. Blumenthal , Mr. Brown , Ms. Baldwin , and Ms. Hirono ) introduced the following bill; which was read twice and referred to the Committee on Veterans' Affairs A BILL To appropriate amounts to the Department of Veterans Affairs to improve the provision of health care to veterans, and for other purposes.

1. Short title; table of contents (a) Short title This Act may be cited as the Veterans Access to Care Act of 2017 . (b) Table of contents The table of contents for this Act is as follows: Sec. 1. Short title; table of contents. TITLE I—Appropriation of amounts for health care for veterans Sec. 101. Appropriation of amounts for Veterans Choice Program. Sec. 102. Appropriation of amounts for health care from Department of Veterans Affairs. TITLE II—Improvement of health care from Department of Veterans Affairs Sec. 201. Program to increase number of graduate medical education residency positions of Department of Veterans Affairs. Sec. 202. Expansion of eligibility for participation in and services provided under family caregiver program of Department of Veterans Affairs. Sec. 203. Authorization of certain major medical facility leases of the Department of Veterans Affairs. TITLE III—Administration of health care from non-Department of Veterans Affairs providers Sec. 301. Modification of process through which Department of Veterans Affairs records obligations for non-Department care. Sec. 302. Modification of report on amounts available under Veterans Choice Program. TITLE IV—Other matters Sec. 401. Emergency designations. I Appropriation of amounts for health care for veterans 101. Appropriation of amounts for Veterans Choice Program (a) In general There is authorized to be appropriated, and is appropriated, to the Secretary of Veterans Affairs, out of any funds in the Treasury not otherwise appropriated, $4,300,000,000 to be deposited in the Veterans Choice Fund under section 802 of the Veterans Access, Choice, and Accountability Act of 2014 ( Public Law 113–146 ; 38 U.S.C. 1701 note). (b) Availability of amounts The amount appropriated under subsection (a) shall be available for obligation or expenditure without fiscal year limitation. 102. Appropriation of amounts for health care from Department of Veterans Affairs (a) In general There is authorized to be appropriated, and is appropriated, to the Secretary of Veterans Affairs, out of any funds in the Treasury not otherwise appropriated, $4,300,000,000 to carry out subsection (c). (b) Availability of amounts The amount appropriated under subsection (a) shall be available for obligation or expenditure without fiscal year limitation. (c) Use of amounts The amount appropriated under subsection (a) shall be used by the Secretary as follows: (1) To increase the access of veterans to care as follows: (A) To hire primary care and specialty care physicians for employment in the Department of Veterans Affairs. (B) To hire other medical staff, including the following: (i) Physicians. (ii) Gynecologists. (iii) Nurses. (iv) Social workers. (v) Mental health professionals. (vi) Physician assistants. (vii) Other health care professionals as the Secretary considers appropriate. (C) To carry out the following: (i) Section 7412 of title 38, United States Code. (ii) Section 7302(e) of such title. (iii) Subchapters II and VII of chapter 76 of such title. (iv) Section 301(b)(2) of the Veterans Access, Choice, and Accountability Act of 2014 ( Public Law 113–146 ; 38 U.S.C. 7302 note). (D) To pay for expenses, equipment, and other costs associated with the hiring of primary care, specialty care physicians, and other medical staff under subparagraphs (A), (B), and (C). (2) To improve the physical infrastructure of the Department as follows: (A) To maintain and operate hospitals, nursing homes, domiciliary facilities, and other facilities of the Veterans Health Administration. (B) To enter into contracts or hire temporary employees to repair, alter, or improve facilities under the jurisdiction of the Department that are not otherwise provided for under this paragraph. (C) To carry out leases for facilities of the Department. (D) To carry out minor construction projects of the Department. (3) To carry out the program to increase the number of graduate medical education residency positions of the Department under section 201. (4) To carry out the major medical facility leases authorized under section 203. (d) Report (1) In general Not later than one year after the date of the enactment of this Act, the Secretary of Veterans Affairs shall submit to the appropriate committees of Congress a report on how the Secretary has obligated the amount appropriated under subsection (a) as of the date of the submittal of the report. (2) Appropriate committees of Congress defined In this subsection, the term appropriate committees of Congress means— (A) the Committee on Veterans' Affairs and the Committee on Appropriations of the Senate; and (B) the Committee on Veterans' Affairs and the Committee on Appropriations of the House of Representatives. (e) Funding plan The Secretary shall submit to Congress a funding plan describing how the Secretary intends to use the amount appropriated under subsection (a). II Improvement of health care from Department of Veterans Affairs 201. Program to increase number of graduate medical education residency positions of Department of Veterans Affairs (a) In general The Secretary of Veterans Affairs shall conduct a program to increase the number of graduate medical education residency positions at covered facilities by not more than 1,500 positions through the payment of educational assistance to participants in the program. (b) Application To participate in the program under this section, an individual shall submit to the Secretary an application for such participation together with an agreement described in subsection (d) under which the individual agrees to serve a period of obligated service in the Veterans Health Administration as provided in the agreement in return for payment of educational assistance as provided in the agreement. (c) Approval by Secretary (1) In general An individual becomes a participant in the program under this section upon the approval by the Secretary of the application of the individual and the acceptance by the Secretary of an agreement described in subsection (d) with respect to the individual. (2) Notification Upon the approval by the Secretary under paragraph (1) of the participation of an individual in the program and the acceptance of an agreement described in subsection (d), the Secretary shall promptly notify the individual in writing of that approval and acceptance. (d) Agreement An agreement between the Secretary and a participant in the program under this section shall be in writing and shall be signed by the participant containing such terms as the Secretary may specify. (e) Conditions for medical residency The Secretary may prescribe the conditions of employment of individuals participating in a medical residency under the program under this section, including necessary training, and the customary amount and terms of pay for such individuals during the period of such employment and training as a medical resident. (f) Obligated service (1) In general Each participant in the program under this section shall serve as a full-time employee of the Department of Veterans Affairs for a period of obligated service provided in the agreement entered into by the participant under subsection (d). (2) Practice area Service by a participant under paragraph (1) shall be in the full-time clinical practice of the profession of the participant or in another health care position in an assignment or location determined by the Secretary. (3) Notification Not later than 60 days before the date of the beginning of the period of obligated service of a participant, the Secretary shall notify the participant of that date. (g) Breach of agreement; liability (1) Liquidated damages for failure to accept payment (A) In general A participant in the program under this section (other than a participant described in paragraph (2)) who fails to accept payment, or instructs the covered facility at which the participant is a medical resident not to accept payment, in whole or in part, of educational assistance under the agreement entered into under subsection (d) shall be liable to the United States for liquidated damages in the amount of $1,500. (B) Treatment of other obligations Liability for liquidated damages under subparagraph (A) is in addition to any period of obligated service or other obligation or liability under the agreement entered into under subsection (d). (2) Liability for certain breaches (A) In general A participant in the program under this section shall be liable to the United States for the amount that has been paid to or on behalf of the participant under the agreement if any of the following occurs: (i) The participant is dismissed from serving as a medical resident at a covered facility for disciplinary reasons. (ii) The participant voluntarily terminates service as a medical resident at a covered facility before completion of such service. (iii) The participant loses his or her license, registration, or certification to practice his or her health care profession in a State. (B) Treatment of period of obligated service Liability under subparagraph (A) is in lieu of any period of obligated service under the agreement entered into under subsection (d). (3) Liability for failing to complete period of service (A) In general If a participant in the program under this section breaches the agreement under subsection (d) by failing (for any reason) to complete the period of obligated service of the participant, the United States shall be entitled to recover from the participant an amount determined in accordance with the following formula: A = 3Φ(t − s/t). (B) Formula variables In the formula specified in subparagraph (A): (i) A is the amount the United States is entitled to recover from the participant. (ii) Φ is the sum of— (I) the amounts paid under this section to or on behalf of the participant; and (II) the interest on such amounts which would be payable if at the time the amounts were paid they were loans bearing interest at the maximum legal prevailing rate, as determined by the Treasurer of the United States. (iii) t is the total number of months in the period of obligated service of the participant. (iv) s is the number of months of such period served by the participant. (4) Payment deadline Any amount of damages that the United States is entitled to recover under this subsection shall be paid to the United States within the one-year period beginning on the date of the breach of the agreement under subsection (d). (h) Covered facilities defined In this section, the term covered facilities means any of the following: (1) A Department facility. (2) A facility operated by an Indian tribe or a tribal organization, as those terms are defined in section 4 of the Indian Self-Determination and Education Assistance Act ( 25 U.S.C. 5304 ). (3) A facility operated by the Indian Health Service. (4) A Federally-qualified health center, as defined in section 1905(l)(2)(B) of the Social Security Act ( 42 U.S.C. 1396d(l)(2)(B) ). (5) A community health center. (6) A facility operated by the Department of Defense. (7) Any other health care facility designated by the Secretary of Veterans Affairs. 202. Expansion of eligibility for participation in and services provided under family caregiver program of Department of Veterans Affairs (a) Family caregiver program (1) Expansion of eligibility Subsection (a)(2)(B) of section 1720G of title 38, United States Code, is amended by striking on or after September 11, 2001 . (2) Clarification of eligibility for illness Such subsection is further amended by inserting or illness after serious injury . (3) Expansion of needed services in eligibility criteria Subsection (a)(2)(C) of such section is amended— (A) in clause (ii), by striking ; or and inserting a semicolon; (B) by redesignating clause (iii) as clause (iv); and (C) by inserting after clause (ii) the following new clause (iii): (iii) a need for regular or extensive instruction or supervision without which the ability of the veteran to function in daily life would be seriously impaired; or . (4) Expansion of services provided Subsection (a)(3)(A)(ii) of such section is amended— (A) in subclause (IV), by striking ; and and inserting a semicolon; (B) in subclause (V), by striking the period at the end and inserting a semicolon; and (C) by adding at the end the following new subclauses: (VI) child care services or a monthly stipend for such services if such services are not readily available from the Department; (VII) financial planning services relating to the needs of injured and ill veterans and their caregivers; and (VIII) legal services, including legal advice and consultation, relating to the needs of injured and ill veterans and their caregivers. . (5) Expansion of respite care provided Subsection (a)(3)(B) of such section is amended by striking shall be and all that follows through the period at the end and inserting shall— (i) be medically and age-appropriate; (ii) include in-home care; and (iii) include peer-oriented group activities. . (6) Modification of stipend calculation Subsection (a)(3)(C) of such section is amended— (A) by redesignating clause (iii) as clause (iv); and (B) by inserting after clause (ii) the following new clause (iii): (iii) In determining the amount and degree of personal care services provided under clause (i) with respect to an eligible veteran whose need for personal care services is based in whole or in part on a need for supervision or protection under paragraph (2)(C)(ii) or regular or extensive instruction or supervision under paragraph (2)(C)(iii), the Secretary shall take into account the following: (I) The assessment by the family caregiver of the needs and limitations of the veteran. (II) The extent to which the veteran can function safely and independently in the absence of such supervision, protection, or instruction. (III) The amount of time required for the family caregiver to provide such supervision, protection, or instruction to the veteran. . (7) Periodic evaluation of need for certain services Subsection (a)(3) of such section is amended by adding at the end the following new subparagraph: (D) In providing instruction, preparation, and training under subparagraph (A)(i)(I) and technical support under subparagraph (A)(i)(II) to each family caregiver who is approved as a provider of personal care services for an eligible veteran under paragraph (6), the Secretary shall periodically evaluate the needs of the eligible veteran and the skills of the family caregiver of such veteran to determine if additional instruction, preparation, training, or technical support under those subparagraphs is necessary. . (8) Use of primary care teams Subsection (a)(5) of such section is amended, in the matter preceding subparagraph (A), by inserting (in collaboration with the primary care team for the eligible veteran to the maximum extent practicable) after evaluate . (9) Eligibility of and assistance for family caregivers Subsection (a) of such section is amended by adding at the end the following new paragraphs: (11) Notwithstanding any other provision of this subsection, a family caregiver of an eligible veteran who is eligible under paragraph (2) solely because of a serious injury or illness (including traumatic brain injury, psychological trauma, or other mental disorder) incurred or aggravated in the line of duty in the active military, naval, or air service before September 11, 2001, is eligible for assistance under this subsection as follows: (A) Not earlier than October 1, 2018, if the family caregiver would merit a monthly personal caregiver stipend under paragraph (3)(A)(ii)(V) in an amount that is in the highest tier specified in the schedule established by the Secretary under paragraph (3)(C)(i). (B) Not earlier than October 1, 2020, if the family caregiver would merit such a stipend in an amount that is in the middle tier specified in such schedule. (C) Not earlier than October 1, 2022, if the family caregiver would merit such a stipend in an amount that is in the lowest tier specified in such schedule. (12) (A) In providing assistance under this subsection to family caregivers of eligible veterans, the Secretary may enter into contracts, provider agreements, and memoranda of understanding with Federal agencies, States, and private, nonprofit, and other entities to provide such assistance to such family caregivers. (B) The Secretary may provide assistance under this paragraph only if such assistance is reasonably accessible to the family caregiver and is substantially equivalent or better in quality to similar services provided by the Department. (C) The Secretary may provide fair compensation to Federal agencies, States, and other entities that provide assistance under this paragraph. . (b) Termination of general caregiver support program (1) In general Subsection (b) of such section is amended by adding at the end the following new paragraph: (6) The authority of the Secretary to provide support services for caregivers of covered veterans under this subsection shall terminate on October 1, 2022. . (2) Continuation of certain assistance The Secretary of Veterans Affairs shall ensure that any activities carried out under subsection (b) of such section on September 30, 2022, are continued under subsection (a) of such section on and after October 1, 2022. (c) Modification of definition of family member Subparagraph (B) of subsection (d)(3) of such section is amended to read as follows: (B) is not a member of the family of the veteran and does not provide care to the veteran on a professional basis. . (d) Modification of definition of personal care services Subsection (d)(4) of such section is amended— (1) in subparagraph (A), by striking independent ; (2) by redesignating subparagraph (B) as subparagraph (D); and (3) by inserting after subparagraph (A) the following new subparagraphs: (B) Supervision or protection based on symptoms or residuals of neurological or other impairment or injury. (C) Regular or extensive instruction or supervision without which the ability of the veteran to function in daily life would be seriously impaired. . (e) Annual evaluation report Paragraph (2) of section 101(c) of the Caregivers and Veterans Omnibus Health Services Act of 2010 ( Public Law 111–163 ; 38 U.S.C. 1720G note) is amended to read as follows: (2) Contents Each report required by paragraph (1) after the date of the enactment of the Veterans Choice Act of 2017 shall include the following with respect to the program of comprehensive assistance for family caregivers required by subsection (a)(1) of such section 1720G: (A) The number of family caregivers that received assistance under such program. (B) The cost to the Department of providing assistance under such program. (C) A description of the outcomes achieved by, and any measurable benefits of, carrying out such program. (D) An assessment of the effectiveness and the efficiency of the implementation of such program, including a description of any barriers to accessing and receiving care and services under such program. (E) A description of the outreach activities carried out by the Secretary under such program. (F) An assessment of the manner in which resources are expended by the Secretary under such program, particularly with respect to the provision of monthly personal caregiver stipends under subsection (a)(3)(A)(ii)(V) of such section 1720G. (G) An evaluation of the sufficiency and consistency of the training provided to family caregivers under such program in preparing family caregivers to provide care to veterans under such program. (H) Such recommendations, including recommendations for legislative or administrative action, as the Secretary considers appropriate in light of carrying out such program. . 203. Authorization of certain major medical facility leases of the Department of Veterans Affairs The Secretary of Veterans Affairs may carry out the following major medical facility leases at the locations specified and in an amount for each lease not to exceed the amount specified for such location (not including any estimated cancellation costs): (1) For an outpatient clinic, Ann Arbor, Michigan, an amount not to exceed $4,247,000. (2) For an outpatient mental health clinic, Birmingham, Alabama, an amount not to exceed $6,649,000. (3) For research space, Boston, Massachusetts, an amount not to exceed $6,224,000. (4) For research space, Charleston, South Carolina, an amount not to exceed $7,274,000. (5) For an outpatient clinic, Corpus Christi, Texas, an amount not to exceed $6,556,000. (6) For an outpatient clinic, Daytona Beach, Florida, an amount not to exceed $12,198,000. (7) For Chief Business Office Purchased Care office space, Denver, Colorado, an amount not to exceed $14,784,000. (8) For an outpatient clinic, Fredericksburg, Virginia, an amount not to exceed $45,015,000. (9) For an outpatient clinic, Gainesville, Florida, an amount not to exceed $7,891,000. (10) For an outpatient mental health clinic, Gainesville, Florida, an amount not to exceed $4,320,000. (11) For an outpatient clinic, Hampton Roads, Virginia, an amount not to exceed $18,141,000. (12) For a replacement outpatient clinic, Indianapolis, Indiana, an amount not to exceed $7,876,000. (13) For a replacement outpatient clinic, Jacksonville, Florida, an amount not to exceed $18,623,000. (14) For an outpatient clinic, Missoula, Montana, an amount not to exceed $6,942,000. (15) For an outpatient mental health clinic, Northern Colorado, Colorado, an amount not to exceed $8,904,000. (16) For an outpatient clinic, Ocala, Florida, an amount not to exceed $5,026,000. (17) For an outpatient clinic, Oxnard, California, an amount not to exceed $5,274,000. (18) For an outpatient clinic, Pike County, Georgia, an amount not to exceed $5,565,000. (19) For a replacement outpatient clinic, Pittsburgh, Pennsylvania, an amount not to exceed $6,247,000. (20) For an outpatient clinic, Portland, Maine, an amount not to exceed $6,808,000. (21) For an outpatient clinic, Raleigh, North Carolina, an amount not to exceed $21,870,000. (22) For a replacement outpatient clinic, phase II, Rochester, New York, an amount not to exceed $3,645,000. (23) For research space, San Diego, California, an amount not to exceed $4,852,000. (24) For an outpatient clinic, Santa Rosa, California, an amount not to exceed $6,922,000. (25) For a replacement mental health clinic, Tampa, Florida, an amount not to exceed $13,387,000. (26) For a replacement outpatient clinic, Lakeland, Tampa, Florida, an amount not to exceed $10,760,000. (27) For a replacement outpatient clinic, Terre Haute, Indiana, an amount not to exceed $4,102,000. III Administration of health care from non-Department of Veterans Affairs providers 301. Modification of process through which Department of Veterans Affairs records obligations for non-Department care (a) In general Subchapter III of chapter 17 of title 38, United States Code, is amended by adding at the end the following new section: 1730B. Recording obligations for care at non-Department facilities Notwithstanding sections 1341(a)(1) and 1501 of title 31, the Secretary may record as an obligation of the United States Government amounts owed for hospital care or medical services furnished under this chapter at non-Department facilities on the date on which a claim by a health care provider for payment is approved rather than on the date that the hospital care or medical services are authorized by the Secretary. . (b) Clerical amendment The table of sections at the beginning of chapter 17 of such title is amended by inserting after the item relating to section 1730A the following new item: 1730B. Recording obligations for care at non-Department facilities. . 302. Modification of report on amounts available under Veterans Choice Program Section 101(q)(2) of the Veterans Access, Choice, and Accountability Act of 2014 ( Public Law 113–146 ; 38 U.S.C. 1701 note) is amended— (1) in the matter preceding subparagraph (A), by striking 30 days and inserting 14 days ; (2) by redesignating subparagraph (F) as subparagraph (H); and (3) by inserting after subparagraph (E) the following new subparagraphs: (F) An assessment of the rate at which amounts deposited in the Veterans Choice Fund have been exhausted during the 90-day period preceding the submittal of the report, including an identification of any major factors that are causing amounts to be exhausted quickly or slowly. (G) An estimate of when amounts in the Veterans Choice Fund will be completely exhausted. . IV Other matters 401. Emergency designations (a) In general This Act is designated as an emergency requirement pursuant to section 4(g) of the Statutory Pay-As-You-Go Act of 2010 ( 2 U.S.C. 933(g) ). (b) Designation in Senate In the Senate, this Act is designated as an emergency requirement pursuant to section 403(a) of S. Con. Res. 13 (111th Congress), the concurrent resolution on the budget for fiscal year 2010.