Veterans’ Medical Care: FY2014 Appropriations
Released: 2014-04-01T00:00:00

Introduction

The Department of Veterans Affairs (VA) provides a range of benefits and services to veterans who meet certain eligibility rules; these benefits include medical care, disability compensation and pensions, education, vocational rehabilitation and employment services, assistance to homeless veterans, home loan guarantees, administration of life insurance as well as traumatic injury protection insurance for servicemembers, and death benefits that cover burial expenses.

The VA carries out its programs nationwide through three administrations and the Board of Veterans Appeals (BVA). The Veterans Benefits Administration (VBA) is responsible for, among other things, providing compensation, pensions, and education assistance. The National Cemetery Administration (NCA) 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 Veterans Health Administration (VHA) is responsible for health care services and medical and prosthetic research programs. 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. 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). The VHA is also a provider of health care education and training for physician residents and other health care trainees. The other statutory missions of VHA are to serve as a contingency backup to the Department of Defense (DOD) medical system during a national security emergency, and to provide support to the National Disaster Medical System and the Department of Health and Human Services as necessary.

In general, eligibility for VA health care is based on previous military service, presence of service-connected disabilities, and/or other factors. Veterans generally must enroll in the VA health care system to receive medical care. Once enrolled, veterans are assigned to one of eight categories (see Appendix ). It should be noted that in any given year, not all enrolled veterans obtain their health care services from the VA. While some veterans may rely solely on the VA for their care, others may receive the majority of their health care services from other sources, such as Medicare, Medicaid, private health insurance, and the military health system (TRICARE). VA-enrolled veterans do not pay premiums or enrollment fees to receive care from the VA; however, they may incur out-of-pocket costs for VA care related to conditions that are not service-connected.

The Veteran Patient Population

In FY2013, approximately 8.9 million of the 22.2 million living veterans in the nation were estimated to be enrolled in the VA health care system (see Table 1 ). From FY2010 through FY2013 the total number of enrollees has increased by 6.6%. Of the total number of enrolled veterans in FY2013, VA anticipated treating approximately 5.75 million unique veteran patients (see Table 2 ). For FY2014, VHA estimates that it will treat about 5.8 million unique veteran patients, and of these, VA anticipates treating more than 674,000 Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans. In FY2014, OEF, OIF, and OND patients would represent approximately10.4% of the overall patients served by the VA.

VHA also provides medical care to certain non-veterans; in FY2014 this population is expected to increase by almost 18,000 patients over the FY2013 level. In total, including non-veterans, it is estimated the VHA will treat nearly 6.5 million patients in 2014, a slight increase of 1.3% over the number of patients treated in FY2013 (see Table 2 ). Between FY2010 and FY2013, the number of patients treated by VA has grown by 7.1%.

The total number of outpatient visits, including visits to Vet Centers, reached 88.7 million during FY2012 and is projected to increase to approximately 92.2 million in FY2013 and 95.5 million in FY2014.

The rest of this report focuses on appropriations for VHA. It begins with a brief overview of VA's budget as a whole for FY2013 and the President's request for FY2014. It then presents a brief overview of VHA's budget formulation, a description of the accounts that fund the VHA, and a summary of the FY2013 VHA budget. The report ends with a section discussing recent legislative developments pertaining to the FY2014 VHA budget.

Advance Appropriations26

In order to understand annual appropriations for the Veterans Health Administration (VHA), it is essential to understand the role of advance appropriations. In 2009, Congress enacted the Veterans Health Care Budget Reform and Transparency Act of 2009 ( P.L. 111-81 ) authorizing advance appropriations for three of the four accounts that comprise VHA: medical services, medical support and compliance, and medical facilities. The fourth account, the medical and prosthetic research account, is not funded with an advance appropriation. P.L. 111-81 also required the Department of Veterans Affairs to submit a request for advance appropriations for VHA with its budget request each year. Congress first provided advance appropriations for the three VHA accounts in the FY2010 appropriations cycle; the Consolidated Appropriations Act, 2010 ( P.L. 111-117 ), provided advance appropriations for FY2011. Subsequently, each successive appropriation measure has provided advance appropriations for the VHA accounts: the Department of Defense and Full-Year Continuing Appropriations Act, 2011 ( P.L. 112-10 ), provided advance appropriations for FY2012; the Consolidated Appropriations Act, 2012 ( P.L. 112-74 ), provided advance appropriations for FY2013; the Consolidated and Further Continuing Appropriations Act, 2013 ( P.L. 113-6 ), provided advance appropriations for FY2014; and the Consolidated Appropriations Act, 2014 ( P.L. 113-76 ), provided advance appropriations for FY2015.

Under current budget scoring guidelines, advance appropriations of budget authority are scored as new budget authority in the fiscal year in which the funds become newly available for obligation, and not in the fiscal year the appropriations are enacted. Therefore, throughout the funding tables of this report, advance appropriations numbers are shown under the label "memorandum" and in the corresponding fiscal year column. For example, advance appropriations for FY2013 authorized by the Consolidated Appropriations Act, 2012 ( P.L. 112-74 ), are shown under a separate memorandum and in the FY2013 column. However, it should be noted that budget authority for FY2013 refers to the budget authority authorized in P.L. 112-74 and augmented by supplemental funding provided by the Disaster Relief Appropriations Act, 2013 ( P.L. 113-2 ), and by additional funding provided by Division E of the Consolidated and Further Continuing Appropriations Act, 2013 ( P.L. 113-6 ), which included funding for the medical and prosthetic research account (the account that is not funded as advance appropriations). Funding shown for FY2013 does not include advance appropriations provided in FY2013 by P.L. 113-6 for use in FY2014. Instead, the advance appropriation provided in FY2013 for use in FY2014 is shown in the memorandum in the FY2014 column. Similarly, funding shown for FY2014 does not include advance appropriations provided in FY2014 for use in FY2015.

Department of Veterans Affairs Budget

The VA budget includes both mandatory and discretionary funding. Mandatory accounts fund disability compensation, pensions, vocational rehabilitation and employment, education, life insurance, housing, and burial benefits (such as graveliners, outer burial receptacles, and headstones), among other benefits and services. Discretionary accounts fund medical care, medical research, construction programs, information technology, and general operating expenses, among other things.

Figure 1 provides a breakdown of FY2013 budget allocations for both mandatory and discretionary programs (see also Table 5 ). In FY2013, the total VA budget authority was approximately $134.1 billion; discretionary budget authority accounted for about 46% ($61.2 billion) of the total, with about 87% ($53.3 billion) of this discretionary funding going toward supporting VA health care programs, including medical and prosthetic research. The VA's mandatory budget authority accounted for about 54% ($72.9 billion) of the total VA budget authority, with about 83% ($60.63 billion) of this mandatory funding going toward disability compensation and pension programs.

Figure 2 provides a breakdown of the FY2014 President's budget request for both mandatory and discretionary programs (also see Table 7 ). For FY2014, the Administration requested approximately $147.9 billion. This includes approximately $63.5 billion in discretionary funding and $84.5 billion in mandatory funding.

Overview of Veterans Health Administration's Budget Formulation31

Similar to most federal agencies, the VA begins formulating its budget request approximately 10 months before the President submits the budget to Congress, generally in early February. VHA's budget request to Congress begins with the formulations of the budget based on the Enrollee Health Care Projection Model (EHCPM). The model estimates the amount of budgetary resources VHA will need to meet the expected demand for most of the health care services it provides.

The EHCPM's estimates are based on three basic components: the projected number of veterans who will be enrolled in VA health care, the projected utilization of VA's health care services—that is, the quantity of health care services enrollees are expected to use—and the projected unit cost of providing these services. Each component is subject to a number of adjustments to account for the characteristics of VA health care and the veterans who access VA's health care services. The EHCPM makes projections three or four years into the future. Each year, VHA updates the EHCPM estimates to "incorporate the most recent data on health care utilization rates, actual program experience, and other factors, such as economic trends in unemployment and inflation." For instance, in 2012, VHA used data from FY2011 to develop its health care budget estimate for the FY2014 request, including the advance appropriations request for FY2015. Table 3 provides a detailed timeline for formulating the FY2014 budget request and the FY2015 advance appropriations request.

Funding for the VHA

As noted previously, VHA is funded through four appropriations accounts. These 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. 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. Specifically, 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. Brief descriptions of these accounts are provided below.

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 (U.S.C.); cost of hospital food service operations; aid to state veterans' homes; and assistance and support services for family caregivers of veterans authorized by the Caregivers and Veterans Omnibus Health Services Act of 2010 ( P.L. 111-163 ). For FY2013, the President's budget request proposed the transfer of funding for biomedical engineering services from the medical facilities account to this account. The Consolidated and Further Continuing Appropriations Act, 2013 ( P.L. 113-6 ), approved this transfer. The President's budget request for FY2014 proposed to continue funding for biomedical engineering services in the medical services account. The Military Construction and Veterans Affairs, and Related Agencies Appropriations bill for FY2014 ( H.R. 2216 ; H.Rept. 113-90 ) that was passed by the House of Representatives June 4, 2013, and the Senate Appropriations Committee reported version of H.R. 2216 ( S.Rept. 113-48 ) continued this transfer for FY2014.

Medical Support and Compliance (Previously Medical Administration)

This account provides for expenses related to the management, security, and administration of the VA health care system through the operation of VA medical centers, and other medical facilities such as community-based outpatient clinics (CBOCs) and Vet Centers. It also funds 21 Veterans Integrated Service Network (VISN) offices and facility director offices; chief of staff operations; public health and environmental hazard programs; quality and performance management programs; medical inspection; human research oversight; training programs and continuing education; security; volunteer operations; and human resources management.

Medical Facilities

The medical facilities account funds expenses pertaining to the operations and maintenance of the VHA's capital infrastructure. These expenses include utilities and administrative expenses related to planning, designing, and executing construction or renovation projects at VHA facilities. It also funds leases, laundry services, grounds maintenance, trash removal, housekeeping, fire protection, pest management, and property disposition and acquisition.

Medical and Prosthetic Research

As required by law, the medical and prosthetic research program (medical research) focuses on research into the special health care needs of veterans. This account provides funding for many types of research, such as investigator-initiated research; mentored research; large-scale, multi-site clinical trials; and centers of excellence. 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.

In general, VA's research program is intramural; that is, research is performed by VA investigators at VA facilities and approved off-site locations. 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.

Medical Care Collections Fund (MCCF)

In addition to the appropriations accounts mentioned above, the Committees on Appropriations include medical care cost recovery collections when considering funding for the VHA. Congress has provided 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. Funds collected from first and third party (copayments and insurance) bills are retained by the VA health care facility that provided the care for the veteran. Table 4 provides details of MCCF collections from FY2009 through FY2014.

In its FY2014 congressional budget submission, the Administration is proposing two legislative proposals to increase collections in FY2014. The first proposal would amend 38 U.S.C. Section 7332(b) and allow the VHA to disclose the veteran's patient records, including the identity, diagnosis, prognosis, or treatment of a patient relating to drug abuse, alcoholism or alcohol abuse, infection with the human immunodeficiency virus (HIV), or sickle cell anemia to the veteran's private health insurance plans for the purpose of VHA obtaining reimbursement for nonservice-connected care. The second proposal would provide authority for VHA to be considered a participating provider whether or not an agreement is in place with a veteran's private health insurance plan. This would allow VHA to collect charges for treatment of a veteran's nonservice-connected conditions.

FY2013 Budget Summary44

President's Request

The President's FY2013 budget request was submitted to Congress on February 13, 2012. The President's budget requested $135.8 billion in budget authority for the VA as a whole (see Table 5 ). This included approximately $75 billion in mandatory funding and $61 billion in discretionary funding. For FY2013, the Administration requested $53.3 billion for VHA. This included $41.5 billion for the medical services account, $5.7 billion for the medical support and compliance account, $5.4 billion for the medical facilities account, and nearly $583 million for the medical and prosthetic research account (see Table 6 ). The total requested amount for VHA represented a 4.1% increase over the FY2012-enacted appropriations. Furthermore, as required by the Veterans Health Care Budget Reform and Transparency Act of 2009 ( P.L. 111-81 ), the President's budget requested $54.5 billion in advance appropriations for the three medical care accounts (medical services, medical support and compliance, and medical facilities) for FY2014. On December 7, 2012, the President submitted a $236.6 million supplemental request for VA for costs associated with Hurricane Sandy, which included $27 million for VHA.

Congressional Action

Congress did not enact a regular Military Construction and Veterans Affairs and Related Agencies Appropriations bill for FY2013 (MILCON-VA Appropriations bill) prior to the beginning of FY2013, and funded most of the VA (excluding the three medical care accounts: medical services, medical support and compliance, and medical facilities) through a six-month government-wide continuing resolution ( P.L. 112-175 ). On January 29, 2013, the Disaster Relief Appropriations Act, 2013, was enacted as P.L. 113-2 . This act provided the approximately $236.6 million in supplemental funding requested by the President for the VA, which included $27 million for VHA.

On March 6, 2013, the House passed the Department of Defense, Military Construction and Veterans Affairs, and Full-Year Continuing Appropriations Act, 2013 ( H.R. 933 ). The Senate passed an amended version of the bill on March 20, 2013, and the House agreed to the amended version the next day. The Consolidated and Further Continuing Appropriations Act, 2013 ( H.R. 933 ; P.L. 113-6 ), was signed into law by the President on March 26, 2013. Division E of P.L. 113-6 contained funding for the VA. P.L. 113-6 provided $133.9 billion in budget authority for the VA as a whole (excluding the Hurricane Sandy Funding Needs supplemental funding provided in P.L. 113-2 ). This includes approximately $72.9 billion in mandatory funding and $61 billion in discretionary funding. For FY2013, funding for VHA is $53.3 billion (excluding the Hurricane Sandy Funding Needs supplemental funding provided in P.L. 113-2 ). Furthermore, as required by the Veterans Health Care Budget Reform and Transparency Act of 2009 ( P.L. 111-81 ), P.L. 113-6 provides $54.5 billion in advance appropriations for the three medical care accounts (medical services, medical support and compliance, and medical facilities) for FY2014.

The Consolidated and Further Continuing Appropriations Act, 2013 ( P.L. 113-6 ), required across-the-board rescissions for all discretionary accounts including those of the VA. Section 3001 in Division G of the act required a 0.1% across-the-board rescission for discretionary VA accounts appropriated in FY2013. Section 3004 in Division G of P.L. 113-6 was intended to eliminate any amount by which the new budget authority provided in the act exceeded the FY2013 discretionary spending limits in Section 251(c)(2) of the Balanced Budget and Emergency Deficit Control Act, as amended by the Budget Control Act of 2011 and the American Taxpayer Relief Act of 2012. Subsequent to the enactment of P.L. 113-6 , the Office of Management and Budget (OMB) calculated that additional rescissions of 0.032% of security budget authority, and 0.2% of nonsecurity budget authority, would be required. Table 5 and Table 6 shows the FY2013 amounts (based on OMB calculations) following the 0.1% and 0.032% across-the-board rescissions. Additionally, Table 5 and Table 6 shows the Hurricane Sandy Funding Needs supplemental funding provided in P.L. 113-2 .

FY2014 VHA Budget

President's Request

The President submitted his FY2014 budget request to Congress on April 10, 2013. The FY2014 President's Budget is requesting $147.9 billion for the VA as a whole (see Table 7 ). For VA medical services, the Administration's budget is requesting $157.5 million in additional funding above the FY2014 advance appropriations of $43.6 billion provided in FY2013. According to the VA, the increased funding levels requested for FY2014 reflect the increased costs of medical care requirements resulting from the implementation of the Caregivers and Veterans Omnibus Health Services Act of 2010 ( P.L. 111-163 ) and the Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012 ( P.L. 112-154 ). In total, the President is requesting $55.2 billion for VHA for FY2014. This includes $43.7 billion for the medical services account, $6.0 billion for the medical support and compliance account, $4.9 billion for the medical facilities account, and nearly $586 million for the medical and prosthetic research account (see Table 8 ). As required by the Veterans Health Care Budget Reform and Transparency Act of 2009 ( P.L. 111-81 ), the President's budget is requesting $55.6 billion in advance appropriations for the three medical care appropriations (medical services, medical support and compliance, and medical facilities) for FY2015 (see Table 8 ).

House Budget Resolution46

On March 13, 2013, the House Budget Committee reported a budget resolution ( H.Con.Res. 25 H.Con.Res. 25, 113 th Congress), and the budget resolution was agreed to by the House on March 21, 2013. According to the committee report that accompanied H.Con.Res. 25 ( H.Rept. 113-17 ):

The resolution calls for $145.7 billion in budget authority and $145.4 billion in outlays in fiscal year 2014 [for Veterans Benefits and Services]. Discretionary spending is $63.3 billion in budget authority and $63.1 billion in outlays in fiscal year 2014. This in an increase of 3.1 percent from last year's discretionary level. Mandatory spending in 2014 is $82.4 billion in budget authority and $82.3 billion in outlays. The ten-year totals for budget authority and outlays are $1.7 trillion and $1.7 trillion, respectively. This resolution also authorizes up to $55.483 billion for fiscal year 2015 in advance appropriations for medical care, consistent with the Veterans Health Care Budget and Reform Transparency Act of 2009. Since the President has yet to submit a budget request this year, the VA's request for veterans-medical-care advance appropriations for fiscal year 2015 is unavailable as of the writing of this concurrent resolution. The amount authorized in this resolution reflects the amount requested in the administration's fiscal year 2013 request for fiscal year 2015 and is the most up-to-date estimate on veterans' health-care needs requested by the Department of Veterans Affairs.

Senate Budget Resolution48

On March 14, 2013, the Senate Budget Committee reported a budget resolution ( S.Con.Res. 8 , 113 th Congress), and the budget resolution was agreed to by the Senate on March 23, 2013. According to the committee print that accompanied S.Con.Res. 8 ( S.Rept. 113-12 ):

The budget resolution sets fiscal year 2014 levels at $145.5 billion for budget authority [BA] and $145.3 billion for outlays for [Veterans Benefits and Services]. Over the FY 2014-2018 period, BA totals $779.5 billion, with $776.4 billion in outlays. From FY 2014-2023, the [Veterans Benefits and Services] function totals $1.688 trillion in BA and $1.68 trillion in outlays. For discretionary spending, the resolution calls for FY 2014 levels of $63.1 billion in BA and $62.9 billion in outlays. BA totals $336.3 billion and outlays equal $333.6 billion over five years. From FY 2014-2023, the discretionary total for [Veterans Benefits and Services] is $730.9 billion in BA and $723.8 billion in outlays.

House Action

On May 15, 2013, the House Military Construction and Veterans Affairs Subcommittee approved its version of a Military Construction and Veterans Affairs and Related Agencies Appropriations bill for FY2014 (MILCON-VA Appropriations bill). The full House Appropriations Committee voted to report the measure on May 21, 2013, and the House passed H.R. 2216 on June 4, 2013. The MILCON-VA Appropriations bill for FY2014 ( H.R. 2216 ; H.Rept. 113-90 ) proposes a total of $147.6 billion for the VA (see Table 7 ). The total includes $84.5 billion for mandatory programs, and $63.1 billion for discretionary programs (see Table 7 ).

H.R. 2216 ( H.Rept. 113-90 ) (see Table 7 ) as passed by the House proposes $54.9 billion for VHA for FY2014, which comprises four accounts: medical services, medical support and compliance, medical facilities, and medical and prosthetic research. The House-passed measure does not include the additional funding amount of $157.5 million (above the FY2014 advance appropriations) for the medical services account that was requested by the President for FY2014, and proposes to rescind $156.0 million from the FY2014 VHA amount that was provided as an advance appropriation in FY2013, giving the Secretary the discretion to allocate these reductions across VHA accounts. H.R. 2216 proposes $55.6 billion in advance FY2015 funding for the medical services, medical support and compliance, and medical facilities accounts—the same level included in the House-passed Budget Resolution, and the President's request (see Table 8 ).

Senate Appropriations Committee Action

On June 18, 2013, the Senate Military Construction, Veterans Affairs, and Related Agencies Subcommittee approved its version of the MILCON-VA Appropriations bill. The full Senate Appropriations Committee marked up the bill and voted to report the measure on June 20, 2013. The MILCON-VA Appropriations bill for FY2014 ( H.R. 2216 ; S.Rept. 113-48 ) proposes a total of $147.9 billion for the VA for FY2014. The total includes $84.5 billion for mandatory programs, $63.5 billion for discretionary programs.

The Senate Appropriations Committee approved measure does not include the full additional funding amount of $157.5 million (above the FY2014 advance appropriations) for the medical services account that was requested by the President for FY2014, and instead proposes a $25 million increase for the medical services account (see Table 8 ). The committee notes that

The justification accompanying the budget request provides few details regarding the data and assumptions that were modified in the updated actuarial model projection. Absent this data, the Committee cannot accurately assess the merits of an additional request. The Committee also notes that the Department routinely carries forward significant funds from one fiscal year to the next and directs that any of funding carried forward from fiscal year [FY] 2013 be applied to unanticipated needs.

Furthermore, the Senate Appropriations Committee approved measure ( H.R. 2216 ; S.Rept. 113-48 ) proposes an additional $100 million for the medical facilities account for FY2014 for nonrecurring maintenance projects (see Table 8 ).

Consolidated Appropriations Act, 2014 (P.L. 113-76)

House and Senate Action

Congress was unable to complete action on any of the FY2014 appropriation acts prior to the beginning of the new fiscal year. Lawmakers also failed to agree on language in a FY2014 continuing resolution (CR). With no agreement in place on October 1, 2013, the resulting lapse in funding led to a partial shutdown of government operations. Congress finally reached agreement on a temporary CR on October 16, 2013, and the President signed the Continuing Appropriations Act, 2014 ( P.L. 113-46 ), the following day to reopen the government. That CR (P.L. 113-46) funded most of the VA (excluding the three medical care accounts: medical services, medical support and compliance, and medical facilities) through January 15, 2014. P.L. 113-73 extended the CR through January 18, allowing extra time for legislative consideration of an omnibus appropriation bill. On January 17, 2014, the President signed into law the Consolidated Appropriations Act, 2014 ( P.L. 113-76 ). Division J of this act included the Military Construction and Veterans Affairs, and Related Agencies Appropriations Act, 2014 (MILCON-VA Appropriations Act, 2014).

In total the MILCON-VA Appropriations Act, 2014 provides a total of $147.9 billion in budget authority for VA programs in FY2014. Of this amount, $55.1 billion is provided for VHA, which comprises four accounts: medical services, medical support and compliance, medical facilities, and medical and prosthetic research accounts. P.L. 113-76 provides $40 million for FY2014 for the medical services account in addition to the advance appropriation of $43.6 billion that was provided in P.L. 113-6 (see Table 8 ). Furthermore, the MILCON-VA Appropriations Act, 2014, provides $85 million for FY2014 for the medical facilities account in addition to the advance appropriation of $4.9 billion provided in P.L. 113-6. This additional funding will be used to address the backlog of non-recurring maintenance needs at existing VA hospitals and clinics. As required by the Veterans Health Care Budget Reform and Transparency Act of 2009 (P.L. 111-81), the MILCON-VA Appropriations Act, 2014, provides advance appropriations of $55.6 billion for FY2015 for three VHA accounts (medical services, medical support and compliance, and medical facilities). Furthermore, P.L. 113-76 rescinds $50 million from the FY2014 VHA accounts (see Table 8 ).

Appendix. Priority Groups and Their Eligibility Criteria