Bill Summary

H.R. 1336 would require the Department of Veterans Affairs (VA) to provide hyperbaric oxygen therapy (HBOT) to veterans diagnosed with post-traumatic stress disorder or traumatic brain injury. The bill also would require the Government Accountability Office (GAO) to update its report on HBOT therapy. Finally, the bill would extend a statutory limitation on pension payments to veterans in Medicaid nursing homes through October 2034.

Estimated Federal Cost

The estimated budgetary effects of H.R. 1336 are shown in Table 1. The costs of the legislation fall within budget functions 550 (health) and 700 (veterans benefits and services).

Basis of Estimate

For this estimate, CBO assumes that H.R. 1336 will be enacted in fiscal year 2025 and that outlays will follow historical spending patterns for affected programs.

Provisions that Affect Spending Subject to Appropriation and Direct Spending

Section 2 would require VA to provide HBOT to veterans diagnosed with post-traumatic stress disorder or traumatic brain injury in two of the department’s regional health care networks during the three-year period following enactment.

Using data from VA about the prevalence of those conditions among veterans and published literature on the costs of HBOT, CBO estimates that roughly 6,000 veterans would participate in the program at an average cost of $27,000 for a course of 40 treatments.

The bill would establish a fund to accept donations for the program; however, CBO anticipates that contributions would be minimal and would not significantly offset the costs of the program. In total, CBO estimates that the temporary program would cost $158 million over the three-year period.

CBO expects that some of the costs of implementing the bill would be paid from the Toxic Exposures Fund (TEF) established by Public Law 117-168, the Honoring our PACT Act. The TEF is a mandatory appropriation that VA uses to pay for health care, disability claims processing, medical research, and IT modernization that benefit veterans who were exposed to environmental hazards.

Additional spending from the TEF would occur if legislation increases the costs of similar activities that benefit veterans with such exposure. Thus, in addition to increasing spending subject to appropriation, enacting section 2 would increase amounts paid from the TEF, which are classified as direct spending. CBO projects that the proportion of costs paid by the TEF will grow over time based on the amount of formerly discretionary appropriations that CBO expects will be provided through the mandatory appropriation as specified in the Honoring our PACT Act.[1]

CBO estimates that over the 2025-2035 period, implementing section 2 would increase spending subject to appropriation by $124 million and direct spending by $34 million.

Direct Spending

In addition to expanding benefits that would partly be covered by the TEF, enacting H.R. 1336 would affect direct spending by extending a statutory limitation on VA pension payments. In total, enacting the bill would decrease net direct spending by $105 million over the 2025-2035 period (see Table 2).

Under current law, VA reduces pension payments to veterans and survivors who reside in Medicaid nursing homes to $90 per month. That required reduction expires November 30, 2031. Section 4 of the bill would extend the reduction for 35 months, through October 31, 2034. CBO estimates that extending that requirement would reduce VA benefits by $10 million per month. (Those benefits are paid from mandatory appropriations and are therefore considered direct spending.) As a result of that reduction in beneficiaries’ income, Medicaid would pay more of the cost of their care, increasing spending for that program by $6 million per month.

In total, enacting section 4 would reduce direct spending by $139 million over the 2025‑2035 period, CBO estimates.

Spending Subject to Appropriation

The discussion above in “Provisions that Affect Spending Subject to Appropriation and Direct Spending” describes the costs of implementing a program to provide HBOT to eligible veterans. Establishing the program would increase spending subject to appropriation by $124 million over the 2025‑2035 period.

Section 3 would require GAO to update its 2015 report on the use of HBOT to treat post-traumatic stress disorder and traumatic brain injury. Based on the costs of similar reporting requirements, CBO estimates that preparing the report would cost less than $500,000.

Uncertainty

CBO's estimate of the costs of H.R. 1336 is subject to uncertainty, particularly with regard to the number of veterans who would receive HBOT under the program. Costs would differ if the number of participants is greater or less than CBO estimates.

Pay-As-You-Go Considerations

The Statutory Pay-As-You-Go Act of 2010 establishes budget-reporting and enforcement procedures for legislation affecting direct spending or revenues. The net changes in outlays that are subject to those pay-as-you-go procedures are shown in Table 1.

Increase in Long-Term Net Direct Spending and Deficits

CBO estimates that enacting H.R. 1336 would not increase net direct spending or on‑budget deficits in any of the four consecutive 10-year periods beginning in 2036.

Mandates

The bill contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act.

Estimate Prepared By

Federal Costs:

Noah Callahan (for veterans’ health care) 
Logan Smith (for veterans’ and survivors’ pensions)

Mandates: Grace Watson

Estimate Reviewed By

David Newman
Chief, Defense, International Affairs, and Veterans’ Affairs Cost Estimates Unit

Kathleen FitzGerald 
Chief, Public and Private Mandates Unit

Christina Hawley Anthony
Deputy Director of Budget Analysis