119-S-3436 Investigative Journalist Impact Analysis

Summary

What changes: S. 3436 requires VA, within one year of enactment, to furnish telehealth and mail‑order pharmacy benefits to eligible veterans in the Freely Associated States (FAS)—subject to agreements—and to begin mandatory beneficiary‑travel payments for care in, to, or from the FAS, with quarterly implementation cost reports to Congress. The Senate passed the bill by unanimous consent on December 17, 2025; it was received in the House on December 18, 2025 and held at the desk. [1]Congress.gov — Text of S.3436 — Caring for Veterans and Strengthening National…[2]Congress.gov — All actions on S.3436 (119th Congress)

Legal context: Current law permits VA care abroad under 38 U.S.C. §1724(f)(1) in the FAS subject to agreements; and §111(h)(1) presently states the Secretary may make FAS travel payments—S. 3436 changes that "may" to a timeline‑bound "shall." [5]Legal Information Institute (Cornell Law School) — 38 U.S.C. §1724 — Hospital c…[4]Legal Information Institute (Cornell Law School) — 38 U.S.C. §111 — Payments or…

Strategic context: The Compact of Free Association (COFA) amendments (2024) renewed long‑term U.S.–FAS compacts and funding; service provision in the FAS interacts with those commitments and with U.S. posture in the Pacific. [6]U.S. Department of the Interior — COFA Amendments Implementation (2024)[7]Financial Times — US passes deal to fund Pacific Islands pacts after delays

Economic Effects

Direct costs rise from building and operating service channels into the FAS; some offsets may accrue from telehealth. Exposure hinges on volumes that GAO says VA does not yet accurately estimate for these geographies.

• VA outlays: Standing up FAS telehealth (platform access, staffing, licensing, cross‑border privacy/security) and activating CMOP mail fulfillment and beneficiary‑travel reimbursements will increase near‑term costs. VA reports 2.4 million unique telehealth users and 11.6 million encounters in 2023—evidence that enterprise‑scale infrastructure exists but will require FAS‑specific onboarding. [8]U.S. Department of Veterans Affairs — VHA Annual Report — Telehealth metrics (2…
• Beneficiary travel: Changing §111(h)(1) from discretionary to mandatory will crystalize payments for FAS travel (airfare, mileage equivalents, lodging where applicable). Current published VA rates are $0.415/mile with standard deductibles; air is reimbursable when it is the only practical mode. Expect per‑capita costs to be high due to oceanic distances. [9]U.S. Department of Veterans Affairs — Reimbursed VA travel expenses and mileage…[10]Legal Information Institute (Cornell Law School) — 38 CFR §70.30 — Payment prin…[4]Legal Information Institute (Cornell Law School) — 38 U.S.C. §111 — Payments or…
• Telehealth cost offsets: Peer‑reviewed and large‑payer analyses find lower total episode costs after telehealth index visits (e.g., −$82 in Medicare; −23% in an employer plan). These savings are plausible where virtual care substitutes for in‑person visits and reduces downstream testing/utilization. [11]University of Michigan Health — Telehealth didn’t increase Medicare visits, but…[12]Healthcare Innovation (Penn Medicine study) — Penn Medicine analysis: teleheal…
• Mail‑order pharmacy operations: VA’s Consolidated Mail Outpatient Pharmacy (CMOP) fills the vast majority of veteran prescriptions and relies primarily on USPS; senators have flagged that postal delays can affect timeliness—an operational risk that grows with trans‑Pacific legs. [13]U.S. Department of Veterans Affairs — VA Mail Order Pharmacy (CMOP) — Program o…[14]U.S. Senate (HSGAC) — Senate Press: Peters & Tester press USPS on delays of ve…
• Population base and forecasting risk: GAO found VA lacks assurance that veteran‑population estimates for the territories and FAS are accurate, and stakeholders believe they’re low—complicating cost projections and workload modeling. [3]U.S. Government Accountability Office — GAO-24-106364 — Veterans Affairs: Acces…
• Program interactions abroad: VA’s Foreign Medical Program (FMP) paid $128.3 million to 8,024 veterans/providers in FY2024 but (as of 2025) uses paper checks extensively and historically has not mailed medicines overseas—both constraints S. 3436 aims to work around in the FAS via new agreements. [15]U.S. Government Accountability Office — GAO-25-107149 — Veterans Health Care: A…[16]U.S. Department of Veterans Affairs — Getting care through VA’s Foreign Medical…

Social Effects

Most effects are concentrated in small, remote communities where citizens enlist at high per‑capita rates and where veterans today face long travel and sparse specialty care access.

• Access gains: GAO documented that veterans in the FAS often travel long distances and many did not qualify for travel benefits; the bill’s mandate plus telehealth and mail pharmacy would close a documented access gap. [3]U.S. Government Accountability Office — GAO-24-106364 — Veterans Affairs: Acces…
• Mental health capacity: VA delivered 54% of outpatient mental health services virtually in 2023; enabling secure video to the FAS extends PTSD and other behavioral health care without requiring flights to Honolulu/Guam. [17]VA News — TeleMental Health: Transforming PTSD treatment for Veterans
• Continuity of medications: Mail fulfillment tends to improve adherence in multiple chronic conditions (observational data, and some randomized encouragement evidence), suggesting potential reductions in avoidable complications if supply chains are stable. [18]American Journal of Managed Care — Dispensing Channel and Medication Adherence:…
• Community context: A House hearing record cites higher per‑capita military service by FAS citizens than many U.S. states—underscoring equity salience of VA service availability where these veterans reside. [19]Congress.gov — House hearing record noting higher per‑capita FAS service in U.S…

Environmental Effects

Net effect likely reduces travel‑related emissions by substituting telehealth for long‑haul patient travel; added mail‑parcel emissions exist but are comparatively small per episode.

• Avoided patient travel: U.S. patient travel to health care generates an estimated 35.7 Mt CO2e annually; shifting even a fraction of FAS veterans’ long‑haul trips to telehealth reduces this footprint. [20]JAMA Network Open — Carbon Emissions From Patient Travel for Health Care (JAMA…
• Telehealth emissions evidence: A 2025 AJMC study estimates nationwide telemedicine in 2023 avoided 21–48 million kg CO2 monthly—directionally supporting reductions when virtual care substitutes for in‑person visits. [21]American Journal of Managed Care — Impact of Telemedicine Use on Outpatient‑Rel…
• Mail‑parcel emissions: CMOP shipments to the FAS will mostly move by air; while each parcel has a footprint, the counterfactual—a round‑trip patient flight to Hawaii/Guam—is typically far larger per episode. This is an inference based on mode‑of‑transport emission intensities and patient‑travel literature. [20]JAMA Network Open — Carbon Emissions From Patient Travel for Health Care (JAMA…

Temporal Analysis

Implementation is staged; near‑term hurdles differ from longer‑run payoffs.

1. 0–12 months after enactment: VA must finalize intergovernmental agreements, configure telehealth routing/licensure, and stand up mail‑order pathways to FAS ZIPs (treated as domestic under USPS DMM 608 but with restrictions and customs forms on certain classes). Beneficiary‑travel payments must begin within a year. Expect initial cost uptick, process friction, and reporting ramp‑up. [22]U.S. Postal Service — USPS DMM 608 — Mail treated as domestic for FAS[1]Congress.gov — Text of S.3436 — Caring for Veterans and Strengthening National…
2. 1–3 years: Access stabilizes as veterans enroll in telehealth and prescription delivery; some per‑visit cost offsets appear; quarterly reporting improves cost/benefit visibility. Persistent risks: postal delays, cold‑chain limits for refrigerated meds to many non‑CONUS addresses, and bandwidth gaps on outer islands. [23]U.S. Department of Veterans Affairs — Meds by Mail (CHAMPVA) — refrigerated/con…[14]U.S. Senate (HSGAC) — Senate Press: Peters & Tester press USPS on delays of ve…[24]DataReportal — Digital 2025: Federated States of Micronesia — Internet use (40.…
3. 3+ years: Potential normalization: lower avoided‑travel costs and fewer missed appointments; emissions benefits accrue if substitution persists; integration with COFA‑era U.S.–FAS health initiatives may strengthen goodwill and continuity. (The COFA amendments fund 20‑year economic assistance; health sector projects are active in the region.) [6]U.S. Department of the Interior — COFA Amendments Implementation (2024)

Unintended Consequences and Risks

Key operational and governance risks that could blunt impact or generate new vulnerabilities.

• Pharmacy compliance gaps: VA’s Foreign Medical Program explicitly does not mail medicines abroad and does not cover U.S.‑purchased meds mailed overseas; S. 3436 would require new agreements, chain‑of‑custody controls, and exceptions to operationalize FAS mail delivery. [16]U.S. Department of Veterans Affairs — Getting care through VA’s Foreign Medical…
• Cold chain and controlled substances: VA programs restrict shipping certain refrigerated products to most addresses outside CONUS; aligning formularies and shipping methods for the equatorial Pacific (heat, long legs) is non‑trivial. [23]U.S. Department of Veterans Affairs — Meds by Mail (CHAMPVA) — refrigerated/con…
• Postal latency and reliability: Senators have documented veteran prescription delays tied to USPS performance; adding long trans‑Pacific segments raises variance. SLA monitoring and backup local fills will be needed. [14]U.S. Senate (HSGAC) — Senate Press: Peters & Tester press USPS on delays of ve…
• Payment integrity: VA OIG found improper payments and eligibility lapses in Beneficiary Travel (special mode) in prior audits; scaling travel payments into the FAS without tight controls risks repeat findings. [25]VA Office of Inspector General (via Oversight.gov) — VA OIG Audit (2018): Benef…
• Data uncertainty: GAO reports VA lacks validated veteran counts in the FAS, so both appropriations requests and performance baselines may miss the mark. [3]U.S. Government Accountability Office — GAO-24-106364 — Veterans Affairs: Acces…
• Geopolitical signaling: Expanding VA services in the FAS likely strengthens U.S. standing under COFA, but it also creates expectations of continuity that outlast annual appropriations—raising exposure if future budgets tighten. This is an inference grounded in COFA implementation documents and recent funding actions. [6]U.S. Department of the Interior — COFA Amendments Implementation (2024)[7]Financial Times — US passes deal to fund Pacific Islands pacts after delays

Key Metrics (context for magnitude)

Figures below are external benchmarks or enterprise stats relevant to likely impact scope.

- VA delivered 11.6 million telehealth encounters to 2.4 million unique veterans in 2023; 54% of outpatient mental health care was virtual. - VA beneficiary travel mileage rate: $0.415/mi (standard deductibles apply). - FMP reimbursements: $128.3M to 8,024 veterans/providers in FY2024. - FSM internet users: ~40.5% penetration (proxy for connectivity constraints). - Telemedicine’s national emissions effect in 2023: 21–48 million kg CO2 avoided per month (model‑based). [8]U.S. Department of Veterans Affairs — VHA Annual Report — Telehealth metrics (2…[17]VA News — TeleMental Health: Transforming PTSD treatment for Veterans[9]U.S. Department of Veterans Affairs — Reimbursed VA travel expenses and mileage…[15]U.S. Government Accountability Office — GAO-25-107149 — Veterans Health Care: A…[24]DataReportal — Digital 2025: Federated States of Micronesia — Internet use (40.…[21]American Journal of Managed Care — Impact of Telemedicine Use on Outpatient‑Rel…

Assessment

Overall stance: neutral. The bill promises targeted access gains and likely emissions benefits by substituting telehealth for long‑haul travel, while crystallizing travel reimbursements for those who still must fly. Offsetting factors are execution risk (agreements, logistics, bandwidth), known vulnerabilities in beneficiary‑travel controls, and uncertain volumes/costs due to weak FAS veteran data. Outcomes will depend on VA’s ability to operationalize compliant mail pharmacy to the FAS, monitor USPS performance, and publish granular quarterly cost/uptake data. [3]U.S. Government Accountability Office — GAO-24-106364 — Veterans Affairs: Acces…[25]VA Office of Inspector General (via Oversight.gov) — VA OIG Audit (2018): Benef…

Sourcing notes

Primary legal/oversight sources and datasets used above; inline citations appear at the claim level.

• Statute and bill history/text: 38 U.S.C. §§1724, 111; S. 3436 (119th), Congress.gov actions. [5]Legal Information Institute (Cornell Law School) — 38 U.S.C. §1724 — Hospital c…[4]Legal Information Institute (Cornell Law School) — 38 U.S.C. §111 — Payments or…[1]Congress.gov — Text of S.3436 — Caring for Veterans and Strengthening National…[2]Congress.gov — All actions on S.3436 (119th Congress)
• VA program data: VHA annual report (telehealth), VA TeleMental Health share, VA PBM CMOP overview, VA travel‑pay page. [8]U.S. Department of Veterans Affairs — VHA Annual Report — Telehealth metrics (2…[17]VA News — TeleMental Health: Transforming PTSD treatment for Veterans[13]U.S. Department of Veterans Affairs — VA Mail Order Pharmacy (CMOP) — Program o…[9]U.S. Department of Veterans Affairs — Reimbursed VA travel expenses and mileage…
• Foreign Medical Program policy and performance: VA FMP pages; GAO 2025 review (FMP). [16]U.S. Department of Veterans Affairs — Getting care through VA’s Foreign Medical…[15]U.S. Government Accountability Office — GAO-25-107149 — Veterans Health Care: A…
• Postal/logistics: USPS DMM 608 for FAS treatment; Senate oversight on prescription‑mail delays. [22]U.S. Postal Service — USPS DMM 608 — Mail treated as domestic for FAS[14]U.S. Senate (HSGAC) — Senate Press: Peters & Tester press USPS on delays of ve…
• COFA/strategic context: DOI implementation page; Financial Times coverage of COFA funding. [6]U.S. Department of the Interior — COFA Amendments Implementation (2024)[7]Financial Times — US passes deal to fund Pacific Islands pacts after delays
• Environmental/economic literature: AJMC/JAMA estimates of telemedicine travel‑emissions effects; Medicare/Penn cost studies. [21]American Journal of Managed Care — Impact of Telemedicine Use on Outpatient‑Rel…[20]JAMA Network Open — Carbon Emissions From Patient Travel for Health Care (JAMA…[11]University of Michigan Health — Telehealth didn’t increase Medicare visits, but…[12]Healthcare Innovation (Penn Medicine study) — Penn Medicine analysis: teleheal…
• Medication adherence (mail‑order): AJMC evidence across therapy classes. [18]American Journal of Managed Care — Dispensing Channel and Medication Adherence:…
• FAS service rates context: House hearing record. [19]Congress.gov — House hearing record noting higher per‑capita FAS service in U.S…