Introduction In FY2019, an estimated 20 million veterans were living in the United States, of which 9.3 million were enrolled in care through the Department of Veterans Affairs (VA). Chapter 17 of Title 38, U.S.C. , requires the VA to provide health care services to eligible veterans through the Veterans Health Administration (VHA) of the VA, which is one of the largest integrated health care systems in the United States. The VHA is composed of nearly 1,700 VA medical facilities. VA care is not a health insurance program; it is primarily a direct provider of care. Meeting veterans' demand for care has been challenging for the VA. Some veteran patients who seek health care services from the VHA experience barriers to receiving in-person care; for example, by being unable to schedule VA medical appointments in a timely manner or having to travel long distances to reach health care facilities. In conjunction with the Veterans Choice Program (VCP), the recently enacted VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 (VA MISSION Act; P.L. 115-182 ), and other measures that aim to expand veterans' access to care, the VA has attempted to address barriers to in-person care using telehealth in VA health care facilities. According to the VHA, telehealth refers to the use of health informatics, disease management and [t]elehealth technologies to enhance and extend care and case management to facilitate access to care and improve the health of designated individuals and populations with the specific intent of providing the right care in the right place at the right time. VA Telehealth Overview VA telehealth is a mode of health care delivery that extends outside of the "brick-and-mortar" health care facilities of the VHA. Telehealth, in contrast to in-person care, functions using information and communication technology (ICT) to transpire an episode of care to a veteran patient, without requiring the patient to visit a service provider in person. Although telehealth generally supplements in-person care, it does not replace VA in-person care. In this context, the use of ICT to deliver telehealth services does not disrupt a veteran patient's daily life activities, such as working and going to school. Veterans do not need to meet their VA provider in-person to receive VA health care services. This type of nondisruptive access to health care services is likely more convenient than the traditional in-person care services used by veteran patients and their civilian counterparts. Telehealth encourages veteran patients to be actively involved in their health care decisions, because it requires veterans to perform telehealth-related tasks such as downloading mobile applications (apps) to connect with VA providers and staff. A mobile app refers to a software program that runs on certain operating systems of mobile devices (e.g., smartphones and tablets) and computers that transmit data over the internet. (See the " VA Mobile Health (VA Mobile) " section in this report). Rural Veterans Legislation and regulations that aim to expand veterans' access to VA telehealth services generally focus on the U.S. population of rural veterans. Many of these veterans experience geographic barriers to accessing in-person VA care, such as having to travel long distances to reach their nearest health care facilities. Of the estimated 9.2 million veterans who were enrolled in the VA health care system in FY2019, approximately 33% of them were rural veterans. According to the VA, "[the U.S. population of rural veterans] is older (56% are over 65), poorer (52% earn less than $35,000 per year), and sicker (a greater number of co-morbidities) than their urban counterparts." In addition to having to travel long distances to reach their nearest health care facilities, rural veterans may experience access barriers to VA telehealth services because they lack access to broadband internet in their communities. Similarly, veterans who live in urban areas also experience access barriers to VA care such as having to wait more than 30 days to receive care through the VA. Integration with the Private Sector According to former Under Secretary of the VHA, David J. Shulkin, MD, who later became the VA Secretary, "[t]he fact is that demand for [v]eterans' health care is outpacing VA's ability to supply [the health care services] in-house." President Trump and the Congress have acknowledged the challenges the VA has faced in supplying VA care in-house by enacting measures such as the VA MISSION Act. The VA has since established new partnerships with private sector vendors, such as Philips Healthcare, T-Mobile USA, Inc. (T-Mobile), and Walmart Inc. (Walmart), under the VA's Advancing Telehealth through Local Access Stations program. The VA established these partnerships with the goal of reducing veterans' access barriers to VA in-person care by expanding their access to VA telehealth services. Report Roadmap To assist Congress as it considers measures on VA telehealth, this report provides an overview of VA telehealth programs and requirements including veteran eligibility and enrollment criteria and VA telehealth copayment requirements; discusses VA providers' authority to provide telehealth services anywhere; discusses the components of VA telehealth; provides an overview of VA teleconsultations; discusses three issues that Congress could choose to consider: (1) access barriers to in-person VA care, (2) lack of access to the internet, and (3) conflicting guidelines for prescribing controlled substances via telehealth across state lines; provides, in Appendix A , a summary table with all abbreviations used in the report; provides, in Appendix B , the history of VA telehealth and a high-level overview of at least one legislative provision that was enacted into law and aims to address VA telehealth, beginning with the 109 th Congress; provides, in Appendix C , a discussion on the VA providers' authority to provide telehealth services anywhere; and provides, in Appendix D , the total number of veterans who received VA telehealth services and the total number of telehealth encounters that transpired during each of the fiscal years FY2009-FY2018. VA Telehealth Programs and Requirements On July 12, 2016, the VA established the Office of Connected Care (OCC) within the VHA. The goal of OCC is to "deliver [information technology (IT)] health solutions that increase a [v]eteran's access to care and supports a [v]eteran's participation in their health care." OCC administers the following four VA telehealth programs: 1. According to the VA, VA Telehealth Services "[improve] convenience to [v]eterans by providing access to care from their homes or local communities when they need it." 2. My Health e VetÂ is the web-based electronic health record (EHR) for veteran patients through which veterans can view, and download electronic protected health information (ePHI); 3. VHA Innovation Program is an annual competitive program that allows VA staff and key stakeholders in the private sector to submit innovative ideas on enhancing VA care; and 4. VA Mobile Health (VA Mobile) develops mobile apps. For its telehealth programs, the VA has requested an appropriation of $1.1 billion for FY2020 and an advanced appropriation of $1.7 billion for FY2021. Veteran Eligibility, Enrollment, and Access Not all veterans are eligible to receive VA care, and not every veteran is automatically entitled to medical care from the VHA. Veterans' eligibility for enrollment in the VHA is based on veteran status (i.e., previous military service), service-connected disability, and income. Veterans enrolled in the VA health care system can receive a range of health care services, including primary care and specialty care via telehealth, as authorized under the VA's medical benefits package . The VA medical benefits package refers to a suite of health care services that are covered for eligible veterans, generally at no cost under certain circumstances. In a given year, however, not all enrolled veterans receive their care from the VAâeither because they do not need services or because they have other forms of health coverage, such as Medicare, Medicaid, or private health insurance. In FY2018, more than 9.3 million veterans were enrolled in VA care. A veteran generally must be enrolled in the VA health care system to access VA telehealth services, which are typically provided on an outpatient basis. A veteran who is not enrolled in VA care can access VA telehealth services under certain circumstances. For example, a veteran who is not enrolled in VA care but who is "tentatively" eligible for VA care could access VA telehealth services on an outpatient basis. Of the 9.3 million veterans who were enrolled in VA care in FY2018, the VA provided 2.29 million telehealth episodes of care to 782,000 veteran patients. An episode of care generally refers to all of the health care services that a VA provider provides to a veteran patient, to treat the veteran's health condition/disability. The Faster Care for Veterans Act of 2016 ( P.L. 114-286 ) required the VA, among other things, to ensure that veterans could schedule their own telehealth appointments. A recent U.S. Government Accountability Office (GAO) report found that neither the Veteran Appointment Request System nor the On-line Patient Self-Scheduling System (OPSS) had the capability to allow veterans to schedule their own telehealth appointments. According to the VHA, access to VA telehealth services is a joint decision between the veteran and his or her care team of VA providers and clinical staff. The care team tells the veteran which clinically appropriate VA care services he or she can access through the VHA. There may be instances when it is clinically appropriate for a veteran to receive in-person care rather than a telehealth service. When the care team decides that it is clinically appropriate for a veteran to receive telehealth services, the veteran would need to opt into accessing VA telehealth services. The veteran patient would then be able to schedule his or her telehealth appointment. Telehealth Copayment Requirements A telehealth copayment refers to the out-of-pocket costs that a veteran patient pays for a telehealth encounter. A veteran patient generally pays $15 per primary care outpatient visit and $50 per specialty care visit at VA medical facilities. According to the VA, copay amounts for telehealth are usually less than for VA in-person care. The VHA does not require veterans to pay a copay for health care services to treat a service-connected disability/condition, nor is a copay required if a veteran meets at least one of the following four main criteria: 1. The veteran patient has a service-connected disability/condition that is rated at 50% percent or more. 2. The veteran patient is a former prisoner of war. 3. The veteran has an annual income that is below the income limit. 4. The veteran is a recipient of the Medal of Honor. Other veteran patients can receive free VA care when they receive care under certain circumstances, such as care for military sexual trauma, care that is part of a VA research project, and care that is provided for compensation and pension examinations. Veteran patients who are not exempt from paying VA copays incur the costs of their VA care. The VA determines a veteran patient's copay by evaluating the rendered telehealth encounter against two factors: (1) the location of the veteran patient when the telehealth encounter transpired and (2) the VA's internal business office protocols on copay amounts for VA care. The Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012 ( P.L. 112-154 ), among other things, allows the VA Secretary to waive veteran patients' copay requirements for telehealth. In March 2012, the VA Secretary began waiving copays for telehealth services provided to veteran patients in their homes. VA Provider Eligibility and Training on Telehealth The Department of Veterans Affairs Codification Act ( P.L. 102-83 ) requires the VA Secretary, among other things, to establish interrelationships and coordinate the delivery of VA health care services with the public and private sectors. Therefore, a health care provider who is either seeking a government position within the VA (referred to as a VA-employed provider ) or seeking to remain as a private sector provider while working with the VA under a contract (referred to as a VA-contracted provider ) is eligible to provide VA care to veterans. A VA provider, either VA-employed or VA-contracted, must hold at least one full, active, current, and unrestricted state license to be eligible to work for or with the VA. The provider can use his or her license to deliver in-person care and telehealth services through the VHA. Each VA provider can decide whether he or she wants to provide VA telehealth services to veteran patients across state lines. The VA MISSION Act, among other things, allows a VA-employed health care provider to provide telehealth services to veteran patients across state lines using only one state license, even in states where the provider is not licensed to practice. ( Appendix C provides an overview of the VA-employed providers' authority to provide telehealth services across state lines using one state license.) A VA-employed provider who chooses to use a single license in this manner must meet the following four statutory requirements of a covered health care professional: 1. the VA provider must be an employee of the VA; 2. the VA Secretary must have authorized the VA provider to provide telehealth services across state lines; 3. the VA provider must agree to adhere to all standards for quality relating to the provision of medicine that is consistent with VA policies; and 4. the VA provider must hold an active, current, full, and unrestricted license, registration, or certification in at least one state to practice in his or her field of medicine. This authority does not extend to VA-contracted providers. Current law does not allow a VA-contracted provider to provide VA health care services, including telehealth, to veteran patients across states lines using a single license in states where the VA-contracted provider is not licensed to practice. A VA-contracted provider, in contrast to a VA-employed provider, must hold a license in each state where the provider chooses to practice. Neither type of provider is required to obtain a specialty license, registration, or certification to practice his or her field of medicine via telehealth through the VHA. The VA encourages its providers to complete the Telehealth Master Preceptor Certification Program. This program offers an educational curriculum on the delivery of VA telehealth, including the VA telehealth modalities used to deliver telehealth services (see the " Telehealth Modalities " section below). The VHA Telehealth Services National Training Center, which is a nationally accredited training center, oversees the program and other telehealth trainings. In FY2018, according to the VA, more than 56,000 VA providers and staff completed at least one training session on telehealth. In that same fiscal year, the VA had provided more than 100,720 telehealth trainings. VA Telehealth Components VA telehealth encompasses four general components: (1) the internet and wireless data, (2) telehealth modalities, (3) VA Mobile Health, and (4) VA teleconsultations. Each of these components is discussed below. Health informatics and data visualizations are not discussed because they are beyond the scope of this report. The Internet and Wireless Data A veteran patient who chooses to access VA telehealth services must be willing to perform telehealth related tasks, such as accessing a health care service and obtaining his or her ePHI (electronic protected health information), using the internetâthe vehicle for which a telehealth episode of care transpires. A veteran patient must have access to the internet to access VA telehealth services on mobile devices and computers. In 2017, according to a VA study of 43,600 veteran enrollees, 77% reported using the internet on an occasional or more frequent basis. Of those 77% of veteran enrollees who reported using the internet, the enrollees performed the following telehealth related tasks: 33% scheduled medical appointments, 45% accessed their EHRs (electronic health records), and 77% searched for information on health. The VA's findings reveal that veterans who are enrolled in the VA health care system are using the internet to perform telehealth-related tasks. However, veteran patients do not necessarily have to have their own internet service to perform telehealth related tasks and access VA telehealth services. For example, veteran patients can access the internet from a VA medical facility, a family member's home, or a local library (access to high-speed internet service typically yields the best internet performance). In addition, a veteran who chooses to access VA telehealth services via a mobile device (e.g., smartphones and tablets) must have adequate cellular data storage. The amount of wireless data storage on a mobile device determines whether the veteran will be able to download and use certain components of VA telehealth such as VA mobile apps. Potential Cybersecurity and Privacy Risks A veteran patient who chooses to perform telehealth-related tasks on a personal mobile device and computer must consider the potential cybersecurity and privacy risks associated with accessing VA telehealth services. During a telehealth encounter, for example, a veteran patient can view, download, and transmit their ePHI over the internet. According to the Federal Bureau of Investigation, mobile devices and internet connections can be compromised when accessed by an unauthorized party. The VHA cannot ensure that a veteran is accessing VA telehealth services on a trustworthy device via a trustworthy connectionâthat responsibility falls upon the user when the user is accessing the service on their personal device. According to the VA, it "will coordinate restoration activities" with internal and external key stakeholders when veteran patients experience cybersecurity and privacy threats. Certain veteran patients can access VA telehealth services on VA issued mobile devices. According to the Federal Communications Commission, the VA provided 6,000 tablets with 4G LTE connectivity to low-income and rural veterans with the goal of reducing the veterans' broadband infrastructure barriers to telehealth in their homes. These veterans are accessing telehealth services on trustworthy devices via trustworthy connections. The VA's Cybersecurity Program ensures that, among other things, ePHI and personally identifiable information that are transmitted via VA devices and systems are protected against cybersecurity and privacy threats. Of course, cybersecurity and privacy risks are not limited to the U.S. veteran patient population. Telehealth Modalities A telehealth modality refers to the mode in which a telehealth episode of care transpires. VA providers offer telehealth services to veteran patients via one of the following three telehealth modalities: (1) home telehealth, (2) store-and-forward telehealth, and (3) clinical video telehealth. The three VA telehealth modalities are described in more detail below. Note that the VHA does not consider VA Mobile Health as a telehealth modality, even though veterans can use this technology to access telehealth services. The VA considers VA Mobile Health as an "essential element of health care" delivery rather than an ICT tool used to deliver telehealth services. In FY2019, the VA is to begin measuring the VHA's performance in addressing the health care needs of eligible veterans who receive telehealth services via these three VA telehealth modalities. For example, one new measurement would analyze the ratio of "the number of unique [v]eterans served through telehealth services (numerator) and the number of unique [v]eterans that receive care through [the] VHA (denominator)." Using this measurement, the VA anticipates that at least 15% of eligible veteran patients will access VA telehealth services in FY2019. Home Telehealth (HT) The home telehealth (HT) modality allows a VA provider who is not located in the same location as a veteran patient to provide the patient with daily case management services for his or her chronic medical conditions, such as chronic heart disease or diabetes. The HT modality allows the VA provider to view medical data and information from a medical device, such as a heart monitor that the veteran patient wears. Telehealth episodes of care via the HT modality generally have no location restrictions unless the veteran patient is on bed rest. From FY2012 to FY2018, the VA provided 6.7 million telehealth encounters via the HT modality to 1.0 million veteran patients. In FY2018, the VA provided 872,705 telehealth episodes of care to 136,741 veteran patients through the HT modality. According to the VA, the case management service that VA providers most often provide to veteran patients via the HT modality is the management of hypertension (commonly known as high blood pressure). Figure 1 illustrates the distribution of services that transpired via the HT modality, for those veterans who received telehealth services for each of the fiscal years FY2012-FY2018. The number of veteran patients who have accessed telehealth services via the HT modality has increased, even though Figure 1 shows a downward trend for the percentage of veteran patients who accessed VA telehealth services via the HT modality. The total population of veteran patients accessing VA telehealth services via the HT modality increased by 142.1%, from 56,484 veteran patients in FY2009 to 136,741 veteran patients in FY2018. However, the number of telehealth encounters that transpired via the HT modality has fluctuated (see Figure 1 and Table D-2 ). The VA provided its financial obligations for the delivery of telehealth services via the HT modality in the agency's FY2020 funding and FY2021 advanced appropriations budget request to the Congress. In FY2019, the VA estimates that $270.6 million was obligated to the delivery of telehealth services via the HT modality. The VA has requested an appropriation of $279.8 million for FY2020 and an advance appropriation of $291 million for FY2021 to deliver telehealth services via the HT modality. Store-and-Forward Telehealth (SFT) The store-and-forward telehealth (SFT) modality facilitates the interpretation of patients' clinical information by allowing a VA provider who is not located in the same location as a veteran patient to assist another VA provider who is located in the same location and has provided in-person care to the veteran patient. Examples of the clinical information include data, images, sound, and video medical records from the veteran patient's radiology and dermatology examinations. The veteran patient does not have to be present during the electronic transfer of his or her clinical information. After receiving the clinical information, the VA provider interprets the clinical information for the other VA provider and provides follow-up care instructions for the veteran patient. From FY2009 to FY2018, the VA provided 2.7 million telehealth encounters via the SFT modality to 2.5 million veteran patients. In FY2018, the VA provided 344,853 telehealth episodes of care to 314,487 veteran patients through the SFT modality. According to the VA, it provides captures, stores, and forwards clinical information mostly for teleretinal i magining via the SFT modality to screen for diabetic eye disease in veteran patients. According to the VA, teleretinal imaging refers to a VA provider's use of a special camera to take a picture of a veteran patient's eye. The picture is electronically sent to an eye care specialist. After reviewing the picture, the specialist then reports his or her findings to the veteran patient's primary care provider. Figure 2 illustrates the distribution of services that transpired via the SFT modality, for those veterans who received telehealth services for each of the FY2009-FY2018. The increase in the number of telehealth encounters that have transpired via the SFT modality seems to indicate that VA providers are increasingly seeking the expertise of their peers. VA providers are presumably seeking additional expertise due to the lack of a given expertise in their respective geographic area and the VA's overall shortage of health care providers. Clinical Video Telehealth (CVT) The clinical video telehealth (CVT) modality allows a VA provider who is not located in the same location as a veteran patient to view, diagnose, monitor, and treat medical conditions of the veteran patient in real-time. The CVT modality functions by allowing the VA provider and the veteran patient to see each other via an interactive live video technology. Telehealth episodes of care via the CVT modality transpire between different VA sites of care, such as from a VA medical center (VAMC) to a veteran patient's home or from a veteran patient's home to a VA provider's home office. From FY2009 to FY2018, the VA has provided 5.7 million telehealth encounters via the CVT modality to 2.1 million veteran patients. In FY2018, the VA provided 1,074,422 telehealth episodes of care to 393,370 veteran patients through the CVT modality. According to the VA, the telehealth service that veteran patients accessed the most via the CVT modality is telemental health , which refers to the delivery of a mental health service via telehealth. Figure 3 illustrates the percentage of veterans who received telehealth services and the number of telehealth encounters that transpired via the CVT modality, for each of the fiscal years FY2009-FY2018. The upward trends in both the percentage of veterans who received telehealth services and the number of telehealth encounters that transpired via the CVT program seem to illustrate that veteran patients are increasingly interested in receiving VA telehealth services via this modality. Veteran patients' interest in the CVT program might stem from it being well established and publicized. The program is the VA's oldest method of telehealth delivery. Additionally, veterans have been able to access telemental health care services via the CVT modality since the VA started providing telehealth services. This report discusses the history of VA telehealth in Appendix B . VA Mobile Health (VA Mobile) VA Mobile allows veterans to access certain health services and ePHI via VA mobile apps on mobile devices (e.g. smartphones) and computers. According to the National Center for Veterans Analysis and Statistics (NCVAS), 97.9% of veterans who were enrolled in the VHA in 2016 owned a smartphone and 78.3% owned a computer (i.e., a laptop, desktop, or notebook computer). Veterans can access the VA mobile apps at any time, regardless of where the veteran is located. According to the VA, "VA Mobile Health aims to improve the health of [v]eterans by providing technologies that expand clinical care beyond the traditional office visit [via mobile apps]." VA Mobile has four overall functions: first, it allows veteran patients to connect and schedule medical appointments with VA providers; second, it provides veterans with access to health care information on topics such as mental health and weight management; third, it allows VA providers to provide case management of veteran patients' disabilities/illnesses from afar; and fourth, it allows VA providers to disseminate best practices among themselves, with the goal of improving the health outcomes of veteran patients. As a reminder, the VA does not consider VA Mobile to be one of the three modalities for the delivery of health diagnostics or health services. VA App Store VA mobile apps, such as those illustrated in Figure 4 , are located in the virtual VA App Store. The VA App Store is a public-facing web-based store that offers 47 mobile apps available to veterans, their caregivers, and VA providers. About two-thirds of the mobile apps in the virtual VA App Store are for veterans and their caregivers. The remainder of the apps are for VA providers. Veterans who are not enrolled in the VHA may access some of the VA mobile apps. Not all of the mobile apps are specific to health care. VA mobile apps provide veterans with access to a range of VA benefit services and information, such as conferring with a VA pharmacist, reviewing current disability benefits, and obtaining information on depression. Veterans who are not enrolled in the VHA, for example, can also access social apps, such as the VA-Department of Defense (DOD) Veteran Link app, which is a secure social networking app for veterans and current servicemembers. Required Login Credentials The public can view the different VA mobile apps in the VA App Store; however, only veterans, their caregivers, and VA providers with certain access accounts can download and use the apps. To download VA mobile apps, a veteran must have login credentials for at least one of the following three accounts: (1) a DOD Self-Service Logon (DS Logon) account, (2) a My Health e Vet account, or (3) an ID. me account. A general overview of each of the three accounts, which are all free to veterans, is provided below. DOD Self-Service L ogon (DS Logon) Account is a federal account that authenticates a veteran's affiliation with the VA and DOD. This secure self-service account allows the veteran to access multiple VA and DOD websites and apps. The veteran can request either a Level 1 (Basic) or a Level 2 (Premium) account, both of which are free. Level 1(Basic) Account allows a veteran to view general information located on a VA and DOD website. Level 2 (Premium) Account allows a veteran to view personal information on VA and DOD websites. The veteran must prove his or her identity to get a Premium Account by answering a set of questions. MyHealth e Vet Premium Account is a federal account that authenticates a veterans' enrollment in VA care. It authorizes a veteran patient to complete health care-related tasks, such as viewing his or her electronic health record, reordering medications, and contacting his or her health care provider via a secure messaging technology. ID. me Account is a private sector account that, in this context, authenticates a veterans' affiliation to the VA and DOD. This account "provides secure identity proofing, authentication, and group affiliation verification for government and businesses across sectors." It is also free to veterans. Required Operating Platforms The veteran's electronic device must operate using either a w eb-based platform , an iOS platform , or an Android platform for a VA mobile app to work on the device. A web-based platform refers to an operating system that has a web-browser such as Internet Explorer and Google Chrome. A VA web-based app such as MyHealth e Vet, which is the electronic health record (EHR) for veterans, is accessible over the internet. An iOS platform refers to the operating system installed on Apple, Inc. (Apple) electronic devices such as the iPhone and iPad. A VA iOS-app is available to veterans who use Apple devices. A veteran who has an Apple device can download VA iOS apps from the VA App Store and from the Apple App Store. A veteran who does not have an Apple electronic device will not be able to access a VA iOS app on a non-Apple device. An Android platform refers to the operating system installed on non-Apple electronic devices (e.g., companies such as Samsung and LG). A VA Android app is available to veterans with devices that do not have the iOS operating platform installed on them. A veteran who has an electronic device with an Android operating system can download VA Android apps from the VA App Store and the Google Play Store, which is a mobile app on an Android device. A veteran who does not have an Android device will not be able to access a VA Android app on a non-Android electronic device. VA Video Connect (VVC) The VA Video Connect (VVC) is a mobile app that veteran patients can download from the virtual VA App Store. The VVC app functions by allowing a veteran patient to connect via live video with a VA provider regardless of where the veteran or provider is located, through the CVT modality. The veteran patient can use the VVC app on a mobile device. To access the VVC app, the veteran patient's mobile device must contain a web camera, speakers, and microphone. In addition, the device must be able to connect to and have access to the Internet. According to the VA, the VVC "uses encryption to ensure privacy in each session." The VA launched the VVC app in August 2017 and has recorded 105,300 telehealth visits via the VVC app from October 2017 to September 2018. The VA's Partnerships with Philips Healthcare and T-Mobile The VA has partnered with private sector vendors Philips Healthcare and T-Mobile to expand veterans' access to the VVC app. Philips Healthcare currently partners with the VA by providing veterans with a "virtual connected care" through the company's Virtual Medical Center. This new partnership with Philips Healthcare aims to place telehealth information and communication technology equipment in 10 posts at the facilities of two veteran service organizations (VSOs) recognized by the President, Congress, and the VA Secretary for the representation of veterans: Veterans of Foreign Wars and the American Legion. The placement of the equipment in the VSO posts would expand VA telehealth services to veterans who are likely to be members of and who frequently visit those two VSOs. However, the program would not exclude non-VSO members from accessing VA telehealth services at the VSO sites. A positive outcome from this pilot program could encourage veterans who are not members of VSOs to visit VSO sites to access VA telehealth services. The VA's partnership with T-Mobile would allow veterans with this wireless service to access the VVC app via their mobile device without incurring additional charges or reducing plan data allotments. According to a VA press release, "veterans will be able to connect to appointments on their mobile devices for no extra charge, regardless of their current data plan." The VA did not provide in its press release the amount of the "extra charge" that veteran patients would have incurred from accessing the VVC app on their mobile devices. It is likely that other veterans who do not have T-Mobile as their wireless service provider would incur the unknown extra charge for accessing the VVC app. The VA has not yet announced any plans to partner with all wireless service providers to ensure that veteran patients who access the VVC app on their mobile devices will not incur additional charges. VA Telehealth Services The telehealth services that the VA provides to veteran patients align with their respective VA in-patient care services. A VA health care service does not change when a VA provider delivers the service via telehealth. For example, a veteran patient who chooses to access telemental health services via the VVC app on a mobile device would receive the same type of mental health services he or she would have received in-person. According to the VA Secretary, the VHA is the largest U.S. provider of telehealth services, having provided 2.29 million telehealth episodes of care to 782,000 veteran patients in FY2018. Of those 782,000 veteran patients, 9% of them were female and 45% of them live in rural areas. Veteran patients can access a range of telehealth services through the VHA. These telehealth services can be grouped into the following seven categories, in alphabetical order: 1. consultative and evaluative telehealth services, 2. disease and illness-specific telehealth services, 3. gender-specific telehealth services, 4. preventative telehealth services, 5. rehabilitative telehealth services, 6. rural-specific telehealth services, and 7. wellness telehealth services. According to the VA, the agency will provide general VA health care services to veteran patients and refer them to private health care providers for health care services that those providers provide "most effectively and efficiently." The VA's decision to refer such services to the private sector might stem from the agency's shortage of VA providers. A veteran can access VA telehealth services from various VA sites of care , such as VA medical facilities, mobile telehealth clinics, and non-VA sites of care such as the homes, work places, and schools of veterans. A veteran, who seeks VA care, including VA telehealth services at non-VA medical facilities and nonfederal facilities from non-VA providers, must receive prior authorization from the VA before accessing such services. The VA generally authorizes a veteran to seek VA care from a non-VA provider when [the existing] VA facilities or other government facilities are not capable of furnishing economical hospital care or medical services because of geographic inaccessibility or are not capable of furnishing care or services required. The VA continues to develop new telehealth services to meet the needs of veterans. According to the VA FY2019 funding and FY2020 advanced appropriations budget request to Congress, for example, the Comprehensive Opioid Management in Patient Aligned Care Teams (COMPACT) team is "testing a telehealth-based self-management training system to promote improved care for [v]eterans receiving chronic opioid therapy." The VA's Partnership with Walmart On December 6, 2018, the VA announced a new partnership with Walmart that aims to reduce access barriers to VA care that underserved veterans experience. Through this partnership, which is part of the VA's Advancing Telehealth through Local Access Stations program, the VA is establishing a pilot program whereby underserved veterans in certain locations would access VA telehealth services in donated spaces at Walmart retail stores. Walmart would provide the VA with operational support. According to Walmart, the prospective locations will be based on "the number of veterans and the health resources offered." The VA has stated that its decision to partner with Walmart is based on the fact that more Americans live near a Walmart store than a VA medical center (VAMC). According to the VA, [90%] of Americans live within ten miles of a Walmart. Ninety percent of veterans [do not] live within ten miles of a [VAMC]. The VA reported to Congress that there were an estimated 172 VAMCs in 2019. For that same calendar year, the VA also reported to Congress that there were other VA medical facilities within the VA health care system, including 23 health care centers, 300 vet centers, and 728 community-based outpatient clinics. The VA has not yet stated how many veterans live near other VA medical facilities in relation to Walmart stores. This information would be helpful to Congress as it considers measures relating to the use of existing VA spaces. This prospective pilot program has raised some concerns, however, because according to the Veterans Rural Health Advisory Committee (VRHAC), Walmart is encountering some of the same challenges that the VHA has met when expanding telehealth services to rural veterans, such as keeping pace with technology for virtual care and the expansion of bandwidth. However, such challenges could be location-specific and not representative of all Walmart retail store locations. VA Teleconsultations Current law (Chapter 17 of Title 38 of the U.S. Code ) refers to teleconsultation as "the use by a health care specialist of telecommunications to assist another health care provider in rendering a diagnosis or treatment." The law defines teleconsultation in relation to VA's delivery of mental health and traumatic brain injury assessments. The VA extends its use of teleconsultations in the delivery of VA care with the goal of improving veteran patients' health care outcomes, particularly those of rural veterans. For example, the VA has adopted and modified the Project Extension for Community Healthcare Outcomes (Project ECHO) learning model, which the Expanding Capacity for Health Outcomes Act ( P.L. 114-270 ) required the HHS Secretary to examine and report on, to create a Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) learning model. , Project ECHO is a global, technology-enabled collaborative learning model, whereby medical educators and specialty care health care providers disseminate best practices to primary care and rural health care providers, with the goal of improving the health outcomes of rural and underserved patients. The best practices are disseminated through different modalities such as teleECHO , which is the delivery of medical education such as patient case-based learning through a virtual network. TeleECHO is delivered through a hub-and - spoke model , which refers to a structure whereby a central point (the "hub") disseminates information to different connecting points (the "spokes"). The VA launched SCAN-ECHO in 2011, with the goal of expanding VA care to rural veterans and veterans that live in medically underserved areas. According to the VA, SCAN-ECHO refers to an approach to provide specialty care consultation, clinical training, and clinical support from specialty care teams to rural primary care providers (PCPs) using video teleconferencing equipment. VA teleconsultations generally transpire under SCAN-ECHO using the hub-and-spoke model. The "hubs" are the specialty care providers who are on specialty care teams, and the "spokes" are the PCPs who are on patient aligned care teams (PACTs). According to the VA, SCAN-ECHO transpires when [PCPs] present a patient's case using multi-site videoteleconferencing equipment. Providers then take information back to the patient for discussion and collaborative decision making. The specialty care team collaborates, culminating in a recommended treatment plan. In addition to case presentations, formal clinical education is provided. The Expanding Capacity for Health Outcomes Act (ECHO Act; P.L. 114-270 ) required the HHS Secretary to examine technology-enabled collaborative learning and capacity-building models and report the findings to Congress no later than two years after enactment. In February 2019, the Office of the Assistant Secretary for Planning and Evaluation (ASPE), within HHS, submitted the required report to Congress. ASPE retrieved information about SCAN-ECHO from the VA and found that the VA has evaluated the use of SCAN-ECHO for medical conditions and health care services such as chronic liver disease, diabetes, and women's and transgender health care services. For example, ASPE found that the VA studied the difference in health outcomes of 62,750 veterans with chronic liver disease between 2011 and 2015. Of those 62,750 veteran patients, 513 of them had received virtual teleconsultations with VA providers who were participating in SCAN-ECHO. According to ASPE, "those receiving the intervention were much less likely to die than those who had no SCAN-ECHO consultation over the same time period." SCAN-ECHO is an example of the VA's efforts to expand the capability of VA telehealth to "underproductive providers to assist access-challenged providers." Issues for Congress The VA is leveraging the use of telehealth with the goal of expanding veterans' access to VA care. Based on its experience with telehealth to date, the VA has stated that increased access to telehealth could reduce the use of VA travel benefits by veterans and reduce hospital admissions. Telehealth is not a new form of health care delivery. It is a multibillion dollar industry in both the federal and private sectors, showing upward trends in telehealth access, utilization, innovation, and spending. Discussed below are three issues that Congress may choose to examine while considering additional topics related to veterans and telehealth services: (1) access barriers to in-person VA care continues to exist, (2) some veterans lack access to the internet, and (3) VA providers' guidelines for prescribing controlled substances via telehealth are different. Access Barriers to In-Person VA Care Continue to Exist According to the VA, the agency cannot meet veterans' demand for VA in-patient care. Congress and the VA have considered measures and initiatives to expand veterans' access to VA care using telehealth. The expansion of VA telehealth does not address the access barriers that veteran patients' face when seeking in-person VA care. Instead, telehealth provides veterans with an alternate way to access health care services through the VHA. The VA is predicting that the U.S. veteran population will decrease by 32%âfrom 20.0 million veterans in 2017 to 13.6 million veterans in 2037. This prediction does not equate to a lower number of veterans seeking, enrolling in, and accessing VA care in the future. For example, more than three-fourths of the 13.6 million veterans that the VA projects will be in the U.S. veteran population in 2037 might choose to enroll in and access care through the VA health care system. Congress may consider whether the VA should continue to expand veterans' access to VA in-person care in VA brick-and-mortar buildings and/or through VA telehealth services by assessing how such modes of delivery effect the cost and quality of care (in addition to timely access). Some Veterans Lack Access to the Internet The overarching goal of the MISSION Act and VA final rule on telemedicine is to expand veteran patients' access to care using telehealth. The use of telehealth services requires that veteran patients have access to the internet to connect to VA telehealth providers. Veteran patients who do not have readily accessible internet connections would likely have difficulty reaching their VA providers. According to the National Center for Veterans Analysis and Statistics (NCVAS), an estimated 20.1% of veterans did not have internet access in 2016. In April 2018, for example, the GAO found that some veterans who live on the U.S. Pacific Islands such as Guam and American Samoa, could not access the internet because of damaged cables and equipment failures that occurred during inclement weather. The VA is investigating ways to expand veteran patients' access to VA telehealth services to address veterans' lack of access to the i nternet . Specifically, t he agency is evaluating the feasibility of non-VA facilities (e.g., libraries, schools, and post offices) serving as i nternet /online hotspots, and retaining VA kiosks where veteran patients can access telehealth services. Congress and the President have responded to this divide by enacting measures such as the Repack Airwaves Yielding Better Access for Users of Modern Services Act of 2018 ( P.L. 115-141 ; RAY BAUM's Act of 2018). The RAY BAUM's Act of 2018 required, among other things, the Federal Communications Commission (FCC) to submit a report to Congress on promoting broadband internet access to veterans, particularly to rural veterans and veterans with low incomes. The FCC submitted the report to the Senate Committee on Commerce, Science, and Transportation and the House Committee on Energy and Commerce in May 2019. According to the FCC's report, the 2.2 million veteran households that do not have access to broadband internet experience barriers when adopting broadband such as the inability to pay for the service and the lack of broadband development in their geographic location. In future discussions regarding this issue, Congress may consider the costs associated with deploying broadband infrastructure in underserved geographic areas. According to the VA, some veteran patients are given tablets "that operate over 4G LTE mobile broadband to support VA Video Connect," where infrastructure is lacking. Conflicting Guidelines for Prescribing Controlled Substances via Telehealth across State Lines Congress continues to address concerns regarding the prescribing of controlled substances such as opioids. The VA MISSION Act and the VA's final rule do not address the prescribing of controlled substances to veteran patients who are not receiving services from within VA medical facilities, or who are not in the same state as the prescribing physician, as permitted under the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 (Ryan Haight Act; P.L. 110-425 ). Section 311(h)(1) of the Controlled Substance Act (CSA), which was added by Section 3 of the Ryan Haight Act, authorized the special registration for telemedicine with the goal of increasing patients' access to practitioners that can prescribe controlled substances via telemedicine in limited circumstances. Current law defines a practitioner as a physician, dentist, veterinarian, scientific investigator, pharmacy, hospital, or other person licensed, registered, or otherwise permitted, by the United States or the jurisdiction in which he practices or does research, to distribute, dispense, conduct research with respect to, administer, or use in teaching or chemical analysis, a controlled substance in the course of professional practice or research. The registration would enable a practitioner to deliver, distribute, dispense, or prescribe via telemedicine a controlled substance to a patient who has not been medically examined in person by the prescribing practitioner. While the CSA authorized the special registration for telemedicine, practitioners have not been able to apply for this special registration. The Drug Enforcement Administration (DEA) has yet to finalize a rule on the registration's application process and procedures and the limited circumstances that warrant it. The Ryan Haight Act expressly exempts VA providers and VA-contracted providers from needing to obtain a special registration in each state where the providers choose to practice, if they meet two conditions. First, the providers must prescribe the controlled substance within the scope of their employment at the VA. Second, the providers must either (1) hold at least one state registration to prescribe a controlled substance or (2) prescribe in a VA health care facility while using the registration of that facility. The special registration, though not implemented yet by the DEA, the MISSION Act, or the VA's final rule on telehealth, might confuse VA providers about whether they must hold a license in each state where they intend to prescribe controlled substances to veteran patients. The special registration would allow a VA provider to prescribe a controlled substance in a state where the provider is not licensed to practice. The MISSION Act and the VA's final rule on telehealth, in contrast to the special registration, do not preempt state laws regarding the prescribing of controlled substances. VA providers must be licensed in each state where the provider intends to prescribe a controlled substance. Congress could consider encouraging the VA to develop guidelines on how its providers would prescribe controlled substances to veteran patients who are not receiving telehealth services from within VA health care facilities. Appendix A. Abbreviations Used in This Report Appendix B. History of VA Telehealth For decades, the VA has provided telehealth services to veteran patients to improve health care access and to address delivery challenges, such as shortages of in-patient beds and health care providers skilled in the delivery of veteran-centric care. In the 1950s and 1960s, for example, the VA had difficulties in recruiting psychiatrists and neurologists. In FY1961, there were 18,722 eligible veterans on a waiting list to receive VA inpatient care for psychiatric and neurological health care conditions. That same year, the VA started testing the use of telehealth, with the goal of addressing the aforementioned challenges that veteran patients were experiencing when trying to access VA in-person care for psychiatry and neurology services. According to the VA's Annual Report for FY1961, the VA tested the use of telehealth by using the closed-circuit television ( CCTV) technology as a telehealth modality. The CCTV technology refers to a system that "links a camera to a video monitor using a direct transmission system." VA physicians and therapists at a VA medical facility in Oklahoma City, OK, had used the CCTV technology to disseminate best practices and trainings on therapy and psychiatry with the goal of improving veteran patients' health care outcomes. According to the VA, its use of telehealth using the CCTV technology was a success because [t]he results indicate that this form of communication can be a valuable tool in the treatment of psychiatric patients and in the training of personnel in psychiatric service. In addition, it shows the potential in a number of other medical applications, such as, for example, an education technique in surgical training. Since then, the VA has aimed to address veterans' access barriers to VA in-person care using updated telehealth technologies and equipment, which are discussed under the " VA Telehealth Components " heading in this report. Legislative History of VA Telehealth The Congress has passed several laws that address VA telehealth. Provided below is a high-level legislative history of VA telehealth, to help inform any future congressional discussion on this issue. For each Congress, beginning with the 109 th (January 3, 2005 to January 3, 2007) there is a brief narrative summarizing at least one legislative provision that aims to address VA telehealth. This list may not be comprehensive. Veterans Benefits, Health Care, and Information Technology Act of 2006 (109 th Congress) The Veterans Benefits, Health Care, and Information Technology Act of 2006 ( P.L. 109-461 ), among other things, required the VA Secretary to increase the number of VA medical facilities that are capable of providing readjustment counseling services via telehealth. Veterans' Mental Health and Other Care Improvements Act of 2008 (110 th Congress ) The Veterans' Mental Health and Other Care Improvements Act of 2008 ( P.L. 110-387 ), among other things, required the VA Secretary to develop a pilot program to assess the feasibility and advisability of providing certain veterans with peer outreach, peer support, readjustment counseling and other mental health services, using telehealth to the extent practicable. Caregivers and Veterans Omnibus Health Services Act of 2010 (111 th Congress) The Caregivers and Veterans Omnibus Health Services Act of 2010 ( P.L. 111-163 ), among other things, allows the VA Secretary to contract with community mental health centers and other qualified health entities with the goal of expanding veterans' access to VA telehealth services. Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012 (112 th Â Congress) The Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012 ( P.L. 112-154 ), among other things, allows the VA Secretary to waive veteran patients' copay requirements for telehealth. The Veterans Access, Choice, and Accountability Act of 2014 (113 th Congress ) The Veterans Access, Choice, and Accountability Act of 2014 ( P.L. 113-146 ), among other things, requires the VA Secretary to improve veterans' access to VA telehealth via mobile vet centers and mobile medical facilities. The Faster Care for Veterans Act of 2016 (114 th Congress) The Faster Care for Veterans Act of 2016 ( P.L. 114-286 ), among other things, requires the VA Secretary to ensure that veteran patients can schedule their own medical appointments for VA telehealth services. John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 (115 th Congress) The John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 ( P.L. 115-182 ; VA MISSION Act of 2018), among other things, removes all geographic barriers to VA telehealth and therefore allows veterans to access VA telehealth services in their communities from any location in the United States, U.S. territories, District of Columbia, and Commonwealth of Puerto Rico. Appendix C. VA Provider Authority to Provide Telehealth Services Anywhere Veteran patients who cannot access telehealth because of provider shortage gaps may benefit from having access to out-of-state telehealth providers in non-VA health care facilities. Generally, states determine whether a health care provider can provide a health care service across state lines because states handle provider licensure. Each state has the authority to establish its own licensure requirements, and each state licensing board has its own eligibility requirements for health care providers. Due to state-specific licensing laws, a health care provider licensed and certified in one state may not be able to provide health care services to patients located in another state where the provider is not licensed. State licensing laws can cause some health care providers to experience geographical and licensing-related barriers to providing health care services across state lines to rural and underserved populations. On August 3, 2017, the White House and the VA announced the Anywhere to Anywhere initiative, which aims to remove the geographic barriers that veterans might experience when accessing VA care. Under this initiative, a veteran patient can access VA telehealth services anywhere from a VA provider located outside of a VA health care facility. The initiative is a joint effort between the VHA, the White House Office of American Innovation, and the Department of Justice. The VA's attempt to expand veterans' access to VA care via telehealth under this initiative was threatened by its providers' experiences of geographic and licensing barriers to delivering the services across state lines. On October 30, 2017, a House Committee on Veterans Affairs report found that the continued expansion of telemedicine across the VA health care system is constrained by restrictions on the ability of VA providers to practice telemedicine across state lines without jeopardizing their state licensure and facing potential penalties for the unauthorized practice of medicine. On May 11, 2018, the VA published a final rule in the Federal Register to exempt its providers who deliver care via telehealth from certain state licensing laws and regulations. Two major elements of the final rule changed the VHA's existing practice delivery: (1) VA providers may deliver telehealth services outside of VA health care facilities and (2) state licensing boards may no longer deny or revoke a VA provider's license if he or she provides a telehealth service in a state where the provider is not licensed to practice in non-VA health care facilities. According to the VA, the prohibition addresses the concerns of some VA providers that chose not to provide telehealth services across state lines in non-VA health care facilities because their state licensing boards might take action against their licenses for doing so. In March 2018, for example, the VA Pacific Island Health Care System reported to the GAO that it had concerns about delivering a telehealth service to a veteran patient in his or her home because a state could require VA providers to be licensed in the state where the patient resides. The final rule does not preempt state laws regarding the prescribing of controlled substances, nor does it extend beyond the telehealth provider's employment at the VA or extend to VA-contracted providers. A VA-contracted provider must continue to practice under the laws and regulations of his or her state of licensure. The rule became effective on June 11, 2018, five days after the enactment of the VA MISSION Act. The VA MISSION Act, among other things, removed all geographic barriers to VA telehealth and therefore, allowed veterans to access VA telehealth services in their communities from any location in the United States, U.S. territories, District of Columbia, and Commonwealth of Puerto Rico. According to Chapter 17 of Title 38 of the U.S. Code , (d) Relation to State Law. (1) The provisions of this section shall supersede any provisions of the law of any State to the extent that such provision of State law are inconsistent with this section. (2) No State shall deny or revoke the license, registration, or certification of a covered health care professional who otherwise meets the qualifications of the State for holding the license, registration, or certification on the basis that the covered health care professional has engaged or intends to engage in activity covered by subsection (a). The VA MISSION Act codified the core principles of the above-mentioned final rule with the goal of protecting VA providers against possible liability issues stemming from state licensure laws. This authority is given only to VA providers that meet the statutory requirement of a "covered health care professional." According to the VA, nearly 10,000 VA providers gained the authority to provide out-of-state telehealth services to veteran patients in non-VA health care facilities in states where the provider is not licensed to practice. Appendix D. Total Number of Veteran Patients who Had Received VA Telehealth Services and Total Number of Telehealth Encounters that Transpired, FY2009-FY2018


Introduction In January 2019, the House agreed to H.Res. 6 , a resolution adopting the rules of the House of Representatives for the 116 th Congress. This report summarizes amendments to House rules affecting floor proceedings in the 116 th Congress (2019-2020), as provided for in H.Res. 6 . In the 116 th Congress, rules changes affected the consideration of legislation on the floor, voting in the House and the Committee of the Whole, and procedures related to Delegates and the Resident Commissioner of Puerto Rico. H.Res. 6 also clarified that religious headdress may be worn in the House chamber at any time, and it included a separate order specifying that, during the 116 th Congress, the House may not table motions to discharge certain measures related to the War Powers Resolution. Consideration of Legislation "Question of the Privileges of the House" Resolution Causing a Vacancy in the Office of the Speaker H.Res. 6 amended Rule IX to establish that a resolution declaring a vacancy in the Office of the Speaker will not qualify as a question of the privileges of the House unless it is offered by direction of a party caucus or party conference. Prior to this rules change, such a resolution offered by any Member would have qualified as a question of privilege. Rule IX concerns resolutions "raising a question of the privileges of the House." Resolutions raising a question of the privileges of the House are those that affect the "rights of the House collectively, its safety, dignity, and the integrity of proceedings." If they are offered from the floor by the majority leader or the minority leader, they have precedence over all other questions except the motion to adjourn. When offered by other Members, they have the same precedence but only at a time scheduled by the Speaker within two legislative days after the proponent announces an intention to offer the resolution. Consensus Calendar The Consensus Calendar is an addition to House rules. It is a list of certain measures that have not been reported by their committees of primary jurisdiction yet have at least 290 cosponsors. The new clause 7 of Rule XV states that, except at the start and the end of a Congress, the House must consider a measure on the Consensus Calendar designated by the Speaker each week should one or more be listed and the House is in session. The Consensus Calendar might provide an opportunity to vote on unreported, broadly supported legislation that would not otherwise be chosen by the Speaker for consideration under suspension of the rules or made in order by a resolution from the Rules Committee. In order to be placed on the Consensus Calendar, a non-reported measure must first achieve the 290-cosponsor threshold (two-thirds of the House's full membership). At that time, the measure's sponsor may present a motion to the Clerk to place the measure on the calendar. This motion is submitted in writing directly to the Clerk, as opposed to being offered on the floor. The written motion is then retained in the Clerk's custody and printed in the Congre ssional Record . The rule directs the Clerk to maintain a list of Consensus Calendar motions and make the list publicly available on the Clerk's website. Following the presentation of the motion, a measure will be placed on the Consensus Calendar once it has maintained 290 cosponsors for a "cumulative period of 25 legislative days," a period of time that is usually equal to 25 calendar days in which the House is in session. (If the primary committee reports the measure during this period, the motion to place the measure on the Consensus Calendar will be considered withdrawn. ) The measure will remain listed on the calendar even if it falls below the 290-cosponsor threshold until it is considered by the House or is reported by the primary committee of jurisdiction. Thus, a committee may report a bill to prevent it from being placed on the Consensus Calendar or to remove it from the Consensus Calendar. The new rule did not create any special procedures for the floor consideration of a measure on the Consensus Calendar. According to the Section-by-Section summary of the rules changes prepared by the Rules Committee, Consensus Calendar measures may be considered "in any manner otherwise available under the rules," which would include suspension of the rules or under the terms of a special rule reported by the Committee on Rules. The Section-by-Section summary also explains that the Speaker will meet the requirement of the rule that a measure on the Consensus Calendar be designated for consideration by making an announcement immediately preceding the consideration of a measure on the floor. Motions to Discharge H.Res. 6 amended clause 2 of Rule XV to require the Speaker to schedule consideration of a motion to discharge that has met the signature and layover requirements of Rule XV within two legislative days after a discharge proponent announces his or her intention to offer the motion. In previous Congresses, motions to discharge, which had met the Rule XV requirements, could be offered on the floor on the second and fourth Mondays of the month if the House was in session on those days. The "discharge rule" enables an unreported measure that has not been scheduled by leadership for floor consideration to be raised on the floor, provided that a majority of the House membership has signed a discharge petition. Any Member may submit to the Clerk a motion to discharge a committee from the consideration of a public measure that the committee has had before it for 30 legislative days or more. A Member may also submit a motion to discharge the Committee on Rules from the consideration of a special order of business (special rule) it has had before it for seven legislative days or more if the measure the rule makes in order has been in committee for at least 30 legislative days or has been reported. Once a majority of the House membership (218 Members) signs the associated discharge petition, the motion is placed on the Calendar of Motions to Discharge Committees. After the motion has been on the calendar for at least seven legislative days, a Member who has signed the discharge petition may announce to the House an intention to offer the motion. As amended, clause 2(c)(1) of Rule XVI now requires the Speaker to schedule motions to discharge the day of the announcement or on one of the next two legislative days. Prior to the change, even after meeting all the other requirements, motions to discharge could be made only on the second and fourth Mondays of a month. If the House was not in session on those days, considerable time could pass between when the other requirements of the rule were met and when proponents could force consideration of their motion. Private Calendar The Private Calendar lists private legislation (measures providing benefits to one or more specified individuals or entities) that has been reported out of committee. House Rule XV provides a special procedure for the consideration of private legislation on the calendar, but in recent Congresses, few measures have been called from the Private Calendar. H.Res. 6 . amended clause 5 of Rule XV to allow the Speaker to direct the Clerk to call a private bill on any day the House is in session if the measure has been on the Private Calendar for seven days. Prior to the 116 th Congress, the call of the Private Calendar was limited to the first and third Tuesdays of the month. If measures are listed on the calendar, the Speaker or designee is to direct the Clerk to call them on the first Tuesday of the month in the order they are listed. Under the amended rule, the Speaker may also direct the Clerk to call a specific measure on other days after the requisite seven-day period has passed. In the latter case, the Speaker must announce to the House an intention to call a private measure. The call, if it is to occur, must occur on the second legislative day after the legislative day the Speaker makes the announcement. Official Objectors are appointed by each party to examine measures on the Private Calendar. If, at the time a bill is called, two Objectors or two other Members object to the measure, the measure is recommitted to the committee that reported it. According to the Rules Committee's summary of H.Res. 6 , the specific requirement for two days' notice ensures that the "Official Objectors are able to be on the Floor at the appropriate day and time." 72-Hour Availability House rules generally afford a time period for Members to review legislative text before considering measures in the chamber. H.Res. 6 . amended Rules XXI, XXII, and XXII to establish, for certain legislative text and committee reports, a 72-hour review period, as opposed to the previous review period, which spanned until the "third calendar day" on which the measures' text or committee reports had been available. The rules amendments actually made two changes: they designated the 72-hour period and, for reported measures, enabled the layover period to begin when the "proposed text of each report" is made available, in contrast to when the official committee report is available. Prior to the changes to the rules, legislative text could meet the three-day layover requirement even if it was not always available for a 72-hour period. For instance, if an unreported bill's text was posted at 9:00 p.m. on a Monday, the bill might have been considered on Wednesday morning, less than 40 hours later. The new 72-hour availability requirement, however, provides an exact time period for layover review before measures may be considered in the House. The requirement applies to proposed text of committee reports and the text of unreported bills and joint resolutions, conference reports, and amendments reported in disagreement from conference committees. The review period begins at the time the text is posted electronically or otherwise made available. Thus, for committee reports, the clock can start with the posting of the report's proposed content, not when the committee has filed and delivered the report to the Clerk, which may occur at a later time. As stated in clause 4 of Rule XIII, the availability requirement excludes supplemental, minority, additional, or dissenting views that may be inserted in a committee report at the request of a committee member. Members are guaranteed two calendar days to submit these optional sections if notice of intent to file supplemental views was given at the time the committee approved the measure or matter. Voting Postponability of Certain Votes (House) H.Res. 6 amended clause 8 of Rule XX to enable the Speaker to postpone a vote on any amendment considered in the House rather than restricting this action to amendments reported from the Committee of the Whole. Votes on the previous question to end debate on any amendment can now be postponed as well. Prior to the rules change, the rule referred only to amendments reported from the Committee of the Whole. Since 1979, House rules have allowed the Speaker to postpone and cluster votes by electronic device. In addition to amendments, several types of measuresâincluding bills, resolutions, and conference reportsâmay be subject to a postponed vote. The Speaker's ability to postpone, cluster, and announce upcoming votes provides some degree of certainty to the voting schedule. Discretion for Five-Minute Votes (House) Under clause 2 of Rule XX, the time for electronic voting is no less than 15 minutes in the House. However, clauses 8 and 9 provide the Speaker with the discretion to reduce to five minutes the voting period in the House if the vote occurs following another electronic vote or following a report from the Committee of the Whole. In previous Congresses, clause 9 stated that the reduced-time option could be exercised if "notice" was given of possible five-minute voting. According to the amended clause 9(a), the Speaker may reduce the voting period if "in the discretion of the Speaker Members would be afforded an adequate opportunity to vote," while clause 9(b) states, "To the maximum extent practicable, notice of possible five-minute voting for a given series of votes shall be issued prior to the first electronic vote in the series." Discretion for Two-Minute Votes (Committee of the Whole) The 116 th rules package amended clause 6 of Rule XVIII to provide the chair of the Committee of the Whole with more discretion to reduce the time for electronic voting. Under clause 2 of Rule XX, the time for electronic voting is no less than 15 minutes in the Committee of the Whole. However, clause 6 of Rule XVIII allows the chair to reduce the voting period to not less than two minutes if the vote occurs in a series. In previous Congresses, the two-minute vote on any proposed question was to occur immediately following the initial 15-minute vote or after the Committee of the Whole resumes. There could be no intervening business or debate. H.Res. 6 removed references to intervening business or debate. Instead, clause 6 now authorizes a two-minute voting period "if in the discretion of the chair Members, Delegates, and the Resident Commissioner would be afforded an adequate opportunity to vote." Delegates and the Resident Commissioner Admittance to the Hall of the House H.Res. 6 expanded the number of position categories allowed entrance to the Chamber when the House is in session. Under the amended clause 2 of Rule IV, the list of individuals eligible for floor privileges now explicitly includes Delegates-elect, the Resident Commissioner-elect, and contestants in elections for Delegate and the Resident Commissioner "during the pendency of their cases on the floor." Clause 2 also states that, in addition to governors of the states, governors of the territories shall "be admitted to the Hall of the House or rooms leading thereto." Notice of Convening During any recess or adjournment of not more than three days, the Speaker, in consultation with the minority leader, may change the time or the location of the next meeting of Congress if circumstances warrant it. The rule granting the Speaker this authority contains notification requirements. H.Res. 6 added, "Delegates and the Resident Commissioner" to the requirements in clause 12 of Rule 1 that "Members" be notified of a change in the time of the next meeting. Committee of the Whole Voting Powers H.Res. 6 reinstated from previous Congresses the voting rights of the Delegates and the Resident Commissioner in the Committee of the Whole. It also re-instated the rules provision that prevents these votes from influencing the final outcome of questions initially decided in the committee. In the 116 th Congress, recorded votes in the Committee of the Whole, which are decided within the margin of the votes cast by the Delegates and the Resident Commissioner, are to be re-conducted in the House, a forum in which Delegates and the Resident Commissioner do not have voting rights. As amended, clause 3(a) of Rule III states that in the Committee of the Whole, the Delegates and the Resident Commissioner "shall possess the same powers and privileges as Members of the House." The term powers and privileges includes the ability to vote. In the 103 rd Congress (1993-1994), Delegates and the Resident Commissioner first received the power to vote in the Committee of the Whole. Since then, their voting status has changed with each change in the majority party. Accordingly, they voted during the 103 rd , 110 th (2007-2008), and 111 th (2009-2010) Congresses, when the Democrats held the majority in the House, but not the 104 th -109 th Congresses (1995-2006) and the 112 th -115 th Congresses (2011-2018), when the Republicans held the majority. During the Congresses in which the Delegates and the Resident Commissioner voted in the Committee of the Whole, the House adopted the associated marginal vote provision under what is now clause 6 of Rule XVIII. That is, if a question is decided in the Committee of the Whole within the margin of votes cast by the Delegates and the Resident Committee, the committee shall rise. The Speaker shall then put the question to the House. After the House votes, the Committee of the Whole shall resume its sitting. Counting for Quorum and Other Procedures The 116 th Congress rules package enabled Delegates and the Resident Commissioner to be counted when ascertaining the presence of a quorum, as well as toward the requisite number to request a recorded vote, in the Committee of the Whole. In addition, the chair was to consider the Delegates' and Resident Commissioner's opportunity to vote before reducing the minimum time for electronic voting. H.Res. 6 amended clause 6 of Rule XVIII to add the phrase Delegates and the Resident Commissioner after the word Members in three places. Consequently, a quorum in the committee became 100 Members, Delegates, and the Resident Commissioner. A request for a recorded vote needs the support of at least 25 Members, Delegates, and the Resident Commissioner. And the chair may reduce the time to vote on any postponed question "if in the discretion of the Chair Members, Delegates, and the Resident Commissioner would be afforded an adequate opportunity to vote." Religious Headdress H.Res. 6 amended clause 5 of Rule XVII to clarify that Members may wear religious headdress in the House chamber. The amendment added the phrase non-religious headdress to clause 5 in order to specify that the hat prohibition did not include religious headwear. Clause 5 now states, "During the session of the House, a Member, Delegate, or Resident Commissioner may not wear non-religious headdress or a hat." War Powers Resolution The 116 th Congress rules package included a section on "separate orders," which are provisions that affect House procedures but are not codified in the standing rules of the House. These separate orders have the same force and effect as House rules. Under one such separate order, H.Res. 6 clarifies that the House may not table a motion to discharge a measure introduced pursuant to Section 6 or Section 7 of the War Powers Resolution ( P.L. 93-148 ). The War Powers Resolution is an act that governs House consideration of joint resolutions, bills, and concurrent resolutions that are introduced after the U.S. Armed Forces engages "in hostilities" without a prior declaration of war. Measures introduced in compliance with the resolution are referred to the House Foreign Affairs Committee. The committee is to report such legislation within a time frame delineated in the resolution. The War Powers Resolution does not provide an automatic discharge process if the committee does not report. Should the measure not be reported, a Member may offer a motion to discharge the committee from further consideration in order to allow it to reach the floor. According to the Rules Committee summary for H.Res. 6 , previous House action on similar procedures "made it unclear" if a Member could then offer a motion to table the motion to discharge. The separate order is intended "to provide certainty for all Members, Delegates, and the Resident Commissioner on this procedure."